You are not eating for 2…

pastaOne of the most common phrases I hear amongst patients and in the media is “I’m eating for two,” when referring to pregnancy as an excuse for excessive food portions. This is just not true ladies. As I tell my patients, you are not, in fact, eating for two, but you are eating for yourself and a tiny baby. So that sandwich you are eating as an appetizer to your actual dinner? Completely unnecessary. I hate to break it to you ladies, but you only need about 200-300 extra calories A DAY. Unfortunately, excessive weight gain and/or obesity during pregnancy is a big deal. First, you run the risk of gestational diabetes, which turns your normal low-risk pregnancy into a high risk pregnancy, complete with food journals, blood sugar logs, and occasionally medications, frequent visits to the doctor, ect. We won’t even go into all that “fun stuff” in this post. Additionally, even without diabetes, we worry about the baby also gaining too much weight. cesarean incision with staples, caesarean.org.ukThis can lead to difficult, prolonged labors, complications during the delivery, and God forbid if you do need a c-section, don’t hold it against your doctor if she can’t make a very aesthetically pleasing incision/scar due to the inches of excessive fat tissue. In these situations, wound healing is at risk for dehiscence (opening of the incision), and risk of infection when the belly hangs low over the wound and creates a breeding ground for bacteria. Aside from the serious risks associated with excessive weight gain in pregnancy, your doctors also have to listen to your complaints about feeling tired, bloated, swollen, aches, stretch marks, “feeling like a whale,” and the list goes on and on. Don’t get me wrong, many of these complaints are inevitable parts of pregnancy, but can also be prevented or lessened in severity by simply watching what you eat.

So how do we prevent these unfortunate circumstances? First off, starting at a healthy prepregnancy weight and BMI is crucial to your overall health and well-being, whether you are planning pregnancy or not. Let’s not kid ourselves, we all love fast food, pizza, beer, and everything that might make you look pregnant when you arn’t.I for one have had an intimate love/hate relationship with pizza, pasta, and McDonalds forever. Recently, we have decided to go our separate ways, and now we are just friends. Trust me, I know your pain over eating right, exercising, and maintaining a healthy weight. weightgain pregBut seriously, its important. If you should find yourself trading that “food baby” belly for a real baby bump belly, a healthy lifestyle is not just crucial for you, but for the health of your baby also.

Every woman and pregnancy is different. That being said, some women may have a little more leeway in how much weight is appropriate during pregnancy. For example, a woman that is already starting out with a high BMI or is overweight has a much smaller window for weight gain than another woman who is underweight. Its not that we are picking on the heavy girls, I promise, we all know you just have more to love. weight-distribution-during-preg-picBut you are already starting out at a riskier weight, and therefore the weight that you do gain, should more or less only be attributed directly to the pregnancy (growing baby, placenta, uterus, blood volume, etc.). So first off, determine your BMI (we all know you’ve seen that app in your phone), and based on your BMI, look at the chart to determine the recommended weight gain for the total pregnancy. 7508_ideal_weight_gain_during_pregnancyLet me reiterate, this is how much weight you should be gaining by the END of your pregnancy, and the majority of that said weight should be happening towards the third trimester. If you find you have almost reached your total weight gain amount halfway through your second trimester, its time for an intervention. It’s not that we’re calling you out on your weight problems. OK maybe we are, but its because we care about you! There are times when excessive weight gain might have pathologic causes, and you might need some lab work and a little more investigation to figure out what’s going on. jessica-simpson-pregnancy-weight-gain-300x300But if it’s because your pregnancy cravings sent you to Olive Garden for bottomless pasta bowls, then we have a problem. But please, I ask that no woman takes offense if that touchy weight gain subject comes up at one of your prenatal appointments. I promise, there is no pregnant woman mold, and we know how everyone has their own shape and size. But it is important to not be careless with eating and overeating during pregnancy. Please, stay away from fatty foods, and foods high in sugar and salts. Go for high fiber foods, veggies, whole grains, proteins, etc. We want a controlled, healthy weight gain that can keep your baby safe, and hopefully help make the pregnancy as enjoyable as possible.

