Tag Archives: Obstetrics

Sexual and Reproductive Coercion

The American College of Obstetrics and Gynecology (ACOG) recently published a committee opinion discussing the subject of Sexual and Reproductive Coercion (SRC).

SRC is a pattern of physical violence or psychologically coercive behaviors intended to control a woman’s sexual decision making, contraceptive use, or pregnancy.

These behaviors are examples of intentional attempts of others, most commonly the male sexual partner, to control the sexual and reproductive rights of a woman.

The coercion includes contraceptive sabotage, where a patient’s partner intentionally hides birth control pills, refuses to wear a condom during intercourse, makes holes in condoms, or forcefully removing intrauterine devices or vaginal contraceptive rings in an attempt to get their partner pregnant against their will.

The coercion, however, may also include pressure from family and friends by embarassing or pressuring a woman through guilt or intimidation into having a child before the woman is ready. It also includes forcing a woman to have an abortion or termination of pregnancy.

Sexual and reproductive coercion is commonly associated with sexual and physical violence. One study involving adolescent mothers on public assistance reported birth control sabotage by over 50% of their dating partner.

Recommendations in order to assist patients at risk for sexual or reproductive coercion include (1) offering  hotline numbers and referrals to local domestic violence shelters and agencies, (2) offering long-acting methods of contraception less detectable to their partners such as the IUD, the Implanon or Depo Provera Injectable. (3) When using an IUD, trimming the string inside the cervix in order to prevent the partner from feeling the string or being able to pull the IUD out, (4) Provide Emergency Contraceptive (Plan B) pills and (5) Provide harm-reduction strategies and safety planning.

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ASK DR NOVOA- Why is Board Certification in Obstetrics Not Necessary?

I recently read a blog written by a Board-certified OB/GYN commenting that she disagreed with the American Medical Association’s position on allowing non-Board certified doctors to practice medicine.
 
Although I can appreciate the need for standardization and minimal requirements in regards to training and experience, I have to strongly disagree with doctors stating that Board-certification is absolutely necessary.
 
If you review each of the Board requirements for the 24 specialties certified by the American Board of Medical Specialties, you will become very aware of a recurrent loop-hole regarding true confirmation of sustained proficiency and expertise in each practice specialty.  Currently, there is no daily, monthly or even yearly monitoring of the practices of Boarded doctors, especially in Obstetrics and Gynecology.  That is to say, that once you pass your Board certification, you are under no obligation, nor are you required to be monitored to confirm that you are practicing in the manner which allowed you to get your Board-certification.
 
As an example.  The American Board of Obstetrics and Gynecology (ABOG) specifically states on it website the following “THE ABOG DOES NOT LICENSE MEDICAL DOCTORS. LICENSING OF MEDICAL DOCTORS IS DONE BY THE RESPECTIVE JURISDICTIONS IN WHICH SUCH DOCTORS PRACTICE.
 
THE ABOG IS NOT RESPONSIBLE FOR ANY MEDICAL DECISIONS MADE OR TAKEN BY ANY MEDICAL PRACTITIONER WHO MAY BE A MEMBER OF THE ABOG. THOSE DECISIONS ARE THE RESPONSIBILITY OF THE TREATING PHYSICIAN AND HIS OR HER PATIENT.”  www.abog.org
 
What this amounts to is that the ABOG and other Boards do not routinely monitor the practice patterns of its member doctors to confirm that they are maintaining even a “minimal level of competency, proficiency or ethics” (except maybe during a re-certification year, where the doctor may be asked to submit up to “10” patient charts for review). “10” charts???? Really???? If the average OB were to deliver only 10 patients per month or 120 per year, this represents an evaluation of only 8.3% of their practice during that re-certification year. For doctors delivering between 200-400 babies per year, the percentage of possible evaluation falls to as low as 3% in that year alone. Further, if they are allowed to “cherry-pick” their case list, it is no wonder that the ABOG may be missing up to 50% of the unnecessary C-Sections which their Board-certified members are doing per year.
 
The tragedy of this problem can best be  demonstrated by the current extraordinarily high level of unnecessary Cesarean Section (C/S) associated with Board-certified OB/GYNs in the United States.  
 
