To Shave or Not to Shave… for your GYN appointment

It is a common concern that is brought to me from both friends and patients alike—shaving for your GYN appointment. Do you shave it all off for better viewing, landscape to show you made the effort, or just let it all hang loose like the primal woman God made you?

From a profession opinion, it truly does not really make a difference to us. We have seen it all. Straight, curly, long, short, bald, afro, in all different trims and styles; pubic hair is as unique as the individual that grows them. If you are the kind of gal that likes mow her lawn on the regular, great. But if you are stressed about getting horrid razor burn, (or you just forgot) then don’t sweat it. Be comfortable with however you wear your downstairs carpeting. We are not here to judge– but if you pimp your pubes, your vajazzled vajayjay will undoubtedly be hilariously scrutinized. Kidding. 

My one recommendation is for those that have long, unruly hair (you know who you are), it is better to have somewhat of a trim, at least around the area of interest, specifically, the labia majora (sides and lips). I say this simply because with better visibility, we are better able to asess and identify problems that might otherwise go unnoticed (condyloma, hpv warts, skin growths etc.). Not that getting a pelvic exam is ever a walk through the park, but it might be more tolerable to not get your strands caught in the machinery. That being said trimming especially before labor and delivery, there is less likelihood of getting rebellious hairs getting caught and pulled if you need stitches after..

Nonetheless, everyone has their own preferences to how they choose to decorate their bush. Embrace it. Or erase it. We don’t care. As your doctors, we are just glad you came in for your dreaded annual exam, so don’t let pubic hair taboos keep you away. Just keep it simple and keep it safe.

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What to Expect…AFTER you were Expecting

th_PregnancyWhile many women often saturate  themselves with extensive information about what they should expect while they are expecting a baby, for many new moms, they find that their research ended after they figured out how to write up their birth plan. Thus, there are a lot of unexpected realities that suddenly appear after they have the baby.

Retrieved from: http://collections.infocollections.org/ukedu/uk/d/Jh1436e/14.html

To start, I’d like to present the definition of postpartum: “(post-par-tum) adjective, occurring in or being the period following parturition [birth]” (Merriam-Webster Dictionary, 2012). I find that many people not in the medical profession practically shudder at this word, as if they thought every time we referred to “the postpartum period” that we were automatically assuming she would have postpartum depression when she got her period. Actually, a patient really told me that. And it is something many other people might also falsely believe. So for clarification, postpartum, and postpartum depression are entirely different concepts, are not ever used interchangeably and postpartum depression will never be shortened or nicknamed to postpartum just for the heck of it (you can’t make this up people). When health providers refer to the postpartum period, we referring to the period of time (not bleeding) that occurs from the time you give birth for six weeks thereafter. While postpartum depression can occur during this time, there are many, many other changes your body will experience that can also be overwhelming if you aren’t prepared.

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One of the most uncomfortable complaints associated with the postpartum period is breast engorgement. This occurs when the breasts fill with fluid from an accumulation of milk and fluid in the tissues, causing the breasts to become very swollen, heavy, firm, and extremely tender (think like the first day after breast augmentation). This can happen in both breastfeeding and formula feeding mothers, and is equally distressing for each.

However, treating breast engorgement is very different depending on if you are breast feeding or not, so pay attention. For breast-feeding women, they best remedy is to continue nursing every 1-2 hours, and use heat therapy with warm compresses, or let warm shower water to run over the breasts. This will increase the circulation to the breasts, and will help to facilitate drainage of fluid accumulation from around the tissue back into circulation, and nursing often will help to empty the breasts and will relieve some of the pressure. Frequent breastfeeding may also be beneficial in preventing breast engorgement, by providing a steady and consistent outflow of milk, decreasing the accumulation of milk in the tissues. Now, for the mother that is not breastfeeding, disregard the previous information. Your best action to treat breast engorgement is to focus on cold therapy NOT heat therapy. Using cold compresses on the breasts will help to decrease the circulation and swelling of the breast tissue. 1427051_f260As crazy as it may sound, cabbage leaves are highly recommended; they are cool, to draw the fluid away from the breasts, relieving some of the pain and swelling. They are also convenient, as the leaves take shape around the breast, and can be easily placed inside your bra, so you don’t have to worry about stuffing your bra full of ice. Additionally, because the breasts will become heavier, both breastfeeding and formula feeding women should wear good supportive bras to reduce the pull on your back and stretching of skin and breasts, and can help to reduce the overall pain and discomfort.

Amongst many other common complaints, many women complain of the achy, cramping feeling in their belly in the day or so following delivery. I feel like a full physiological explanation of the reason for their cramping is sometimes more helpful than the ibuprofen we give you, so try to follow along with all the gory details. During labor, the uterus intermittently contracts and relaxes in order to dilate the cervix and expel the baby from the womb. Very soon after the baby is born, the same thing occurs when the uterus expels the placenta (the afterbirth). Now, the placenta is actually attached to the inner lining of the uterus, and is kind of like a connection (or barrier, however you want to look at it) between the baby’s blood vessels and circulation and the mother’s. As such, you can imagine the high blood supply the is provided to the placenta, and when it separates from the uterus and is delivered, there is basically an open wound of open blood vessels. 6934W It is a rather complex process, but we’ll keep it as basic as possible here…In order to control the bleeding, the uterus again starts to contract down on itself, firm and constant, in order to constrict the blood vessels to reduce the bleeding. This doesn’t always happen on its own, and so a common practice is to stimulate the contractions further by infusing pitocin (the same drug used to make contractions stronger during labor), or by “massaging” the uterus down into a contraction.

