Bra Recycling: Passing on the Wealth

Motherwear Great Support Nursing Bra
(Sizes to 50K)

I was so thrilled to find this organization that recycles bras and passes them along to other women around the world in need of a good bra.  The URL is www.brarecycling.com 

If you're like me, you have bras in your drawers that you don't wear very often.  You may have tried a new style or design and found you didn't like it very well, or the fabric/color didn't suit you, or you've changed sizes.  It always sits very poorly with me to waste perfectly good clothes, but I didn't figure that Goodwill or other such organizations would accept such an intimate item as lingerie, so I have quite a few just languishing in my drawers.  But now there's a place to donate!

This is especially important for those of us who are a special size.  It's so hard to find good plus-size clothes second-hand; imagine how hard it is to find good bras in our size when money is an issue!  They are so expensive to buy new.

So if you wear a larger band size (more than about 42 or so), a larger cup (D or more), have a mastectomy or post-surgery bra, or have some nursing bras you no longer need, I hope you will especially consider donating to this group.

Below is more information about the company and where to send the bras.  Some communities also have drop-off sites where you can drop off the bra instead of having to pay shipping costs; info about that can be found here. And here is a link to the donation paperwork you need to fill out.

[I should probably add the disclaimer that I know nothing about this group or its validity as a charity.  Caveat Emptor. However, they do have a page that discusses which charities they donate the bras to, if you want to do more research.]



From the company's "about" page:

What is The Bra Recyclers all about?

• We are a textile recycling company focused on doing our part to recycle and reuse bras (textiles) that unnecessarily go to landfills
• We buy and sell recycled bras, which are re-distributed through exporters and organizations to developing countries around the world
• We have created and support a network of Bra Recycling Ambassadors who assist us in providing deserving women with used or unused bras as they transition back to self-sufficiency

What Type of Bras Are Needed?

• Bras in good condition; Clasps and straps need to be functional
• All sizes and styles of bras
• Special needs bras, post breast surgery and maternity bras

Recovering and Recycling Your Bras

We make it easy for you to recover and recycle all of the old or new bras sitting in your lingerie drawers waiting to be worn by a deserving woman in your community. Just follow 4 easy steps:

• Wash It. All bras should be washed.
• Tag It. Fill out Bra Recycling Form.
• Box It. Place your bras in a box or large envelope.
• Drop It Off or Mail It to:

The Bra Recyclers
3317 S. Higley Rd, Ste 114-441
Gilbert, AZ 85297

Summer Fluff: The Bobs

Here's a little musical fluff to brighten up your summer day.  Anybody else here a fan of The Bobs?

I've seen The Bobs perform a few times over the years, and I love their off-beat virtuosity. They are an a capella group with a twist.  And they are awesome.

I'm a big fan of a capella music (just vocals, no instruments) and doo wop music in general.  However, this is not your grandma's a capella music.  They've been called "New Wave A Capella" and they specialize in very off-beat, often humorous songs, either covers of other material or original songs written by members of the group. They merge pop, blues, and jazz, often utilize non-traditional harmonies, and generally push the envelope of a capella music in a major way. They describe themselves on their website in the following way:

The Bobs (prat)fall outside a cappella traditions, landing in a hot tub of humor and vocal prowess. What other band can headline The American Songbook series, open for Frank Zappa and The Dead, and perform for 700 million people on the Emmy Awards?

The Bobs were founded in 1981 but hit the big time in 1984:

Matthew Stull and Gunnar Madsen founded The Bobs in 1981 in Berkeley, California, and were quickly joined by bass singer Richard Greene and über-alto Janie Scott. They performed in the San Francisco area until a 1984 Grammy nomination for their unique vocal cover of the Beatles’ “Helter Skelter” catapulted them into a national and international tour schedule.

As is common in many groups, they have rotated through several different singer line-ups over the years. MatthewBob and RichardBob are the longest-serving members of the group, and are currently joined by DanBob and AngieBob. (Yes, all the members have "Bob" in their psuedo-names.) More information (including upcoming concerts and how to buy their albums) is available at their website, The Bobs.

If you ever get the chance to see them in person, take it!  They're famous for their show patter, so it's usually a very entertaining show.  If you are very traditionally-minded in your music preferences, you might not enjoy some of their songs (which can be pretty offbeat harmonically), but generally speaking, the humor and the sheer virtuosity with which they perform is enough to win over most people.

Here are a few videos of some of their more wide-appeal songs to get you started.

The first is "There Ain't Nobody Here But Us Chickens."  It's a cover of an old Louis Jordan song, and it's straightforward and fun.  Check out the cool scatting by DanBob Schumacher.



Here is "The Tight Pants Tango", a tribute to the dancing that happens when your cell phone rings when ensconced in the pocket of pants that are far too tight.



Here is a link to another video of "The Tight Pants Tango". You can't see everyone, so it's not as good a video, but it's got all the lyrics listed, so some might enjoy looking at that one instead.

Finally, for cat fans everywhere, a very bizarre but funny song called "Fluffy's Master Plan for World Domination" about how cats are plotting to take over the world. It's a fan's amateurish video of The Bobs soundtrack, mind, but it's still fun.  Enjoy!

CesareanRates.com: Transparency in Maternity Care

www.cesareanrates.com 

There's a new website out that I've been wanting to highlight for a while.  Now, as the author struggles to finance her work on the site, it's even more important that I publicize the site.

The site is called cesareanrates.com and it has the cesarean rates for most of the states in the U.S. and the provinces in Canada.

Most importantly, not only does it have the cesarean rates by state/province, it also has the cesarean rates by individual hospital.

Earthy-birthy types who read my blog probably already know about this wonderful resource, but others may not.  It makes for very interesting reading and I recommend the site.

