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Patient Care, Pediatrics, Pregnancy, Stanford News, Women's Health

A prenatal partnership that benefits patients, medical students

A prenatal partnership that benefits patients, medical students

prenatal partnership

Over on the Lucile Packard Children’s Hospital Stanford blog, writer Julie Greicius highlights an elective program at Stanford’s medical school that fosters personal connections between prenatal patients and Stanford medical students. The course is designed to offer doctors-in-training the opportunity, early on, to be on the other side of patient care. Emily Ballenger, who’s expecting twins later this month, and medical student Sunny Kummar have partnered up through the program, with Sunny offering extra support by attending prenatal appointments, the babies’ birth, and the first few pediatric appointments.

Relationship building is fundamental to patient-centered care, and with this program the doctor-to-be has the opportunity to identify with the patient experience in his or her supportive role. Without the pressures of being in the medical provider role, the student has the opportunity to practice listening, empathy and compassion.

The value of programs such as this is that they shift the paradigm of the traditional-doctor patient relationship. The scale is tipped from being purely clinical to one focused more on listening and learning from each other. The patient, the doctor-in-training, and their future patients all stand to benefit.

Ballenger’s obstetrician is Susan Crowe, MD, who has long supported the program. “I encourage my patients to participate because it’s a win for future care of obstetric and pediatric patients,” she says in the piece. “I really believe that the patient-centered care we strive for can be better achieved if we train our physicians to really learn from and listen to our patients themselves. One of the biggest strengths of the program is that the patient perspective comes first. It sets the groundwork for that way of thinking in terms of training our medical students.”

Medical schools around the country offer similar programs, recognizing that it’s the human connection that initially draws young doctors to medicine, and Stanford has offered this program since at least 1991. The course directors are Yasser El Sayed, MD, obstetrician-in-chief at Stanford Children’s Health, and Janelle Aby, MD, clinical associate professor of pediatrics.

Previously: Countdown to clinics: The 5 best things about jumping into third year
Photo courtesy of Lucile Packard Children’s Hospital

Parenting, Pediatrics, Pregnancy

Losing Jules: Breaking the silence around stillbirth

My birthday is coming, and I’m dreading it. I can’t celebrate; I’d like to go to bed and wake up twenty-four hours later. It’s not because I’m a year older. It’s because it’s the anniversary of the death of my second child, Jules.

My experience is nothing unique. Death anniversaries haunt most people: the anniversary of the death of a parent; the anniversary of a friend’s suicide, the day a father or husband died in battle. My nightmare began on the morning of my birthday, three years ago. I was beginning my 38th week of pregnancy, and I felt great. All signs pointed to a normal, healthy baby. I woke up early the morning of July 30 and my water broke. With great excitement, I grabbed my overnight bag and headed to the hospital with my husband and my (then) 4 1/2 year old son, Miles.

Although I’m not religious, I baptized Jules with my tears and told him how much I loved him. Then I did the hardest thing I’ve ever had to do in my life: I put him down, and I left.

We checked into the obstetric intake bay, and the nurse began to hook me up to a fetal monitor. She couldn’t get it to work and remarked that it must be malfunctioning. She brought in another monitor, and she couldn’t pick up the baby’s heartbeat on that one either. Then she brought in an MD with an ultrasound. I looked at the image of my beautiful son on the screen. There was no pulsing heart in his rib cage. He was dead.

I went into the kind of shock that people describe as “a bad movie.” Everything slowed down and became tunnel-like. I felt removed from the situation, almost observing the scene from a distance as the staff wheeled me to a room at the end of the maternity ward to deliver my stillborn child. I remember the rose a nurse placed on the outside of the door to mark that this room was different. She closed the door when the sounds of newborns drifted down the hall to my room. She was extremely compassionate and held me through some of my labor pains. I asked for Pitocin to speed the birth, and Jules was born quickly. His death was ruled a cord accident.

