Birth Trauma, a failure or a tragedy?
December
16 ,
2009
I've been asked by our twitter followers to discuss birth trauma, and I had to spend a few days thinking about how to approach this topic. At first I started collecting data on different types of birth trauma, their causes, how to prevent them, and so on. Briefly speaking, I started to approach the subject like I do every other medical subject I treat every day.
But then it struck me that I have so much more to say than that. I want to describe to you some of my most distressing experiences as an obgyn, and how they have affected me and how I approach what I do every day.
I love what I do for a living, in case you haven't noticed yet by reading my blog. One of the greatest joys of my job is delivering a beautiful happy baby to a set of proud new parents. Fortunately, the experience is usually full of pride, joy, and excitement for everyone, and I get to feel like I was a part of something so wonderful that words cannot describe.
However there have been a few occasions in my career where there have been injuries to the babies that I delivered. I've experienced a broken bone, a laceration, and even an eye injury. I remember every single one as if it happened yesterday. Often I encounter patients that remind me for some reason or other of the patients that I delivered that had the injury and I relive the moment of delivery in my mind.
The feeling of a tiny little bone breaking in my hand. I shake and shudder, and sometimes cry every time I think about it. I remember speaking with the little girls new Mom, explaining what happened and why, explaining the particular risks involved, and looking her in the eyes. She didn't want to know why, just what would be done for her baby, what was the prognosis. Not even a hint of anger, she just wanted to know how her baby was going to heal.
The sight of a baby whose eye was injured by my surgical instrument, the sadness and disappointment in myself, all of my pride seemed to disappear in a flash. One minute I was a confident surgeon, the next minute I felt like a sloppy fool.
My colleagues reviewed the case, after reading through the records, reviewing the tests, studies and notes; they tried to give me encouragement.
I was told: "It could have happened to anyone" "Under those circumstances - you should be proud of yourself" "I could never have done it better myself" and so on. But nothing consoled me. Until I spoke to Mom and Dad. The look in their eyes of trust. They just wanted me to tell them what happened and how. What is the prognosis? How will their baby be treated? What kind of doctor do they need, and can we give them a proper referral. Not a hint of anger, only love and concern. The parents made me feel like a doctor again. They just found out that their baby was injured, and they reminded me what the primary concern is. The health of the person you are taking care of. Not whose fault it is, not my self esteem or confidence, not my malpractice insurance premiums, but the Mom and the baby.
I learned this from Moms and Dads. In a way, it was from these few cases that I learned the value of what I do every day. I take care of people, beautiful people, and I am one of the luckiest people in the world.
Is Yaz safe? What are the facts?
December
09 ,
2009
The New York Times reported September 25 on the controversy surrounding Yaz and Yasmin, two popular birth control pills (BCPs). The claim is made that these pills increase the risk for developing dangerous blood clots.
Let’s take a step back for a moment and remind ourselves how birth control pills work. Most pills use a combination of both estrogens and progestin’s to prevent ovulation, and Yaz and Yasmin do this as well. It is estimated that without any medications, about 1 woman in 10,000 will have a blood clot in a given year. However, if they are taking birth control pills, that number increases to about 3 in 10,000. (But don't forget to consider that more than 50 women in 10,000 will get a blood clot due to pregnancy.) This is the case with all birth control pills, so what's different about Yaz and Yasmin?
Yaz and Yasmin differ from the others in the form of progesterone used in the pill. They use a unique type of progesterone called drospirenone. The research on drospirenone is confusing. One study (sponsored by the manufacturer Bayer) found no increased risk in blood clots, while two studies by independent researchers found a slight increase in blood clots from drospirenone.
The two studies that showed an increased risk from drospirenone over other forms of progesterone compared the rates of blood clots on each progestin. Let’s take a closer look at these studies that show an increased risk. A Danish study by Lidegaard, published in the British Medical Journal, examined women taking different types of oral contraceptives. Comparing drospirenone to levonorgestrel (a progestin found in many other pills), they found that annually, 5.5 women out of 10,000 on levonorgestrel BCPs had blood clots, while about 8 women out of 10,000 on drospirenone had blood clots. A similar increase was also found when other progestin’s (desogestrel and gestodene, found in OrthoCept, Mircette, and others) were compared to levonorgestrel.
