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Monday, August 26, 2013

Placenta Accreta, Part One: What Is Accreta?

Illustration of placentas (and truncated umbilical cords),
showing the difference between normal and abnormal placental
implantation with differing degrees of accreta; look at the light red
areas where the placenta touches the uterus to see the difference
Image from Wikimedia Commons

As a follow-up to the many discussions we have had about too-high cesarean rates, we are talking about late complications from cesareans.

Beyond the usual immediate surgical risks (infection, hemorrhage, anesthesia problems, blood clots, and accidental damage to surrounding tissues), many people don't realize that cesareans can cause problems in future pregnancies after the cesarean.

In particular, the risk for abnormal placentation rises with each successive cesarean.  These include:
  • placental abruption (the placenta shearing off before the baby is ready to be born) 
  • placenta previa (a low-lying placenta that covers or nearly covers the cervix)
  • placenta accreta (an abnormally attached placenta that has difficulty detaching after birth)
All of these can be life-threatening to both mother and baby.

Today we are going to discuss placenta accreta in all of its scary variations.

How Does the Placenta Work?

Before we discuss placenta accreta, it's helpful to know a bit about how the placenta implants and what it does.

The placenta is like a trading post or interface where mother and baby exchange goods (nutrients, oxygen, and waste) back and forth.

Essentially, the placenta performs the functions of lungs, kidneys, and digestive system for the fetus until it is born, not to mention supplying the hormones needed to support the pregnancy and being a filter to keep out most harmful substances.

However, it's important to note that the baby's blood and mother's blood don't mix. This is to keep the mom's body from treating the baby as a foreign invader and attacking it.

Placental Circulation, from Gray's Anatomy
(via Wikimedia Commons)
To trade the nutrients, oxygen and waste, the blood of the mother and chorionic villi of the baby are lined up next to each other but they don't actually mix blood supplies. Or as one author explains:
Mom's blood flows into the blood lake on her side of the placenta, which bathes the chorionic villi that are threaded through with fetal blood vessels. Small molecules and nutrients (like oxygen, glucose, vitamins, fatty acids, calcium, antibodies, and so on) flow from Mom to baby, and waste products (like carbon dioxide, urine, and metabolic wastes) flow from baby to mom. 
Weighing in at about 1 ¼ pounds when fully grown, the placenta works like a two-way filter. Stuff goes through it from one side to the other and vice versa.

Another author explains it this way:
When the placenta first implants on the inner uterine wall, it secretes enzymes which dissolve the ends of the capillaries which come to the inner surface of the uterus. As a result, the open ends of the arterial capillaries spout little fountains of blood behind the placenta, and the open ends of the venous capillaries return the blood to the mother's heart, like little bathtub drains. This is called an arterial-venous shunt. A lake of blood forms behind the placenta, and the baby's capillaries in the placenta, which remain intact (like little loops), are continually bathed in this lake of the mother's blood. Through this process, oxygen and nutrients pass from the mother's lake of blood, through the baby's capillary walls, and into the baby's blood stream, and waste products pass from the baby's capillaries to the mother's blood.
maternal side of placenta on left
fetal side of placenta on right
To the left, check out the picture of the the maternal vs. the fetal side of the placenta. Notice that the mother's side looks very different than the baby's side.

The mother's side is very red and bumpy. This is where the lake of blood was and where most of the interface between mother and baby happens. The bumps and folds help increase the surface area with which the blood can interact.

On the other hand, the baby's side looks smooth, shiny, and blue. The umbilical cord emerges from this side and takes the nutrients and other materials to the baby.

So to summarize, the fetal placenta creates an interface with the mother where it interacts with the mother's blood without actually implanting into the muscle of the uterine wall. Once the baby is born, the uterus contracts, the placenta releases, and the maternal blood vessels shut off.

Placenta accreta, on the other hand, changes this arrangement in key ways.

Placenta Accreta

Briefly put, placenta accreta is an abnormally attached placenta.

Each month when a woman ovulates, the lining of her uterus (the endometrium) changes in anticipation of a possible pregnancy.  If there is no pregnancy, this lining sheds via the woman's period. But if a pregnancy occurs, the lining of the uterus transforms, becoming the decidua.

The decidua helps the placenta with the exchange of nutrients, gases and waste products, and helps protect the baby from the mother's immune system. The decidua also keeps the placenta from invading the mother's uterus.

In placenta accreta, the decidua is deficient, allowing the placenta to attach itself directly into the maternal tissues.  How deeply it attaches determines the severity of the accreta.
Image Source: Reitman 2011, Anesthesiology

In an accreta, the placenta invades the deficient decidual layer and attaches to the wall of the uterus. Because of this, it isn't able to easily shear off and fully detach once the baby is born.  In medical terms, the placenta is "morbidly adherent."

In other words, it is stuck and won't come off easily, or may only detach partially.  This is a problem because the open maternal blood vessels that feed the lake of maternal blood can't shut off.  As a result, the mother can hemorrhage severely until the placenta is removed and the uterus behind it contracts and starts shrinking. About 75% of accretas are in this form, where the placenta is morbidly adherent to the uterus but has not grown deeply into it.

