Fetal Heart Monitoring ( Why do we do it? What does it tell us?)

Hello again! I've once again been a huge slacker at writing, but will try to be better:) I recently had a case (a few months ago) of a patient who was very self educated so to speak in the ways of childbirth. She had her typical birth plan and desire to go "natural." Now, first off, let me say, I fully support natural and birth plans, and such to the extent that they are safe, and that if I detect something may not be going well with your baby from monitoring and such that my patients are going to trust me and my formal education and experience to know when more monitoring or intervention is necessary.


However, in this scenario, many natural patients desire intermittent monitoring which is acceptable when the baby has a reactive initial non-stress test for 30 minutes of monitoring and is not having decelerations in the heart rate during or after contractions. If neither of the those criteria are met, further continuous monitoring is necessary.


I would like to state the reason why this issue has become complicated for some "natural" patients. Since the 1970's, when continuous fetal monitoring came to be the standard of care, there has been no decline in the rate of cerebral palsy cases in newborns. There has also been a rise in cesarean deliveries, likely because we panic too much over certain types of decelerations in the heart beat and rush to c/section too soon. Thus, increasing cesarean rates. The cerebral palsy rate situation is complicated. We know preterm birth causes many of the these cases, and since the 1970's we have gotten more aggressive at saving more and more babies at earlier gestational ages, even as early as 23 weeks, which obviously holds risk for  CP (cerebral palsy). Cerebral palsy, we know is caused from lack of oxygen at some point to an area of the brain. This could even occur in utero prior to birth and have nothing to do with preterm birth or even anything going wrong during the delivery. These are the confusing cases. So, with that knowledge, ACOG (American Congress of Obstetrician's and Gynecologists) has said, that it is appropriate to do intermittent monitoring in labor on low risk appropriate women and that not all decelerations in the fetus warrant urgent delivery. So.... for a non expert who sees their baby have a decel or two and not know how to accurately evaluate the whole picture, they may think, well, ACOG says I'm fine, my baby is moving, send me home and do nothing more.  How many of you feel good about that if that was your baby??


The problem with this logic is that it depends on the gestational age of the baby, the type of decels, if there are contractions, bleeding, etc.  If the patient was only 25 weeks along and the decels were just occasional variable type, meaning the baby is just rolling on the cord and dropping the heart beat here and there, that is a normal variant we expect to see. We would never deliver a 25 week baby early for something like that. However, let's say the patient is more than 1 week over due, so she is almost 42 weeks. We know that there is an increased risk for stillbirth in a patient like this. Let's now say her baby has some random "late" decels. This means the deceleration is occurring after a contraction. This is a concerning type of decel. This means the baby is experiencing a brief drop in oxygen as the baby's chemoreceptors trigger a response for the baby to try to constrict peripheral blood flow back to the baby's vital organs. This tells us the placenta is not functioning as well as it should. This is a baby that could be in jeopardy if it is not delivered in the near future. If the baby continues to have late decels, it will slowly become hypoxic and either die in utero if sent home this way or if not delivered vaginally in a reasonable time or by c/section could also experience lack of oxygen and be at risk for serious brain injury. We can assess how hypoxic a baby is at birth by obtaining a cord ph. If this is less than 7.0, we know the baby experienced some level of lack of oxygen. If it was rapidly corrected and delivered, those babies usually do fine. However, if the hypoxemia went on for a long period of time and was un- noticed those babies can be permanently damaged for life, meaning wheelchair, feeding tube, lack of communication, etc.


There are other ominous decelerations that we know result in bad outcomes as well. Prolonged minimal variability- meaning the fetal heart beat doesn't fluctuate more than 5 beats per minute. It pretty much looks like a straight line, there are no changes and no accelerations. This is also a sign of placental insufficiency and is not good. This is a baby that needs to be delivered. The other type of decel that is an emergency is a prolonged decel. If your baby's heart beat drops in labor and doesn't come back up despite interventions such as rolling you, increasing IV fluids, or meds to stop contractions, your baby needs an emergency c/section. Babies show us they are in trouble when their heart rate suddenly drops below 100 and doesn't come back up. They are not getting the oxygen they need and will die without delivery.


