An informative blog site for patients living in the Yuba Sutter area in the field of Obstetrics.
Saturday, October 29, 2011
HSV in pregnancy
Herpes in Pregnancy
Genital herpes is an infection caused by the herpes simplex virus or HSV. There are two types of HSV, and both can cause genital herpes. HSV type 1 most commonly infects the lips, causing sores known as fever blisters or cold sores, but it also can infect the genital area and produce sores. HSV type 2 is the usual cause of genital herpes, but it also can infect the mouth. A person who has genital herpes infection can easily pass or transmit the virus to an uninfected person during sex.
Both HSV 1 and 2 can produce sores (also called lesions) in and around the vaginal area, on the penis, around the anal opening, and on the buttocks or thighs. Occasionally, sores also appear on other parts of the body where the virus has entered through broken skin.
HSV remains in certain nerve cells of the body for life, and can produce symptoms off and on in some infected people.
According to the U.S. Centers for Disease Control and Prevention, 45 million people in the United States ages 12 and older, or 1 out of 5 of the total adolescent and adult population, are infected with HSV-2.
Nationwide, since the late 1970s, the number of people with genital herpes infection has increased 30 percent. The largest increase is occurring in young teens. HSV-2 infection is more common in three of the youngest age groups which include people aged 12 to 39 years.
How does someone get genital herpes?
Most people get genital herpes by having sex with someone who is having a herpes “outbreak.” This outbreak means that HSV is active. When active, the virus usually causes visible lesions in the genital area. The lesions shed (cast off) viruses that can infect another person. Sometimes, however, a person can have an outbreak and have no visible sores at all. People often get genital herpes by having sexual contact with others who don’t know they are infected or who are having outbreaks of herpes without any sores.
A person with genital herpes also can infect a sexual partner during oral sex. The virus is spread only rarely, if at all, by touching objects such as a toilet seat or hot tub.
What are the symptoms?
Unfortunately, most people who have genital herpes don’t know it because they never have any symptoms, or they do not recognize any symptoms they might have. When there are symptoms, they can be different in each person. Most often, when a person becomes infected with herpes for the first time, the symptoms will appear within 2 to 10 days. These first episodes of symptoms usually last 2 to 3 weeks.
Early symptoms of a genital herpes outbreak include
Itching or burning feeling in the genital or anal area
Pain in the legs, buttocks, or genital area
Discharge of fluid from the vagina
Feeling of pressure in the abdomen
Within a few days, sores appear near where the virus has entered the body, such as on the mouth, penis, or vagina. They also can occur inside the vagina and on the cervix in women, or in the urinary passage of women and men. Small red bumps appear first, develop into blisters, and then become painful open sores. Over several days, the sores become crusty and then heal without leaving a scar.
Other symptoms that may go with the first episode of genital herpes are fever, headache, muscle aches, painful or difficult urination, vaginal discharge, and swollen glands in the groin area.
Page 2 of 3
(Continued from Page 1)
If you have been infected by HSV 1 and/or 2, you will probably have symptoms or outbreaks from time to time. After the virus has finished being active, it then travels to the nerves at the end of the spine where it stays for a while. Even after the lesions are gone, the virus stays inside the nerve cells in a still and hidden state, which means that it’s inactive.
In most people, the virus can become active several times a year. This is called a recurrence. But scientists do not yet know why this happens. When it becomes active again, it travels along the nerves to the skin, where it makes more viruses near the site of the very first infection. That is where new sores usually will appear.
Sometimes, the virus can become active but not cause any sores that can be seen. At these times, small amounts of the virus may be shed at or near places of the first infection, in fluids from the mouth, penis, or vagina, or from barely noticeable sores. You may not notice this shedding because it often does not cause any pain or feel uncomfortable. Even though you might not be aware of the shedding, you still can infect a sex partner during this time.
After the first outbreak, any future outbreaks are usually mild and last only about a week. An infected person may know that an outbreak is about to happen by a tingling feeling or itching in the genital area, or pain in the buttocks or down the leg. For some people, these early symptoms can be the most painful and annoying part of an episode. Sometimes, only the tingling and itching are present and no visible sores develop. At other times, blisters appear that may be very small and barely noticeable, or they may break into open sores that crust over and then disappear.
The frequency and severity of recurrent episodes vary greatly. While some people have only one or two outbreaks in a lifetime, others may have several outbreaks a year. The number and pattern of repeat outbreaks often change over time for a person. Scientists do not know what causes the virus to become active again. Although some people with herpes report that their outbreaks are brought on by another illness, stress, or having a menstrual period, outbreaks often are not predictable. In some cases, outbreaks may be connected to exposure to sunlight.
How is genital herpes diagnosed?
Because the genital herpes sores may not be visible to the naked eye, a doctor or other health care worker may have to do several laboratory tests to try to prove that symptoms are caused by the herpes virus. A person may still have genital herpes, however, even if the laboratory tests do not show the virus in the body.
A blood test cannot show whether a person can infect another with the herpes virus. A blood test, however, can show if a person has been infected at any time with HSV. There are also newer blood tests that can tell whether a person has been infected with HSV 1 and/or 2.
How is genital herpes treated?
Although there is no cure for genital herpes, your health care worker might prescribe one of three medicines to treat it as well as to help prevent future episodes.
Acyclovir (Zovirax)
Famciclovir (Famvir)
Valacyclovir (Valtrex)
Recently, the Food and Drug Administration approved Valtrex for use in preventing transmission of genital herpes. (See section below: How can I protect myself or my sexual partner?)
During an active herpes episode, whether the first episode or a repeat one, you should follow a few simple steps to speed healing and avoid spreading the infection to other places on the body or to other people.
Keep the infected area clean and dry to prevent other infections from developing.
Try to avoid touching the sores.
Wash your hands after contact with the sores.
Avoid sexual contact from the time you first feel any symptoms until the sores are completely healed, that is, the scab has fallen off and new skin has formed where the sore was.
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(Continued from Page 2)
Usually, genital herpes infections do not cause major problems in healthy adults. In some people whose immune systems do not work properly, genital herpes episodes can last a long time and be unusually severe. (The body’s immune system fights off foreign invaders such as viruses.)
If a woman has her first episode of genital herpes while she is pregnant, she can pass the virus to her unborn child and may deliver a premature baby. Half of the babies infected with herpes either die or suffer from damage to their nerves. A baby born with herpes can develop serious problems that may affect the brain, the skin, or the eyes. If babies born with herpes are treated immediately with acyclovir, their chances of being healthy are increased.
If a pregnant woman has an outbreak, which is not the first episode, her baby’s risk of being infected during delivery is very low. In either case, if you are pregnant and infected with genital herpes, you should stay in close touch with your doctor before, during, and after your baby is born.
If a woman is having an outbreak during labor and delivery and there are herpes lesions in or near the birth canal, the doctor will do a cesarean section to protect the baby. Most women with genital herpes, however, do not have signs of active infection with the virus during this time, and can have a normal delivery.
Is genital herpes worse in a person with HIV infection or AIDS?
Genital herpes, like other genital diseases that produce lesions, increases a person’s risk of getting HIV, the virus that causes AIDS. Also, prior to better treatments for AIDS, persons infected with HIV had severe herpes outbreaks, which may have helped them pass both genital herpes and HIV infection to others.
How can I protect myself or my sexual partner?
If you have early signs of a herpes outbreak or visible sores, you should not have sexual intercourse or oral sex until the signs are gone and/or the sores have healed completely. Between outbreaks, using male latex condoms during sexual intercourse may offer some protection from the virus. When used with these precautions, Valtrex can also help prevent infecting your partner during heterosexual sex.
Is any research going on?
The National Institute of Allergy and Infectious Diseases (NIAID) supports research on genital herpes and on herpes simplex virus (HSV-1 and HSV-2). Studies are currently underway to develop better treatments for the millions of people who suffer from genital herpes.
While some scientists are carrying out clinical trials to determine the best way to use existing drugs, others are studying the biology of herpes simplex virus. NIAID scientists have identified certain genes and enzymes that the virus needs to survive. They are hopeful that drugs aimed at disrupting these viral targets might lead to the design of more effective treatments.
Meanwhile, other researchers are devising methods to control the virus' spread. Two important means of preventing HSV infection are vaccines and topical microbicides. Several different vaccines are in various stages of development. These include vaccines made from proteins on the HSV cell surface, peptides or chains of amino acids, and the DNA of the virus itself.
NIAID and GlaxoSmithKline Biologicals are supporting a large clinical trial in women of an experimental vaccine that may help prevent transmission of genital herpes. The trial is being conducted at more than 20 sites in 15 states nationwide. For more information, click here Herpevac Trial for Women.
Topical microbicides, preparations containing microbe-killing compounds, are also in various stages of development and testing. These include gels, creams, or lotions that a woman could insert into the vagina prior to intercourse to prevent infection.
Where can I get help if I’m upset about having genital herpes or I have an infected partner?
Genital herpes outbreaks can be distressing, inconvenient, and sometimes painful. Concern about transmitting the disease to others and disruption of sexual relations during outbreaks can affect personal relationships. If you or your partner has genital herpes, you can learn to cope with and treat the disease effectively by getting proper counseling and medicine, and by using ways to prevent getting infected or infecting someone else, as mentioned above.
Where can I get more information?
National Herpes Resource Center and Hotline
919-361-8488 (9 a.m. to 7 p.m. Eastern Time, Monday through Friday)
http://www.ashastd.org/hrc/index.html
National STD and AIDS Hotline
1-800-227-8922 or 1-800-342-2437 (24 hours a day, 7 days a week)
National Institute of Allergy and Infectious Diseases
http://www.niaid.nih.gov
Friday, September 30, 2011
Smoking in Pregnancy Raises Birth Defect Risk
Health & Pregnancy
Study Provides 'Encyclopedic' Evidence of Link Between Birth Defects and Smoking During Pregnancy
By Brenda Goodman
WebMD Health News
Reviewed by Louise Chang, MD
July 11, 2011 -- Babies born to moms who smoke are more likely to have certain birth defects compared to infants with mothers who don't smoke during pregnancy, a large new study shows.
The study, a fresh look at 50 years of research, is the first scientific review of studies that have looked at the connection between smoking and birth defects. It includes information on nearly 12 million infants, including 173,000 that were born with malformed bodies.
"This is a seminal paper," says Michael Katz, MD, senior vice president of research and global programs for the March of Dimes and a professor emeritus at Columbia University.
Katz says previous studies have revealed piecemeal links between maternal smoking and birth defects, particularly the risk for cleft lips and cleft palates. But none has ever revealed such a comprehensive picture of the harms smoking is likely to cause.
"This is an encyclopedic review," Katz tells WebMD.
Smoking and Birth Defects
Experts have long suspected that smoking cigarettes was unhealthy for mother and baby. Indeed, cigarette labels already include the federally mandated warning that "smoking during pregnancy can harm your baby."
The new study shows how smoking is associated with increases in specific risks.
For the review, researchers culled 50 years of research on smoking and birth defects, narrowing their focus to just 172 studies.
They extracted data from those studies and pooled the numbers to create a big-picture look at birth defects related to cigarette smoking.
Babies born to mothers who smoked had roughly 20% to 30% higher odds of having shortened or missing arms and legs, cleft lips and cleft palates, and abnormally shaped heads or faces compared to babies born to nonsmoking mothers.
"These defects last a lifetime," says study researcher Allan Hackshaw, deputy director of the University College London Cancer Center in the U.K. "They can be fixed to some extent, but they're visible on the baby and infants and more or less for life."
