Blog

Can I find a doula- friendly obstetrician?

May 2, 2013 by Dr. Tamar K. Gottfried Leave a Comment

Historically, the birth of a baby has been a family event. Throughout much of human history, a woman has given birth surrounded not only by her birth attendant, but by female family and friends who bring their combined experiences to help make her labor and delivery as easy as possible. Nowadays, this is no longer a given. Many women live far from family members or find that their close friends and family may not have any prior birth experience to share with them. This lack of support and knowledge can often complicate the birth experience, especially for a woman who is planning an unmedicated labor and delivery.

In the modern, mobile society, many couples need an extra person to help them navigate the birth process, someone to replace the knowledgeable family members of the past. This is where a doula comes in. A doula is an experienced birth attendant that can be hired by a couple to help them during labor and delivery and even after the baby comes home. Sounds like a great idea- why wouldn’t most obstetricians be thrilled to have a doula in the labor and delivery room? Unfortunately, many OBs have a misconception of the role of the doula or have had an isolated bad experience and feel that their role in the process will be threatened if a couple has a doula there.

Ideally, a doula is an asset to both the laboring woman and to the medical staff. She can help a woman find different ways to transcend the pain of labor, she can help translate medical terminology and what is going on, she can support a couple in the decisions they make during the birth process. A doula, an expectant couple and their medical team all have the same goals- a healthy mom and baby, achieved by as natural a process as can safely happen.

Tamar Gottfried is a Board Certified Obstetrician/ gynecologist practicing general Ob/gyn in Mesa Arizona and affiliated with Banner Desert and Banner Gateway Medical Centers. She can be contacted at 480-545-0059. This is a general interest article only and is not intended to be medical advice. See a medical professional before making medical decisions

My baby is almost due- do I need a birth plan?

September 10, 2012 by Dr. Tamar K. Gottfried Leave a Comment

Expectant mothers are bombarded with tasks to complete for the births of their babies- It can be a bit overwhelming. Is a birth plan a necessary part of the pre-baby preparation? Not necessarily.

A birth plan is a lists of likes and dislikes to help guide the medical staff in the labor and delivery department to meet the needs and expectations of a couple. There are many birth plan templates on line and in pregnancy advice books. However, for the majority of couples, the preferences expressed in these prefabricated birth plans do not apply to them. For example, many of the birth plans state that the couple wishes to avoid routine shaving, enemas, and episiotomies- most of which have not been standard practice since the 1970s. For a couple who do not have strong objections to hospital policies or who are not planning an unmedicated delivery, a birth plan may not be needed.

Birth plans are more important for couples whose wishes might deviate from standard labor and delivery practices. The couple who wants to avoid any intravenous fluids or fetal monitoring, who want certain music playing in the room, who do not want any pain medicine offered or even mentioned, or who want to deliver in an alternative position should write out their preferences ahead of time and discuss them with their OB well before they are in labor. That way, their doctor understands their vision of their labor, and can explain which desires are easy to fulfill, and which will be more difficult, or even unsafe and why.

The best birth plan is one that is put together during the last months of pregnancy and is brought to the obstetrician and labor and delivery units to be discussed before the craziness of labor begins. As an obstetrician, I am always happy to discuss birth plans with expectant parents at OB visits. Most importantly, the birth plan should also include some flexibility, since, however important a birth plan is, it is more important to have a safe labor and birth that ends with a healthy mother and child.

So I’m pregnant and eating for two- Can I eat as much as I want now?

September 9, 2012 by Dr. Tamar K. Gottfried Leave a Comment

The old adage that pregnancy is a time of “eating for two” has been around for some time. Yes, the pregnant mom IS eating for two, but one of them is very small. For most of us, eating whatever and as much as we want IS a fantasy. Unfortunately, during pregnancy, it is no more of a reality than at any other time.

