An Abnormal Fetal Ultrasound
A 30-year-old gravida 3, para 2 patient who is 23 weeks pregnant presents with findings of placenta previa. She has a history of two prior pregnancies with placenta previa that were delivered by cesarean section. Ultrasonography and MRI studies are obtained. What is the diagnosis?

Breaking the silence surrounding stillbirth

I had a great patient on my last workday. It is very unusual for me to have patients who have done childbirth classes, and even more unusual for them to come and actually use the techniques from the classes. This couple had relaxing music going the whole time she was in labor, and they even had a birth ball (she didn't use it when I was there, I don't know if she did on the previous shift or not). She focused on her music and got comfy in the bed in her "zone" and didn't even claim to be in pain until she was like 7cm's - and she was a primip (first timer)!

Most of the time, if we get a primip talking it up about wanting to go without the epidural, we're supportive but kind of thinking in the back of our mind "might as well get the epidural consent done now" because so many first timers just don't realize what they are in for and end up asking for the epidural before long.
But this patient meant business. It was nice and soothing and calm in the room the entire time, when it was time to push I kept the lights low and let her do what her body told her to do for the most part. Voila, beautiful baby boy! It was very nice and I'm glad she was able to do it the way she wanted.

Good things on the home front:

• Thank the Lord, M finally finished the Diary of Anne Frank... which he was supposed to finish like a month ago for (home)school, with a study guide. Doesn't sound like a big deal, but I was so over hounding him to finish it already!
• I jumped in the pool and swam some laps after work, yay me... I really need the exercise.
• The boys and I are going to see Harry Potter and the Half-Blood Prince tomorrow morning.
• I thought my younger boys may not be able to keep going to their same school in the Fall (related to No Child Left Behind stuff), but today the school board people told me that their school would still be a school of choice for them (they can still go there & get transportation for it). Whew! What a load off my mind!!!!
  If I chose to do it, they would also be able to attend Florida Virtual School's Connections Academy or Florida Virtual Academy (K12); two options which I still have not completely ruled out & which I would have probably chosen for sure had they not been able to keep going to their current school. It may still be a consideration depending on exactly how they are placed for the Fall.
• Getting closer to our vacation! So excited! Can you tell?

Check out "Free on Friday"- the Pantry 72 Shelf Reliance giveaway for food storage.

Overall, we have been kind of "Q" word at work lately, but as always it is very feast or famine.

My last workday was not "Q"; kind of "B" in fact. My morning started out nice enough, just a 23 hour observation 35 weeker vag bleeding patient that would probably get sent home around noon. My mistake was when I had the gall to pull out my cheesy vampire book and a coke to sit down and have a drink. Obviously a no-no. The nerve of me!

I ended up doing a repeat section (with a combo of the way-jerkiest MD and the jerkiest anesthesia person, too...ughh, both of who forgot that I didn't have my miracle worker outfit on that day; also my computer wouldn't work until the thing was almost all the way done, etc. etc.). The anesthesia person I usually get along with ok, he's just kind of OCD about things but I can handle him.

The OB MD is super unnerving to me, not because I give two shits less what she thinks of me, actually I almost hope she doesn't because that would imply some kind of sybiosis between us on a personal level. I'll stick with "take care of the patient and then we'll be on our way" (that is, IF she took care of her patients! and when I MUST take my turn working with her). I guess she's just unnerving because I kind of despise her as person and as a physician. And that's saying a lot because there are not many people on Earth that I would say that about. I'm certainly not perfect & I know that others aren't, either. Maybe I don't know her well enough to find the good traits in her that could offset the bad. Gag. Maybe I should try harder and at least elevate myself to pitying her Napoleonic-complex self. But, she's intelligent enough to be an MD, so I'm not letting it hide behind that rationalization. And I could grudgingly get past my own gagathon time spent with her, but the patients... I would love to give examples but that would probably be too revealing.

That said, luckily the section went very smoothly (for the patient and her baby's part) and they did very well. The gender was unknown and she was hoping for a girl but got another boy, frank breech. It was one of those babies that I would almost give a '10' apgar if I was the baby nurse, he was so pink. After I took the mom to recovery downstairs, I picked up the last part of the recovery for the baby & met them back up together in postpartum. All this time, the nurses on the floor were scurying like crazy with a fairly full board.

Next, I took a 30 weeker with decreased fetal movement. That problem was resolved as soon as I put her on monitoring - the baby started moving well. Good. But the patient reported that she had started feeling crampy on the way to the hospital, and the monitor showed contractions. No prenatal records, and clinic "had a meeting going on" and couldn't send them (??? WTF???), but no hx of bleeding/previa per pt, got fetal fibronectin, exam revealed closed inner os. Good.

No real urinary complaint, but got urinalysis in case of hidden UTI making things irritable. Gave her lots of water to drink. Asked her to pee (full bladder can irritate uterus).

Next, terbutaline. Meanwhile, one of my colleagues acted as baby nurse and "caught" the baby I was supposed to catch in another room while I was giving the dose, she came to let me know and I went to do that baby (she strictly caught and did the 1 min. apgar).

