Ripening the Cervix, and Induction of Labor
a discussion for patients by Martina Nicholson, MD, FACOG
WITH MANY THANKS to Dr. Aaron Caughey, MD, MPP, MPH, PhD, at UCSF, for the expert review of the data and nuances of this topic.
When we wonder about the "best" time for delivery of a pregnant woman, there is now sufficient data about how long the cookies should stay in the oven, so they will come out golden brown, not underdone or overdone. And the answer is 39-40 weeks. There is the lowest chance of morbidity at that time. So now we are trying to get as many babies as possible to deliver within that window of opportunity.
After the edge of "term" there is more risk of the baby being surrounded by inadequate water, so the cord can become squeezed in labor, as the contractions intensify. The cord brings oxygen to the baby, and if it is too "vulnerable" it will not deliver enough, so that the baby gets stressed, and then distressed". This makes it important to try to get through labor when there is still enough fluid around the baby so that the cord can float freely, and pass oxygen in and carbon dioxide out. The placenta is "breathing" for the baby, until delivery.
Also, the baby can go poop in the water, which is called meconium. If the baby takes deep gasping movements, the fluid in the baby's lungs can be so noxious, covering the insides of the lung surface, that the baby can not breathe air when it comes out. The baby has to make a transition from being in a watery world, to being in air, and learning to breathe, rather than get all its oxygen from the placenta, through the umbilical cord. So it is very important for the baby not to gasp and inhale deeply the meconium. We now know that babies gasp as a reflex, when they are inside and there is not enough oxygen. So we want them not to have long or deep fetal heart beat decelerations, which cause them to feel less oxygen, and gasp. Babies can tolerate some stress, some low-oxygen, for awhile. But labor can be long and hard, and if it is getting harder and harder to get enough oxygen, the baby will become "distressed"-- and need to be bailed out.
So a big part of the work of doctors, in watching labor, is to gauge how much stress the baby is under, and whether the baby is bearing up under it. In a fast, easy labor the water is abundant, the cord is not compressed with contractions, and mother's pushing allows a natural squeezing which may help the lungs be less full of water, and more ready to take in air when the baby first breathes.
In a long hard labor, there is also the risk of infection, which can rise from bacteria which naturally live in the vagina, up into the uterus. So it is really important for the mother to be delivered as promptly as possible, to reduce the risk of infection passing to the baby. The mother also can get a deep infection in the walls of the uterus, which is called "chorioamnionitis" (infection in the bag of waters) and later, "endometritis"(infection in the lining of the uterus)--and this causes the walls of the womb to be less capable of contracting efficiently, both in labor, and afterward, to keep from bleeding from the raw site where the placenta was attached.
When a baby is post-dates, and has meconium, and has infection, it is like 3 strikes against them. For this reason, we want to get them delivered when they are ripe but not at risk.
Some women look askance at us, for trying to talk them into being induced at term. They need to understand that this is the underlying reason. For most moms and babies, it is safer, and there is more chance of a successful vaginal delivery, if we don't wait till two weeks overdue.
In general, I try to "let the river flow, rather than trying to push the river". But sometimes we need to nudge someone into labor to get them to deliver in the best window of opportunity for safety.
What stops us? The last process of pregnancy before labor is cervical ripening. If the cervix is like a green apple, it is much harder to get it to open. It needs to be like a ripe peach. The soft, squishy, mushy tissue will more easily begin to open up. So what we now use, to get the "ripeness" we need, is prostaglandins. The medicine Cytotec, or misoprostol, was invented for ulcers, but it was found to be exactly what is needed to make the cervix ripen. This is what does it naturally, in most women. But some women don't make enough. So we can give them this medicine, vaginally or orally, and the cervix will respond by ripening.
After the cervix is ripened, which may take around 24 hours, the uterus can begin to open up the cervix, by contracting. The contractions are like a castle opening a heavy drawbridge. The drawbridge is drawn up and into the castle walls. We sometimes have to use pitocin, a medicine which is dripped into mom through the iv, to help this process of lifting open the cervix.
Another thing that has to happen is the baby has to come down deeper into the pelvis, and make it through the outlet of the bones. Some babies are just too big for the bones of their moms. Others are lying in a position which makes it harder to get through the pelvis. And some have a tight loop of umbilical cord holding them up. Sometimes we can change the mom's position to help get the baby to turn and come through the pelvis. Sometimes we can actually reach in and turn the baby's head a little, to get it to do this.
