A first-time pregnant mom was understandably nervous at the beginning of her pregnancy. After a few prenatal visits, she became calm and was obviously enjoying her journey. However, as she got closer to her due date, she began to express some concerns and during her last prenatal visit, she asked me if I could tell how much her baby weighed. It’s a common question, however there are no magical answers. I informed her that the fundal height gives us reassurance that the baby is growing and an ultrasound’s estimated weight can be off by one to three pounds. She continued to look concerned and stated that a family member had just delivered a baby that weighed nine pounds and she needed a second operation because she had “torn” so badly. I silently cringed and my patient looked terrified. I asked whether her relative had been pushing for more than two hours at the time of birth and she replied that her relative had actually pushed for four. She continued to explain that she had witnessed her relative’s labor, felt something was wrong but was reluctant to voice her concerns because “the doctor knew best.”

This is the 21^st century and that mindset has to change. First, I reassured my patient that the chances of her having a complication similar to her relative were extremely remote. The definition of an arrest of labor means that a first-time mom should not push for greater than three hours and a woman who’s had children should not push no longer than two. She was now empowered with that information and had the right to challenge ANYONE if faced with that condition. While there is no magic formula for predicting an accurate birth weight, Nature does give us signs. If a woman is adequately pushing for the prescribed periods and not making progress, there is a PROBLEM that usually requires an operative solution. Fatigue, distractions and sometimes incompetence can cloud a health care provider’s judgment. If you suspect that something is wrong while you are in labor, by all means, please speak up. Nature has endowed you with a gift called instincts. Please don’t be afraid to use it.

1. Ultraviolent rays are not your friend. Wear a hat with a three-inch brim and sunglasses when sitting in the sun
2. Use a sunscreen with a minimum of 15 SPF or higher
3. Women of color should also use a sunscreen. The incidence of skin cancer has increased for all races in recent years.
4. You can swim in a chlorinated pool but check the chlorine level. The pH level of a pool should be between 7.4 to 7.6. Avoid using a public or private pool if it has been “shocked” (given extra chemicals).
5. Enjoy your barbeques but don’t eat food that has been left outside for more than 2 hours.
6. Use insect repellent to protect yourself from bugs if you go outside but use it sparingly. Mosquito bites increase the risk of developing the West Nile Virus which causes inflammation of the brain and spinal cord. Both the Center for Disease Control (CDC) and the U.S. Environmental Protection Agency (EPA) state it is safe for pregnant women to use insect repellents, specifically the longer-lasting agent DEET. For longer hours spent outside (over 3-4) use a repellent that contains at least 20% DEET. Products with more than 50% DEET does not offer additional protection and should not be used in pregnancy.
7. Use Oil of Lemon Eucalyptus or PMD as a natural pesticide if you prefer to avoid chemicals.
8. Stay well hydrated when in the sun. Drink plenty of water.
9. Don’t over exert yourself in extreme heat. The human fetus’ temperature is about 1 degree higher than its mother’s and cannot regulate its temperature. If you remain cool, so does your baby.
10. Thunderstorms increase during the summer. Have your disaster supplies ready as well as emergency numbers and a route mapped out to the hospital.

Summer is a time of enjoyment but please — play it safe.

Today’s economy has proven that no one is exempt from losing a job; a home; a spouse or their dignity. If the truth be told, we are all just one paycheck away from getting the dreaded pink slip. Medicaid insurance is the government’s safety net for the working poor and has traditionally been shunned by physicians but now hospitals are following suit.

I remember when the only cancer specialists in a small Louisiana town wouldn’t provide cancer patients with chemotherapy if they had Medicaid so the patients either sought care in another town or died from benign neglect.  Perhaps it’s the memory of those cancer  patients who were denied access to care that makes me fight so hard for my patients to be delivered at a quality hospital despite the hospital’s alleged resistance. In New York City, it’s a well-known fact that a renowned teaching hospital places Medicaid pregnant patients on separate floors but at least they accept them for obstetrical care.

Complicating my dilemma is another community hospital that has had quality care issues in the past and would “love” to have my patients because their patient census is shrinking. Most of the physicians in the community no longer deliver at their institution opting to take their patients to a new competitor hospital that recently opened its doors for business.

Although I have been involved in a recent arm-wrestling match with powers-that-be to “steer” my patients in a certain direction, I ultimately leave the decision up to the patients regarding their hospital of choice. If a hospital accepts Medicaid insurance, then they have to accept Medicaid patients.