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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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STDs+PID=Salpingitis

Salpingitis is one of the complications caused by Pelvic Inflammatory Disease, a sexually transmitted infection whereby the causative agent, usually a Gonococcus or Chlamydial infection, ascends upwards throughout the female genital tract, starting in the vagina and spreading to the superior structures of the uterus, fallopian tubes, and ovaries. The resulting inflammation usually causes severe abdominopelvic pain and tenderness, with accompanying fever and vaginal discharge (Kumar, 2010).

Although Pelvic Inflammatory Disease is a treatable condition, the infection has the potential to produce long-term structural defects, that could cause infertility (Gibson, 1999). In the attempt to fight off the infection by the body’s immune response, many histological changes may result from the process, leading to scar tissue formation in place of normal endometrial tissue. In the organs where optimal functioning of the structures is essential for successful reproductivity, alterations resulting from cellular tissue repair may impede the ability for normal ovulation processes to occur. Some of the dysfunctions are the result of scarring of the tubes, and tuboovarian abscesses that permanently occlude the fallopian tube, inhibiting the passing of the ovum for fertilization (Bozoyan, 2006). Furthermore, the inflammation to the adnexa significantly increases the risk of ectopic pregnancies due to the resulting damages in tissue function induced by the infection and immune responses (Gibson, 1999).  In addition, acute salpingitis is often undiagnosed, or seen in later stages, due to a slow progression of symptoms that may be only mildly experienced.  When symptoms present as severe enough to seek treatment, the infection has often progressed to encompass the majority of the reproductive organs, and significant structural damage may have already occurred (Gibson, 1999).

As healthcare professionals, it is imperative to initiate aggressive treatment to eliminate the inflammation as soon as possible in order to prevent further damage and complications. Furthermore, early education on healthy and safe sexual practices should be initiated whenever possible to enhance understanding, and  prevent incidences of sexually transmitted infections.

References:

Bozoyan, M., (2006). Pelvic inflammatory disease; Sexually transmitted infections.

Armenian Medical Network. Retrieved from http://www.health.am/sex/more/pelvic_inflammatory_disease/

Gibson, M. (1999). Pelvic inflammatory disease: chronic sequelae of salpingitis.

Contemporary OB/GYN, 44(8) 123

Kumar, V. (2010).  The female genital tract. Robbins and Cotran; Pathologic basis of disease, pp 1009-1010. Philadelphia: Elsevier.

Nursing School 101: Bed Baths

Previously in nursing history, performing bed baths on patients was a trivial, time-consuming task that not only has been seen to be cost inefficient due to the amount of time taken to prepare and perform the bed bath, but also poses several risks to the skin integrity of the patient in a number of circumstances, due to cross-contamination, drying out of skin from soap, and removal of critical natural substances essential to maintaining skin integrity. There have been many attempts to improve the effectiveness of the bed bath, in the form of inventions such as using soaked wash cloths, and various types of bath mitts, (U.S. Patent) that have decreased time consumption of the bed bath, but still posed challenges when maintaining skin integrity of the client. It wasn’t until 1995, that a team of nurses addressed each individual problem of the bed bath, and came up with a solution that not only decreased the workload for nurses, and improves cost effectiveness, but allows for cleansing and removal of dirt without drying of the skin or sacrificing the skin’s natural defenses.

A recent study in Japan showed that the workload of nursing care centers its highest percentage of time and cost in giving complete and partial bed baths. This survey, conducted using Conjoint Analysis, wanted to measure the value of hospital care and make an effort to estimate where the majority of the workload of nurses was being placed throughout daily tasks. The results were listed as bed baths holding the greatest workload, followed by giving intravenous medications in second, and assessing vital signs in third. In regards to cost, the survey concluded that, with the assumption that the average salary of a registered nurse in Japan was 25 thousand yen, a complete bed bath served a value of approximately 93.38 yen for a single unit (Anezaki, Aso, & Ohkusa, 2006). For a nurse that performs bed baths to several patients daily, it decreases the amount of time the nurse has to commit to more effective measures of care, such as administering medications on time, and adhering to the needs of more critical patients.