Having cesarean rates available by hospital is incredibly useful information.  If you live in an area where you have the choice of more than one hospital, you can see which ones have very high baseline cesarean rates and which ones don't.

Such information has to be interpreted with caution, of course, since some hospitals have higher loads of high-risk patients who might be expected to have higher cesarean rates. This is a legitimate concern.  However, even among hospitals that serve higher-risk patient populations, cesarean rates can vary widely. So while caution has to be used when viewing this data, it still can be useful to the consumer.  Some hospitals really do have a strong climate of overutilization of cesareans, and consumers should have access to that information before choosing to become a customer of that hospital.

So let's talk a little bit more about the variations in cesarean use and the importance of transparency in cesarean rates for quality control purposes.

Image Use Disclaimer: I received express permission from creator Jill Arnold of The Unnecesarean to use the cesareanrates.com images. If you want to use them, please ask her permission first.

Variations in Cesarean Utilization

One of the attitudes we have to fight against all the time in Cesarean Awareness advocacy is the common public perception that cesareans are only done when necessary.  In other words, most people assume that if a woman had a cesarean, it was usually because she needed it and it saved her or her baby's life.

Yes, cesareans can be life-saving, and there is no doubt that having them available is a wonderful thing.  Absolutely no argument there.

However, while cesareans mostly used to be used only when truly needed, there are many cesareans being performed today that are not medically indicated.  And the strong regional variations in cesarean use just reinforce this.

Below is a chart from Jill's site of the ten hospitals with the highest c-section rates in Florida.

Now look at a chart from Jill representing the ten hospitals with the highest c-section rates in Utah.

So the hospital with the highest cesarean rate in Florida has a rate TWICE as high as the hospital with the highest cesarean rate in Utah.

Come on, are the uteri of women in Utah really that much more efficient as the uteri of women in Florida? No, of course not.  The fact is that cesarean rates are highly variable by region, by hospital, and by doctor, and many of these variations are not explainable by demographic differences or risk caseload.

Even within one regional area with similar demographics and patient risk profiles (and eliminating cesareans for indications like breech, thought to be "necessary" by some providers), cesarean rates can vary widely.

While doctors like to blame women for high c-section rates (the overused "women are too old or too fat" or "women are requesting these cesareans" arguments), the truth is that provider practice patterns have far more influence on cesarean rates than factors attributable to women themselves.

The Childbirth Connection, an organization devoted to improving maternity care, confirms this trend:

The cesarean rate varies broadly across states and areas of the country, hospitals, and maternity professionals. Most of this variation is due to "practice style" rather than differences in the needs and preferences of childbearing women.

In other words, your chances of "needing" a cesarean at one hospital in your area may be quite different than your chances of "needing" a cesarean in a different hospital in your area.  Even if you fall into a supposedly "high-risk" category, your chances of "needing" a cesarean can vary widely, depending on who you see and their practice patterns around birth.

While some cesareans truly are prudent and at times even life-saving, many cesareans performed today are not.  Women deserve to know which hospitals have high rates of cesarean utilization and which do not, so that they can make informed choices about where they go to birth, should they choose to have a hospital birth.

Caveats

I would like to tell you that hospital-level cesarean rates area available for all 50 states, but alas, that's not true.  Last I checked Jill's site, the following states did not have hospital-level information about cesarean rates available:

• South Carolina
• North Carolina
• Georgia
• Arizona
• Connecticut
• Hawaii
• Idaho
• Iowa
• Kansas
• Michigan
• Missouri

Why is this information not available uniformly? The reasons vary. Some states don't think consumers are interested in this information and so don't provide it. Or pencil-pushers decide that providing cesarean rates to the public is not a Department of Health budget priority.  A few states have decided that health consumers have no right to this information and refuse to release hospital-level cesarean rates, despite many requests to do so.

There is information in each of the links above on how to contact these states directly to request that this information be made public.  Sometimes, if a state gets enough requests, they make providing hospital-level cesarean rates more of a priority.  (We were able to do this recently in my state.)

On the other hand, sometimes states actively refuse to provide hospital-level cesarean rates because doctors have actively campaigned to keep these rates private, on the grounds that the public is not smart enough to understand the concept of mitigating factors (like a high-risk caseload, etc.).  Or they simply don't want the bad publicity for their hospitals.

This is ridiculous.

As health consumers, we deserve to have public health information about various hospitals and their quality of care.  And we deserve this information for maternity-related care as well as basic overall care.  

The Importance of Transparency

Transparency is a HUGE up-and-coming issue in healthcare.  As one quality watchdog group notes:

You may not realize there are differences in the quality of care provided by different hospitals. Hospitals are busy and complex places. Every day, hundreds of patients are receiving hundreds of different procedures. Medical mistakes are a leading cause of death each year, causing more deaths each year than car accidents, breast cancer and AIDS. 

There is good news! Hospitals can take steps to prevent mistakes and protect patients from unnecessary injury. Even better, there is information available to help you determine the quality of your local hospitals.

More and more, groups such as consumerreports.org and the Leapfrog Group have begun to document basic information on Quality of Care measures, such as which hospitals have high rates of hospital-acquired infections, which have poor overall patient safety, and which have high rates of medical mistakes or medication errors.

However, these quality monitoring efforts are in their infancy.  Some hospitals participate voluntarily, but some actively resist any attempt to shine a spotlight more closely on care practices. Yet experience shows that when substandard results are highlighted and a program is developed to address these issues, outcomes can be improved.

It is important to be careful when comparing results from different hospitals, but even with this caution in mind, transparency in Quality of Care measures can be useful in improving care and patient outcomes.

Transparency and Participatory Medicine are concepts whose time has come.

How does this translate to maternity care?  In maternity care, substandard care translates to high rates of maternal or neonatal infections, high rates of early scheduled deliveries, higher-than-average deaths, and a too-high cesarean rate.