Maternal smoking was associated with a 27% excess risk of gastrointestinal abnormalities, including problems with the throat, esophagus, colon, intestine, bile ducts, gall bladder, and liver.
Additionally, infants born to smokers had 50% higher odds of being born with their intestines hanging outside the body and a 20% increased risk of being born with a blocked or closed anus.
Smoking accounted for a 9% increased risk of heart defects and a 13% higher risk that baby boys would be born with undescended testes.
The study is published in Human Reproduction Update.
How Cigarettes May Harm Developing Babies
Cigarette smoke contains about 4,000 chemicals. Researchers don't fully understand how that toxic mixture may cause birth defects.
But they have some suspicions.
Part of the problem may be that the baby isn't getting enough oxygen when mom smokes.
Nicotine, the addictive substance in cigarettes, causes blood vessels to constrict, which may choke off the supply of oxygen to the fetus.
And carbon monoxide, a colorless, odorless gas that's present in high levels in cigarette smoke, binds more strongly to hemoglobin -- the molecule that ferries oxygen through the blood -- than oxygen itself, lowering the amount available to the baby.
"It personally absolute stuns me that some people still smoke during pregnancy," Hackshaw says.
Studies show 14% of women in the U.S. smoke while pregnant. That number jumps to 20% expectant mothers under age 25.
"The advice has to be 'don't smoke'," says Katz.
Though smoking is a tough habit to kick, he says many women do successfully quit after they find out they're pregnant.
"The motivation is much stronger in pregnant women than in the population at large," he says. "It's less difficult to persuade people who are pregnant to stop smoking than anyone else."
Study Provides 'Encyclopedic' Evidence of Link Between Birth Defects and Smoking During Pregnancy
By Brenda Goodman
WebMD Health News
Reviewed by Louise Chang, MD
July 11, 2011 -- Babies born to moms who smoke are more likely to have certain birth defects compared to infants with mothers who don't smoke during pregnancy, a large new study shows.
The study, a fresh look at 50 years of research, is the first scientific review of studies that have looked at the connection between smoking and birth defects. It includes information on nearly 12 million infants, including 173,000 that were born with malformed bodies.
"This is a seminal paper," says Michael Katz, MD, senior vice president of research and global programs for the March of Dimes and a professor emeritus at Columbia University.
Katz says previous studies have revealed piecemeal links between maternal smoking and birth defects, particularly the risk for cleft lips and cleft palates. But none has ever revealed such a comprehensive picture of the harms smoking is likely to cause.
"This is an encyclopedic review," Katz tells WebMD.
Smoking and Birth Defects
Experts have long suspected that smoking cigarettes was unhealthy for mother and baby. Indeed, cigarette labels already include the federally mandated warning that "smoking during pregnancy can harm your baby."
The new study shows how smoking is associated with increases in specific risks.
For the review, researchers culled 50 years of research on smoking and birth defects, narrowing their focus to just 172 studies.
They extracted data from those studies and pooled the numbers to create a big-picture look at birth defects related to cigarette smoking.
Babies born to mothers who smoked had roughly 20% to 30% higher odds of having shortened or missing arms and legs, cleft lips and cleft palates, and abnormally shaped heads or faces compared to babies born to nonsmoking mothers.
"These defects last a lifetime," says study researcher Allan Hackshaw, deputy director of the University College London Cancer Center in the U.K. "They can be fixed to some extent, but they're visible on the baby and infants and more or less for life."
Maternal smoking was associated with a 27% excess risk of gastrointestinal abnormalities, including problems with the throat, esophagus, colon, intestine, bile ducts, gall bladder, and liver.
Additionally, infants born to smokers had 50% higher odds of being born with their intestines hanging outside the body and a 20% increased risk of being born with a blocked or closed anus.
Smoking accounted for a 9% increased risk of heart defects and a 13% higher risk that baby boys would be born with undescended testes.
The study is published in Human Reproduction Update.
How Cigarettes May Harm Developing Babies
Cigarette smoke contains about 4,000 chemicals. Researchers don't fully understand how that toxic mixture may cause birth defects.
But they have some suspicions.
Part of the problem may be that the baby isn't getting enough oxygen when mom smokes.
Nicotine, the addictive substance in cigarettes, causes blood vessels to constrict, which may choke off the supply of oxygen to the fetus.
And carbon monoxide, a colorless, odorless gas that's present in high levels in cigarette smoke, binds more strongly to hemoglobin -- the molecule that ferries oxygen through the blood -- than oxygen itself, lowering the amount available to the baby.
"It personally absolute stuns me that some people still smoke during pregnancy," Hackshaw says.
Studies show 14% of women in the U.S. smoke while pregnant. That number jumps to 20% expectant mothers under age 25.
"The advice has to be 'don't smoke'," says Katz.
Though smoking is a tough habit to kick, he says many women do successfully quit after they find out they're pregnant.
"The motivation is much stronger in pregnant women than in the population at large," he says. "It's less difficult to persuade people who are pregnant to stop smoking than anyone else."
Vitamins May Lower Risk of Birth Complication
Health & Pregnancy
Vitamins May Lower Risk of Birth Complication
Study Shows Daily Multivitamin May Cut Risk of Preterm Births, Low Birth Weight, Neural Tube Birth Defects
Reviewed by Laura J. Martin, MD
Aug. 19, 2011 -- Women who take a multivitamin every day around the time of conception appear to have a reduced risk for delivering low-birth-weight babies, a new study shows.
Daily multivitamin use was also associated with a lower preterm birth risk among normal-weight, but not overweight, women.
Since about half of pregnancies are unplanned, taking a multivitamin every day could prove to be an important intervention for improving birth outcomes, especially among women who are not actively trying to conceive a child, study leader Janet M. Catov, PhD, of the University of Pittsburgh, tells WebMD.
“Just like folic acid supplementation, multivitamin use immediately before and after conception may be a simple strategy for lowering pregnancy risk,” she says.
Vitamins and Birth Risk
In earlier research, Catov and colleagues found that taking a multivitamin in the months before and after conception decreased the risk for developing the pregnancy-related condition preeclampsia, which can lead to stroke and even death.
That study and the newly published one included close to 36,000 Danish women enrolled in a national birth registry who were asked about their use of multivitamins in the weeks before and after conception.
About 60% of the women reported taking multivitamins during this period.
After adjusting for risk factors for preterm birth -- including smoking, obesity, and age -- normal-weight and underweight women who took multivitamins had a 16% reduction in preterm delivery risk compared to women who did not take the supplements.
Catov says it is not clear why a similar association was not seen in overweight women.
Multivitamin use in the weeks before conception was associated with a 10% to 20% reduction in low birth weight, regardless of the weight of the mother-to-be. Taking multivitamins regularly in the weeks after conception was associated with a 33% reduction in risk.
The study, which appears online today, will be published in the September issue of the American Journal of Clinical Nutrition.
More Than Just Folic Acid
The benefits of taking the vitamin-B supplement folic acid around the time of conception and eating folate-rich foods are well established. The vitamin is known to reduce the risk for preterm births, low birth weight, and neural tube birth defects.
Most multivitamins contain folic acid, but the researcher says other nutrients in the vitamins -- including zinc, and vitamins C and E -- may also contribute to better birth outcomes.
No evidence of harm associated with multivitamin use was seen in the study, but Catov says the researchers will continue to study this.
“We need to look more closely at the potential for adverse outcomes before recommending multivitamin use as a strategy for lowering pregnancy risk,” she says.
Ob-gyn Jennifer Wu, MD, of Lenox Hill Hospital in New York City, already recommends multivitamins that contain calcium to her patients when they tell her they are trying to conceive.
“Taking a multivitamin is a good habit to get into because many women have nutritional deficiencies that we want to correct, ideally before conception,” she tells WebMD. “It is not just about pregnancy. Many younger women don’t get enough calcium and these women are missing out on bone building that will help protect them in their 60s and 70s.”
Monday, August 29, 2011
Pertussis
Signs & Symptoms
Español: Signos y síntomas
Pertussis (whooping cough) can cause serious illness in infants, children and adults. The disease usually starts with cold-like symptoms and maybe a mild cough or fever. After 1 to 2 weeks, severe coughing can begin. Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks.
In infants, the cough can be minimal or not even there. Infants may have a symptom known as "apnea." Apnea is a pause in the child’s breathing pattern. Pertussis is most dangerous for babies. More than half of infants younger than 1 year of age who get the disease must be hospitalized. Learn more about pertussis complications.
Pertussis can cause violent and rapid coughing, over and over, until the air is gone from the lungs and you are forced to inhale with a loud "whooping" sound. This extreme coughing can cause you to throw up and be very tired. The "whoop" is often not there and the infection is generally milder (less severe) in teens and adults, especially those who have been vaccinated.
Early symptoms can last for 1 to 2 weeks and usually include:
Runny nose
Low-grade fever (generally minimal throughout the course of the disease)
Mild, occasional cough
Apnea – a pause in breathing (in infants)
Because pertussis in its early stages appears to be nothing more than the common cold, it is often not suspected or diagnosed until the more severe symptoms appear. Infected people are most contagious during this time, up to about 2 weeks after the cough begins. Antibiotics may shorten the amount of time someone is contagious.
As the disease progresses, the traditional symptoms of pertussis appear and include:
Paroxysms (fits) of many, rapid coughs followed by a high-pitched "whoop"
Vomiting (throwing up)
Exhaustion (very tired) after coughing fits
The coughing fits can go on for up to 10 weeks or more. In China, pertussis is known as the "100 day cough."
Although you are often exhausted after a coughing fit, you usually appear fairly well in-between. Coughing fits generally become more common and severe as the illness continues, and can occur more often at night. The illness can be milder (less severe) and the typical "whoop" absent in children, teens, and adults who have been vaccinated.
Recovery from pertussis can happen slowly. The cough becomes less severe and less common. However, coughing fits can return with other respiratory infections for many months after pertussis started.
Prevention
Español: Prevención
On This Page
Vaccines
The best way to prevent pertussis (whooping cough) among infants, children, teens, and adults is to get vaccinated. Also, keep infants and other people at high risk for pertussis complications away from infected people.
In the United States, the recommended pertussis vaccine for infants and children is called DTaP. This is a combination vaccine that protects against three diseases: diphtheria, tetanus and pertussis. For maximum protection against pertussis, children need five DTaP shots. The first three shots are given at 2, 4, and 6 months of age. The fourth shot is given between 15 and 18 months of age, and a fifth shot is given before a child enters school, at 4–6 years of age. Parents can also help protect infants by keeping them away as much as possible from anyone who has cold symptoms or is coughing.
Vaccine protection for pertussis, tetanus and diphtheria fades with time. Before 2005, the only booster available contained protection against tetanus and diphtheria (called Td), and was recommended for teens and adults every 10 years. Today there are boosters for pre-teens, teens and adults that contain protection against tetanus, diphtheria and pertussis (Tdap). Pre-teens going to the doctor for their regular check-up at age 11 or 12 years should get a dose of Tdap. Teens who did not get this vaccine at the 11- or 12-year-old check-up should get vaccinated at their next visit. Adults who did not get Tdap as a pre-teen or teen should get one dose of Tdap. Pregnant women who have not been previously vaccinated with Tdap should get one dose of Tdap postpartum before leaving the hospital or birthing center. Adults 65 years and older (grandparents, child care providers, and healthcare providers) who have close contact with infants should get a dose of Tdap, following the newest vaccine recommendations. Getting vaccinated with Tdap is especially important for families with and caregivers of new infants.