As far as ACOG goes, they would never support or stand by a provider who ignored a fetal tracing with ominous signs such as late decels or minimal variability, even if they were irregular and periods where the rest of the strip looked ok, such as was the case with my patient a few months ago. The risk in ignoring this, or sending someone home to potentially come back with a dead baby is too great a risk. I've thought a lot about this patient and her case over the past few months because of her difficult personality and trying to explain the importance to her of keeping her for monitoring and ultimately delivery for the safety of her baby. She did end up delivering a healthy baby by c/section a day later due to non-reassuring tracing and a large baby that wouldn't descend, but I have felt perplexed by her case due to things she said to me while she was mad about staying and the way she felt she was right over the rest of us who have seen things go awry quickly over the years if non-reassuring tracings on babies are not delivered.


I guess what I am saying here is, I see a LOT of natural patients, and I do a LOT of intermittent as well as continuous monitoring and non-stress tests in my office and the hospital on babies, and not every situation is the same, whether you are "natural" or not. And, if you are "natural," your placenta can still age and have problems that warrant intervention. And while most the time intermittent monitoring is appropriate and most decelerations are a normal variant during labor and don't need much intervention, if any, some are definitely NOT ok, and are clearly giving us warning signs such as a yellow or red light to slow down or stop and do not proceed or there may be a problem. These warnings must be heeded. Please be aware that you cannot read one or two articles, even from ACOG and believe you know how to read a tracing properly and self diagnose. Those of us in this profession have taken many classes and are certified in reading these tracings. We have years of experience in this. We ultimately have your baby's best interest and health in mind when we want to monitor more at certain times or if there are ominous signs.


Take Care out there ladies!!

Whooping Cough/Pertussis and Why should YOU get vaccinated??

Hi ladies! Sorry I've taken a year long blogging break! I didn't realize it had been so long. I've been wanting to mention the topic of whooping cough for awhile now because of the recent rise in this illness and the push for vaccination during pregnancy.


Whooping cough or Pertussis is a serious bacteria that damages the lining of the respiratory tract and causes symptoms that can range from mild cold/cough symptoms in an adult to serious in a baby and more importantly, can be deadly in infants. Unfortunately, there has been a rise in recent years in this bacteria making a comeback likely due to people not vaccinating as much and possibly the vaccine not lasting as long as was originally thought (10 yrs).  Babies less than 6 months old are the most susceptible because their immune systems are less mature and also because their accessory muscles in their chest are not very mature and strong and therefore, they have a harder time coughing and clearing the mucous that develops. Ultimately they cannot get enough air (thus making the whoop sound) and they can deteriorate rapidly and die.


Although no intervention is ever perfect in keeping our babies from becoming ill from this illness or any illness, the best way we have so far is to encourage vaccinating moms, siblings, and close caretakers of these infants. The CDC (Center for Disease Control) along with ACOG (American College of Obstetricians and Gynecologists) is advising women get the TDAP vaccine with each pregnancy in the last trimester to help give babies some passive immunity towards whooping cough and to boost mom's immune response in protecting mom against getting the illness and accidently spreading it to her baby. The TDAP vaccine which protects against tetanus, diphtheria, and pertussis (all different bacterias including whooping cough), is a dead vaccine meaning it won't cause illness, but will cause your body to create antibodies against that bacteria. This is the best protection we can offer at this time for your newborns safety until they are old enough to receive their own vaccines and build their strength and immune system.


And of course, we always encourage hand washing, avoiding crowds with your baby, and keeping people with colds and other illness away until they are well. If you have any other concerns about vaccinating with this, please ask your provider. We have this vaccine available at our clinic and offer it to all women in the last trimester of pregnancy!!