In a more severe form, Placenta Increta, the placenta actually grows deeply into the muscle of the uterus.  It is nearly impossible for these placentas to detach unless they are cut out. This can lead to massive hemorrhages that often necessitate a hysterectomy.

In the most severe form, Placenta Percreta, the placenta grows not only into the muscle of the uterus but through the outer layer (serosa) and often into adjacent structures nearby.  This is an extremely life-threatening situation because it can't be solved with "just" a hysterectomy; the placenta must be removed from other areas and any organ damage must be fixed.  Percretas usually grow into the mother's bladder  or bowels (which are the structures nearest most percretas) and women can suffer severe injury. Sometimes women even die from percretas.

Summary

Placenta accreta comes in three levels of severity ─ accreta, increta, and percreta.

Thankfully, most accretas don't involve an increta or a percreta. However, even without these severe forms, an accreta is still a very serious complication that has the potential to become life-threatening.

Fortunately, foreknowledge of an accreta, careful management protocols, and being in the right delivery setting can significantly lower the risk for mortality and morbidity. So if you have been told that you have an accreta, don't panic. Chances are that you and your baby will be okay.

However, you need to know that a significant blood loss is likely, a transfusion may be needed, and a hysterectomy is a distinct possibility (depending on the severity of the accreta). In the most severe cases, nearby organs may be damaged as well. Management and delivery in a large regional hospital with OBs that are very experienced with dealing with accretas will optimize your chances for the best outcomes.

Sadly, the incidence of accretas has increased in parallel with the rising cesarean rate.  This is because scarring and damage to the uterine lining during a cesarean predisposes to abnormal placentation. Indeed, the more cesareans a woman has, the higher her risk for placenta accreta.

Some risk factors for accretas cannot be controlled, but a high underlying cesarean rate is a risk factor that is preventable on a population-wide basis, and routine repeat cesareans is a risk factor that is highly preventable on an individual basis.  

Placenta accreta is an extremely serious complication that is becoming all too common.  A casual attitude towards cesareans, an over-utilization of them in low-risk mothers, and a lack of access to Vaginal Birth After Cesarean (VBAC) is part of the cause.

This is yet another reason why reducing the cesarean rate and keeping access to VBAC is so important.

Next post: Accreta incidence, risk factors, risks, and management


References*

Increase in Incidence of Abnormal Placentation

Obstet Gynecol Clin North Am. 2013 Mar;40(1):137-54. doi: 10.1016/j.ogc.2012.12.002. Placenta accreta, increta, and percreta. Wortman AC, Alexander JM.  PMID: 23466142
Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate. The prenatal diagnosis of placenta accreta by ultrasound along with risk factors including placenta previa and prior cesarean delivery can aid in delivery planning and improved outcomes. Referral to a tertiary care center and the use of a multidisciplinary care team is recommended.
Aust N Z J Obstet Gynaecol. 2004 Jun;44(3):210-3. Is placenta accreta catching up with us? Armstrong CA, Harding S, Matthews T, Dickinson JE. PMID: 15191444
...METHODS: A retrospective review of all cases of placenta accreta and variants during the period of 1998-2002. Individual charts review followed case ascertainment via the hospital obstetric database. RESULTS: Thirty-two women with placenta accreta (or variant) were identified. Median maternal age was 34 years, with a median parity of 2.5. Seventy-eight percent of cases had had at least one prior Caesarean birth, and 88% of cases were associated with placenta praevia. Pre-delivery ultrasonography was performed in all cases, providing diagnostic sensitivity of 63% and specificity of 43% with a predictive value of 76%. Hysterectomy was performed in 91% of cases with median intraoperative blood loss of 3000 mL. There were no maternal deaths in the current series. CONCLUSION: A strong association between placenta accreta, placenta praevia and prior Caesarean birth has been demonstrated. As there is the potential for significant maternal morbidity the risk of placenta accreta needs to be recognised and women at risk should be considered for delivery at an institution with appropriate expertise and resources in managing this condition.
*More detailed references in the next post

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Monday, August 19, 2013

Cesarean Wound Complications: A Reason to Avoid CS in Women of Size

image from caesarean.org.uk 
It's no secret that surgery is harder in "obese" people and there is more risk for infection and other wound complications.

This is why doctors generally discourage surgery in fat people.

However, somehow this caution against routine surgery in fat people doesn't seem to apply when it comes to pregnancy, where some care providers routinely just schedule an automatic cesarean section in women with a BMI over 40 (and often under that).

Even when a routine cesarean is not scheduled, research shows clearly that care providers have a lower surgical threshold for "obese" women, and manage labor in this group in a way that leads to more cesareans.

The bottom line here is that cesarean sections in obese women are extremely common, even though the surgery is harder and more risky in this group. And that means many women of size deal with cesarean wound complications. That's a tough way to start motherhood and can interfere with breastfeeding and bonding.