The easiest thing for adults to do is to get Tdap instead of their next regular tetanus booster—that Td shot that they were supposed to get every 10 years. The dose of Tdap can be given earlier than the 10-year mark, so it is a good idea for adults to talk to a healthcare provider about what is best for their specific situation.
Treatment
Pertussis is generally treated with antibiotics and early treatment is very important. Treatment may make your infection less severe if it is started early, before coughing fits begin. Treatment can also help prevent spreading the disease to close contacts (people who have spent a lot of time around the infected person) and is necessary for stopping the spread of pertussis. Treatment after three weeks of illness is unlikely to help because the bacteria are gone from your body, even though you usually will still have symptoms. This is because the bacteria have already done damage to your body.
There are several antibiotics available to treat pertussis. If you or your child is diagnosed with pertussis, your doctor will explain how to treat the infection. Learn more about the antimicrobial treatment recommended by CDC for treatment of pertussis. (208 KB, 20 pages)
Español: Signos y síntomas
Pertussis (whooping cough) can cause serious illness in infants, children and adults. The disease usually starts with cold-like symptoms and maybe a mild cough or fever. After 1 to 2 weeks, severe coughing can begin. Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks.
In infants, the cough can be minimal or not even there. Infants may have a symptom known as "apnea." Apnea is a pause in the child’s breathing pattern. Pertussis is most dangerous for babies. More than half of infants younger than 1 year of age who get the disease must be hospitalized. Learn more about pertussis complications.
Pertussis can cause violent and rapid coughing, over and over, until the air is gone from the lungs and you are forced to inhale with a loud "whooping" sound. This extreme coughing can cause you to throw up and be very tired. The "whoop" is often not there and the infection is generally milder (less severe) in teens and adults, especially those who have been vaccinated.
Early symptoms can last for 1 to 2 weeks and usually include:
Runny nose
Low-grade fever (generally minimal throughout the course of the disease)
Mild, occasional cough
Apnea – a pause in breathing (in infants)
Because pertussis in its early stages appears to be nothing more than the common cold, it is often not suspected or diagnosed until the more severe symptoms appear. Infected people are most contagious during this time, up to about 2 weeks after the cough begins. Antibiotics may shorten the amount of time someone is contagious.
As the disease progresses, the traditional symptoms of pertussis appear and include:
Paroxysms (fits) of many, rapid coughs followed by a high-pitched "whoop"
Vomiting (throwing up)
Exhaustion (very tired) after coughing fits
The coughing fits can go on for up to 10 weeks or more. In China, pertussis is known as the "100 day cough."
Although you are often exhausted after a coughing fit, you usually appear fairly well in-between. Coughing fits generally become more common and severe as the illness continues, and can occur more often at night. The illness can be milder (less severe) and the typical "whoop" absent in children, teens, and adults who have been vaccinated.
Recovery from pertussis can happen slowly. The cough becomes less severe and less common. However, coughing fits can return with other respiratory infections for many months after pertussis started.
Prevention
Español: Prevención
On This Page
Vaccines
The best way to prevent pertussis (whooping cough) among infants, children, teens, and adults is to get vaccinated. Also, keep infants and other people at high risk for pertussis complications away from infected people.
In the United States, the recommended pertussis vaccine for infants and children is called DTaP. This is a combination vaccine that protects against three diseases: diphtheria, tetanus and pertussis. For maximum protection against pertussis, children need five DTaP shots. The first three shots are given at 2, 4, and 6 months of age. The fourth shot is given between 15 and 18 months of age, and a fifth shot is given before a child enters school, at 4–6 years of age. Parents can also help protect infants by keeping them away as much as possible from anyone who has cold symptoms or is coughing.
Vaccine protection for pertussis, tetanus and diphtheria fades with time. Before 2005, the only booster available contained protection against tetanus and diphtheria (called Td), and was recommended for teens and adults every 10 years. Today there are boosters for pre-teens, teens and adults that contain protection against tetanus, diphtheria and pertussis (Tdap). Pre-teens going to the doctor for their regular check-up at age 11 or 12 years should get a dose of Tdap. Teens who did not get this vaccine at the 11- or 12-year-old check-up should get vaccinated at their next visit. Adults who did not get Tdap as a pre-teen or teen should get one dose of Tdap. Pregnant women who have not been previously vaccinated with Tdap should get one dose of Tdap postpartum before leaving the hospital or birthing center. Adults 65 years and older (grandparents, child care providers, and healthcare providers) who have close contact with infants should get a dose of Tdap, following the newest vaccine recommendations. Getting vaccinated with Tdap is especially important for families with and caregivers of new infants.
The easiest thing for adults to do is to get Tdap instead of their next regular tetanus booster—that Td shot that they were supposed to get every 10 years. The dose of Tdap can be given earlier than the 10-year mark, so it is a good idea for adults to talk to a healthcare provider about what is best for their specific situation.
Treatment
Pertussis is generally treated with antibiotics and early treatment is very important. Treatment may make your infection less severe if it is started early, before coughing fits begin. Treatment can also help prevent spreading the disease to close contacts (people who have spent a lot of time around the infected person) and is necessary for stopping the spread of pertussis. Treatment after three weeks of illness is unlikely to help because the bacteria are gone from your body, even though you usually will still have symptoms. This is because the bacteria have already done damage to your body.
There are several antibiotics available to treat pertussis. If you or your child is diagnosed with pertussis, your doctor will explain how to treat the infection. Learn more about the antimicrobial treatment recommended by CDC for treatment of pertussis. (208 KB, 20 pages)
Foods to Avoid When You're Pregnant
Pregnant? Think twice about these foods to avoid health risks for you and your baby.
Reviewed by Kathleen M. Zelman, MPH, RD, LD
When you’re expecting, what you eat and drink influences your child’s health, possibly forever. Everyday foods and beverages take on new meaning, as some may present a danger to your developing baby.
Whole and lightly processed foods, such as whole grains, lean meats, fruits and vegetables, legumes, and low-fat dairy should form the basis of your pregnancy diet. Here are items that you may want to avoid while you're pregnant.
Raw or Undercooked Food of Animal Origin
Undercooked animal foods -- such as rare meat, raw oysters, clams, sushi, unpasteurized eggs, raw cookie or cake dough, and homemade eggnog), may contain an array of bacteria, viruses, and parasites. To reduce your risk of foodborne illness, test the doneness of meat, poultry, and fish with a food thermometer, cook eggs until they are no longer runny, and follow baking instructions -- don't eat raw dough.
Hot Dogs, Luncheon Meats, and Unpasteurized Dairy Foods
These foods are prone to Listeria monocytogenes, a bacteria that causes listeriosis, which may result in miscarriage, stillbirth, or other serious health problems.
Besides hot dogs and luncheon meats --- which include deli ham or turkey, bologna, and salami -- other processed meats and seafood that may contain listeria include refrigerated pates or meat spreads, and refrigerated smoked seafood (such as salmon, trout, whitefish, cod, tuna, or mackerel). These items may be labeled as "nova-style," "lox," "kippered," "smoked," or "jerky."
Refrigerated smoked seafood is safe when it's part of a cooked dish, like casseroles. Luncheon meats and frankfurters are OK to eat if you reheat them until they are steaming hot, says Michael Lu, MD, UCLA professor of obstetrics, gynecology, and public health and author of Get Ready to Get Pregnant: Your Complete Pre-Pregnancy Guide to Making a Smart and Healthy Baby.
"Pregnant women should avoid getting the fluid from hot dog packages on other foods, utensils, and food preparation surfaces, and wash their hands after handling hot dogs, and deli luncheon meats," to further decrease potential contact with listeria, Lu says.
Unpasteurized dairy foods are also prone to listeria.
Avoid raw milk and dairy products made from unpasteurized milk, such as Brie, feta, Camembert, Roquefort, blue-veined, queso blanco, queso fresco, and queso Panela.
Certain Seafood and Fish
Large fish -- such as swordfish, shark, tilefish, and king mackerel -- harbor higher concentrations of mercury, compared to other fish. Mercury is a byproduct of coal-burning plants that interferes with the normal development of a growing child's brain and nervous system.
According to the FDA, pregnant and nursing women may eat up to 12 ounces weekly of seafood low in mercury, including salmon (farmed and wild), shrimp, canned light tuna, pollock, sardines, tilapia, and catfish. Because albacore (white) tuna has more mercury than canned light tuna, the FDA recommends that pregnant women limit albacore tuna to no more than 6 ounces a week, and include it in the 12-ounce limit.
Fish caught for sport in rivers, lakes, ponds, and streams may also contain industrial pollutants that play havoc with a developing nervous system. Recreational anglers should check the safety of waterways with their local health departments.
Page 2 of 3
Pregnant? Think twice about these foods to avoid health risks for you and your baby.
(continued)
Raw Vegetable Sprouts
The FDA advises everyone, regardless of pregnancy, not to eat raw sprouts -- including alfalfa, clover, radish, and mung bean sprouts.
The reason: Bacteria can get into sprout seeds and are "nearly impossible" to wash out, states the FDA's web site. The FDA recommends that pregnant women request that raw sprouts not be added to your food.
It's OK to eat thoroughly cooked sprouts, according to the FDA.
Drinks to Limit or Avoid
Alcohol (beer, wine, or spirits) robs developing cells of oxygen and nutrients, preventing normal fetal development. The effects of alcohol exposure in the womb on intellectual abilities and physical growth are permanent.
According to the CDC and the March of Dimes, there is no level of alcohol consumption that's known to be safe at any time during pregnancy.
Unpasteurized juices, such as cider purchased from roadside stands, at farms, or in stores. These products are prone to germs, including E. coli. Check the label to be sure juice is pasteurized.
Lead is linked to low birth weight, preterm delivery, and developmental delays in children. If you have an older home with pipes made of lead, it can leach into your tap water, and home filtration systems may not prevent it from reaching you.
If you’re in doubt about your tap water, have it tested.
Bottled water isn't necessarily purer; it's often repurposed municipal water.
Caffeine from coffee, tea, soft drinks, energy beverages, and other sources may increase the risk of miscarriage, reduced birth weight, and stillbirth, but the research is conflicting. The March of Dimes recommends limiting caffeine consumption to 200 milligrams a day. That's about the amount found in 12 ounces of coffee.
Bisphenol A (BPA)
BPA is an industrial chemical used to make many hard plastics and the liners of many canned foods. It's an endocrine disruptor that could disturb normal fetal development, Lu says.
The FDA is studying BPA and has not recommended that pregnant women avoid BPA. But in January 2010, the FDA stated that "recent studies provide reason for some concern about the potential effects of BPA on the brain, behavior, and prostate gland of fetuses, infants, and children." Most of those tests have been done on animals, and the FDA says there are "substantial uncertainties" about BPA's effects on human health. The plastics industry has maintained that low levels of BPA exposure are safe.
If you choose to avoid BPA while pregnant, a wide range of BPA-free plastics and glass containers are available.
Herbal Teas and Supplements
Herbal teas are caffeine-free, but their safety is unclear when you’re expecting. There are no reliable human studies on the safety of herbal preparations, including supplements such as Echinacea and St. John’s wort, during pregnancy.The FDA does not routinely monitor the quality of dietary supplements.
Page 3 of 3
Pregnant? Think twice about these foods to avoid health risks for you and your baby.
(continued)
Herbal Teas and Supplements continued...
"While it’s probably safe to drink the herbal teas found on supermarket shelves, pregnant women should avoid large quantities of herbal tea, and completely avoid herbal supplements," Lu says.