More importantly than the time consumed by the nurse in preparing and performing bed baths, is the lack in the overall quality of care a bed bath is really providing to the patients. Ideally, a bed bath would consist of numerous washcloths and water changes to prevent cross-contamination in different areas of the body being washed (Burke, 2002). In reality, there serves no time to complete such tasks, and the same water and washcloth is used to service the entire body. Because the skin is the body’s primary line of defense against the outside world, maintaining proper skin integrity is essential to many patients recovering in the hospital. The use of different kinds of soaps causes dryness to the skin of many individuals, especially the elderly, whose skin is at highest risk for breakdown due to a decrease in moisture and elasticity in the skin. These soaps also remove some of the essential acids and salts of the skin that help prevent growth of harmful bacteria (U.S. Patent). In an effort to decrease costs, washcloths that are used are of poor quality, and are coarse and harsh to the skin, increasing friction while cleaning. In combination with the skin drying action of the soap, the risk of skin breakdown increases dramatically, putting patients at higher risk of developing pressure ulcers and skin infections (U.S. Patent).

In attempts to improve washcloth quality by making softer texture cloths, there was a deficit in the ability to remove dirt and the cloths often would disintegrate after getting wet. Some of the solutions used as a substitute for soap did not prove to be effective in eliminating bacteria, nor did they leave the natural acid mantle of the skin intact (U.S. Patent). The solution of one problem often led to the deficit of another critical factor in developing a product that would not only be cost efficient and less time consuming for the nurse, but that would provide critically important quality of care to the patient’s skin in cleansing with effectiveness to reduce growth and transmission of bacterial organisms, and also provide safety to the integrity of the skin to prevent dryness and breakdown. Even better would be a way to produce bulk quantities of the product for efficient storage while maintaining proper sterile technique. Developing a product with all of these crucial characteristics seems impossible without sacrifice in another area. Originally thought up by Susan M. Skewes, RN, using a set of soft wash cloths soaked in cleanser and placed in sealed plastic bags until use, the “Bag Bath” took on a series of experiments, alterations and improvements to create the ultimate bathing tool (Skewes, 1994). After formulating this product, the question was if it was actually more efficient than the traditional bed bath. A study consisting of 30 patients and 21 nurses took place using the “Bag Bath” products, and a survey sought out questions to determine the level of satisfaction with the bathing technique. Overall, the survey showed that 81% of the nurses “stongly agreed” that the bag bath saved them a significant amount of time in bathing patients. The study showed that the average time to give the bed bath using the product was approximately 12 minutes (Skewes, 1994), compared to traditional bed baths requiring 20 minutes or more (Burke, 2002). Amongst other findings were the patient satisfaction rates. Skewes reports her findings in her article “No more bed baths” where approximately 80% of the patients strongly agreed that they felt cleaner, and their skin felt softer after receiving the ‘bag bath’. More importantly, nearly all the patients that received this bathing technique from admission to discharge had no findings of skin integrity break down or impairment, and those that had breakdown before use of the bag bath actually had improved skin integrity by discharge (Skewes, 1994).

Shortly after her debut with the “Bag Bath,” Skewes teamed up with fellow nurses and engineers John P. Martin, and Russell Raddatz to finding a more impressible form of the bag bath. After many long months of research and testing, the inventors finally developed the ideal product to performing the bed bath efficiently and cost friendly. The product, titled Cleanser-Impregnated Cloths for Cleansing the skin, was formulated with the idea of maintaining sterility until use, being kept in a sealed polyethylene bag for safe storage. The bags consist of a various number of disposable cloths in quantities of 2, 4, 6, 8, and 10 cloths, for a variety of complete, partial, pediatric, and facial cleansing techniques, that allows for disposal of each cloth after being used in a certain area. This technique prevents cross-contamination of the body parts, and risk of infections in greatly reduced. Each cloth consists of cotton and polyester fabrics, woven together with needle puncture to ensure the softness of the fabric, and maintaining the integrity of cloth. Each cloth is damp with a cleansing solution that does not need to be, and should not be rinsed from the skin. The solution will evaporate, leaving behind remnants of vitamin E and therapeutic skin formulas to render the skin feeling fresh and soft. Because the product is able to store indefinitely if unopened, it can be bought wholesale in large quantities to reduce cost. Because the cloths are disposable, and require almost no time for preparation, the workload is significantly reduced, and the nurses and patients are much happier with the use of the product in comparison to the traditional bed bath (U.S. Patent)

