The Trial of Labor

Telling . . . one of the top searches that brings people to my blog these days is “myomectomy aftermath.”

Today I was in class trying to follow along in a fast-paced discussion of voice pathologies.  One such pathology discussed was the Human Papilloma Virus which can attack the vocal folds.  Colds and other viral infections can manifest as papillomas (small harmless epithelial tumors) on or near the vocal folds (membranes of the voice box).  This is called Recurrent Respiratory Paillomatosis (RRP).

RRP shows up in children, and the suspected cause is a HPV-infected mother.  When a baby descends through his/her mother’s birth canal, the baby can contract HPV if the mother carries the virus.  Adult onset RRP evidently is becoming more prevalent, possibly due to changing sexual practices.

In the course of teaching us about HPV and the respiratory equivalent, RRP, the instructor stated that pregnant women with HPV have have their babies “delivered” via cesarean section.  The instructor was given this information by . . . you guessed it . . . a DOCTOR!  I couldn’t hold my tongue.  I wanted my colleagues to be sure to know that although a doctor may suggest that a pregnant woman with HPV should have a cesarean, that it’s not a mandate.

I wish I had told my colleagues that uniformly recommending cesarean delivery due to HPV is not an evidence-based practice.  Why is this important?  What if a pregnant woman enters this practitioner’s speech & hearing clinic complaining that her voice is hoarse and weak, and upon further investigation, it is discovered that she has RRP.  This practitioner may tell her that she’ll have to have a cesarean because she has RRP.  That may be one more woman who, heeding the advice of her care providers, would be cut.

Let’s look at some of the literature on the net about both HPV and RRP. (See sources at the bottom of this post.)
Frequency:  According to the RRP Foundation, there are maybe 20,000 active cases of RRP in the U.S., and the CDC estimates that less than 2,000 children contract RRP in a year.  HPV is quite prevalent - approximately 20 million Americans are infected.
Transmission.  Active condyloma during pregnancy or HPV can cause a baby to become infected, but occurrence is deemed RARE.  As stated previously, RRP is becoming more prevalent in the adult population possibly due to changing sexual practices, and HPV has a strong connection to sexual practice.
Childbirth recommendations:  Cesarean delivery is not completely protective from RRP though recommended for consideration when visible condyloma is present in a primaparous pregnant patient.  Cesarean delivery is not protective against RRP in mothers with genital warts.

Well-meaning practitioners from other unrelated fields can and do contribute to the cesarean problem.  However uncomplicated a cesarean may seem when presented antiseptically from a medical provider or behavioral clinician, important questions are not being asked:

1. How likely is transfer of the presumed pathogen
2. How is cesarean delivery protective against the transfer of specific STDs and other viral infections
3. What physical complications can arise for the mother with a cesarean
4. What physical complications can arise for the baby due to a cesarean
5. How does cesarean delivery affect the mother-baby dyad
6. What psychophysical or emotional complications can arise after cesarean delivery (or after traumatic birth experiences); how and when do they manifest
7. What complications may arise (at birth, in childhood, during puberty, in adulthood) from possible RRP transfer
8. How should the patient/client prioritize the risks/benefits of vaginal or cesarean birth
9. What does the mother (and her support team - partner, family members, close friends, etc.) desire
10. Who is more important - the mother or the baby

This last question is the most perplexing, it seems, for the medical community.  Babies are born innocent and vulnerable.  They are unable to advocate for themselves.  In protecting the rights of the unborn or barely-born (not that I oppose that ultimately, I might add), care providers knowingly and unknowingly subvert the rights of the mother.  The mother is here right now.  She is hopefully a positive contributor to her community.  She may already care for other children.  She may have a life partner.  When her health and happiness is compromised for the well-being of her innocent child, is our society really any better for it?  Which is more important - kinetic energy, a life in process, a current contribution . . . or potential energy, a life about to begin, a possible contribution.

I hope readers will take to heart the broadest implications of this post.  First, medical doctors and insurance companies are not the only ones adding to the increasing cesarean rate.  We find well-meaning contributors in some of the most unlikely places.  Second, questions beyond “how easy is it to fix” must be asked when the life and well-being of the mother-baby dyad is at risk.

For more information on cesarean delivery, please visit the International Cesarean Awareness Network (ICAN) and Childbirth Connection.

Sources Consulted:
CDC information on HPV - http://www.cdc.gov/STD/HPV/STDFact-HPV.htm
Condyloma in Pregnancy Is Strongly Predictive of Juvenile-Onset RRP - http://www.greenjournal.org/cgi/content/full/101/4/645
Course notes
eMedicine - http://www.emedicine.com/med/topic2535.htm
Genital HPV Infection Learning Module - http://depts.washington.edu/nnptc/core_training/clinical/PDF/HPV2008.pdf
RRP Foundation - http://www.rrpf.org/
Women’s Health, HPV and Genital Warts - http://www.womenshealth.gov/faq/stdhpv.htm

Tags: genitalHPV, HPV, papilloma, recurrent respiratory papilloma, RRP, cesarean rate, cesarean epidemic, cesarean awareness, ICAN, protective cesarean

I have to give a BRAVA! to Indexed.  A fellow plurker posted a link to this site, and I nearly peed my pants (which by the way would have been a crime as I am on the most awesome couch ever put on this planet).