Retrieved from: http://helid.digicollection.org/fr/d/Js3015e/8.4.html

I was very fond of my instructor Jane, who always said “Ok darling, we’re just going to mash a bit on your belly now to stop the bleeding.” To me, this is a more accurate description than “massaging.” Over the next few hours to days, the mother may feel that cramping as the uterus tries to maintain a firm contraction. This may occur in several situations, one of them being while breastfeeding. As if breastfeeding wasn’t already the best thing to do for the baby, it is great for the mother too. Nipple stimulation by the baby suckling produces a hormone called Oxytocin. This probably reminds you of that medicine I mentioned earlier, called Pitocin, which is actually the synthetic version of Oxytocin. If you received Pitocin during labor, you can recall that the contractions started or got stronger after getting this med. Similarly, secretion of Oxytocin also stimulates uterine contractions. While this is also known as the “love hormone,” which is associated with feelings of motherly instinct and love towards the baby, this hormone plays a major role in keeping the uterus contracted to control bleeding, thus explaining why some women may feel somewhat crampy during or after breastfeeding.

Retrieved from: http://www.medivisuals.com/images/products/detail/104111_05X.jpg

But rest assured, this discomfort is temporary, and will go away within a day or so,  and so please do not let this be a discouragement to breastfeeding! Another situation that may increase the cramping is when there is a full bladder. Think about the limited amount of space in the pelvis (I know, its hard to think of it as being anything but small after pushing out that baby). When there is a full bladder taking up space, it can push the uterus up and away from the pelvis, distorting the space needed for a contracted uterus, and thus, it may become soft, or “boggy.” In an attempt to compensate, the uterine contractions may become irritable and more uncomfortable. Additionally, there may be increased vaginal bleeding as a result of a soft uterus. This brings us to our next topic…

Retrieved from: http://www.thirdage.com/hc/c/what-is-postpartum-hemorrhage

Vaginal bleeding can understandable be a nuisance to the woman who has not had a period for the last 9-10 months. Bleeding is a result of a couple different factors including the process of involution (see above paragraph), as well as any lacerations or tears in the vaginal or cervix. Small tears in the vagina are common, and do not necessarily require stitches if they are not bleeding, though a midwife may throw a few stitches to enhance the healing process and prevent bleeding or infection later. The first day the bleeding is usually the heaviest, and should usually subside to a light period within the next day or 2, though the bleeding may increase if there is a full bladder (see above paragraph), so it is very important to be mindful of going to the bathroom and urinating every couple of hours to prevent the uterus from getting boggy, and reduce the amount of blood loss. Occasionally, I hear some concern from women that they start to bleed more or pass clots after they get up, especially in the morning. This then leads to the mindset that they should stay resting in bed to keep from bleeding more. While you should never ignore a noticeable increase in bleeding, it is common to notice more bleeding after getting up, especially after laying in bed for a few hours. This is because the vagina is basically a hollow vault, and when you are laying down, the pelvis is in a horizontal plane rather than vertical while standing, instead of dripping out, the blood tends to pool in some of the spaces and corners in the vagina and around the cervix. Then, when you change to a sitting or standing position, gravity works, and then the bleeding becomes evident. Additionally, blood tends to become clotted when it is still, so if you are laying for a few hours with pooled blood in the vagina, it may become somewhat thick or clotted, and come out when you stand or use the bathroom. As most other aspects of pregnancy, bleeding will eventually subside, most women will probably have at least some spotting for a couple of weeks after giving birth, and it may then become a whitish discharge before it stops completely. Now, for some women who are breastfeeding consistently, the bleeding (resuming your period) may not return for several months. images-4Aside from abstinence, lactational amenorrhea is one of the oldest and most natural methods of contraception, and is recognized by many cultures and religions around the world in which modern contraceptive alternatives are prohibited. Breast feeding is essentially Mother Nature’s way of naturally spacing out pregnancies (assuming ancient ancestors breastfed exclusively for the first many months to years of life). However, there is a catch! Do not foolishly assume that just because you are breastfeeding means that you won’t get pregnant. images-3In order to rely on the lactational amenorrhea method, breastfeeding should pretty much take place consistently, every 1-3 hours throughout the day. Pumping, formula supplementation, and prolonging time between feedings increase your chances of getting pregnant again, and if your feeding practice includes any pumping, use of formula, or you are only breastfeeding every few hours (such as when the baby starts to sleep through the night), you should consider yourself fertile, and at risk of getting pregnant again, even if you have not gotten your period yet. You should then consider using another form of contraception.

