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Time to Deliver? Mother Nature Knows Best

Thursday, December 30th, 2010

For years, I’ve been sounding the alarm about Cesarean delivery on-demand, and have persuaded my patients that childbirth isn’t something you can simply pencil into your schedule when convenient. It’s not just that a baby needs all the time nature gives her within the womb to develop, and that delivering just a few days early can mean that lung development and other functions may be potentially compromised. Cesareans are major surgery, which brings inherent danger to both mom and newborn. Necessary Cesareans are often life-savers. Unnecessary Cesareans can be just the opposite.

And now, at last, the word is spreading.

The San Jose Mercury News reports:

Babies born early through induction or C-section without a medical reason are nearly twice as likely to spend time in the neonatal intensive care unit, researchers say. They also are more likely to contract infections and need breathing machines, according to a 2009 study in the New England Journal of Medicine and a number of other reports.

“We are finding out that the last weeks of pregnancy really do count,” said Leslie Kowalewski, an associate state director for the March of Dimes.

“At 35 weeks, the brain is only two-thirds of what it will weigh at 40 weeks.” Many organizations are responding with programs designed to eliminate early elective deliveries. Most significantly, chapters of the American Congress of Obstetricians and Gynecologists have begun to notify doctors about the serious consequences of performing early elective births.

With luck, as information about potential consequences spreads, expectant mothers and their doctors will decide to let nature take her course, for the sake of the mom’s health and her baby’s.

– Yvonne S. Thornton, MD, MPH

Why is the Maternal Mortality Rate in the U.S. So High?

Thursday, May 27th, 2010

In the richest nation on earth, with an advanced health care system, and the technology available to monitor and treat mothers and their babies, you’d expect the United States to have among the lowest rates of maternal mortality. So it’s distressing to learn that, although it’s still relatively rare for mothers to die as a result of pregnancy and childbirth, it happens here more often than it should. The U.S. is ranked 41st in maternal deaths among 171 nations analyzed by U.N. experts. That’s a worse record than virtually any other developed country — even worse than a good number of under-developed countries. What’s even more distressing: the death rate is rising.

The question is why? Why is pregnancy so risky in such a rich nation?

Often, the reason is a pre-existing disorder that complicates pregnancy, such as obesity, high blood pressure, or diabetes. The lack of access to good quality care among the uninsured also puts women at risk, leaving them without diagnosis and treatment for conditions that can cause problems until the condition gives rise to a full-blown emergency.

But there’s one contributor to maternal death that might surprise you. Our wealth, itself, could be contributing to the risk, because it encourages the prevalence of Cesarean-on-demand.

According to the CDC, in 2007, 31.8 percent of births were by Cesarean section. The rates of births by C-section have risen every year for at least eleven years.

While C-sections can be, and often are, life-saving, it’s difficult to justify that high a rate. The World Health Organization estimates that the U.S. rate is twice what would be medically necessary.

Cesarean births are now treated as routine, but major surgery is never routine. Major surgery comes with the risk of complications, including hemorrhage. And the C-section, as common as it has become, is still major surgery.

Childbirth is usually very safe, but it could be safer. Giving all women access to pre-natal care and preventive medicine is an important start. But it’s also important to remember that a woman’s body was designed to deliver babies the old-fashioned way. And choosing unnecessary surgery instead could be inviting trouble.

– Yvonne S. Thornton, MD, MPH

Babies I’ve delivered, all grown up

Friday, April 30th, 2010

Other doctors deal mostly with unhappy occasions, from a sniffle to serious illness, but obstetricians are there for the happiest times – the birth of a child – which is why I always say I have the best job ever.

I was reminded of just how wonderful my specialty has been to me by an e-mail from a patient transferred to my care 16 years ago, who eventually had to undergo a complicated cesarean delivery. As a maternal-fetal medicine specialist, I was called in by her obstetrician for difficult cases like hers.

She was carrying twins and had been in the hospital for a week. The night before the delivery, she’d had a very rough time. To help get through it, she’d watched “The Sound of Music” on TV.

The next day, in the delivery room, I delivered her babies by cesarean, fraternal twins, one boy, one girl. As I sent the babies off to the nursery, I noticed that her ovaries were very large and purple and asked if she’d been on fertility drugs. She hadn’t been but I called in two more specialists to consult and chatted with her as we reviewed the situation. Despite their enormous size and color, the ovaries did not pose a threat to her health and I decided to leave them where they were and just watch the situation.

We got to know each other better as I visited each day. When she mentioned the movie she’d seen the night before the delivery, I told her that it was one of my favorites and that I’d copied Maria’s wedding veil for my own wedding. After she and her babies went home, we stayed in touch and I sent her a copy of my first memoir, THE DITCHDIGGER’S DAUGHTERS.

