July 18, 2012
In Native American culture there is a premise that Nature thrives on order but it is man who creates the disorder. That thought came to mind last month when I presented yet another malpractice case for review with a panel of colleagues. A patient wanted to be induced at 39 weeks and inevitably had significant complications with a poor birth outcome. In my expert opinion, I suggested that the physician should have waited until the patient was 41 weeks before she attempted an induction and one of my colleagues thought that I was vehemently wrong. “She was full-term and entitled to an induction” he practically shouted in my ear. “That’s not the point,” I countered. There was no reason to do the induction except for physician and maternal convenience. I reminded him that most high-risks specialists will start fetal monitoring and nonstress tests (NSTs) at 40 weeks to document fetal well being and then induce labor at 41 weeks if it has not started spontaneously.
At 39 weeks, the cervix is usually thick which means it has to be softened with medication before Pitocin (the medicine that starts contractions) can be given. Anytime an induction goes beyond 48 hours, there is a strong possibility that it will end in a C-section. At 41 weeks, the cervix is usually soft and if an induction must be started, it has a much greater success rate for a vaginal delivery.
Very few physicians will allow a patient to deliver beyond 42 weeks because the baby gets too big and the placenta becomes old. An “old” placenta, aka “grade 3” means the baby could possibly receive inadequate oxygen and inevitably there will be meconium which is an internal bowel movement that sometimes indicates fetal distress.
According to the Bloomberg News, “Aetna has renegotiated maternity payments with 10 hospitals around the country so far, bringing rates for cesareans and vaginal births closer together.” This will inevitably decrease my colleagues’ checking accounts but please do not look for sympathy from me. The standards of medical care were written for a reason. Performing inductions of labor for the sake of “convenience” is certainly not one of them.
January 4, 2012
For years I struggled to define what I was doing as a physician regarding patient care. I finally figured it out. I was attempting to improve birth outcomes. An outcome is another way of saying end result and for most pregnant women the desired result is a healthy baby. There is an erroneous assumption that all pregnant women will have healthy babies. Unfortunately, this is not always true. Out of the 4 million babies born each year, according to the National Center for Health Statistics, 1.3 million babies require special care after they’re born. About 6 percent of newborns or 200,000 babies per year require life-saving intensive care that could have occurred before, during or after their births. What happens at the time of birth potentially depends on how much homework (aka due diligence) was done prior to going to the first prenatal appointment.
My goal for 2012 is to encourage women to become significantly more proactive regarding their healthcare, especially if they’re pregnant. Background checks of hospitals, clinics and healthcare providers should be done on a routine basis prior to making an initial appointment. Obstetrics is a specialty of the unexpected. A “normal” pregnancy could become “abnormal” in a matter of minutes in the labor room. Unwanted conditions such as diabetes, high blood pressure and premature labor rear their ugly heads. Can your healthcare provider handle these problems appropriately?
The untimely death of Hip Hop artist “Heavy D” aka Dwight Arrington Myers is a teachable moment in prevention. An autopsy confirmed that Myers had died from a blood clot to his lungs, also known as a pulmonary embolism. Myers had a previous history of obesity and heart problems. He was returning from England which is an extremely long flight. Sitting for greater than 2 hours increases the risk of developing blood clots in the legs. I wonder if anyone had advised him to stand every 2 hours for 15 minutes as a precaution. This advice also applies to pregnant women.
The story of Flight 1549, aka the “Miracle on the Hudson” is inspiring. The pilot, Captain Skully Sullenberger miraculously landed a plane in the Hudson River after the plane’s engine had been compromised by low-flying birds. His skill and proficiency saved 150 lives. Can your healthcare provider and hospital handle the unexpected? I certainly hope so.
The Smart Mother’s Guide to a Better Pregnancy was written to help pregnant women improve birth outcomes. There will also be future webinars to assist as well.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
October 10, 2011
The story of Tanya* is compelling. She was 24 weeks pregnant with her third child and the hospital was threatening to send her home. Two years ago, she faced similar circumstances and delivered a baby at 23 weeks. Luckily, the baby is now two years old but the one before that was not so lucky. Tanya presented to a local hospital during her first pregnancy because of complaints of abdominal pain. She was sent home because her contractions “weren’t regular.” Ten hours later, Tanya returned to the hospital because of a “nagging feeling that something was wrong” although her contractions were still not regular. Unfortunately, her cervix was dilated and the contractions could not be stopped. Her son was born alive but died one hour later because the hospital was not equipped to deal with premature newborns. Tanya’s second pregnancy was similar to her first because she developed premature contractions again, at 23 weeks. As with the first pregnancy, her contractions were not strong and regular so she was discharged home from the hospital with a monitor that was supposed to help. It didn’t. Luckily, she had an appointment with her high risk physician the next day who informed her that she was dilated although she did not have regular contractions. Her preterm labor could not be stopped but this time, her baby did not die.
