Pics of the new office for my good friend Erin in Texas and anyone else interested in looking!

Nurses Desk

Staff break room

4D ultrasound room

Flat screen TV for easy viewing in 4D room

Regular exam room

Blood draw, blood pressure, and weight room

Waiting room

Front Desk

Our new office!

Hey everybody! Our new office will be done this next week. Come visit us at 5285 S. 400 E. STE B. Washington Terrace. We are right behing New Image Day Spa, kiddie corner to Weber Credit Union as you are driving in on Adams Ave towards Ogden Regional.

Breast and Ovarian Cancer update...

We recently had a presentation from the breast cancer/ genetic screening doctor from University of Utah at one of our OB dept. meetings. I learned a few interesting things I'd like to share, especially because I never have posted on breast cancer or ovarian cancer.

First of all, there is a fairly new law called GINA I believe. It stands for Genetic Information non-discrimination act (I believe). This law prevents insurance companies from declining insurance to you based on known genetic mutations that have caused or may cause in the future cancers, etc. This is especially important for women with a significant family risk cancer for breast cancer. We are now encouraging you to get the BRCA genetic screening test so you are aware of how at risk you may be for breast cancer and ovarian cancer as well, if you are positive for this mutation. Although it may be psychologically stressful for you to know this information, it may also be useful for to get more thorough screening such as MRI yearly for breast cancer versus just mammography. Also, if you choose to undergo a mastectomy or oopherectomy (removal of ovaries), you may be able to prevent breast and/or ovarian cancer all together. I found it quite interesting that by removing ovaries alone, breast cancer risk is reduced as much as 68%! This is due to the decline in hormones...which has it's downfalls too, but is better than getting breast cancer:) If you undergo mastectomy, your risk is reduced by 90%. Of course this is not a desirable option for some, but it is certainly something to consider in women with a strong hereditary risk and a + BRCA test.

It is important to note that regardless of family history, everybody in the general population has an 8% risk of breast cancer and this is why we encourage mammograms yearly starting at age 40. We also encourage monthly self breast exam. This entails feeling the entire breast for lumps that feel hard, non-tender, and do not move easily. It is also important to look at the breast and note any changes in skin appearance, or uneven hanging of the breast, or the nipple pulling to one side. If you have any of these changes you should see your healthcare provider right away.
It is typical to note breast tenderness and even some lumpy, mobile tissue at times such as with your menstrual cycle, or with breast feeding. Some women have fibrocystic breast tissue that feels lumpy and may require ultrasound or biopsy to decipher benign from a malignant lump.

We also recommend yearly clinical breast exam in which your healthcare provider palpates your breasts for worrisome lumps or changes. It helps to have someone trained in recognizing normal changes and typical breast tissue from worrisome changes that necessitate further evaluation.

Well, good luck with your screening exams, and as always, come in and get examined and ask questions if you are concerned about your own risks!

VBAC-Are you a good candidate?

So I've had patients ask me about VBAC (vaginal birth after cesarean) and whether or not this is the best option for them. This is a one of those things that is very individual and may or may not be the right thing for you.

First of all, VBAC has risk whether you've had a vaginal delivery before or not. There is approximately 1-2% percent risk of uterine rupture (from the previous scar on the uterus) during labor and delivery. There is risk of hemorrhage and fetal death from this, as well as hysterectomy (removal of your uterus). If you choose to take this risk, it is necessary for an obstetrician to be immediately available during your labor in the event that emergency c/section and/or hysterectomy is necessary. Because of this, CNM's (in this area) do not do VBAC's. We can however see you for prenatal care and then if you are an appropriate candidate for VBAC and desire this, you can transfer to an OB willing to offer VBAC and go from there.

Secondly, are you someone that VBAC would be successful or more likely than not to be successful? If your reason for having a c/section with the first or 1 or 2 of your deliveries (no more than 2 or VBAC is not allowed due to risk) was because of a breech baby, placenta previa, non-reassurring heart tones in labor, severe pre-eclampsia or HELLP syndrome where you didn't get the chance to labor or some other reason besides failed trial of labor, then you may be a good candidate for VBAC. This is especially true if your cervix is softening, dilating, and effacing the last month of pregnancy.