Jules was so beautiful, so perfect and so still that at first I was afraid to hold him. The staff wrapped him in a hospital blanket and put him in the baby gurney. A pediatrician came to give him a newborn exam with a mix of horror and grief on his face. Cautiously, I picked Jules up and held him and rocked him for a very long time. I desperately didn’t want to leave him there, and I desperately wanted to hold my living son, Miles, who was at a friend’s house. Although I’m not religious, I baptized Jules with my tears and told him how much I loved him. Then I did the hardest thing I’ve ever had to do in my life: I put him down, and I left.

My husband and I went through a special kind of hell in the weeks and months that followed. My milk came in, and I had to bind my swollen breasts and ice them for days. I couldn’t sleep, and when I did, I had nightmares. Worst of all, we had to explain to our son Miles that baby Jules was not coming home from the hospital. Sweet Miles began our healing when he thought about this for a few moments, and said, “So, Jules is now a twinkle in Papa’s eye.”

The community wrapped its arms around our family. Our house filled with flowers, and we had more food than we knew what to do with. What surprised me the most was how many women reached out to me to share their own stories of stillbirth. In the first 24 hours after we got home, our neighbors came over to talk to us about their baby dying in-utero near term. Over the course of the next few months, I spoke to many women who had lost babies, mainly by stillbirth, but not exclusively. I had no idea that in this age of medical advancement 1 in every 167 babies in the United States is stillborn (.pdf). Just over half a percent (.6 percent) doesn’t sound like a lot – until it’s you. Statistically, this has probably happened to someone you know, but they probably don’t talk about it. I know of three people – either in my circle or once removed – who have had stillbirths since mine.

I describe the initial weeks after Jules’ death in military terms: It felt like our family took a direct hit. Over time, I became skilled in answering people when they asked, “So, how’s your baby?” Those questions lasted for a year and a half. I sought counseling with health professionals who had experienced stillbirth or infant death. I’m not Jewish, but I went to talk to a Rabbi. She helped me to understand a beautiful philosophy: that we owe it to the dead to try and live well and fully. I’m still here, and I shouldn’t squander my time. It’s not always easy, especially when someone asks, “So, you have just the one?” But I work hard to live well and fully every day, especially on the anniversary of what would have been a joint birthday for Jules and me.

Polly Stryker works as a producer and editor at KQED Radio, an NPR affiliate in San Francisco, where she lives with her family. She is writing a book called “Losing Jules” for her son, Miles.

Previously: A call to “break the silence of stillbirth”
Image of Jules’ footprints in featured entry box courtesy of Polly Stryker

Medicine and Society, Pregnancy, Research

Study offers clue as to why parents of daughters are more likely to divorce

Study offers clue as to why parents of daughters are more likely to divorce

poppy2Here’s something that caught my attention this morning (likely because I’m the mom of two girls): A new study provides a possible reason behind reports that parents with firstborn daughters are more likely to divorce than those with firstborn sons. According to researchers from Duke and University of Wisconsin-Madison, it could be due to girls being “hardier than boys, even in the womb.”

A recent university release further explains:

Throughout the life course, girls and women are generally hardier than boys and men. At every age from birth to age 100, boys and men die in greater proportions than girls and women. Epidemiological evidence also suggests that the female survival advantage actually begins in utero. These more robust female embryos may be better able to withstand stresses to pregnancy, the new paper argues, including stresses caused by relationship conflict.

Based on an analysis of longitudinal data from a nationally representative sample of U.S. residents from 1979 to 2010, Hamoudi and Nobles say a couple’s level of relationship conflict predicts their likelihood of subsequent divorce.

Strikingly, the authors also found that a couple’s level of relationship conflict at a given time also predicted the sex of children born to that couple at later points in time. Women who reported higher levels of marital conflict were more likely in subsequent years to give birth to girls, rather than boys.

“Girls may well be surviving stressful pregnancies that boys can’t survive,” Hamoudi said. “Thus girls are more likely than boys to be born into marriages that were already strained.”

The intriguing findings appear in the journal Demography.

