Obstetrician

Ectopic Pregnancies: Dr. Tanya Goodwin

/ Jordyn Redwood / Leave a comment

Today I’m going to talk about ectopic pregnancy. An ectopic pregnancy really means any pregnancy not in the uterus. Mostly this refers to pregnancy in the fallopian tube or tubal pregnancy.


The uterus has a fallopian tube attached to each side. At the end of each fallopian tube are delicate fingerlike projections called fimbriae. These fimbriae function to catch ova (eggs) released from the ovary and help transport the egg(s) down the tube and into the uterus. Sperm actually meet the ovum (egg) in the tube. The resulting early embryo is then wafted down to the uterus where implantation normally occurs. Tiny little hair-like structures inside the fallopian tube called cilia beat rhythmically, also moving the embryo along the tube. If the embryo gets stuck along the way then an ectopic/tubal pregnancy occurs. The embryo grows in the narrow tube until the tube can no longer accommodate it. The tube then ruptures, causing bleeding into the abdomen.

An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age. Wikipedia
Symptoms of tubal pregnancy include missed period (which may be a short irregular one), spotting, and pelvic/abdominal pain. The pregnancy test will be positive. OB/GYN’s specifically look at the blood (serum) pregnancy test result called a beta HCG. This result is typically abnormally low compared to a healthy pregnancy in the uterus. Normally this value, early in pregnancy, should double every 48 hours. If these values do not double appropriately, then a tubal pregnancy is suspected.

If a woman presents with a positive pregnancy test, a tender distended belly, low blood pressure, and rapid pulse, then she must be taken for emergency surgery as blood from the ruptured tube is spilling into the abdomen resulting in shock.

Most of the time, this scenario is not that dramatic. There may be blood leaking from the end of the tube, or the tube may not have ruptured. If caught early enough by pelvic ultrasound, and if the tube hasn’t ruptured, then the tubal pregnancy can be treated medically with Methotrexate. This is an anti-neoplastic medicine (meaning killing growing cells) that is injected into a muscle (ie usually buttock/hip). This hopefully should kill (dissolve) the ectopic pregnancy. Given the appropriate conditions, Methotrexate works well. The pregnancy hormone levels must be watched carefully until they decline to zero. Occasionally a second dose is needed. Sometimes Methotrexate fails and surgery to remove the tubal pregnancy is necessary.

Surgery for tubal pregnancy can involve removing the part of the tube affected if it is ruptured (salpingectomy). If the rupture is slight or not at all, then the tube may be surgically slit open, the ectopic pregnancy scooped out, and the tube heals over time (salpingostomy). These surgeries are usually done laparascopically.

Any woman having a tubal pregnancy is at risk to have another tubal pregnancy in the future. We tell these women to be checked out early the minute they know they are pregnant.

Risk factors for tubal pregnancy are previous tubal pregnancy, scarred tubes from tubal infections, endometriosis (also can scar tubes), smoking (causes the cilia to not beat properly, and previous tubal ligation (sterilization by tying tubes, burning them, or placing special clips/rings on tubes). Tubes can re-cannulize or grow back together. Also assisted reproduction such as in vitro fertilization (IVF) can increase the risk that the embryo can migrate up into the tube.

More rare and extremely dangerous ectopic pregnancies include cornual ectopics (getting stuck in the junction where the tube inserts into the uterus), cervical ectopics (in cervix), and pregnancies inside the abdomen. These pregnancies can get very large and when rupture occurs it can cause extensive blood loss.
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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Inter-Hospital Transfer of the Pregnant Woman: 2/2

/ Jordyn Redwood / Leave a comment

Dr. Tanya Goodwin concludes her two-part series on NICU designations and transfer of the OB patient. Excellent information for any author writing this scenario. You can find Part I here.

Welcome back, Tanya!

Prior to any transfer, the woman’s pre-term labor must be assessed. The OB performs a history and physical examination while the nurses attach a fetal Doppler and a Tocometer to record fetal heart beat and uterine contractions respectively, start an IV, and they or a lab tech draw blood.

MPR News

Typical blood work would include a complete blood count (for evidence of infection, anemia, or clotting problem) electrolytes (blood chemistry), type and screen (in case blood transfusion necessary or injection for blood type – Rhogam). If the woman is contracting then medications to stall labor are started (Magnesium Sulfate IV, Procardia orally).