Duffy MacKay, ND, is the vice president of the Council for Responsible Nutrition, a trade group for the supplements industry. In an email to WebMD, MacKay states that "there are herbs and other supplements that can be used safely to support a healthy pregnancy” but tell your doctor or midwife about any supplement use during pregnancy.
MacKay says there is "scientific consensus" that these common herbs and supplements should be avoided during pregnancy:
Herbs that contain stimulants or caffeine-containing supplements, especially those that are intended to promote weight loss, guarana, kola nut, betel (Piper betle), Citrum aurantium, yohimbe, theobromine (cocoa extract), Garcinai cambogia.
Other botanicals to avoid while pregnant include golden seal, Cascara sagrada, black walnut, wormwood, tansy, pennyroyal, senna, saw palmetto, pao d'arco, MacKay says.
MacKay also advises women who are pregnant, or who could become pregnant, not to take 10,000 or more IU per day of vitamin A because of the risk of birth defects. And MacKay says that "many newer and specialty nutrients have not been proven safe for use during pregnancy and should be avoided."
The bottom line: Talk to your obstetrician about any herbal supplements or vitamins before taking them during pregnancy.
Foods That May Cause Food Allergy
If you, your child’s father, or one of your other children has allergies, your baby is more likely to have food allergies.
The American Academy of Pediatrics says that avoiding certain food allergens, such as peanuts and peanut products, during pregnancy and when nursing a child may reduce allergy in susceptible children.
But there’s little, if any, benefit to avoiding allergens during pregnancy and breastfeeding for everyone else.
Before changing your diet, talk to your doctor about your family history of allergies and asthma, and speak with a registered dietitian who is knowledgeable about food allergies.
Excess Calories
You’re eating for two now, but you don’t need twice the calories. Gaining too much weight threatens your health, and may increase the risk of childhood overweight in your future child.
In the second trimester, add 340 calories a day to your pre-pregnancy calorie needs, and 450 a day more in the third trimester. But if you’re very overweight at conception, or if your physical activity level drops, you may need fewer calories during pregnancy. Still, pregnancy is not a time to try to lose weight. Ask your doctor or dietitian what calorie level is right for you.
There is room for treats like ice cream, chips, and cookies during pregnancy, but it’s important to choose foods that do double duty by providing the additional calories you need, as well as the extra nutrients that maximize your baby’s development.
Friday, August 12, 2011
Stretch Marks from WebMD
Stretch Marks Getting Under Your Skin?
Smoother Skin Doesn't Have to Be a Stretch, Doctors Say, Because Treatment Options Abound
By Annabelle Robertson
WebMD Feature
Reviewed by Louise Chang, MD
When Adrienne Nugent of San Antonio gave birth to her third child, she was dismayed to see that the stretch marks from her earlier pregnancies -- which she had diligently tried to minimize with topical creams and ointments -- had multiplied.
She'd heard that stretch marks were hard to avoid, but Nugent wasn't particularly concerned. She was looking forward to abdominoplasty surgery.
"I still have some stretch marks, but they're very, very low on my belly," says the 38-year-old. "Most got cut out with my tummy tuck."
Not everyone is willing to go to such lengths to get rid of stretch marks, however. So it's important to understand first what causes stretch marks, and what steps, if any, you can take to prevent them.
What Causes Stretch Marks?
Known by doctors as "striae" (usually "striae distensae" or, in the case of pregnancy, "striae gravidarum") stretch marks typically appear after rapid weight gain or loss. They are most common during pregnancy and the teen years, when growth spurts and increased levels of steroid hormones cause significant changes throughout the body. Stretch marks can also be brought on by obesity and weight lifting.
Genetic factors -- including inherited defects of connective tissues -- also play a role, Mohamed L. Elsaie, MD, MBA, says in the August 2008 issue of Esthetic Dermatology News. But the basic cause of stretch marks is unknown.
"Basically, if your mother had them, you're probably going to have them," says Leslie Baumann, MD, director of the University of Miami Cosmetic Group and author of The Skin Type Solution.
Stretch marks affect as many as 90% of all women, she says, and they are not easy to get rid of. Once they have passed the initial stage, when they are red or purple, to the later stages, where they become white or silver -- often with deep indentations -- they are much more challenging to treat.
Prevention, therefore, is key.
"Avoiding rapid weight gain or loss is a good start. For those who are pregnant or experiencing the hormone changes of the teen years, it is crucial to moisturize," Baumann says. "Skin becomes more pliant, more plasticized and better able to stretch when it's well hydrated."
She recommends moisturizing three or four times a day with products that contain cocoa butter or shea butter as a prime ingredient. Massage the moisturizer deep into breasts, belly, hips, and buttocks.
How to Get Rid of Stretch Marks
The appearance of stretch marks depends on the color of your skin; they can start out pink, reddish brown, brown, or dark brown, and fade over time to a more silvery color. Once stretch marks have appeared, it's essential to treat them as early as possible. Research has focused exclusively on the early stages of stretch marks, when they are still red or purple and most readily respond to treatment, Baumann explains.
Page 2 of 3
Smoother Skin Doesn't Have to Be a Stretch, Doctors Say, Because Treatment Options Abound
(continued)
How to Get Rid of Stretch Marks continued...
Grocery stores, pharmacies, and web sites boast a multitude of products and cosmetics that claim to "repair" striae. However, only a few work, she says.
Here's a rundown of the products available for stretch mark removal and what they can -- and cannot -- do:
Wheat germ oil: There is not much scientific data on whether home remedies for stretch marks, such as wheat germ oil, can help. One recent study did find it helped improve stretch marks in their early phase.
Glycolic acid: Widely touted for its rejuvenation powers, glycolic acid is a sugar cane derivative and a member of the alpha hydroxy acid (AHA) family. It most likely works on stretch marks by increasing collagen production, says Baumann. Glycolic acid can also be administered in higher doses by a dermatologist. Treatment typically costs around $100 and requires three or four office visits before results will appear.
Vitamin C: Certain formulations of vitamin C, which have become increasingly popular as over-the-counter brands, may also increase collagen production and help early-stage stretch marks, says Baumann. For maximum effect, combine with glycolic acid. Vitamin C supplements may also be effective. She suggests 500 milligrams three times a day.
Peptide-containing products: Peptide-containing products, which are widely marketed as effective "repair" creams, are a waste of time and money, Baumann says. Despite commercial claims, there is no convincing data that these work.
Retinoids: A family of products that includes vitamin A, retinoids have been shown to be fairly effective in increasing collagen and elastic production during the early stages. Retinoids should be avoided entirely if pregnant or nursing. Retinol, tretinoin, and the prescription medications Retin-A, Renova, Tazorac, and Differin are examples of retinoids.
Glycolic acid and retinoids: Using these together may provide better results. According to Elsaie, while glycolic acid alone for stretch mark treatment has not been fully studied, a trial comparing glycolic acid plus tretinoin with glycolic acid plus vitamin C both showed equal improvement and increased elastic in stretch marks after 12 weeks of daily application. Various prescription-strength retinoids are often applied as a preparation to "rev up" the skin before a glycolic acid peel is applied.
Laser treatment: This popular treatment option is used by many dermatologists, and they are also being tried on white stretch marks, as well.
Linda K. Franks, MD, a clinical assistant professor at New York University School of Medicine and director of Gramercy Park Dermatology Associates, is a big fan of laser procedures, which she frequently uses in her New York City practice to treat both red/purple and white stretch marks.
"Lasers promote synthesis of healthy, new collagen, which has been damaged when stretch marks appear," she explains.
For red and purple marks, Franks uses a vascular laser which targets swollen and inflamed blood vessels and helps with skin cell production and increased collagen production. Treatments usually require three to six sessions at an average rate of $450 per session.
Page 3 of 3
Smoother Skin Doesn't Have to Be a Stretch, Doctors Say, Because Treatment Options Abound
(continued)
How to Get Rid of Stretch Marks continued...
"Vascular lasers won't take away the superficial skin but will take away the redness," she says. "The redness is caused by blood flow. V-Beam treats those blood vessels.
One laser that may help minimize older, more entrenched stretch marks is the fractionated laser, which hits tiny "fractions" of the skin, often in a grid-like pattern. Franks describes the process as "smudging" the lines of stretch marks, which makes them less distinct.
Like most Floridians, Franshely Calero, 25, loves to go to the beach near her home in Miami. But after giving birth to her son one year ago, she was plagued with stretch marks and became too embarrassed to take off her shirt.
Pink at first, the stretch marks turned white after three or four months and deepened significantly. So Calero decided to try a fractionated laser that has been approved by the FDA for use with age spots, acne scars, and "mask of pregnancy" also known as melasma. She received three laser treatments.
"They're still there but they're a lot less noticeable. I mean, a lot," she says. "I had big, deep wide ones on my stomach. You could run your finger over them and it was like falling into a pit. They were super wrinkly and saggy. Now, the skin is more even and smooth. It doesn't look like my body has been taken over by stretch marks."
Expect to pay up to $1,000 per session for these treatments, and be prepared to pay for at least three sessions.
Even in the best cases, however, Franks warns not to expect perfection. She estimates that patients will see about 30% improvement but is quick to add that almost everyone who does the treatments is usually quite pleased.
"People are resigned to the fact that stretch marks are permanent and can't be fixed, but there are ways to treat them," Franks says. "There will always be some left, though, whether you're treating the red ones or the white ones."
Preterm Labor
Preterm labor
Preterm birth is any birth that occurs before the 37th week of pregnancy. It is the cause of many infant deaths and lingering infant illnesses in the United States. Every pregnant woman needs to know about preterm labor and birth—why it happens and what she can do to help prevent it.
Preterm birth occurs in about 12 percent of all pregnancies in the United States, often for reasons we just don't understand. A normal pregnancy should last about 40 weeks. That amount of time gives the baby the best chance to be healthy. A pregnancy that ends between 20 weeks and 37 weeks is considered preterm, and all preterm babies are at significant risk for health problems. The earlier the birth, the greater the risk.
You might have read in the newspapers about babies who are born really early and do very well. But it's important for you to know that those babies are the exceptions. Babies who are born very preterm are at a very high risk for brain problems, breathing problems, digestive problems, and death in the first few days of life. Unfortunately, they also are at risk for problems later in their lives in the form of delayed development and learning problems in school. The effects of premature birth can be devastating throughout the child's life. The earlier in pregnancy a baby is born, the more health problems it is likely to have.
Why Does preterm labor occur?
There are no easy answers. Stress might play a part for some women, personal health history or infection for others, or smoking or drug use for others. With funding from the March of Dimes and others, researchers are studying how various factors contribute to the complex problem of premature labor and birth.
Who is at risk for preterm labor?
Preterm labor and delivery can happen to any pregnant woman. But they happen more often to some women than to others. Researchers continue to study preterm labor and birth. They have identified some risk factors, but still cannot generally predict which women will give birth too early. Having a risk factor does not mean a woman will have preterm labor or preterm birth. It just means that she is at greater risk than other women.
Three groups of women are at greatest risk of preterm labor and birth:
Women who have had a previous preterm birth
Women who are pregnant with twins, triplets or more
Women with certain uterine or cervical abnormalities
If you have any of these three risk factors, it's especially important for you to know the signs and symptoms of preterm labor and what to do if they occur.