Diet during pregnancy is important to the health and growth of the growing fetus, but the amount of weight gain required varies according to a mother’s pre-pregnancy weight. While an underweight woman needs to gain over 35 lbs to grow a healthy baby, an overweight lady can gain as little as 10-15 lbs to do the same. Not gaining enough weight in pregnancy cause cause issues with inadequate fetal growth, while excessive weight gain can lead to gestational diabetes, large babies, cesarean delivery and difficulty with weight loss after delivery.

It is perfectly normal to maintain weight, or even lose weight in the first trimester due to decreased appetite, nausea, or even vomiting, which is common in early pregnancy. Some women even gain weight in the early months of pregnancy because they find that eating throughout the day can reduce nausea. In contrast, by the third trimester, an average weight woman should be gaining about a pound a week.

How does a pregnant woman gain a healthy amount of weight during pregnancy? For the underweight to normal weight mom, it may mean eating 6 small meals throughout the day, snacking healthily on smoothies and trail mix and peanut butter sandwiches or granola. For the woman at risk for an excessive weight gain, it may mean drinking only calorie free beverages ( no sugary soda, juice or vitamin waters) and low or nonfat milk ( a couple glasses a day max). It also means making sure that there is protein at each meal (even breakfast) and weighing and measuring foods to keep a food diary. Some women gain too much even though they are eating the right kinds of foods, because they are eating too much of them.

For women of all sizes who are experiencing an uncomplicated pregnancy, exercise is an important component of every day. Simply moving enough to get the heart rate up at least 30 minutes a day helps promote healthy fetal growth and development. No one is required to become a distance runner during pregnancy, but continuing previous exercise routines or developing new low impact habits is ideal. For more personalized advice about weight gain and exercise during pregnancy, contact your obstetrician.

I don’t want a pregnancy now, but maybe in the future. What are options in long term reversible contraception?

September 8, 2012 by Dr. Tamar K. Gottfried Leave a Comment

Although the birth control pill and sterilization are the most popular forms of contraception, these options are not for everyone. There is a large group of women that want to avoid pregnancy for several years, but want the option of a pregnancy in the future. For these women, who may worry about forgetting to take a daily pill, missing a doctor’s appointment or losing insurance coverage and not being able to pay for birth control pills or shots, long acting reversible contraception (LARC) methods are a safe and convenient option.

An increasingly popular example of a LARC is the Mirena Intrauterine Device (IUD). Mirena is a T- shaped device that is inserted in a woman’s uterus for up to 5 years. It slowly releases progesterone over that time period, making the uterus an unfriendly place for sperm, preventing pregnancy. A happy side effect of Mirena is that the hormones in it thins the uterine lining, lightening the monthly period to almost nothing. While there can be irregular bleeding at first, most women using Mirena have barely any bleeding each month. Fortunately, the dose of hormone in Mirena is quite low and mostly acts inside the uterus, so other side effects (weight gain, mood changes) are minimal.

Unfortunately, Mirena only comes in one size (designed for a uterus that has carried a pregnancy) and is not always a good option for the woman who has never been pregnant. Sometimes Mirena can be difficult to insert or can be pushed out by uterine cramps in these cases. Also, since Mirena goes into the uterus, it is not ideal for the woman who is not in a monogamous relationship and could be exposed to sexually transmitted diseases. These STDs, combined with an IUD can cause a more serious pelvic infection. For women who do not want these risks associated with an IUD, the Implanon device is a great alternative.

Implanon (soon to be called Nexplanon) is an small rod which is inserted into the inner arm in a painless office procedure, and slowly releases a form of progesterone over a 3 year period. Side effects are minimal, but include irregular bleeding, which lessens with time. This method is ideal for women who want long term birth control, without the risks of a uterine method. The rod is small, can’t be seen by others unless pointed out to them, and is easy to remove when the time comes.

The third LARC is for the woman who wants to avoid hormones altogether. The Paragard IUD has been around for decades and is a reliable long term method. It is a copper device that is inserted in the uterus and creates an anti- sperm effect on the uterus which prevents pregnancy. Major side effects include heavier and crampier periods, making it a better option for the woman who has light, reasonable periods to begin with.