Before the OB or labor nurse performs a vaginal exam to assess cervical dilation, a sterile speculum is inserted into the vagina and a special swab called fetal fibronectin is done (a positive result increases the risk that the woman will deliver pre-term). If ruptured membranes are suspected then a sample of fluid is evaluated for amniotic fluid. If the water hasn’t broken pre-term, then the OB does an internal exam to check for cervical dilation.


Antibiotics may be given to decrease the risk of neonatal Group B Streptococcal sepsis (severe and life threatening bacterial infection) Also a corticosteroid injection may be given to the woman between 26 – 32 weeks gestation to help accelerate fetal lung maturation.

Once the woman is assessed for labor, the OB must make a decision as to the probability that his/her patient will make it to another facility without giving birth en route or encounter a medical complication. The OB’s first obligation is to the mother, and then fetus. Stabilizing the pregnant woman is paramount. The fetus depends on the health of the mother.

A U.S./governmental code called EMTALA or Emergency Medical Treatment and Active Labor Act forbids rejection of care and transfer of an unstable patient to another facility. This applies to all hospitals that participate (or receive payment) from Medicare/Medicaid, which is virtually every U.S. hospital. Its original intention was to prevent hospitals from “dumping” indigent patients into “charity hospitals”.

The OB explains the situation to the woman and any family she consents to relay medical information to. This is typically the father of the baby. Risks and benefits of transfer are discussed with the woman and “family” and the woman must give consent to be transferred.

The OB then calls a “transfer center” relaying information regarding the woman’s status and the necessity for transfer to a higher level of care. The transfer center finds the nearest suitable facility and connects the admitting OB to the receiving/accepting OB. Medical information is exchanged. Once the patient is accepted, then depending on distance or urgency, the woman is transported via helicopter (weather permitting) or ambulance. If this is a neonate, then the pediatrician is in charge of obtaining appropriate transport. Nurses also give nurse-to-nurse report. Medical records generated are copied and go with the patient. Everyone involved keeps one another updated as to the outcome, hopefully a happy ending but unfortunately not always that way.

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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Inter-Hospital Transfer of the Pregnant Woman: 1/2

/ Jordyn Redwood / Leave a comment

I’m pleased to host Dr. Tanya Goodwin as she discusses the difference between NICU’s and their designation. This will be Part I of her post. Part II covering transfer specifics will be on Wednesday.

One thing I want to point out is the Trauma Center designations run opposite of NICU’s. A Level I Trauma Center is where the most critical patients are taken if possible. Level II and Level III can always stabilize but may need to transfer the patient out.

Welcome back, Tanya!

Most pregnant woman will happily deliver their babies in a comfy hospital maternity unit. But for a few, their labor and delivery may need to be at a more specialized facility, or their infants may need to be transferred to an appropriate NICU or Neonatal Intensive Care Unit.

So how does this all happen?


Aside from a rare, life threatening maternal illness or a pregnant woman involved in a traumatic accident, transfer of the pregnant woman is usually based on the neonatal need.


A woman between 36 and 40+ weeks gestation (last month of pregnancy) can stay at a level I facility. Their babies will do quite well in a regular newborn nursery. Occasionally, a full-term baby may not adjust well to extrauterine life or have breathing problems or unforeseen medical or surgical issues that requires prompt transport to level II or III NICU (usually level III).


A level II nursery or special care nursery can accommodate those infants between 32 and 35 weeks. A 35 “weeker”, if doing well can stay at a level I /newborn nursery. Infants in a Level II are mainly there to feed and grow or receive a course of antibiotics.


Level III NICU’s are for babies that need long term care such as assistance with respirations via ventilators, medical or surgical issues. They may need to be fed through special nutritional intravenous fluids. These are the NICUs you usually see on TV.


A newer level, IV, has been touted as the place for extreme pre-term babies, between 22-25 weeks. Level III/IV are in urban centers (tertiary centers or teaching hospitals) where there are 24 hr neonatologists/sub-specialty neonatologists, physicians, surgeons, anesthesiologists, fellows, residents, and medical student. A very busy place!