Got that done, back to 30 wkr. We usually do 1 dose of terb and then 2 more PRN. First dose seemed to calm her down so I watched. The contractions broke back through after a while, so I gave the next two doses which were keeping her calm up to shift change. Her fetal fibronectin and UA came back negative and she didn't have a hx of preterm birth, so hopefully she went home.

I actually was lucky because I didn't really have many patients at a time, it was just mostly steady for me. Dealing with the section OB MD was the only bad part really. Still, I forgot to put in for no lunch. Still, I was so beat that I slept really well last night.

Vacation is coming soon:

Fertility Awareness-Based Methods: Another Option for Family Planning

Zicam warning - The FDA advised people not to use Zicam intranasal products that contain zinc, because of the risk of anosmia (loss of the sense of smell), which may be long-lasting or permanent.

The FDA's warning only applies to the following Zicam products:

• Zicam Cold Remedy Nasal Gel
• Zicam Cold Remedy Gel Swabs
• Zicam Cold Remedy Swabs, Kids Size

... said the FDA's action came as a surprise. "Had we had the opportunity to sit down with the FDA beforehand, we are confident that the FDA would have agreed that the scientific data clearly demonstrated the safety of our products."

I have to say, I'm kind of freaking out about this recall... and not because I'm afraid of anosmia... it's because I love this product! I have been using it for like 10 years with great success and no side effects except no-to-much-less-severe colds!!!!!!!!!!!!! I wish I had known ahead of time so I could stock up - I hate the way the lozenge version tastes!

Couple of cool blogs about history of infant feeding and historical breastfeeding pictures:

Infant Feeding in History

Historic Infant Feeding photographs - Jennifer James is on a quest to find information and historic photographs showing moms breastfeeding in public before it became taboo.

I'm off today after a long day at work yesterday. It was a good day patient-wise, my girl that delivered did awesome, she had several children already and had done birth both medicated and without. She ended up just getting one dose of Stadol and had a quick and great delivery.

Some things going on at work that I'm not thrilled about, but I'm thinking it'll all come out in the wash so I'm trying to just sit back. (Not always as successully as I should). Sigh.

Also thinking that with the economy, it's not the best time to be taking our big vacation. Maybe I should just be saving that money to be more prudent, but I'm already committed to it with plane tickets, etc...

All in all, things are great, though. The kids are relaxing and enjoying summer vacation. They are in the pool every day & having a blast.

C-section births are becomming a given, especially in Florida

Canadian doctors to stop automatic c-sections for breech

Breastfeeding linked to high grades, college - "By focusing on differences between siblings, we can rule out the possibility that family-level factors such as socioeconomic status are driving the relationship between having been breast-fed and educational attainment" Original study here.

"On June 11, Representative Carolyn B. Maloney (NY) and Senator Jeff Merkley (OR) introduced the Breastfeeding Promotion Act in both houses of Congress. This is the first time the bill has been introduced in the Senate.

Forty-seven states, the District of Columbia, Puerto Rico, and the Virgin Islands already have enacted various laws protecting breastfeeding mothers, but they are not uniform and most are not comprehensive. Ask your Representative and Senators to co-sponsor the Breastfeeding Promotion Act to provide a unified national policy to keep mothers, their children, and their communities healthy.

Take Action here

We know that breastfeeding is good for mothers, babies, and society. The medical evidence shows that NOT breastfeeding increases the baby's risk of infections, diarrhea, SIDS, obesity, diabetes, asthma, and childhood leukemia, and increases the mother's risk of breast and ovarian cancers and diabetes.Breastfeeding also has significant economic and environmental benefits for families, employers, and society.

Given all of these benefits, all major medical authorities (including the Department of Health and Human Services), recommend that babies get no food or drink other than breast milk for their first 6 months and continue to breastfeed for at least the first 1-2 years of life. But mothers need more support: only 12% of U.S. mothers are exclusively breastfeeding at 6 months, and only 21% are still breastfeeding at 1 year.

Interest in breastfeeding is at an all-time high: 77% of women breastfeed their infants at birth. But breastfeeding rates drop rapidly after hospital discharge. More than 50% of women with infants less than one year old are in the labor force. Employed mothers are more likely to stop breastfeeding early if they do not receive the support they need in the workplace.

Together we can change this! Tell Congress to support the Breastfeeding Promotion Act to provide the support mothers need!

The Breastfeeding Promotion Act (H.R. 2819, S. 1244) includes five provisions:

Amends the Civil Rights Act of 1964 to protect breastfeeding women from being fired or discriminated against in the workplace.
Provides tax incentives for businesses that establish private lactation areas in the workplace, or provide breastfeeding equipment or consultation services to their employees.
Provides for a performance standard to ensure breast pumps are safe and effective.
Allows breastfeeding equipment and consultation services to be tax deductible for families (amends Internal Revenue Code definition of "medical care").
Protects the privacy of breastfeeding mothers by ensuring they have break time and a private place to pump (applies to employers with 50 or more employees, see text of legislation for details).
You've been making great strides at the state level, and we know we can do it at the national level too! With a few clicks of the mouse today, you can help build critical support for a groundbreaking bill to protect, promote, and support breastfeeding in the United States.

