March 15, 2010
A blue-ribbon panel of physicians, midwives and other healthcare providers convened at the National Institute of Health to discuss the dilemma of vaginal birth after cesarean (VBAC). At the end of the three-day-conference, they issued a statement that read: “Given the available evidence, TOL (trial of labor) is a reasonable option for many pregnant women with a prior low transverse uterine incision.” Most obstetricians know that, however convincing the hospitals is another matter.
The vacillation of VBAC policies makes me dizzy. In the late eighties and early nineties there was a tremendous effort to promote VBACs and dispel the myth of “once a cesarean section, always a cesarean section.” I recall the days of my residency training when we would call hospitals in foreign countries in an attempt to document a uterine incision of a pregnant patient who had one previous cesarean section and had presented to our hospital in labor. To section or not to section, was the issue at hand. If a woman had a vertical uterine incision, then she must have a repeat cesarean section to avoid the possibility of rupturing the uterus. However, is she had a low transverse or horizontal incision, than ideally, she was a VBAC candidate, barring any other issues such as more than two cesarean sections, fibroid surgery (aka myomectomy) and other uterine procedures that are too complicated to mention.
I blissfully remember taking care of a patient with two previous c. sections who presented in labor at 8 centimeters. She ultimately had a successful VBAC and I was greatly relieved. I dreaded doing repeat c. sections. Fighting layers of scar tissue (adhesions) from previous surgery is not a pretty sight when you’re attempting to reach the uterus and deliver a healthy baby.
Today, most hospitals will not allow VBACs unless the physician remains in the hospital during the patient’s entire course of labor. Since most physicians refuse to do so, a patient is forced to have a repeat c. section. When you deny a woman’s freedom of choice, please be prepared for the consequences. VBAC activism is on the rise and I hope it continues to spread.
March 3, 2010
Asthma occurs when the air in the lungs are reversibly blocked because of infections, allergies, cigarette smoke, pets, cold weather and severe exercise. Its symptoms include coughing, wheezing and shortness of breath that becomes worse at night. Poorly controlled asthma can cause severe complications for both mother and unborn child and it is now recommended that all pregnant women with asthma have peak flow studies.
A peak flow meter is a small, hand-held device used to monitor a person’s ability to breathe out air. It measures the airflow through the lungs and the degree of obstruction or blockage in the airways. Peak flow readings are higher when patients are well and lower when the airways are narrowed. The meter is also color coded: Green means everything is okay. Yellow means “caution” or some of the airway is blocked and medication is required. Red indicates a medical emergency dictating immediate medication and a phone call to a physician. Readings in the yellow and red zone have been associated with prenatal complications such as preterm labor and babies weighing less than five pounds.
Pregnant women should avoid asthma triggers such as mold, dust, rodents, pollens and cigarette smoke. Certain pets might have to be avoided as well. If symptoms of asthma become worse during pregnancy, medications might have to be changed or adjusted and a consultation from a high-risk obstetrician and/or an asthma specialist is recommended. Do not increase the frequency of your medication without the supervision of a physician as some asthma medication can cause complications, including irregular heartbeats and uncontrolled diabetes if taken improperly. It is also not recommended that pregnant patients take over-the-counter antihistamines such as Loratadine or Cetirizine before 12-weeks because of its increased association with birth defects.
Pregnant women with well-controlled asthma should anticipate a favorable outcome. When mom can breathe, the baby can breathe as well. What a wonderful sigh of relief.
February 22, 2010
Patients do not come in neat little packages with straight forward pregnancies nor are their complications obvious. Some pregnancies are complicated not only by health issues but social issues as well. Take Karen* for example. She was considered mentally “slow”. Her parents gave her up at the age of eight and she subsequently grew up in group homes.
Karen had an innocence that made everyone want to protect her and I was at the top of the list. She had a friend name Shirley* who was also pregnant and they eventually became roommates. I was not Shirley’s physician, but I wish I had been. Both Karen and Shirley made plans for the birth of their babies and assumed they would grow up together.
Two weeks before Shirley’s due date, she began bleeding bright red blood but was hesitant to go to the hospital. When she finally arrived, her baby was dead from a premature separation of the placenta; a condition known as placental abruption. Shirley most likely had pre-eclampsia, a disease that sometimes goes unrecognized.
The day before Karen’s due date, her blood pressure became elevated, there was protein in her urine and her feet were swollen. I referred her to the hospital with a diagnosis of pre-eclampsia. Karen brought home a healthy baby. Shirley left the hospital with empty arms.
Here are three important things every pregnant mom needs to know about pre-eclampsia:
- If you are over 20 weeks pregnant and your feet are swollen someone needs to check your blood pressure
- If your blood pressure is “normal” but you have protein in the urine, the urine needs to be sent for a 24-hour specimen AND you need to be given the results
- If there is more than 300 gram of protein in the urine, you may have pre-eclampsia and a decision needs to be made whether your baby should be delivered
Sometimes the diagnosis of pre-eclampsia is missed because a patient doesn’t have the usual presentation of extremely high blood pressure. Karen was Caucasian; Shirley was African American. Both had the same illness that ended with very different outcomes.
If Shirley ever becomes pregnant again, I’d be honored to be her physician. Every pregnancy deserves to have a happy ending.
