Author: Ashley Franklin

​​Ashley is a member of the University Of Central Florida College Of Medicine class of 2017. She graduated from Rollins College with a B.A. with Honors in Chemistry. Ashley is a varsity rower of ten years, as well as an enthusiastic runner, cyclist, climber, and hiker. She is passionate about women’s health, and plans to pursue a career in Obstetrics and Gynecology. Her research interests include exercise in pregnancy, the health concerns and practices of pregnant athletes, adolescent gynecology, the implementation of new OB/GYN guidelines, and medical education. Ashley also enjoys reading, crocheting, collaging, and dancing.

Categories
Clinical Lifestyle Public Health

What’s the Deal with Vaginal Breech Delivery?

Back in May, I attended the 2016 American College of Obstetrics and Gynecology (ACOG) Annual Scientific and Clinical Meeting in Washington, D.C. On my first day, I watched Dr. Annette E. Fineberg, a board certified obstetrician and gynecologist from Sutter Davis Hospital in California, present a short film on upright vaginal breech delivery. The movie featured a woman at term deliver in the operating room by resting on all fours on her hands and knees. She swayed her bottom from side to side in order to promote fetal descent and as a way to cope with pain, as she did not receive an epidural. The baby crowned, bottom first, and then slowly spontaneously delivered its legs, trunk, arms, and finally, head. A successful vaginal breech delivery (VBD)!

Ever since watching that amazing film, I have been interested in reading and talking about VBDs. But on the residency program interview trail, I have begun to notice a trend that some providers seem to have strong, negative attitudes regarding VBDs of singletons. One person even glared and incredulously responded, “No one in the country does those.” I think Dr. Fineberg and the other clinicians I have met that do would disagree.

But I do wonder why providers feel so strongly about a particular position regarding more controversial topics in reproductive health. In regards to vaginal breech delivery, I think that a big prejudice is the absolute horror stories every seasoned OB/GYN has to tell about the time they saw a baby’s head get stuck. These accounts are upsetting, sad, and help explain why someone might think me ridiculous for even asking about training in vaginal breech delivery.

The most common response, though, that I receive is something like, “We don’t do those. But you will probably not find many programs that do since ACOG does not recommend vaginal breech deliveries.” This reply is less emphatic and more accurate if following the 2001 ACOG committee opinion, which states, “planned vaginal delivery of a term singleton breech [is] no longer appropriate.”1 The reasoning in 2001 was largely based on results from the Term Breech Trial, a large, multi-institution, randomized control trial comparing planned vaginal birth with cesarean deliveries for term singletons with breech presentation. This study indicated that neonatal morbidity and mortality significantly increased with vaginal breech versus cesarean section delivery.2

Since the 2000 Term Breech Trial, clinicians have begun to question if vaginal breech deliveries should have a strict ban. Instead, there is evidence suggesting that vaginal delivery is a safe option in select women with breech presentation. The authors of the Term Breech Trial performed two prospective studies in which they examined maternal and child outcomes at both 3 months and 2 years post-partum. At two years post-partum, there was no longer a difference in mortality nor neurodevelopmental delay in the children born by vaginal breech delivery versus cesarean section.3 Retrospective studies with specific protocols similar to those described in the Term Breech Trial have shown excellent neonatal outcomes for vaginal breech delivery of term singletons.4-6 In 2015, Berhan and Haileamlak published a meta-analysis of 27 articles with a total population of 258,953 women comparing the morbidity and mortality of term singleton breech mode of delivery between 1993 and 2014. While the relative risk of perinatal mortality and morbidity was 2-5 times higher in planned vaginal delivery versus cesarean, the absolute risks of several variables, including perinatal mortality (0.3%) and fetal neurologic morbidity (0.7%), were low.7

In the updated committee opinion on vaginal breech delivery published in 2006 and reaffirmed in 2016, ACOG states that “planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.”8 The Royal College of Obstetricians, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada report similar recommendations.9-11 According to the ideal candidate for a term, singleton vaginal breech delivery is the following:12-14

  • Frank or complete breech presentation with flexed or neutral head attitude;
  • Estimated fetal weight between 2500 and 4000 grams;
  • A patient willing and comfortable with a trial of labor;
  • Clinically adequate maternal pelvis.

Contraindications to vaginal breech delivery are categorized as a fetal, maternal, or provider factor:12-14

Fetal Factors

  • Incomplete breech;
  • Hyperextended neck;
  • Cord presentation;
  • Fetal growth restriction or macrosomia;
  • Congenital anomaly incompatible with vaginal delivery (e.g. thyroid mass).

Maternal Factors

  • Patient unwilling to attempt/uncomfortable with a trial of labor;
  • Clinically inadequate maternal pelvis;

Provider Factors

  • Lack of operator experience.

Obstetrics governing bodies agree that external cephalic version—whereby a provider uses their hands on the abdomen to rotate the fetus in utero from breech to vertex presentation—should be recommended and attempted first before considering vaginal breech delivery. And all leading sources recommend that an experienced provider needs to be leading the delivery.

But if there are few opportunities in residency to practice vaginal breech delivery, how will there BE any future providers who qualify as experienced?

First and foremost, I hope to enter a residency program that provides me with the training I need to be a competent women’s health provider. But I also intend to seek training in vaginal breech deliveries, whether it is via simulations—which RCOG notes is an appropriate way to build experience 9—or via an elective at another institution where there may be further opportunities. My goal is twofold: (1) offer the best individual options for mode of delivery to my future patients; and (2) help lower cesarean section rates in the United States. Hopefully, I will get the right match!

References

  1. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.340: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2006 Jul;108(1):235-7.
  2. Hannah ME, Hannah WJ, Hodnett ED, Saigal S, and Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet. 2000;356(9239):1375-1383.
  3. Whyte H, Hanna ME, Saigal S, et al Term Breech Trial Collaborative Group, Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191:864-871.
  4. Guiliani A, Scholl WM, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol. 2002;187:1694-8.
  5. Alarab M, Regan C, O’Connel MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407-12.
  6. Borbolla Foster A, Bagust A, Bisits A, Holland M, Welse A. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Autralian and New Zeland Journal of Obstetrics and Gynaecology. 2014;54:333-339
  7. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: A meta-analysis including observational studies. BJOG 2015: DOI; 10.1111/1471-0528.13524
  8. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.265: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2001 Dec;98(6):1189-90.
  9. Guideline No 20b: The Management of Breech Presentation. Oxford: RCOG, 2006.
  10. Kotaska AK, Menticoglou S, Gagnon R. SOGC Clinical Practice Guideline No. 226: Vaginal Delivery of Breech Presentation. JOGC. June 2009.
  11. RANZCOG, Cobs-11: Management of the Term Breech Presentation. Melbourne: RANZCOG, 2009.
  12. Hofmeyr JG, Lockwood CJ, Barss VA. Overview of issues related to breech presentation. UpToDate: Accessed 10/11/2016
  13. Hofmeyr JG, Lockwood CJ, Barss VA. Delivery of the fetus in breech presentation. UpToDate: Accessed 10/11/2016
  14. Secter MB, Simpson AN, Gurau D, et al. Learning from Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breach Deliveries. JOGC 2015