Pelvic Organ Prolapse

 

Hi Ladies, this is a guest article from a writer at drugwatch.com. They help with awareness for drugs and products that can have harmful effects when used incorrectly or which have been found later to have been found to have harmful effects. One of these is the product mesh that has been used for pelvic prolapse surgery. This article is well written and discusses alternative options to surgery and little bit about prolapse in general. Hope you all enjoy:)  Christy

Strengthening the Pelvic Floor
Though many women are not aware of their pelvic floor, it performs many functions. The pelvic floor primarily supports the pelvic organs—like the uterus, bladder and rectum—but also provides support for the baby during pregnancy, plays a role during childbirth and contributes to sexual function and orgasm, balance and continence.

The pelvic floor HYPERLINK "http://www.drugwatch.com/transvaginal-mesh/pelvic-organ-prolapse.php"can be HYPERLINK "http://wwwdrugwatch.com/transvaginal-mesh/pelvic-organ-prolapse.php" weakened as a result of obesity, pregnancy, depleted estrogen levels during menopause, straining during childbirth, high-impact activities or chronic cough. When it loses its ability to function properly, pelvic floor disorders like stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can result.


Pelvic Floor Disorders
SUI refers to the accidental release of urine during everyday activities like laughing, coughing or sneezing, or anything that places pressure on the bladder.

Prolapse occurs when pelvic organs droop into the vagina. It can have varying levels of severity. Some women never experience symptoms, and it is not a condition that necessarily progresses. However, women who experience symptoms describe the pain and pressure of pelvic organs shifting out of position, moving lower and resting against the vaginal wall.

In severe cases of these conditions, surgery to repair the pelvic floor can bring relief. However, surgeries that use HYPERLINK "http://www.drugwatch.com/transvaginal-mesh/"transvaginal HYPERLINK "http://www.drugwatch.com/transvaginal-mesh/" mesh have higher rates HYPERLINK "http://www.drugwatch.com/transvaginal-mesh/" of complications like debilitating pain, organ perforation, sexual dysfunction and the need for revision surgeries. Procedures that do not can be equally effective.

Surgery should be considered only after natural treatments have proven unsuccessful. Nonsurgical treatments—ranging from physical therapy to the use of a vaginal pessary—can be effective in reducing symptoms.


How to Strengthen the Pelvic Floor
As with all things, eating well and exercising can do wonders for pelvic floor maintenance. Exercises like Pilates and yoga are known for encouraging core strength, pelvic floor engagement and good posture.

Physical therapy gives women individualized pelvic health care. Physical therapists may use electrical stimulation, similar to chiropractic, to exercise pelvic floor muscles. In a similar way, therapists may use biofeedback therapy to help locate and isolate the pelvic floor muscles.

After using biofeedback to make sure the correct muscles are being used, physical therapists will recommend that women perform Kegel exercises every day. These subtle contractions can be performed while lying down or sitting, but therapists recommend completing them standing and during other activities to really build strength.

Kegel exercises have been known to restore continence, ease labor, prevent prolapse or reverse mild symptoms, and improve the sex lives of many women. These exercises are particularly important after childbirth, which is known to weaken the pelvic floor.

Physical therapists may also include massage therapy to reduce inflammation, increase blood flow and help realign displaced tissues and organs. Therapists can also create custom exercise plans and provide instruction on techniques that women and/or their partners can use at home.


Linda Grayling is a writer for Drugwatch.com. She enjoys keeping up with the latest news in the medical field.
 