Lifestyle and environmental risks
Some studies have found that certain lifestyle and environmental factors may put a woman at greater risk of preterm labor. These factors include:
Late or no prenatal care
Smoking
Drinking alcohol
Using illegal drugs
Exposure to the medication DES
Domestic violence, including physical, sexual or emotional abuse
Lack of social support
Stress
Long working hours with long periods of standing
Exposure to certain environmental pollutants
Medical risks
Certain medical conditions during pregnancy may increase the likelihood that a woman will have preterm labor. These conditions include:
Urinary tract infections, vaginal infections, sexually transmitted infections and possibly other infections
Diabetes
High blood pressure and preeclampsia
Clotting disorders (thrombophilia)
Bleeding from the vagina
Certain birth defects in the baby
Being pregnant with a single fetus that is the result of in vitro fertilization (IVF)
Being underweight before pregnancy
Obesity
Short time period between pregnancies (less than 6-9 months between birth and the beginning of the next pregnancy)
Groups at increased risk
Researchers have also identified certain groups that are at increased risk of having a premature baby. These groups include:
African-American women
Women younger than 17 and older than 35
Women who have a low income
Preventing preterm labor and birth
You can help prevent preterm birth by learning the symptoms of preterm labor and following some simple instructions. The first thing to do is to get medical care both before and during pregnancy. If you do have preterm labor, get medical help quickly. This will improve the chances that you and your baby will do well.
Medications sometimes slow or stop labor if they are given early enough. Drugs called corticosteroids, if given 24 hours before birth, can help the baby's lungs and brain mature. This can prevent some of the worst health problems a preterm baby has. Only if a woman receives medical care quickly can drugs be helpful. Knowing what to look for is essential.
Treatment with a form of the hormone progesterone may help prevent premature birth in some women who have already had a premature baby.
Symptoms of preterm labor
Remember, preterm labor is any labor that occurs between 20 weeks and 37 weeks of pregnancy. Here are the symptoms:
Contractions (your abdomen tightens like a fist) every 10 minutes or more often
Change in vaginal discharge (leaking fluid or bleeding from your vagina)
Pelvic pressure—the feeling that your baby is pushing down
Low, dull backache
Cramps that feel like your period
Abdominal cramps with or without diarrhea
If you start to have any of these symptoms between 20 weeks and 37 weeks of pregnancy, follow the instructions in the section below "What to do if you have symptoms of preterm labor."
Don't let anyone tell you that these symptoms are "normal discomforts of pregnancy"! If any of them (you don't need to have all of them) happen before your 37th week of pregnancy, you need to do something about it.
What to do if you have symptoms of preterm labor?
Call your health care provider or go to the hospital right away if you think you are having preterm labor. Your provider may tell you to:
Come to the office or go to the hospital for evaluation.
Stop what you are doing and rest on your left side for one hour.
Drink 2–3 glasses of water or juice (not coffee or soda).
If the symptoms get worse, or don't go away after one hour, call your health care provider again or go to the hospital. If the symptoms go away, take it easy for the rest of the day. If the symptoms stop but come back, call your health care provider again or go to the hospital.
When you call your provider, be sure to tell the person on the phone that you are concerned about the possibility of preterm labor. The only way your provider can know if preterm labor is starting is by doing an internal examination of your cervix (the bottom of your uterus). If your cervix is opening up (dilating), preterm labor could be beginning.
You and your health care provider are a team, working together to have a healthy pregnancy and healthy baby. Your team works best when both of you participate fully, so your knowledge about preterm labor can be essential in helping to prevent a preterm birth. Talk to your health care provider about all of this, and be sure to keep all of your prenatal care appointments. Preterm birth is one of the complications of pregnancy that health care providers are working hard to eliminate. Your participation in this effort is just as important as theirs!
April 2008/April 2010
Tuesday, August 2, 2011
VBAC: Vaginal Birth after Cesarean
If you have undergone a cesarean delivery, you are not alone. In November 2005, the Centers for Disease Control and Prevention reported the national cesarean birth rate was the highest ever at 29.1%, which is over a quarter of all deliveries.
If you desire to try a vaginal delivery this time around, you’ll be happy to know that 90% of women who have undergone cesarean deliveries are candidates for VBAC. Quite interestingly, the highest rate of VBAC is in women who have experienced both vaginal and cesarean births and given the choice, decide to deliver vaginally.
In most published studies, 60-80% or 3 to 4 out of 5 women who have previously undergone cesarean birth can successfully give birth vaginally. After reading the information below and discussing it with your health care provider, you will be able to make an informed decision on whether VBAC may be an option for you this time around.
The greatest concern for women who have had a previous cesarean is the risk of a uterine rupture during a vaginal birth. According to the American College of Obstetricians and Gynecologists (ACOG), if you had a previous cesarean with a low transverse incision, the risk of uterine rupture in a vaginal delivery is .2 to 1.5%, which is approximately 1 in 5001.
Some studies have documented increased rates of uterine rupture in women who undergo labor induction or augmentation. You will want to discuss the possible complications of induction with your health care provider. Recently, ACOG stated that VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk.2
If you were given the following reasons for a previous cesarean and are considering a repeat cesarean, you may wish to discuss the following with your health care provider:
Dystocia: Dystocia refers to a long and difficult labor due to slow cervical dilation, a small pelvis, or a big baby. Many women who are given this reason for previous cesareans, deliver vaginally the next time, and give birth to a bigger baby than the first! ACOG states that the effects [or difficulties] of labor with a baby more than 8 ¾ lbs have not been substantiated.
There is not evidence that a big baby necessitates a cesarean. The pelvis and the baby's head are not rigid structures and both mold and change shape to allow for birth. During labor there are certain positions that a woman can use to help open up the pelvis, allowing a larger baby to move through. For example, squatting opens the outlet of the pelvis by 10%.
Genital Herpes: For many years, women with a history of herpes almost always delivered by cesarean, due to the risk of passing herpes to the baby during delivery. Physicians would do cultures in the last weeks of pregnancy and if the virus were active, a cesarean would be scheduled. Now ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable.
Fetal Distress: When it comes to the life of the baby, there is no question in a mother’s mind of what to do. If the baby is in distress, cesarean deliveries can be life saving. According to the Centers for Disease Control and Prevention, 9% of cesarean deliveries in 1991 were due to fetal distress. Fetal heart rate monitoring can be a routine part of the VBAC procedure, which helps detect fetal distress.
Your purchase supports the APA
What is the criterion I must meet to be considered for VBAC?
No more than 2 low transverse cesarean deliveries.
No additional uterine scars, anomalies or previous ruptures.
Your health care provider should be prepared to monitor labor and perform or refer for a cesarean if necessary .
Your birth location should have personnel available on weekends and evenings in case a cesarean is necessary.
What other criteria would make me a good candidate for a VBAC?
If the original reason for a cesarean delivery is not repeated with this pregnancy
You have no major medical problems
The baby is a normal size
The baby is head-down
In what situations would VBAC not be recommended?
If you are pregnant with twins
If you have diabetes
If you have high-blood pressure
Comparing a Repeat Cesarean to a VBAC:
1. ACOG Practice Bulletin, No. 5, July 1999
2. ACOG, Midwifery Today, Winter No 36, page 47.
3. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
International Cesarean Awareness Network, http://www.ican-online.org/
Last Updated:12/2006
If you desire to try a vaginal delivery this time around, you’ll be happy to know that 90% of women who have undergone cesarean deliveries are candidates for VBAC. Quite interestingly, the highest rate of VBAC is in women who have experienced both vaginal and cesarean births and given the choice, decide to deliver vaginally.
In most published studies, 60-80% or 3 to 4 out of 5 women who have previously undergone cesarean birth can successfully give birth vaginally. After reading the information below and discussing it with your health care provider, you will be able to make an informed decision on whether VBAC may be an option for you this time around.
The greatest concern for women who have had a previous cesarean is the risk of a uterine rupture during a vaginal birth. According to the American College of Obstetricians and Gynecologists (ACOG), if you had a previous cesarean with a low transverse incision, the risk of uterine rupture in a vaginal delivery is .2 to 1.5%, which is approximately 1 in 5001.
Some studies have documented increased rates of uterine rupture in women who undergo labor induction or augmentation. You will want to discuss the possible complications of induction with your health care provider. Recently, ACOG stated that VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk.2
If you were given the following reasons for a previous cesarean and are considering a repeat cesarean, you may wish to discuss the following with your health care provider:
Dystocia: Dystocia refers to a long and difficult labor due to slow cervical dilation, a small pelvis, or a big baby. Many women who are given this reason for previous cesareans, deliver vaginally the next time, and give birth to a bigger baby than the first! ACOG states that the effects [or difficulties] of labor with a baby more than 8 ¾ lbs have not been substantiated.
There is not evidence that a big baby necessitates a cesarean. The pelvis and the baby's head are not rigid structures and both mold and change shape to allow for birth. During labor there are certain positions that a woman can use to help open up the pelvis, allowing a larger baby to move through. For example, squatting opens the outlet of the pelvis by 10%.
Genital Herpes: For many years, women with a history of herpes almost always delivered by cesarean, due to the risk of passing herpes to the baby during delivery. Physicians would do cultures in the last weeks of pregnancy and if the virus were active, a cesarean would be scheduled. Now ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable.
Fetal Distress: When it comes to the life of the baby, there is no question in a mother’s mind of what to do. If the baby is in distress, cesarean deliveries can be life saving. According to the Centers for Disease Control and Prevention, 9% of cesarean deliveries in 1991 were due to fetal distress. Fetal heart rate monitoring can be a routine part of the VBAC procedure, which helps detect fetal distress.
Your purchase supports the APA
What is the criterion I must meet to be considered for VBAC?
No more than 2 low transverse cesarean deliveries.
No additional uterine scars, anomalies or previous ruptures.
Your health care provider should be prepared to monitor labor and perform or refer for a cesarean if necessary .
Your birth location should have personnel available on weekends and evenings in case a cesarean is necessary.
What other criteria would make me a good candidate for a VBAC?
If the original reason for a cesarean delivery is not repeated with this pregnancy
You have no major medical problems
The baby is a normal size
The baby is head-down
In what situations would VBAC not be recommended?
If you are pregnant with twins
If you have diabetes
If you have high-blood pressure
Comparing a Repeat Cesarean to a VBAC:
1. ACOG Practice Bulletin, No. 5, July 1999
2. ACOG, Midwifery Today, Winter No 36, page 47.
3. Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
International Cesarean Awareness Network, http://www.ican-online.org/
Last Updated:12/2006
Friday, July 8, 2011
Maternity Leave from Babycenter.com
What is maternity leave?
Maternity leave, now often called parental or family leave, is the time a mother (or father) takes off from work for the birth or adoption of a child. Actual paid "maternity leave" — while the norm in every other developed country — is unusual in the United States, although some enlightened companies do offer new parents paid time off, up to six weeks in some cases.
Most likely, you'll use a combination of short-term disability (STD), sick leave, vacation, personal days, and unpaid family leave during your time away from work.
The picture did improve in 1993 with the passage of the Family and Medical Leave Act (FMLA), which entitles most workers to up to 12 weeks of job-protected medical leave for birth or adoption. However, the FMLA doesn't cover those who work for smaller companies and guarantees only unpaid leaves.
Which benefits are available to you will depend very much on which state you live in. In 2002, California led the way in enacting paid family leave, and other states such as Massachusetts and New Jersey are considering following suit. And not all states allow women to take short-term disability leave to cover pregnancy, birth, and postpartum recovery.
Your employer may have policies that dictate the order in which you can take different kinds of leave. In any case, you'll want to start looking into your options as early as you can during your pregnancy and make sure you have all your paperwork sorted out before the baby arrives.
How does short-term disability work?