If your reason for c/section was because you labored a long time ( like 24+ hours), and your cervix never dilated, or it dilated but the baby never dropped or you pushed for 2-3+ hours and the baby never descended into the pelvis enough to deliver or to place a vacuum or forceps to attempt vaginal delivery, you are NOT a great candidate for VBAC. This is a circumstance that is likely related to you having a small pelvis and trying for a vaginal delivery again will result in the same problem. Although this is not always true, (maybe your baby was larger last time or the head was not coming down straight, etc.) it tends to be more likely that you will need a c/section again anyway, and your better option is just to schedule the repeat cesarean.

The other thing you should be aware of with VBAC is that it is preferrable that you go into labor on your own, and have an epidural during labor (in case of emergency c/section). If you are dying to just be started and your cervix is not ready, you should probably be anticipating a repeat c/section.

Well, hope this helps with your understanding of VBAC. As usual, please ask if you have any other questions or concerns regarding this. I can't always remember every detail of every topic to put on this blog. This is just the general gist....

Preconception considerations....

In response to Pricillas question. The major component of preconception is making sure you have folic acid in your system. It is preferred that you are taking a multi-vitamin or prenatal vitamin with at least 400-1000 mcg of folic acid per day for 2-3 months prior to pregnancy. If you have a history of a baby with a neural tube defect you definately want to be getting the higher amount of folic acid the 1000 mcg dose. This is available as a rx as well.
Having a yearly exam is good too, but is probably less important than the folic acid. The yearly exam screens for cervical and breast cancer as well as evaluating weight, blood pressure, bad habits such as smoking and lack of exercise that may put your future pregnancy in a riskier category. It is always better to start pregnancy healthy with a normal weight and blood pressure if preferred and to have already stopped smoking. We can't stress the need to stop smoking enough.
Any doctor, nurse practitioner, nurse midwife, etc. is just fine to do a regular yearly exam and hopefully remind you of of the above listed considerations. Good luck!

Alcohol and Pregnancy

So to answer one of Meagans questions on the last post, let's talk about alcohol for a minute. Currently, the guidelines regarding alcohol in pregnancy are do not drink. Period. The reason is that we really do not know what amount of alcohol causes birth defects or developmental/behavioral problems later in childhood. Most of the literature suggests that hard alchohol consumption on a daily basis is the major contributing factor to fetal alcohol syndrome. However, it is difficult to do research on such a subject because no woman wants to drink regular amounts of heavy or lighter alcohol to find out later what the effects are. Further, many women probably deny or lie about any amounts they are consuming and thus would scew results. As for the question regarding wine... there are countries I've read about in Europe where pregnant women do drink 4-8 oz of wine with dinner at least a few times/week and do not have children with problems (that we know of). Thus, we believe that it likely would take heavier more regular consumption of alcohol to cause major problems. The problem is we just don't know the magic amount of alcohol that would be a problem or wouldn't be. I still believe wine is a little bit of a heavier alcohol...not like vodka or everclear, but not as low as beer. Most wine still contains 11-18% alcohol which may be enough to be problematic for a fetus especially if consumption is daily. I doubt occasional wine intake would contribute to many problems, but I can't say for sure. I think if you were going to drink something occasionally, I'd pick beer or a wine cooler because the alcohol amount is so much less. That being said, the real answer we no of for now, is no alcohol at all. That way, you don't have to wonder later if what you consumed contributed to some problem in your child should some issue arise.

Fish and Preterm Labor

Speaking of interesting articles by ACOG this month- they published one that showed increased intake of fish decreases risk of preterm birth in patients who have experienced preterm birth before. They found that 2-3 servings per week of fish particularly early in pregnancy had the greatest benefit, and that eating more than that did not show any extra benefit. However eating fish less than once a month for patients with increased preterm birth risk increased their risk of preterm birth again.

It is unknown if taking fish oil capsules has the same effect as eating fish. In this particular study, the patients who were given capsules started them at 16-21 weeks gestation and this did not decrease their risk for preterm delivery. Thus, it is either important to start them earlier in the first trimester or perhaps prior to pregnancy or to stick with fish as there may be some other dietary supplement in fish that decreases the risk of preterm labor/birth.

The study did not look at other socioeconomic factors, but as I tell all of my patients, 2 servings of fish/week is reasonable and may have added benefit of reducing preterm labor.
Happy fishing!

Back to the Home Birth Topic

So, recently in the May 2011 addition of the ACOG journal (American College of Obstetricians and Gynecologists) were two articles discussing the topic of planned home birth. I'd like to share some key points from their articles as things to consider with homebirth. However, it appears they have based their information off of only one study in the Netherlands and the rest of their research has to do with the physicians ethical practice of medicine and what they feel is in the best interest for patients.