Photo credit: MIKI Yoshihito

 

 

Categories
Clinical General Law Opinion Patient-Centered Care Pharmacology Public Health

Access to Contraception

Contraception is essential to a woman’s health, empowerment, equality, and independence. This belief is championed by the Center for Reproductive Rights, Guttmacher Institute, Planned Parenthood, and others. More importantly, governing bodies of health care overwhelmingly defend access to contraception:

 “Contraception is a pillar in reducing adolescent pregnancy rates.”

  • The American Academy of Pediatrics [1]

 “Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman.”

  • American Academy of Family Physicians [2]

“The American College of Obstetricians and Gynecologists [ACOG] supports access to comprehensive contraceptive care and contraceptive methods as an integral component of women’s health care and is committed to encouraging and upholding policies and actions that ensure the availability of affordable and accessible contraceptive care and contraceptive methods.”

  • American College of Obstetrics and Gynecology [3]

“Access to safe, voluntary family planning is a human right. Family Planning is central to gender equality and women’s empowerment, and it is a key factor in reducing poverty.”

  • United Nations Population Fund [4]

“This policy supports the universal right to contraception access in the United States and internationally.”

  • American Public Health Association [5]

“Family Planning, an integral component of sexual and reproductive health, is a critical pillar for health and development; it is also a human rights issue…When women are denied their right to and choice of family planning methods, they become trapped in a vicious cycle of poverty, poor health outcomes from ill-timed pregnancies and limited capacity to fully realize their potential.”

  • World Health Organization [6]

 

Contraception is regarded by the CDC as one of the 10 greatest public health achievements of the 20th century.[7] Of the many reversible contraceptive options available, implant and intrauterine device are most effect, with less than 1% risk of failure for both perfect and typical use compared to an 18% failure rate for typical male condom use.[8] Of course, condoms are the only available contraceptive method that also protects against transmission of infections, including the human immunodeficiency virus (HIV) and human papilloma virus transmission through certain makes of condoms.

Benefits of contraception include: improved health and well-being, reduced global maternal mortality, pregnancy spacing and subsequent health benefits, increased participation of females in the workforce, and economic independence for women.[9]

In the United States, 70% of women ages 15 to 44 years old are sexually active and do not want to become pregnant. Thus, 70% of reproductive aged women are at risk of unintended pregnancy. The Guttmacher Institute, a leading researcher of reproductive health, reported that consistent and correct use of modern contraception (i.e. condom, hormonal contraception, long-acting method, or permanent method) without any gaps in use during all months a woman is sexually active resulted in 68% of sexually active reproductive age women avoiding an unintended pregnancy.[10] These women accounted for only 5% of unintended pregnancies that occurred in 2008. In comparison, 41% of the 3 million unintended pregnancies were a result of inconsistent modern contraceptive use and 54% resulted from nonuse.[10]

Sadly, in addition to other Catholic-based religious organizations, the United States Conference of Catholic Bishops argues that contraception does not prevent unintended pregnancy nor reduce abortion rates.[11] The USCCB also does not believe that contraception is basic health care.[12] Instead, the USCCB states,

 “Contraception is an elective intervention that stops the healthy functioning of healthy women’s reproductive systems. Medically it is infertility, not fertility, that is generally considered a disorder to be treated.”

Let me be clear. Access to contraception is basic health care. 222 million women globally have an unmet need for modern contraception.[4] This burden is highest in vulnerable populations such as adolescents, those from low socioeconomic households, those with HIV, and internally displaced persons.[4]

The WHO issued guidance and recommendations on “Ensuring human rights in the provision of contraceptive information and services,” in which officials outline nine priority actions policy makers and providers need to take to ensure that human rights are protected in the provision of contraceptive information and services.[13] These steps include:

  1. Non-discrimination in provision of contraceptive information and services
  2. Availability of contraceptive information and services
  3. Accessibility of contraceptive information and services
  4. Acceptability of contraceptive information and services
  5. Quality of contraceptive information and services
  6. Informed decision-making
  7. Privacy and confidentiality
  8. Participation
  9. Accountability [of programs that deliver contraceptive information and services]

In regards to current politics and policy proposals, accessibility of contraceptive options includes affordability.

Under the Affordable Care Act (ACA) healthcare law, preventative women’s health services—including well-woman visits; screening for gestational diabetes; human papilloma virus testing; counseling for sexually transmitted diseases; counseling and screening for HIV; contraceptive methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for interpersonal and domestic violence—are covered without any co-payment, co-insurance, or deductible.[14] For reference, if the ACA healthcare law were not in place, the average out-of-pocket cost for birth control would be $78-$185 per year.[14] For myself, my oral contraceptive pills cost $30 per month, totaling $360 per year! This was a financial burden as a student—but essential for my overall health—and so, I budgeted. But not everyone has that capability.

The ACA’s expansion of health care coverage and improved access to care also resulted in reductions in delayed care, as well as improved maternal and newborn outcomes. From 2010 to 2014, the proportion of women who reported delaying or forgoing care due to cost concerns dropped by 3.4%.[15] The health care law also funded the Strong Start for Mothers and Newborns Initiative, a collaboration between the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Administration on Children and Families. The initiative aims to reduce preterm birth rates and improve maternal and newborn health outcomes. This is key because full-term babies have improved outcomes compared to those born in an early, term elective delivery.

The United States Human Health and Services notes that actuaries, insurers, and economists generally estimate that contraception provisions are at least cost-neutral and may, in some cases, result in cost-savings when taking into account the costs and benefits of unplanned pregnancies.[14] In 2009, the UNPF and Guttmacher Institute published a detailed report explaining how family planning and maternal and newborn health services saves lives and money. Preventing and/or postponing unintended pregnancies results in fewer expenses due to the decreased need for maternal and newborn health care and the management of unsafe abortions.[16] In addition, ensuring standards of maternal and newborn health care reduces the rates of complications and subequently incurred high costs.