In 1967, the rate of C/S was only 5%, today it is 33%.  Despite this embarrassingly high rate of C/S, we have not seen any documented benefits in the literature when comparing the risks vs. benefits to either the baby or the mother with having such a high rate of C/S as compared to the rate during the 1970s.
 
It is estimated that 500,000 C/S per year are unnecessary with greater than 90% of them being performed by Board-certified OB/GYN doctors.  
 
In comparison, the risks of complications associated with non-board certified OB/GYN doctors, certified mid-wives and family practice OB/GYNs are much LOWER when comparing both low and high risk patients.
 
The Center for Disease Control (CDC), the World Health Organization (WHO), and Healthy People 2010 have all recommended the benefits of keeping a rate of C/S at or below 15%.
 
The reasons for all this are obvious.  Doctors are practicing defensive medicine and for the convenience of the doctor over the needs and benefits of the patient.  This includes both non-boarded and Board-certified doctors.  However, with greater than 90% of OB/GYN doctors being boarded, the problems with obstetrics in today’s society is overwhelmingly due to the behavior of Board-certified OB/GYNs.
 
Now, after decades of seeing what has been going on, year after year, the American Congress of Obstetrics and Gynecology (ACOG) has finally starting to comment that there is a problem.  However, this is still too little, too late.
 
What needs to happen with all the Boards, is that doctors claiming proficiency and expertise based on being board-certified should be required to post monthly stats for the general public to review in order to confirm this level of proficiency on a day to day basis.  Until this happens, all being board-certified means is that you passed a written test and passed an oral exam stating what should be done, but not necessarily agreeing to practice that way in order to maintain your board-certification.
 
Until this happens, I refuse to be board-certified by the ABOG.  However,  I practice what I preach and I post my delivery stats online every month for the general public to review.  Despite delivering between 300-500 babies per year and specializing in complicated deliveries, such as Twin Vaginal Delivery and Vaginal Birth After Cesarean Section (VBAC), I have a primary C/S rate of less than 7% and VBAC failure rate of less than 10%.
 
As far as CME,  I am required to have 24 per year to keep my Texas Medical License.  I, however, have earned over 1000 (yes, one thousand) in the past 3 years.
 
So, for my colleagues that are Board-certified, please help do something about the problem and stop pretending that Board-certification has the merits that you are bestowing upon it.  We all know of Board-certified doctors that routinely practice below the recommended standards and are ethically challenged.  We all know that Board-certification doesn’t keep any doctor from practicing the way they want to practice, especially in ways that make it easier for the doctor.  We all know that an overwhelming number of Boarded doctors are practicing defensive medicine (which is unethical).  We all know that very few times, if ever, does a Board-certifying body make one its Fellows produce statistics regarding their practices.
 
Until a Board-certified doctor is required to prove that not only can they pass a test, but that they practice every day the way they stated when they became Boarded, the American public is better off evaluating both Boarded and non-Boarded doctors on a case by case basis.
 
Sincerely,
 
Dr. Julio C. Novoa, M.D.

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ASK DR NOVOA- Is it ethical to plan a C-section for a contest?

Question: For the past few years, the first New Year’s Baby born in El Paso has received gifts from one of the El Paso societies.

It has actually gotten pretty competitive with a number of OB doctors intentionally scheduling New Year’s Eve Cesarean Section deliveries in order to help their patients get the prize.

However, this seems both unnatural and unfair. With an elective or scheduled repeat C/S as an option in order to win this contest, it makes it almost impossible for a patient who is trying for a natural vaginal delivery and has been laboring for hours or for days to possibly win. A C/S delivery planned out and timed for delivery can take as little as 15 minutes to perform, while a vaginal delivery can take days.

I had actually agreed to participate not thinking that it had a negative impact, but I am sincerely reconsidering. I have started to get a lot of negative comments about the contest.

As a doctor who strongly supports a woman’s right to have a vaginal delivery, especially in cases of previous C/S (Vaginal Birth After Cesarean Section), I worry that I am sending out the wrong message to take the easy way out and have a C/S in order to win a contest, when the fairest way is to celebrate the delivery of the first baby born by vaginal delivery rather than by C/S.