Now, a new study confirms that cesarean wound complications rise as BMI rises. This is not really a surprise, but the study still had lessons to teach the obstetric community ─ if it would just be open to hearing them.

Results of the Study

In the study, the rate of wound complications (infections, wound disruptions) rose in a dose-response relationship to BMI. The wound complication rates were:
  • BMI <30    -            6.6%
  • BMI 30-40 -            9.2%
  • BMI 40-50 -          16.8%
  • BMI 50+    -          22.9%
That means that nearly 1 out of 6 women with a BMI of 40 or more and nearly 1 in 4 women with a BMI of 50 or more developed a significant wound complication.

Not good. But there are studies where the wound complication rate in women of this size is even higher. Alanis 2010 found that nearly 1 in 3 women with a BMI of 50 or more developed cesarean wound complications.

A good reason to stop doing so many cesareans in women of size, right?

Too bad that's not the lesson most care providers will take from this. Many care providers' only answer to the high rate of cesarean wound complications is that obese women need to lose weight before pregnancy. Period.

Never mind that the cesarean rate is outrageously high in obese women and could probably be lowered.  Never mind that many care providers routinely schedule automatic cesareans for women with a high BMI, most of which are questionable.

Never mind that very few "morbidly obese" people lose weight to a so-called normal BMI, let alone maintain that loss for any length of time. Never mind that trying to lose weight yet again often leads to weight cycling, which is a strong risk factor for weight gain in the long run.

And never mind that many of these cesarean wound complications might be preventable with different techniques and protocols more appropriate to these women's size.

Nope, the answer to everything is to tell women to just lose weight, rather than to lower the cesarean rate in obese women or to study how to improve outcome in this group independent of losing weight.

Deep down, some care providers seem to believe that fat women deserve whatever complication happens and don't feel very motivated to study how to improve outcomes in high-BMI women. Others may feel complications are simply a logical consequence of adiposity and not very preventable.

Yet how do they know these outcomes aren't preventable if they don't even study it?

It just stumps me how care providers can have about a 50% c-section rate (or more) in very obese women and have done so little study on how to improve outcomes in this group.

But be that as it may, there are still things to be learned from this study.

Lessons from the Study

Here are a couple of lessons that care providers should be taking from this study.

Lesson #1 - Unless there is a compelling medical reason to use a vertical incision, STOP using it in women of size.

In the study, surgeons did more vertical incisions on women as obesity increased. Yet vertical incisions are associated with increased rates of wound complications and infections in obese women in a number of studies.

It's rarely truly necessary to use a vertical incision, even in extremely obese women, and it increases the risk for poor outcomes. Low transverse incisions have been used successfully even in women of 400-500 pounds without poor outcomes.

If care providers want to lessen wound complications in obese women, then they need stop doing so many vertical incisions. Yet some are still promoting the idea that vertical incisions are the incision of choice in fat people. Wrong.

Lesson #2 - Start studying ways to improve post-cesarean outcomes in women of size. 

Considering that half or more of obese women undergo cesareans in some areas of the U.S. (!!!), why haven't there been studies trying to examine how to reduce complications in these women?

For example, I'd love to see some large randomized trials on optimizing cesarean techniques for women of size, like what dose of antibiotics is best for morbidly obese women. Recent research shows that current antibiotic dosage is not adequate for many high-BMI women but very little research has been done on the efficacy and safety of increasing antibiotic dosage in this group.

Research on other surgical procedures suggests that many obese people benefit from extended antibiotic regimens, more frequent dosing, use of extended-spectrum drugs, and topical infusions of antibiotics during surgery. It may take a combination of increased doses and other techniques to truly bring down the rates of surgical site infections; when will there be research to discover what is the best antibiotic dosage and regimen for "morbidly obese" women who have had a cesarean?

In addition, care providers should study whether changes in surgical technique could improve outcomes in this group. There have been some trials on whether or not to suture the adipose layer and whether or not to use drains, but more research on this is needed to confirm what previous studies seem to show. Currently, the research seems to suggest that there is a strong benefit from suturing the adipose layer, but that surgical drains may do more harm than good. Let's do more research to answer this question definitively.

Closure materials and methods may be relevant as well. The wound complications study we are discussing mentions that more obese women were closed using staples instead of subcuticular stitches, yet some recent research suggests that staples may predispose to more wound complications. Non-absorbable versus absorbable stitches may make a difference, too. Stitching takes longer than staples, especially in heavier women, but doing it (and using optimal materials) might be another way to lower the risk for problems.

Examine wound-healing treatments too, like wound vacs and medicinal honey, to see which ones work the best for speeding surgical healing for those obese women who experience wound complications.

The important thing is to study these options more closely in this population and then develop and implement Best Practice Recommendations for them, instead of just shrugging our shoulders and lamenting the rate of problems.

Lesson #3 - The biggest lesson here is that cesareans should NOT be done without good reason in women of size.  