Keeping these considerations in mind, our current political climate is of great concern because on January 20, 2017, President Donald Trump issued an executive order to repeal the ACA.[17]

I received an email update this week from ACOG reporting that the AAFP, American College of Physicians, AAP, ACOG, and American Osteopathic Association mailed a joint letter representing over 500,000 physicians asking the White House and Congressional leaders to “stand with us and for America’s women” because “healthy women can better participate in our economy and our workforce, and can reach higher levels of educational attainment.” The letter also identifies four priorities moving forward, one of which is to ensure that women have affordable access to evidence-based care.[18]

ACOG’s committee opinion on access to contraception emphasizes full implementation of the ACA requirement that,

“…new and revised private health insurance plans cover all U.S. Food and Drug administration-approved contraceptives without cost-sharing, including non-equivalent options from within one method category (eg. levonorgestrel as well as copper intrauterine devices).” [3]

Throughout the next few months and years when you are voting or exercising your right to debate the very real challenge we face to reduce health care costs, please remember that investing in family planning and maternal and newborn health care services saves money. And remember that leading healthcare organizations—the very governing bodies who set the standards for evidence-based care—strongly advise that the White House and Congress to write healthcare laws that ensure affordable women’s health care and access to contraception. I urge readers to fight for access to contraception, a necessary and significant human right.

For more information about available contraceptive options, please see the “Birth Control (Contraception): Resource  Overview” published by ACOG, available at http://www.acog.org/Womens-Health/Birth-Control-Contraception#Patient.

References

  1. Committee on Adolescence. Policy Statement: Contraception for Adolescents. Pediatrics. 2014
  2. Klein DA, Arnold JJ, and Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician. 2015;91(9): 625-633.
  3. American College of Obstetricians and Gynecologists. Access to contraception. Committee Opinion No. 615. Obstet Gyneco.l 2015;125:250-5.
  4. United Nations Population Fund and Center for Reproductive Rights. Family Planning. Available at: http://www.unfpa.org/family-planning. Accessed November 29, 2015.
  5. American Public Health Association. Universal Access to Contraception; Policy 20153. November 2015. http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/12/17/09/14/universal-access-to-contraception. Accessed: November 28, 2016.
  6. World Health Organization. Family Planning Summit, 11 July 2012: WHO’s Commitment. Available at: http://www.who.int/reproductivehealth/topics/family_planning/WHO_commitment_fp.pdf?ua=1. Accessed: November 30, 2016.
  7. Sonfield A, Hasstedt K, Kayanaugh MI, Anderson R. The social and economic benefits of women’s ability to determine whether and when to have children. New York (NY) Guttmacher Institute; 2013. Available at: http://www.guttmacher.org/pubs/social-economic-benefits.pdf. Accessed: November 29, 2016.
  8. Guttmacher Institute. Contraceptive Use in the United States. September 2016. Available at: https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states. Accessed: November 29, 2015.
  9. Starbird E, Norton M, and Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016;4(2):191-210.
  10. Guttmacher Institute. Infographic: Contraception is highly effective. July 2013. Available at: https://www.guttmacher.org/article/2013/06/infographic-contraception-highly-effective. Accessed: November 28, 2016.
  11. Emergency Contraception Fails to Reduce Unintended Pregnancy and Abortion. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/emergency-contraception-fails-to-reduce-unintended-pregnancy-abortion.cfm Accessed: February 2, 2017.
  12. Fact Sheet: Contraceptive Mandates. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/contraceptive-mandates.cfm Accessed: February 2, 2017.
  13. Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations; 2016. Available at: http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf?ua=1. Accessed: November 28,2016.
  14. S. Department of Health & Human Services. Fact Sheets: Women and the Affordable Care Act. Available at: https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/women-and-aca/index.html. Accessed: November 28, 2016.
  15. Simmons A, Taylor J, Finegold K, Yabroff R, Gee E, and Chappel A. The Affordable Care Act: Promoting Better Health for Women. ASPE Issue Brief;2016:1-10.
  16. UNFPA and Guttmacher Institute. Adding it Up 2014: The Costs and Benefits of Investing in Sexual and Reproductive Health. UNFPA, Guttmacher Institute. 2016;1-56.
  17. The White House Office of Press Secretary. Executive order minimizing the economic burden of the patient protection and affordable care act pending repeal. Available at: https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and. Accessed: January 2, 2017.
  18. Healio Family Medicine. AAFP, ACP, others join forces in new effort to protect women’s health. Available at: http://www.healio.com/family-medicine/womens-health/news/online/%7B1b88e282-cd33-402c-a97a-bea5ef45238f%7D/aafp-acp-others-join-forces-in-new-effort-to-protect-womens-health . Accessed: January 2, 2017.

Photo credit:

Blue coat photos

Categories
Opinion Psychology Public Health

Take a Stand against Domestic Violence

October is Domestic Violence Awareness Month. This is particularly relevant at the moment, because on October 7th the Washington Post published a 2005 recording of President-Elect Trump bragging about kissing and grabbing women without permission. Since the leak, the president-elect has consistently referred to such comments as “locker room talk.” In a recent interview with Anderson Cooper, Melania Trump further dismissed the seriousness of her husband’s comments by stating, “I heard many different stuff—boy’s talk. The boys, the way they talk when they grow up and they want to sometimes show each other, ‘Oh, this and that’ and talking about the girls.”

It is time to be clear. Trump’s comments may echo in locker rooms or be the status quo among young men, but that does not make it forgivable to joke about sexual violence. And to imply that joking about sexual violence against women is somehow more tolerable when it is said by an immature male or in a sporting environment only further encourages the perception that men have an implicit ownership of a woman’s sexual rights.

In a 2010 report entitled “Preventing Intimate Partner and Sexual Violence Against Women,” the WHO emphasizes the need to understand and target the factors that commonly lead to intimate partner violence and sexual violence against women. Unfortunately, an overwhelming burden of intimate partner violence and sexual violence against women occurs at the hands of men. This becomes unsurprising when one identifies the factors that promote violence against women. The WHO lists “patriarchy, power relations, and hierarchical constructions of masculinity and femininity as a predominant and pervasive driver of the problem.” The paper further argues that “dismantling hierarchical constructions of masculinity and femininity predicated on the control of women, and eliminating the structural factors that support inequalities are likely to make significant contribution to preventing intimate partner and sexual violence.”

Several examples of such social and cultural norms are cited in the report, but one appears to be particularly relevant in the setting of Trump’s recent comments: the idea that a man has a right to assert power over a woman and is considered socially superior to her. In the leaked video, Trump supports his right to kiss and grab women with the argument that “when you’re a star, they let you do it. You can do anything.”