Tanya contacted her Bedrest Coach, DarlineTurner-Lee, owner of Mamas On Bedrest that provides support to high risk pregnant moms and Lee contacted me. She asked for advice regarding Tanya who was 24 weeks and about to be inappropriately discharged home from a specialized teaching hospital. I offered strategies on Tanya’s behalf but there weren’t necessary. One of the physicians at the hospital convinced the staff to allow Tanya to remain in the hospital until 28 weeks. There are lessons to be learned from her case
- Trust your instincts. Tanya was correct in not wanting to be discharged home because of her previous history. Women who delivery preterm babies (especially at 23 weeks) are bound to do it again. The chances of survival are far greater at 28 weeks than at 24 weeks
- She obtained an advocate and sought a second opinion. 2 heads are always better than 1 especially when there is doubt about a diagnosis or treatment
- If you have a high risk problem, always attempt to be admitted to a Level 3 hospital where they have specialized care for newborns
Tanya expressed her gratitude by saying “. . . I thank God for people like you and the staff who fight for our little miracles.”
1 out of 8 pregnant women will deliver a premature baby in the US each year. Hopefully, this time, Tanya will not be one of them.
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.
March 16, 2011
To everything there is a season and mine comes to an end today. For 760 weeks I attempted to give quality care to my patients. The task was not always easy especially when most of my patients held the unenviable position of having a high risk pregnancy and receiving Medicaid or being uninsured. Babies have a right to be born healthy regardless of their mothers’ income or insurance status.
The memories of my tenure at the county health department are indelible. I remember the woman who paid to be taken across the border only to be abandoned and walked from San Salvador to Texas. And the obese patient who rode a bicycle to the clinic with a blood pressure of 221/110. Of course she refused to go to the hospital because she alleged that they treated her “like dirt.” I begged, pleaded, and personally drove up the street to fill her blood pressure medication prescription to avoid her having a stroke or seizure in my exam room. My nurse found an ambulance company that was willing to take her to the high risk specialty hospital where she delivered prematurely in order to save her life and that of her baby’s.
And then there was dear Priscilla* (name changed) who had a bipolar breakdown and was about to be inappropriately discharged from the labor room triage until I advocated from my home around midnight and found her a hospital bed in my county where she was appropriately admitted, treated and subsequently delivered. There was also Katy* (name changed) who was sent home inappropriately with low fluid and subsequently went “on vacation.” I tracked her down in another state, told her to go to the nearest hospital where she was emergently admitted and delivered via c/s. My advocacy, diagnostic saves and battles with hospital clerks (who practice medicine without a license) continued for almost 15 years. It was difficult, stressful and at times frustrating, especially when the administration’s emphasis was on patient volume and money as opposed to quality patient care.
As this chapter of my life closes, I’d like to think that I’ve made a small but unique difference in the lives of others. I will indeed miss my patients, but I will not miss the stress. Service is the price we pay for being here. I hope I have served humanity well.
March 7, 2011
My profession has been “outed” by the New York Times’ articleTalk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy, by Gardiner Harris and I am breathing a sigh of relief. It’s about time the public knew the repugnant truth.
Harris describes how psychiatrists no longer perform talk therapy because of changes in how much insurance companies will pay. So they now prescribe and adjust medications leaving the personal crisis of patients “unexplored and unresolved” and relegate talk therapy to a lower priced therapist such as a social worker or a psychologist. The article centers around Dr. Donald Levin, a psychiatrist who has relinquished his professional protocols in order to accommodate the insurance industry. Levin can no longer remember his patients’ names and by his own admission, “trains himself not to get too interested in their problems. He does not want to get sidetracked trying to be a semi-therapist.”
According to the article, recent studies suggest that talk therapy is as good as or even better than drugs in the treatment of depression but less than half of the patients receive talk therapy. Levin earns $150 for three 15-minute medication visits as compared with $90 for a 45-minute talk therapy session. Levin, like many physicians had his wife, a former therapist, take over the role of his business manager and her comments were all too familiar and sad. Harris writes “Ms. Levin firmly asks for a co-payment which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars.” Ms. Levin states “This is about volume and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do that.”