When the baby is distressed, or there is thick meconium, or the baby has a body which is too big for the mom's bones, we do a Cesarean Section. This surgery has helped millions of babies to be safely born, with lungs which can breathe, and not having severe infections, and so they can stay with their moms and breastfeed, and not need to go to the nursery in exhaustion and need tubes, iv's and oxygen to help them get out of trouble. A lot of people think doctors are making unnecessary interventions, because they do not understand these facts. All our monitoring is to make sure the baby and the mom are both safe through the process of labor. We want to help babies be born safely, and in optimum health, like golden brown cookies!
Monday, June 15, 2009
Monday, May 25, 2009
Women docs at Esalen
Women in the circle at Esalen
Laughing, making bead necklaces,
Telling stories,
Sharing time and space:
Beautiful, beautiful world--
Green spring grasses
Dancing,
Trees full of new leaves,
Rushing stream below the bridge,
Cool air over the meditation room,
Jasmine on the hill path,
Sunlight on the baths,
Whales spouting in the bay,
In the silvery blue ocean.
Lettuce and spinach from the garden,
Poppies and marigolds,
And alyssum,
Cedars cleansing the air,
Shadows full of midnight stars,
Warm water steaming in the stone pools,
Sinking down into that goodness and warmth,
Looking out to sea forever--
Reborn, renewed, refreshed.
The circle widens,
As we occupy this sacred space,
Here and there a friendly face,
Someone who knows our secret sorrows,
And shares the strength of our vocation.
We desire to serve,
And also to be healed.
We also are wounded,
And now we can bandage those wounds for each other;
Balm in Gilead,
Warm sunlight on the stones,
Warm water holding us,
Girlish laughter in our hearts,
Songs sung with guitars and full throats;
”Happiness runs in a circular motion,
Thought is like a little boat upon the strand,”
Kindness springs from the full heart,
As we stand up together in the circle.
mn 09
Laughing, making bead necklaces,
Telling stories,
Sharing time and space:
Beautiful, beautiful world--
Green spring grasses
Dancing,
Trees full of new leaves,
Rushing stream below the bridge,
Cool air over the meditation room,
Jasmine on the hill path,
Sunlight on the baths,
Whales spouting in the bay,
In the silvery blue ocean.
Lettuce and spinach from the garden,
Poppies and marigolds,
And alyssum,
Cedars cleansing the air,
Shadows full of midnight stars,
Warm water steaming in the stone pools,
Sinking down into that goodness and warmth,
Looking out to sea forever--
Reborn, renewed, refreshed.
The circle widens,
As we occupy this sacred space,
Here and there a friendly face,
Someone who knows our secret sorrows,
And shares the strength of our vocation.
We desire to serve,
And also to be healed.
We also are wounded,
And now we can bandage those wounds for each other;
Balm in Gilead,
Warm sunlight on the stones,
Warm water holding us,
Girlish laughter in our hearts,
Songs sung with guitars and full throats;
”Happiness runs in a circular motion,
Thought is like a little boat upon the strand,”
Kindness springs from the full heart,
As we stand up together in the circle.
mn 09
Saturday, May 9, 2009
Staying home when sick
Dear friends,
The CDC is sending daily updates on the Flu epidemic, and they recommend we tell people to STAY HOME WHEN SICK, FOR 7 DAYS.
I love this advice. I love the whole reasonable approach to isolation, and urging people to take it on themselves to protect society at large from their germs, their potential threat. We have all these frenzied people multitasking, driving themselves crazy, and overwhelmed with fear and anxiety, and a bunch of talking heads who have no wisdom with tongues wagging on and on; and someone said most people watch 8 hours a day of television. I can't even fathom that. So, I love the simplicity and clarity of the advice, stay home.
I would like to add my favorite new advice. Get the most comfortable chair in your house and put it in a sunny spot in your living room, and sit in it for 10 minutes every morning. You can close your eyes, or drink a cup of tea, but just sit down in the sunshine, and breathe. If you are moved by this to try doing it for 10 minutes in the afternoon, even better. Drop your blood pressure and your cortisol. Take care of yourself. Be tender to yourself. Nurture yourself. Take a warm bath. Do not listen to any more thought-police and fearmongers.