Short-term disability is meant to cover your salary — or a portion of it — during the time that you're unable to do your job due to illness, injury, or childbirth. Many large employers and unions offer it, as do several states. (It's generally provided automatically to all employees or residents, not as an optional benefit you have to sign up for.)
If your state provides STD, you may pay a small amount out of each paycheck to cover your share. If your employer or union provides it, the cost may be covered for you. If none of them provides STD, or if the coverage is insufficient, you can purchase your own policy or additional coverage through an insurance provider for a monthly premium.
Private STD insurance through your employer or a provider will generally pay between 50 and 100 percent of your salary for a certain number of weeks, depending on how many years you've worked for the company. (The maximum amount you can receive is usually capped.)
Six weeks is the standard amount of time covered for pregnancy. Some plans allow more time if you've had complications or a cesarean delivery, and many also cover bedrest before birth.
State STD benefits typically cover half to two thirds of your salary, and the coverage for pregnancy usually lasts four to six weeks but can last up to 12 weeks. In California, for example, you're covered at 55 percent of your usual salary for up to six weeks per 12-month period. You may be able to get coverage for eight weeks or longer after the birth if you've had a c-section or medical complications, but your doctor must certify this.
If both your state and your company offer STD, you may be required to use the full state benefit and have your employer's coverage make up the rest. You'll still end up with the same amount of pay as if you were getting your employer's full benefit, but you'll get it in two checks, one from the state and one from your company's provider.
Many programs require that you be out of work for up to a week before you can start to collect disability benefits. Your employer or your state's program may require you to use up your accrued sick days or vacation days before your disability benefits kick in. That's not necessarily a bad thing, as those days are paid at your full salary.
Will I have to pay income tax on disability income?
It depends on who's paying the insurance premiums for your coverage. The portion of your salary that you receive from your employer's coverage is taxable, but no income taxes will be taken out of your checks, so you'll end up owing the money in April. (On the other hand, you'll be able to take an extra deduction for having a new dependent, so that may offset the amount.)
Money you receive from a state disability program is generally not subject to federal or state income taxes. If you pay for the disability insurance yourself, the benefits you receive are also tax-free.
What do I do when my short-term disability coverage runs out?
Some new moms decide to return to work once their coverage runs out, which is typically after about six weeks. (Of course, some have to return even sooner if they're relying on a state benefit that only pays half of their normal salary and they can't afford to make up the difference.)
If you've accrued vacation, personal, or sick days, you may want to use them to extend your leave. Some companies will even allow you to take vacation or sick days that you haven't yet accrued. In some cases, however, you may be asked to reimburse the company for those days if you decide not to return to work after your leave.
You may also be eligible for unpaid disability leave. If you're unable to return to work when your STD coverage runs out, some states allow you to take a certain amount of unpaid pregnancy disability leave. (California has a particularly generous provision, allowing up to four months for women disabled by pregnancy, something that has to be certified by a doctor.)
You won't get paid during this time, but your employer will be required to hold your job for you until you're able to return (or until the leave runs out). Your employer may require that you use up your sick days before taking unpaid disability leave.
How can I find out whether I'm entitled to unpaid leave?
Start by asking your company's human resources department. Under the FMLA, many employers are required by federal law to allow their employees (both men and women) 12 weeks of unpaid leave after the birth or adoption of a child. At the end of your leave, your employer must allow you to return to your job or a similar job with the same salary, benefits, working conditions, and seniority.
You are among the 60 percent of U.S. workers who are eligible if you meet both of the following conditions:
You work for the federal government, a state or local government, or any company that has 50 or more employees working within 75 miles of your workplace.
You've worked for your employer for at least 12 months and for at least 1,250 hours during the previous year (an average of 25 hours per week for 50 weeks).
There are a few exceptions: Your employer isn't required to keep your job open for you if you're in the highest-paid 10 percent of wage earners at your company and your employer can show that your absence would cause substantial economic harm to the organization.
Another exception is if you and your partner work for the same company. In this case, you're only entitled to a combined 12 weeks of parental leave between the two of you.
Even if you're not eligible under the FMLA, you may still be eligible for leave under your state's provisions, which are usually more generous than the FMLA, or under your company's family leave policy.
Your employer may require that all the paid leave you take (STD, vacation, sick leave) count toward the 12 weeks required by the FMLA. But some states allow you to take the full 12 weeks in addition to whatever paid leave you take. Individual employers may also allow this.
You can use your unpaid leave in any way you want during your pregnancy or during the year after your child is born. That means you can take it all at once — right after the birth or placement of your child, for example — or, as long as your employer agrees, you can spread it out over your child's first year by taking it in chunks or by reducing your normal weekly or daily work schedule.
If you're considering unpaid leave, think about how much time you can reasonably afford to take. Also think about whether your partner can take any time off and when it would be best for him or her to do that.
You and your partner may decide to take leave at the same time, but if you want to stretch out the time that at least one of you is home with the baby, consider overlapping your leaves, taking them consecutively, or spreading your time off over the year.
What happens to my benefits while I'm out on leave?
According to the FMLA, your company must continue to keep you on its health insurance plan while you're on leave, whether it's disability or family leave. Most typically, a company will pay your premiums but ask to be reimbursed for your share (the amount that's usually taken out of your paycheck).
If your company is particularly generous, it may cover your share and not ask you to pay it back. However, in rare cases, your employer may choose to put you on COBRA, a program in which you continue to be covered under the same plan but you must pay the entire premium yourself (at an average of about $500 a month).
If you tell your company that you don't plan to return to work following your leave or if your job is eliminated while you're gone, your employer may stop paying your premiums and may even require you to pay back the money spent to maintain your health insurance while you were on leave. That's unless the reason you're not returning to work is that you've developed a serious medical condition or some other circumstance beyond your control (say, your spouse is transferred to a job in another city and you have to move).
The FMLA doesn't require employers to allow you to accrue benefits or time toward seniority when you're out on leave. That means the clock may stop on things like vacation accrual and the amount of time you can say you've been with the company in order to qualify for things like raises based on seniority, additional vacation days, participation in your company's 401k plan or vesting of your company's matching investment, or vesting of stock options.
Finally, you won't be able to contribute to your 401(k) or flexible spending account while you're on leave because you're not receiving a paycheck from your employer and thus can't contribute pre-tax dollars.
What if I'm adopting a child or taking in a foster child?
You're not qualified for disability leave in this case, but you are allowed 12 weeks of unpaid leave under the FMLA — or possibly more under your state's provisions or your company's policy.
Generally this leave begins once the child arrives at your home or when you leave to go get the child if you're adopting from another country. You may also be eligible to take time off during the adoption process to meet with lawyers or attend home visits. You can take paid vacation time as well, and some states and employers even allow you to use your sick leave.
How and when should I request leave?
Federal guidelines require you to request leave at least 30 days before you plan to take it, but it may be best to give your boss more advance notice — you don't want to wait until you're obviously showing to tell your employer about your pregnancy. But you may want to wait until after your first trimester, when your risk of miscarriage goes down significantly.
After that, think about breaking the news as soon as you've thought through your leave request and your post-pregnancy work schedule. You'll be in a stronger position to negotiate a leave if you approach your boss with a specific plan and allow him or her plenty of time to help you implement it. (If you have trusted co-workers who have been through this before, ask them how they handled their leave and what kind of reaction they got.)
How do I decide when to start my leave?
There's no "right time" to stop working. A lot will depend on your energy level, how easy or complicated your pregnancy becomes after the initial exhausting months, and the stress and physical labor involved in your job. Your financial situation will also be a factor, as the sooner you start your leave, the sooner it will run out after your baby's born.
Some women start their leave when they're seven or eight months pregnant, while others work right up until delivery. You'll need to monitor your pregnancy to determine the right time to start maternity leave. If your doctor puts you on bedrest or complications develop that require you to be out of work before you give birth, you'll most likely be put on short-term disability if your state or company offers it.
Under the FMLA, you can start taking unpaid leave anytime during your pregnancy — or anytime thereafter — as long as you conclude your leave within the first 12 months after your child's arrival. Check with your human resources department to find out if any limitations apply under your company's leave policies.
What if my employer denies my request for unpaid leave?
If you're sure you qualify under the FMLA or your state's provisions, make sure you've given the required notice and you have a plan to get your responsibilities covered while you're gone. Then, gently let your employer know more about these laws. Contact the U.S. Department of Labor for an FMLA fact sheet and advice on how to get your employer to comply. But start by being reasonable. You don't want to alienate your boss by making demands unless you have to.
If reason doesn't work and you believe you're entitled to leave, contact your regional office of the Labor Department's Wage and Hour Division to file a complaint. A phone call from the Labor Department to your employer can resolve most problems.
If the problem is not resolved, the Labor Department will investigate your complaint and may sue your employer on your behalf. If you don't get immediate results, consider hiring a lawyer who is familiar with employees' rights to help you.
You may also want to get in touch with Equal Rights Advocates, a national nonprofit organization that advocates for women's rights in the workplace. Call ERA's confidential, toll-free hotline at (800) 839-4372 for advice on issues related to maternity leave and pregnancy discrimination.
Where can I get more information?
To find out what kind of disability or unemployment insurance and other family leave provisions are currently available or coming soon to your state, check with your state's Department of Labor. You can also search the Internet for your state's disability insurance policies.
For a directory of companies that offer private short-term disability coverage for individuals, contact the Health Insurance Association of America.
For more information on the FMLA and family leave policies, contact:
U.S. Department of Labor
Wage and Hour Division
200 Constitution Avenue NW
Washington, D.C. 20210
Phone: (866) 487-9243
National Partnership for Women & Families
1875 Connecticut Avenue NW, Suite 710
Washington, D.C. 20009
Phone: (202) 986-2600
Fax: (202) 986-2539
Families and Work Institute
267 Fifth Avenue, 2nd Floor
New York, NY 10016
Telephone: (212) 465-2044
Fax: (212) 465-8637
Thursday, July 7, 2011
Group B Streptococcus from American Pregnancy Association
Group B streptococcus (GBS) is a type of bacterial infection that can be found in a pregnant woman’s vagina or rectum. This bacteria is normally found in the vagina and/or rectum of about 25 % of all healthy, adult women.
Those women who test positive for GBS are said to be colonized. A mother can pass GBS to her baby during delivery. GBS is responsible for affecting about 1 in every 2,000 babies in the United States. Not every baby who is born to a mother who tests positive for GBS will become ill.
Although GBS is rare in pregnant women, the outcome can be severe, and therefore physicians include testing as a routine part of prenatal care.
How can I find out if I have Group B Strep infection?
The Centers for Disease Control and Prevention (CDC) has recommended routine screening for vaginal strep B for all pregnant women. This screening is performed between the 35th and 37th week of pregnancy (studies show that testing done within 5 weeks of delivery is the most accurate at predicting the GBS status at time of birth.)
The test involves a swab of both the vagina and the rectum. The sample is then taken to a lab where a culture is analyzed for any presence of GBS. Test results are usually available within 24 to 48 hours.
The American Academy of Pediatrics recommends that all women who have risk factors PRIOR to being screened for GBS (for example, women who have preterm labor beginning prior to 37 completed weeks' gestation) are treated with IV antibiotics until their GBS status is established.
How does someone get group B strep?
The bacteria that causes group B strep normally lives in the intestine, vagina, or rectal areas. Group B strep colonization is not a sexually transmitted disease (STD). Approximately 25% of all healthy women carry group B strep bacteria. For most women there are no symptoms of carrying the GBS bacteria.
What if I test positive for Group B Strep infection?
