Prevent Complications Associated With Cesarean Delivery

A wonderful, concise, evidence-based article by Dr. Patrick Duff was published in the December edition of Obstetrics and Gynecology entitled, "A Simple Checklist for Preventing Major Complications Associated with Cesarean Delivery".

Dr. Duff proposed the following evidence-based eight steps to significantly reduce maternal morbidity and mortality associated with cesarean delivery:

1. Clip the hair at the surgical site just before making the incision

2. Cleanse the skin with chlorhexidine solution rather than povidone-iodine solution

3. Administer broad-spectrum systemic antibiotic prophylaxis before the surgical incision rather than after the neonate's umbilical cord is clamped

4. Remove the placenta by traction on the umbilical cord rather than by manual extraction

5. Close the uterine incision in two layers rather than one

6. In women whose subcutaneous tissue is greater than 2 cm in thickness, close the layer with a running suture

7. Patients at intermediate risk for deep vein thrombosis [BMI > 30, those with gross varicose veins, those immobilized for > 4 days before surgery, those who have concurrent medical illness that predisposes to thromboembolism (e.g. sickle cell disease, sickle cell C disease, cancer, antiphospholipid syndrome, hereditary thrombophilia with no history of DVT or PE)] should receive prophylaxis postoperatively with either sequential compression devices or subcutaneous heparin

8. Patients at high risk for postoperative deep vein thrombosis (those with more than two risk factors in the moderate-risk category, those with prior DVT or PE, those who have a cesarean hysterectomy) should receive prophylaxis with both sequential compression devices and subcutaneous heparin until the patient is fully ambulatory

Referenced article: Obstet Gynecol 2010;116:1393-6

Mindfulness and Parenting

A very helpful excerpt on the benefits of practicing mindfulness while undertaking the challenges of parenting - from Jon Kabat-Zinn's chapter "Parenting and Practice" in Wherever You Go There You Are: Mindfulness Meditation in Everday Life.

And it gets more challenging as the children grow older and develop their own ideas and strong wills. It's one thing to look after the needs of babies, which are very simple, after all, especially before they can talk and when they are at their absolute cutest and most adorable. It's quite another to see clearly and to respond effectively and with some modicum of wisdom and balance (after all, you are the adult) when there is a continual clash of wills with older children, who are not always so cute and cuddly, who can argue circles around you, tease each other mercilessly, fight, rebel, refuse to listen, get into social situations in which they need your guidance and clarity but may not be open to it; in short, whose needs require a constant energy output that leaves you little time for yourself...

These trials are not impediments to either parenting or mindfulness practice. They are the practice if you can remember to see it this way. Otherwise, your life as a parent can become one very long and unsatisfying burden, in which your lack of strength and clarity of purpose may lead to forgetting to honor or even see the inner goodness of your children and yourself.

Children can easily become wounded and diminished from a childhood which consistently fails to adequately honor their needs and their inner beauty. Wounding will just create more problems for them and for the family, problems with self-confidence, with communication and competencies, problems that don't disappear on their own as the children grow older but usually amplify...

It is obvious that, with all that energy going outward, there has to be some source of energy coming in which nurtures and revitalizes the parents...I can think of only two possible sources (of this energy): outside support from your partner, other family memebers, friends, baby-sitters and so on and from doing things you love, at least occasionally; and inner support, which you could get from a formal meditation practice...if you can make even a little time in your life for stillness, for just being, for just sitting, or for doing a little yoga, for nourishing yourself in ways that you need to be nourished...

Parenting and family life can be a perfect field for nindfulness practice, but it's not for the weak-hearted, the selfish or lazy, or the hopelessly romantic. Parenting is a mirror that forces you to look at yourself. If you can learn from what you observe, you just may have a chance to keep growing yourself.

Picture: My husband, Stuart and our three sons in 2003 (Mitch 19, Shayne 14, Alex 13)

I wish I knew then what I know now!

Chronic Pelvic Pain

I attended a very fascinating conference over the weekend. The event was hosted by the International Pelvic Pain Society in Chicago, Illinois. Throughout the 4-day event, a common thread linked many common pain syndromes of the anatomic structures below the umbilicus and above the upper thighs. Such ailments include chronic pelvic pain, Irritable Bowel Syndrome (IBS), Interstitial Cystitis (IC) and other bladder pain syndromes, dyspareunia (pain with intercourse), vulvar pain, vaginal itching/pain, hip pain, fibromyalgia, postoperative pain, back pain, endometriosis.