Two of the most common scenarios requiring maternal transfer are pre-term labor (labor before completed 36 weeks pregnancy) and premature rupture of membranes (water breaking before 36 weeks). These conditions frequently co-exist, but not necessarily. If the OB is in a level I unit, then transfer of the woman is considered. If the OB is in a level II unit then depending on the gestation, the woman may stay or may be transported. No problem if already in a tertiary hospital.

More on this topic Wednesday.
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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Obstetrical Emergencies: Prolapsed Umbilical Cord

/ Jordyn Redwood / Leave a comment

If you’re a writer and you are wondering about a grave situation to put a pregnant, delivering woman into– this might be your solution. A prolapsed cord.

Heidi Creston, OB RN extraordinaire returns to discuss this obstetrical emergency.

Welcome back, Heidi!

The umbilical cord connects the baby from its umbilicus (belly button) to the placenta (afterbirth) inside the uterus (womb). The cord contains blood vessels, which carry blood, oxygen and nutrients, to the baby and waste products away. After the baby is born, the cord is clamped and cut before delivery of the placenta.
A prolapsed cord is when the umbilical cord slips or falls through the open cervix (entrance of the womb) in front of the baby before the birth. When the cord prolapses, it reduces the amount of blood and oxygen supply to the baby. This causes an emergency situation, which requires immediate delivery of the infant.
A doctor, midwife, or labor nurse will need to insert a hand in your vagina to lift the baby’s head to stop it from squeezing the cord. Alternatively a catheter (tube) may be put into your bladder to fill it up with fluid. This will help to hold the baby’s head away from the cord and reduce pressure on it.
If the provider is able eliminate pressure on the cord through positioning, and the vaginal delivery is imminent, then they may proceed with the vaginal birth. Most providers will perform an emergency Cesarean section.
Patients will be placed in a knee chest position, in order to reduce compression on the cord. The labor nurse will hold the fetus’s presenting part in the vaginal canal, when the physician is ready, the nurse will apply pressure pushing the fetus back up into the uterus. The physician will then remove the infant via Cesarean section.
A prolapsed cord is a desperate situation for the infant requiring everyone to work very quickly.
           
Prolapsed cords are usually the result of multiple gestations (twins, triplets etc), malpresentation of the fetus (transverse or breech), polyhydramnos (to much fluid around the baby), artificial rupture of membranes (water breaking), or if membranes rupture before head is fully engaged.
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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.
Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 

Rare Disorders – Flesh Eating Disease

/ Jordyn Redwood / Leave a comment

I’m so pleased to host Tanya Goodwin, OB/GYN extraordinaire. She’ll be stopping by on a monthly basis to offer her insight into all things medical.

Welcome, Tanya!

http://www.medicinenet.com/necrotizing_fasciitis/article.htm

As a medical student I was taught about a barrage of diseases, acute and chronic, common and rare. One of the rare was necrotizing fasciitis.

Thinking I’d never encounter this deadly disease, I forgot about it until one night as a second year OB/GYN resident (4 year specialty training after medical school) when I was called to evaluate a woman who was transferred from a community hospital to our large teaching institution with possible necrotizing fasciitis.

I briefly reviewed this disease before I took the elevator, along with my intern (aka 1st year resident) to the ninth floor, ready to evaluate this young woman.

It was midnight when we entered her room. My attending (supervising physician) had accepted her transfer as a direct admission, bypassing her need to enter via the emergency department.
She laid in the bed, covered with a white hospital sheet, her husband holding her hand. He darted his eyes towards us. Why would he trust us? His wife’s condition had worsened despite being hospitalized for the last three days.
During that time, she’d received intravenous antibiotics upon the recommendation of a doctor who specialized in infectious diseases. The consult was requested by her obstetrician who had admitted her to the hospital one week after she had given birth vaginally to a healthy baby boy.

Diagnosis? Necrotizing fasciitis.

Necrotizing means dying or death and fasciitis refers to inflammation of the fascia, a tough connective tissue overlying muscle. Rare, the incidence of NF is approximately 1 in 450,000 or 600 people per year.

Otherwise known by the moniker, Flesh Eating Disease.

During childbirth, the obstetrician performed an episiotomy, a surgical incision of the perineum, that skin between the vagina and anus to afford a wider opening to deliver the baby. After the delivery, the episiotomy was sutured closed. The woman went home with her baby, but had called the OB’s office several times with complaints of episiotomy pain, a common occurrence.