If you test positive for GBS this simply means that you are a carrier. Not every baby who is born to a mother who tests positive for GBS will become ill. Approximately one out of every 200 babies whose mothers carry GBS and are not treated with antibiotics, will develop signs and symptoms of GBS disease. There are, however, symptoms that may indicate that you are at a higher risk of delivering a baby with GBS. These symptoms include:
Labor or rupture of membrane before 37 weeks
Rupture of membrane 18 hours or more before delivery
Fever during labor
A urinary tract infection as a result of GBS during your pregnancy
A previous baby with GBS disease
In this case your physician will want to use antibiotics for prevention and protection.
According to the CDC, if you have tested positive and are not in the high risk category, then your chances of delivering a baby with GBS are:
1 in 200 if antibiotics are not given
1 in 4000 if antibiotics are given
How can I protect my baby from Group B Strep infection?
If you test positive for GBS and meet the high risk criteria, then your physician will recommend giving you antibiotics through IV during your delivery to prevent your baby from becoming ill. Taking antibiotics greatly decreases the chances of your baby developing early onset group B strep infection..
For women who are group B strep carriers, antibiotics given before labor begins are not effective at preventing the transmission of the group B bacteria. Since they naturally live in the gastrointestinal tract (guts), the bacteria can come back after antibiotics. A woman may test positive at certain times and not at others. That’s why it is important for all pregnant women to be tested for group B strep between 35 to 37 weeks of every pregnancy.
If you are at a low risk, the decision to use antibiotics is up to you. There are herbal remedies that you can take 2-3 weeks before delivery that a midwife or homeopathic physician can recommend.
How does Group B Strep infection affect a newborn baby?
Babies may experience early or late-onset of GBS.
The signs and symptoms of early onset GBS include:
Signs and symptoms occurring within hours of delivery
Breathing problems, heart and blood pressure instability
Gastrointestinal and kidney problems
Sepsis, pneumonia and meningitis are the most common complications
Newborns with early-onset are treated the same as the mothers, which is through intravenous antibiotics.
The signs and symptoms of late-onset GBS include:
Signs and symptoms occurring within a week or a few months of delivery
Meningitis is the most common symptom
Late-onset GBS is not as common as early-onset
Late-onset of GBS could be a result of delivery, or the baby may have contracted it by coming into contact with someone who has GBS.
Frequently Asked Questions:
How serious is GBS? GBS can cause bladder infections and uterine infections for the mother. In serious cases GBS can cause meningitis, sepsis, pneumonia or result in stillbirth of the newborn.
If I test positive for GBS does that mean my baby is going to get it also? No. Approximately 1 out of every 200 babies who are born to mothers who carry GBS will become ill. However, there are certain symptoms that put a mother at a higher risk than others.
What can I do to prevent my baby from getting GBS disease? Intravenous antibiotics (antibiotics given through IV) are recommended during delivery to reduce the chance of your baby becoming sick. It is recommended that antibiotics are given once labor has begun and every 4 hours during active labor until baby is delivered.
Do I have to take antibiotics, or is there a natural alternative? It is your choice if you want to take antibiotics. There are certain herbal methods that you can take 2-3 weeks before delivery that a midwife or homeopathic physician can provide for you.
If I am having a cesarean delivery, do I need to be treated for GBS? If you tested positive for GBS and labor has not begun ( including your water has not broken) than you do not need to be treated for GBS during delivery. If you are GBS positive, your water has been broken and/or labor has begun, most health care providers will still require you to be treated for GBS even if you are having a cesarean delivery.
If I had a positive group b strep culture done early in pregnancy, will they test me again? The latest recommendation from the CDC states that if a woman has a positive culture anytime during the current pregnancy, she will not need to be re screened and will automatically need to be treated with antibiotics during labor.
Is Group B Strep related to strep throat? No, the two are not related.
Can a woman who tests positive take oral antibiotics before delivery? Treating the mother with oral antibiotics during the pregnancy may decrease the amount of GBS for a short time, but it will not eliminate the bacteria completely and will leave the baby unprotected at birth. Also, waiting to treat the baby with antibiotics after birth is often too late to prevent illness if the baby is at high risk for contracting it.
Are antibiotics safe for the baby? Penicillin (Category B) is commonly used during pregnancy in non-allergic patients. There are substitute drugs for those who are allergic to penicillin, but they could still experience an allergic reaction. It is best to discuss the pros and cons with your health care provider.
Tuesday, June 7, 2011
Inducing Labor from WebMD
Inducing Labor
In many cases if a pregnancy isn't proceeding as it should, or if the health of the mother or baby is threatened, doctors have to speed up the process by inducing labor.
Why Is Labor Induced?
According to the CDC, about one out of every five pregnant women in the U.S. has their labor induced. There are a number of reasons for inducing labor, from a late delivery to a medical complication in the pregnancy.
Your doctor might induce labor if:
*You are one to two weeks past your due date. Past 42 weeks, you and your baby are at greater risk for complications, and the placenta that nourishes your baby in the womb may have diminished so much that it can no longer properly feed your baby. The baby also may breathe in his first bowel movement (called meconium), which can block his airways.
*The membrane that holds the amniotic sac surrounding your baby breaks (your "water breaks") and you don't go into labor on your own (once your water breaks, you and your baby are at greater risk for infection).
*You have a health condition, such as high blood pressure (preeclampsia), gestational diabetes, bleeding, or an infection in your uterus, which puts your health or your baby's health at risk.
*Your placenta is partially or totally covering the opening to the uterus (placenta previa), or has separated from the wall of the uterus (placenta abruption).
*The umbilical cord drops down into the vagina (prolapses).
*The baby is sideways (transverse) in the uterus.
*Tests show that your baby is no longer growing or developing at a normal rate, or the baby's heart rate is abnormal.
Sometimes women (or their doctors) decide to induce labor for nonmedical reasons, for example if they live far away from the hospital and their doctor is worried that they won't get there in time if they do go into labor. Inducing labor for nonmedical reasons is controversial, however, because there are some minor risks involved.
How Is Labor Induced?
Normally during labor, the lower end of the uterus (cervix) softens. This is called ripening. The cervix thins out (effaces) and opens (dilates). In order for the baby to be born, the cervix must be fully effaced and dilated to allow the baby's head to get through.
Before the doctor will induce labor, she will check your cervix and the baby's position to find out whether you are far enough along for induction will work.
Doctors use medications and other methods to efface and dilate the cervix artificially so that the baby can be born. Labor induction techniques include:
*Stripping the membranes. The doctor will insert a gloved finger into your vagina and move it back and forth to separate the membrane that connects the amniotic sac to the wall of the uterus. This is called "stripping the membranes," and it causes the body to release hormones called prostaglandins, which ripen the cervix and may lead to contractions. You may feel some cramping and have some spotting after this procedure. Usually this method of inducing labor is done in your doctor's office, and you'll be sent home to wait until contractions begin.
*Ripening the cervix. Medications called prostaglandins can dilate your cervix enough to prepare it for labor. Prostaglandins are manmade versions of chemicals in the body that both ripen the cervix and stimulate the uterus to contract. You take prostaglandins either by mouth or via a gel or suppository inserted in the vagina. (Your doctor shouldn't give you prostaglandins if you've had a previous c-section because of the increased risk of uterine rupture.) Another way to ripen the cervix is by inserting a thin tube called a catheter with a balloon at the tip. When the catheter is placed in your uterus, the balloon is inflated with water, which causes the cervix to expand.
*"Breaking your water." If your cervix is already at least partially dilated, your doctor can "break your water" by making a hole in your amniotic sac using a small plastic hook. Once your amniotic sac has broken, you should start having contractions. You'll need to deliver within about 24 hours to prevent infection.
*Triggering contractions. The drug Pitocin can bring on contractions to induce or move your labor along. Pitocin is an artificial form of the hormone oxytocin, which triggers and strengthens contractions. It's delivered through an intravenous (IV) tube in your arm. Your doctor will start with a small dose and will gradually increase it until your contractions are strong and frequent enough for the baby to be born.
Aside from stripping the membranes, which is typically performed in the doctor's office, these methods of inducing labor will be done in a hospital where both you and your baby can be carefully monitored.
Some women go into labor and deliver within a few hours after induction of labor begins. Others take one or two days to begin labor. If you don't go into labor with any of these methods, especially once your water is broken, you'll need to have a C-section.
What Are the Risks of Inducing Labor?
Generally, inducing labor is safe. The techniques used to induce labor shouldn't hurt, although they may cause your contractions to come on stronger and more often than they would naturally.
Inducing labor, especially with prostaglandins and Pitocin, may be more risky for women who have had a previous C-section or other surgery to the uterus. There is also a very small risk that the placenta will separate from the wall of the uterus (placental abruption) with these medications if the contractions become too intense. If the contractions are too strong, the doctor will reduce the dose of medication or stop it altogether.
Breaking the amniotic sac can lead to infection if you don't deliver within a day or two after your doctor tries to induce labor. In rare cases, the umbilical cord can slip out before the baby (prolapsed cord).
Can I Induce Labor Myself?
Tales abound of home remedies that supposedly bring on labor. Women past their due date have done everything from downing castor oil to rubbing their nipples to expedite the process. These methods can be uncomfortable, and there really isn't much scientific evidence to back them up.
Here is a rundown of a few popular home labor-induction methods:
*Sexual intercourse. The idea is that sex can trigger contractions, both from the sperm (which contain prostaglandins) and from the woman's orgasm. However, research is lacking on the subject, and one study found that sex didn't have any effect on time to labor.
*Nipple stimulation. Stimulating the nipples releases the hormone oxytocin, which naturally triggers contractions, but the cervix must already be ripe for this to work. Too much nipple stimulation also can produce very strong contractions that can actually be dangerous to the baby.
*Herbal remedies. A number of herbs, including blue cohosh and black cohosh, have been touted for triggering labor, but there isn't enough evidence to prove they work. What's more, herbs can be dangerous if not used properly, so don't take any herb for inducing labor without first talking to your doctor.
*Castor oil. Research shows castor oil probably won't do anything to induce labor, but it probably will irritate your gastrointestinal tract enough to make you feel sick to your stomach.
*Walking . It's always a good idea to stay active throughout your pregnancy, but studies haven't proved that walking can induce labor.
Unless your doctor feels that it's time to induce labor for medical reasons, it's always better to let nature take its course.
Friday, June 3, 2011
Antepartum Testing from Healthline.com
Definition
Antepartum testing involves the use of electronic fetal monitoring (EFM) or ultrasound (US) to assess fetal well-being as determined by the fetal heart rate (FHR) and other characteristics during the antepartal period, which is the period spanning from conception to labor. Antepartum tests include the nonstress test (NST), modified biophysical profile (MBPP), contraction stress test (CST), oxytocin contraction stress test (OCT), biophysical profile (BPP), doppler flow studies, amniocentesis, cordocentesis, and fetal echocardiography.
Purpose
Antepartum testing can start as early as 24 weeks but usually begins after 32 weeks of pregnancy depending on the mother's physical status. It provides a means for the physician and pregnant woman to identify any problems and be alert to any changes that may necessitate additional testing or interventions. The testing results reflect how well the placenta is functioning in its ability to adequately supply blood and, therefore, oxygen to the fetus.