No, Mr. Trump, you cannot.

The WHO highlights methods to prevent intimate partner violence and sexual violence against women, stating that there are three main approaches for changing social and cultural norms: correcting misperceptions that the use of sexual violence is normal and common among peers, media awareness campaigns, and directly working with men and boys to educate them on the topic. I hope that the media storm surrounding the video’s release, as well as the responses to it by prominent figures will serve to raise awareness, because women, men, and children alike should be able to live a life free of violence.

Readers, take a stand against domestic violence of all forms. Challenge jokes that diminish the seriousness of such acts. To fail to question only perpetuates the pervasive social and cultural acceptance of violence against women. Do not tolerate the perception that men are socially superior to women. Educate others that domestic violence, including intimate partner violence and sexual violence against women, is a global epidemic that affects us all.

I encourage current and future medical providers to seek the education they need to be a first resource for survivors of domestic violence. Make preventing and responding to intimate partner violence and sexual violence a priority in your clinical practice.

The National Intimate Partner and Sexual Violence Survey (NISVS) 2010 Summary Report defines five types of sexual violence:

  • Rape – “any completed or attempted unwanted…vaginal, oral, or anal penetration through the use of physical force, threats to be physically harmed, or when the victim was drunk, high, drugged, or passed out and unable to consent.”
  • Being made to penetrate someone else
  • Sexual coercion – “unwanted sexual penetration that occurs…after being pressured in ways that included being worn down by someone who repeatedly asked for sex or showed they were unhappy; feeling pressured by being lied to, being told promises that were untrue, having someone threaten to end a relationship or spread rumors; and sexual pressure due to someone using their influence or authority.”
  • Unwanted sexual contact
  • Non-contact unwanted sexual experiences – “unwanted experiences that do not involve any touching or penetration, including someone exposing their sexual body parts, flashing, or masturbating in front of the victim, someone making a victim show his or her body parts, someone making a victim look at or participate in sexual photos or movies, or someone harassing the victim in a public place in a way that made the victim feel unsafe.”

According to the NISVS, nearly 1 in 5 women (18.3%) and 1 in 71 men (1.8%) in the United States (U.S.) have been raped at some point in their lives. And nearly 1 in 2 women (44.6%) and 1 in 5 men (22.2%) in the U.S. experienced sexual violence other than rape. Worldwide, this rate is higher, with 1 in 3 women (35.6%) experiencing either physical and/or sexual intimate partner violence or non-partner sexual violence.

Domestic violence can refer to intimate partner violence, but also encompasses child abuse, elder abuse, or abuse by any member of a household. The World Health Organization (WHO) identifies four forms of intimate partner violence: acts of physical violence, sexual violence; emotional (psychological) abuse; and controlling behaviors.

Intimate partner and sexual violence disproportionately affects women worldwide, and can significantly impact a woman’s reproductive health and the health of her baby if she is pregnant. Women who have been physically or sexually abused by their partners have a 16% higher risk of having a low birth weight baby (16%). They are twice as likely to have an induced abortion, and almost twice as likely to experience depression.  In some regions, women who experienced partner violence were 1.5 times more likely to acquire HIV and 1.6 times more likely to have syphilis. Of women who experienced non-partner sexual violence, they were 2.5 times more likely to have alcohol use disorders and 2.6 times more likely to have depression or anxiety.

In 2013, the WHO produced a clinical and policy guideline entitled “Responding to intimate partner violence and sexual violence against women,” noting that health care providers are identified by survivors of intimate partner violence as the first and most trusted professional contact they would seek. These WHO guidelines emphasize the need for undergraduate medical curricula to include education on how to recognize, manage, and treat issues of IPV and sexual violence. Providers need to be prepared to give survivors immediate access to post-rape care, ideally within 72 hours, which includes psychological support, emergency contraception, and HIV and other STD prophylaxis.

For more information about domestic violence or how you can help please see the resources below:

If you are in immediate danger, please call 911.

If you or a loved one think that you are a victim of abuse in any form, please call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY) now for anonymous, confidential help available 24/7.

REFERENCES

  1. Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
  2. WHO/LSHTM. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2010.
  3. WHO/LSHTM. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2013.
  4. Violence against women: Intimate partner and sexual violence against women. Fact sheet. Reviewed September 2016. Accessed on 10/14/2016 at http://www.who.int/mediacentre/factsheets/fs239/en/

Featured image:
utopia banished by kr428

Categories
Clinical Narrative

Why I Stand with Planned Parenthood

After writing “ Storytelling and Patient Advocacy,” I cuddled up to a cup of warm coffee and reflected on the various moments in my life that inspired me or motivated me to take action. I thought about my story; why I applied to medical school and why I have certain research interests. Then I asked why I want to improve access to and the quality of reproductive health care. Immediately I thought about the question friends and family frequently ask me: “Why would you support Planned Parenthood if you want to help women?” My answer is this story:

As a third year medical student who will soon be applying to an obstetrics and gynecology residency, I am afraid.  The recent violence in my community and continued aggression against Planned Parenthood suggests that aligning oneself with the organization is risky.  Becoming an obstetrician gynecologist (OB/GYN) has been my dream since elementary school, so I feel anxious when family members share concerns that publicly supporting Planned Parenthood ensures I will not match to an OB/GYN program.  Will standing with Planned Parenthood keep me out of a program?  Is it OK to discuss abortion training on a residency interview?  Or do I need to use code like, “What family planning training opportunities are available?”  And in light of the attack on the clinic in Colorado, is my life in danger?  A pro-reproductive rights provider and avid supporter of Planned Parenthood wrote to me, stating that she is afraid to rotate at their clinics for fear of an attack.  She hauntingly added, “The terrorism is working.”  I almost never employ self-censorship, yet I too hesitated to continue to develop a professional relationship with Planned Parenthood.  Even scarier is to discuss that affiliation publicly.  A friend reminded me that in times of confusion or fear, it is best to have a mantra that can elicit courage.  My inner voice reminds me, “Be a rock star woman.”