The “heart” of medicine has flat-lined. Could someone PLEASE perform CPR? STAT!

Pregnant mothers who are at risk for premature labor can now be tested with a culture called Fetal Fibronectin (aka FFN) that can predict whether they will deliver in the next 72-hours. If the FFN is positive, steroid treatments are immediately given to the pregnant mother to promote lung maturity of the unborn baby so that it will be able to breathe on its own.  

The measurement of the cervix of a pregnant woman can help predict whether she will have her baby prematurely. If her cervix is less than 2.5 cm or one-inch, she should receive high-risk obstetrical care.

Spina Bifida a condition that causes paralysis because the spinal cord is located outside of the back as opposed to inside the spinal canal. This condition can now be treated with fetal surgery BEFORE the baby is born thanks to advance imaging of ultrasounds and screening tests.

 “Perfection” at birth no longer dictates the quality of human life. I strongly encourage pregnant women to become well versed in these very progressive treatments and request them as needed. A less than perfect beginning can still have a happy ending.

Let us give thanks and rejoice.

                Anyone who is remotely familiar with obstetrics knows that the APGAR score is a useful tool for determining the newborn’s status shortly after it is born. APGAR scores were developed by Dr. Virginia Apgar, a Columbia University trained anesthesiologist and evaluates the baby’s heart rate, muscle tone, respiratory rate, reflex response and color at one and five minutes of life. Each criterion is given either 0, 1 or 2 points. An APGAR score of 0 to 3 after five minutes is suspicious for a birth brain injury.

                When the baby does not receive enough oxygen in the womb, its brain cells becomes damaged causing permanent injury. However, that dismal prognosis has begun to change, thanks to hypothermia (cooling) therapy. According to a large medical study called Cochrane, “. . . parents should expect that cooling will decrease their baby’s chance of dying, and that if their baby survives, cooling will decrease his/her chance of major disability.” What a MAJOR breakthrough in medical science and a reason to celebrate for expectant parents.

                One of the first institutions to use this method was the University of California at San Francisco. I contacted the nurse in charge of the program and she was kind enough to share their protocol. In order for the cooling method to work, it must be used within the first six hours of life. Here’s how it works:

1. Your baby must be 36 weeks or greater
2. Must have an APGAR score of less than 5 at 10 minutes
3. Must have received chest compressions  and/or intubated or received a mask helping it to breathe at 10 minutes of life
4. Have a low blood gas within the first 60 minutes of life
5. Have signs suggesting HIE which include having a seizure, poor muscle tone, poor feeding or be in a coma.

                Although the cooling method is expected to become the standard of care in the future, there are hospitals that are already using it. Does your hospital use hypothermia? The answer could save your baby’s life.

1. A normal heart rate of 120 to 160 beats per minute. The heart rate of a sleeping newborn is between 85 to 90 bpm
2. A breathing rate of 40 to 60 breaths per minute. A fast breathing rate could indicate heart problems
3. Good muscle tone. Poor muscle tone could indicate possible Down Syndrome or a nerve condition
4. A temperature o between 97.7 to 99.5°F.  Temperatures too high or too low could indicate a serious infection
5. Appropriate color. Blue lips, tongue or chest could indicate a  heart condition
6. Spontaneous urination and passage of one stool
7. Two successful feedings and is able to swallow, breathe and suck while feeding
8. A normal hearing screen
9. Normal glucose (sugar) level if baby was premature, mother was a diabetic
10. Normal bilirubin level

In addition, it is recommended that breastfeeding begin very soon after the delivery and that the newborns are breastfed 8 to 10 times per day. Non-breastfed infants are given one-half to one ounce of formula every four hours. All infants are treated with an eye antibiotic gel to prevent an infection from gonorrhea. The hepatitis B vaccine is also given to the newborn and as well as Vitamin K to protect against bleeding disorders. All babies must be seen by medical professionals within 72-hours of its hospital discharge.

The first 24-hours of a newborn’s life is critical and helps set the stage for the rest of its life.

                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.

http://www.msnbc.msn.com/id/21134540/vp/35803789#35803789

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.

Well, now that the Democratic Party has received a smack down in Massachusetts, maybe someone will FINALLY listen to the people. Our window of opportunity for change is now apparently closed and my patients and profession will continue to suffer.

MLK said it best: “All that good men need to do for evil to flourish is nothing.”