The testing is done for pregnancies at risk for maternal and/or fetal complications. Some of these risks include:
any chronic illness in the mother, such as high blood pressure, diabetes, or autoimmune diseases, including systemic lupus erythematosus (SLE)
problems with previous pregnancies, such as a history of unexplained stillbirth
fetal complications, such as intrauterine growth restriction (IUGR) (growth in the fetus below the tenth percentile), birth defects, twins, or other multiple gestations in which a growth discrepancy occurs, such as twin-to-twin transfusion syndrome
problems in current pregnancy, including pregnancy-induced hypertension frequently referred to as preeclampsia); gestational diabetes (diabetes caused by pregnancy) requiring the use of insulin; premature rupture of the membranes (PROM); too little or too much amniotic fluid (the liquid surrounding the fetus) called oligohydramnios and polyhydramnios, respectively; vaginal bleeding; placental abnormalities, i.e., partial abruption (a portion of the placenta pulls away from the wall of the uterus), or placenta previa (a condition in which the placenta is covering the cervix instead of near the top of the uterus)
Antepartum testing is also used in low-risk pregnancies to evaluate decreased fetal activity, a lag in fundal height (as measured from top of the pubic area to the highest point in the midline at the top of the uterus), and postdates or post-term pregnancy. A normal pregnancy is 40 weeks and testing should begin at 41 weeks to assess the status of the placenta, which may no longer be capable of meeting the baby's needs. This can be indicated by the FHR pattern, amniotic fluid status, and fetal movement patterns.
Description
The spectrum of fetal assessment includes fetal movement (FM) counting, nonstress test (NST), modified biophysical profile (MBPP), contraction stress test (CST), oxytocin contraction stress test (OCT), biophysical profile (BPP), doppler flow studies, amniocentesis, cordocentesis, and fetal echocardiography. Fetal movement should be determined on a daily basis by all pregnant women regardless of risk status. The woman should be instructed to monitor fetal movement by selecting a consistent time of day to document how long it takes to feel 10 fetal movements. She should call her healthcare provider if there are fewer than 10 movements in a 10-hour period or immediately if there are no movements in any 10-hour period. She should also be instructed to report significant decreases in fetal activity from the baby's normal pattern. This daily monitoring of FM by all pregnant women is the least expensive and easiest of all antepartum tests to perform.
Non-stress test (NST)
The NST is performed with an electronic fetal monitor (EFM) that traces the fetal heart rate (FHR) and the presence of any contractions on a monitor strip. The mother reclines with a slight pelvic tilt to prevent compression of the large blood vessels by the pregnant uterus. The EFM is applied to her abdomen by two straps: one is to listen to the FHR by means of a transducer, and the other is to pick up any contractions by pressure on a tocodynameter. The NST indirectly provides information about fetal status by the observation of FHR accelerations that occur with fetal movement. If a fetus is not receiving adequate oxygen from the placenta, the FHR will not accelerate, but if the oxygen supply is sufficient, accelerations will be noted. If it is difficult to obtain fetal movements, a vibroacoustic stimulator (VAS) is sometimes used to provide a loud noise to awaken the fetus and produce the desired results. The minimum amount of time required for an NST is 20 minutes. During those 20 minutes, there must be two accelerations in the FHR that are 15 beats above the baseline FHR and last for 15 seconds, often called the 15 by 15 rule. Depending upon the conditions, however, it may sometimes take up to 60 to 90 minutes to obtain definitive results.
Modified biophysical profile (MBPP)
The MBPP is performed in the same manner as the NST with a limited ultrasound (US) performed to assess the amount of amniotic fluid, which is reported as the amniotic fluid index (AFI). Following the NST, an US is done to observe the amount of amniotic fluid present in four quadrants, which are divided along the umbilicus midline and perpendicular to the midline. There must be no fetal parts or any umbilical cord present in any of these pockets of fluid in order to be counted.
Contraction stress test (CST) and oxytocin contraction stress test (OCT)
The contraction stress test (CST) is similar to the NST except the FHR is evaluated for accelerations, 15 beats higher than baseline lasting 15 seconds, and in response to contractions as well. A CST requires the presence of three uterine contractions (UCs) within a 10-minute period lasting at least 40 seconds and of moderate intensity. During a contraction, the blood flow to the baby is temporarily restricted, which provides a form of "stress" to the baby. The baby's response to this stressor reveals significant information regarding available oxygen stores. If contractions are not spontaneously present, the pregnant woman will be instructed on the use of nipple stimulation to produce contractions through the release of natural oxytocin, or oxytocin can be administered through an intravenous infusion (IV) called pitocin to produce contractions. When oxytocin is administered IV, it is called an oxytocin contraction stress test (OCT). The CST/OCT is generally used after an abnormal NST is obtained in order to verify if there are problems present. Many clinicians require their diabetic patients to have at least one CST/OCT a week to assure fetal well-being. Maternal blood pressure is taken with each test.
Biophysical profile (BPP)
The biophysical profile (BPP) is performed by an ultrasound exam over a 30-minute period. The ultrasonographer/examiner looks for gross fetal movement, i.e., kicking and moving around; fetal tone, i.e., making a fist; breathing movements (which the mother can often perceive as hiccoughs); and amniotic fluid volume. A score of 0 or 2 points is assigned to each observation with the results of the NST also adding 2 points for a total possible score of 10 points.
Doppler flow studies, amniocentesis, cordocentesis, and fetal echocardiography
A physician or specially trained ultrasonographer performs Doppler flow studies, which examines the blood flow in the umbilical artery and the baby's middle cerebral artery. An experienced obstetrician/perinatologist performs the amniocentesis or the cordocentesis. For the amniocentesis, an US is used to determine an appropriate place to insert a needle and withdraw amniotic fluid for testing. In a similar manner, US is used with cordocentesis, but in this procedure a needle is guided into the umbilical cord to withdraw fetal blood for testing. Fetal echocardiography is a specialized ultrasound of a baby's heart. Since it detects most congenital heart defects, it is recommended if a baby is at a higher risk for a defect than the risk in the general population. The majority of health insurance companies do cover a portion, if not all, of the tests' costs.
Precautions
Clinicians should only prescribe these tests if they are ready to intervene when faced with worrying results. A fetus is considered viable at 24 weeks since that is the minimum gestational age for sufficient lung development. There are no significant risks to the mother or the fetus from the nonstress test (NST), modified biophysical profile (MBPP), or the biophysical profile (BPP). Ultrasound waves utilized in detecting the FHR and for the BPP are painless and safe because this method employs no harmful radiation. There is no evidence that sound waves cause any harm to the mother or the baby.
Aftercare
If the test results are acceptable, the pregnant woman is instructed to continue following her current medical regimen and return for additional testing on the dates prescribed. For NSTs/MBPPs/CSTs, the time period between tests should be no longer than three to four days under high-risk conditions with fetal movement counting taking place in between testing dates. Ultrasounds should be rescheduled as the need dictates per the physician. Electronic fetal monitoring occurs after an amniocentesis or cordocentesis to assure fetal well-being.
Risks
There are no complications per se from the tests themselves with the exception of unfavorable test results or supine (lying horizontality on the back) hypotension secondary to a pregnant woman lying on her back for an ultrasound. When a pregnant woman lies on her back, the vena cava (one of two large veins that return blood from peripheral circulation to the heart) can become compressed from the pressure of the pregnant uterus such that blood flow to the heart is significantly reduced. There are potential complications from an amniocentesis, i.e., preterm labor, spontaneous rupture of membranes, fetal or placental injury; and the clinician performing the procedure should explain what these are prior to the procedure. There are similar risks and potential complications from cordocentesis as well which should be explained.
Normal results
Usually, a report of normal results for NSTs provides reassurance that the fetus is healthy and should remain so for three to four days, at which time repeat testing will be necessary. A normal NST is reported as being reactive, which means the fetal heart is "reacting" to movement such that the FHR is accelerating 15 beats per minute above the baseline FHR for 15 seconds twice within a 20-minute period of time. A non-reactive NST is one that fails to meet this criterion within an 80 to 90 minute period of time. For an extremely preterm fetus, a normal NST is reported as being reactive for gestational age, which indicates the FHR demonstrated two accelerations of 10 beats per minute above baseline for 10 seconds over a 20–30 minute period. Typically, the central nervous system is not completely mature until approximately 32 weeks gestational age, and a report of reactive for gestational age takes this into consideration. It is important to remember that a normal result does not guarantee that no problems are present. Although very rare in occurrence, false normal results can be observed.
The CST results are reported as reactive/negative, reactive/suspicious, reactive/positive (a very unlikely result), or non-reactive/negative, non-reactive/suspicious, non-reactive/positive. The reactive/non-reactive part of the test report refers to the presence or absence of accelerations. The negative part refers to no decelerations being present with uterine contractions (UCs). "Suspicious" refers to the presence of some decelerations with UCs, and "positive" refers to the presence of decelerations more than 50 percent of the time with UCs. A suspicious or positive result requires further evaluation, i.e., prolonged EFM monitoring or a BPP. A normal BPP report without an NST is 8 points and 10 points with a reactive NST. Six points is suspicious and requires either a CST or a repeat BPP within 24 hours. A total of 4 points is not reassuring and requires immediate evaluation by prolonged EFM.
All results are given to the primary physician who must then make a decision as to the appropriate course of action. Abnormal CST results generally indicate the baby is not receiving sufficient oxygen and may not be capable of withstanding the stress of labor and subsequent vaginal delivery. If this is the case, a cesarean section may be performed. The final outcome depends on the mother's individual circumstances. Severe pregnancy-induced hypertension may require immediate delivery via cesarean section. In some cases, medications such as betamethasone may be given to the mother to speed up the lung maturity of the baby. If the mother's cervix is favorable for induction, labor may be induced.
KEY TERMS
Amniotic fluid—The liquid in the amniotic sac that cushions the fetus and regulates temperature in the placental environment. Amniotic fluid also contains fetal cells.
Deceleration—A decrease in the fetal heart rate that can indicate inadequate blood flow through the placenta.
Fundal height—Measured by a tape measure from the top of the symphysis pubis, over the arch of the growing uterus, to the top of the fundus.
Oxytocin—A hormone that stimulates the uterus to contract during child birth and the breasts to release milk.
Pitocin—A synthetic hormone that produces uterine contractions.
Vibroacoustic stimulation—In the biophysical profile, use of an artificial larynx to produce a loud noise to "awaken" the fetus.
Parental concerns
The healthcare provider should give a complete explanation to the pregnant woman and her partner regarding the tests, i.e., what to expect, how long the test may take, what it means, and why it is being done. It frequently helps if the pregnant woman has eaten prior to undergoing the test. Pregnant women should know that every test is not compulsory, and that if the results of the test do not matter to the parents, it may not have to be performed.
See also High-risk pregnancy.
BOOKS
Freeman, Roger, et al. Fetal Heart Rate Monitoring, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.
Gabbe, Steven, et al. Obstetrics, 4th ed. London: Churchill Livingstone, 2001.
Neilson, J. P., and Z. Alfirevic. "Doppler ultrasound for fetal assessment in high risk pregnancies (Cochrane Review)." In The Cochrane Library, vol. 3. Chichester, UK: John Wiley & Sons, Ltd., 2004.
Pattison, N., and L. McCowan. "Cardiotocography for antepartum fetal assessment (Cochrane Review)." In The Cochrane Library. Chichester, UK: John Wiley & Sons, Ltd., 2004.
Tucker, Susan. Pocket Guide to Fetal Monitoring and Assessment, 4th ed. St. Louis, MO: Mosby, 2000.
ORGANIZATIONS
American College of Obstetricians and Gynecologists. 409 12th Street, SW, PO Box 96920, Washington, DC 20090. Web site:
Association of Women's Health, Obstetric, and Neonatal Nursing. 2000 L Street, NW, Suite 740, Washington, DC 20036. Web site:
Linda K. Bennington, RNC, MSN, CNS
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