Some hospitals would argue that a high cesarean rate is not a sign of substandard care. The World Health Organization disagrees, noting that high rates of non-medically indicated cesareans translate into a higher rate of adverse maternal outcomes, including admission to Intensive Care Units, blood transfusions, hysterectomies, and maternal deaths. Other risks include blood clots, wound infections, anesthesia accidents and other problems.  Clearly, overuse of cesareans has risks.

There is an ongoing argument over what the "most optimal" cesarean rate should be, but that's beside the point.  Whatever the "ideal" rate is, women deserve to know the baseline cesarean rate of their hospital of choice, and how that compares to other hospitals.  Then it is up to them which hospital they choose.

Final Thoughts

CesareanRates.com is a powerful new tool for healthcare consumers.

One of the many useful things on the website is the listing of the cesarean rates of all the U.S. states (both alphabetically and by highest-to-lowest rates). There is also a graph showing the increase in cesarean rates over time in the U.S.  Rates from the Canadian Provinces are available as well.

I like the Top Ten slideshow, where slides from several representative states list the hospitals with the highest cesarean rates in those states.  You'll see that quite a few hospitals have c-section rates around 50%-60%, while other states' rates are not nearly so high. This is a good micro-demonstration of how much variation there can be in cesarean rates from hospital to hospital and state to state.  (Click on the page number on the bottom to freeze a particular state's slide.)

Another useful thing is a state-by-state listing of the VBAC ban policies of individual hospitals.  This information can already be obtained from the International Cesarean Awareness Network’s VBAC Policy Database but it's useful to have it all in one place with the hospital-level cesarean rates.

You can read more here about why Jill Arnold created this new site:

CesareanRates.com is a snapshot of online cesarean rate reporting in the United States as of January 2012. The site compiles the most current hospital-level data accessible to the public online, whether reported directly by a state’s department of health or gathered from state hospital association web sites via pull-down menus. The initial goals of the site are to a) show the (poor) quality and inaccessibility of hospital-level information available to the public, b) to assess whether there is public demand for this information and c) to work toward establishing a precedent for hospital data transparency.

How might this site be useful for a typical healthcare consumer?  Jill elaborates on that question here:

As with everything pregnant people can get their hands on, it is one of many tools. Everyone makes decisions differently and weighs things based on their unique experiences, values, preferences and education. For example, a 60% total cesarean rate might trigger a different reaction for different people. A woman that passionately wants to avoid an unnecessary cesarean section might be deterred from giving birth there, while one hoping for an elective primary section might infer something about the culture of the hospital and seek a provider that delivers babies there. Another person might try to evaluate what exactly that means and start investigating why it is so high, while someone else might not care one way or the other where they give birth as long as they are with a care provider they like. 

Ideally, it would be nice to see the site used by pregnant people for the purpose of seeking preference-sensitive care and opening up dialogue with their provider about what they can expect at the hospitals at which their provider has privileges.

If you want to know more about how cesarean rate information is reported. watch the following short video on the technical aspects of such data collection.



Go, check out www.cesareanrates.com. If you get an additional moment, go to its Facebook Page and "like" it as well.  Blog about it and pass on the link so more people know about this invaluable resource.

And if you can, donate to the author so she can continue carrying on this work.

Thank you, Jill, for your hard work on this site.  Brava!


References

Health Aff (Millwood). 2006 Sep-Oct;25(5):w355-67. Epub 2006 Aug 8. Geographic variation in the appropriate use of cesarean delivery. Baicker K, Buckles KS, Chandra A.   PMID: 16895942

There is enormous geographic variation in the use of cesarean delivery: For births over 2,500 grams, adjusted cesarean rates vary fourfold between low- and high-use areas. Even for births under 2,500 grams, high-use counties have rates that are double those of low-use ones. Higher cesarean rates are only partially explained by patient characteristics but are greatly influenced by nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure. Areas with higher usage rates perform the intervention in medically less appropriate populations-that is, relatively healthier births-and do not see improvements in maternal or neonatal mortality.

Am J Obstet Gynecol. 2007 Jun;196(6):526.e1-5. Variation in the rates of operative delivery in the United States. Clark SL, et al.   PMID: 17547880

OBJECTIVES: This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN: We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS: In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION: Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.

Obstet Gynecol. 2010 Jun;115(6):1201-8. Regional variation in the cesarean delivery and assisted vaginal delivery rates. Hanley GE, Janssen PA, Greyson D.   PMID: 20502291

OBJECTIVE: To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery. METHODS: Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n=116,839)...RESULTS: Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries. CONCLUSION: Our results illustrate substantial regional variation in the use of cesarean delivery that cannot be explained by patient illness or preferences. This variation likely reflects differences in practitioners' approaches to medical decision-making.

Birth. 2005 Sep;32(3):170-8. Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service? Mahoney SF, Malcoe LH. PMID: 16128970

BACKGROUND: Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations...METHODS: We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999... RESULTS: The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03). CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.

Prior Vaginal Birth Decreases the Risk for Uterine Rupture in VBAC

Here's an entry in the no-duh Olympics.  You would think this didn't need to be pointed out, but sadly, to some folks it does.

Most caregivers know that once a woman has had a VBAC, she is at decreased risk for rupture  (the scar coming apart) in any future pregnancies.

The risk is never zero, mind.....once a cesarean, always a risk to some degree, whether you choose VBAC or repeat cesarean, which is why it's important to avoid that first cesarean whenever possible.....but a prior vaginal birth (either before or after the cesarean) does seem to lessen the risk for rupture.

However, once in a while, we in ICAN (the International Cesarean Awareness Network) hear about some ignorant caregiver telling women that they can only have one VBAC and then must have all repeat cesareans, or that the risk for rupture remains just as high each time, even after you've already had a VBAC. Wrong!

