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Month: June 2014

Home 2014 June

Why Doesn’t CWCC Recommend Vaginal Birth After C-Section? (VBAC)

June 30, 2014Obstetricsadmin

Patients coming in to their first pregnancy visit will read in our “Frequently Asked Questions” document that our doctors do not recommend or offer vaginal delivery after C-section, also known as “VBAC” (Pronounced “Vee-back”).  Although this is offered by some doctors in the community, we feel that it is important for you to understand our reasoning and at times can recommend another group who may feel differently if a patient feels strongly about attempting VBAC.

We understand that very few patients wanted to have a C-section when it occurred the first time, and it can be a very disappointing time and can be attached to a whole bunch of emotions about losing an experience that we really longed for, and sometimes even felt was necessary to be a complete woman or mother.  For many women vaginal delivery is almost a rite of passage and taking away the possibility that this will ever happen can be heartbreaking. While understanding that fully, we also know that most women agree that the primary goal in pregnancy is to have a healthy baby, and the decision about whether or not to have a C-section must always have that goal in the forefront, eclipsing all others.

Sometimes the decision to have that first C-section is relatively easy, like when the baby is in acute distress.  While still disappointing, we find much less emotional aftermath in that kind of situation than in cases when something happened that the patient can imagine was at least partly under her control. If the baby just would not come out after a prolonged labor and a C-section was the result, we can torture ourselves with ideas like “maybe I could have pushed harder”, “maybe I should have waited longer”, or if the baby was too big or was breech “may I should have gained less weight or not done (enter any activity) that could have cause the baby not to turn”.

It is amazing how our brains can play these tricks on us, and not surprising how strongly we might feel about making this right next time, and achieving or goal with the next pregnancy to compensate for whatever we feel that we lost the first time.  In many instances I have found that a strong desire for VBAC is coming from this type of emotional place, which can feel so strong that it surpasses our real goal of putting the baby first.

Granted, few people want a C-section.  It is a fairly major surgery, it hurts afterwards for a couple of weeks, and goes against some of our strongest desires to let things happen naturally, let the baby come when she wants to, and to be a “real woman” by having the experience of labor and delivering a baby vaginally. For many of us these are all strongly imprinted ideas that go beyond our culture and back to a very primal level.  It’s good to keep in mind that currently in countries where C-sections are not available (and in the relatively recent past in our own country), obstetric disasters are common; mothers and babies are permanently damaged or die regularly, and “letting things happen naturally” is proven to be not always such a good idea. (There is a prior blog on this topic, at the following link: http://cwccblog.com/a-world-with-no-c-sections/).

After we have had one C-section for whatever reason, as much as we might grieve about that reality, there is a scar on the uterus itself which is always a weak point, and that scar can cause major issues in future labors if labor is allowed to take place. Generally C-sections are done though a horizontal incision low on the uterus, which we call a “low transverse” C-section. (Sometimes the incision on the skin may be vertical, but the incision on the uterus is almost always horizontal).  Rarely a C-section is done through a vertical uterine incision (the skin incision in this case may be horizontal, so you can’t judge by the skin) which is called a “classical” C-section since that is how they all used to be done in the old days.  Very preterm babies or babies in unusual positions such as being sideways may occasionally be delivered by a classical C-section, but at CWCC that represents less than 1% of C-sections.

When we are in labor, the uterine muscle (which in pregnancy is the largest muscle in our body) contracts forcefully every 2-3 minutes for hours.  Each time the uterus contracts, it puts strain on that old scar. Just like a seam in a piece of clothing is a potential weak point under stress, the old scar is always a weak point even years after healing, and can occasionally by torn open by the pressures of labor. When that happens, it is called a uterine rupture, and the baby and/or cord and placenta can be partially or completely expelled from the uterus into the abdominal cavity. The result is a complete or partial loss of oxygen for the baby, and a true emergency which requires intervention within minutes to resolve without the risk of permanent injury to the baby. If a significant uterine rupture occurs in a major hospital and is recognized immediately, with an operating room and anesthesia immediately available and a doctor standing right at the bedside, it can still be impossible to get the baby delivered in a safe timeframe to avoid the possibility of permanent neurologic damage to the baby, or worse.