Instructed, as usual, to apply anesthetic foam and to take an oral pain medicine, she did so but with no improvement. After multiple phone calls, she now complained of not only refractory episiotomy pain, but fever and chills, malaise, and reddening of her genitals and inner thighs. She was told to come to the doctor’s office.

Diagnosed with an episiotomy infection, her OB admitted her to the hospital for intravenous antibiotics. The redness spread, her fever continued, she was now nauseated, and her blood work showed a significantly elevated white blood cell count consistent with a severe infection. An infectious disease consult was then made by her OB.

Necrotizing fasciitis is caused by invasion of bacteria into the fascia after a break in the skin. Many bacteria or a single offender are the culprits. Typical bacteria are of the streptococci family such as Group A streptococcus or a staphylococcus, both found on our skin. The disease really is not “flesh eating” as the toxins from the bacteria do the damage.

Some have contracted NF by swimming in water containing Vibrio vulnificans. These victims of NF had a portal of entry: a skin scrape or laceration. Those at risk for necrotizing fasciitis are people with lowered immunity from chronic diseases such as autoimmune disorders, diabetes, and liver disease, but it is also seen in healthy people or those that have had surgery or an incision. Symptoms are pain, swelling, redness, feeling poorly, nausea, vomiting, and fever.

What I saw that night still sticks in my memory 20 years later. The woman’s thighs down to just above her knees looked like the worst sunburn I’d seen. At this point, she felt nothing in the affected area as numbness had set in.

My attending physician had examined her as well. After explaining the gravity of the situation, the woman was taken to the operating room to debride, or cut out, the dead tissue. In two surgeries, the first taking all night, she had her vaginal tissues and thighs removed.

She died the second day in the intensive care unit. The bacteria had spread to all her deep tissues. She became septic and died of multiple organ failure, leaving a grieving husband and a newborn son.

NF has a mortality rate greater than 70%. If diagnosed early and treated promptly with surgical debridement, some literature suggests a mortality rate of 33%. Unfortunately for this woman, the diagnosis was correct, but the initial and critical treatment was not.

Hopefully as more providers are aware of this deadly disease, more cases of necrotizing fasciitis will be correctly diagnosed and promptly treated, saving lives.
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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com.

Are Home Deliveries Safe?

/ Jordyn Redwood / Leave a comment

I’m pleased to host Tanya Cunningham today as she discusses the safety of home deliveries. I think this is another one of those instances where some important information is not as prominent as what is portrayed by celebrities and others.

What do you think? Welcome, Tanya!

The birth of a new baby is a life changing, exciting event in the lives of the expecting mother and father to be. The number of decisions to be made are numerous and often overwhelming. One question many expecting parents ask is whether to give birth in a hospital setting or at home with the aid of a certified nurse midwife (CNM).