For all the Homer Simpson caregivers out there who need a primer on this topic, here's a research review that clearly shows that the risk for uterine rupture is significantly decreased in women who have had a prior vaginal birth.  D'oh!

This is another reason why it is so important to prevent cesareans whenever possible.  A vaginal birth is protective against so many complications, including one of the most serious, uterine rupture.  Even if a cesarean becomes truly necessary in a particular pregnancy, it is strongly to everyone's advantage if the woman has had a vaginal birth first, or if she has a vaginal birth (VBAC) afterwards. In most cases, it is more risky to expose them to successive cesareans, particularly multiple repeat cesareans.

Yet research shows the primary cesarean rate rising, and the VBAC rate dropping.

Graph from U.S. National Center for Health Statistics

Don't get me wrong.  I don't hate cesareans. It is wonderful to have life-saving technology and surgery available when truly needed, and there certainly are cases where a cesarean makes more sense. But don't underestimate the power of nature.

On a population-wide basis, vaginal birth offers the most benefits to most mothers and babies. We evolved to give birth vaginally, and we circumvent that casually at our peril.

This research points out yet again that it is to most birthing women's advantage to have a vaginal birth in their history. Most of the time, unnecessary primary cesareans and routine repeat cesareans should be avoided if possible.


Reference

Arch Gynecol Obstet. 2011 Nov;284(5):1053-8. Risk of uterine rupture in women undergoing trial of labour with a history of both a caesarean section and a vaginal delivery. de Lau H, et al. PMID: 21879334

PURPOSE: To determine the risk of uterine rupture for women undergoing trial of labour (TOL) with both a prior caesarean section (CS) and a vaginal delivery.

METHODS: A systematic literature search was performed using keywords for CS and uterine rupture. The results were critically appraised and the data from relevant and valid articles were extracted. Odds ratios were calculated and a pooled estimate was determined using the Mantel-Haenszel method.

RESULTS: Five studies were used for final analysis. Three studies showed a significant risk reduction for women with both a previous CS and a prior vaginal delivery (PVD) compared to women with a previous CS only, and two studies showed a trend towards risk reduction. The absolute risk of uterine rupture with a prior vaginal delivery varied from 0.17 to 0.46%. The overall odds ratio for PVD was 0.39 (95% CI 0.29-0.52, P less than 0.00001).

CONCLUSION: Women with a history of both a CS and vaginal delivery are at decreased risk of uterine rupture when undergoing TOL compared with women who have only had a CS.

Kids' Bucket List

A little fluff for the post-Holiday week.....how about an Open Thread Question?

What's on your "bucket list" of must-have skills for kids to learn before they grow up and move out?

I'm not talking about bucket lists in the usual sense (things you want to do before you die), but instead, vital skills you think children should have before they move out of the house and start living on their own.

If you are a parent, what things have you made (or intend to make) a priority in your house?  If you aren't a parent, what did you wish your parents had taught you that you really needed to live on your own?  Or conversely, what were the things your parents did teach you that were very helpful or fulfilling skills to have?

My bucket list for my kids includes a lot of life skills and practical stuff, as well as things to keep them well-balanced human beings.  Some we are doing well on, and some are still on the "to-do" list.  Let's chat about a few.

Life Skills

In terms of life skills, I want my kids to have what I consider to be essential skills like first-aid/CPR, knowing how to swim, what to do in a disaster, that sort of thing.  You'd be surprised how many people don't know basic first-aid, for example.  It's just common sense for everyone to have good training in this.

I also think every child should know how to do some basic gardening.  My mom taught me a little bit of gardening, but I was known as the Black Thumb of Doom for many years because I killed plants left and right.  It took a number of tries before I figured it out as an adult and could raise a halfway decent garden.  I'm still a pretty casual gardener by serious gardening standards, but I raise enough that I could help our family in hard times. I'm trying to pass this along to my kids, but they certainly aren't overly enthusiastic about it.  Still, they'll have at least some knowledge in it.

Similarly, I think kids should know how to put up food.  This is a skill that has been lost in many families. Despite growing up on or near farms (in the Depression and WWII, no less!), neither my parents nor my in-laws ever learned canning or putting up food from their own parents, and so we in turn, never learned it either. But we as a society are far too dependent on a food supply system that is easily broken down during disasters or sudden fuel-supply crises.  It's important to not only have some of your own bought food reserves, but also to know how to grow your own and store it safely.  I'm still learning this skill; I'm making my oldest two learn it with me as well this summer.

I think all kids should have some experience with camping, nature, fire-making, and outdoor skills. Sadly, I got little of this in my upbringing.  As a result, I am just not Nature Girl; I get too cold too easily to be comfortable camping for long.  However, I'm working on building up some practical skills like fire-making and outdoor cooking skills anyway, just in case. Luckily, my husband is an Eagle Scout so he has made sure his boys are involved in Boy Scouts and are getting plenty of practical outdoor skills.  We haven't been as good with my daughters, mostly for coincidental (not sexist) reasons, but it's something I want to remedy.  My oldest has some significant medical issues so she's not going to be Nature Girl either, but we still have time to teach my littlest one some good skills, and the older one, like me, can at least learn some stuff. Definitely something we need to work on.

Another thing we've really fallen short on in our house is practical skills like how to take care of mechanical stuff, like cars and other machinery. I don't know anything about it; I've always depended on my husband.  Not a good idea. I want all my kids to have these skills, but frankly, we have just been too busy to pursue this, and so I feel like I've really fallen down on this important skill. It's on our "to-do" list.

What other life/essential skills can you think of that kids should learn before they become adults?

Practical Skills

On the practical side, I think all kids should know how to cook for themselves, do their own laundry, clean house properly, take care of the yard, etc.  It floors me how many kids leave home without knowing how to do these things, or with minimal cooking skills etc.