 

Anezaki, H., Aso, Y., & Ohkusa, Y. (2006). Evaluation of Nursing Care—Using

conjoint analysis. Journal of Japan ,Academy of Nursing Science 26(4): 102-109.

 

Burke, A. (2002). Personal Care II. Nursing Assistant Education. From

http://www.nursingassistanteducation.com/site/courses/eng/nae-pc2-eng.php

 

Skewes, S. (1994). No more bed baths! RN Magazine 57: pp 34

 

Caesarean Deliveries and the Development of Childhood Allergies and Respiratory Issues

As medical advancements make more and more contributions to the way patients receive treatment, there seems to be an all time high in the rate of Caesarean sections amongst normal births. Reasons for this include the desire for quick, uncomplicated labor, and fears and lack in confidence regarding natural childbirth (Childbirth Connection, 2007). As a result of this increased incidences of C-sections, there has been more research exploring long-term effects of this method of birth on the children. The most significant findings have been increased rates of asthma, allergies, and chronic bronchitis amongst children delivered by c-section versus those delivered vaginally. In a retrospective cohort study, children that had been recently diagnosed in the past decade with any respiratory disorders, including allergies and dermatitis were investigated on their birth statistics, including birth weight, delivery method, gestational age, and maternal behaviors (Renz-Polster, 2005).  This investigation found a significant correlation between delivery by c-section and incidence of respiratory problems and allergies later in life. The pathologic process is thought to be due to the lack of microorganism exposure during the birthing process (Renz-Polster, 2005). The thought rises from the idea that decreased exposure to environmental organisms in the first few days of life leads to increased rates of allergy development; the normal intestinal flora of the newborn is generally acquired as it is exposed to organisms in the vaginal tract during the birthing process. This phenomenon is thought to be one of the most important factors contributing to this study, because it is associated with the necessary introduction to environmental organisms that leads to the development of immune system tolerance outside the sterile fetal environment (Renz-Polster, 2005). When the infant is removed by c-section, there is no contact with the maternal vaginal flora, and microbiotic exposure is experienced differently through skin contact over the next few days, with introduction of a different type and quantity of microorganisms (Renz-Polster, 2005). Furthermore, natural mechanical processes of a vaginal birth allow the expulsion of amniotic fluid from the lungs of the infant as its chest is compressed through the birth canal. In this manner, the infant’s lungs are better primed for the first breath, as opposed to during c-sections, where there is no mechanical compression of the chest, and fluid removal is often extracted by suction mechanisms, often leaving the infant with fluid still in the lungs, making it harder for it to begin breathing on its own.

With these findings, it is imperative that as health care providers we stress the importance of avoiding birth by Caesarean if at all possible. We need to provide out patients with the education necessary over what to expect during the birthing process, and how to appropriately manage delivery without surgical interventions. This is probably the most critical factor to implement, to explore delivery options before maternal stress and exhaustion from labor is experienced. This will lead to better informed consent, and will likely reduce the incidence of delivery by c-section. Furthermore, it is also important to inform our patients that subsequent deliveries after a c-section are often routinely performed as c-sections, further increasing the amount of risk for developing allergies and respiratory problems in the family later in life.

References:

Childbirth Connection (2007). Choices in childbirth. The New York guide to a healthy birth.

Renz-Polster, H. (2005). Caesarean section delivery and the risk of allergic disorders in childhood. Clinical & experimental allergy, 35: 1466–1472. doi: 10.1111/j.1365-2222.2005.02356.x