Although there are benefits to both hospital and home births, the American College of Obstetricians and Gynecologists does not recommend home births due to a concern for safety and a need for much more research according to Dr. Joseph R. Wax of Maine Medical Center in Portland.
The benefits of home births that appeal to expectant mothers include a more relaxed or therapeutic setting, decreased risk of tearing and episiotomies, decreased risk of hemorrhage, decreased risk of infections, and a sense of autonomy concerning her birth plan.
In a systematic review of literature by Laurie Barclay, MD and Hien T. Nghiem, MD, they found that planned home births have a worrisome neonatal mortality rate triple that of hospital births, despite similar perinatal mortality rates. So while an actual delivery may go as planned, triple the number of newborns die in the first month of life after a planned home birth.  Barclay and Nghiem also found the 9% of parous (repeat mothers) and 37% of nulliparous (first time mothers) had to be transported to the hospital during planned home labor.
Other safety concerns I personally cannot ignore is the “what if” factor. Hopefully everything does go as planned whether delivering at home or at a hospital, but what if the new mother does hemorrhage in the postpartum period? The amount of blood loss in minutes can be catastrophic, and if it’s me, I want to be in a hospital setting where quick and timely interventions such as an emergent blood transfusion can save my life.
Another example is fetal distress. If severe or prolonged enough, an emergent or “crash” c-section may be a necessity. Again, if it’s me in the delivery room, I take comfort knowing an OR is seconds away if needed.
I love the idea of the home delivery, but I don’t love the realities. The reality is, even in the most straightforward, low risk pregnancies, unforeseen and even emergent complications can occur during labor and delivery. I do feel the OB hospital setting and staff have been vilified a bit, as time driven, heartless wardens chaining the laboring woman to a hospital bed with fetal monitoring against her will.
As a postpartum RN, I can assure you our first interest is the health of the mother and baby. As long as their well being isn’t compromised, mothers are encouraged to labor as they wish. At the hospital where I work, women are free to roam the halls and utilize birthing balls and birthing tubs. There are many women who deliver naturally, and their birth plans are respected and followed.
If you’ve had a negative experience in a hospital setting delivering a baby, feeling rushed by medical interventions or that a c-section might have been premature, remember, that may be more of an issue with your health care provider or the staff working at the time. I’d encourage you to research doctors who are more flexible and work with expectant/laboring mothers to follow their birth plans as closely as possible.
We who are in the business of delivering and caring for new mothers and babies seek to be as therapeutic as possible, but there are times when medical interventions are necessary to protect the health and well being of either the mother or baby. While delivering a baby at home might be more desirable to an expectant mother as far preserving her autonomy, the truth is hospital deliveries are safer. If you’re expecting or planning to have a child in the future, be sure you make an informed decision when considering where to deliver your precious little one.
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Tanya Cunningham is a mother/baby RN and lives in Missouri with her husband and two small children. She has been caring for mothers and their newborns for almost four years, before which she was a RN in the USAF. During that time, Tanya worked on a multipurpose inpatient unit for two and a half years (taking care of ortho, neuro, medical, general surgical, and tele) and a family practice residency clinic for a year and a half. Tanya earned her BSN at Oral Roberts University.
Tanya has been writing children’s stories for almost 2 years now and is working towards being published. She enjoys raising her children, cooking, and reading medical suspense/mysteries, especially those in Christian Fiction. You can find out more about Tanya by visiting her website.

Perinatal Providers: Scopes of Practice

/ Jordyn Redwood / Leave a comment

Heidi Creston returns today for her monthly blog post. Today, she covers a very important topic: scope of practice for different obstetrical providers. Scope of practice dictates what a medical provider can and cannot do so it is important to know a particular providers limitations. For instance, as a registered nurse, I cannot diagnose illness though most nurses are very good at this very thing and we may indicate to a family what we think is going on. However, only a physician, nurse practitioner, or physician’s assistant can diagnose.

Now, I’ll turn it over to Heidi.

It is especially challenging for the perinatal patient to understand the scopes of practice that different providers offer. As authors, we must remember that our audiences are impressionable, and may believe your fictional story as the Gospel truth. If your character is a perinatal provider it is imperative, that you keep them working within the means that their occupation allows.

The providers:  Obstetrician-Gynecologist, Perinatologist, Family practitioner, Certified Nurse Midwives, and Doula’s.

Obstetrician-Gynecologist (OB/GYN) is a medical doctor who provides both clinical and surgical care for their patients. The OBGYN serves not only the perinatal patient but all women’s medical issues from puberty to post hysterectomy.

Perinatologist is an obstetrician who specializes in the care management of high-risk pregnancies. Patients assigned to a perinatologist are referred out by their OBGYN or family practitioner due to the extensive or specialized care that is required maternally and or for the fetus. Patients with cardiac issues, diabetes, Eclampsia or HELLP, and multiple gestations are prime examples of patients referred to perinatologists. Fetuses with severe abnormalities such as gastrocentisis or Tetralogy of Fallot are also referred.

Family practitioner is a medical doctor who specializes in the health care of all family members. They are prepared to provide normal OB/GYN care, but usually refer pregnancies and other women’s health issues to an OB/GYN. All family practitioners are trained to perform Cesarean births in an emergency and also to assist other specialists in doing the procedure.

Certified Nurse Midwives are registered nurses who have earned their master’s degree in nursing, with a strong emphasis on clinical training in midwifery. Midwives work with obstetricians who are always available to assist if complications occur during pregnancy, labor, or delivery. CMW’S can assist with cesarean sections but can not perform them independently.

Doulas are not licensed or certified personnel. Doulas are support liaisons hired by the patient, to assist them through the pregnancy, and offer support during the labor process. There currently are no mandatory qualifications, regulations or requirements necessary in order for someone to become a doula.

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.