Obviously in reality all of those factors are not always in place, and even a small delay in recognition or lack of immediate availability of resources can use up precious seconds.  If oxygen is completely cut off, which can occur in some uterine ruptures, we only have about 4 minutes to get the baby delivered before acid levels rise in the baby’s bloodstream which can cause brain damage and not too long after that, death. While most cases of uterine rupture still allow some degree of oxygenation to the baby, it is limited at best and time to delivery is critical. Countless cases exist of fetal brain damage and death from uterine rupture; this is not a hypothetical issue, it is a very real one.  A further issue is that a ruptured uterus is very damaged and sometimes cannot be repaired. Dramatic blood loss can occur sometimes resulting in maternal death and frequently in the need for hysterectomy, as well as the need for massive blood transfusions which can cause other issues.

That being said, the risk of uterine rupture with VBAC is not high. With one low transverse incision, the risk of uterine rupture is about 1%, and approximately doubles for each additional C-section. For a classical C-section the risk is probably about 10%, although VBAC is never recommended in these cases so data is limited. Proponents of VBAC stress that 99 percent of attempted VBACs do not result in rupture and they are correct. The problem is that we cannot predict who that 1% will be, and as mothers ourselves we feel that the bottom line is that we go to great lengths to protect ourselves and our children from things that have a much lower risk than 1%, when the outcome is potentially disastrous. Think about vaccinations for example, or getting routine pap smears, or wearing seat belts, or childproofing our doors and cupboards, or not letting our kids walk to the park alone. We could ignore all of those things and 99% of the time we would be fine, but we do them because the possible outcome that we are trying to avoid is so serious.

When it comes down to it when choosing VBAC vs. a scheduled repeat C-section, I ask patients to consider only one question, which is “what is the safest thing for the baby?” If that is the only consideration, then the answer is clear.  Of course we would not put a mother at significant risk in order to reduce a small risk to the baby, since there are two patients involved. Luckily in this country at the Woman’s Hospital of Texas and with your well trained CWCC doctors, the risk to the mother of repeat C-section is very minimal. While each successive C-section has a slightly higher risk of bleeding, adhesion formation, and placental issues such as placenta accreta (where the placenta grows into the old C-section scar and often requires hysterectomy to remove), the vast majority of repeat C-sections are completely uneventful. While having 4 or more C-sections can start to significantly increase surgical risk, in reality we rarely come across a patient who wants more than 3 for obvious reasons, and we have done up to 5 C-sections without incident in patients who request this.

Our goal at CWCC is to reduce the risk of the first C-section as much as safely possible, so that the decision about VBAC is less common.  But once a C-section has occurred,  we always ask ourselves “what is best for the baby?” and recommend repeat C-section,  as this is always what we would choose for ourselves and for our own family members.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Isn’t “Natural” Childbirth Better For The Baby?

June 24, 2014Obstetricsadmin

At CWCC we truly respect differing opinions about childbirth preferences and our goal is to make your labor experience personal and aligned with your own beliefs as much as possible. But we hope that this article will dispel some common myths about childbirth and help you to be educated in your decision making, and not let decisions be based on non- scientific information.

It is not uncommon at an early pregnancy visit for a patient (especially with the first pregnancy) to express her ideas about how she wants her labor experience to be. One of our first responses to these ideas is always to ask her to understand that the labor process is dynamic and unpredictable, and while having wishes is human nature, labor is a unique time when we have to “go with the flow” and follow the course that the process takes us on, and trust that your provider has your best interests and those of your baby in mind with all of her decision making. Making firm decisions about what you want can lead to disappointment when things don’t go a planned or when the reality of the situation forces you to change your mind about something that you thought was set in stone.

For example, we discourage patients from saying “I am not getting an epidural, no matter what”, since if they have never experienced labor they may find that they are disappointed or embarrassed if their position changes. Similarly, thought processes starting with ideas like “I will be devastated if I have a C-section”, “I don’t want Pitocin no matter what” or “I don’t want to tear” are fraught with the possibility of emotional fall- out if our plan does not become a reality, and labor is a unique opportunity to relax and put your trust in our hands and recite that part of the Serenity Prayer which asks us to “accept the things I cannot change”.

For patients leaning towards a “natural” (unmedicated) childbirth, it is important to know that there is certainly some great wisdom in the natural childbirth literature, but we have found that there are also several common myths that are propagated in the community and online. Below we will go through the most common ones and add the scientific viewpoint for balance.