Postpartum Depression

Depression is a problem that can occur at any time in a person's life. However, women are more prone to it than men, particulary after childbirth. I'd like to first say, that if you have depression or have had depression in the past, you are not alone! This is a topic that many women don't talk about or neglect to tell their phyician or midwife about it out of fear or belief there is nothing they can do about it. Women build up excitement and anticipation for the birth of the their baby for nine months, sometimes to feel let down and depressed after the experience when they wish they felt joy and elation.
   During pregnancy, female hormones estrogen and progesterone are high. They help maintain the pregnancy and prepare the body for childbirth. After delivery, there is a rapid decline in hormones to allow the body to produce prolactin for breast feeding and to go back to "normal." Unfortunately, the mixture of drop in hormones, plus lack of sleep from a newborn, frustrations with a fussy baby or breast feeding difficulties, and pain from delivery can all attribute to depressed mother. It is important to note that these feelings are valid and not abnormal. Newborns are time consuming and difficult no matter how much you love them and how great of a mother you are.
  Recovering from depression may take time and some different approaches. I like to tell my patients first off to take care of themselves! You cannot take care of someone else unless your own needs are met. Take time each day to shower, get dressed, do your hair or make up if desired. I also recommend light exercise or more moderate to intense exercise if you are past 6 weeks and your doctor has cleared you to do so. Exercise releases endorphins that make you feel good naturally. It also helps with post partum weight loss that boosts most womens' mood. Communication with your partner, friends, and family is also beneficial. They often do not understand if you don't tell them that you need help. Most would be happy to watch the baby for an hour or so so you can take time for you! Let people help you! Let your partner know how you feel and what he or she can do to alleviate your stress or anxiety.
  Lastly, there are medications to take to help the depression if you are still not feeling any better. Most medications are safe to take with breast feeding and may help you feel more rational, less anxious, and better rested. There are medications such as Prozac, Zoloft,  Celexa, and Wellbutrin that have been around a long time and are well studied and tolerated and can provide some much needed relief for some people.
  There are also counselors who are available to talk with you and help you work through your own individual situation, as everyone has different stressors and problems that may worsen their depression.
  It is important to remember that a depressed mother may have difficulty bonding with her newborn. It is so important in the beginning for mom and baby to have a special bond, and for the baby to feel love and trust from his or her mother. These beginning relationships are the foundation for your baby's life long relationships with people and the outside world. Make them worthwhile and meaningful for both of you!!
  So don't be ashamed if you are depressed. Feel free to call and speak with your provider and get help. Good Luck!!

The Different types of Midwives

So I often get asked about the different types of midwives. Sometimes, I get strange looks when I tell people I'm a midwife. Unfortunately, in this day and age people still think that midwives are all the same. That we all deliver babies at home or that we have worse outcomes than medical doctors when the opposite is actually true. There are different types of midwives however. Just like there are different specialities of doctors. Before I start, I would like to say that midwife means "with woman." I believe all of us midwives have the best interest of the woman and her baby at heart although our levels of education and types of practice may differ. First off, there are Certified Nurse Midwives, which is what I am. We are midwives with a Master's degree in nursing and emphasis in midwifery. We have been registered nurses most of us with experience in the hospital setting in labor and delivery prior to going to a nurse midwife program. We first have to have a Bachelor's degree in nursing followed by acceptance to a Master's or doctorate program in midwifery. We are trained in natural childbirth as well as medical intervention childbirth when necessary with care being taken to fully understand women's individual needs and birth preferences. We also provide some primary care and gynecologic care as well such as pap tests, birth control and care of menstrual problems, etc. The majority of us deliver babies primarily in the hospital setting at 96%. We have arrangements with an obstetrician for emergencies and are under the same credenitaling and review process for hospital privleges as physicians are. We also carry malpractice insurance that typically only covers us for delivering babies in a hospital setting. Some CNM's also deliver in birth centers and at home.

The next type of midwife is a Direct Entry Midwife. These midwives primarily deliver babies at home or in birth centers. Many do have arrangments for OB back up if needed, but the majority do not have malpractice insurance and they will have you sign consents prior to your care having you acknowledge this. They do not have hospital privileges. Most of them have had some experience in assisting other midwives prior to going to training in midwifery. They do not have to be nurses prior to being midwives. They usually go through a midwifery training program that lasts about a year. They are licensed with the state and are accountable for their statistics in delivery, etc. The majority do a great job and have great outcomes. They are very suitable for low risk and completely natural delivery. They do not however have licensure to prescribe if emergency drugs or pain relief medications are desired. They are allowed to administer oxytocin and oxygen in emergencies and they must transfer their patients to the hospital if an emergency arises.

There are also lay midwives who get their training more apprenticeship like. Their experience and time of training may vary. They are much like Direct entry midwives in giving oxytocin and oxygen as needed and that they usually deliver at home or in a birth center, sometimes with a group of other similar midwives. Many have great outcomes as well as less intervention in many circumstances leads to better outcomes in low risk women.