Just last week, those twin babies turned 16 and my patient sent me some photographs of them looking all grown up.  It brightened up my day to see them, and to know that I had a hand in bringing them into the world. She also spoke of how she loved my book. So I can’t wait until my new memoir, SOMETHING TO PROVE, is published this fall. She’s going to be one of the first people I send a copy to.

– Yvonne S. Thornton, MD, MPH

Pregnancy and Swine Flu: a Dangerous Combination

Friday, December 4th, 2009

The word from the Centers for Disease Control is that women who are pregnant are at high risk from the H1N1 virus, also known as the swine flu.

If you’re pregnant, you need to get vaccinated with both the seasonal and the H1N1 vaccines. It’s the single best way to protect yourself and your baby from the flu. And don’t let the anti-vaccination rumors swirling around the Internet scare you into delaying or avoiding a flu shot. According to the CDC, the seasonal flu vaccine has been administered to millions of women and has not been shown to harm women or their babies. The 2009 H1N1 flu shot is made in the same way and in the same places as the seasonal flu shot.  You may receive both flu shots at the same time; however, they should be given at different sites on your body, e.g., left arm and right arm.

Although recent cases of swine flu have been diminishing, influenza epidemics tend to come in waves. So even if there are few new cases of the flu in your area, it may just be a lull and you could get hit by the next wave. Get vaccinated now, if the vaccines are available in your area. Get everyone in your household vaccinated to prevent the disease from spreading among family members. Babies under 6 months of age are too young to get the vaccine so it’s especially important to their health that other members of the household are vaccinated to protect against family members spreading the virus.

Here are some other ways you can protect yourself from the germs all around us.

  • Wash your hands often with soap and water. Or use small bottles of alcohol-based hand sanitizer you can carry in your purse.
  • If you have flu symptoms, call your doctor immediately. Pregnant women tend to get more serious cases of this flu and it’s important to get treatment. Your doctor can prescribe medicines that will help.
  • Don’t assume that, just because you don’t have a fever, you don’t have the flu. This flu doesn’t always cause fever.
  • Try to avoid contact with others who appear ill. If someone in your family gets sick, ask your doctor to prescribe medications that may prevent you from getting sick, too, such as Tamiflu® or Relenza®.
  • Cover your nose and mouth with a tissue when you cough or sneeze and throw the tissue away immediately. If a tissue isn’t available, sneeze into your sleeve, not your hand.
  • Keep your cabinets well stocked with non-perishable foods as well as other basics and medicine that you might need if you got sick.

The CDC warns that if you are pregnant and experience any of the following, you must call 911 immediately:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Sudden dizziness
  • Confusion
  • Rapid pulse over 100 beats per minute
  • Severe or persistent vomiting
  • A high fever that is not responding to Tylenol®
  • Decreased or no movement of your baby

Just remember, the nasal spray vaccine is not licensed for use by pregnant women because it is a live, attenuated virus. Pregnant women should not receive nasal spray vaccine for either seasonal flu or 2009 H1N1 flu. After delivery, women can receive the nasal spray vaccine, even if they are breastfeeding.

In summary, get vaccinated, practice good hygiene, and call your doctor immediately if you get sick, and you and your baby should come through this flu season just fine.

– Yvonne S. Thornton, MD, MPH

Labor & Delivery: Don’t try this at home

Monday, November 30th, 2009

Most women today have no idea how dangerous it once was for a woman to give birth. The maternal death rate today is about eight per 100,000 births.  When home births were in style, the maternal death rate was 83 per 100,000 births – 10 times the number of deaths.

Women today almost never die in childbirth because, when things go wrong during labor and delivery, medical professionals can step in and prevent emergencies from becoming tragedies.

Which is why I want to scream when I read nonsense like the following, from a website calling itself “Born Free.”

“Welcome to Bornfree! This site is based on the belief that childbirth is inherently safe and relatively painless provided we don’t live in poverty, and do not interfere either physically or psychologically. Drugs, machinery, and medical personnel are not only unnecessary in most cases, they are also no match for a woman’s own intellect and intuition.”

The site quoted above advocates for unassisted childbirth at home. No doctor. No midwife. And no professional help at the ready if something goes wrong.

Ordinarily, I wouldn’t get too exercised over an obscure website. But, it’s how I found this website that has me troubled. It was featured in an article on ABC News.com in the “Entertainment” section. The article mostly extolled the concept of women giving birth at home, with neither a midwife nor a doctor present, giving only the briefest nod to the caveats from an ob-gyn.

In the age of reality TV, maybe a piece about women risking their lives to experience “freebirth” makes good copy. Maybe, because it was in the Entertainment section, this quote from a mother who recently gave birth on her own didn’t raise any eyebrows: “…it is not risky if you do your homework.”