Image courtesy of Michelle Brandt

Parenting, Pregnancy, Technology, Women's Health

First-time moms often seek information online prior to first prenatal visit

First-time moms often seek information online prior to first prenatal visit

pregnant_laptopWhen I was eight weeks pregnant with my first child, I walked into my obstetrician’s office for my initial prenatal visit. I vividly remember being exhausted and sucking on watermelon lollipops for the entire two-hour appointment in an effort to relieve my morning sickness. While in the office, a nurse handed me a thick folder stuffed with various pamphlets and fact sheets on everything from nutrition to genetic testing – but much of the information reviewed wasn’t new to me. I’d already logged plenty of hours online reading about such topics.

So I was interested to read today about findings of a Penn State study showing that many other first-time moms also turn to “Dr. Google,” as well as social media, to find answers during the early weeks of their pregnancy. Women also continued turning to the Internet for information after their doctor visit and found traditional literature lacking. From a release on the study, which appears in the Journal of Medical Internet Research:

Following the women’s first visit to the obstetrician, many of them still turned to the internet—using both search engines and social media—to find answers to their questions, because they felt the literature the doctor’s office gave them was insufficient.

Many of the participants found the pamphlets and flyers that their doctors gave them, as well as the once-popular book What to Expect When You’re Expecting, outdated and preferred receiving information in different formats.

They would rather watch videos and use social media and pregnancy-tracking apps and websites.

“This research is important because we don’t have a very good handle on what tools pregnant women are using and how they engage with technology,” says [Jennifer Kraschnewski, MD]. “We have found that there is a real disconnect between what we’re providing in the office and what the patient wants.”

Noting the prevalence of misinformation online, Kraschnewski added, “We need to find sound resources on the Internet or develop our own sources” [to refer patients to].

Previously: Text message reminders shown effective in boosting flu shot rates among pregnant women and Examining the effectiveness of text4baby service
Photo by Adam Selwood

Pain, Pregnancy, Stanford News, Women's Health

Study shows women prefer less-intense pain at the cost of a prolonged labor

Study shows women prefer less-intense pain at the cost of a prolonged labor

child_birthAs a friend’s due date approached, she confided in me that the thought of going into labor was terrifying. It was her first pregnancy and we debated at length the pros and cons of having an epidural for pain management. Her main concern, like others, was that the common method of pain relief could prolong labor. Recent findings have shown that an epidural can lengthen the second-stage of labor for more than two hours.

In the end, she decided her birth plan needed to be flexible and include the option of an epidural, regardless of how it may impact the length of her labor. New research shows many would agree. Brendan Carvalho, MBBCh, chief of obstetric anesthesia at Stanford and lead author of the study, told Reuters that “Interestingly, intensity is the driver” behind women’s labor preferences.

More from the article:

For the study, Carvalho and his colleagues gave a seven-item questionnaire to expectant mothers who had arrived at the hospital to have labor induced but were not yet having painful contractions. The women took the survey a second time within 24 hours of giving birth.

The questionnaire pitted hypothetical pain level, on a scale of zero to 10, against hours of labor.

A sample question asked, “Would you rather have pain intensity at two out of 10 for nine hours or six out of 10 for three hours?”

Both pre- and post-labor, women on average preferred less intense pain over a longer duration, according to results published in the British Journal of Anaesthesia.

Previously: From womb to world: Stanford Medicine Magazine explores new work on having a baby
Photo by Mamma Loves

Global Health, Health Disparities, Pregnancy, Research, Women's Health

In poorest countries, increase in midwives could save lives of mothers and their babies

In poorest countries, increase in midwives could save lives of mothers and their babies

midwifeThe World Health Organization reports that most maternal deaths are preventable; yet, preterm birth complications rank among the top 10 causes of death in low- and lower-middle-income countries. Two recent studies from the Johns Hopkins Bloomberg School of Public Health have explored the role skilled midwives may play in saving the lives of women and their babies in poor counties.

In one study, published in The Lancet, researchers found that deploying a small number of midwives – 10 percent more every five years through 2025 – in the world’s 26 poorest countries could stave off a quarter of the maternal, fetal and infant deaths there.