On a side note, I'd like to say that 90% of home birth in low risk women go just fine with no complications. Statistically, midwives have lower incidence of cesarean section (because we don't stick with Friedman's curve for labor progress) and less interventions that could cause an emergency. We also rarely use vacuum extraction which increases risk of brain injury or shoulder dystocia. We rarely cut epiosotmies which decreases risk for third and fourth degree lacerations. Also, statistically midwives have bigger babies perhaps because of the stress on proper nutrition and weight gain that is within normal ranges for different size women. Overall, midwives have great outcomes and very personalized intuitive care:)

Twins....

So I was recently asked about twins and vaginal delivery vs c/section so here goes. Twins can deliver vaginally if they are both head down. Twins are a complicated situation all around though because risk of preterm delivery (approx 50%) and other risks with twins such as monoamniotic and cord transfusion issues, but I won't get into those in this post. As far as delivery goes, if the twins are delivered preterm such as less than 32 weeks, and it is not a first vaginal delivery, it may be reasonable to deliver them breech or allow the head first one to deliver and the second one deliver breech if fetal heart tones on that twin are appropriate and the baby is descending the birth canal well on its own. Generally twins are taken by c/section if they are beyond 34 weeks and not head down though. The reason is because if the head becomes entrapped in the cervix after the rest of the body has delivered, they can become strangulated or end up with broken necks trying to maneuver them out that way. It is safer to just do the c/section. Even if one is head down and delivers vaginally, the other one may stay breech and is still a risk for head entrappment or other cord prolapse and problems in that transition period of waiting for the second twin to drop. Therefore, instead of having to hurry and prep mom for an emergency c/section after delivery through the vagina on the first, a c/section is performed from the beginning to ensure safety of both babies. However, if both babies present at term head down, they will likely stay that way and vaginal birth is reasonable as long as both babies are tolerating labor well. Sometimes twins don't tolerate things as well because of placental or cord issues and may warrant a c/section regardless.

Episiotomies

I get a lot of questions from patients and potential patients about episiotomies (incision in perineal area to enhance opening during vaginal delivery). I would like to talk about why they are used and then why I generally avoid them all together, although there are rare circumstances where they may be necessary. Years ago episiotomy was used on a regular basis by many physicians and some midwives to expedite the delivery of the baby by making the vaginal opening larger. Many felt and some still do probably that a nice clean incision is better than a spontaneous vaginal tear that could be jagged, etc. There are some emergency situations that occasionally warrant an episiotomy. The first being shoulder dystocia. In the event that the head delivers and the shoulders get stuck, if it is really tight fit, the episiotomy can help make room for practitioners hand to reach in and help relieve the dystocia. The other time is if the head is crowning and has been for some time and fetal heart rate is dropping and having the ability to rapidly deliver for the safety of the baby may be a time that episiotomy is useful.
Now for the downfalls, and the reason why I almost never cut episiotomies. There is ample evidence that suggests that cutting an episiotomy even a lateral one increases the risk of third and fourth degree lacerations meaning the tear has extended through the anal sphincter and rectum. Cutting and episiotomy is like cutting material. When you make a cut, subsequent tearing is much easier and generally more severe than had that skin been left intact and only torn slighty naturally or not at all. There are consequences for women with third and fourth degree lacerations besides the pain of healing. These severe types of lacerations increase the risk for anal incontinence as well as other problems such as having fecal matter in the vagina if they are not repaired correctly. So, this is the reason why episiotomies are frowned upon generally. Plus, a little patience and allowing the perineal skin to stretch on it's own almost always leads to a safe delivery, less tearing, and better recovery for the mother.
Hope this answers any questions about episiotomy!!

Bradley Method versus lamaze vs. hypno vs...whatever?

I often get asked by patients what the best method is for going "natural" during childbirth. Many patients are becoming more educated and realizing that often the things we "routinely" do in the hospital may pose added risk of c/section, infection, etc. Some of things such as pitocin use, rupturing membranes artificially, frequent vaginal checks, placement of monitoring tools internally, etc. have likely lead to some of the above mentioned interventions that are not preferable. Therefore, the trend is leaning once again toward self education and reliance that your body can do this without unnecessary interference. That being said, labor is still a painful process and is a lot of work for your body, and therefore, knowing the best option to help you cope and succeed with the delivery you desire is important!

