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What the...?  Did my vagina just fall out?!

6/28/2016

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No, sadly, this isn’t just an urban myth.  Uterine and vaginal prolapse affect as many as 1 in 3 women who have had one or more children.  While each women may experience a different degree of symptoms, the chance of needing surgery for either symptomatic prolapse (or incontinence) is around 11%.  So, even though this topic may not come up over dinner with friends, remember that if you are having problems, you aren’t alone.

What causes pelvic organ prolapse, and what are the risk factors (how do I stop it?!)?  Pelvic organ prolapse is caused by loss of pelvic support provided by the levator ani muscle, vagina and pelvic connective tissue as well as neurologic injury due to the stretching of the pudendal nerve during childirth.  Risk factors include anything causing consistently increased intraabdominal pressure (ie repeated heavy lifting, chronic cough, chronic constipation), increasing age (particularly menopausal status), elevated BMI, Hispanic ethnicity, history of operative vaginal delivery or episiotomy, having had large babies or a large number of babies, and history of previous hysterectomy or other prolapse surgery.

Where does prolapse occur?  Apical prolapse occurs as either the uterus or top of the vagina descends toward the vaginal opening.  Anterior prolapse occurs along the vagina beneath the bladder, and posterior prolapse happens along the vagina in front of the rectum.

Do I have it?!  The most common presenting symptom of pelvic organ prolapse is the feeling of pressure or bulge within the vagina.  You probably won’t experience prolapse to the degree in the pictures below (whew!), and mild prolapse, while common, doesn’t necessarily require intervention anyway.


What do I do about it?  Again, even though it is common, unless it begins to cause other health issues such is urinary retention/inability to void, recurrent urinary tract infections, kidney damage or difficulty with bowel movements, you aren’t obligated to do anything.  I even had a patient with severe prolapse who knit herself a purse to keep her uterus in (seriously!).  However, if any of the above issues are present, or your symptoms are affecting your ability to be as active as desired or causing difficulty being intimate with your partner, evaluation is generally advised.

What are treatment options?  Other than expectant management, more conservative treatment options include Kegels and vaginal estrogen.  Alternatively, another choice may be placement of a pessary (vaginal splint made of rubber), although this does require regular maintenance with removal and cleaning, which are generally done by the patient.  Lastly, surgical treatment is often a good option for healthy patients, particularly if they desire to maintain sexual function.  Much like a hernia of the abdominal wall, there are several choices of procedure available for treatment of pelvic organ prolapse available.  Fortunately, nearly all of these options can be done minimally invasively, which helps the patient get back on her feet faster.  Even the patient with severe prolapse below was able to leave the hospital the day after surgery.

So, if you are having any issues with pelvic organ prolapse, be sure to chat with your doctor because you aren’t alone..even if it’s not a topic during your dinner conversations like it is at our house :)  (I would like to include a special thanks to our patient who graciously allowed use of the pictures demonstrating a before and after of her prolapse.  As she said, “Women need to know about this!”)

Nick
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Now that my baby is here, why am I so sad?  A brief discussion of postpartum depression

6/21/2016

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The birth of your baby is supposed to be one of the best times of your life, right?  So does that mean those who experience postpartum depression aren’t normal?  Not at all.  In fact, between 10-15% of all mothers deal with postpartum depression, and this doesn’t include those who experience the “baby blues.”  Nor does it include the 4% of fathers who also experience some degree of postpartum depression.

What causes postpartum depression?  The large drop in estrogen and progesterone immediately following childbirth can cause depression, much like the smaller changes in hormone levels around the time of the menstrual cycle can contribute to stress or mood swings.  Other risk factors for the development of postpartum depression include low infant birth weight, baby admission to the neonatal ICU, tobacco use during the last 3 months of pregnancy, physical abuse and partner, traumatic, or financial stressors during pregnancy.  A history of depression prior to pregnancy is also a risk factor.

