September 17, 2012
You have been which might be considered fluid for the past two days. You call your provider, who advises you to go to the hospital for further evaluation. Upon your arrival at the hospital, the nurse does something called a nitrogen test. Nitrogen is a substance that turns blue when exposed to amniotic fluid, mucus or blood. Your nitrogen test proves negative. Should you be discharged home? Yes or No.
The answer is no, you should not be discharged home. You first need to have an ultrasound to make certain you have adequate fluid. You could have legitimately been leaking fluid for several days and now have no fluid. Without fluid, an infection called chorioamnionitis could easily develop. Or if your fluid is extremely low (also known as oligohydramnios), you might need to be delivered.
Did you learn something? Well here’s another quiz also taken from the book:
You have had a dull headache all day. For the past two weeks you have received nonstress tests because you complained of decreased fetal movement. You had a two-hour wait before a bed became available in the triage unit. The nurse takes your vital signs, and your blood pressure is 140/90. After twenty-five minutes, your nonstress test is reactive, the triage unit is becoming busy, and the nurse calls your physician with a report of your NST results but omits your blood pressure result and complaint of a headache. However, she does advise your physician that the labor is busy and they need your bed. Your physician’s midwife is on call and sends you home. Is this correct?
No. Although the nurse was correct to report a reactive nonstress test, she did not mention your elevated blood pressure or your complaint of a headache. In this clinical situation, other tests would be necessary to make certain that you are not developing pre-eclampsia.
In pregnancy, the unexpected things, if not managed properly could get you in trouble. Sadly, many healthcare providers do not discuss potential problems with patients until they are smack in the midst of a crisis.
Want to be prepared? Then order a copy of The Smart Mother’s Guide at www.smartmothersguide.com. Remember a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
April 2, 2012
The topic of vaginal birth after cesarean section (aka VBAC), is in the news again. According to OB-GYN News, a recent medical study has shed some light on the dreaded VBAC complication, uterine rupture. A uterine rupture is the opening of a previous uterine scar or incision that occurs while the uterus is contracting in labor. Although rare, occurring 1 in every 5,000 to 8,000 pregnancies, its results are life-threatening and can result in significant bleeding and shock. Traditionally, a uterine rupture was difficult to diagnose with signs and symptoms presenting only after a catastrophe such as fetal death or significant bleeding. However, there is new hope in sight.
According to Dr. Lori Harper of Washington University in St. Louis, slow progression of labor after reaching 7 centimeters in women who are attempting a trial of labor after c. section (TOLAC ) may signal signs of uterine rupture. Women who have never had children dilate 1.2 centimeters per hour while women who have had previous children progress at 1.5 centimeters per hour. If a woman with a previous c. section makes progress to 7 centimeter and then her labor pattern slows down, this is a cause for concern. Labor progress is determined by how quickly the cervix dilates each hour. According to Harper, once a patient has reached 7 centimeters and the cervix is taking 10 to 13 minutes longer than expected, there is a possibility that the uterine incision might be separating, especially for patients who are being induced with a medication called Pitocin. Harper emphasizes that slow progress before 7 centimeters during (TOLAC) does not necessarily suggest a uterine rupture, but slow progress after 7 centimeters does.
Harper suggests that patients should be examined every hour as opposed to two, if their labor slows down after reaching 7 centimeters. The adoption of this protocol might improve the safety of VBACs significantly; therefore if you’re pregnant and contemplating a VBAC, please consider discussing this with your healthcare provider.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
March 5, 2012
Today will be a day of mourning for pregnant women who are uninsured and receiving Medicaid in Houma, Louisiana. Their local hospital closed its maternity and neonatal units because of a $2.9 million dollar budget cut. Over 100 employees will lose their jobs, many whom have held their positions for over 20 years. This closing will have a ripple effect and is an increasing phenomenon that has besieged many hospitals across our nation. Over thirteen hospitals in Philadelphia closed their labor and delivery departments and in my own backyard, South Seminole Hospital in Florida did the same. What’s going on? Hospitals claim they’re losing money and government insured and non-insured pregnant women are feeling the aftermath. These are some very scary times.