Generally, you are advised to avoid sex or anything in the vagina (tampons, fingers, douches) for six weeks after you give birth. If you are not nursing regularly, frequently, or formula feeding, you should consider some contraceptive alternatives, which should be discussed with you before you leave the hospital, and again at your 6 week follow-up appointment. As mentioned above, breastfeeding is an effective and easy way to prevent another pregnancy right away if the method is used properly, however, even then, it is reasonable to still use alternative methods for additional protection.images-2 If your last pregnancy didn’t occur because you forgot to take your birth control pill, you might be a good candidate for the birth control pill (just kidding!). Birth control pills are great forms of contraception for most women after having a baby (should not be used in women with history of or current blood clots, smokers over 35, breast cancer, conditions mentioned on all the commercials, etc). Depending on if you are breastfeeding or not however, will determine the kind of pill you can take. For women that are breastfeeding, pills containing estrogen may reduce the milk supply, and so it is recommended to use a progestin-only pill, also known as a mini-pill. These are considered to be safe to the breastfeeding baby, and are highly effective when used correctly (make sure you don’t miss a pill, take it at the same time every day, or you may get spotting, your period, or another pregnancy). If you are not breastfeeding your baby, either progestin-only or combination contraceptives (combination estrogen/progestin pills are the usual common pill) are appropriate. Additionally, breastfeeding or formula feeding women can also receive Depo Provera shots, we often encourage you to return to your clinic about 2 weeks after you deliver to get the shot. Another excellent method to consider at your 6 week appointment is the IUD, both the hormonal (Mirena) and non-hormonal IUD (Paraguard) are safe for breastfeeding and very effective for preventing pregnancy (see my blog ‘Got IUD?’ for info).

mch_postpartum_hair_lossAnother cause for concern brought by women after having a baby is that they notice their hair is falling out. While this can be very distressing, it is usually not a cause for concern. During pregnancy, hair and nails tend to grow faster, thicker, and seem healthier. Unfortunately, after pregnancy, hair and nail growth returns to normal, and women may shed the excess hair and fullness that grew during pregnancy. This may be very upsetting, thinking all of your hair is falling out, when in reality, the hair is just returning to the way it was before pregnancy.

Retrieved from: http://www.health.utah.gov/prl/factsheet.htm

As mentioned at the beginning of this blog, postpartum depression is another problem that may occur in the weeks to months after having a baby. It is not uncommon to initially have feelings of sadness, anxiety, and crying in the first few days after having your baby. This is usually temporary, and should normally reside within a few days. Postpartum depression on the other hand is a much more serious condition, which usually has symptoms occurring after a few weeks to months after having the baby. Signs of postpartum depression may be very generalized, such as feeling tired, sad, stressed, or loss of interest in activities and things you used to be interested in. These should be considered early warning signs of the possibility for postpartum depression, and you should contact your midwife or OB as soon as possible to discuss your feelings. Many women may feel hesitant to express concerns about such feelings, for fear of being judged, labeled “a bad mother,” getting their baby taken, or being locked away in a crazy house. It is so important to not let these fears cloud your own judgement of talking to your provider; we are not here to pass judgement or labels on your parenting, and pretty unlikely to lock you away or take your baby. But that’s why it is so important to seek help early on, so that we can help you from becoming a harm to yourself and your baby.

While I hope this blog is useful and informative to many women, please take all information carefully, and do not substitute this info for professional medical advice or diagnosis. This blog is merely a briefing of some common discomforts of the normal postpartum period, but sometimes these discomforts can prelude to serious complications, and should never be ignored. If you do have concerns especially heavy bleeding, severe cramping, breast pain, odorous vaginal discharge or fever (just to name a few!) notify your doctor as soon as possible to be evaluated. Thanks for reading!

This blog is in dedication to Cody, one of my best friends, who just gave birth to beautiful baby Kaya on January 3.

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Real or fake? The boob job dilemma

Whether breast augmentation may be seen by some as tacky taboo, others may marvel at the prospect, while still others just simply enjoy all the talk about boobs. While breast augmentation is by no means unheard of, understanding breast implants in relation to breast cancer and breast feeding is not the hottest topic. Regardless, of whether you are in favor of silicone, saline, or the good old fashioned all-natural, its  likely that either you or someone you know has breast implants. Please share the info.

About Breastfeeding…

ImageAs mentioned in one of my previous posts, “Breast is Best”. The American Academy of Pediatrics recommends that babies should be exclusively breast fed for the first year of life. This is not only beneficial to the nutritional intake of the infant, but breast feeding is also exceedingly beneficial to the mother as well (see my blog post for more info: https://g8rk8.wordpress.com/2011/03/26/breastfeeding-to-keep-kosher/). A common concern among women who have, or are considering breast implants, is the ability to breastfeed. ImageThe literature is varied, however, the review by Cruz and Korchin (2010) summarizes key investigations related to breast feeding success following augmentation. While there are a multitude of potential factors that could impede breastfeeding (in both augmented and non-augmented breasts), incision site remains to be a common denominator in nearly all studies. Though the differences between the periareolar and submammary approaches were minimal, these incision sites generally had the least success with breastfeeding when compared to transaxillary approaches. This is possibly due to a couple factors. First, the tissue surrounding the underside of the nipple is composed of many glands, ducts, and nerves that are involved in lactation. Damage to any of these structures can therefore interrupt the process of milk production, leading to absent or insufficient milk supply. Additionally, the periareolar incision involves severing many superficial nerves in the nipple, and is thus most often linked to decreased nipple sensation. Nipple sensation plays a crucial role in milk production; the suckling sensation produces a reflexive stimulation of the pituitary gland, with subsequent release of prolactin, an essential hormone needed for lactation (Cruz & Korchin, 2010). While it was thought that the transaxillary approach may have better breastfeeding outcomes due to reduced manipulation of breast tissue, this approach does, however, involve extensive trauma to the nerves and lymph nodes that are essential to proper mammary gland function. Another theory that has recently been suggestion for future investigation is the association of small “hypoplastic breasts,” and inadequate milk supply (Cruz & Korchin, 2010). ImageThis theory suggests that women who have difficulty breast feeding following breast augmentation are more likely to have had small, inadequately developed breast tissue prior to augmentation (thus inciting desire for surgical enhancement). Finally, placement of the breast implant is significantly related to breastfeeding ability. Typically, the implant is placed under the muscle (submuscular) or under the glands (subglandular). When the implants are placed under the glands, there is a greater chance of complications related to pressure from the implant against the glands, more discomfort during breastfeeding, and the possibility of capsular contraction (a long term complication of implants) that could potentially interfere with the breast anatomy and function of the glands.