So, first off, let's talk about the Bradley method. This came about many years ago by a Dr. Bradley and I believe it is the method most women will succeed with because it is the most normal and reasonable. I would estimate that >90% of my patients who use this method or take classes for this do succeed. It encompasses the attitude that labor and delivery are normal processes and don't usually require interevention unless necessary for the life of the mother and/or baby. Notice how I used the word "usually.." This method still requires intermittant monitoring of the baby and mom (vital signs, etc) and if abnormalities are noted, intervention may still be necessary. This method focuses much on nutrition and proper eating and weight gain for the mother. I believe this is crucial to pregnancy! They encourage 80-100 gms of protein per day...which I thought was a lot, but it certainly makes sense to help maintain sugars and help with weight gain and diabetes prevention. Plus, a normal weight infant is less likely to have or cause birth trauma than a very large one:) The Bradley method also focuses on knowing the mechanisms of labor and how your body functions, so it is less mysterious and scary. They focus on natural breathing vs lamaze which is very regimented breathing that sometimes leads to hyperventilation...which is not good for the mom or the baby. I think when you understand your body as a labor machine capable of doing this, and give it the proper diet and exercise to prepare this is the method you can and will succeed at!

Hypno birthing is also a popular method and there are many great classes and instuctors in this as well. It is more mediation, breathing, and hypnosis focused, although I've only ever had one patient I've delivered that I believe was truly "hypnotized" for her delivery. I think most women can't get that deep into their meditations and when they are not they sometimes panic and have no other information to pull from. Then they give in to medications or epidural. Both of which I think are reasonable options, but do have side effects that would not otherwise be present if they you still going "natural."
Lamaze is a bit old fashioned. Although relaxation and breathing are critical components to natural, certain altered chest breathing in rhythm and focusing on this so much is probably not the best. I think it often leads to hyperventilation which alters the blood gas of the baby and mother. This is what makes you feel "tingly" and "dizzy" both common complaints we see in hyperventilating patients. This typically leads your nurse to think you need more oxygen and they put an oxygen mask on you making the problem worse! You need to slooooow down, relax and breathe into a paper bag if necessary to take in less oxygen.
So in a nutshell, those are my thoughts on those options. I do have information on classes for all of these methods at my office if you would like more information on this.

And as always, I believe the birth experience is about you. If you choose epidural or other medications don't feel bad! Labor is hard work and exhausting and not all labors are the same. It is not a race or competition to see how much better or equal you are to anyone else who has done it. There is more than one right way to have a baby. Good Luck!

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!

What is the GBS test?

GBS or group B strep is a pathogen that approximately 1/3 of all women carry. It is not a sexually transmitted infection and it doesn't make women or their partners sick. However, newborns born to women with positive GBS vaginal/rectal cultures are prone to sepis (wide spread infection) or illness because of their immature immune systems. Only about 5% of babies born to a GBS+ woman would actually become sick, but the illness can be so rapid and the newborn could potentially die, therefore, we perform universal testing and treatment for all women. Testing occurs usually between 35-37 weeks gestation unless preterm labor or premature rupture of the amniotic sac occurs. In the latter case we would test and treat immediately. Otherwise, we routinely swab (with a q tip type swab) in the vagina and slightly into the rectum during the last month of pregnancy. We do the rectal swab because the majority of strep actually lives in the intestinal tract and that area is still a risk factor for transmission to the baby. If the culture is positive we give intravenous antibiotics at the onset of labor and continue to give them intermittantly every 4 hours until delivery to prevent infection in the newborn.
Some patients may be positive with one pregnancy and negative with another. The reason is because strep can colonize (grow) and once it has grown to a certain level it is picked up on culture and said to be capable of causing infection in the baby. Once we treat you, it may stay at low enough levels that it is not a problem in future pregnancies. However, we will often treat anyway (especially if you'd prefer) if you have been positive with other pregnancies and negative with the current one just in case the bacteria grows in the time from doing the test to the time of labor even though current guidelines do not say this is necessary. We also repeat the test if it is negative and you don't deliver within 4 weeks to see if it turns positive in that time.
For those of you going natural and concerned about the IV with being strep positive, we recommend treating it with antibiotics and then we can hep cap your IV between doses so you can still feel free to get up and move or walk. You can even soak in the bath once you are treated (and preferably if your water bag is intact).