In conclusion, there are multiple birth control options for the woman who wants a few years of protection. A gynecologist can help a woman decide which one is best for her individual situation.

I feel a vaginal bulge- Are my insides falling out?

July 27, 2012 by Dr. Tamar K. Gottfried Leave a Comment

Pelvic prolapse is a common complaint in women, especially those who have ever been pregnant. Sometimes, it is something noted by a gynecologist on a yearly exam. Other times, women notice a bulging while in the shower or wiping. Although many women are initially alarmed by this, pelvic prolapse comes in varying degrees and often has little to no impact on a woman’s daily life.

Prolapse is when there is a decrease in strength or a tear in the supportive tissue of the vagina, allowing the nearby organs to bulge into the vagina, especially during bearing down (exercise, coughing, straining for a bowel movement). A bulge in the vagina can be the rectum (rectocele), the bladder (cystocele), the intestines (enterocele), or the uterus. If a woman has had a hysterectomy, the vagina itself can prolapse, bulging into itself. The organs don’t actually come into the vagina, they just push onto the vaginal wall, creating a bulge or ball.

In severe cases, prolapse can cause an uncomfortable pressure sensation, can irritate the vaginal tissues, and can cause bladder or bowel dysfunction. A woman with symptomatic prolapse can try physical therapy or can use a device called a pessary to relieve her symptoms. Pessaries are made of rubber or silicone and come in different sizes and shapes. They are worn in the vagina to hold things in place. Some women use these only during waking hours- others wear them all the time and, if they are not capable of taking them in and out, see a gynecologist for regular removal and cleaning every few months. When conservative measures fail, there are a number of surgeries that can be done for prolapse. However, it is important to refrain from repetitive coughing or heavy lifting after prolapse surgery to minimize the chance of recurrence.

Fortunately, many cases of pelvic prolapse are mild. For these women, who have mild prolapse and minimal to no symptoms, there is no treatment necessary. This is a condition that can be monitored yearly at the Annual Gyn Exam and may never impact a woman’s life.

What is it like to have robotic assisted gynecologic surgery- a physician’s perspective

July 26, 2012 by Dr. Tamar K. Gottfried Leave a Comment

As an ob/gyn physician, the last thing I wanted to do was have gynecologic surgery on myself. Much to my dismay, I discovered that my uterus was hosting several large fibroid tumors. Since I didn’t have any of the typical symptoms of heavy or painful periods, my first instinct was to ignore them. However, given that my uterus was the size of a 4-5 month pregnancy, it became apparent that the fibroids were going to have to be removed before they got larger or grew enough tumor friends that a minimally invasive surgery was not an option.

Although many women in their 40s would jump at the opportunity to have a hysterectomy and be done with periods forever, I was relatively fond of my uterus. It had carried three lovely kids, and I was hoping to go through life with as many of my parts intact as possible. For this reason, and the distant dream of having a little girl to add to my brood of boys, I chose to have a myomectomy, a surgery to remove just the fibroids and preserve my uterus. Additionally, because I am self employed and do not like to spend more than a few days away from my patients, I chose to have the surgery done laparoscopically. My surgeon would use the da Vinci robot to remove my fibroids through 4 tiny incisions and I would return to work in a week.

There is a joke among medical personnel that our medical issues always turn out to be more complicated than anticipated and I was no exception. My surgery- supposedly to remove 5 fibroids in 4 hours- turned out to be a 6 hour procedure to remove 14 tumors. Even so, my gifted surgeon did this through the promised 4 tiny incisions and I was walking unassisted to the restroom within a few hours postop. I was off the IV, drinking fluids and on just a few pain pills that first night and home the next day. My second day home, I went for a 25 minute walk outside and was taking over the counter Advil for pain.