Breast Cancer Screening…

While breast feeding with breast implants is an important topic that is left untouched by many women’s health providers, the primary intention of this blog was to discuss and bring awareness to the myths, risks, and screening tools for breast cancer in someone with breast implants. It is no secret in the health care field that breast implants pose substantial challenges to current breast cancer screening measures such as self-breast exams, clinical breast exams, and mammography. However, the greater majority of clinical investigations exploring the incidence of breast cancer following augmentation have shown little to no difference in statistics between augmented and non-augmented breast cancer patients3. In fact, some studies actually saw better cancer prognoses for patients with implants. There are several theories that have been elicited from this conclusion. This will be addressed after a review of the obstacles (booby traps?) imposed by implants on breast cancer screening. Chiefly, reduced imaging quality of mammograms is a primary concern with breast implants. Mammography provides detection of different densities in breast tissue, identifying possible tumors, which appear as radiopaque white masses  (pardon my lack of radiology expertise from that definition). This screening technique is a widely used and recommended method for the early detection of breast masses. Unfortunately, breast implants possess similar opacity to tumor masses, and can often lead to inconclusive and inaccurate results if a significant portion of breast tissue is obscured from the image.

Therefore, the more breast tissue that can be isolated from the implant, the better the likelihood of a more accurate mammogram. As mentioned previously, submuscular placement refers to implants that are placed under the muscles of the chest wall. This allows for more breast tissue to be dispersed away from the implant, and thus less opportunity for masses to be concealed. The same concept is true for self and clinical breast exams. The submuscular implant is well separated from the glandular breast tissue, and thus provides a firm “backdrop” with which to compress the breast tissue, providing greater ability to distinguish the different textures of tissue3. It is essential, however, to have an adequate knowledge of self-exam techniques, and the ability to distinguish between normal breast tissue, implant structures, and possible pathology.

Health care provider skepticism to breast implants may be related to challenges in reliable early detection of abnormal breast masses4.  However, as mentioned, several studies have had surprising results of breast cancer detection in augmented versus non-augmented breasts. Some studies found that women with breast implants often detected masses and were diagnosed at early stages of the disease, and frequently had smaller sized tumors than women without implants4.  Theories behind this concept are as follows:

  • Increased body awareness. Women who have undergone breast augmentation generally display a greater awareness of body image, identification of changes, and comfort with self assessment and examination3.
  • Increased implementation of self breast exams through the use of massage to prevent capsular contraction4.
  • Better educated about proper assessment, screening measures, and consistent follow-up.
    • Women with breast implants tend to have increased interaction and communication with surgeons and other health care providers about expectations, recommendations, and what to look out for3.
    • Women with breast implants are more likely than women without implants to have regular mammograms3.
    • Possible anatomical advantages: enhanced local immune response and surveillance due to the presence of a foreign body; compression of surrounding breast tissue leading to conservative blood distribution and reduced blood supply to growing tumors4.

In general, most of the research has shown very little other significant differences in either rate of detection, extent of metastasis, or disease prognosis amongst women with or without breast implants3. While these theories are simply just that, they do offer a firm foundation for consideration in a risk versus benefit analysis. I hope this blog has shed some light on a very unspoken issue in women’s health, and please pass on the information. I don’t feel breast implants are in any way better or worse than not having implants, but I respect and support the choice to do so if desired. As always, please take all information in this blog with a grain of salt. This is not professional medical advice, simply a casual discussion. Do not use this info as a substitute for professional medical attention.

 

References:

1Cruz, N., & Korchin, L., (2010). Breastfeeding After Augmentation Mammaplasty with Saline Implants. Annals of Plastic Surgery, 64(5): 530-533.

2Strom, S., Balwin, B., Sigurdson, A., Schusterman, M., (1997). Cosmetic saline breast implants: A survey of satisfaction, breast-feeding experience, cancer, and health. Plastic and Reconstructive Surgery, 100(6):1553-1557

3Smalley, S., (2003). Breast implants and breast cancer screening. Journal of Midwifery & Women’s Health, 48(5): 329-337.

4Deapen, D., (2007). Breast Implants and Breast Cancer: A Review of Incidence, Detection, Mortality, and Survival. Plastic and Reconstructive Surgery, 120(7):70S-80S

Infertility

Its ironic that so many young women spend the better part of our teenage years and early twenties worrying about getting pregnant, and then when their minds are finally ready to be pregnant, their bodies no longer are. ImageA couple weeks ago I was fortunate to have the opportunity to spend the day shadowing a nurse practitioner at an infertility and reproductive medicine clinic. I learned so much about the little things that are so frequently overlooked by most women (such as diet and exercise) and the significance it has on reproductive success. I hope this discussion provides insight and ideas for success when trying to plan for pregnancy.