What’s the difference between the baby blues and postpartum depression? Postpartum blues generally begin 2-3 days after childbirth.  The symptoms involve feelings of sadness, guilt or anger toward themselves, their baby or their partner.  A woman may cry for no reason, wonder if she is capable of caring for her newborn, and be unable to sleep.  These symptoms differ from postpartum depression in that they are generally more mild and resolve on their own in 1-2 weeks.  However, postpartum depression usually doesn’t begin until 1-3 weeks postpartum (although it may take as long as a year before it develops), and it involves intense feelings of sadness, despair or anger that keep a woman from being able to do her daily activities.

How is postpartum depression treated?  Often antidepressants are a first line of treatment.  Talk therapy with a mental health care professional may also be appropriate.  Very rarely is hospitalization required, and this is generally reserved for patients who may be at risk to harm themselves or others.
Tell me more about antidepressants.  SSRIs (selective serotonin re-uptake inhibitors) are usually the type of antidepressant used first, and it may take up to 3-4 weeks before these medications become effective.  Side effects are usually mild and may include weight gain, decreased libido, drowsiness, and GI distress.  Be sure to notify your provider if you experience suicidal or homicidal thoughts or ideation.  Although these medications may be passed through breast milk, the concentration of antidepressants in breast milk is typically very low. Be sure to let your doctor know if you are breastfeeding while taking these medications as well as notifying the doctor for your baby.

Does this mean I have to take medications for the rest of my life?  If your mood stabilizes, then a trial of weaning your antidepressant may be appropriate.  This may be an option as soon as 3-6 months after starting the medication, or it may be better to continue for at least a year.  Before stopping or weaning your antidepressant, be sure to discuss your treatment plan with the provider who prescribed the medication for you.

What to watch out for:  Be sure to seek care immediately if you have thoughts of harming yourself, your baby or another person, or if you begin to see things that aren’t really there.  A partner may also notice concerning symptoms that aren’t apparent to you, and if this is the case, it is prudent to seek further evaluation.

Remember, just because you experience postpartum depression, that doesn’t make you a bad mother or “not normal.”  More than 1 in 10 mothers will require treatment for postpartum depression following pregnancy, and that’s ok.  Help can be found at your doctor’s office, support groups, your hospital, and of course, your family.  Having postpartum depression is nothing to be ashamed of; not seeking help is.  

Nick
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What is Delayed Cord Clamping?

6/14/2016

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Not only is delayed cord clamping one of the most common items on most birth plans generated by the Internet (obviously, the most reliable source for birth plans), but it is also one of the most common questions I get from my patients. Along with epidurals, episiotomies, and VBACs, I usually get a request daily to delay cord clamping as much as possible.

What does delayed cord clamping actually mean? Immediate clamping is clamping of the cord within 15 seconds of delivery of the baby. Delayed clamping is clamping of the cord between 25 seconds to 3-5 minutes. The purpose of this delay is to potentially increase baby's blood volume. The cord usually stops pulsating between 3-5 minutes. The risks and benefits of delayed cord clamping have been studied extensively and they are different for preterm and term infants.

Preterm Infants (baby that is born before 37 weeks gestation): Delayed clamping usually involves waiting between 25 seconds to 3 minutes in preterm infants. Studies have shown that delayed cord clamping in preterm infants has resulted in fewer blood transfusions, 50% reduction in intraventricular hemorrhage (brain bleeds which are common in preterm neonates) and necrotizing enterocolitis (NEC is a disease of the intestines of premature infants; the wall of the intestine is invaded by bacteria, which causes local infection and inflammation that can ultimately destroy the part of the intestine). Most NICU's have developed a protocol based on gestational age to determine how long to delay clamping and milking of the cord.

​Term Infants (baby that is born at or after 37 weeks gestation): Studies in term infants have shown that an additional 80 mL transfer of blood occurs by one minute after birth. This can supply extra iron and result in a higher hemoglobin in term neonates that have undergone delayed cord clamping at birth and up to 3-6 months after birth. However, there appears to be some risks associated with delayed cord clamping in term infants. Several studies noted that there was an increased need for phototherapy for jaundice after birth among infants who underwent delayed cord clamping. Just what you wanted--your baby in a tanning booth :)  In addition there is concern that infants that are born at high altitude (we are almost at 5000ft in Idaho Falls) have an increased risk of fetal polycythemia (excessive thickening of blood that can affect oxygen transport and transfer of nutrients) when delayed umbilical cord clamping is performed.