Start slowly when they are young, then gradually add chores for these things as they age.  This is important not only for life skills, but this is also how kids learn to be responsible, good workers.

We sometimes have playdates with friends, and it always shocks me when children eat a meal but don't take their dishes to the sink, or open a fruit leather and then just drop the wrapper on the floor and walk off.  What am I, your slave?  But apparently that's the way some houses are run.  Gah!

I'm not a fan of what I call Martyr Mothering ─ doing it all for your family so they don't have to. I don't like Martyr Mothering because it doesn't make your children (or husband) independent functioning humans, it makes a slave out of you by taking up most of your time (that could be spent on other activities), it doesn't teach children responsibility for themselves and their own actions, and it teaches a lack of acknowledgement/gratitude for the work of others and for the tasks that make a pleasant family home.

Now, of course, every family negotiates their own balance of chores ─ who does what, etc.  And that balance doesn't have to be the same for your family as for mine. Yet I see that many children don't have to do many chores and aren't learning how to care for themselves. You're really not doing your child any favors if you do everything for them or they have few chores.

Please, teach your children how to help out and how to be reasonably self-sufficient before they leave home.

Well-Balanced Human Being Skills

I think kids need experience in a variety of interest and pursuits in order to make them well-balanced human beings.  Enable your children to explore many activities.

I dislike the "specializing" approach that many parents take with their kids today ─ the kid has sports sports SPORTS all the time but never has a music class (or vice-versa).  Or the child never has the opportunity to take an art class, or to learn how to sew. Some become obsessed with one or two things and never explore anything else.

Children need to explore a variety of things before they can understand where their own interests and skills lie; it's good for kids to try new things and to experience gentle failure as well as success.  It's part of building their character.  Even highly specialized people like the Olympic-level athlete or the professional musician need to have other interests; being a well-rounded person will only help them in their chosen specialty.

Another important thing is to give children the opportunity to help in causes larger than themselves, to volunteer their time/energy for a good cause or to help others.  It's too easy to become centered only on yourself in our society; seeing the needs of others helps make children deeper, more empathetic people.

But while kids should have the opportunity to explore many different activities and to work in charitable causes, I'm also not a fan of over-scheduling children.  Children need "down" time to just play.  Imagination is a vital part of a child's life, and not just for little children. Teens need it too.

Turn off the computer and TV regularly, provide kids with a few basic games, toys, dress-up clothes, balls, swings, or whatever, and then just stand back and let them figure out how to play by themselves.  They struggle a bit at first, but in time they figure it out, and they are so much healthier for exercising those imagination muscles.  And "down time" really helps de-stress kids in a very stressed society.

Final Thoughts

Of course, all this is easy to say, harder to do.  We all fall down in some areas, and no parent ever "perfectly" prepares their children 100%.  You do the best you can to make them well-rounded and give them essential life skills, but you always have to remember that you are only the facilitator.

In the end, children are their own people and they make decisions about priorities for themselves as they grow.  We try to help them be well-rounded and diverse, but sometimes you can lead a horse to water but you can't make them drink, as the saying goes.  Some things children have to learn on their own.

For me, the goal is to offer the opportunity for building important skills and pursue lots of different interests, but it's always subject to the realities of life.  Sometimes the budget doesn't have room for all the classes you'd like to give your children.  Sometimes you just don't have the opportunity to help them pursue a certain activity. Sometimes you just don't have the skill set, budget, or extra time to help them with certain things.  You can seek out other mentors to help, but there are always limits that have to be acknowledged.  That's normal.

A kids' bucket list is not about making parents feel guilty for all the things they can't do, but rather just a road map to help parents be thoughtful about what they are doing to prepare their children for adulthood. Realizing that there will be gaps in these skills and forgiving yourself for that is part and parcel of the journey of parenting.  You just do the best you can, realize that you can't do it all, and let the rest go.  Remember that teaching children to be self-actualized learners goes a long long way towards filling any gaps.

So, in an ideal world, what are the things on your "bucket list" for your child?  If you don't have kids, what skills did your parents give you that were helpful, and what do you wish you had gotten? What do you wish people would give their kids more of?

This is an open thread; I welcome lots of comments and discussion.

Gardening Rainbows

A recent double rainbow in my back yard at twilight.
Light at the end of the tunnel for this stressful year!

I finally got out to my garden this week after an intensely busy and high-pressured winter and spring. What a stressful year I had at work!  I'm always busy, but this year I was busy with a capital "B", and stress arrived in an economy-sized package.  Alas, that limited many of the other projects I had going (including my writing); so frustrating.  Apologies for some minimalist blogging content this spring.

I had so many things I wanted to try in the garden this year, but getting such a late late start meant that some of them just aren't going to get done this year. Feh.

However, once in a while I managed to steal a moment here and there to plant something this spring, so I do have carrots and peas going in various stages.  I had some garlic and onions overwinter, so that's helpful.  Surprisingly, I had some brussel sprouts overwinter too, so we'll see if that turns into anything. Of course I have my perennial fruits and veggies, like asaparagus, raspberries, strawberries, cherries, etc.  These form the core of my garden this year.

Asparagus Ferns to the left,
and the Rhubarb of Doom to the right

We were able to harvest asparagus this year. I planted it last year and you don't harvest the first year, so this was the first time we got to eat our own home-grown asparagus.  You harvest only minimally the second year, so we were sparing in our harvest, but I can see this is going to be a source of much delight to us. We love asparagus at our house!  Served al dente with a little garlic aeoli, or grilled with a little olive oil....Oh, sooo sooo good.  I'm just sad asparagus season is over now. But that's okay...they are busy building roots so they can give us lots of yummies next year. You can see the ferns that asparagus spears turn into in the picture above on the left.