What do you think? Should there only be one contest or should the first vaginally delivered baby be crowned the first New Year’s Baby of the Year?

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ASK DR NOVOA – Midwives and Vaginal Deliveries

A recently published 2009 report from the CDC states that the number of deliveries being done by midwives in the US continues to increase. Congratulations!!!

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ASK DR NOVOA – Is the Cesarean rate too high?

Unfortunately the rate of C/S in the US is almost 33%. During the 1970’s it was only 5%. We need to do better for the benefit of our patients and their babies.

Please see the following Youtube video with more of Dr. Novoa’s thoughts.

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ASK DR NOVOA – What are your thoughts on VBACs?

My thoughts about VBAC or Vaginal Birth After Cesarean section is discussed in the following Youtube video.

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ASK DR NOVOA – What are some of the questions I should ask when selecting an obstetrician?

I have created a Youtube video which includes 12 questions to ask when selecting an obstetrician.

Please review the video below.

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ASK DR NOVOA – I was recently pregnant but lost the baby. I didn’t believe my doctor so I repeated my pregnancy test about a week after the loss. The test says I am pregnant. Does this mean I am pregnant again?

No. I doubt that you are pregnant.

Both urine and blood pregnancy tests are extremely sensitive and can accurately determine if you are pregnant just a few days before your missed period.

The lowest level of HCG, which is the hormone of pregnancy that can be determined by home pregnancy tests is 20mIU/ml.

However, once pregnant, your level of HCG will double every 2-3 days. So after a few weeks, your HCG level can literally be greater than 10,000mIU/ml.

If there is a loss of a pregnancy, such as a miscarriage, HCG will no longer be produced, but you will continue to test positive on a pregnancy tests from 1-3 weeks depending on how high the HCG level reached.

Eventually HCG will no longer detectable since your body eliminates it just like any other hormone, but until this happens, you may not have a period or ovulate, so you need to realize that getting pregnant again may take a few months.

Therefore, it is best not to test for pregnancy after a miscarriage for at least a month after the loss in order to confuse you about being pregnant again.

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Filed under Blog, Gynecology, Obstetrics, Questions of the Day

ASK DR NOVOA – I was thinking of getting an epidural when I am in labor, but I was told it will increase my chances of a C/S and can cause permanent damage to my back. Is this true?

Generally speaking, NO and NO.

The epidural, short for epidural analgesia, is a procedure where a small catheter is placed in the epidural space of the back. Once placed, both pain medication and anesthesia can be given over a number of hours or even days.

For most women, it can mean the difference between smiling through their contractions or suffering for hours until they deliver their baby.

In general, greater than 95% of women will request the epidural for pain management. Unlike oral, intravenous or intramuscular medication, which will eventually enter the bloodstream of the baby, the epidural does not cause the transmission of these types of drugs to the baby.

Some studies have suggested that the use of the epidural can increase the length of labor and increases the risk of C/S. However, when your OB follows the recommended guidelines for labor management, there is very little risk of complications.

Many women believe that the epidural causes permanent or chronic back pain. This can occur but is not due to the actual placement of the epidural line, but, rather, on back injury sustained when moving or straining while pushing without sensing pain. The easiest way to understand this is that the epidural can allow you to literally put your foot behind your head without feeling pain. When you can do this, there are no warning signs being sent from your back to your brain saying “Don’t Do This”. Therefore, it is very easy to injure your back without even knowing it while the epidural is working.

If you are interested in statistics, the risk of neurological injury or paralysis from an epidural is 1/250,000. The risk of death is 1/100,000.

Despite this, the epidural is extremely safe and is highly recommended in order to help a woman avoid the intense pain of labor and enjoy her labor with a smile.

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ASK DR NOVOA – Is it harmful to eat Chili or hot sauce when I am pregnant.

NO.

Although a pregnant woman may have a more sensitive stomach, eating spicy food or chili will not harm a baby.

An additional consideration is if you suffer from indigestion or acid reflux which could make your symptoms worse by eating spicy, or food with pepper or chili.

So as long as you can handle the taste, go ahead and enjoy your chili.

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