Many of my friends know that I’m doing a vocal science program this summer in Denver.  It’s funny that I was directed to this site, because I drew something on my last exam that would probably resonate with Jessica Hagy, the talented author of Indexed.

I’ll have to redraw it and post it for you.  Perhaps there is some way for me to combine line drawing with mind mapping to help make some of the concepts I am learning more digestible for the voice community.  Hmm . . .

Tags: index, line drawing, vocology, vocal science, Jessica Hagy, plurk

My husband and I honeymooned in Jamaica ten years ago.  We had a fabulous time taking catamaran cruises, sunbathing, playing sand volleyball (and winning the international championship - woot!), learning how to wind surf, scuba diving.  I also began to develop sun sensitivity.

The summer after our honeymoon I noticed that I would get these annoying itchy bumps on my arms, especially on my elbows and wrists, whenever I was out in the sun and got too hot.  The student health center doctor didn’t think it looked like a sun allergy or a heat rash.  Over the years it has gotten worse.  It’s a horrible problem now but somewhat controlled through liberal and regular application of high-SPF sunscreen.

I was browsing twitter and friendfeed today, and a friendfeed friend posted a link to this post about the danger of sunscreen.  Great - what do I do now?

Here are some of the strategies I’ve developed over time.  This isn’t rocket science, people.  But do consider that your long-term health (and that of your children, especially if you drench them in sunscreen as I do) may be at stake.

1. Spend 10 minutes in the sun without sunscreen every day.  We all need vitamin D, and we certainly aren’t getting the minimum amount from our diets!
2. Try to find a sunscreen with the least amount of unnatural ingredients.  Use it to build up a base tan.
3. Wear a hat and sunglasses.
4. Sit in the shade when you can.
5. Wear long-sleeved shirts when you’re hiking or gardening.
6. Avoid the sun between 10:00 am and 4:00 pm.

The problem for me is that not only do I have this sun allergy, but also I have problems with melasma.  Lucky me.  So I ask again - what do I do now??

Tags: sunscreen, sun allergy, melasma

I’m supposed to have some more blood testing done later this cycle.  On CD3 I had FSH and estradiol levels checked.  Fortunately they came back just dandy - lo and behold my 35-1/2 year old advanced maternal age eggs are doing just fine.  Of course this does bust my hypothesis that my fibroid is caused by imbalanced estrogen levels.  Actually, one of the nurses said that the estrogen-fibroid connection is only relevant in post-menopausal women.  I haven’t done follow-up research to decide if I agree.

Anyway, the RE told me to buy an ovulation prediction kit (OPK) to determine when I would ovulate this cycle.  He didn’t trust me when I said that I *know* when I ovulate.  So, I spent the $24.00 on the cheapest OPKs I could find.  (By the way, Dollar Tree does not uniformly carry OPKs any more.  Drat!)  Let me just say that OPKs are the most stupidly designed hormone tests EVER.  When you test you will likely get 2 lines, but that doesn’t mean that the appropriate hormone (LH, I believe) has been detected.  Oh no.  You need 2 lines of equal strength or your line should be stronger than the test/constant line.  So, is it an equal line?  What if both lines are equally weak?  What if I *think* I’m seeing a strong and equal line but it’s not really accurate.  At the end of the day, I just ended up taking the stupid test so I could say I did it and then rely on my body’s very reliable signs to tell me that yes indeedy I did ovulate when I thought I did.

How am I so sure that I ovulated?  Well, without divulging too many gory details, here are some good ways to know: cervical os open, lots of egg-white-like cervical fluid, ovarian pain, elevated basal body temperature to name a few.  In my case, ovulation is starting to get a bit uncomfortable.  Am I really feeling new pain on the left or am I feeling pain there because I think I should be feeling pain there because I now know that there’s a fibroid there that the doctor has told me needs to be surgically removed?  I feel this discomfort every month.  Isn’t that a bit strange considering that we supposedly ovulate on alternating sides?

Anyway, I called to let the office know that I ovulated.  One of the doctor’s nurses called me back and gave me the good news about my FSH and estradiol levels.  She was far more informative than the other nurse I talked to last week about my test results.  However, she also wanted to talk to me about my x-ray.  Huh?

Evidently my doctor has been carrying around my chart with him.  My new medi friend says that it’s not unusual for a doctor to carry around patient files.  Ok.  Back to the story.  So, he has just recently looked at my HSG picture.  (He wasn’t the doctor that ordered or performed the HSG.  However, why was he looking at the film?  He supposedly had already looked at it and decided that I didn’t have a Mullerian Anomaly.)  What?  And she said that he’s going to want to do a sonohysterogram on CD6 next month.  What?  After the ultrasound he did at my appointment, he very confidently told me that the fibroid is definitely causing me problems; a sono was NOT necessary; get on the books for a myomectomy.