When are care providers going to study how to lower the cesarean rate in this group?

There are many studies documenting and bemoaning a high c-section rate in obese women. Yet rarely do they study whether this rate can be changed with different management.  

 Care providers are not powerless to lower the c-section rate; many studies have shown that cesarean rates can be lowered safely when attention is focused on the problem.  But not one study has been done to try and see if the cesarean rate in obese women could be lowered.

The easiest way to do this would be to stop the common practice of planned cesareans. In one recent study, a third of very obese women had primary cesareans without labor. If one out of every three or four of these women then develop serious wound complications (not to mention the downstream complications of placental issues in future pregnancies), that's a LOT of morbidity resulting from cesareans that are questionable in the first place.

Once you reduce non-labor cesareans, start studying ways to lower the labor cesarean rate in this group. Many care providers believe that a high cesarean rate in labor is inevitable in very fat women, yet studies show very different rates. This suggests that there is room for change.

For example, one study of "super obese" (BMI 50+) women from the U.K. showed half the cesarean rate of a similar group in Kentucky and another group in Canada.

Cesarean rates in "super obese" women are often nearly 50-60% in some areas of North America, yet this U.K. study had a cesarean rate of 30% in women of the same size. This shows that the cesarean rate in labor could be far less in "super obese" women, and is potentially modifiable.

Most very obese women rarely see midwives and this may also be part of why they have high cesarean rates, since hospitals with a high rate of births attended by midwives tend to have lower cesarean rates.  Obese women are induced at very high rates, and this may be a strong part of the cesarean rate in this group as well.

There are many possibilities for trying to lower the cesarean rate in obese women, but at this point, no one is even trying to do so.

If you want to lower the high rate of cesarean wound complications in obese women, the most effective way to do so is to lower the number of cesareans done in this group.

Summary 

 This study shows that cesarean wound complications tend to rise as BMI rises. This is hardly ground-breaking research.

However, it would be far more groundbreaking if researchers turned their attention to proactively preventing more of these complications.

If 1 in 4 (or more) high-BMI women are experiencing significant wound complications, then something needs to change instead of just accepting this occurrence as inevitable.

Unfortunately, most care providers would look at this data and say that it means we need yet another anti-obesity campaign to scare women into losing weight before pregnancy, despite the stacks of evidence showing how difficult and how unlikely this is to happen.

Make no mistake, I'm all for encouraging people to be as healthy as possible, but the data clearly shows that massive, sustained weight loss is very unlikely in most fat people. Putting all your prevention eggs in the weight loss basket means that there will be a lot of egg on the faces of the care providers involved.

Instead, what providers should be doing is recognizing the opportunities that underlie this data.  We don't have to have a 1 in 4 wound complication rate in obese women.  We can change that outcome. Let's start studying how.

The first and most important step, of course, is to stop DOING so many cesareans in women of size.  That includes stopping the all-too-common practice of routine planned cesareans in obese women. It means questioning whether a cesarean in a woman of size is truly indicated on a case-by-case basis, instead of blithely accepting that a high cesarean rate "goes with the territory" in this group. It also means doing large-group research to discover ways to lower the labor cesarean rate in women of size (hint: stop doing so many inductions and expand midwifery access for obese women) and demanding accountability from care providers with extremely c-section high rates in this group.

The second step is to stop doing vertical incisions on obese women unless truly medically needed. This will lower the rate of wound complications and will make postpartum recovery easier, not to mention being less disfiguring to the mother. In addition, stop teaching that vertical incisions are preferable in women of size, when the evidence clearly indicates that they are not. Although most care providers use low transverse incisions in their obese patients, some stubbornly keep doing and even promoting vertical incisions in this group. This takes a big toll on the women who are subjected to them. It's past time for this outdated practice to be retired.

The third step is to research surgical technique and protocols to lessen the risk for wound complications when a cesarean truly is needed in women of size. Study whether surgical drains are helpful or harmful in obese women, research optimal antibiotic dosing and regimens, examine whether closure technique and materials need adjusting, and subject wound healing techniques to closer scrutiny to see which are most optimal in this group.

Although wound healing is always going to be more challenging in obese women, a high rate of cesarean wound complications is not inevitable. Instead of bemoaning the situation, find ways to improve outcomes in this group without having to tie it to unlikely goal of weight reduction.

Bottom line...stop doing so many cesareans on women of size.  And when they are truly needed, have some quality research in place to show how the risk for wound complications can be lessened in this group.