The first topic that seems to have the greatest impact on fertility is diet and weight. Yes, it is those dreaded words that no woman ever wants to hear. While most of the women that came to the clinic were not necessarily obese, many of them could generally be considered at least mild to moderately overweight, and a small handful were slightly underweight. Image One of the first steps to improving fertility is to obtain a healthy weight. For the woman that needed to gain a few pounds, it wasn’t recommended that she consume all the Krispy Kreme donuts within a 10 mile radius, on the contrary, for both over and under weight women, they were advised to restrict the amount of carbohydrates in their diets, and eat foods high in protein and vitamin rich fats. While some of the providers admitted to being more carb-tolerant, some of the doctors are insistent about clients following a strict no-carb diet. While choosing between that bagel and getting pregnant might seem to be a no-brainer to the hopeful mother to be, it seemed that most women became more heartbroken learning some of the best fruits and “first line diet foods” were still off limits. As I mentioned earlier, women don’t want to hear that they need to go on a diet and lose weight. For the fluffy gal, its something she already knows, and doesn’t need to be told again. That being said, the explanation over WHY carbs are bad is brilliant, and it went something like this…

At the initial consultation, the nurse practitioner sat down to review lab results from their bloodwork. While most primary care labs check blood glucose, a less common lab is the amount of blood insulin. A very high majority of the women we saw at the clinic had high levels of insulin. ImageThe way this related to their fertility was explained as such: “When you eat meals that are high in carbohydrates, your body produces insulin, which is a hormone needed to transport the carbs into a usable form of energy in the cells. That is a normal response. However, insulin inhibits estrogen production, which is a major hormone of the reproductive system that is essential for fertility to help your eggs grow. When you eat a meal that is high in carbs, your insulin levels rise (which is a normal response), but while your insulin was up, you didn’t produce any estrogen that night.” This very cut-and-dry explanation was very enlightening, and made complete sense. While the actual physiology behind this concept is far more complex, coupling this diet with exercise to boost metabolism and lose weight is the first step women need to take to help in getting pregnant.

ImageAnother bright idea to improve chances of getting pregnant is to consider the type of lubricant used (if any), and how it may affects the quality of sperm. It might seem obvious to avoid a spermicidal lubricant if you are trying to conceive, but what about the rest of the commonly used lubes? In general, most of the water-based products are not beneficial to sperm quality, as they can decrease sperm motility and lifespan. ImageThey already have enough obstacles just trying to find that egg, why complicate things? Instead, some good alternatives to use (if needed) are natural oils such as mineral and cannola oil. Additionally, men should avoid wearing restrictive tight clothing, especially with excessive heat.

A very important concept to keep in mind is that there are only certain days that it is possible to conceive. While daily intercourse does seem to have s slight advantage (improved sperm quality), it is never the less essential to know the optimal time for intercourse (especially if you don’t have sex every day). The old school Natural Family Planning Method is one of the best ways to determine what days you are most likely to ovulate. Keep a menstrual diary. Record the first day you get your period. This is the single most important step to take to improve chances of getting pregnant. This is also very beneficial after you become pregnant, as it allows for accurate dating and gestational age of your baby. Most women have 28 day cycles, meaning from the first day of one bleeding period to the first day of the next. ImageKeeping a detailed diary month to month is very helpful to predict when you will ovulate, because in most normal cycles, ovulation takes place 14 days before menstrual bleeding occurs. It is a retrospective assessment that may not be apparent until a few cycles have been recorded. Additionally, you should make note of any irregular spotting in between periods, as this may indicate hormonal abnormalities and/or absence of ovulation.

Another good way to determine when you might be ovulating is by the quality of your cervical mucous. Most of us have noticed occasional differences in the color and consistency of the discharge on their underwear. Most of the time, during the infertile days of the cycle, the mucous is thicker, sticky, not as much, and may not always be apparent. Around the time of ovulation, the mucous becomes thinner, and more evident. The consistency is similar to that of an egg white. This is what you want to look for, as it usually changes within 1-2 days of ovulation. However, when evaluating vaginal discharge, know what is normal and what is not. Foul odor, green, yellow, or grayish color, or white, chunky consistency may be indicative of an infection. Being regularly screened for STD’s will help improve fertility, because STD’s such as chlamydia for example, can spread to the uterus, tubes, and ovaries, causing inflammation and structural abnormalities, that could contribute to problems with fertility later.

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Fertility is based on numerous complexities, that are beyond the depth of this discussion. That being said, infertility is also a complex issue that takes into account various disciplines, including age, medical history, hormones, male factors, STD’s, genetics, and much much more. Now I am by no means an expert in this subject; while I want to provide information learned from my experience at the infertility clinic, coupled with tid-bits of educational  information I’ve learned from class, I am only providing a non-formal discussion, and should not be substituted for a professional opinion =)

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Elective labor inductions: Inducing a disaster?