Levin states his office is like a bus station; that the “quality of care he offers was poorer than when he was younger; and how he makes a diagnosis within a 45-minute visit because he “plays the game” in order to get paid. Although Dr. Levin’s specialty is psychiatry, the phenomenon that he described applies to ALL specialties, including obstetrics. The doctor-patient relationship is dead and nothing short of a miracle will resurrect it back to life. In my next post, I’m going to share some personal experiences and make an announcement. Until then, remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
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.
August 11, 2010
According to Dr. Holcomb, approximately 1 in 1500 pregnancies is affected by cancer. However as women delay childbearing to ages 30 and 40, there is an increased incidence because the peak age of cancer occurs at age 40. Cervical cancer is the most common cancer found during pregnancy and usually presents as vaginal bleeding. A Pap smear done during the first prenatal visit will reveal the diagnosis. A colposcopy procedure done during pregnancy is extremely important to detect invasive disease which would then require aggressive treatment. In my own clinical practice, I had a patient who had a low grade abnormal PAP during a previous pregnancy but unfortunately the disease has now progressed to a high-grade Pap smear three years later with her current pregnancy. She is being watched very closely with repeated colposcopy procedures and has been encouraged to stop smoking which is a risk factor for cervical cancer.
If microinvasive cervical cancer is detected, the pregnancy may continue to term and a c. section is only necessary for obstetrical reasons. A post-partum hysterectomy is not necessary if the patient desires to have more children. If invasive cervical cancer is detected before 24-weeks, radiation therapy will cause a miscarriage 35 days after treatment in the first trimester and 45 days after treatment in the second trimester. If invasive cervical cancer is detected after 24-weeks, delivery is done by a cesarean section at term, and the patient then receives radiation therapy. The lower the stage of cervical cancer detected during pregnancy, the higher the survival rate. PAP smears save lives.
Breast cancer is the second most common malignancy detected during pregnancy and affects 1 in 3,000 women. Twenty percent of women will have breast cancer before age 35 and 1-2 percent are pregnant at the time of diagnosis. The later the diagnosis, the worse the prognosis. A modified radical mastectomy is well tolerated during pregnancy. If the patient has a lumpectomy, therapeutic abortions do not improve the prognosis. Chemotherapy is used in advanced cases after the first trimester. If future children are desired, a 2-3 year waiting period is recommended. Actress Christine Applegate is an example of a breast cancer survivor who is now pregnant with her first child.
Melanoma is the third most common cancer diagnosed during pregnancy and ovarian cancer is the fourth. Ovarian cancer presents more danger to the mother than the fetus. An ovarian cyst greater than 5 centimeters detected during pregnancy requires surgery to rule out cancer, preferably done at 18 weeks. Most ovarian cancers found during pregnancy are stage 1 which has a good prognosis.
Although rare, cancer can occur during pregnancy. Early detection can save lives. A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
June 23, 2010
A recent Dutch study (see Birth Complications More Common at Night) of over 700,000 births revealed that newborn deaths and complications occurred more often at night which came as no surprise. In a make-believe- world, everyone would have a baby before the end of the day-shift in a fully-staffed hospital manned by people who are alert. But reality is a different story. Obstetrics is a specialty of the unexpected and women can spontaneously develop labor at the most inconvenient times within a 24-hour day. Yet, all is not lost. With proper recognition of potential red flags, a pregnant woman may have a wonderful delivery even if it’s at the most wretched hour of the night or early morning. Based on my years of clinical experience and medical malpractice case reviews, here are some tips worth remembering:
- Try to be admitted to a hospital where they have 24-hour anesthesia service to avoid waiting for them to arrive from home. If there’s an emergency, an “in-house” anesthesia department will save precious time.
- Try to deliver in a level 3 hospital has neonatology specialists in the event that you baby requires immediate specialized care after birth.
- Make sure your information is updated properly during the change of shifts. If your fetal tracing has been lousy during the past hour or your blood pressure has been elevated, the incoming staff should be made aware.
- Do not hesitate to ask about the whereabouts of the doctor or midwife if they are not in the hospital. By law, the admitting physician or midwife should be documenting your care by writing notes on a chart. Your physician or midwife has the ultimate responsibility for your care; not the nurse. If you’re in a teaching hospital and being managed by resident physicians, always ask to meet their supervisor, the attending physician.
- Ask whether you’re making progress in labor. If you’ve been the same number of centimeters for greater than two hours, there might be a problem with your labor.
Being in labor at night should no longer be a grave concern. When you are empowered with the proper information, the chances of encountering birth complications will be greatly reduced.
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!