The options for Houma’s uninsured pregnant women or women who receive Medicaid are quite limited. A few years ago, they could have gone to Lafayette Hospital in Lafayette; or Earl K. Long in Baton Rouge or Charity Hospital in New Orleans. Sadly, all of those hospitals have closed their labor and delivery department. I know those hospitals well, having worked and lived in Louisiana for almost four years as a community health physician.
Although Houma is a small, close-knit community, its hospital provided hundreds of prenatal visits for pregnant women in nearby parishes. They interacted like family. The nurses at Leonard J. Chabert Medical Center are devastated and apprehensive about the future of the pregnant women knowing that most cannot afford to go to private physicians and many have high risk problems. Consequently, many of these patients will be forced to travel over 300 miles on a 5-hour trip to Shreveport, Louisiana to receive prenatal care at its charity hospital.
I strongly encourage the State of Louisiana to brace itself for an increase in infant and perhaps even maternal deaths. Many high risk patients are simply not going to be able to make that 300-mile trek to Shreveport without adverse consequences. Any perceived benefit from that $2.5 million dollar budget cut will quickly dissipate based on the spike of NICU admissions that are sure to come.
The women and their unborn babies deserve better. Shame on the State of Louisiana.
February 22, 2012
To be forewarned is to be forearmed. That is the mantra that should be adopted by all potential patients who are engaged in our present healthcare system and especially pregnant women. Information is power and you can never have too much regarding your health. There is a trend for pregnant women to write a birth plan regarding their delivery but there should also be an action plan during the third trimester.
Listed below are questions taken from Harvard Medical School’s Family Health Guide. I strongly encourage you to become familiar with these questions because they could inevitably save your life or the life of your baby. Many of them address the warning signs of pre-eclampsia (swelling of the hands and face) and preterm labor (leaking fluid).
- Do you have adequate support at home from family or friends?
- How do you feel? Have you had any problems since your last visit?
- Have you had any vaginal bleeding or spotting?
- Have you had any pain or uterine cramping?
- Have you had any discharge or leakage of fluid from your vagina?
- Have you noticed swelling of your face or ankles?
- Have you had any problems with your vision?
- Are you getting frequent headaches?
- Have you noticed a change in the frequency or intensity of fetal movement?
- Are you planning to breast-feed or bottle-feed?
- Have you selected a pediatrician for your baby?
- Are you taking classes on labor and delivery?
- Have you made arrangements for your family’s health insurance to cover your baby when the baby is born?
- Have you purchased a special car seat to hold your baby when riding in your car?
- Have you decided on whether the baby will have a circumcision, if a boy?
- Have you talked with your doctor about the length of your stay in the hospital?
- Do you know the signs of going into labor so that you can call your doctor when labor begins? (These include uterine contractions and rupture of the membranes).
A good defense begins with a good offense. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
February 15, 2012
In 1952, Dr. Virginia Apgar, an anesthesiologist, developed a system to evaluate the baby’s response to its new external environment outside of the uterus and revolutionized newborn care. The Apgar score can determine whether the newborn will need more intensive care and is used world-wide. It evaluates the baby’s condition after the 1st and 5th minute of life by looking at it heart rate, respirations (or breathing), muscle tone, reflexes and skin color. Each of these five conditions is assigned a score of 0, 1 or 2. Ideally, the perfect baby is one that has a heart rate above 100 beats per minute, a good cry, active motion, coughing, sneezing or crying and completely pink. The ideal score is 10 after 5 minutes. If the five-minute score is less than 7, additional scores are obtained every five minutes for a total of 20 minutes. About 90 percent of newborns will have a score between 7 and 10 and need no further intervention. But what happens if the baby’s Apgar score is less than 7? Approximately 10 percent of newborns will require intervention and 1 percent will need serious intervention or help at birth.
An article in the August 2011 edition of The Journal of Obstetrics and Gynecology addressed the question of whether Apgar scores less than 7 have long-term effects on the baby’s future academic performance in school. It is well known that low Apgar scores increase the risk of neurological problems however very few studies evaluated children’s school performance at age sixteen until recently. A Swedish study reviewed over 800,000 with available Apgar scores and determined that babies with APGAR scores of less than 7 will have lower academic achievements at the age of 16. So, what’s a mother to do if she has a baby with an APGAR less than 7? Request a neurological examination of your newborn and look for future delays in speech patterns or walking. The earlier a problem is identified, the better the chances for improvement. According to the medical study, “Apgar score at birth is a powerful marker of neonatal health and effect on future academic achievements.”