But ask an ob-gyn and you’ll get a much different albeit less entertaining quote.

Yes, so-called “freebirth” is risky. And no, you can’t mitigate the risk by doing “homework.” Approximately 40 percent of high-risk patients appear to be low-risk before labor and delivery. No amount of “homework” can prepare a woman for suddenly finding herself among those 40 percent. If she’s at home, without medical attention, she and her baby could be in serious danger.

Most certified nurse midwives are affiliated with hospitals today precisely because the unexpected can and does happen during childbirth and having medical and surgical teams within shouting distance can mean the difference between life and death. The birthing process is still the 11th leading cause of death in women between 15 and 44 years of age.

When I was in the military, we received a stat call about a home birth gone wrong. The woman lost all muscle tone in her uterus after the birth of her child. By the time the ambulance got her to Bethesda, she had bled to death.

So I’ve seen firsthand how “freebirth” can be a recipe for disaster.

– Yvonne S. Thornton, MD, MPH

CVS: a first trimester alternative to amniocentesis

Tuesday, August 25th, 2009

Amniocentesis (amnio) is a test that identifies the presence of a chromosomal or genetic defect in the growing fetus, such as Down Syndrome or Tay-Sachs disease.

But amniocentesis can’t be done until a woman is between 16 and 20 weeks pregnant. If a serious problem is found, and the patient chooses not to continue with the pregnancy, then it is a more involved procedure than during the first trimester. And it can be more heart wrenching to have to make such a decision after investing so much hope in a pregnancy that has progressed to 18 or 20 weeks.

What many prospective parents don’t realize is that there is an alternative to amniocentesis that can be done during the first trimester, as early as 10 weeks. It’s called chorionic villus sampling (CVS). It’s about as safe as amniocentesis. Either procedure (CVS or amnio) has a fetal loss rate (miscarriage) of less than 1%. And, in most cases, CVS can be as good a choice or better.

As one of the investigators for FDA trials of the procedure in the mid-1980s, I was among the first physicians in the U.S. to gain significant experience in chorionic villus sampling.

If you are older than 35 and your ob-gyn has recommended prenatal genetic testing but hasn’t offered this alternative to you, it may be because fewer physicians are trained in CVS than in amnio.

But you and your pregnancy should not be penalized just because your physician does not perform CVS.

If you’d prefer to have chorionic villus sampling, check with one of the major academic medical centers in your area where CVS is more likely to be performed regularly. And be sure to have it done by a physician who has over 100 procedures under his or her belt, because the procedure has a steep learning curve. The miscarriage rate is directly related to the experience of the person performing CVS.

The advantage with CVS is that you will know the results of the test within a week, while you are still in your first trimester.

– Yvonne Thornton, MD, MPH

Why your Ob-Gyn should be board-certified

Wednesday, July 22nd, 2009

It’s almost impossible to judge a professional’s skills if you’re not a member of that profession. Only a radiologist can say whether another radiologist accurately read a CT scan. Only a dentist can attest to the quality of the crown another dentist fits over a molar.

So how do you, a layperson, judge the qualifications of your doctor? If they drive fancy cars, wear designer clothes, and charge the highest fees in the community, you can be sure they’re successful. But does that mean they’re qualified? You can ask your girlfriends or your sister or mother to recommend someone. You can determine whether you have rapport with a physician. But that won’t tell you about qualifications, either.

If you want to know whether the kind, caring person you select has the minimum qualifications, there’s one way to determine that. Go here to see whether your doctor is board-certified.

Board certification isn’t mandatory. Once a doctor gets a medical degree and a state license to practice medicine and surgery, he or she can practice any specialty. No law requires a doctor to complete a four-year residency in a specialty, such as ob-gyn, in order to be called a specialist. Nothing prevents a doctor from giving him or herself the title of obstetrician or fertility expert or perinatal specialist or really, almost anything.

But only board certification assures you that the doctor has earned that title.

A board certified doctor has gone a giant step further than a physician who hasn’t passed her boards. After completing a residency program, passing a written test in the specialty, and practicing for a year or two, she’s gathered up all her cases and submitted them to an august body known as the American Board of Obstetrics and Gynecology. Before these distinguished university professors and chairs of departments, she’s been extensively questioned about real and hypothetical situations and asked about diagnoses, patient management and treatment.

As an oral examiner for the American Board of Ob-Gyn since 1997, I’ve certified hundreds of new ob-gyn candidates who have proven their capabilities under difficult circumstances. And there were some who did not pass because they didn’t meet those high standards.

So I speak from experience when I say that board certification is the minimum you should expect from your doctor.