I also planted rhubarb plants last fall, but that was a bit of a fail. I've never grown rhubarb before, so I didn't realize just how HUGE they get.  But you can see the Rhubarb of Doom in the picture above.  Uh, a little large for a raised bed planter, ya think? Obviously, it doesn't need the babying of being in a raised bed, based on its dinosaur-sized leaves.  So we're going to have to dig this puppy up and move it to a better spot.  I'm not looking forward to that job.

You can see the first strawberries of the season above. We're harvesting strawberries like crazy now. I will have enough to make a large batch of freezer jam that's just from our garden; in the past, I've had to supplement with berries from various Farmer's Markets.  I probably will again for later batches, but it's very satisfying to be able to do a few batches that are just from our garden.  I love strawberry freezer jam the best because you can use minimal sugar and the freezer jam keeps more of the fresh strawberry flavor. It's like a eating a little burst of summer in the middle of the winter. Flippin' awesome.

We also just started harvesting the first raspberries.  OMG, is there anything better than the first raspberries of the season???  Usually we just eat these fresh, but I put in a whole bunch more raspberries last year and so will need to put some up somehow...especially since we'll be harvesting raspberries into October.  Made some raspberry muffins yesterday, may try some raspberry sauce, some white chocolate raspberry bark, some raspberry chipotle sauce, and will also just freeze some straight up.  Any other great raspberry suggestions?  I'm going to have a lot.

We are knee-deep in cherries from our trees right now. I have to figure out what to do with them before they go bad. I don't much care for cooked cherries (so canning them is out) but love the fresh ones. I think we are going to freeze them raw.  Just wash them, pit them, put them on some parchment paper on a cookie tray and stick them in the freezer to freeze individually, and then bag them for later in the year.  I've heard that eating fresh-frozen cherries (no sugar, no additives) right out of the freezer is a real treat.  I'll let you know!

I have lots of plums starting to ripen, and many apples have set, so I'm looking forward to canning some plum chutney and applesauce later in the summer.  Looks like we'll have a few fresh pears too. However, my pluots (mix of an apricot and a plum) are total duds so far.  Maybe next year.

We did finally get some other stuff planted.  I was so late that I mostly used starts from the store, but that's okay; I'm not a gardening snob.  I have broccoli that's almost ready; the head has gotten a lot bigger than when I took the above picture.  We love fresh broccoli, which is good because we'll be having a lot in the next few weeks before we get slammed by hot weather.

I planted eggplant for the first time this year.  I'm not a big eggplant fan, but thought we'd give it a try. If all else fails, my MIL will eat them. Also put in a zillion tomatoes (for my special homemade spaghetti sauce, yummm), potatoes, pumpkins, green beans, swiss chard, zucchini, and cukes.

As some of you know, I have some knee issues from a bad car accident a few years ago.  This is why I mostly garden in raised beds.  But of course, raised beds are not cheap to build.  So this year, I'm contemplating trying straw bale gardening to expand my raised beds inexpensively.

Image from WSU Master Garden blog, wsumgtc.wordpress.com 

You condition a straw bale, then plant certain types of garden plants in the straw bales, like pumpkins or cukes or tomatoes (with staking).  It's raised bed gardening on the cheap. Then you use the decomposing straw left over for your potato beds next year, or put it in your compost pile. It's late to start this process, but what the heck.  I'm going to give it a shot anyhow.

I'm also looking at creating some sort of adapted portable cold frame/hoop house for my garden. I want to be able to cover the tomatoes to extend their season in the fall, and I want to be able to grow some cold-weather crops in the winter but be able to protect them from the very coldest weather.  So we'll be experimenting with that this summer.  Updates next fall.

So that's what's up with me right now.  I'm trying to get the kids' summer schedule organized (one's in Alaska with Scouts right now), I'm trying to get the garden established and weeded, I'm trying to start canning, and I've got to get my office cleaned before the cameras from the Hoarding shows arrive.  Oh yeah, and work on some writing projects.

What are you up to this summer? Got any big plans? If you garden, tell me what's going in in your garden!  Anybody got any great recipes for raspberries?

Induction of Labor: An Incredibly Common Intervention Today

Here is a big, major recent study from the NIH that shows just how pervasive induction of labor is in U.S. society today and how it influences cesarean rates.

This study covered 19 hospitals across the U.S. over the space of a number of years.  It shows that nearly half of all first-time mothers are having their labors induced these days, and almost a third of those who have children before (multips).

Of those who are induced, a third of first-time mothers and nearly half of multips had an "elective" induction or "no recorded indication for induction" at term.  In other words, most of the time, these inductions are not being done for legitimate medical reasons like high blood pressure or serious concerns about the baby's well-being; instead, they're largely being done for convenience.

Yes, some moms ask for induction because they get tired of being pregnant, so some of this is being driven by consumers.  But it's also being strongly driven by many OBs who want to practice "daylight obstetrics" ─ induce in the early morning (or start the night before), break their water at noon, and be home in time for dinner.  Many start mentioning induction early in the pregnancy, planting the idea, so that when the end of pregnancy comes and women are uncomfortable, they are primed and ready to agree to an induction before it's really needed.

The question is whether nearly half of women should be induced, and what kind of risks are being imposed by this strong drive for induction of labor.

It also shows that inducing first-time moms presents a particularly high risk for cesarean, that cesareans are often done too early ("failure to wait"), and that inducing on an unripe cervix (low Bishop's Score) also often leads to cesareans.

[These are particularly relevant points for "obese" women, as I've pointed out before.]

All these have strong implications for lowering the national cesarean rate, as the authors note in their conclusion.  But are most care providers listening?  As I've said previously:

The $64,000 question is ─ will the publication of this study make any difference? Will hospitals change their policies and induce less women? Will doctors wait longer before resorting to cesareans? Will doctors and hospital administrators reverse their formal and informal VBAC bans? Will everyone involved make a concerted effort to reduce the cesarean rate ─ or will it just continue to be business as usual? 