1. Epidurals are dangerous for the baby. 

We are commonly told by patients that they don’t want an epidural for a variety of reasons such as that they increase the risk of C-section, are risky for the mother, or cause harm to the fetus.

Many studies have looked at the risk of C-section due to labor arrest with epidurals compared to labors without epidurals. The results of these studies have differed widely from a small increased risk, to no risk, to a small risk only if given too early in labor, to no risk even if given early in labor. Putting all these studies together it is clear that the effect is minimal at best, especially if the epidural is given when a patient is actually in labor (not in so called “latent labor” which is the period before true labor). Some studies and our own observations frequently show that the immediate relief of pain and relaxation that comes from epidural administration can actually speed up the labor process, and not infrequently a stalled natural labor can resolve right after the patient relaxes with her epidural in place.

The likelihood of C-section from fetal heart rate changes is also very rare as a result of an epidural. While occasionally maternal blood pressure can drop right after an epidural and this can temporarily affect the fetal heart rate, it can almost always be resolved with position change and this would be a very unusual reason to do a C-section.

Since millions of women have been getting epidurals around the world annually for many years, there is plenty of data on the risk of an epidural to the mother. The risk of any major complication from an epidural done by a professional anesthesiologist trained in obstetric anesthesia (as at Woman’s Hospital) is exceedingly low. Minor risks such as temporary sore spot or bruise at the point of placement, a headache, which can last for a few days, or lack of adequate pain control can occur in a small subset of patients but do not result in permanent harm. Serious problems such as death, permanent back pain or nerve damage are so rare that no patient in CWCC’s history has ever had such a problem.

Epidurals are absolutely not harmful for the baby. The beauty of an epidural is that the anesthetic drugs stay in the epidural space (a space surrounding the nerves that come from our spinal cord) and a negligible amount gets into the bloodstream (from where it could cross the placenta to the baby). This is why patients with an epidural feel mentally clear; they are not getting any drugs to their brain, nor is the baby. On the other hand IV medications do travel to the baby and make both the baby and mom quite sedated. Furthermore, IV pain medications just don’t work that well and make us drugged up and unable to participate in the labor process.

The bottom line is that we feel that epidurals for relieving the pain of labor are one of the best developments in women’s health ever made, and you would be hard pressed to find an obstetrician in the western world who volunteered to go through her own labor without one. One way of looking at it is that you get the same baby at the end, and there are no medals given for unnecessary suffering. But we respect each woman’s right to choose and will support you in an unmedicated birth if that is your choice, but do hope that this decision is not made due to misinformation about safety.

2. Pitocin is dangerous. 

Pitocin is a medication which acts like our natural hormone oxytocin to stimulate contractions of the uterus. While like most things it can be dangerous if used irresponsibly, Pitocin is a wonderful and frequently lifesaving drug which allows us to start or speed up the labor process in cases that require the baby to be delivered for maternal or fetal health reasons, when labor progress has slowed or stopped, as well as in elective cases.

Very strict guidelines are in place at all modern hospitals (including our own) regarding the safe dosing of Pitocin. Since this drug makes the uterus contact, too much can cause contractions to be too strong and not give the fetus time to rest between contractions, and this could cause a lack of fetal oxygen over time. Even when given at the conservative recommended doses, patients on Pitocin have continuous fetal monitoring to make sure that any fetal heart rate changes are recognized immediately, and the Pitocin can be reduced or turned off. Pitocin is very short acting which is why a continuous drip is used, and also why turning it off results in almost an immediate reduction in contractions.

Pitocin saves lives in cases when induction of labor is necessary in cases of maternal high blood pressure, low amniotic fluid, fetal growth issues and a number of other obstetric complications. But more often Pitocin is used in a normal labor when the labor progress has significantly slowed or stopped. In these cases Pitocin is an alternative to C-section, and frequently gets labor going again in a patient who otherwise would have been headed to surgery. This is why we discourage patients from having their minds set on not getting Pitocin in labor. If one persisted in that point of view, in many cases your doctor would be forced to perform a potentially unnecessary C-section.

Sometimes patients choose to have their labor induced for social reasons, and this is a choice that we support if the pregnancy is at least 39 weeks and the cervix is ready. Sometimes the distance from the hospital, busy work or family schedules and other factors make this a good decision for a particular family and in these cases judicious use of Pitocin is similarly very safe.