A couple years ago, after my reproductive and endocrinology module, and after being influenced by readings about sexually transmitted disease (STD) pathology, I requested a full STD screen during my annual well-woman exam. The nurse told me, “We don’t do that here. You’ll have to go somewhere like Planned Parenthood.”  I left embarrassed and did not follow-up with another clinic.  Enter my third year clerkships when, on a pediatric service, my team treated a 15 year old female who was 21 weeks pregnant presenting with “vaginal pain and fainting during sex.”  I was ecstatic to finally manage an obstetrics (OB) case, and I excitedly took a medical history.  While writing my notes, I overheard a group of nurses say that this girl would not have “gotten herself pregnant” if she knew how to use a condom.  I interjected that the American College of Obstetrics and Gynecology now recommends long-acting intrauterine devices (IUDs) as the leading contraceptive option for adolescents because it is the most effective, safe, private, and does not rely on user consistency (ACOG, 2012).  Three nurses and a resident mistakenly retorted that IUDs cannot be given to adolescents or females who have not been pregnant due to increased risks to the uterus.  Because an intrauterine device is placed inside of the uterus during an office pelvic exam and contains a small string that trails into the vagina, old theories warned about uterine perforation, pelvic inflammatory disease (PID), and subsequent infertility.  They are wrong.  There are no cases of infertility following IUD use, no increased absolute risks for PID, and minimal incidence of uterine perforation (ACOG, 2012; ARHP, 2015).  Shockingly, this has been known in the medical community for more than a decade, yet there continues to be widespread ignorance about it among healthcare professionals.

I observed a similar case during a later clinical experience.  I listened to the physician refuse an IUD to a young woman with a history of unintended pregnancies based on his belief that adolescents are promiscuous and will develop pelvic infections.  His words, “We don’t offer those here.  You’ll have to go somewhere else like Planned Parenthood.”  Do you see the pattern?  It is no secret that judgement, ignorance, and prejudice exist in healthcare.   What is a medical student to do when faced with blatant disregard for clinical guidelines and scientific evidence that has been undisputed by science for over a decade?  I decided to contribute to the advancement of research and education by volunteering with Planned Parenthood, an organization that provides safe, up-to-date, and judgement-free care.

I regularly volunteer at Planned Parenthood as a patient escort, walking patients from their vehicles to the clinic doors.  Let me set the scene.  My local office is visited by anywhere from three to more than twenty protestors daily.  They stand on the sidewalk mostly shouting and waving signs at passing cars.  A few people silently pray with a rosary.  The first time I arrived, I had to excuse myself to the restroom because the hateful screams of “Baby killer with blood all over your hands!” were too shocking for me to bear.  Eventually I became better equipped to disregard protestors. However, that took time, and if I, a student medical provider, was mortified when my gynecologist’s office told me to go to Planned Parenthood for a standard STD screen, can you imagine the emotions a young patient experiences when walking from their car at a Planned Parenthood clinic, listening to protestors scream?  So I stand for hours in front of a Planned Parenthood clinic, deflecting the endless onslaught of insulting remarks, in the hopes that people can feel a little more secure receiving an STD screen, a pap smear, an IUD placement, or yes, an abortion.

The fact remains that Planned Parenthood is a leading provider of reproductive health care services.  A central focus is prevention, encompassing STD and cancer screening as well as contraception.  They provide prenatal services and references for those choosing to pursue adoption, in addition to abortion services and other reproductive health care.  The Guttmacher Institute, another source of global sexual and reproductive health, reported in July 2015 that half of all pregnancies each year (greater than 3 million) are unintended; the same statistic that has existed for two decades (Guttmacher, 2015).  More than half of women of reproductive age (13-44 years old; 38 million) need contraceptive services, and 20 million of those women require publicly funded services and supplies.  In addition, the average Planned Parenthood health center serves significantly more women seeking contraceptive services than all other publicly-funded safety-net clinics.

An interview on Fresh Air with Jonathan Eig, author of The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution, made me think more about Planned Parenthood’s role in women’s health care.  In the book he describes the challenges scientists and Margaret Sanger faced when trying to develop a “magic pill that would allow women to control when and if they got pregnant”—Wouldn’t that be great?  Oh wait, we thankfully have that now in pill, patch, injection, implant, and intrauterine device forms.  The developers of the pill studied progesterone’s effect on inhibiting ovulation under the guise that they were studying infertility treatment.  I wonder if the current, hostile climate surrounding Planned Parenthood will later be compared to the ludicrousness of 1950s-era United States, when our country outlawed female contraception, while allowing men to easily purchase condoms.  When I learn about the backlash surrounding the development of birth control, arguably the most important invention of the 20th century, how could I let threats prevent me from supporting an organization that is one of the few to consistently provide safe and evidence-based services without judgement?  The answer is, I cannot.  My career goal is to help women access and achieve the best reproductive care.  That is why I stand with Planned Parenthood.

References:

American College of Obstetrics & Gynecology. (2012). ACOG committee opinion no. 539: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol. 117(6):1472-83.

Association of Reproductive Health Professionals (2015). The Facts About Intrauterine Contraception [Fact Sheet]. Retrieved from http://www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/The-Facts-About-Intrauterine-Contraception-

Guttmacher Institute. (2015). Publicly Funded Family Planning Services in the United States [Fact Sheet]. Retrieved from http://www.guttmacher.org/pubs/fb_contraceptive_serv.html

Featured image:
Me (far left) escorting guests to the annual Planned Parenthood of Southwest and Central Florida Fundraising Gala.

Categories
General Narrative Public Health

Storytelling and Patient Advocacy

Yesterday, I received a perfectly-timed message on a group thread. My friend wrote that she loves patient advocacy.

“Me too,” I thought, as I filed away notes from a Planned Parenthood of Southwest and Central Florida Meeting hosted by the Leadership Action Team (LAT). What was the purpose of that meeting? To train volunteers on how to employ storytelling in their advocacy work. Planned Parenthood trains all of its staff members, and now volunteers, in the “Story of Self” curriculum created by Get Storied® , which is a program designed to teach businesses how to create social change through the art of storytelling.

The meeting began with introductions and a moment to safely process the recent shooting in our hometown. A young volunteer explained how the event affected her and her family:

I learned about the shooting on Facebook…And honestly, all I saw was, ‘Massive Shooting,’ and thought, ‘Oh, another shooting,’ and kept scrolling. I didn’t understand the gravity of the situation, until that night while watching the news with my mom. I looked over at my mom and she was crying. She just said, ‘I am afraid for you.’ She’s never before expressed concern about my activities. But now she says, ’I am afraid for you.’

This volunteer was young, but her voice carried a surprising amount of assuredness. I felt her confusion and fear. The next attendee shared their story, and then the next, and so forth as the meeting progressed.

