Monday, September 14, 2009

Miscarriage- Tragedy of Now...Hope for the Future

My heart sinks almost immediately after I start the trans-vaginal ultrasound. I desperately look for a flicker or a movement where the heart beat would be.

At the same time my mind is rehearsing what I may have to say. “I’m sorry but the pregnancy has stopped growing”. No, that doesn’t make sense. “I’m sorry but the baby has passed away”. Don’t like that either.
What do I say? She should be about 7 weeks pregnant. Just missed her period a couple of weeks ago. Like most couples they didn’t want to allow themselves to get too excited. I am sure however, that like most couples from the moment the home pregnancy test gave them the positive signal, the cautious day dreaming began. What names for boys and girls? Which color for the baby’s room? Daycare or babysitter at home?
“I am very sorry but I don’t see a heart beat on ultrasound today”. I then explain the miscarriage process but mainly try to listen.
This is not something that is usually taught very well in medical schools. I made mistakes at the beginning of my career and placed my foot several times in my mouth before settling into what I know now.
What I have learned over the years is to separate the tragedy of the moment from the hope for the future. Too many people resort to minimizing the emotional effects of an early miscarriage as a way to comfort the grieving couple.
All the stages of grief apply to an early pregnancy loss, from denial and guilt through to acceptance and hope. It is not unusual to feel isolated with these emotions because the couple may not know anyone else who has had a miscarriage. It is not exactly a topic that comes up often during dinner parties and family gatherings.
Unfortunately miscarriages are very common. Approximately 15% of known pregnancies will end up in a miscarriage. However if you include all the pregnancies that are lost before a woman even misses a period, the number is a staggering 50%. Most of these are due to chromosomal abnormalities which are sporadic in nature. This means that in most cases it appears to be a chance event.
“Is it because of something that I did or didn’t do, maybe something I ate?” The feeling of guilt is inevitable. You cannot cause a miscarriage by lifting something heavy or having sex and no it wasn’t that second glass of wine you had before you knew you were pregnant. The list goes on.
As reassuring as it is to know that the woman did not cause this miscarriage, it is disturbing to live with the lack of control. “How can I make sure that this does not happen again?”
There are a few things that can help minimize the risk of having a miscarriage. The most important thing is to be in an optimal state of health. If you have chronic illnesses such as diabetes they should be well controlled. With the help of your provider you can identify any environmental factors such as excess alcohol and cigarette smoking. You will probably need practical help to manage both of these habits.
There are some suggestions that moderate consumption of caffeine may increase the risk of miscarriage in the first trimester.  One cup of coffee a day should not pose an increased risk, as long as you take into account your entire intake of caffeine (including that in caffeinated sodas).
Guess what?! Exercise is good for you! As long as your provider has not identified any reason why you cannot exercise, it has been shown that not only is it safe but it may lower the risk of miscarriages.
Despite all of these adjustments there are a minority of women that experience recurrent early pregnancy losses. The guidelines at this time recommend starting to look for potential reasons after two to three consecutive miscarriages. I’ll leave this topic for another day.

I have been present and shared this emotionally devastating time with a few of my patients. I have also been privileged and have had the pleasure to deliver their healthy newborns sometime later. I cannot help but wish that I had the power to show them the future as a way to ease their pain. But I can't. I know that for now we should mourn the loss.

Tuesday, September 1, 2009

Labor Pains- Natural Birth? I Hope Nobody Reads This!

If nobody reads this, maybe we can continue to label those women that say they want to have natural birth as a bunch of hippies and wierdos. Then when we fail to provide them with resources to maximize their chances of achieving what they want, we won't feel as bad. Great idea!
If nobody reads this, maybe we can continue to smile knowingly everytime we meet someone who wants to try labor without an epidural.We can continue to make mental bets on how long they will last. After all, what else is there to offer them?
If nobody reads this, maybe when our patients say they want to try natural birth we can go on telling them, "sure just come in on the day and we'll see how you manage!".
Perhaps many of those that want to have a natural birth like the idea of it but don't want to put much time and effort into preparing for it anyway. I tried this philosophy on running the marathon once. It didn't work out too well!
The question is, who has time for all of this when things seem to be working just fine? How can change happen?

If we really wanted to make a change, we would initially create a sense of urgency. Then we would put together a guiding team that would include patients, physicians, midwives, nurses, hospitals etc. (if you can't tell, I've just read "Our Iceberg is Melting" by John Kotter!). The solutions would be decided upon as a TEAM.
Since no one will hopefully reads this, I can be honest and say that many women who choose a non-pharmacologic approach to pain management are often ill-prepared. Some of the ones that succeed look at the pain as a side-effect of a normal process (labor). They may even say crazy things like they felt "able to transcend their pain and experience a sense of strength and profound psychological and spiritual comfort during labor". Yeah! Whatever!
So what are some of the things that we do know about this option?
In contrast to epidurals, the primary goal is not to make the pain disappear. Instead, the woman is educated and assisted by her caregivers, childbirth educators, and support people to take an active role in decision-making and using self-comforting techniques and nonpharmacologic methods to relieve pain and enhance labor experience. If a woman after a few hours in labor decides to get an epidural it is not a sign of failure. For some, just the ability to walk around for a period of time and feel more in control can be very satisfying.
The birth environment and continuous labor support from the father, family member or doula are very important aspects of this approach. A doula that is familiar with the family and the physician can provide tremendous support. A prior meeting or discussion will make sure that everyone shares the same mental model of what to expect when the time comes.
These are some of the options for non-pharmacologic pain management in labor even with the system that we have in place now;
Water Immersion: Many women find the feeling of being immersed in warm water very comforting and relaxing especially in the beginning phases of labor. It has been shown that in "low risk" pregnancies this is a safe practice.
Sterile Water Injection: Also called a "water block", usually involves four small injections in the skin of the back to primarily relieve pain in that area. The injections can be painful but the relief can last 45 to 120 minutes.
Touch and Massage: Women clearly appreciate these and they appear to reduce pain and enhance feelings of well-being.
Acupuncture and Acupressure: As long as this approach is performed by trained practitioners it seems to be safe and provides a great deal of satisfaction to those that have tried it. It remains to be seen how it can be integrated in healthcare institutions.
Hypnosis: Hypnosis used for childbirth is almost always self-hypnosis; the hypnotherapist teaches the woman to induce the hypnotic state in herself during labor. Sometimes her partner is taught to signal her into the hypnotic state. I have seen the positive effects of this technique in my patients that I have referred to Dr Jay Stone. He makes his materials available on line at .

There are many techniques that can help decrease the pain of labor and sometimes eliminate the need for epidurals and medications. Not all of them may be available or appropriate depending on the risk level of the pregnancy. Most of these methods need a good deal of preparation and time investment by the woman and everyone involved in her care. Although our current system is not fully set up to support these approaches it doesn't mean that they are completely out of reach.

It does seem like a lot of work though! Like I said I'm glad nobody's gonna read this.