Remember, a healthy baby doesn’t just happen. It takes a smart mother who knows what to do.
January 9, 2012
On a hot summer night in 1990, my chief resident (who was also my BFF) and I were on call at Harlem Hospital. We were informed that a “guest” was coming to interview us. Hot, sweaty and looking haggard rather than glamorous, we wanted to choke our director when Spike Lee walked through the door with film crew in tow. Lee was there to film the infamous movie, “Mo Better Blues.” We introduced him to our staff, he hung out with us all night and a patient allowed him to witness her delivery. Lee, dressed in paper scrubs, stared in awe as most people do when witness the miracle of birth. He graciously sent the patient a dozen roses the next day. I’m sure it’s not a coincidence that one of the main character’s in the movie was named Clarke, which just happened to be the name of one of our favorites nurses on duty that night. Denzel Washington was coming the next night but I was scheduled to go on vacation and someone else got the pleasure of meeting him. But here’s where the hypocrisy begins. When it came time to film the actual delivery for the movie, our residency director (who hadn’t delivered a baby in over 20 years) pulled rank and hijacked the part. To his credit, Spike Lee paid for the patient’s delivery.
On January 7, 2012, Lenox Hill Hospital in New York City, shut down its entire 4th floor, prohibited employees from using cell phones and security cameras were taped. “Ingrid Jackson,” aka Beyonce Knowles Carter was having a baby. All hands were on deck and the hospital functioned at its highest level of proficiency. Unfortunately, the same day that Blue Ivy Carter entered the world, 2 women died of maternal complications. Many more had abruptions, premature labor, shoulder dystocias and stillbirths. $1.3 million dollars bought quality care for Beyonce, something that should really be experienced by all.
While I’m ecstatic about the arrival of Blue Ivy Carter, especially since her father and I were once residents of the humble Marcy Projects; my prayer is that Lenox Hill Hospital will take their windfall profit of $1.3 million dollars and put it to good use. How about donating ultrasounds, maternal fetal consultations and (OMG), a couple of free deliveries for uninsured pregnant women? And I’m sure they won’t boot Beyonce out of the hospital one day after her C. Section.
The birth of Blue Ivy Carter, while joyful, is yet another glaring example of separate and unequal health care treatment. Congratulations Jay and B. As you bask in the glow of your daughter’s safe arrival, please take time to remember those who may not be as fortunate.
September 14, 2011
Every year there are approximately 4 million babies born in the U.S. and most will arrive in a hospital or a Birth Center. However, there are moments when this may not be the case. In the past 4 years the number of home births has increased by 20% and these births will hopefully be attended by a midwife or someone skilled in childbirth. But then, there are those unexpected births that no one was prepared for; the ones that occur at the most inopportune time and place, even on an airplane in flight. These are the ones that the mother never “saw” coming, although she might have experienced warning signs but didn’t take heed.
Most unexpected deliveries occur because of prematurity. What are the signs that a pregnant woman should not ignore?
- Low back pain that lasts for greater than an hour. This is typically how premature labor begins.
- Abdominal pressure that lasts for greater than an hour
- Leaking fluid from the vagina
- A sudden urge to have a bowel movement
Any of these signs requires an immediate trip to the labor and delivery suite as soon as possible.
If you are bleeding (especially passing clots), get off your feet and attempt to lie down on your left side while someone prepares to take you to the hospital. If the blood is bright red, this is a medical emergency because the placenta might be separating and the baby might be depleted of oxygen.
If your membranes rupture (water “breaks”) and there is a rope-like structure hanging from your vagina, it could be the baby’s umbilical cord. Call 911 immediately and do not allow the cord to be squeezed or manipulated. Lie down, preferably with your feet lifted on pillows with the cord undisturbed. This is ca cord prolapsed which means the baby’s in a breech position (feet first) and is an obstetrical emergency.