Speaking of police, I just read that San Jose's police dept. is considering putting in place a program which already exists in SF and Palo Alto. They will turn the jail into a de facto drying out center, where all the drunks and drug addicts can clear up their heads, and then be released without charges. This will allow them to go on with their lives, and reduce the costs and criminal justice mess. (This only applies to the problem of drunkenness, not any other crime committed while intoxicated). It will protect the public safety, their primary goal. If they get a certain number of arrests for drunkenness in a 6-month period, they will be formally charged. So there is some built-in follow-up and encouragement to get sober.
The other joyful news I heard this week is that 18,000 people came to Madison Square Garden to hear Pete Seeger on his 90th birthday, sing "This land is your land". What a wonderful thing! God bless America!
The CDC is sending daily updates on the Flu epidemic, and they recommend we tell people to STAY HOME WHEN SICK, FOR 7 DAYS.
I love this advice. I love the whole reasonable approach to isolation, and urging people to take it on themselves to protect society at large from their germs, their potential threat. We have all these frenzied people multitasking, driving themselves crazy, and overwhelmed with fear and anxiety, and a bunch of talking heads who have no wisdom with tongues wagging on and on; and someone said most people watch 8 hours a day of television. I can't even fathom that. So, I love the simplicity and clarity of the advice, stay home.
I would like to add my favorite new advice. Get the most comfortable chair in your house and put it in a sunny spot in your living room, and sit in it for 10 minutes every morning. You can close your eyes, or drink a cup of tea, but just sit down in the sunshine, and breathe. If you are moved by this to try doing it for 10 minutes in the afternoon, even better. Drop your blood pressure and your cortisol. Take care of yourself. Be tender to yourself. Nurture yourself. Take a warm bath. Do not listen to any more thought-police and fearmongers.
Speaking of police, I just read that San Jose's police dept. is considering putting in place a program which already exists in SF and Palo Alto. They will turn the jail into a de facto drying out center, where all the drunks and drug addicts can clear up their heads, and then be released without charges. This will allow them to go on with their lives, and reduce the costs and criminal justice mess. (This only applies to the problem of drunkenness, not any other crime committed while intoxicated). It will protect the public safety, their primary goal. If they get a certain number of arrests for drunkenness in a 6-month period, they will be formally charged. So there is some built-in follow-up and encouragement to get sober.
The other joyful news I heard this week is that 18,000 people came to Madison Square Garden to hear Pete Seeger on his 90th birthday, sing "This land is your land". What a wonderful thing! God bless America!
Friday, May 8, 2009
10 points for Healthcare reform
Here are my ideas for health care reform, as globally and succinctly as I can put them. Since this is a time when the "masters of systems analysis are designing how it is going to look, I thought I would throw my two cents'worth out there, and if you agree, please send your thoughts on to your congressional representatives. I personally believe Single Payer would be the cheapest for the patients, as the overhead is forcibly lower, but it may not be possible, so point 4 is to cover the alternative of having to work with insurers.
1. Public health needs to be important again, and needs to have a coherent national, state and county infrastructure capable of handling natural disasters, and pandemic flu, as well as treating the 20% of population below poverty line. I also believe all illegal immigrants should be covered, but we also need to close the borders and have comprehensive immigration reform.
2. "actuarially sound"-- no lopsided, uncovered areas. Also mental health needs to be covered, as part of total health care. Total population data for risk “pools”.
3. "Compare apples to apples" in policies, and basic health needs need to be covered; chronic pain and the needs of the dying for hospice should be covered for everyone.
4. 15% profit limit for all insurance companies.
5. National tort reform, as in MICRA in California, which will also save states billions. Also all docs can compete for jobs without the hidden overhead. All congenital illnesses to be covered by a health care pool so people don't sue for cerebral palsy which is no one's fault.
6. Everyone needs to have a credit card with their data and coverage on it, to present for billing and in emergencies, will get vital info quickly to admitting hospitals.