In earlier times, a surgery like the one I had would have meant 6 weeks out of commission and a difficult recovery. I am fortunate that the latest technology has allowed me to return to activity within days. At this rate, I plan to be running and lifting weights by next week. This may not be a “typical” recovery, but it is possible. In conclusion, minimally invasive surgery, like the one I had, is possible and available to appropriate candidates. Although I am not currently performing the robotic procedures, my office partner, Dr. Lori Carrillo and my own surgeon, infertility specialist, Dr. Millie Behera, are available for consulation.

I’m ready to get pregnant- What do I do now?

July 26, 2012 by Dr. Tamar K. Gottfried Leave a Comment

It is a momentous day in the life of a family when the decision is made to add a member. To ensure the safest pregnancy and delivery, there are many things a woman can do to prepare. First and foremost, a woman should optimize her health before trying to conceive. This means doing blood tests to ensure that her childhood immunizations to illnesses like German measles are still working. It also means going over any medications she is taking to make sure that they are safe during pregnancy. A woman with chronic conditions such as high blood pressure, diabetes or depression should make sure she is in the best control possible prior to getting pregnant.

Another preconception must is starting a daily regimen of folic acid. This can be taken by itself, or as part of a prenatal vitamin. Folic acid helps prevent neural tube defect, a common birth defect. Stopping unhealthy habits is also recommended prior to pregnancy- this includes alcohol, tobacco, and a sedentary lifestyle. Additionally, a women should try to be at her healthiest weight prior to conceiving.

Even before a woman is ready to conceive, she should begin tracking her menstrual cycle. In a typical 28 day cycle, a woman is most fertile 10 to 14 days after the first day of her period. If the cycle is longer, such as 35 days, then her fertile time is 21 days after her period starts. Alternatively, for a woman with a short 3 week cycle, she is most fertile on day 7 of her cycle. To increase chances of conception, a couple should abstain for a few days before the most fertile period, and then begin having intercourse every other day during the fertile time.

It is important to remember that, even in perfect conditions, only 1 out of 5 couples will conceive on any given month. However, 80% of couples trying to conceive will be pregnant within a year. With this information in mind, prepare for pregnancy, and do not be discouraged if it doesn’t happen the first few months of trying. Most couples will achieve their dream in less than a year.

I’m pregnant and stuff is leaking out of me- How do I know if my water’s broken?

July 26, 2012 by Dr. Tamar K. Gottfried Leave a Comment

One of the most vital pieces of information in pregnancy is whether or not an expectant mother’s membranes have ruptured. Once the water has broken, a fetus is no longer protected against infection. If this happens very early in a pregnancy, this can be devastating and endanger the health of mother and child. At term, ruptured membranes mean that it is time to deliver a baby- regardless of whether labor has started on its own. Sometimes the water breaks naturally during the course of labor. Other times, it breaks spontaneously and without warning. It can be a small trickle of fluid or a large gush- either way, it is important for the Mom to recognize what is going on and present to her maternity ward for evaluation.

There are other sources of “leakage” during pregnancy. It is extremely common for a pregnant mom to experience a white to clear, liquidy discharge during the 2nd and 3rd trimesters. This typically doesn’t have an odor or cause itching, but can be enough to require a change in panty liners several times a day. This is a harmless discharge of white blood cells and is normal. Another cause of leakage is urine. Pregnant bladders are often not as strong, and forces such as coughing, sneezing and laughing can cause urine to leak. Usually this fluid will have a typical odor and won’t continuously leak.

When a woman’s water breaks, the fluid is typically thin or watery, clear to yellow, sometimes green or blood tinged, and without odor. It will continue to leak, sometimes every time the woman moves or bears down. Sometimes it is difficult to distinguish from other sources of leakage. The important thing to know is that any suspicious of ruptured membranes in pregnancy has to be evaluated by a medical professional. This is not something that can wait until the next day or the next OB visit, it should be checked within a few hours.

At the hospital, the nurses or OBs can do a simple speculum exam and a lab test to determine if the water is broken. Sometimes an ultrasound is done to see if the amniotic fluid level is low. If the water is broken, it is time to have a baby, usually by induction of labor. If ruptured membranes are ruled out, a woman can go home to await her baby’s arrival with peace of mind.