It's positive that the questions are being asked and dialogue is being opened ─ but I am not holding my breath. Perhaps this is the beginning of a reversal of the pendulum, but the momentum is so strong towards inductions and cesareans right now that it's going to take a mighty counterforce indeed to really reverse things.

It's up to us to be part of that counterforce for change.

Am J Obstet Gynecol. 2012 Mar 23. Induction of labor in a contemporary obstetric cohort. Laughon SK, Zhang J, Grewal J, Sundaram R, Beaver J, Reddy UM.  PMID: 22520652

Source: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.

OBJECTIVE: We sought to describe details of labor induction, including precursors and methods, and associated vaginal delivery rates. 

STUDY DESIGN: This was a retrospective cohort study of 208,695 electronic medical records from 19 hospitals across the United States, 2002 through 2008. 

RESULTS: Induction occurred in 42.9% of nulliparas and 31.8% of multiparas and elective or no recorded indication for induction at term occurred in 35.5% and 44.1%, respectively. Elective induction at term in multiparas was highly successful (vaginal delivery 97%) compared to nulliparas (76.2%). For all precursors, cesarean delivery was more common in nulliparas in the latent compared to active phase of labor. Regardless of method, vaginal delivery rates were higher with a ripe vs unripe cervix, particularly for multiparas (86.6-100%). 

CONCLUSION: Induction of labor was a common obstetric intervention. Selecting appropriate candidates and waiting longer for labor to progress into the active phase would make an impact on decreasing the national cesarean delivery rate.

Pregnancy After WLS: The Risk for Internal Hernia

Image from Greenstein and O'Rourke,
Am J Surg, 2011

One of the risks that tends to be de-emphasized to women considering Gastric Bypass (GB) surgery is the risk of internal hernia, especially one that occurs during pregnancy.

What is an internal hernia?  Here is one definition:

An internal hernia is defined as a protrusion of intestine through a defect within the peritoneal cavity, as opposed to an external (or incisional) hernia that protrudes through all layers of the abdominal wall. Internal hernias almost always occur through iatrogenic defects created surgically.

The consequences of developing an internal hernia can include Small Bowel Obstruction (SBO), lack of adequate blood supply to the intestine and resulting necrotic tissue, gangrene, and a need for bowel resection.  In extreme cases, it can lead to death.

Granted, the risk for internal hernia is not a big risk, although it's difficult to pin down exactly what the risk really is.  One study found a 3.1% incidence of internal hernia after GB in a series of 2000 patients, while a different study found a 4.5% rate in a series of 1000 patients.  Another study found a higher rate of 6.9%.  A meta-analysis of 26 studies found an incidence of 2.5%, with a mortality rate of 1.1%.

However, these are internal hernia rates in the general GB population; the risk may be higher in pregnant women because pregnancy shifts the internal organs around and increases intra-abdominal pressure:

The incidence of internal hernia after [Laproscopic Gastric Bypass] is between 0.2 and 8.6 percent based on multiple studies...The particular case of pregnancy— with the mass effect of an enlarging uterus—may predispose to this condition...Due to the increasing scope of this problem and its potentially devastating consequences, surgeons should have a high clinical suspicion for internal hernia after LGBP.

Of course, it's important to remember that most women who have a Gastric Bypass and then a pregnancy afterwards will not experience an internal hernia.

However, there are some women who develop a hernia during pregnancy after Gastric Bypass, and it can be a very serious issue.  Women and babies have died from this complication (see case reports below). Therefore, it's important to raise awareness about this possible risk.

Any time a pregnant woman with a history of Gastric Bypass experiences significant abdominal pain, this must be taken very seriously.  

Physicians with experience both in WLS (Weight Loss Surgery), pregnancy, and intestinal issues should be consulted. Oftentimes, E.R. or family practice doctors miss internal hernias, CT scans are not always definitive, and as a result, there are a number of scary "near-miss" stories out there.  Most authorities agree that exploratory surgery is usually warranted, just in case, since a delayed or missed diagnosis is not unusual and can be deadly.

One of my concerns is whether or not this risk is adequately explained to women before they have WLS.  WLS is being actively marketed to fat women as a way to make childbearing "safer," yet are they really being told enough about this possible complication of pregnancy after GB?

And if they choose to go ahead, have the surgery, and then have a pregnancy, have they been sufficiently alerted to watch for abdominal pain and to seek help immediately if it occurs?

On a more cynical note, isn't it interesting that these cases are being recounted as case reports in the medical literature, but yet you rarely see them listed in the studies on pregnancy after WLS?  Granted, this complication is not so routine you'd see a lot of cases of it, but for every case report that is published, there are probably a number more that are not being written up.

Why isn't there more attention to this complication in the pregnancy-after-WLS literature? Given at least a 2-3% incidence of internal hernias after WLS in the general population and the number and seriousness of pregnancy-related case reports in the literature, you'd expect to see some of these documented in the large studies on pregnancy after WLS.  And yet, you almost never do.

Hmmmmmm.


References

*Note: Additional case reports can be found on Pubmed but were not listed here because they did not have an abstract available for review.

Case Reports on Internal Hernias During Pregnancy After GB

Acta Obstet Gynecol Scand. 2012 Apr 24. doi: 10.1111/j.1600-0412.2012.01421.x. Pregnant woman with fatal complication after laparoscopic Roux-en-Y gastric bypass. Renault K, et al.    PMID: 22524680

...We report a 22 year old woman, who had previously undergone uncomplicated laparoscopic Roux-en-Y gastric bypass. She was admitted with severe abdominal pain at 35 weeks of gestation. A cesarean section with delivery of a healthy baby in combination with an exploratory laparotomy was performed. Internal herniation was suspected, but not identified during surgery. Three days later she died of a severely gangrenous small bowel secondary to internal herniation. This fatal case illustrates a potential complication and difficulties in the managment of pregnant women who have undergone Roux-en-Y gastric bypass. In these women observation and investigations based on multidisciplinary approach is vital if abdominal pain develops, with involvement of intestinal surgeons experienced in bariatric surgery as well as radiologists with specific knowledge of relevant imaging procedures.

