July 9, 2012
Amber Scott is a very lucky woman. She was 38 weeks pregnant and had complained about a headache all day which was mistakenly thought to be a migraine. It wasn’t. More than likely it was pre-eclampsia and somehow the diagnosis was missed. Amber’s husband told her to lie down and presumably left the house. He attempted to contact her throughout the day and when he arrived home, he found her unresponsive with one eye open and the other closed. She was moaning and had vomited. When she arrived at the hospital, an emergency c-section was performed and Amber’s baby was saved. It was determined that Amber had a blood clot to her brain which was removed surgically as well as part of her skull in order to avoid damaging her brain. Amber was in a semi coma with a guarded prognosis but miraculously, she had progressed enough to see her baby 6 weeks after the delivery.
Amber is able to move her right side but will require many months of rehabilitation. Some women are not so lucky. A pregnant woman that has complaints of a severe headache needs immediate attention. If she’s in her third trimester, it should be assumed that she has preeclampsia until proven otherwise, especially if the headache doesn’t go away after taking analgesics. Headaches are usually the first sign of high blood pressure in a pregnant woman and should not be ignored. Complaints of headaches associated with blurry vision, abdominal pain, swollen hands or feet and “spots” in front of their eyes needs to be addressed immediately even if it means going to the hospital first before calling your midwife or physician.
The definitive treatment for preeclampsia is the delivery of the baby because it is the placenta that is thought to contribute to the rising blood pressure. If the blood pressure becomes too high, a woman may have a seizure, also known as eclampsia and suffer a stroke that could be potentially fatal.
Headaches during pregnancy should never be ignored or assumed to be a migraine and requires an immediate blood pressure checks. Taking this precaution might inevitably save your life.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
March 30, 2011
I read an article in my local newspaper the other day that gave me reason to pause. The State of Florida intends to hand over 3 million Medicaid patients to managed care companies who will reduce payments to physicians and hospitals. In exchange for accepting these low payments for professional services, doctors are guaranteed through pending legislation that no matter what egregious errors they make, the patient will only receive a maximum of $250,000 in a medical malpractice lawsuit. This is definitely a “lose-lose” situation for patients.
Managed care is bad news for pregnant women. Extremely bad news. Every ultrasound, lab test and hospital admission that your physician or midwife orders on your behalf will have to be pre-approved by a gatekeeper who is on a mission to increase the profits of their company by reducing the amount of money that is spent on you. So you must therefore be on a mission to keep both you and your unborn baby out of harm’s way. How do you do that? Here are a few suggestions that are taken from The Smart Mothers Guide to a Better Pregnancy:
- Research your prospective healthcare provider through your State Board of Medicine’s licensing department to make certain they do not have any 7-figure malpractice suits settled or pending
- If you’ve had a previous high-risk pregnancy, request a referral to a Maternal Fetal Medicine high-risk specialist for your prenatal care
- If you delivered a preterm baby in the past, chances are likely you will do it again. Ask to have your cervix measured when you have an ultrasound and if it’s short , request a referral to a high-risk specialist
- If you have vaginal bleeding and are pregnant, do not leave a doctor’s office or an emergency room without someone doing an ultrasound to confirm that (a) the fetus is alive and (b) the pregnancy is not in the fallopian tubes (aka) ectopic pregnancy. An undiagnosed ectopic pregnancy could rupture and cause havoc.
- If you complain of a vaginal discharge, do not leave your healthcare provider until someone gives you a diagnosis and treatment. Untreated vaginal infections can lead to preterm labor. Bacteria is not your friend when you’re pregnant
- Back and lower abdominal pain should not be ignored, especially if you are less than 36 weeks. It could represent signs of premature labor
- Become familiar with fetal tracings. Flat lines and “u-shaped” curves during labor could mean your baby is in trouble and needs to be delivered quickly
- Try to deliver in a hospital that has a level 3 nursery and/or a NICU (neonatal intensive care unit)
- If a hospital mistreats you, contact its administrator. If you’re still not satisfied, file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) http://www.jointcommission.org/
- Trust your instincts. I can’t emphasize this enough.
Prevention is the key to reducing medical injury, not taking away someone’s right to sue.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do. Check out the video below for my information and pick up a copy of The Smart Mother’s Guide
February 28, 2011
I was greeted by those words during a patient’s recent post partum exam and was both gratified and humbled. A potential disaster was avoided and her pregnancy had a happy ending.
Katina* (name changed) had registered for prenatal care early so when her blood pressure was a little “different” at 32 weeks, the change was duly noted. She wasn’t complaining of a headache, her feet weren’t swollen but this was her first pregnancy which placed her at an increased risk of developing pre-eclampsia. A blood pressure of 120/82 would seem normal to most people but in Katina’s case it wasn’t. She was sent to the hospital and then discharged home with instructions to monitor her blood pressure daily and I asked her to return in one week for closer scrutiny.