Reference

Am J Perinatol. 2013 Jun 13. [Epub ahead of print] Maternal Obesity and Risk of Postcesarean Wound Complications. Conner SN, Verticchio JC, Tuuli MG, Odibo AO, Macones GA, Cahill AG. PMID: 23765707
Objective: To estimate the effect of increasing severity of obesity on postcesarean wound complications and surgical characteristics. 
Study Design: We performed a retrospective cohort study of consecutive cesarean deliveries at a tertiary care facility from 2004 to 2008. Four comparison groups were defined by body mass index (BMI; kg/cm2): < 30 (n = 728), 30 to 39.9 (n = 1,087), 40 to 49.9 (n = 428), or ≥50 (n = 201). The primary outcome was wound complication, defined as wound disruption or infection within 6 weeks postoperatively. Surgical characteristics were compared between groups including administration of preoperative antibiotics, type of skin incision, estimated blood loss (EBL), operative time, and type of skin closure. 
Results: Of the 2,444 women with complete follow-up data, 266 (10.9%) developed a wound complication. Compared with nonobese women (6.6%), increasing BMI was associated with an increased risk of wound complications: BMI 30.0 to 39.9, 9.2%, adjusted odds ratio (aOR) 1.4 (95% confidence interval [CI] 0.99 to 2.0); BMI 40.0 to 49.9, 16.8%, aOR 2.6 (95% CI 1.7 to 3.8); BMI ≥50, 22.9%, aOR 3.0 (95% CI 1.9 to 4.9). Increasing BMI was also associated with increased rates of midline vertical incision, longer operative time, higher EBL, and lower rates of subcuticular skin closure. 
Conclusion: A dose-response relationship exists between increasing BMI and risk of postcesarean wound complications. Increasing obesity also significantly influences operative outcomes.

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Wednesday, August 7, 2013

Ham Radio

image from Wikimedia Commons
Every summer I try to have a project of some sort to work on. Sometimes these have an emergency preparedness focus, though not always. Not because I'm a big "prepper" per se, but because it's only common sense to prepare for bad weather, power outages, and natural disasters.

For the past several summers I have worked on learning more about pectin choices and how to can food so I can have more food on hand that doesn't have to be refrigerated (and to preserve the bounties of my garden!).

I have also worked on building up readiness kits, improving our fire safety, emergency water supplies, and lighting and heating options if power outages occur, etc. We still have a ways to go on all these goals, but it's all about making progress, not being perfect.

This year, I decided to get my ham radio license. So today I'm going to blog about that in honor of National Preparedness Month, which is coming up soon.

What is Ham Radio?

"Ham" Radio is a hobby where amateurs (as opposed to broadcast professionals) communicate with each other via radio waves.

Although most hams use voice communication, ham radio can include other types of communication, including Morse code, digital communication (emails and the like), and even some analog television.

From the ARRL website:
Amateur Radio (Ham Radio) is a popular hobby and a service in which licensed participants operate communications equipment. Although hams get involved for many reasons, they all have in common a basic knowledge of radio technology and operating principles, and pass an examination for the FCC license to operate on radio frequencies known as the "Amateur Bands." These bands are radio frequencies reserved by the Federal Communications Commission (FCC) for use by hams at intervals from just above the AM broadcast band all the way up into extremely high microwave frequencies.
So basically, a ham radio is a radio that allows you to broadcast and receive in frequencies that the FCC has designed for amateur radio operators. The website explains this further:
Look at the dial on an old AM radio and you'll see frequencies marked from 535 to 1605 kilohertz. This is one radio "band." There are other bands of radio spectrum for amateur, government, military and commercial radio uses. If you could hear the many different bands, you would find aircraft, ship, fire and police communication, as well as the so-called "shortwave" stations, which are worldwide commercial and government broadcast stations from the U.S. and overseas. Amateurs are allocated 26 bands (i.e., specific groups of frequencies) spaced from 1.8 Megahertz, which is just above the broadcast radio frequencies, all the way up to 275 Gigahertz! Depending on which band we use, we can talk across town, around the world, or out to satellites in space. Hams can even bounce signals off the moon!
In other words, the electromagnetic spectrum involves an extremely wide range of frequencies. Some are used for public broadcast, like on the radio or the TV.  Some bands are reserved for military use, government use, or for police and fire personnel.

However, the government has reserved 26 bands of frequencies for the use of amateur radio enthusiasts (hams). On these bands, we can communicate via voice, Morse code, radio teletype, email and other data transmissions, and even via TV. However, before you can use these bands, you have to become licensed in order to ensure that you use them safely and responsibly.

Ham radio can be done in any country that offers licensure. However, each country has its own rules about access and licensure. The following information is about U.S. licensure. Information about Canadian licensure can be found here. For other countries, google the country's name and "ham radio" to get the rules for licensure.

Why Get Involved with Ham Radio?

One of the first things ham radio operators get asked is why they do it. Frankly, people get involved with ham radio for many reasons, but there are three reasons that are the most common.

Some do it because they are interested in electronics and this is a good way to pursue that interest. I would say that's the story of the majority of hams, especially the old-timers in the field. There are a lot of engineers who are hams, and a lot of geeky-minded folk who just like to fiddle with electronic stuff. Ham radio offers the perfect hobby for them.

However, that's not me; I knew nothing about electronics before now and don't have any special interest in it.  I find the field somewhat interesting in theory, but I have many other interests that are more compelling. So while having an electronics hobby is a motivator for a lot of people, it wasn't for me.