They state that "planned home births were associated with a twofold increased risk of neonatal death." They further state that the cause of this may be largely in part due to distance from a hospital in the event of an emergency (many patients studied lived >20 minutes from hospitals). They also state that the majority of home deliveries there are not attended by Certified Midwives, but rather by lay midwives who lack experience and the skill to save a baby or mother if needed. They also stated percentages of complications were higher in first time pregnancies in women laboring at home versus those who had experienced other births.

The College does however, note the right of the patient to make an informed medical decision being fully aware of her risks to herself and to her baby. They also advise physicians not to participate in home birth, but to give care and advice during pregnancy despite where the patient decides to deliver and to be willing to provide emergency care in the hospital when needed if a patient participating in home birth necessitate emergency hospital care.

So here are my thoughts. I respect ACOG's present position and generally I try to follow their guidelines for care of my patients. However, I don't feel that they have enough research on other areas (like Sweden) where they have Certified Midwives providing home births in areas close to the hospital etc. I still believe there are places where home birth is safe and effective for LOW RISK women.

I've decided if any of you out there would like to try home birth, I may be willing to deliver you at home if you see me throughout pregnancy for your care, are extremely low risk and remain that way throughout pregnancy. You would also have to live within 15 minutes from the local hospitals that I have privileges at, be willing to sign arbitration and home birth consent forms and pay out of pocket for this service if your insurance does not cover home birth. Further, I will likely not exceed 2-3 home births/month as this may complicate things with my other patients, hospital deliveries, and office/clinic schedule. This is open as a trial period and I may stop if I feel it is putting you, your baby, or myself at too much risk.

I welcome all comments!

Breastfeeding

Sorry I'm such a slacker at blogging. I'd like to say I'll get better, but that might be lying.

I've been thinking about topics I may have missed, and I got to thinking about one of my favorite parts of motherhood....breastfeeding. This is one of those difficult postpartum tasks that many women unfortunately give up on due to struggles with latch, pumping, etc. I'd like to encourage my patients out there to not give up! As most of you know, breastfeeding has sooooo many benefits to the baby as well as for yourself. To start with, it provides your baby with the right amount fats, proteins, carbohydrates, and water for your baby's growth and hydration. Secondly, it provides your baby with antibodies you've made towards infections which supports your baby's immune system and prevents illness in your baby. It may also decrease the risk of SID (sudden infant death syndrome) in the first year of life. Third, it's FREE! What can motivate you more than saving money on formula? I don't know about you, but that was a huge motivator for me:)

Ok, now that we've covered some benefits for the baby, let's cover benefits for you. First off, as your baby breastfeeds as a newborn, the hormone oxytocin is released in your body and this release causes your uterus to cramp and go back to it's original size. This further decreases your bleeding and risk for postpartum hemorrhage- yeah! Second benefit to you is that breastfeeding decreases your risk for breast cancer and possibly other gynecologic cancers. It may also help you lose weight faster and get back to your pre-pregnancy weight.

So why do people stop breastfeeding? The major reason I see is difficulty with latch or breast infections. One way to help encourage breastfeeding is education. I encourage my patients to take breastfeeding classes prior to delivery to learn about positioning, latch, pumping and storing milk (if you have to go back to work or be away from your baby), and signs and symptoms of infection. Fortunately, breast infections are usually easy to treat with antibiotics or creams, and if you stick it out, the infection will cure and you continue breastfeeding. Please feel free to call if you think you have an infection or need help with this. There is also Le Leche League and lactation consultants available through the hospital to help you as well. Do not give up!

Lastly, there are a few conditions when a woman should not breastfeed. If you have HIV, herpes lesions on your breast, or tuberculosis you should not breastfeed. However, most other illnesses including respiratory viruses, flu, stomach viruses, and other bacterial infections (including mastitis) are still safe to breastfeed. Many medications are also safe with breastfeeding, but check with your provider or pediatrician if you are unsure what medications are safe.

One last note- make sure you are eating plenty of healthy calories with breastfeeding. You must consume approximately 500-800 calories more per day to make milk and you must drink plenty of water- at least 8-10 glasses per day, if not more. If you begin exercising, you may also need to increase your calories beyond the 800 calories to continue to make milk. If you think your milk supply is drying up, it may be that you are not consuming or drinking enough fluids. It actually takes more calories to make milk than it does to grow a baby in pregnancy- so don't skip meals trying to lose weight. The pregnancy weight will gradually come off with time.

Good Luck!