Clinical Problem

The continuing evolution of technology has led to the demand for new innovations in heath care that are suitable for the changing socioeconomic needs of the fast-paced lifestyle in modern society. The implementation of contemporary medical interventions and resource utilization have improved outcomes and allowed access to more options and flexibility in the management of care.  Although there is always a possibility for complications, critical situations may necessitate the use of risky interventions to improve patient outcomes. Recently, procedures that were once indicated for problem management are now being used electively to provide patient satisfaction and convenience. This is seen very often in maternity units when pregnant women request or agree to unnecessary interventions to induce or augment labor.Image

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Although artificially promoting labor is often indicated in high-risk situations, induction may be implemented in healthy pregnancies for the sake of preference. Inductions are often considered as resourceful, as they can allow birth to occur in a timely manner that is often convenient to the parties involved. Frequently, healthy women will request an induction due to time restraints, or in an effort to alleviate the discomfort and anxiety of waiting in the final days of pregnancy. While it may provide a sense of control and increased patient satisfaction, the overall convenience of labor induction is questionable. Recent risk-reduction initiatives have found an increased incidence of unfavorable outcomes due to complications associated with elective inductions in normal pregnancies that could have otherwise been avoided.

Background of the Problem

The objective in investigating the outcomes of induced labors is to determine if there is a relationship between the use of elective inductions and the rising incidence of C-sections. If research reveals an increased risk for Caesareans, recommendations against unnecessary elective labor inductions may be in order.  The ultimate goal is to decrease the need for C-section, and avoid unnecessary interventions by addressing the root of the problem. With confirmation from the evidence, hospital policies and standards of practice can be revised to reduce preventable complications by promoting non-interventional labor management in the absence of problems (Varney, 2004). Additionally, all parties involved in the management of labor and delivery would be impacted by these conclusions. Not only do the findings suggest changes in the provision of care, it can also serve as a critical foundation for patient education during decision-making and informed consent.

Although “being normal” is a concept that is deeply desired amongst today’s society, is it is a wonder why so many patients and providers alike endorse utilization of interventions indicated for the abnormal patient. The midwifery model of care recognizes that childbirth is in fact a normal, physiological process , and supports conservative management by integrating art with science, and using technology judiciously (Varney, Kriebs, & Gegor, 2004).

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Our culture, however, commonly perceives childbirth as a pathophysiological event that requires intervention of normal processes. Essentially, the trend lies in trying to fix what is not broken, and trying to solve problems that don’t necessarily exist.

Background Questions

Using interventions that alter normal physiologic processes have the potential to instigate a cascade of subsequent interventions. In attempt to maintain relative stability, additional interventions become necessary to promote ideal correspondence to expected outcomes (Simpson & Thorman, 2005). Invariably, interventions may lead to further deviations from normal, facilitating physiologic instability, and increasing the risk of morbidities.

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Despite the “convenient” advantages that are often perceived with electively inducing labor, patients become subjected to no food intake, strict bed rest, continuous monitoring, intravenous fluids, and greater frequency and intensity of contractions (Simpson & Thorman, 2005). This can lead to more maternal discomfort and exhaustion that may prolong the second stage of labor, as well as predispose the need for forceps or vacuum assisted delivery and C-section. Furthermore, fetal distress has been associated with inductions as a result of uterine hyperstimulation, extensive head compression, meconium aspiration, and prolapsed cord (Gabbe, Niebyl, & Simpson, 2007). Non-reassuring fetal heart rates often lead to emergent delivery by Caesarean section (Simpson & Thorman, 2005).

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Additionally, Simpson and Atterbury (2003) identify other potential complications associated with induction such as fetal cephalohematoma, placental separation, uterine hemorrhage, fetal death, and significant pelvic floor injuries with perineal and anal lacerations causing urinary and fecal incontinence. With the abundance of potential complications from induction, patients may develop a sense of fear, anxiety, and loss of control that emphasizes the perception of childbirth as a dangerous pathological process and will often electively choose a C-section. Because many institutions prohibit vaginal birth after Caesarean (VBAC), more women are being obligated to undergo C-sections for subsequent births, further increasing the incidence. Invariably, the more a procedure occurs, the more complications associated with the procedure are likely to result. As health care providers striving to improve patient care and morbidity, even a low complication rate is too many.

With an ultimate goal of enhancing birth outcomes, taking steps to avoid preventable complications is a crucial component to reduce mortality and morbidity in childbirth.

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References

Gabbe, S., Niebyl, J., & Simpson, J., (2007). Obstetrics: Normal and problem pregnancies,

(5th ed.). Philadelphia: Churchill Livingston

Simpson, K., & Atterbury, J., (20030). Trends and issues in labor induction in the United States:

implications for clinical practice. Journal of Obstetrics, Gynecology, & Neonatal Nursing, 32: 767–779

Simpson, K., & Thorman, K., (2003). Obstetric “conveniences”: Elective induction of labor,

Caesarean birth on demand, and other potentially unnecessary interventions. Journal of Perinatal & Neonatal Nursing, 19(2): 134-144

Varney, H., Kriebs, J., & Gegor, C., (2004). Varney’s midwifery, (4th ed.). Sudbury, MA: Jones

and Bartlett Publishers, Inc. 