Upon Katina’s return, her blood pressure was 140/90 so off she went to the hospital’s labor and delivery triage department for further evaluation. Upon her arrival, the blood pressure appeared to have improved. The resident physicians on duty made snide remarks, insinuating that she was referred inappropriately. As she was about to be discharged, the baby’s heartbeat dropped precipitously. Before Katina could blink, a team of physicians and nurses descended upon her with full force. They shoved papers in her face requesting a signature for an emergency c/section and informed her that it was possible she could die as well as her baby. Her blood pressure had escalated through the roof and her heart raced dramatically. She was quickly put to sleep, a ”stat” c. section was done, and her baby was born alive. For the next four days, the hospital staff had difficulty controlling her blood pressure and her heart continued to pound at rates above 150 beats per minute. It was one of the most harrowing experiences of her life however in the end, both mother and baby were discharged home and are now fine. Katina experienced what we in medicine call a “diagnostic save.” A life was saved because the proper diagnosis was made in a timely manner. How often does that happen? Not often enough. The Smart Mother’s Guide to a Better Pregnancy was written to improve those statistics. If you can “see it” then you can treat it. Pregnant moms must be empowered to help their healthcare providers “see” the problem before it spins out of control.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
February 21, 2011
Having a baby can be a beautiful thing until something goes wrong. The tragedy is that many high-risk conditions can be managed appropriately if the patient is cooperative and the healthcare provider is competent and well trained. Unfortunately, almost 600 pregnant women die in the U.S. each year from complications and the most common complication is significant blood loss after birth or Postpartum Hemorrhage (PPH).
PPH occurs when there is a blood loss of 500cc or greater for a vaginal delivery and 1000 cc after a Cesarean Section. Or, if you were admitted with a hemoglobin of 12 and it drops by ten points to 11, there should be a high index of suspicion for PPH as well. Therefore, if you feel lightheaded or dizzy, have palpitations or an increased heart rate after delivering a baby inform the hospital staff immediately. The most common cause of PPH is uterine atony or lack of contractions after the baby is delivered. Any pregnant condition that stretches the uterus significantly such as having twins or a higher gestation, excess amniotic fluid (aka polyhydramnios), a prolonged induction of labor (greater than 24-hours), increases the risk of PPH. Retained products of conception such as the placenta also places the patient at risk for developing PPH.
Other risk factors for PPH include:
- Women with a known placenta previa
- African American women
- Hypertension or pre-eclampsia
- Mothers with infants weighing greater than 8.8 pounds (or 4,000 grams)
- Mothers with greater than 7 children
- Women with a history of Hemophilia
If you have any of the risk factors listed above, please be pro-active and discuss the possibility of a PPH with your healthcare provider. Specifically, you want to know
- How many PPHs have they handled?
- Does the hospital do mock emergency drills (especially if your hospital is not a teaching hospital) as practice?
- Will your hospital have blood readily available upon your admission in labor?
- Will the proper labs be ordered at your time of admission? This is very important. Your blood type as well as your ability to clot blood (aka coagulation studies) should be ordered at the time of your admission, NOT when you’re bleeding to death. Most women die because their clotting factors could not be replaced fast enough.
Please do not be intimidated about having these discussions. They could very well save your life. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
Watch my new informational video regarding such topics!
October 20, 2010
There are many reasons why some women wait until the 11th hour to show up for prenatal care and all of them are equally frustrating. For teens, it’s fear and sometimes denial that they’re even pregnant. For women with several children, it becomes more complicated. They know that they need to see a professional but the distractions of life gets in the way. They postpone making an appointment because of work obligations, transportation issues, or lack of insurance and then use the emergency room as a back-up. By the time they seek professional services, their pregnancy is in trouble.
My long-standing patient was a perfect example. Her first prenatal visit was very late and by the second visit she developed complications. Of course, she had the worst insurance plan and finding a specialist that accepted it was a challenge.
As I began to discuss her complication, she burst into tears. She said she was scared; she had x-number of children; she didn’t have transportation; why can’t we take the baby now? What if, what if, what if? I had a waiting room filled with patients but I allowed her to vent, and then asked a simple question: Why didn’t she come to see us sooner? There was a moment of silence and then she rattled off a list of excuses. Gratefully, a specialist agreed to see her the following day. Why is it important to receive early prenatal care? Let me count the ways:
- The earlier you have an ultrasound; the more accurate your due date
- An accurate due date will allow proper scheduling of an induction of labor should you encounter a problem and reduce the chances of the baby being born too soon or too late because of wrong dates.