We learned that there are three key components to one’s story of self: a challenge, a choice, and an outcome. Zac, the chair of the LAT, shared his story of self, which described the healthy relationship with his mother and the openness with which she educated him regarding sexual matters when he was an adolescent male. The two-to-three-minute story, complete with a joke about educational materials containing graphic penis pictures, ended powerfully with the line,

When I walk into a Planned Parenthood, it’s the same kind of environment my mom created for me for talking about sex.

We received our first assignment, which was to reflect on the experiences in our lives that have shaped the values which call us to leadership. The program will later have us refine the various details of our stories, practice in one-on-one and group sessions, identify ways in which we plan to use storytelling in our advocacy work, and take action. We had five minutes to silently reflect.

Ok, what is my campaign? Women’s health. Yeah, but what specifically? To help women access and achieve the best reproductive health care possible. Nice. So why do you want to do that? Because reproductive health is the most important thing in the world! Ok, but why?

Figures of maternal morbidity and mortality popped into my head. I could see again the absence of a clitoris and labia in my Nigerian patient who underwent female genital mutilation as a young girl. I remembered the way the vaginal introitus feels beneath my hands—stretched and strong—as a baby’s head begins to crown. The voice of an adolescent girl echoed, “I mean I want to have sex, but like, I’m not a slut.”

It is easy for me to think of patient stories that depict why I am pursuing a career in Obstetrics and Gynecology. But a story of self is just that. A story of SELF. I struggled to think of inspiring personal experiences.

Time is up! No.

Each person in my small group shared their story and received feedback. My turn circled around and I rambled on about women’s health. I managed to state two strong lines, “I volunteer at Planned Parenthood because it still remains the one place to offer judgement-free care. Not even my own gynecologist can say that.” But my story lacked focus and a compelling personal example.

That night after receiving my friend’s text, I began to think more about the meaning of patient advocacy. As a medical student, I think my primary role in patient advocacy is to ensure that my medical team knows about our patients’ health histories and needs. During my internal medicine/family medicine clerkship, in order to help care for a patient, I compiled a short document of excerpts from the World Health Organization, Centers for Disease Control, and American College of Obstetrics and Gynecology regarding HIV prophylaxis treatment in pregnant women with negative HIV status who have regular, unprotected sex with an HIV positive partner. In that instance, helping my resident defend her treatment plan was my way of advocating for my patient’s health. Patient advocacy means that I volunteer monthly to escort patients safely into Planned Parenthood clinics. It is the reason why I study exercise and pregnancy, so that I can advocate for pregnant athletes seeking to find a balance in the pre- and post-partum periods. Additionally, patient advocacy means that I write on the MSPress Blog about topics that matter.

Stories in medicine can break stigma, help people relate to the struggles of others, and empower someone to raise their voice.  Stories identify why we should care about an issue, and can inspire others to take action. Although I do not yet have an organized understanding of the many personal experiences that inspire me daily to fight for reproductive health care, I think I am well on my way to becoming a strong patient advocate. Fortunately, I do have a clear goal: support the improvement of access to reproductive healthcare and higher quality of reproductive healthcare for all.

Quoted persons in this paper gave permission to be on the record.

Featured image:
Story by Alexander Affleck

Categories
Clinical Public Health

Health Care Responsibilities: Zika

While attending a residency application question and answer meeting, I learned that 2016 marks the first year in over a decade that my mentor will not be taking medical students on an international health elective. She emphatically explained that it would be unethical to expose students to known Zika virus-infected areas, and irresponsible to potentially create a reservoir of Zika virus to bring back to the United States. Her second point resonated with me, because I had just examined a patient in clinic who commutes every two weeks between Puerto Rico and Orlando, Florida. He is a 30-year old male who engages in sexual activity with women only and reports inconsistent condom use. This worries me.

Puerto Rico has been hardest hit by the Zika virus pandemic, and is ground zero for Zika virus infection in the United States and territories. Between index case documentation on November 23, 2015 and January 28, 2016, there were 155 suspected Zika virus disease cases in Puerto Rico (Thomas, 2016). As of May 18, 2016, there are 544 reported travel-associated Zika virus disease cases (10 sexually transmitted; 1 Guillain-barré syndrome) in the United States and 0 locally-acquired vector borne cases (http://www.cdc.gov/zika/geo/united-states.html). The U.S. Zika virus infection in the United States and territories (USZPR) and the Zika Active Pregnancy Surveilance System (ZAPSS) registries are tracking cases of pregnant women with any laboratory evidence of possible Zika virus infection in the U.S. and territories, and reporting data every Thursday at the following website: http://www.cdc.gov/zika/geo/pregwomen-uscases.html  As of May 12, 2016, there were 157 pregnant women in the U.S. and District of Columbia with laboratory-suspected Zika virus infection.

Zika virus can spread from a pregnant woman to her fetus and is known to cause microcephaly and other brain abnormalities (ACOG Practice Advisory, March 31, 2016). The virus can also be transmitted through unprotected sex with a male partner, spurring the Centers for Disease Control and Prevention (CDC) HAN (Health Alert Network) advisory for the prevention of sexual transmission of Zika virus (Oster, 2016). Clinical criteria for Zika virus disease include the presence of (Simeone, 2016):

  • Guillain-Barre syndrome;

OR

  • in utero findings of microcephaly or intracranial calcifications in a mother with clinically compatible symptoms or epidemiologic risk factors (eg. sexual activity with a known Zika infected man) for Zika virus infection;

OR

  • one or more of the following symptoms
  1. fever;
  2. rash;
  3. arthralgia;
  4. conjunctivitis

Zika virus disease is not the first maternal virus infection to cause or be associated with congenital abnormalities, but it is the first known mosquito-borne infection to cause congenital anomalies in humans. The virus’ current behavior and long-term health consequences are still poorly understood, imparting urgency to disease control efforts. The CDC travel advisory for the country of interest by our international health elective recommends the following:

  • Women who are pregnant should not travel to areas in which there is known vector-borne disease;
  • Women who are pregnant should use condoms or not have sex (vaginal, anal, or oral) during the pregnancy with a male who has been exposed to a Zika-infected area;
  • Women and men who are trying to become pregnant should consider the risks of a Zika virus infection and strictly follow steps to prevent mosquito bites;
  • Men who traveled to or live in an area with Zika, and who have a pregnant partner, are recommended to use condoms or not have sex (vaginal, anal, or oral) during the pregnancy.

Reflecting on my clinical encounter with the Puerto Rican male who commutes regularly between known-Zika infected areas and the imminently vector-infected United States, I wonder if he is aware that he poses a risk. Does he believe, as so many often do, that he could not possibly be the one to acquire or sexually transmit an infection? Has he considered the possibility that he could serve as a viral reservoir?