From a release:

The estimates were done using the Lives Saved Tool (LiST), a computer-based tool developed by Johns Hopkins Bloomberg School of Public Health researchers that allows users to set up and run multiple scenarios to look at the estimated impact of different maternal, child and neonatal interventions for countries, states or districts. For this analysis, the tool compared the effectiveness of several different alternatives including increasing the number of midwives by varying degrees, increasing the number of obstetricians, and a combination of the two.

In the other study, published in PLOS One, researchers used the LiST tool in the world’s 58 poorest countries, where they found that 7 million maternal, fetal and newborn deaths will occur between 2012 and 2015. The release continues:

If a country’s midwife access were to increase to cover 60 percent of the population by 2015, 34 percent of deaths could be prevented, saving the lives of nearly 2.3 million mothers and babies.

The researchers say boosting coverage of midwives who provide family planning as well as pregnancy care to 60 percent of women would cost roughly $2,200 per death averted as compared to $4,400 for a similar increase in obstetricians. Midwives are cheaper to train and can handle interventions needed during uncomplicated deliveries, while obstetricians are needed when surgical interventions such as cesarean sections are necessary, [lead author Linda Bartlett, MD] says. Midwives can administer antibiotics for infections and medications to stimulate or strengthen labor, remove the placenta from a patient having a hemorrhage as well as handle many other complications that may occur in the mother or her baby.

Previously: Indonesia’s cash transfer programs are valuable, Stanford health fellow findsStudy cautions babies born at home may be at increased risk for health problemsSimple program shown to reduce infant mortality in African country and Should midwives take on risky deliveries?
Photo by Vinoth Chandar

Big data, Obesity, Pregnancy, Public Health, Women's Health

Maternal obesity linked to earliest premature births, says Stanford study

Maternal obesity linked to earliest premature births, says Stanford study

preemiefeetExpectant mothers who are obese before they become pregnant are at increased risk of delivering a very premature baby, according to a new study of nearly 1,000,000 California births.

The study, which appears in the July issue of Paediatric and Perinatal Epidemiology, is part of a major research effort by the March of Dimes Prematurity Research Center at Stanford University School of Medicine to understand why 450,000 U.S. babies are being born too early each year. Figuring out what causes preterm birth is the first step in understanding how to prevent it, but in many cases, physicians have no idea why a pregnant woman went into labor early.

The new study focused on preterm deliveries of unknown cause, starting from a database of nearly every California birth between January 2007 and December 2009 to examine singleton pregnancies where the mother did not have any illnesses known to be associated with prematurity.

The researchers found a link between mom’s obesity and the earliest premature births, those that happen before 28 weeks, or about six months, of pregnancy. The obesity-prematurity connection was  stronger for first-time moms than for women having their second or later child. Maternal obesity was not linked with preterm deliveries that happen between 28 and 37 weeks of the 40-week gestation period.

From our press release about the research:

“Until now, people have been thinking about preterm birth as one condition, simply by defining it as any birth that happens at least three weeks early,” said Gary Shaw, DrPH, professor of pediatrics and the lead author of the new research. “But it’s not as simple as that. Preterm birth is not one construct; gestational age matters.”

The researchers plan to investigate which aspects of obesity might trigger very early labor. For example, Shaw said, the inflammatory state seen in the body in obesity might be a factor, though more work is needed to confirm this.

Previously: How Stanford researchers are working to understand the complexities of preterm birth, A look at the world’s smallest preterm babies and New research center aims to understand premature birth
Photo by Evelyn

Medical Education, Pregnancy, SMS Unplugged

The hospital becomes a different place: pregnant in medical school

The hospital becomes a different place: pregnant in medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

bun_oven2“What was it like to be pregnant on the wards?”

I was pregnant throughout most of my third year of med school, so I’ve been asked this question a lot. For a while I had a habit of brushing it off. “Being pregnant isn’t extra work,” I would point out. “The baby-growing happens automatically while you go about your day.” But over time, I realized that the hospital became a different place for me when I became pregnant, both because of the mental state I brought to my learning and because of how I was treated by others. Here are some of the best and the worst aspects of my own 40 weeks living in that world.