Some get involved in ham radio because of its potential for communication and making friends. The cool thing about ham radio is that you can make contact with people all over the world, even including astronauts on the Space Station! How cool is that? I have to be honest; I like that part.

Ham radio is like having instant gratification pen pals. No need to wait for a letter to wind its snail-mail way to you; you just press the button and talk. However, although this aspect is cool and I hope to help promote an increased awareness of geography with my kids via ham radio, making new contacts is not my main motivation. Having lived all over the country and visited a few places around the world, I've got plenty of friends and contacts.

No, for me, the appeal of ham radio is its usefulness in an emergency. No, I'm not worried about a zombie apocalypse and I'm not a conspiracy-minded end-of-the-world prepper. However, I have lived through or near a couple of natural disasters and am more aware of the challenges of such scenarios than most people, and am disappointed in how unprepared most people are for such a possibility.

My area of the country is prone to certain types of natural disasters and I want to be more prepared for that possibility, that's all. And Ham radios are extremely useful during emergencies:
In times of disaster, when regular communications channels fail, hams can swing into action assisting emergency communications efforts and working with public service agencies. For instance, it was the Amateur Radio Service which kept New York City agencies in touch with each other after their command center was destroyed during the 9/11 attack. Ham Radio came to the rescue during Hurricane Katrina, where all other communications failed.
I took CERT (Community Emergency Response Training) classes a few years ago, which is where I learned more about the usefulness of ham radios in an emergency.  And I thought, Hey, I could do that.

After a car accident a few years ago ruined my knee, I had to come to terms with the fact that I'll be of limited use in some ways during emergencies. I won't be able to help with Search and Rescue at all, so I wondered what I could even do to help. But the CERT instructor pointed out that I can do first aid, I can help with triage, I can help coordinate emergency services, and I can help distribute emergency supplies. Those are all important roles in a disaster.

In addition, I realized that I could help even more in emergencies if I became a licensed ham radio operator. This is a critical role in a large-scale disaster, yet it's one I could do without further ruining my knee. So I decided that when I got the chance, I would get my ham radio license.

But I've been putting it off.  It's hard to find time when you are so busy!  But when my local ham radio club advertised that it was giving classes towards licensure this summer, I signed up, and also signed up my youngest son. I decided that this would be my big summer project this year.

Cost

Many people think about becoming a ham but hesitate because they think it costs a lot to get started. The truth is that the cost varies, but it can be done pretty cheaply if you are careful.

You can buy a book and other study materials to help you prepare for the technician's license, but honestly, everything's on the internet already.  You don't have to buy a book if you don't want to.

You can take a class too.  Most are offered for free through local ham clubs, though I'm sure there are classes somewhere that cost too.  But again, all the material is available for free on the internet.

Taking the test cost $15.  I recommend studying heavily before you take the test so you can pass it at the first testing session. The test isn't that hard, but you do have to really know your FCC rules, ham radio specs, some basic electronics, basic safety rules, and some simple math formulas (easy algebra, nothing hard). Most people wouldn't pass it without at least some studying, but once you put that effort in, the test is not hard to pass because you can find all the questions online and study up ahead of time.

The actual radio itself is the part that costs. You can spend as much or as little as you'd like. Most beginners start out with small hand-held 2 meter band radios.  Brand new, they cost somewhere between $100 to $200. However, you can find used hand-held 2 meter radios much cheaper than that at ham radio flea markets and online.

The experts recommend starting with a simple unit and then investing in more equipment once you are more familiar with the field and decide you'd like to upgrade. But many people stay with a simple 2 meter hand-held radio and don't upgrade much at all.

So yeah, there is a little bit of investment, mostly in getting the actual radio itself.  But if you get a used unit and do your studying online, it can be pretty affordable.

Levels of Licensure

There are three classes of ham radio licensure in the United States:
  1. Technician
  2. General 
  3. Extra
These levels are sequential. You have to pass them in the above order.  However, if you're feeling ambitious, you can test for multiple levels at one test session (pay the testing fee once and pass the Technician level, then take the General test at the same test session without having to pay more, etc.).

Each class of licensure has different levels of responsibility and privileges.  Basically, the higher your licensure, the wider the range of frequencies you get to access.

However, it's important to note that NO class of U.S. licensure requires learning Morse Code anymore! 

This is the biggest thing that keeps most people from pursuing ham radio. Until 2007, Morse Code (abbreviated as CW for "Carrier Wave") was required for licensure, but it was eventually recognized that this requirement was keeping many people away from licensure and was not really a vital skill for amateur radio anymore. So while learning Morse Code is strongly encouraged at some point, it's definitely not a requirement for ANY class of licensure in the U.S. anymore.

Technician-class operators have to take a 35-question test (and get at least 26 right) to pass. The test is on radio theory, basic electronics, RF safety, FCC regulations, and operating practices. Once the test is passed and a call sign received, Technicians get access to bands that allow local communications and often national communications, as well as the possibility of some limited international communication on a few high frequency ("short wave") bands.