7. National bargaining power for Medicare for pharmaceuticals and medical equipment.
8. Financial coverage for FDA, NIH, medical schools and nursing schools, and research institutes.
9. Consider Federal Reserve Board of Health to distribute federal dollars over the "pie"-- all CMS, MEDICAID, and indigent and public health, docs, hospitals, research, and pharmaceuticals; and to decide what should be in the "basic healthcare package". This body would be like the federal reserve board for money-- it would be buffered from the politicians, and also from the executive branch, and yet they will have to decide what proportion each of the competing interests should get, of the limited "pie". This body could thus respond in emergencies by increasing one side of the budget if needed.
10. A consistent cost of living increase allowance for physicians, so we are not paid artificially low rates in comparison with every other business in the USA.
PS. We desperately need more nursing schools, and coherent structures of nursing schools and standards. It would be great if local community colleges were given the mandate to fill that need, and ability to provide more nurses to local hospitals and generate jobs in local communities.
Thanks for listening!
1. Public health needs to be important again, and needs to have a coherent national, state and county infrastructure capable of handling natural disasters, and pandemic flu, as well as treating the 20% of population below poverty line. I also believe all illegal immigrants should be covered, but we also need to close the borders and have comprehensive immigration reform.
2. "actuarially sound"-- no lopsided, uncovered areas. Also mental health needs to be covered, as part of total health care. Total population data for risk “pools”.
3. "Compare apples to apples" in policies, and basic health needs need to be covered; chronic pain and the needs of the dying for hospice should be covered for everyone.
4. 15% profit limit for all insurance companies.
5. National tort reform, as in MICRA in California, which will also save states billions. Also all docs can compete for jobs without the hidden overhead. All congenital illnesses to be covered by a health care pool so people don't sue for cerebral palsy which is no one's fault.
6. Everyone needs to have a credit card with their data and coverage on it, to present for billing and in emergencies, will get vital info quickly to admitting hospitals.
7. National bargaining power for Medicare for pharmaceuticals and medical equipment.
8. Financial coverage for FDA, NIH, medical schools and nursing schools, and research institutes.
9. Consider Federal Reserve Board of Health to distribute federal dollars over the "pie"-- all CMS, MEDICAID, and indigent and public health, docs, hospitals, research, and pharmaceuticals; and to decide what should be in the "basic healthcare package". This body would be like the federal reserve board for money-- it would be buffered from the politicians, and also from the executive branch, and yet they will have to decide what proportion each of the competing interests should get, of the limited "pie". This body could thus respond in emergencies by increasing one side of the budget if needed.
10. A consistent cost of living increase allowance for physicians, so we are not paid artificially low rates in comparison with every other business in the USA.
PS. We desperately need more nursing schools, and coherent structures of nursing schools and standards. It would be great if local community colleges were given the mandate to fill that need, and ability to provide more nurses to local hospitals and generate jobs in local communities.
Thanks for listening!
Sunday, May 3, 2009
Curiosity, faith and scientific method
Experiment
"Experiment, make it your motto day and night,
experiment, and it will lead you to the light;
if this advice you'll only employ,
the future will offer you infinite joy and merriment,
experiment,
and you'll see."
(from the song by Steven Sondheim)
A valuable point to be made is that uncertainty and inquiry, and
willingness to live with curiosity, are the basis for the modern
mind, the scientific enterprise. I would say that some of us lean
toward the "one" more than the "many," but we have in us the
willingness to stay with curiosity. Most of the people I have known who
are what I think you might describe as "religious" are not really mystically
enlightened. They are simply yearning; and leaning on the tradition
and insights which have been given historically by the few mystics and
brilliant people who have existed. And yet, there are cumulative
experiences of meaning, in medicine, as well as in other areas of our
lives.
I think we are working on many different levels all the time, and
that peace is every step. The main thing is the intentionality. If we
intend to be healers and peacemakers, we lend ourselves to the "higher
power". We could call that bending ourselves to God's will. On any
given day, we have many little tasks, and sometimes a big one, and all
these things add up in a life; so that if we keep trying, if we miss
the boat on one task or moment, we can become recollected and clear
and humbly offer ourselves to God's will in the next moment. Ongoing
willingness is the needed self-corrective, for growth.