Good stuff:

  • An incredibly meaningful OB/GYN rotation. Being pregnant when I first coached a woman through labor and delivered her baby made an already surreal, beautiful experience even more personal. Furthermore, delivering other people’s babies demystified childbirth for me, making it way less scary when it was my turn.
  • Being taken more seriously by some families on Pediatrics. Fairly or not, many parents trust other parents more than they trust the clinical training of a pediatrician. Although I wasn’t a parent yet, I looked kind of like one. So I was often granted some (unearned) credibility in their eyes.
  • A powerful reminder of how health affects everything else. I was lucky to have an easy pregnancy by most standards, but there were days when minor symptoms—nausea, joint pain, headaches I couldn’t treat with medication, or just feeling a little off—made the already draining demands of med school take more of a toll. After this experience, I try to have more patience when I ask my patients to navigate complex health systems or make major life decisions all while suffering from symptoms far more severe than the ones that brought me down.

Bad stuff:

  • Feeling like my identity was reduced to “the pregnant student” in the minds of some of my superiors. A handful of attendings thought that pointing at my belly and asking “What’s going on in there?” was totally appropriate behavior for rounds. One resident would greet me by asking “still pregnant?” when it had been only two hours since he had last seen me. Another time I was pointedly quizzed in clinic about the recommended amount of weight gain during pregnancy (not OB/GYN clinic, which would have made sense).
  • Assumptions about my professional seriousness based on my appearance. I was once scrubbed into the operating room during my third trimester and the attending surgeon asked me if I was interested in Surgery. Before I could answer, the resident blurted out incredulously, “does she look like she’s interested in Surgery?” Few times in my life have I been more aware of my gender and the barriers that come with it. The flip side of that coin is that when people found out I was interested in Pediatrics, they would often respond with a knowing nod and say, “of course, that makes sense.” I wanted to explain that I am interested in Peds for reasons that I find professionally compelling, and wanting to have my own kids is a separate decision.
  • Never being able to get my work done without having to answer well-meaning pregnancy questions. While I was pregnant, many people I had to collaborate with in the hospital wouldn’t get around to talking about the patient with me until I at least shared my due date and explained that it’s not a boy even though I “carry it all in the front.” It wasn’t the end of the world enduring some overly personal small talk, but it did sometimes get frustrating.

In the great scheme of things, the way Stanford Med handled my pregnancy gets an A+ in all the most important, practical ways. My mentors and advisors were overwhelmingly supportive, I was never penalized for having to attend medical appointments, and I was granted a huge amount of control over my academic schedule and timeline. Nonetheless, the learning environment was undeniably different because of my pregnancy. I hope that by speaking openly about it, I can help future students in my position experience more of the good lessons that came with pregnancy on the wards, and less of the negative assumptions.

Jennifer DeCoste-Lopez entered medical school at Stanford in 2010. She was born and raised in Kentucky and went to college at Harvard before heading to the West Coast for medical school. She currently splits her time between clinical rotations, a medical education project in end-of-life care, and caring for her daughter, who was born in 2013. 

Photo by Chip Harlan

Cancer, Fertility, Parenting, Pregnancy, Women's Health

A cancer survivor discusses the importance of considering fertility preservation prior to treatment

pregnancy_testBack in 1998, Joyce Reinecke, JD, was on a cross-country business trip when her increasing fatigue and lightheadedness resulted in her being admitted to the emergency room and the discovery that she had tumors in her stomach, one of which was necrotic and bleeding causing her to be severely anemic. She was diagnosed with leiomyosarcoma, and the tumors, as well as all of the surrounding lymph nodes, were surgically removed. Before she was discharged from the hospital an oncology fellow casually mentioned to Reinecke that since she was scheduled to start chemotherapy she might want to consider options to preserve her fertility.

At the time, Reinecke and her husband hadn’t considered how her treatment would affect their future plans to have a family. The couple eventually decided to complete a round of in vitro fertilization and work with an agency to select a gestational carrier. Their twin daughters were born in February 2000. Reinecke, executive director of the Alliance for Fertility Preservation, shared her patient perspective during a keynote speech at the Family Building After Cancer: Fertility Preservation and Future Options Symposium held at Stanford earlier this month.