What's the Difference Between Doctors and Midwives?

This is a question I get asked a lot by patients or potential patients seeking an obstetric provider. The answer consists of many things and some different philosophies in general. Of course, there are some midwives who practice differently, and some obstetricians who practice differently, so you can't put everyone into the same nutshell, but here are the main differences. Doctors have been to medical school and have done a residency in their specialty area which includes surgery and management of high risk medical conditions. Certified Nurse Midwives (CNM's) have received Bachelor's degrees in nursing and have most have gone to graduate schools for Master's degrees in nurse midwifery. We do clinical hours and deliveries over about 2 yrs of school which consists of clinic time managing pregnancy, primary care, and gynecologic care. We also deliver babies and assist c/sections in many hospitals. Some do deliveries in birth centers and a small portion about 4% in this country do home births. Direct Entry Midwives are midwives who have had some training usually about 1 yr and perform most deliveries at home or in birth centers. There are also lay midwives who learn the trade from experience and time with other lay midwives. They perform home births.

The general philosophy of midwives is that pregnancy and childbirth is a natural and normal process that requires care of the woman, but that less intervention usually leads to better outcomes-such as a lower c/section rate. We also focus on educating our patients about things to watch for and do during pregnancy to encourage a healthy mom and baby and vaginal birth. We offer more time during prenatal visits to educate our patients and to really take time to know them and care for them. Most of us, myself included want our patients to feel that their desires are being addressed and that we are giving our patients educated options to choose from to meet their desires for childbirth. I personally don't think there is just one way that is the best way. I think natural births are wonderful, but there are some women that do not desire this and just because you choose a midwife doesn't mean you can't use medication or an epidural if desired. We/I just want you to be comfortable and safe and feel like you had a great experience. We never put your safety on the back burner either. We do intervene when necessary and consult or manage your care with an obstetrician if things are varying from a normal safe path. That being said, most midwives have lower c/section rates, bigger babies, and less preterm delivery. Part of the latter is likely because of the education time we try to take with our patients.

Last but not least, midwives usually spend more time with you during your labor offering labor support or emotional support and advocating with the nurses and other care providers on your behalf to help you get the birth experience you want. So, if you are

considering a midwife, come on in, you won't be disappointed!

HPV AND CERVICAL CANCER

HPV or human papillomavirus has 100+ strains, a few of which are considered "high risk" meaning they can cause cervical cancer. HPV is sexually transmitted, and because it is a virus, it is not curable. However, like flu virus, there is a vaccine to protect young women (and men now) against the dangerous strains of HPV. Not all HPV infections will turn into cervical cancer. In many cases, your body will take care of the virus and you will not require treatment for abnormal pap tests or cancer. However, your body may not treat all of the strains, and some of them may mutate and cause changes in the cervical cells which may lead to cancer down the road. Most abnormal cervical tests take 5+ years before they would be considered as full blown cancer requiring hysterectomy, etc. However, there are some cases that move faster and therefore, it is important to follow up with regular screenings, colposcopy, or other treatment as recommended by your provider. Further, there are other types of cancer that are not caused by HPV and that is why all women must be screened, not just women with muliple partners.
Gardisil and Cervarix are vaccines that are available to prevent cervical cancer. The vaccines are recommended for women aged 14-27. It must be given in three separate doses and most insurance does cover this vaccine, so if you fall in this age group, check with your insurance and your provider and get vaccinated! Gardisil also prevents certain types of HPV that cause genital warts as well, so if this vaccine is right for you, you may be "killing two birds with one stone!"
So....don't skip out on those yearly exams or vaccines!