Bearing the Birth

When the vast majority of our society thinks of a birth scene, the subsequent images they have may look  something like this…

…but more than likely, you are probably imagining a distressing scenario of a woman that looks sweaty and terrible, with her legs high in stirrups, exposing her dignity to the world. She has an expression of pain and terror on her miserable face, while a doctor under a drape chimes in with the chorus shouting “PUSH!!” in between exasperated gasps of “hee-hee-hoo.” (see video below…)

To the surprise of many, birth does not have to be an event of misery. Most mothers would agree that the happiest day of their lives is the day their children were born. Aside from the joy of finally meeting your baby, giving birth should be as enjoyable an experience as the outcome. A crucial mission of midwives is the intent to change the way modern society (women, men, and even medical professionals) perceive how child birth “should be.” One of the significant issues concerning most people is how to deal with the pain. While I will be making another post in the future discussing the many different strategies midwives use to manage discomfort in labor, this post aims to explore a timeless factor of childbirth, pushing, and the many mistakes and misconceptions we have developed about such a primitive force.

Pushing, or bearing down, together with the downward force of the uterine contractions, creates a strong positive pressure in the abdomen that allows the baby to move through the birth canal. While these forces are no doubt crucial for delivery, pushing requires an immense exertion of energy. Unfortunately, many women fail to realize that there is a right and wrong way to push, and if not done correctly, all their hard work can leave them with nothing but mere exhaustion. One way to push might be described as puffing out your cheeks, holding a deep breath, and forcing your belly out as far as it will go. The other method of pushing can be thought of as similar to taking a massive….. Full force effort down towards your butt, and releasing loud, guttural grunts and moans. I will leave you to guess which method of pushing is more effective; hang your vanity at the door baby, this is childbirth.

This may come as a shock to many, but our bodies were designed to know how to give birth. While many women in labor benefit from the emotional support and coaching from their loved ones and providers, they generally are able to commandeer the birth on their own (epidurals labors not included). What we don’t realize is that as birth starts to take that crucial turn (where the fetal head exerts strong downward pressure on the nerves in pelvic floor and rectum), women experience an automatic reflex to bear down. I have heard it described as “feeling good to push.” Women in labor begin to develop their own natural rhythm and technique in response to the events taking place in their body. When implementing what is known as a supportive approach, providers take a more passive role, and “encourage women to push in response to the involuntary, physiologic urges that normally occur during second-stage labor” (Osborne & Hanson, 2011). Using this method, research has found a significant increase in birth outcomes and overall maternal satisfaction with the birthing process. On the contrary, however, modern obstetrics takes a more aggressive approach to labor management in what is known as a directive approach. Early OBGYN practitioner Constance Beynon summed it up perfectly when she described her colleagues approach as “seeming to consider it their function to aid and abet and even coerce the mother into forcing the fetus as fast as she can through her birth canal,” (Beynon, 1957). This approach utilizes direct instruction for the woman to perform sustained, strenuous bearing down efforts starting from the time they are fully dilated until birth. While this method undoubtedly would seem like the more effective route to giving birth, one must question the pathophysiology behind these aforementioned actions.

First, pushing that involves holding of the breath is known as closed-glottis pushing. This also utilizes a physiological phenomenon known as the Valsalva maneuver, by which holding of the breath and bearing down creates increased intrathoracic and abdominal pressure (much like the force used to pop you ears), and stimulates the vagus nerve, and the increased pressure inhibits blood return to the heart, resulting in reduced cardiac output, and decreased heart rate and blood perfusion. This is why many people have fainting spells while on the toilet—decreased blood supply and oxygenation to the brain. Considering that the fetus depends on maternal blood perfusion of the placenta, it is not surprising that we see evidence of fetal decelerations during continuous prolonged pushing episodes. On the other hand, open-glottis pushing, quite the opposite, using groans, grunts and animalistic vocals is just as effective, and allows for controlled respiratory exchanges that decrease the risk of acidosis and hypoxemia.

Another point to consider cautiously with this method of pushing is one of the reasons it is so frequently used—its effectiveness. We all know that giving birth is like pushing a watermelon through a hole the size of a lemon. When women push and push with a closed glottis, the fetal head gains speed and momentum, occasionally shortening the length of time of labor, and very frequently resulting in major vaginal tears and lacerations. Think about it. When that watermelon pops through that tiny hole, the poor vagina could hardly stand a chance. Conversely, patience is always rewarded, and alternating between controlled pushing and breathing can make all the difference by allowing the pelvic floor to stretch and accommodate the baby’s head and thus less tearing of the tissue.

A final point to make is the unnecessary insistence for a speedy second stage, whereby women are instructed to start the pushing process as soon as they reach 10 cm. Just because you have become fully dilated does not mean its time to cut the cord. Even when dilation is complete, there is still a good chance that the baby is still relatively high in the pelvis. Consider the anatomy the baby must travel before it is born. It must come down first then out. Using our advanced human brains, we know that gravity is most likely not going to help bring the baby out, but it most certainly can pull the baby down until it is low enough to be pushed out. This is a concept known as “laboring down.” Using gravity together with the continuous force of the contractions is a great way to conserve energy (birth can be Green too!), and still keep labor progressing. By starting to push unnecessarily at the moment you learn you are completely dilated, you are putting yourself at risk for exhaustion (not that you haven’t already been up for days), as well as other issues (see points #1 and # 2 above).

A found a couple tips on how to really enhance pushing efforts the other day in the “midwife bible,” also known as Varney’s Midwifery (2004).

1. Breath control: implementing a variety of breathing techniques during pushing can ensure that you are generating plenty of intrabdominal pressure, as well as allowing for adequate gas exchange and oxygenation of the tissues.

