October 10, 2011
Dilemma: Hospital Says Leave When You Think You Should Stay
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.
*Name changed.
September 14, 2011
Help! The Baby’s Coming!
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
- Bleeding
- 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.
September 12, 2011
A Miracle at 43
There are some patients that keep you humbled. Barbara Tate was one of those patients. With a shopping list of chronic conditions a mile long, she was told she could never carry a baby because she had miscarried two during her early 20’s. She suffered the hammer blows of diabetes, high blood pressure, congestive heart failure and asthma. And it doesn’t stop there. Tate also had a history of two slipped disks, a cellulitis infection and a non-cancerous tumor on her adrenal gland. In fact she was scheduled to have surgery until she discovered she was pregnant at the age of 43. She was strongly encouraged to terminate the pregnancy because of her multiple medical conditions but she didn’t. Tate viewed her pregnancy as a miracle and for all intent purposes, it was. After age 37, there is a rapid decline in the ability to conceive although not impossible.
Her baby was born three months early and it appears that she was unaware of the classic signs of premature labor. On the day of her child’s birth, she had been complaining about back pain but attributed it her adrenal tumor. She rested and then got up to use the bathroom thinking that she had an “accident” when most likely it was probably a case of ruptured membranes (or her water “breaking.”) At that point, the baby’s feet were emerging and Tate called for help. Luckily, the baby delivered spontaneously and did not require assistance perhaps because it only weighed 2-pounds-7 ounces. By the time the Emergency Medical Support team arrived, the only thing left to do was cut the umbilical cord. Both mother and baby were whisked to the local hospital initially but then the baby was transferred to a regional hospital 79 miles away in critical condition. Tate was discharged home the next day and the baby’s condition has improved.
Tate’s case is yet another example of a near-miss pregnancy and delivery disaster and she would certainly have benefited from someone performing a
- measurement of her cervical length by ultrasound during the early second trimester to determine her risk factors for preterm labor
- a referral to a maternal fetal medicine specialist given her complex medical history
- a referral to a Healthy Start Program to obtain social service support
Tate’s car is not in the best condition so friends have volunteered to drive her 160-miles in order to visit her baby and donation jars for gas money has been left in strategic locations. Her determination is commendable. Although the baby had a stormy beginning, hopefully it will continue to thrive. Miracles do happen. Hopefully Tate’s story will inspire infertility patients to please, keep the faith.
June 1, 2011
What Every Pregnant Woman Needs to Know About Progesterone Gel
Of the 4 million babies born in the U.S. each year, approximately 12.3 percent of them will be premature and 3.56 percent will occur before 34 weeks. Premature birth is one of the leading causes of severe handicaps and has an annual cost of approximately $26 billion dollars. Although risk factors for preterm labor have been identified, there is still no cure. As stated in a previous blog post, when the cervix becomes weak (a condition called cervical insufficiency), the patient is at risk for second trimester miscarriages and preterm labor. Also, if a patient has a previous history of premature birth then she needs her cervix measured in a future pregnancy. If her cervix is short and measures between 16 mm and 25 mm before 23 weeks, she is at risk for premature labor and delivery. The recommended treatment for a short cervix is either progesterone suppositories or injections. A few months ago, there was profound controversy over an FDA approved injection that would cost approximately $1500.00 if purchased by the manufacturer, K-V Pharmaceuticals. Bending under political pressure, K-V reduced their price to $690.00.
The more options that are available for treatment of premature labor, the greater the chances are of achieving a full term baby. In the past two months, a new study has emerged which describes a progesterone gel that reduced birth rates before 33 weeks by 45 percent and improved newborn outcomes. This is a significant result. The earlier a preterm birth occurs, the greater the risk of having a baby who will subsequently have brain damage or physical handicaps. Therefore, the progesterone gel has great potential regarding reducing obstetrical complications. It will also provide patients with an option other than reliance on the progesterone injection. What are the differences between the progesterone injection and the gel? The injection is given once a week in the muscle but the gel has to be used daily. An injection has to be given, but the gel can be self-administered. The treatment should ideally begin at 16 weeks but no later than 21 weeks and must be continued until 37 weeks or delivery.
Any pregnant patient with a history of preterm labor should have seek early prenatal care and have their cervix measured via an ultrasound. If it is 25 mm or less, then the use of the progesterone gel might be a viable option in the near future.
Remember, a healthy pregnancy doesn’t just happen; it takes a smart mother who knows what to do.
September 7, 2009
National Infant Mortality Awareness Month
Did you know that nearly seven babies will die before their first birthday for every thousand who are born in the U.S. and the rate for African American, Hispanic and Native American women, are even higher? Premature births occurring before thirty-seven weeks and low-weight babies, weighing less than five pounds account for the highest number of deaths in the U.S.
In recognition of September as the National Infant Mortality Awareness Month, I’d like to share some SMART tips to pregnant women:
S = Seek prenatal care early. Problems in pregnancy cannot be fixed at the last minute. Tests for genetic problems can only be detected in the early first and second trimesters. A first trimester ultrasound is also the MOST accurate in terms of a due date.
M = Mention all high-risk factors such as family history of diabetes, high blood pressure or bleeding. Do not omit information such as smoking or “recreational” drugs. It will come back to haunt you.
A= Ask to have your cervix measured during your ultrasound if there is a previous history of premature contractions or delivery. A cervical length of 2.5 centimeters or less is a risk factor for preterm labor.
R= Research your hospital and prospective physician or midwife carefully. Is the physician or midwife skilled in managing high-risk conditions? Will they continue to see you even if you lose your insurance? Has the hospital had any recent outbreaks of antibiotic-resistant – infections in the newborn nursery? Is there 24-hour anesthesia?
T= Test for potential problems such as Gestational Diabetes, Sickle Cell Trait or sexually transmitted infections.
The U.S. is one of the most industrialized countries in the world, yet we rank below Cuba and Taiwan, with respect to our national infant mortality rate. The health of a nation is judged by its national infant mortality rate. We can do better. We must do better. The health of our future generation is depending on it.
April 1, 2009
Premature Deliveries: An Uphill Battle
Of the 4 million babies born each year in the United States, one out of eight will be premature. Minority women carry the greatest risk and are usually caught off guard. Premature babies face multiple challenges and many die within the first year of life. These challenges include cerebral palsy, physical and intellectual disabilities in addition to emotional family trauma. Each year $26 billion dollars are spent taking care of premature babies in neonatal intensive care units and is a public health crisis.
The good news is that there are new methods of diagnosis that can identify women who are at risk and prolong their pregnancy as much as possible. Ladies please take note: Having your cervix measured at 22 weeks can predict who will be at risk for having babies too soon. If your cervix measures 20 to 25 centimeters, treatment with progesterone is offered that has been shown to reduce the rate of premature deliveries that occur before 32 weeks. An awareness of having risk factors can empower you to seek proper treatment early and improve your chances of having a healthy baby.
Please report pressure, back pain or abdominal pain to your healthcare provider immediately. Pain or pressure that occurs four or more times in one hour could indicate premature labor and can be treated if diagnosed in a timely manner. Also get tests for sexually transmitted infections, especially if you have a vaginal discharge, and get treated for urinary tract infections). Bacteria are not your friend during pregnancy however antibiotic therapy is priceless if given in time.
Pregnancy is one of the most important milestones of your life. A healthy pregnancy doesn’t just happen; it takes a SMART mother who knows what to do.