Today I was swimming in the big pool for my back. It is so interesting
being in water, and being able to feel the water around my body, and
think about where the edges of "me" vs. the water are. And how to
submerge ourselves into God's plans. What I think an agnostic mind
would say about that, is that we need to stay curious, not feel like we
are "there" in some defined way. And being curious is a good way to be
able to find things out which are new, beyond the horizon of the "known";
and to continue to be creative, and make new things happen.
It is very much to give oneself to process, not to something static.
So I appreciate the innate agnosticism of the scientific mind. But
also I appreciate the mystery of loving and being loved. And I am very
interested to see and learn about how others approach and witness to
what they call "the higher power". I am also partial to the God of
coffee and doughnuts, especially when it comes with the kind of
meeting where people are trying to talk about what matters to them.
And I appreciate the goodwill which helps us move beyond statements we
resent; when we see that the person speaking did not intend to hurt or
dishonor us. I appreciate that we are still here, trying to discuss
the issue in a civilized way. I salute you; and hope that somehow,
our microcosmic experience of discussing this without burning people
at the stake or chopping heads off, will bring the "hundredth monkey"
to the international debate so full of hatred and intolerance and
killing. It seems to me possible that the "mulch" of our society may
help, along with the scientific mindset, to bring a new meta-physical
vocabulary to the issue. Which actually could be a great help toward
learning to live in peace. We could make room for each other to exist,
and continue to try to reduce our frictions and conflicts.
"Experiment, make it your motto day and night,
experiment, and it will lead you to the light;
if this advice you'll only employ,
the future will offer you infinite joy and merriment,
experiment,
and you'll see."
(from the song by Steven Sondheim)
A valuable point to be made is that uncertainty and inquiry, and
willingness to live with curiosity, are the basis for the modern
mind, the scientific enterprise. I would say that some of us lean
toward the "one" more than the "many," but we have in us the
willingness to stay with curiosity. Most of the people I have known who
are what I think you might describe as "religious" are not really mystically
enlightened. They are simply yearning; and leaning on the tradition
and insights which have been given historically by the few mystics and
brilliant people who have existed. And yet, there are cumulative
experiences of meaning, in medicine, as well as in other areas of our
lives.
I think we are working on many different levels all the time, and
that peace is every step. The main thing is the intentionality. If we
intend to be healers and peacemakers, we lend ourselves to the "higher
power". We could call that bending ourselves to God's will. On any
given day, we have many little tasks, and sometimes a big one, and all
these things add up in a life; so that if we keep trying, if we miss
the boat on one task or moment, we can become recollected and clear
and humbly offer ourselves to God's will in the next moment. Ongoing
willingness is the needed self-corrective, for growth.
Today I was swimming in the big pool for my back. It is so interesting
being in water, and being able to feel the water around my body, and
think about where the edges of "me" vs. the water are. And how to
submerge ourselves into God's plans. What I think an agnostic mind
would say about that, is that we need to stay curious, not feel like we
are "there" in some defined way. And being curious is a good way to be
able to find things out which are new, beyond the horizon of the "known";
and to continue to be creative, and make new things happen.
It is very much to give oneself to process, not to something static.
So I appreciate the innate agnosticism of the scientific mind. But
also I appreciate the mystery of loving and being loved. And I am very
interested to see and learn about how others approach and witness to
what they call "the higher power". I am also partial to the God of
coffee and doughnuts, especially when it comes with the kind of
meeting where people are trying to talk about what matters to them.
And I appreciate the goodwill which helps us move beyond statements we
resent; when we see that the person speaking did not intend to hurt or
dishonor us. I appreciate that we are still here, trying to discuss
the issue in a civilized way. I salute you; and hope that somehow,
our microcosmic experience of discussing this without burning people
at the stake or chopping heads off, will bring the "hundredth monkey"
to the international debate so full of hatred and intolerance and
killing. It seems to me possible that the "mulch" of our society may
help, along with the scientific mindset, to bring a new meta-physical
vocabulary to the issue. Which actually could be a great help toward
learning to live in peace. We could make room for each other to exist,
and continue to try to reduce our frictions and conflicts.
