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

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


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


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


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


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


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


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


Take Care out there ladies!!

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

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


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


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


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

Pelvic Organ Prolapse

 

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

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

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


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

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

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

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


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

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

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

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

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


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

Postpartum Depression

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

The Different types of Midwives

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

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

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

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

Twins....

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

Episiotomies

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