Twenty percent of women suffer from chronic pelvic pain (CPP). The typical patient with CPP doesn't look "sick", is frequently embarrassed by her symptoms, fears she will not be taken seriously by her doctor and has difficulty speaking to loved ones about her symptoms. Sufferers of CPP frequently experience alienation, hopelessness, anxiety, depression, suicidal ideation, sleeplessness, narcotic addiction concerns, sexual dysfunction, loss of relationships and loss of employment.

Women who seek medical advice for CPP are often discouraged as so many are told, "There is nothing else in there that could hurt - everything we have looked at is normal." The pelvic muscles, ligaments and nerves of the pelvis are the common denominators in CPP - regardless of the etiology.

The basics of the chronic pain cycle: (1) recurrent activation of the afferent nerves from the source of pain to the dorsal horn of the spinal cord; (2) prolonged release of neurotransmitters in the dorsal horn including substance P; (3) upregulated inflammatory response and release of other neurotransmitters in the dorsal horn; (4)resultant loss of sensitivy or hypersensitivity of the tissue pain source with expansion of the receptive field; (5) prolonged exposure to painful stimuli eventually causes centralization of the pain (i.e. communication with the brain) and local upregulation of pain fiber generation and inflammation resulting in hypersensitivity to pain and organ dysfunction (6) resulting in muscular contraction, other tissue changes and ultimate end-organ dysfunction.

The goals of chronic pain management consist of removal of the noxious stimulant if still present, and modulating the neurological and immune response (i.e. neuromodulation) to an insult. Examples of neuromodulation include biofeedback, drugs with neurotropic and psychotropic effects (oral and topical), soft tissue manipulation and utilization of neurostimulatory devices that stimulate including TENS units, acupuncture and sacral nerve stimulation. The suggested treatments vary according to the type and source of pain. Research indicates that peripheral pain is best treated with topical applications whereas visceral (organ e.g. bladder) pain is best treated with dorsal horn nerve activation.

Little was mentioned regarding complementary and alternative therapies for CPP other than hypnosis for IBS and acupuncture for IC. Lifestyle modification has proven beneficial for those with chronic inflammatory conditions, including CPP. Such alterations in every-day behaviors serve most people well, such as following an anti-inflammatory diet, consuming anti-inflammatory supplements, smoking cessation and limiting exposure to other environmental toxins. Because the efficacy of hypnosis in treating IBS has proven to be helpful, presumably other mind-body approaches should be consider (e.g. mindfulness meditation, Tai-chi, Yoga, guided imagery, art therapy, music therapy, aromatherapy, etc.) Energy therapies should also be considered as acupuncture has already proven helpful. It is important that these treatment modalities be subject to scientific inquiry in reference to treatment of CPP.

Congratulations and thanks to those scientists who continue to pursue additional knowledge. My learning has just begun.

Resources:

International Pelvic Pain Society Intake Form

National Vulvodynia Association Tutorial

Anti-inflammatory Diet

Fibromyalgia Information Foundation

Pelvic Pain and Urgency/Frequency Scale

Handy Portion Control Advice

SIZE UP YOUR PROTEIN
Protein fuels our energy and helps build strong muscles. Use the area and thickness of your palm to eyeball how much chicken, fish or tofu you should be eating in a single sitting.

SIZE UP YOUR VEGGIES
What should accompany your protein? Scoop up two fist-sized portions of fresh veggies for a ton of nutrients and antioxidants.

SIZE UP YOUR SALAD
Use both your hands like serving spoons to lift up a big portion of leafy greens. To give yourself about a tablespoon of dressing, use the length of your thumb as a guideline.

SIZE UP YOUR FRUIT
When you're figuring out how many berries to pile on top of your morning yogurt, fill your hand for just the right portion of fresh fruit.

SIZE UP YOUR FATS
These are the guys we really have to watch out for (they taste so good it's easy to overdo it!). For butter and oil, use your thumbnail as a measure.

What is Integrative Medicine?

The Defining Principles of Integrative Medicine

Andrew Weil, M.D. - What is Integrative Medicine? from Andrew Weil, M.D. on Vimeo.

1.Patient and practitioner are partners in the healing process.

2.All factors that influence health, wellness, and disease are taken into consideration, including mind, spirit, and community, as well as the body.

3.Appropriate use of both conventional and alternative methods facilitates the body's innate healing response.

4.Effective interventions that are natural and less invasive should be used whenever possible.