- The diagnosis of high risk problems such as Gestational Diabetes, Pre-eclampsia, placenta previa, anemia, poor fetal growth and a host of other issues can be detected BEFORE they spin out of control.
- Every pregnant woman, even those with “undocumented” citizenship are entitled to temporary Medicaid for 45 days based on your income and there are federally funded community health centers for those without insurance.
- No matter how many times a woman becomes pregnancy, each pregnancy is different.
Small changes can make big differences. Please begin your prenatal care early.
Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.
July 26, 2010
When you’re constantly fighting for people to do the right thing, something is terribly wrong. One of my best friends called the other day in a state of despondency. Her patients needed to have a C. Section and the anesthesiologist was acting like a jerk. The patient had two previous successful VBACs but this time had a placenta previa which meant the placenta was covering the opening to the womb . A vaginal delivery was impossible. The patient was 38 weeks and my friend instinctively felt that she needed to be delivered. Gratefully, she wasn’t bleeding.
The anesthesiologist refused to give the patient an epidural, citing her “high-risk” status and was also rude in the process. He felt the main hospital operating room was a more appropriate arena for the delivery as opposed to the labor and delivery suite. My friend had had problems with this physician before. He would play the “dumping” game using any excuse to postpone performing a case until the next shift took over. My friend was not about to play Russian-Roulette with the patient’s baby and refused to send her home. “What should I do?” she asked in frustration. “I’m trying not to lose my composure and I’m not in the mood to fight.”
My friend needed encouragement. I reminded her that she was a brilliant physician whose calling was to heal women and save babies. I suggested that she get the hospital’s administrator and ob-gyn chairman involved to deal with the anesthesiologist directly and document on the patient’s chart why she was unable to deliver the baby. Above all, she must trust her instincts.
The high-risk specialist agreed with my friend’s assessment and wrote a note on the chart as well. My friend shared her dilemma with the nurse-in-charge who then took control of the situation and forced the hand of the anesthesiologist.
The baby was ultimately delivered and had a low APGAR score at one minute although there was nothing on the fetal tracing to suggest why. Had my friend not intervened, the baby could have possibly died.
My friend scored a moral victory with this delivery. But what will happen the next time?
June 21, 2010
When you try to do the right thing in medicine, it’s a very lonely walk. I’ve been a physician for over two decades but have yet to develop immunity to hospital politics and corporate agendas. It still hurts beyond measure when my patients encounter discrimination simply because they have Medicaid.
Today’s economy has proven that no one is exempt from losing a job; a home; a spouse or their dignity. If the truth be told, we are all just one paycheck away from getting the dreaded pink slip. Medicaid insurance is the government’s safety net for the working poor and has traditionally been shunned by physicians but now hospitals are following suit.
I remember when the only cancer specialists in a small Louisiana town wouldn’t provide cancer patients with chemotherapy if they had Medicaid so the patients either sought care in another town or died from benign neglect. Perhaps it’s the memory of those cancer patients who were denied access to care that makes me fight so hard for my patients to be delivered at a quality hospital despite the hospital’s alleged resistance. In New York City, it’s a well-known fact that a renowned teaching hospital places Medicaid pregnant patients on separate floors but at least they accept them for obstetrical care.
Complicating my dilemma is another community hospital that has had quality care issues in the past and would “love” to have my patients because their patient census is shrinking. Most of the physicians in the community no longer deliver at their institution opting to take their patients to a new competitor hospital that recently opened its doors for business.
Although I have been involved in a recent arm-wrestling match with powers-that-be to “steer” my patients in a certain direction, I ultimately leave the decision up to the patients regarding their hospital of choice. If a hospital accepts Medicaid insurance, then they have to accept Medicaid patients.
The “heart” of medicine has flat-lined and is in dire need of CPR. STAT!
June 14, 2010
The greatest social changes usually begin at the grassroots and works its way up. Based on growing dissent regarding limited options for VBACS, a panel of the National Institute of Child Health Development (NICHD) met in March of this year to determine why VBACs were declining. Between 2006 and 2008, 20% of obstetricians stopped offering VBAC as an option. In 2006, the numbers were even higher at a rate of 26%. The NICHD panel concluded that a trial of labor is a reasonable option for many women with a prior cesarean delivery (see “Vaginal Birth After Cesarean: New Insights”). So, why all the fuss and resistance? Because there is a small risk of uterine rupture (less than 1%) and most hospitals require a physician to be in the hospital to manage a laboring VBAC patient. Dr. George Macones was interviewed in a recent ob-gyn newspaper and I’d like to share some of his observations and comments. Macones is a maternal fetal medicine specialist and the ob-gyn chair at Washington University in St. Louis.