In light of current evidence regarding Zika virus disease and the significant risks, I agree with my mentor’s decision to limit medical student international travel to Zika-infected areas. And I ask myself and readers, what is the responsibility of medical professionals in regards to communicable disease containment?

For more information, please see the American College of Obstetrics and Gynecology (ACOG) and CDC websites for clinical updates. An updated practice advisory by ACOG and the Society for Maternal-Fetal Medicine can be found at this link: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak

 

References

Thomas DL, Sharp TM, Torres J, et al. Local Transmission of Zika Virus — Puerto Rico, November 23, 2015–January 28, 2016. MMWR Morb Mortal Wkly Rep 2016;65place_Holder_For_Early_Release:154–158. DOI: http://dx.doi.org/10.15585/mmwr.mm6506e2

Oster AM, Brooks JT, Stryker JE, et al. Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65place_Holder_For_Early_Release:120–121. DOI: http://dx.doi.org/10.15585/mmwr.mm6505e1

American College of Obstetrics & Gynecology. ACOG Practice Advisory: Updated Interim Guidance for Care of Women of Reproductive Age During a Zika Virus Outbreak. March 31, 2016. Available at: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak  Retrieved May 23, 2016.

Simeone RM, Shapiro-Mendoza CK, Meaney-Delman D, et al. Possible Zika Virus Infection Among Pregnant Women — United States and Territories, May 2016. MMWR Morb Mortal Wkly Rep. ePub: 20 May 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6520e1

Featured image:
Zika Mosquitoes (05810440) by IAEA Imagebank

Categories
Lifestyle

Blue bird day, fresh pow, and a baby on the way

Meet Laura Matsen Ko, orthopedic surgeon, avid runner/skier/hiker/cyclist, and new mother to a  beautiful baby boy, Logan.  Laura and her husband, both orthopedic surgeons at Orthopedic Physician Associates (opaortho.com), practice and adventure in the Pacific Northwest. Together, they developed the website, seattlejointsurgeons.com, which allows patients to access comprehensive and accurate information on orthopedic care.

I met Laura recently on Instagram via a post shared by Oiselle (oiselle.com), a Seattle-based women’s running apparel store named after the French word for bird. In the post, photographed by Kevin, Laura is captured as a pregnant backcountry skier posed on the summit of snowy Mt. Baker.  A flurry of follow requests, instant messages, and emails between us quickly snowballed into a cross-country friendship.  Our easy rapport is not unexpected considering our shared passions. We are both passionate about helping injured athletes (and specifically pregnant athletes) get back to their sports as soon as possible.  After learning of my research interests in antenatal exercise, Laura agreed to a semi-formal interview about her background and experiences related to exercise during pregnancy.

 

First, tell me a little about yourself. I did some Instagram sleuthing and noted scrubs, ortho, a lot of snow, and Thomas Jefferson.

I was born and raised in Seattle, Washington. I went to Whitman College in Walla Walla, WA where I enjoyed being an outdoor leader on backcountry ski trips and mountaineering trips. My senior year I decided to go out for Cross-Country, and surprised myself by placing 9th at Nationals (D3).  Then I bike raced that spring and got 2nd at Nationals (D2). That was a huge surprise and a thrill.

I went to medical school in Portland, Oregon at Oregon Health and Sciences University (OHSU) and continued on at OHSU in an Orthopedic Surgery residency. I did two Ironmans while I was there, including qualifying for, and finishing, the world championship in Kona, HI.

About that time I got to meet my husband who was a year behind me in the Orthopedic Residency, and I finally convinced him to go for a real date with me after one of our rainy runs together.  Throughout residency we trained for various marathons together and enjoyed active vacations; anything from cycling to backcountry skiing. 

After we finished residency, we headed to Philadelphia. I did a fellowship in Adult Reconstruction. I chose the field of hip and knee joint replacement surgery because it gives me the opportunity to help people return to the activities they enjoy using surgery and personalized rehabilitation.

 

How many years have you been a backcountry skier and mountaineer?

My father and older brother taught me in my teenage years.  We had been backpacking our whole lives, they had been climbing, and I always aspired to go out with them.  When I was 13 I took a year-long course with my Dad to learn how to safely rock climb, mountaineer, snow camp, and manage avalanche risk and rescue.  That winter my brother took me out in the backcountry and I got stronger and smarter. That summer we climbed five Washington volcanic peaks including Mt Rainier.

 

What kind of role does skiing have in your life?

Backcountry skiing is a wonderful treat—unlike running it does take a bit of equipment and a bit of driving but it’s totally worth it! I love getting out into the wilderness without anyone around. I equally love the hiking up (“skinning” up) the mountain as much as the fresh, sweet turns on the way down!

 

Tell me about your pregnancy.

Logan was my first pregnancy.  I have always been active, and continuing my activity seemed right to me.  I bike-commuted to my work at the hospital, rain or shine, which was about a 15-mile commute. I did this through my second trimester, and then we decided it was too high of a risk to continue cycling due to the short and often rainy dark days in Seattle.  My OB, husband, and father all pushed me to stop bike-commuting.  I ran up to two weeks prior to him being born.  I skied two days before he was born—in bounds alpine one day and three days of very rigorous backcountry skiing.  These were about 6 hour days of hiking hard uphill and then skiing down in fresh powder.  It was so fun to feel like I was sharing this experience with Logan.

Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.

The day I went into labor I did elliptical and weights and performed a major total hip revision surgery.  Throughout the second half of my pregnancy I had some issues with SI joint and foot pain, but in general my body held up well.

I did a lot of research about heart rates, but the data seemed inconsistent. 

 

Laura’s difficulty navigating antenatal exercise guidelines is not surprising.  A study by Lieferman (2012) demonstrated that almost half of medical providers (48%, N=89) were unfamiliar with current national exercise guidelines for pregnant women and half of respondents advised a reduction in exercise in the third trimester, even for uncomplicated pregnancies.  Concurrently, a 2006 study demonstrated that about half of surveyed obstetricians recommended heart rate maximums and a reduction in exercise load during the third trimester—two policies not specified in current guidelines (Entin, 2006).

The American College of Obstetrics and Gynecology (ACOG) and the U.S. Department of Health and Human Services recommend that healthy pregnant and post-partum women engage in 30 minutes of moderate intensity exercise for most, if not all, days of the week (ACOG, 2015; DHHS, 2008).  Pregnant women who habitually perform vigorous-intensity aerobic activity may engage in higher intensities under the guidance of a medical provider.  Heart rate maximums are no longer indicated.  Instead, pregnant women use ratings of perceived exertion to monitor their exercise intensity.  For most women, moderate effort is comparable to a brisk walk, at an intensity one can maintain for hours. It should result in heavy breathing, but not so much that the exerciser is unable to hold a short conversation. Vigorous activity, on the other hand, should make the exerciser feel short of breath, but still able to speak a sentence.