The second study, done in the Netherlands by van Hylckama Vlieg, found similar results. Extrapolation from their data shows that drospirenone had an annual rate of 12 blood clots per 10,000 women aged 30-40.
To make a long story short, Yaz and Yasmin, which use drospirenone, have a higher risk of blood clots than the pills that use levonorgestrel. This risk is not dramatically higher, and is similar to the slightly elevated risk from other BCPs containing desogestrel and gestodene.
As I have emphasized numerous times throughout this blog. You cannot make a one sided decision when you are considering any medication or treatment. Everything has both risks and benefits. You always need to weigh the risks and benefits as they relate to your specific situation in order to decide what the right thing for you to do is.
When weighing the risks and benefits of birth control, don’t forget that BCPs have been shown to decrease the risk of ovarian and endometrial cancer. They also definitely decrease the medical risks associated with pregnancy! You should also remember that only Yaz has been approved for both for acne and premenstrual dysphoric disorder. So if you’re on Yaz or Yasmin, don’t panic. They are still safe to use, and they will still accomplish the purpose that you hoped for when you decided to take them. If you talk to your doctor, weigh the risks and benefits, and consider the evidence. Then you can decide whether or not you should switch to a different pill with a different progestin.
Do you need a doula at your birthing experience?
December
01 ,
2009
Our Twitter followers have requested that we discuss doulas, so here we go. If you haven't yet started following us on Twitter, please click here to stay up to date on the latest news from the obgyn world and askmyobgyn.com. You can also have the occasional opportunity to suggest new topics for discussion, and I find it especially gratifying that I can respond to the people that actually read this blog, and discuss the things that are on their minds.
First of all, what is a doula? According to DONA (Doula Ass. of North America) the word "doula" comes from the ancient Greek meaning "a woman who serves" and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.
They have a great website, and it is worthwhile checking it out if you want to learn more about doulas, but you came to this blog to hear what I have to say, so I will tell you some advice from personal experience.
Everyone needs a support person in labor. You absolutely need at least one person who will be there for you while you go through this momentous, stressful, and powerful event. You need someone who will be your advocate, someone to talk to, help you, coach you, and give you strength. You also need someone to share this incredible moment with. Somehow, great occasions are made even greater when someone is there to share it with.
However, the decision regarding designating a doula can still be complicated. The vast majority of women do not choose doulas; rather they choose to rely on a close friend or family member to help them. This could be your spouse, your BFF, your Mom, or Godmother, or whomever you trust and want to share this moment with. You need to think about the following issues when deciding who you will choose.
Who do you WANT to share this moment with (this may mean that not every great aunt of yours who told you they HAVE to be there, SHOULD be there)?
Who will be there for YOU, and not for themselves?
Who can you rely upon when you are under stress that they will remain calm and focused?
Who knows and understands your wishes and feelings, and will be willing and ready to advocate for YOU based on your feelings and beliefs?
Who will be there to support you the ENTIRE time, from beginning to end, no matter how long or difficult it may be?
Who will cry with you when your baby is born, and be there to cherish those first few moments of your new baby's life in the "outside world"
If there is an obvious answer to these questions, then you have your man/woman! I don't think you need a doula. You have the support person that you need.
Let me also tell you what you don't need.
You don't need someone who will always be there to tell you what you should want and what you should do
You don't need someone who will regale you with stories about "when I had my baby....."
You don't need someone who will act as a barrier between you and your care providers because they already "know everything" about labor and your doctors/midwives/nurses don't know what they are doing. (I presume that by now you have chosen care providers that you are comfortable with because you trust them)
You don't need someone who will tell you how you SHOULD be feeling, and how you SHOULD react to situations
Now that we've established these guidelines, let’s see where a doula can play a very helpful role. If the answer to the first set of questions is "I don’t know who that person is" then you need a doula. If that is you, I highly recommend that you find a doula in your area, either someone who does it for money, or a volunteer. Interview her (they are almost always women, though I have come across a male doula once, and he happened to be really good) carefully, and make sure she passes the tests we just mentioned. And now you have someone who will really help make your birthing experience less stressful and more what you imagined it should be. If she doesn't pass the tests find another one.
I have seen some really awesome doulas in my career, and they were a great part of the team. But I have also seen a few (though a very definite minority) who were more of a hindrance and nuisance then anything else.
I would love to hear your doula stories, pro, con or otherwise.