According to Macones, there are no scientific models that can predict who will succeed and who will fail a trial of labor after cesarean section but he did offer these helpful insights:
- A VBAC candidate who has had a previous vaginal delivery has an 89% success rate for a VBAC and fewer complications as opposed to a woman who has never had a vaginal delivery. It is therefore not appropriate to ask women who’ve had successful vaginal deliveries to have repeat c. sections based on “hospital policy.”
- Women who have spontaneous labors have more successful VBACs than women who are induced in labor.
- Doses of oxytocin or Pitocin greater than 20 mu/min increase the risk of uterine rupture
- Intrauterine pressure catheters do NOT accurately predict uterine rupture and should not be used for that purpose.
- VBAC candidates who need more than one medication to induce labor are at an increased risk of uterine rupture
- If a VBAC candidate has an epidural and still feels significant pain or needs frequent doses of the epidural anesthetic, there is a significant risk that there might be a uterine rupture.
Performing repeat c. sections in women who have had previous vaginal deliveries is morally wrong. Patient safety should always take precedence over physician convenience.
June 2, 2010
Herpes Simplex Virus (HSV) is a family of viruses that has been around for so long, it was described in ancient Greek and Egyptian history. Herpes is usually contracted through close bodily contact and although there are six types that can affect humans, the most common infections of pregnant women are caused by Herpes 1 (HSV 1) and Herpes 2 (HSV2).
Herpes 1 is an infection that causes fever blisters located on or near the mouth. In the past it was less common than Herpes 2 but in recent years is now responsible for 30 to 50% of lesions found on or near the vaginal area. Herpes 2 is an infection that causes blister-type lesions in the genital area and is usually painful to touch. The first-time (or primary) infection is usually the worst and is associated with painful and burning urination, fluid-filled blisters in the genital area, fever and sometimes a headache. Any infection thereafter is called a recurrent infection which is usually milder and has fewer symptoms. Contrary to popular belief, most infections are spread from one person to another when there are NO lesions or what’s commonly called asymptomatic shedding.
A first-time infection is treated with a medicine called Acylovir taken three times a day for 7 to 14 days. If a pregnant woman has Herpes 2 and a fever, she has to be admitted to the hospital to decrease her chances of developing pneumonia. For pregnant patients with recurrent infection, it is recommended that they take acyclovir three times a day beginning at 36-weeks up until the time of birth. Valtrex medicine may also be taken twice per day if the patient can’t tolerate Acylovir.
If lesions are present during labor, a cesarean section MUST be done to avoid an infection of the newborn. One out of 3200 babies will be infected with Herpes that causes severe diseases of the eye, skin and mouth. 80% of babies will die of Herpes 1 and 2 if they are not treated.
Please inform your healthcare provider of any symptoms of active lesions or previous history of Herpes immediately to avoid preventable complications.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
Educate yourself by purchasing my latest book The Smart Mother’s Guide To A Better Pregnancy!
May 24, 2010
Pregnancy is certainly not the optimum time to have a surgical procedure however there are certain conditions when it is necessary. The most compelling reasons to have surgery while pregnant include acute appendicitis, gallstones that block the bile duct, torsion or twisting of an ovarian tumor and trauma to the abdomen that results in damage of an internal organ, bleeding or the threat of harm to the unborn fetus.
Appendicitis is sometimes difficult to diagnose during pregnancy however the location of pain is helpful regarding making the diagnosis. Patients with appendicitis sometimes have fever and abnormal lab results but this is not always the case. Although the appendix is usually on the lower right side of the abdomen during pregnancy is shifts towards the middle. Therefore, when attempting to make the diagnosis, a physician will examine the patient lying down and also tilted to her left side. If the pain shifts to the left side, the pain is probably from the uterus and not the appendix.
The safest time for a pregnant woman to have surgery is during the second trimester. An epidural or spinal anesthesia is safer than general anesthesia for many reasons. It is more difficult to place a breathing tube down a pregnant woman’s throat because hormone’s make the throat smaller. The patient also has an increased risk of aspirating or having food or liquid in her windpipe as opposed to her stomach.
There should always be an obstetrician and pediatrician consultant on hand prior to and during the surgical procedure, especially if the patient is in her third trimester. According to the latest medical literature, there are no anesthetic medications that cause birth defects to the unborn fetus, provided the surgery is not done during the first trimester. The heart tone of the fetus should always be monitored during surgery. Because a pregnant woman has an increased risk of developing blood clots, it is strongly advisable to wear “compression” stockings during a procedures. These stockings are available in the hospital and compress or squeeze the blood vessels in the legs to promote better circulation.
Following these suggestions will greatly improve your chances of having a surgical procedure that will not adversely affect your pregnancy. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.