We look forward to continuing our important work together to improve the health of mothers and babies, and thank you in advance for your support!

United States Breastfeeding Committee
2025 M Street, NW, Suite 800
Washington, DC 20036
Phone: 202/367-1132
Fax: 202/367-2132
E-mail: office@usbreastfeeding.org
Web: www.usbreastfeeding.org"

My last labor patient was sent over from the office for elevated blood pressures and protein in her urine at her prenatal visit. She got the usual fetal monitoring (NST), serial blood pressures, and lab work (usually CBC, CMP, UA... sometimes uric acid, PT, PTT, fibrinogen, fibrin split depending on the provider and the situation). Her baby looked great, she didn't have physical assessment symptoms of preeclampsia (headache, epigastric pain, edema, clonus, jumpy reflexes, visual disturbances, etc.) her pressures were high but not horrible, but the protein was +3 on the Albustix (backed up with lab work) so that clenched it & she was deemed a keeper for induction since delivery is the only "cure" for preeclampsia. Her cervix was barely 1cm, thick, high, and posterior which probably would have been most well-suited to Cytotec (misoprostil) or Cervidil, except that she was contracting too much for prostaglandins (we don't give them if patient has >10ctx/hr). Pitocin was started.
Fast forward about 18 hours... nada. Nothing. No change. Very little contraction pain. Time to regroup. MD offers for patient to stop Pit for a couple of hours and try the Cervidil after all. Patient asks for cesarean (with support... ummm... suggestion, really, of family memebers). Because baby appeared large (4100 grams/ around 9lbs) on a late ultrasound, at around 90% with a large abdominal girth that MD felt may predispose to shoulder dystocia, she states that she won't push for the Cervidil like she normally would. It was explained that the ultrasound can be off by a pound or so. Patient wants cesarean. Baby boy is 7lbs.11oz.

Newsflash:
Cocaine and heroin harm placenta ...actually kind of interesting, it looks like coke and heroin "causes an increase in the passage of some [other] chemicals into the fetus." So theoretically, not only would baby be getting the coke/heroin but increased exposure to whatever else may be ingested.

We're going to meet up with some friends who are visiting FL from the W. coast today. We may leave early and brave Downtown Disney since the kids are dying to go to the Lego store there. It sounds like a blast to fight sweaty crowds in the blistering heat! But the kids did well in school, so they deserve a little reward :)

Vitamin D Deficiency Linked to BV (BV is a highly prevalent vaginal infection that is associated with adverse pregnancy outcomes)

Neonatal Outcomes may be better with VBAC -


After a couple of hellish weeks at work with a lot of preemies and c-sections, the last week or so has been nice with great couples and healthy babies!

Today was the last day of school for my two younger boys - they have done really well this year and I've very proud of them! M is finishing up a few things and he'll be done with his school year here at home, too. Woohoo!

Couple of cool blogs:
http://trendytravelista.com/
http://www.zacsunderland.com/ - Zac Sunderland is attempting to be the youngest person in history to sail around the world alone! He started at 16!



Continuing to plan our summer vacay, too! Here's our route.

Bleeding disorders going undiagnosed; new guidelines to help:

outlined the definitive signs that may signal the presence of a bleeding disorder in women. 

... will appear in the July issue of the American Journal of Obstetrics and Gynecology. 

..about 25 percent of women with heavy menstruation may have an undiagnosed bleeding disorder

In previous studies, women who ultimately were treated for a bleeding disorder reported waiting 16 years, on average, before being diagnosed. 

Without the laboratory test, the consortium says women and doctors should be on the lookout for the following:

• Heavy blood loss during menstruation
• Family history of bleeding disorder
• Notable bruising without injury
• Minor wound bleeding that lasts more than five minutes
• Prolonged or excessive bleeding following dental extraction
• Unexpected surgical bleeding
• Hemorrhaging that requires blood transfusion
• Postpartum hemorrhaging, especially if occurs more than 24 hours after delivery.

Also, 

Autism, ADHD, and Medicated Births

Peaceful Revolution: Why Breastfeeding Needs To Be Part of Health Care Reform

How Much Weight Should Women Gain During Pregnancy? article based on these new guidelines from the Institute of Medicine:
Women who are underweight (BMI less than 18.5) should gain 28-40 pounds.
Women of normal weight (BMI of 18.5-24.9) should gain 25-35 pounds.
Women who are overweight (BMI of 25-29.9) should gain 15-25 pounds.
Women who are obese (BMI of 30 or more) should gain 11-20 pounds.


Great labor/delivery yesterday... baby labor'd wayyyy on down so that mom only had to push once or twice... only bad thing is baby was big and mom got a 3rd degree... ouch! But it was otherwise smooth, everyone healthy and happy. She was able to open her eyes and watch him come out and up to her chest :)

Lonely Planet's site has the coolest feature, you can buy their books by the chapter in .pdf form if you don't need the entire guide.