If you have a strong urge to have a bowel movement at home that is associated with contractions or abdominal pain, be aware that this could represent an impending delivery. Sit on a bed or floor with your knees separated to see if someone can visualize the head of the baby. If so, call 911 for guidance and further instructions. If the baby should be born unexpectedly, gently rub its back to stimulate crying and keep it warm in a blanket until the emergency technicians arrive.
Although you assume that your delivery will be “normal,” it never hurts to be prepared for the unexpected. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
July 27, 2011
No one likes pain, least of all pregnant women. Although obstetricians do a great job providing prenatal care and childbirth deliveries, there is always room for improvement regarding patient education.
The management of labor pain is usually delegated to the Anesthesia Department within a hospital or an ambulatory center. The goal of anesthesia is to eliminate physical pain and any suffering that might be a result of pain. However pain and suffering may not always be about cause and effect. To quote the literature, “Although pain and suffering often occur together, one may suffer without pain or have pain without suffering.” Some women want to eliminate pain and others view it as a normal process. However, to the well initiated, it is well known that women who are in pain and “suffering” do not progress as quickly in labor as those who are pain free. For those pregnant moms who would prefer not to have “drugs” here are some options however, please keep in mind that information regarding the safety and effectiveness of these methods is “scientifically” limited, meaning the subjects involved in medical studies to prove whether these methods work or not are small. Having said that, listed below are some of the most popular ways to reduce pain without drugs, however, please consult your physician or healthcare provider prior to using them.
1. Be in an environment that simulates home such as a birthing room. Although home deliveries are increasing, the American Congress of Obstetricians and Gynecologists does not support this method.
2. Continuous labor support such as a doula
3. Immerse in warm water to cover the abdomen and reduce labor pain
4. Sterile water injections in the lower back to decrease back pain
5. Walk around the hospital during the early 1st stage of labor provided your vital signs are stable
6. Touch and massage therapy
7. Acupuncture and Aromatherapy
9. Transcutaneous Electrical Nerve Stimulation (TENS)
10. Obtain childbirth education
Listing these options does not constitute a personal endorsement of any of the methods but is provided to increase a pregnant woman’s options regarding enhancing her birth experience and having a greater sense of control regarding the process.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
May 11, 2011
At one time, a hospital would be called a 24-hour institution but now it’s a business. Within this business are shift workers that include nurses, technicians, clerical staff and even hospital employed doctors who are now called hospitalists. In a teaching hospital resident physicians also work in shifts so the responsibility of patient care is always being transferred from one group of healthcare providers to another. Do they always communicate effectively? Regrettably, “no.”
Sign-outs, handoffs, shift changes, nurses’ report. These are the multiple names for the process where a departing provider is responsible for letting the arriving provider know what’s going on with the patient. According to statistics, 80% of medical mistakes occur during shift changes and 50 to 60% of them are preventable. Listed below is an excerpt from The Smart Mother’s Guide to a Better Pregnancy that teaches pregnant moms what things should be known during a shift change.
“While in labor, there will most likely be a change of shift and a transfer of information should occur. However, it is not always successful. Information is sometimes lost, incomplete, misunderstood or inaccurate. Your doula or a family member should make a list of all tests that have been ordered since your admission. He or she should also know your most recent vital signs, including your blood pressure and whether your baby’s fetal tracing was reassuring. Other important include:
- The length of time since your membranes ruptured: the longer your membranes have been ruptured, the greater your chances of developing an infection in the amniotic sac around the baby called Chorioamnionitis
- A positive group B strep that must be treated with antibiotics to prevent your baby from contracting the infection
- The length of time you have been receiving Pitocin. The status of your fetal tracing should be noted to make certain that the baby can tolerate the contractions caused by Pitocin.
- Any other significant clinical issue that might have been discussed that could adversely affect your labor
Before the end of a shift, your family member or doula might ask the departing nurse or provider to review his or her notes regarding your care and ask “Is this correct?” When the new shift takes over, your doula or family member would show them the notes and ask whether they received the same information that was verified by the previous shift.
The path to a successful delivery becomes much straighter when everyone marches in the same direction. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.