2. Body control: while the lithotomy position (laying on back, legs in stirrups) is a less than optimal way for humans to deliver, many women choosing epidural pain relief are left with very few other options. The best practice for body positioning generally involves legs apart (duh.), and knees to chest or elbows, allowing you body to essentially curl around your belly (and your baby). Also, it is beneficial to keep the chin tucked to the chest (emphasizing that belly curl).

3. Applying a counterforce of resistance with the arms: a very common tool we use in labor and delivery is the “tug-o-war” technique, which really helps when women are not pushing the right way (see above paragraphs for more info). This technique utilizes the counterforce motion the arms provide when simultaneously bearing down (pushing) and pulling (elbows bent) on a towel or sheet with your midwife.

4. Vaginal stimulation: another very common finding on the L&D unit is the nurse or midwife inserting two fingers into the vagina and exerting downward pressure to the rectum. This can be helpful especially in women with epidurals or those who don’t know how to push right. By pressing down on the posterior vaginal walls, we are stimulating the nerves of the pelvic floor to elicit a reflexive pushing response, very much in the same way the baby’s head does as it descends into the forward curvature as the pelvis (this event is often described as the unbearable urge to push or have a bowel movement).

So, in effort to sum things up: do yourself and your baby a favor and be patient, take things slow, and let your body do the talking.

Beynon, C. (1957). The normal second stage of labour: a plea for reform in its conduct. Journal of Obstetrics & Gynaecology, 64:815-820

Varney, H., Kriebs, & Gegor (2004). Varney’s Midwifery, (4th ed.), Jones and Bartlett Publishers: Ontario, Canada

VBACk to the basics…respecting human dignity during childbirth

“The worth of the person is not affected by disease, disability, functional status or proximity to death…nursing care aims to maximize the values that the patient has treasured in life,” (American Nurses Association [ANA], 2001). While all of the core principles in biomedical ethics have crucial significance in healthcare, respect for patient autonomy and the right to self-determination weigh heavily on the quality of nursing practice. As stated in the first provision of The Code of Ethics for Nurses (2001), “the nurse…practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual.” This provision emphasizes the magnitude of an individual’s right to autonomy and self-determination in recognizing and respecting human dignity. It sets a standard of priority in nursing practice, and decision-making that sets the foundation to improve overall quality of life (Beauchamp, & Childress, 2009). Although pathophysiological processes generally serve as the basis for healthcare, nurses are continually advocate for, and treat, the patient, not the disease. This concept is frequently demonstrated by the practice of informed consent, the right to refuse medical treatments or procedures, and the right of patients to receive accurate information and be actively involved in their health and the care they receive

A rising dilemma in women’s health today is the controversy over vaginal birth after cesarean (VBAC). Many healthcare providers, hospital institutions, and insurance companies have outlawed the option for women with a prior C-section to have subsequent deliveries vaginally.  As the rate of cesarean deliveries steadily rises, women will be forced to abandon their right to childbirth and self-determination by involuntarily consenting to an unnaturally invasive procedure. 

While the latest practice guidelines agree that trial of labor after cesarean (TOLAC) is generally safe for most women in the absence of contraindication (American College of Obstetricians and Gynecologists, [ACOG], 2010), the risk for complications and ensuing lawsuit liability has led to loss of VBAC support from nearly a third of hospitals and at least ½ of obstetrical practitioners (NIH Conference Statement, 2010). In recent surveys regarding VBAC litigation and liability, ACOG confirmed assumptions that liability concerns had significant influence on recent childbirth practices. Nearly 20% of providers refused TOLAC services due to high costs of malpractice insurance despite patient preferences and requests (ACOG, 2009).

Although VBAC and TOLAC are acceptable child birthing practices, the moral interests in ethical principles are heavily in question. While uterine ruptures have accounted for less than 1% of failed attempts of TOLAC, the resulting incidence of neonatal disability associated with uterine rupture is significantly less than the risk of some invasive diagnostic procedures, such as chorionic villus sampling and amniocentesis (Bonanno, Clausing, & Berkowitz, 2011). Additionally, cesarean deliveries have been associated with greater incidences in postpartum depression, posttraumatic stress disorder, and negative perceptions of the child birthing experience (Lobel & DeLuca. 2007).

Thus, the argument for support of beneficence and nonmaleficence is lacking in sufficient integrity. Furthermore, justice cannot be regarded due to the inequality of interests being served by providers choosing to preserve legal and social precedence in place of patient values and beliefs (Beauchamp, & Childress, 2009). The remaining principle of moral service and professionalism demonstrates the significance of patient centered values, and human dignity to support the superior influence of self determination and respect for autonomy in biomedical ethics.

Please watch this beautiful video….

http://www.thebirthmovie.com/

Reference:

American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: vaginal birth after previous cesarean delivery. Obstetrics & Gynecology, 116: 450–63.

American College of Obstetrician Gynecologists. ACOG survey on professional liability. American College of Obstetrician Gynecologists.

American Nurses Association, (2001). Code of Ethics for Nurses. Nursebooks.org: Silver Spring, MD.

Bonanno, Clausing, & Berkowitz, (2011) VBAC: A Medicolegal Perspective. Clinical Perinatology, 38: 217–225

Lobel M., & DeLuca, R., (2007). Psychosocial sequelae of cesarean delivery: Review and analysis of their causes and implications. Social Science of Medicine, 64(11):2272–84.

NIH Conference Statement. Vaginal birth after cesarean. Obstetrics & Gynecology, 115:1279–95.