3. Clamping the cord immediately is bad for the baby.

Many studies have been done on this issue and the data is pretty clear that in full term babies the timing of cord clamping makes very little difference. http://cwccblog.com/when-is-the-best-time-to-clamp-the-umbilical-cord/

4. Episiotomies are bad

There is no scientific evidence that a routine episiotomy is a good idea and your CWCC doctors do not do routine episiotomies. That being said, sometimes an episiotomy avoids much more major damage. The more babies you have had, the less likely it is that we will have to make a cut in the tissue to allow the baby to safely deliver. Most often the decision of whether or not to make a cut to assist the safe delivery of the baby occurs with the first pregnancy. In general, second and further deliveries are at low risk of a major tear and we usually allow the tissue to tear a little spontaneously if necessary and are less likely to make a cut.

At the moment at which the baby’s head is half way out, your doctor will make a quick decision about how likely the tissue is to have a significant and potentially harmful tear, and will sometimes cut a small episiotomy to avoid a major tear. A major tear may extend into the rectum or cause other serious damage and it is always our goal to avoid that.
If you have other questions about natural childbirth or labor myths, please talk to your provider!

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Can I Do About Painful Sex After Menopause?

June 16, 2014Gynecology, Menopauseadmin

Menopause is a challenging time for many reasons, as we are forced to face the reality of our own aging and loss of fertility, as well as a myriad of unpleasant symptoms that come from a drop in our ovarian hormone production. While the average age for ovarian function to cease is 51, in many women it can occur much earlier, or even as late as 60.

Right at the same time as we are dealing with the emotional realties of menopause, seeing new wrinkles in the mirror and a new tire forming around our waist, we often are thrown another loop which is that sex becomes painful. Dropping estrogen levels cause very real changes in the vagina including a lack of moisture production and a thinning of the tissue which also becomes less elastic and prone to tear. The vaginal tissue becomes pale as blood flow to the areas is decreased, and the vagina can start to shrink to a point at which intercourse can be difficult or even impossible.

Luckily there are very good treatments for post-menopausal vaginal changes and this pain and dryness can almost always be resolved. Since the problem is caused by low estrogen, the mainstay of treatment is putting estrogen back into the tissue. For women experiencing a wide range of menopausal symptoms such as hot flashes, and night sweats as well as vaginal pain, taking an estrogen product that treats the whole body may be appropriate. For women with isolated vaginal pain and dryness, estrogen can be directly applied to the vagina at a much lower dose and this avoids some of the side effects (such as the potential for increasing breast cancer risk) that the systemic products may have. Even if a systemic product is used, additional vaginally administered estrogen can help in many cases.

There are three estrogen products on the market that we recommend to treat vaginal pain and dryness and each has pros and cons. They all contain the same product, which is bio-identical estradiol (biologically the same as human estrogen). The first is a cream which is applied with an inserter 2-3 times weekly (”Estrace”). It works well but is a bit messy and hard to keep up with. The second is a tablet which is also inserted with an applicator (“Vagifem”). It is less messy but also is hard to keep up with. The third is a circular flexible ring which is placed and removed by the patient and stays in the vagina for 3 months (“Estring”). Many of our patients prefer this as it is no trouble to keep up with and delivers a small even dose every day, and overall is the lowest dose product which has the best results. Interestingly studies on Estring show that such a minuscule amount of estrogen gets above the waist (it is almost all bound locally) that even breast cancer patients can usually safely use it once they are cancer free. None of these work overnight as they require time for new healthy tissue to replace the old unhealthy tissue, and results may take 3-6 months to be noticeable. In the meantime using a lubricant such as Astroglide can help to reduce pain.

A unique non-estrogen product is also available in pill form to treat post-menopausal vaginal pain and dryness. “Osphena” is a not estrogen but is in a class of drugs called “SERMs” (selective estrogen receptor modulators) which act like estrogen in some tissues but like anti-estrogens in others. Other very similar drugs include Tamoxifen which is used to reduce breast cancer risk but also helps bone density, and Raloxifene which is a bone builder but also reduces breast cancer risk. Osphena was initially being developed as a bone builder and it does have a good effect on the bone, but incidentally was found to have an estrogen-like effect in the vagina, so the decision was made to market it for that purpose. While it has not been studied enough on the breast yet to make this promise, it is certainly likely to decrease breast cancer risk since the other drugs in this class do.