What does all this mean??? There are some clear benefits to delayed cord clamping for preterm neonates, and NICU protocols should be followed for preterm infants. However, for term infants while delayed cord clamping for 60 seconds may increase iron stores and hemoglobin levels, delayed clamping beyond 60 seconds (as many internet sites recommend until after the cord stops pulsating) may increase the risk of jaundice requiring phototherapy and polycythemia at high altitudes, which ultimately results in a longer hospital stay for your otherwise healthy baby.

When to avoid delayed cord clamping: If you plan on cord blood banking, you should avoid delayed clamping because it will reduce the volume of blood obtained, and if your baby requires immediate resuscitative efforts (extra help breathing/crying), then delayed cord clamping should be deferred.

​Pam
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Epidural Shaming: "I was “shamed” for wanting pain medication!"

6/7/2016

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Lately, so many of my patients have confided in me that they are afraid of requesting pain medication during labor.  They have been told by friends or family members that by getting an epidural they are "wussing out", harming their baby, or depriving themselves of the true birth experience.  For thousands of years, women have had to endure pain during childbirth. Now that in 2016 we have the technology and options, it is ironic there is a childbirth culture that is determined to limit women's choices by shaming.  So let's review some basics about epidurals and their safety profile.  

1.  What is an epidural? An epidural is a regional anesthetic which means it does not affect your entire body. The goal of an epidural is to provide pain relief,rather than anesthesia, which is a total lack of feeling.  The anesthesiologist will inject medication through your mid back in order to numb the nerves that carry pain signals to your uterus and cervix during labor.  After that, a small tube or catheter is threaded through the needle into the epidural space. The needle is then carefully removed, leaving the catheter in place to provide medication either through periodic injections or by continuous infusion.The catheter is taped to the back to prevent it from slipping out.  

2.  Are epidurals harmful to my baby?  No.  As this medication does not cross the placenta it does not affect your baby.  Occasionally after epidurals are placed, it can affect your blood pressure, which can have effects on your baby's heart rate.  However, this is usually quickly corrected with medication.  A lot of women will request pain medication in their IV because they feel this is safer for their baby than an epidural, however what they don't realize is that these medications all cross the placenta and can cause the following: CNS and respiratory depression, impaired early breastfeeding, and decreased ability to regulate body temperature.  


3.  What are the other side effects of epidurals?  Hypotension (decreased blood pressure as discussed in the previous question), ringing in the ears, shivering, uneven anesthesia, numbness that can contribute to difficulty pushing and spinal headaches (this usually does not occur until a couple days after your epidural was placed). 


4.  If I get an epidural am I more likely to have a cesarean section?  No.  Currently the evidence does not show an increased incidence of cesarean section, use of forceps, or use of vacuum delivery with epidural anesthesia.

5.  If I get an epidural will it increase my time in labor?  It will not increase the first stage of labor (the time required for your cervix to dilate from 0 to 10 centimeters); however, studies have shown that it may slightly increase the duration of the second stage of labor (the time that you are pushing).  

Bottom line: labor hurts.  Embrace the pain management technique that works for you and make sure you talk to your provider about all your options.  I’m sure you’ve probably heard the story of the friend who went through 12 hours of labor and 2 hours of pushing without screaming once or even breathing hard, but for others, they may require more pain relief.  And that’s OK!  It is estimated that more than 60% of moms in the U.S. receive an epidural for pain control during labor, but you should not have to go through it with feelings of guilt or inadequacy.  Getting an epidural does not mean you are weak or a failure, nor does it mean you love your baby less than a mom who chooses not to use anesthesia.  While giving birth is the most incredible experience of your life, remember, you are pushing a watermelon through your vagina and there is no shame in asking for relief from the pain.  No matter how you deliver, with or without pain control, you'll be leaving the hospital with the same prize:  a brand new baby!

​Pam
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