To continue the conversation, I reached out to Reinecke about the issue of fertility and cancer survivorship. In the following Q&A, she discusses advancements in the field, why patients need to be proactive in sharing their wishes to have a family with providers, and questions to consider prior to treatment.

What motivated you to focus your career on expanding patient and provider awareness of fertility preservation?

When my girls were around two, I received several inquiries from family acquaintances who had young adults in their lives who were newly diagnosed with cancer. These people had reached out to my parents, to try to understand more about what I had done, where I had gone, etc. in order to preserve my fertility. In speaking to others and hearing about their challenges in finding fertility information and services, I started to really feel that something about the status quo was not right. These patients/family members had learned about possible infertility because they knew of my story, not because their doctors had discussed it with them. This really emphasized to me that my situation – learning about my possible infertility in a very ad hoc way – was not unique, not unusual, but the norm, and perhaps, lucky.

I began doing research around the issue, to see what was out there, what information was available online, etc. I found very little, but I did stumble upon information that Fertile Hope was having a fundraiser. I was in complete shock that a new nonprofit focused on this very issue existed, not to mention that it was based in New York. I went to the fundraiser, signed up to volunteer, met with Lindsay Beck, and signed on as Employee #2. The rest is history.

A past study shows that less than half of U.S. physicians are following the American Society of Clinical Oncology’s guidelines suggesting all patients of childbearing age be informed about fertility preservation. How can patients make sure they get the necessary information about their fertility options prior to treatment?

This question is tricky, because I feel like the onus for initiating this discussion has to be on the provider. Newly diagnosed patients are overwhelmed with all sorts of medical information and decisions to make, not to mention the emotional distress of the diagnosis. Also, patients don’t know what they don’t know. Sometimes providers mistakenly believe a patient isn’t interested in fertility preservation because they don’t ask about it. However, providers have to remember that newly diagnosed young adults probably have very little understanding about how chemotherapy and radiation work – unless they have a cancer that has a direct impact on their reproductive system they probably have no inkling that their fertility is at stake.

That being said, patients need to advocate in their own interest (or enlist a family member to help them do this if they cannot during this difficult time). That means communicating their wishes and values about future parenthood with their providers. That means asking the right questions: Will I be able to have children in a few years? Ever? What can I do about it? It might also mean being able to challenge their doctor’s disapproval or ask that treatment be pushed back [so the patient has time to] bank sperm or eggs. Which is sometimes hard to do.

Continue Reading »

Pregnancy, Research

Pregnant women may experience music more intensely, study shows

pregnant musicAt a shower recently, a few veteran moms exchanged tales of “super smell” they’d experienced during pregnancy. (One reported having detected a pizza inside an unmarked car driving along her street – through her closed window and the delivery man’s, plus exhaust from the car’s tailpipe.) Sensitivity to smell is but one possible heroic power of pregnancy, it turns out. A new study by scientists at the Max Planck Institute for Human Cognitive and Brain Sciences in Germany  found that when listening to music, pregnant women showed stronger physiological responses than women who were not pregnant but still experiencing elevated estrogen levels due to an oral contraceptive cycle.

Fifteen women who were pregnant and 17 who were not took part in the study, listening and responding to different qualities of music and having their blood pressure measured. From a release:

[The researchers] played short musical sequences of 10 or 30 seconds’ duration to female volunteers. They changed the passages and played them backwards or incorporated dissonances. By doing so, they distorted the originally lively instrumental pieces and made listening to them less pleasant.

The pregnant women rated the pieces of music slightly differently, they perceived the pleasant music as more pleasant and the unpleasant as more unpleasant. The blood pressure response to music was much stronger in the pregnant group.

The authors noted, “Such an enhanced physiological response in pregnant women could potentially facilitate prenatal musical conditioning.”

The study was published in the journal Psychophisiology.

Previously: The anxiety and pain reducing powers of Adele and Can music benefit cancer patients?
Photo by giuliaduepuntozero

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