Obstetrics (OB) providers are encouraged to educate women about the health benefits of exercise during pregnancy. These benefits include improved gestational diabetes control, lower rates of antenatal and post-partum depression, and relief for back pain.  There are several absolute contraindications to exercise during pregnancy, including incompetent cervix or cerclage, multiple gestation at risk of premature labor, persistent second- or third-trimester bleeding, and preeclampsia.  For a full list of absolute and relative contraindications, consult the ACOG Committee Opinion Number 650 (ACOG 2015).  Certain activities are also identified as safe or unsafe.  Unbeknownst by Laura, down-hill snow skiing is listed as an activity to avoid due to an inherently high risk of falling and subsequent abdominal trauma.

Laura continues:

I didn’t really follow [the guidelines] after talking with friends and reading.  I didn’t do sustained high intensity intervals, but if I was running stairs and my heart rate got up to 165-170 on the way up but dropped to 120 on the way down, I felt that my baby was getting sufficient perfusion.  Each mother has a different pregnancy experience and the biggest factor is to listen to your body.  Exercise made me feel happy and alive so I kept doing it.  Plus pregnancy can do such a warp on body image.  Exercise helped normalize my feelings about the changes in my body.

 

Why do you think it is most important to listen to your body?

We are all so different. As you’ve seen with your med student classmates, we need different amounts of sleep, caffeine, food, exercise, fresh air… so no single guideline will work.  We all must strive to learn our bodies. 

My physician friend had a 10-lb baby.  She was extremely active, and pre-pregnancy she ran and played soccer.  Obviously our pregnancy (and delivery and post-partum) experiences were totally different and not fair to compare.  She says she tried to play soccer 7 weeks post-partum and she “felt like her uterus was going to fall out.” Another physician friend had a 9 lb baby with a very large head.  She was walking over 5 miles a day until she delivered, but is challenged to get back to walking more than a couple blocks now (2 weeks post-partum) after her more traumatic vaginal delivery. A third physician friend who had always been extremely active in basketball and volleyball was placed on bed rest at 22 weeks for all three of her babies. 

I never want to be compared to other women or make other women feel that they just didn’t push hard enough because of my activity levels.  I’m one person and this was one pregnancy. The next pregnancy could be totally different!  These other women are a lot tougher than me—they had a more challenging pregnancy, delivery, and recovery.  And they had to be very patient with their bodies.

 

Did you have any conversations with your OB provider(s) about your exercise practices during the pregnancy?  

Yes… some. They thought I was a little nuts but were supportive.  Except for the skiing.  My OB was a little shocked to hear that I’d been skiing.

In the first couple weeks post-partum I mostly tried to work on some baseline fitness with walking and stairs.  I tried to wait until 6 weeks to really increase my activity but I wasn’t able to wait.

 

Explain the 6 week mark. 

Well I was told by my OB and the nurse practitioners to not exercise hard until 6 weeks.  BUT I started running at day 16 and as of 4 weeks was up to about 30-40 miles a week with one day of hill repeats and one day of fartleks. I made it to 8 miles in sub 8 pace with a couple 7:30 until around 4 weeks.  I think my first race will be a half marathon at 2.5 months postpartum.  I’m not going to be the fastest.  Partly because of recent pregnancy but also because of sleep deprivation, returning to work, and not having enough time in the day!

16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.
16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.

Do you have any friends who also skied during their pregnancy?  

 I knew people who were running and rock climbing in their pregnancy and a lot of friends who just stayed fit with walking.  I don’t know anyone else who skied during their pregnancy but I’m sure people out there do it!  I’d mainly suggest borrowing your father’s huge rain coat and possibly his ski pants because there is no way you’re fitting in your bibs from pre-pregnancy.  And don’t push the speed and steepness; mostly enjoy being out there!  You don’t want to fall.

There are definitely other pregnant skiers and a few inspired, future Mamas:

5

On the mountaineering trips, what, if any, issues did you have with harness fit?

Due to the season I didn’t mountaineer in the second half of pregnancy, so it wasn’t an issue.  One of my friends got a lower and upper body harness for her pregnant rock climbing trips.

 

What kinds of emotions did you encounter during your pregnancy when you were not able to do activities that you enjoy?

I found it super frustrating when others placed restrictions on me. My husband quickly found that he had to present my change in activities as a risk/ benefit. When he told me “no more cycling,” I just wanted to rebel. However he did recently have to fix a clavicle fracture on a woman who was 16 weeks pregnant. She got hit while bike commuting. Thankfully her fetus is okay.  That story will make me more conservative with my cycling in my next pregnancy.

At 4.5 weeks post-partum I restarted bike-commuting to work for some half days of clinic.  It felt amazing to be back out there and I was so much faster with less weight, higher lung capacity, and likely an increased hematocrit. 

 

Is there anything you want to tell future mothers? 

Listen to your body and don’t read too much.  Wear support stockings if you work on your feet.  Know that you will lose the weight.  Fast. 

 

Physicians?

Support your patients.

For future and current obstetrics providers, the Canadian Society for Exercise Physiology developed the PARmed-X for Pregnancy, a physical activity readiness medical questionnaire that guides discussions on exercise during pregnancy in an outpatient setting.  The form may be accessed online (http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf) and is useful for most pregnant women.  Athletes, however, have sport-specific safety concerns, training goals, and requirements that may be unfamiliar to the average obstetrics provider.  These topics may be explored on an as-needed basis during prenatal visits.

A big thank you to Laura Matsen Ko for sharing your inspiring story!  Thank you also to my friend Hannah, who initially tagged me in the Oiselle Instagram post.

 

References

  1. Leiferman, J., Gutilla, M., Paulson, J., Pivarnik, J. (2012). Antenatal physical activity counseling among healthcare providers. Open Journal of Obstetrics and Gynecology, 2, 346-355
  2. Entin, P. L., Munhall, K. M. (2006). Recommendations regarding exercise during pregnancy made by private/small group practice obstetricians in the USA. J Sports Sci Med, 5, 449-458.
  3. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol 2015;126:e135–42
  4. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans.  Department of Health and Human Services Washington, DC; 2008.

Featured image:
Laura Matsen Ko skiing. Photographed by Kevin Ko.