Saturday, May 2, 2009
Sunday, April 19, 2009
Partners in Health
I was looking at the monthly e-newletter from PIH, which is the organization founded by Paul Farmer, MD. The book MOUNTAINS BEYOND MOUNTAINS details the life and work of this extreaordinary physician, who is treating the poorest of the poor in Haiti, and in many other places now as well. He has tremendously changed the way international health programs deal with Tuberculosis and HIV/AIDS. The article which caught my attention is by a midwife who is volunteering in Haiti, and was answering a question-- "what is women's health?" She answers that when women are coming in for screening for cervical cancer (Pap smears), they ask questions about their children, and their children's health, and also about sexuality, relationships with spouse or significant other, contraception and family planning, domestic violence, how to increase the family income so their children can have a better future, nutrition and self-care, among other things.
These are the same sorts of concerns women have here, and yet we are supposed to code the visits only around issues of a "gynecologic finding or disease". I am sick of this myopic set of rules, with built-in non-rewards for trying to meet the needs of patients one-on-one, in the issues of their lives. I am sick of the insurance companies knowing what I talk with my patients about, because I don't think it is their business, and it removes privacy from the patients. The whole stupid morass we got into with HIPPA was to help with privacy, but it is a freeway of information to the insurance company while there is a stranglehold on being able to give family members relevant information to help them deal with the illnesses of their loved ones.
Anyway, I really love the work that PIH is doing in Haiti and in other places, and one of the most valuable things is to give each patient an accompanying person, as an advocate who helps keep them coming for their appointments, and who makes sure they are eating and sleeping, and taking their medicines. Small stipends are given to the starving patients with Tuberculosis, to make sure they get enough to eat. Traditionally, Tuberculosis is a disease of poverty, and when people can't eat well, they are so tired and listless that they end up dying of this disease. They NEED to eat, to be able to keep their immune function strong. Same with HIV/AIDS. SO the idea of the "accompagnateur" is vital.
What is also a big piece of the puzzle for countries with very high amounts of poverty-stricken people is that there are not enough resources for public health. This includes the money for securing a safe water supply-- putting in wells and pipes and plumbing for towns; and keeping the latrines away from the water sources. In Paraguay, most of the children were severely anemic, because they walked barefoot, and hookworms would enter their feet from the grass. The hookworms have a fecal pathway, and if the rains washed contaminated waste matter into the grasses and fields, the next cycle would begin again. We were able to reduce the childhood anemia and infestation rates tremendously once we started helping each family to get a concrete floor for the latrines, and to help them choose a site for it where the water supply would not be endangered in the flooding rains.
I hope you will take a look at the PIH website, and maybe become a donor. The work they are doing is so important!
These are the same sorts of concerns women have here, and yet we are supposed to code the visits only around issues of a "gynecologic finding or disease". I am sick of this myopic set of rules, with built-in non-rewards for trying to meet the needs of patients one-on-one, in the issues of their lives. I am sick of the insurance companies knowing what I talk with my patients about, because I don't think it is their business, and it removes privacy from the patients. The whole stupid morass we got into with HIPPA was to help with privacy, but it is a freeway of information to the insurance company while there is a stranglehold on being able to give family members relevant information to help them deal with the illnesses of their loved ones.
Anyway, I really love the work that PIH is doing in Haiti and in other places, and one of the most valuable things is to give each patient an accompanying person, as an advocate who helps keep them coming for their appointments, and who makes sure they are eating and sleeping, and taking their medicines. Small stipends are given to the starving patients with Tuberculosis, to make sure they get enough to eat. Traditionally, Tuberculosis is a disease of poverty, and when people can't eat well, they are so tired and listless that they end up dying of this disease. They NEED to eat, to be able to keep their immune function strong. Same with HIV/AIDS. SO the idea of the "accompagnateur" is vital.
What is also a big piece of the puzzle for countries with very high amounts of poverty-stricken people is that there are not enough resources for public health. This includes the money for securing a safe water supply-- putting in wells and pipes and plumbing for towns; and keeping the latrines away from the water sources. In Paraguay, most of the children were severely anemic, because they walked barefoot, and hookworms would enter their feet from the grass. The hookworms have a fecal pathway, and if the rains washed contaminated waste matter into the grasses and fields, the next cycle would begin again. We were able to reduce the childhood anemia and infestation rates tremendously once we started helping each family to get a concrete floor for the latrines, and to help them choose a site for it where the water supply would not be endangered in the flooding rains.
I hope you will take a look at the PIH website, and maybe become a donor. The work they are doing is so important!
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