5.Integrative medicine neither rejects conventional medicine nor accepts alternative therapies uncritically.

6.Good medicine is based in good science. It is inquiry-driven and open to new paradigms.

7.Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount.

8.Practitioners of integrative medicine should exemplify its principles and commit themselves to self-exploration and self-development.

Links:
Arizona Center for Integrative Medicine
Find an Integrative Medicine Provider

Acupuncture May Ease PCOS

Research from Sweden suggests that acupuncture can help normalize menstruation and lower levels of testosterone in women with polycystic ovarian syndrome (PCOS).

This common disorder affects 13 percent of all women of reproductive age. It may cause a large number of small cysts to form on the ovaries, disturb hormone production and lead to an increase in testosterone secretion. As a result, affected women don’t ovulate normally and are at risk of infertility, obesity, type 2 diabetes and cardiovascular disease.

Although the cause is unknown, the Swedish researchers said that some women with the syndrome often have high activity in a part of the nervous system that we cannot consciously control -the sympathetic nervous system - and that this may be an important underlying factor.

In this study, a group of women with PCOS was treated for four months with electro-acupuncture in which needles are stimulated with a weak, low-frequency electric current; another group of women was given heart rate monitors and told to exercise three times a week and a third, control group, was told about the importance of exercise and a healthy diet but received no other instruction. The investigators found that sympathetic nervous system activity decreased in women who received acupuncture or exercised and that menstruation became more normal among the women underwent acupuncture treatments.

Reference: Stener-Victorin E, et al. Low-frequency electro-acupuncture and physical exercise decrease high muscle sympathetic nerve activity in polycystic ovary syndrome. American Journal of Physiology - Regulatory, Integrative and Comparative Physiology, August, 2009.

Vitamin D

Highlights of Dr. Paykel's Presentation

• Who is at risk for Vitamin D deficiency? Exclusively breast-fed infants, dark skin, aging, northern climate dwellers, city-dwellers, those who cover their heads when outside, sunscreen users, lactose intolerance, s/p gastric bypass, cystic fibrosis patients, gallbladder disease, IBS, obesity, women.


• Diseases associated with vitamin D deficiency: osteoporosis, breast, colon and ovarian cancer; autoimmune disorders such as multiple sclerosis, rheumatoid arthritis and diabetes; Seasonal Affective Disorder (depression during winter months), cardiovascular disease and hypertension, Alzheimer’s Disease.


• Osteoporosis progression slows at 32 ng/mL ; goal of therapy should be 50 – 80 ng/mL to decrease cancer risks


• Sources of Vitamin D: sun, food, supplements


• Sun block SPF 8 or greater reduces conversion of Vitamin D in the skin by 95%
  If using sunscreen, apply after sun exposure for twenty minutes


• Adequate sun exposure: Bikini-wearing, 10:00 a.m. – 3:00 p.m., 2-3 x per week
  Everybody living North of 37 degrees latitude (basically, North of line extending across the U.S. from Atlanta, GA to Los Angeles, CA) should take supplements (2000 IU daily) from October through March


• Dietary sources of vitamin D include: wild-caught, fatty fish, dairy products, fortified cereals, fortified orange juice, egg yolks and cod liver oil


• Take Vitamin D supplements during meals with fatty foods


• Vitamin D3 is better than Vitamin D2 for supplementation (except prescription strength only comes in D2)


• Children should receive 400 IU Vitamin D3 daily


• Lab to order: 25-hydroxy-Vitamin D [AKA: 25(OH)D]


• Definitions: “deficiency” <> 32 ng/mL


• Too much vitamin D in the system: > 200 ng/mL


• Treating vitamin D deficiency when measuring 25(OH)D :
  <>: Vitamin D2 50,000 IU weekly x 1 year
  21-31 ng/mL: Vitamin D2 50,000 IU weekly x 12 weeks then Vitamin D3 2000 IU daily; recheck in 1 year
  32 ng/mL: Vitamin D3 2000 IU daily


• Who should not take Vitamin D without supervision? Individuals with impaired kidney function


• Food sources Vitamin D (IU)
  Pink salmon, wild caught, 3 oz 530
  Sardines, 3 oz 231
  Tuna, canned, 3 oz 200
  Cow’s milk, 8 oz 100
  Fortified O.J., 8 oz 100
  Fortified cereal, 1 cup 40-50
  Eggs (Yolk), 1 oz 30
  Cod Liver Oil, 1 oz 1, 360