Yvonne S. Thornton, MD, MPH

For my father, Donald Thornton, on Father’s Day

Friday, June 19th, 2009

Dear Daddy,

You know how much I relied on your guidance as I was growing up. But I wonder what you’d think if you knew that, even now, more than 26 years after we lost you to a stroke on a snowy February day, your wisdom still guides me.

I know you regretted dropping out of school as a young man and, although you seemed content to work 16 hours a day, it must have hurt not to have the opportunity to better yourself.

I know you wanted better for us, your children.

We may have grumbled when we were kids because you demanded so much. You insisted we get the highest grades in our classes. An A wasn’t good enough for you. You expected every grade to be an A+. We had to reach so high that nobody could yank us back down.

People laughed when you told them your five girls were going to grow up to be doctors. Impossible, they said.

And yet, as the first African-American woman to be board-certified in maternal-fetal medicine (high-risk obstetrics), I’m living proof that your dreams weren’t impossible after all.

Your dreams and your demands for us to do our best are the reasons why, among your five daughters, two are now physicians, one, an oral surgeon and another grew up to be a lawyer.

But I owe you for more than my career in medicine, Daddy. There isn’t a problem that I come across in life where I don’t ask myself, what would Daddy do? There isn’t a day that goes by that I don’t think of you. There will never be a time when I will stop missing you.

Even though, I know, you’re very much with me. Even now. Happy Father’s Day.

– Yvonne S. Thornton, MD, MPH

Pregnancy and the pill

Tuesday, June 16th, 2009

For many women, taking the pill is more a matter of delaying pregnancy until the time is right rather than preventing it all together.

So, the big question becomes, how long after you stop taking the pill can you expect to become pregnant? No two women are alike but, generally speaking, pregnancy is possible the next time you ovulate. You may ovulate within two weeks after finishing up your last package of birth control pills. So, theoretically, you could become pregnant almost immediately. However, as we all know, there are many variables. Some couples try for years to become parents without success.

It almost seems an unfair trick of the heavens that it’s sometimes the women who don’t want to become pregnant who easily do.

That means, if you’re dead set against pregnancy, and you stop the pill, you need to begin another form of contraception immediately. I actually recommend that my patients begin using an alternate contraceptive before getting off the pill so they get into the habit of using it.

Otherwise, you may have to get into the habit of changing diapers.

– Yvonne Thornton, MD, MPH

A letter from a reader that touched my heart

Wednesday, June 10th, 2009

I usually blog about women’s health but I wanted to depart a bit from that today because of a letter that a young woman named Jacinta sent me.

Jacinta read my memoir, The Ditchdigger’s Daughters, and found in the story the encouragement she needed to become a doctor herself. But let me allow her to tell it in her own words:

“I am 19 years old. I just finished reading your book and it truly inspired me. I want to work with children in the medical field and reading about the obstacles that you overcame to work in the medical field really encouraged me to work harder to accomplish my dream. The thing that really encouraged me was at the end of the book when you and your sisters were sitting around reminiscing about the things that your dad had taught you down through the years … ‘Daddy was the bow, we were the arrows and he aimed high. He didn’t say midwives, he said doctors. He didn’t say dental assistants, he said dentist.’ He always encouraged you all to be leaders and to be the best at whatever you did. That really stuck with me when I read it.

“I can be a leader. I love kids and I always knew that I wanted to work with them, but I never really decided how I wanted to work with them. So I decided that I would either be an obstetrician or a pediatrician.

“… I watched your interview on C-SPAN and I remember you saying that your father told you that the only person that can stop you is you. Well I’m not going to let me stop me so I decided to work towards all my dreams.”

As those who have already read The Ditchdigger’s Daughters know, my father was a blue collar laborer and my mother cleaned houses for a living. But they were determined to see their five daughters do better. They insisted that we work hard, get as much education as we could, and aim for the top. My father had a dream that we would all become doctors. Two of us are physicians now, one is an oral surgeon, another became a lawyer with a Ph.D.,  and one, a court reporter.

I want to take this opportunity to speak to all those like Jacinta, whose families may not have all the advantages. You can make a better life for yourself. If my sisters and I could do it, you can do it. Believe in yourself and be willing to work harder than you ever imagined possible. Then, work harder still. Stay in school, study like your life depends on it (because, in a way, it does), and don’t let anything hold you back, especially not your own negative notions about the limits placed on you from the outside.

And I want to say thank you to Jacinta. Knowing that my book touched you means so much to me.

It’s letters like yours that have inspired me to begin working on a new memoir that picks up where The Ditchdigger’s Daughters left off. I hope that this book, too, will persuade readers to reach higher, study harder, and pursue their dreams.

– Yvonne S. Thornton, MD, MPH