One benefit is that it is a daily pill and some patients find that preferable to placing something in the vagina. Unfortunately the main side effect is hot flashes. Since Osphena is an anti-estrogen in some areas of the body, one of those areas is unfortunately the temperature sensors in our brain. For this reason we rarely recommend Osphena to a woman early in menopause who is already experiencing hot flashes, and also cannot give it to patients who are taking systemic estrogen for hot flashes (you should not take both estrogen and an anti-estrogen simultaneously). A good candidate for Osphena might be a woman in her 60s with vaginal pain and dryness who is past the point of hot flashes and prefers a pill to a vaginal medication.

Of course there are some non-hormonal reasons for vaginal pain after menopause and a physical exam with your provider is important to make sure there is not something more serious going on. While it is our job to ask, don’t be afraid to bring up this very intimate topic with your provider at your next visit.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Is This New Alternative To Pap Smears For Cervical Cancer Screening?

June 10, 2014Gynecologyadmin

Many of you may have heard in the news that the FDA recently approved a new screening test for cervical cancer. We are CWCC think this is very exciting news, especially for women in the developing world, and we know you will be interested to hear the details.

As you all probably know, cervical cancer is almost always caused by the virus called HPV (human papilloma virus). We discussed this is another blog and here is the link to get you up to date on that information. (http://cwccblog.com/do-i-still-need-a-pap-smear-every-year). The short version is that most of us are exposed to the HPV virus at some point in our lives through sexual activity, but in the majority of cases our immune system clears it up and no treatment is required. That is why it is not recommended to even test for it in women under 30, because it’s so common and usually goes away. If we still carry it when we are over 30 it is less likely that it will clear on its own and we start watching more closely for signs of pre-cancerous change which can be treated easily in most cases before any harm is done. For patients who follow these guidelines, cervical cancer is extremely unlikely to develop.

Traditionally we have done cervical cancer screening by doing a pap smear, which gets a sample of cells from the cervix to examine for precancerous changes. In addition to checking the cells, for patients over 30 an HPV test is added. In reality, for patients over 30 we are really only reacting to the HPV result, so the cellular part is of little or no value, since precancerous changes essentially go along with a positive HPV result, and if the HPV is negative we essentially disregard the cellular test results.  Following that evolution in practice over the past few years, a new test has been approved which only tests for HPV, and this could theoretically be done at home with a vaginal swab that patients could do themselves.  Essentially it is the exact same test that is currently done from a traditional pap smear in women over 30.

The test checks for the DNA of 14 types of HPV which are possibly players that could cause cervical cancer (there are over 50 types of HPV, but most of them don’t cause cervical cancer). The current suggested guidelines for this product are to ask patients with a positive test to come in to see the doctor if they have a positive test, and if they test positive for one of the most “high risk” types of HPV (either type 16 or 18) then the recommendation is to do a cervical biopsy to check for precancerous changes.  That is also pretty much what we do already when handling traditional pap smear results, although we may wait a year in some cases to see if the HPV goes way before we do a biopsy.

Critics of the new test worry that if too many young women do this test that it may lead to over treatment of patients who are HPV positive when the virus normally clears on its own.  We agree that women under 30 should NOT do this test, for the same reason that we haven’t recommended that for years with the traditional pap. We also are concerned that if this test is done at home and patients over 30 are negative for HPV, that they won’t come to their annual exams, and it is important to remember that there are many other disease processes that we screen for at an annual exam, including ovarian, uterine, breast, bladder, vaginal and vulvar issues.  But overall we think it is a great development, and will be a fantastic tool for women to use in environments where medical care is hard to find, such as in the developing world, where most cervical cancers occur.  In places like Africa this test could allow triage large numbers of women without the need for a medical exam, and follow-up of HPV positive patients, particularly those with HPV type 16 and 18, could be directed to a clinic that otherwise would be overwhelmed by screening the entire population.

While this test has been approved by the FDA, at the time of this blog it is not currently available to the public or to doctors. If a patient is in our office having an exam, we will currently continue using the pap smear and HPV testing for women over 30, but we look forward to finding out what the future holds for recommending that certain patients do this test themselves at home as an adjunct to their annual exam and will keep a close eye on this product so that we can keep you up to date.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

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