General-class operators get access to a wider range of bands that allow greater ease in long-distance communications, including international communications. This test also involves 35 questions.  You have to have passed your Technician class test in order to take the General test.

Extra-class operators get privileges on all U.S. Amateur Radio bands and in all modes.  This is a harder class of license; there are 50 questions and the test is reputed to be much more difficult than the previous two classes. Questions are on FCC regulations, specialized operating practices, advanced electronics theory, and radio equipment design

The following summary of which modes, bands, and frequencies are allowed with each class of licensure can be found here:
With a Technician Class license, you will have all ham radio privileges above 30 megahertz (MHz) including the 2-meter band. Technicians may operate FM voice, digital packet (computers), television, single-sideband voice and several other modes. Technicians may also operate on the 80, 40, and 15 meter HF bands using CW, and on the 10 meter band using CW, voice, and digital modes.
In addition to Technician Class [privileges], General Class operators may use high power transmitters and have access to the 160, 30, 17, 12, and 10 meter bands and access to major parts of the 80, 40, 20, and 15 meter bands. 
Extra Class [operators...have] the privilege of operating on all authorized Amateur Radio frequencies.
Licensure lasts for 10 years before you have to renew.  And as long as you renew within that period (or a 2-year grace period afterwards), you don't have to re-take any test. You don't have to take any more tests or go for any additional license levels if you don't want to, as long as you keep your current licensure active.

Many people become a Technician and never go any further, but ham clubs really encourage people to go for at least their General.

When I took my Technician's test recently, I did so well on the test that they strongly encouraged me to take the General, but I know that I'm such a newbie to the field that I'd need a lot more time to study for that. But it certainly did encourage me to consider it.


My Path to Licensure

 I started my path to licensure with a Ham Radio course, presented by our local Ham Radio club. Hams have a passion to see the hobby spread to other people, so many take pride in mentoring others. Sometimes this takes the path of a formal class, sometimes it's informal mentoring, but there is usually some sort of path to licensing available through your local ham club.

My younger son and I took the class. It was a 3-week class, once a week for about 3 hours. My son missed one of the classes because he was away Scouting, but I went to all three. (I'll help him get caught up on what he missed later on; he and his brother have both expressed an interest in getting their radio merit badge.)

The classes were good (if a little boring at times), but they went a little fast for me as a total newbie to the subject. There were a number of folks there who had an engineering or electronics background, so our teacher tended to give short shrift to basic concepts. (Engineers often forget that the rest of us don't know their jargon and need a primer to get up to speed.) I was able to keep up reasonably well but it all made a lot more sense to me after I studied the basic concepts on my own.

I studied via a book I purchased at the class (for $20). I probably could have done it easily without the book. I mostly bought it because I thought it would be a good idea to have a hard copy of ham principles for the long term, since in an emergency the internet probably wouldn't be available.

I also did a lot of online studying, which was INVALUABLE.  Can't recommend it highly enough. That's what really helped turn the corner for me on understanding the material. I might not have passed the test without it, honestly. It allowed me to work at my own non-geek speed through the basic electronics concepts and terminology.

I still feel the class was important, though. I tend to get a bit intimidated or overwhelmed when learning a new subject; I get frustrated with all I don't know, I worry about "doing it wrong" (typical perfectionist stuff), or I want to know it all now. I do best watching or listening to someone explaining it first, getting a basic understanding of something, and then doing the book learning.  If I hadn't taken the class first, I'm not sure I would have really "gotten" the material, even with online help.

So for me, the course was important in getting me through my intimidation factor and helping me see that even a total non-geek like me could become a ham. But in terms of mastering the material, the online study was what helped the most.  So I recommend both.  However, everyone learns differently, and some people do very well with just the online materials.  YMMV.

There are any number of websites devoted to taking practice tests for the licensing.  The good news is that there is a pool of around 400 questions that are used for the technician's license, and all are available online.  Many sites have them available to peruse, and will generate sample tests for you so you can see how you'd do taking the test.

This is SO helpful because you never know which 35 questions out of the nearly 400 available will be randomly selected for your test. You might be fine one time and totally bomb the next time. It all depends on which questions you get.  Some areas I was very comfortable with, and some areas I was totally clueless on.  Taking multiple practice tests helped me shore up my weak areas.

I found one study site particularly handy; https://hamstudy.org/.

This site gives you the test questions via virtual flashcards. You can see the question and its choices; if you get the answer wrong, you can "turn over" the flashcard and get a written explanation of the question and the right answer.  On other practice test sites, they give you the question and tell you when you're wrong, but don't tell you why you were wrong.  This one helps you work on your weak areas more easily, right there as part of the practice test instead of having to search all over the site. So while there are many sites out there you can use, this was the one that helped me the most as a newbie.

I kept taking the practice tests until I could consistently not only pass the test, but get 90% or better. I also took the time to go over all 394 possible questions and their explanations. Eventually I got to the point where I could pass with 100%.  On my actual licensing test, I didn't quite get 100%; I missed one question (on a stupid error, oops).  But I did better than many of the people around me.