My gyn just told me I have antibodies to Herpes in my blood. What does this mean??

January 24, 2012 by Dr. Tamar K. Gottfried Leave a Comment

There are few things that alarm patients more that hearing that they have antibodies to herpes in their blood. What they hear is “I have herpes” even though this isn’t always the case. Many times, tests for herpes antibodies are included in STD panels and in routine blood work for newly pregnant woman. These tests look for evidence of prior exposure to either the Herpes I or Herpes II virus. A positive result can occur if a person has ever been exposed to these viruses. Exposure could happen by coming into contact with the virus through oral or genital contact, even by a kiss from someone with a cold sore.

While Herpes I is usually oral and Herpes II usually genital- either can be found in the other location. Someone who has either herpes virus can be contagious without even having a lesion and pass along the virus unknowingly. Alternatively, a person can have be exposed to the virus and develop antibodies without ever having an outbreak. Just because the antibodies are in the bloodstream does not mean that an outbreak will ever occur. These antibodies can lay dormant for years or even decades. Most of the time, if one partner in an ongoing relationship has antibodies to Herpes, the other person does too. This can be verified with blood work.

In conclusion, the presence of Herpes antibodies on a blood test does not mean that an outbreak of Herpes will ever occur. However, in times of physical or emotional stress, or when the immune system is suppressed (like during pregnancy), there is a higher risk of an outbreak. For this reason, we use preventative antiviral medicines to prevent Herpes outbreaks at the end of pregnancy. More information regarding the Herpes viruses and their diagnosis and treatment can be found at my Mesa Ob/gyn office.

Fetal movements during pregnancy: how do I know if my baby is normal?

January 23, 2012 by Dr. Tamar K. Gottfried Leave a Comment

Mesa Gynecologist Dr. Tamar Gottfried discusses one of the most memorable days of a pregnancy. This is the day that a mother first feels her baby move. Typically this occurs at about 21 weeks for a first time mom and as early as 15 weeks for an experienced mom. The fetus actually starts moving earlier than this, in the first trimester, but the early movements are so small and the uterine muscle so thick that these early movements are difficult to feel. The first fetal movments feel like intestinal gas bubbles or the fluttering of butterfly wings and are only felt by the mother-to-be. As the fetus grows larger and the uterine muscle thins out, both parents can start to feel the kicks, hits and somersaults of the developing baby. Early movements can be inconsistent and irregular, but, by the start of the third trimester at 28 weeks, regular daily movements should be noted.

As the third trimester progresses, mothers may notice that the fetus becomes less active. Sometimes they are simply noting the waking/sleeping cycles of the baby. Like babies once they are born, fetuses tend to be lulled to sleep by the movements of their mothers when they are active, and wake when their mothers are resting. An average fetus after 28 weeks should have at least 2 active periods a day- defined by 10 or more movements in an hour. Keeping track of these movements is called Kick Counting. We don’t expect to see this much movement every hour; just at least twice a day. While babies do move less dramatically (less turns and twists) as the end of pregnancy approaches, they should still have a good number of kicks, hits and taps.

What does it mean if a fetus is not moving at least 10 times in any hour? It may mean nothing or it may mean that the mother is dehydrated and needs to drink, or eat or that she is active and needs to rest and concentrate on counting fetal movements. However, if a mom has eaten or drank and relaxed and still can’t count 10 movements, it may mean that the placenta is no longer performing adequately. Decreased fetal movement can indicate a lack of fluid around the baby limiting movement or a placenta that isn’t working well enough to provide nutrition to the baby. For this reason, decreased fetal movement should prompt an immediate visit to the Ob office or to the maternity ward at the hospital for a nonstress test and ultrasound. Delay can have disastrous consequences. This is not something that can wait until the next morning to be evaluated.

In conclusion, fetal movement is a reassurance that a baby is doing well on the inside. A decrease in movement may indicate a problem and should be addressed right away. For more information regarding fetal kick counts or fetal movement charting, you can call our Mesa ob/gyn office.