*Names have been changed
January 25, 2010
Former U.S. Senator John Edwards’ admission of paternity regarding a child not conceived by his wife brings to mind Ruth Padawer’s New York Times Magazine article, Who Knew I was NOT the Father, published a few months back. Padawer described the dilemma of Mike L. whose DNA proved he was not the biological father of a girl that he had raised from birth. Mike was extremely conflicted because he still loved his daughter deeply. However, upon learning that his former wife was about to marry the alleged biological father of their child, he asked the courts to relinquish his child support payments. Surprisingly, they refused. Mike continues to pay child support to his former wife and his daughter’s biological dad and he is not happy.
DNA tests have proven that 40% of children are born outside of marriage and the number of paternity tests has increased by 60% in the past decade. With a swab from the cheek, life can change dramatically. Most states require an unmarried couple to complete an Acknowledgement of Paternity (AOP) before the baby’s birth certificate is signed. However, there is a growing movement to have mandatory paternity tests done, even for married couples.
Life is indeed, messy. Most state-appointed judges will NOT let non-biological fathers to stop paying child support in the “best interest of the child.” According to the courts, if a man acknowledges paternity and a bond has been established with the child, it would be disruptive for that relationship to disappear. It is now recommended that a presumed father, biological mother or biological father challenge paternity before the child turns 2. This would allow for any discrepancies to be resolved before deep parental bonds have formed. However, there are men who dispute this proposal stating a man may not discover he is not the child’s biological father until years later.
As an obstetrician, I have witnessed the heart break on both sides of the fence. Sex is not a benign act. It can and DOES bring forth creation. It is therefore prudent that everyone act responsibly and HONESTLY. Children shouldn’t suffer because of misguided adults.
December 28, 2009
“A newborn baby abandoned in a Kenyan forest was saved by a stray dog who apparently carried her across a busy road and through a barbed wire fence to a shed where the infant was discovered nestled with a litter of puppies.” CBS News covered this story as well.
This baby girl was dressed in a torn shirt and wrapped in a plastic bag when the dog found her in a poor neighborhood near a forest in Nairobi. She was approximately two days old. “When the dog picked up the baby in a dirty bag, it came and dropped her behind the wooden building where the dog has its puppies,” stated an eyewitness. The baby was found by children who had heard her cry and was eventually taken to the hospital where, with the exception of an infected umbilical cord, was doing well. This story gave me reason to pause. Obviously, the act of abandonment was superseded by the will of a higher power who proclaimed that this baby would live. What amazed me the most was the compassion and bravery of the dog. It had risked its own life by crossing a busy street while holding on to the baby, faced physical harm as it crawled underneath a barbed wired fence and shared its resources by placing the baby alongside its own litter of puppies. Perhaps the dog understood how miraculous this newborn baby was even if its own mother didn’t.
In a world of infinite possibilities, miracles can occur under the most unusual circumstances. And yes, we can gain profound insight, even from a dog.
This excerpt is taken from The Smart Mother’s Guide® to a Better Pregnancy. All Rights Reserved.
July 23, 2009
I’ve loved writing for as long as I can remember thanks to my late Aunt Dot, who instilled this passion at an early age. She would proudly tell her friends that I had been reading the New York Times since the age of 8. While I don’t know how true that is, I do have an intimate relationship with the written word and know that it is mightier and stronger than man-made weapons.
For the past five years, I’ve tried to put words on paper that would empower pregnant women to take control of their pregnancies and thus my book, The Smart Mother’s Guide to a Better Pregnancy Was Born. The landscape of healthcare as changed dramatically since I stepped out of residency training. Physicians no longer control the healthcare profession.
Right now, we’re in the midst of a pitched battle to reclaim our profession but in the meantime, four million babies will be born each year in the U.S. Those babies and their moms must be protected. Please read my interview with Carol Borthwick of the Qean Group below to find out how.
May 9, 2009
In celebration of Mother’s Day, I’d like to share a few pearls from my book, The Smart Mother’s Guide® to a Better Pregnancy. Those who orbit my universe know how impassioned I am about babies. Crazy would probably be a better term. I cringe when a newborn is admitted to the NICU because someone wasn’t paying attention.
The path to a successful delivery becomes much straighter when everyone marches in the same direction. Knowing how to sidestep some of the imperfections of our hospital systems will greatly improve your chances of having a successful delivery.
Please take my Smart Mother’s Guide Quiz© and see how you do:
You are thirty-five weeks pregnant and were admitted to the hospital by your physician for suspected pre-eclampsia or high blood pressure. You were also evaluated by the maternal-fetal medicine specialist, who recommends inducing your labor in the morning after he has obtained your lab results. The next morning your physician’s partner is on call. He examines you and states that he is going to discharge you home because your blood pressure has improved. Is the physician correct?
The maternal-fetal medicine specialist had ordered lab tests and had recommended an induction of labor. You should request that the on-call physician discuss your case with the maternal-fetal medicine specialist before discharging you since there is a difference of opinion regarding your care. The specialist wanted to induce you for a reason. Sending you home would place both you and your baby in harm’s way.
For more helpful tips regarding pregnancy and delivery, please pick up a copy of the Smart Mother’s Guide® to a Better Pregnancy available at all book stores and Amazon.com.
A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.