So much depends on which test you get with the luck of the draw. I recommend taking them over and over until you consistently get high marks, and reviewing your wrong answers each time so you can fix the problem and get it right. That's the best way to nearly guarantee passing your real test the first time out.

The formal test is offered once a month in my area, at a local fire station. You have to find out what the schedule is in your area. A whole bunch of Volunteer Exam Coordinators (VECs) from the local ham club gave and proctored the test. The actual test doesn't take very long (although you can take as long as you like on it), but be prepared to wait for a while afterwards. Three separate people have to check your test and verify you passed it, and then there's paperwork to be filled out. So allow at least an hour to two hours for the test process.  It might not take that long, but better to allow for it just in case.

I also recommend getting a Federal Registration Number (FRN) ahead of time. Otherwise, you have to put your Social Security Number on the ham licensing form you fill out that day, and I'm not a fan of giving out Social Security Numbers casually. But you can do that online securely ahead of time, and then just use the FRN at the actual test.

The test session costs $15, and you can take the test as often as you'd like for that $15. There was a 12 year-old boy who took the Ham Radio class with my son and I; he didn't pass the first time he took the formal written test, but he was able to re-take it that day for the same $15. That's cool. Also, the tests for Technician, General, and Extra licensure are offered at the same time; if you feel confident in your material, you can pass the technician test and then move on and take the general directly afterwards, all for that same $15.  So that's a nice option for those who want to kill two birds with one stone.

Personally, I decided I needed time to study for the next level, since this field is so new to me.  I'll look online at how hard the material is for the general license and then decide if I'll pursue it. My son still needs to take his Technician's license test, so maybe I'll study up and take the General test about the time he's taking his Technician's test.  We'll see.

Final Thoughts

 The process to get my ham radio license was both harder and easier than I thought it would be.

It was harder in that I had to learn a lot of technical terms, electronics theory, and FCC regulations that were all very new to me. For someone who knew nothing about electronics, that was a bit of a learning curve.

But it was easier in that all the questions were available online, there were tons of resources for taking practice tests ahead of time, and once you learned the basics, most of the questions were really not hard at all.

I'm sure there are some people who just memorize the answer to the question, but I found it way more helpful to try to understand the principles behind the question and get it right that way. Then you can apply the knowledge more uniformly in other questions.

I haven't gotten on the radio yet; I have to wait for my official call sign first. In the meantime, I'm going to check out my local ham radio club's monthly meeting, just to get more comfortable with the process and to see what new info I can pick up. I'll also take my kids at some point in the future so they can learn about ham radio too.

Anyone else out there a ham?  Ever considered becoming one?



Good Ham Radio Links

 General Ham Radio Links
Practice Tests for Your Technician's License
Taking Your Technician's License
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Saturday, August 3, 2013

Plus-Sized Nursing Pictures in Honor of World Breastfeeding Week

In honor of World Breastfeeding Week, here are a few more breastfeeding pictures of big moms that I've been sent in the last year or so.  I've also included some I've had in my files for a while and haven't used here.

Readers, don't forget that I collect breastfeeding pictures of women of size. This collection is important because almost no breastfeeding resources routinely include pictures of breastfeeding women of size.

We need to remind the world that many "obese" women can and do breastfeed just fine.  

 Sadly, there are far too many care providers who believe that fat women can't or won't or shouldn't breastfeed. We need to show them that there are fat women who do breastfeed quite successfully.

If you'd like to share your picture, you can email it to me, kmom AT  plus-size-pregnancy  DOT org. Don't forget to give me formal permission to use your picture and say how you want it attributed.  

I welcome shots from all women, but would especially welcome breastfeeding shots of high-BMI women of color (who are even more under-represented in breastfeeding resources).

In the meantime, enjoy these nursing photos of various well-rounded women!




The two pictures above are from a mom who is "morbidly obese," yet had a wonderful natural vaginal birth in a birthing center, something you might think would never happen if you listened to some care providers. 

Some care providers also think that women of that size should not be allowed to birth in a birthing center, or are too "high-risk" to have access to low-tech alternatives. Yet many women of size have found that going low-tech was the key to their best chance at a vaginal birth, not to mention a more gentle and supportive birth experience.

Nursing also went well and is still going nearly 2 years later, a nice anti-dote for the commonly-held belief among some providers that larger women rarely breastfeed for very long (when they breastfeed at all).

I especially love the first shot. Beautiful!




The baby in the above pictures was born somewhat premature (but was a VBAC!).  

Although preemies face many challenges in establishing breastfeeding (and no mom of a preemie should beat herself up if breastfeeding doesn't work out), this does show that preemies can often learn to breastfeed with time and patience.  It's not easy, but it's extremely beneficial to a preemie's health so it's definitely worth pursuing if circumstances permit.

Don't you just love the second shot?  What an adorable little face!


Here are a few other nursing shots from my files.  Enjoy!









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