Why has his story changed?  Did he forget that he had already looked at the HSG?  Did he forget that he said a sono was no longer necessary?  Did he forget that he wanted to schedule me for surgery?  Or did he receive some input from one of his partners or the radiologist with regard to the HSG or recent ultrasound?  Is he confusing me with another patient?

Can I just say that I’m very frustrated and that my trust in this medical professional is waning?  Three different doctors; three different diagnoses; at least three different protocols.  It’d be nice for there to be some agreement with regard to a plan of action, particularly between my new OB and this RE.  Or do I need to go back to the drawing board?

I happened upon an interesting self-ascribed feminist post about “medical rape” and the “medicalization of childbirth.”  I’m certain that I have written about being an empowered patient, since that is one of my goals as a childbirth activist - to help empower women to participate in their health care, ask questions, get second opinions, etc.

I’m not sure the original author has much knowledge of the socio-political dynamic in part responsible for the current state of modern medicine.  However, she makes some good points.  For instance:

The male medical establishment - even with female practitioners - tend to subvert women and suppress their decision-making ability, especially in the reproductive health sector.  Why?  Well, it is easiest to exert power over a woman when she is on her back with her feet in stirrups, her butt hanging over the edge of a paper-clad table, and a speculum shoved into her private parts.  Who hasn’t felt vulnerable and less powerful in that position?

I’m not suggesting that all obstetricians are bad or that men make sucky gynecologists, not any more than I’d suggest that cesareans are completely unnecessary, or that the safest place to have a baby is at home.  Then again, statistically about half of the cesareans performed in this country are not necessary (and don’t improve our infant mortality rate), and actually staying home is the best way to ensure that unnecessary interventions aren’t performed on you when you’re only 2cm dilated at the hospital.  Unfortunately, a growing number of women are dissatisfied with the services their obstetricians provide, are disgusted by medico-legal decision-making when it comes to women’s (and babies’) physical and psychological well-being during the childbearing year, and suffer poor childbirth outcomes.

Something has to give.

Tags: obstetrics, gynecology, medical rape, medicalized childbirth, awareness, advocacy, childbirth

I just talked with my regular OB.  He was under the impress that I had a Mullerian Anomaly (such as a septate uterus) and a major contributor to my recurrent pregnancy loss.  I’ve seen a Reproductive Endocrinologist recently who came up with his own recommendation.  He suggested that my 1-1/2 inch fibroid was distorting my uterine cavity and causing the recurrent pregnancy loss.  He said that he would be “very concerned” about that fibroid.

I double-checked my obstetric records from my 2004 pregnancy.  The fibroid was discovered during a 10-11 week ultrasound (a first-time mom, I was nervous that the midwife didn’t find my baby’s heartbeat).  The fibroid was roughly 4.5 cm then and is therefore about the same size now.  However, I don’t believe it to be a cause of my recurrent losses.  Rather, it is a symptom.  It is a symptom of imbalanced hormones, usually too much estrogen.

Anyway, my OB’s nurse called me today to say that he (my OB) would NOT recommend a myomectomy for a non-symptomatic small fibroid.  I don’t bleed without stopping; I don’t have unmanageable pain.  Since I already have a cesarean scar, he sees no reason to add to that.  Phew!

So, if anyone tells you that you definitely need a myomectomy, please do seek other opinions.  Your uterus may just say “thank you.”  In my case, it should be thankful that I’m saving it from at least two more uterine surgeries.

I am doing an intensive research study program this summer in Denver.  I’m learning more than I ever thought I needed to know about how the voice works.  Yesterday was an anatomy crash course which sent me to Amazon to purchase anatomy coloring books.  Yes, I did say COLORING books.  Today was a crash course on biomechanics - ya know, just enough to really scramble my noodle.  Newton’s Laws and all that.

I know that eventually there will be some neat way to apply what I’m learning about the hard sciences even to my advocacy work.  I’ll share my ruminations as they attack me in my dreams.  Currently I’m still considering sending a pipe bomb to one of my old doctoral professors.  (No, not really!)  I’m disgusted that I have a terminal degree (a doctorate for chrissakes!) and don’t already know 1/8 of the material I’ve encountered in the last two days of class.

I read a FriendFeed “friend’s” tagged post, and thought I might add some random details about myself:

• I used to be a Republican, sort of - I worked for CNN during the 1992 RNC and interviewed for a job with Senator Phil Gramm whom I met through an assistantship I held with then Mayor (now Congresswoman) Kay Granger (whom I wrongly assumed was a Democrat)
• I still like mac & cheese and hot dogs (and yes I know that hot dogs are made of lips, asses, and worse)
• I pick the random wiry black hairs off of my blonde head; they grow back
• I can sing lower pitches than some men
• I carry around water and don’t drink it; I prefer coffee and alcoholic bevies
• I’m a social mediaphile - I FriendFeed, I Plurk, I Tweet, I blog, I post, and e-mail is becoming much less relevant to my on-line experiences

Anyone else want to share their gory details??

I wish I was kidding.  I’m not.  I was insensed to read that a woman in Colorado was denied coverage because of a prior cesarean.  I hope you’ll read Navelgazing Midwife’s post.  It’s a good summary of the situation.

Ick.