Am Surg. 2005 Mar;71(3):231-4. Small bowel ischemia after Roux-en-Y gastric bypass complicated by pregnancy: a case report. Charles A, et al.   PMID: 15869139

...This case report involves a 23-year-old female at 25 weeks gestation with a 1-day history of diffuse abdominal pain and vomiting. She had a RYGB with a 15 cc micropouch 6 months prior to the commencement of this pregnancy. All radiologic investigations were normal. Esophagogastroscopy was performed revealing an ischemic Roux limb of the gastric bypass. At laparotomy, an internal hernia involving the afferent limb was identified at the site of the Roux anastomosis compromising portions of both the afferent and Roux limbs. Nonviable portions of both the afferent and Roux limbs were resected. Gastrointestinal continuity was achieved by fashioning a gastro-gastrostomy and a jejuno-jejunostomy, thus reversing the original gastric bypass procedure. The immediate postoperative period was complicated by fetal demise. With the increase in bariatric surgery, small bowel ischemia after Roux-en-Y gastric bypass will most likely become more prevalent, particularly in women of childbearing age.

N Engl J Med. 2004 Aug 12;351(7):721-2. Maternal and fetal deaths after gastric bypass surgery for morbid obesity. Moore KA, Ouyang DW, Whang EE. PMID: 15306679  Full text available here.

[Letter to the NEJM, discussing a case report of internal hernia and complications in a woman at 31 weeks' gestation, 18 months after a gastric bypass. Both mother and fetus died.]

Surg Obes Relat Dis. 2009 May-Jun;5(3):378-80. Epub 2008 Sep 9. Internal hernia after gastric bypass surgery during middle trimester pregnancy resulting in fetal loss: risk of internal hernia never ends. Efthimiou E, Stein L, Court O, Christou N. PMID: 19026598

[No abstract available for this case report, but the title tells us the fetus died.]

Obstet Gynecol. 2005 May;105(5 Pt 2):1195-8. Pregnancy after gastric bypass surgery and internal hernia formation. Kakarla N, et al.  PMID: 15863579

BACKGROUND: Gastric bypass is a surgical procedure that is increasingly performed in the United States to treat morbid obesity. Because of the changes associated with pregnancy, women with a history of gastric bypass surgery may be at an increased risk of gastrointestinal complications during the antepartum period, as demonstrated by these cases. CASES: The first patient presented at 12 weeks of gestation with abdominal pain. Computed tomography scan revealed rotation of the small bowel mesentery. In the operating room, a Petersen's internal hernia was observed. The second patient presented at 34 weeks of gestation with epigastric pain, nausea, and vomiting. An abdominal computed tomography scan suggested distention of the biliopancreatic limb, duodenum, and bypassed stomach. She underwent exploratory laparotomy with repair of an internal (mesenteric loop) hernia. CONCLUSION: As obstetricians, we should be aware of the potential for internal hernias in pregnant patients who have undergone bariatric surgery.

Obes Surg. 2010 Dec;20(12):1740-2. Epub 2009 Mar 25. Late intestinal obstruction due to an intestinal volvulus in a pregnant patient with a previous Roux-en-Y gastric bypass. Gazzalle A, et al.  PMID: 19319613 

This is a case of a 33 weeks pregnant woman, presented 2 years after laparoscopic Roux-en-Y gastric bypass, with abdominal pain for 2 days. A laparoscopic cholecystectomy was performed 1 day earlier in another hospital, without improving the pain. She presented at our hospital with acute abdominal pain and clinical signs of intestinal obstruction, undergoing an exploratory laparotomy that revealed a volvulus and necrosis of the jejunum from the gastroenteroanastomosis through the lateral enteroenterostomy, which was resected with the reconstruction of the Roux-en-Y limb performed at the same operation. Patient and neonate presented with improvement after surgery and the patient was discharged on postoperative day 15. Internal hernias after bariatric surgery have been reported as the cause of acute abdomen problems during pregnancy, which may progress to necrosis and perforation. The delay of surgical intervention could have brought a tragic outcome for mother and neonate.

Obes Surg. 2010 Dec;20(12):1737-9. Epub 2009 Jan 28. Small-bowel volvulus in late pregnancy due to internal hernia after laparoscopic Roux-en-Y gastric bypass. Naef M, Mouton WG, Wagner HE.   PMID: 19184255

Internal hernias are a specific cause of acute abdominal pain and are a well-known complication after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Although internal hernias are a rare cause of intestinal obstruction, they may evolve towards serious complications, such as extensive bowel ischemia and gangrene, with the need for bowel resection and sometimes for a challenging reconstruction of intestinal continuity. The antecolic position of the Roux limb is associated with a decrease in the incidence of small-bowel obstruction and internal hernias. The best prevention of the formation of these hernias is probably by closure of potential mesenteric defects at the initial operation with a non-absorbable running suture. We present a patient in late pregnancy with a small-bowel volvulus following laparoscopic Roux-en-Y gastric bypass for morbid obesity and discuss the available literature. For a favorable obstetric and neonatal outcome, it is crucial not to delay surgical exploration and an emergency operation usually is mandatory.

Obes Surg. 2009 Jul;19(7):944-50. Epub 2008 Oct 2. Small bowel obstruction and internal hernias during pregnancy after gastric bypass surgery. Torres-Villalobos GM, et al.   PMID: 18830790

Small bowel obstruction (SBO) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Internal hernia (IH) a potential problem associated with RYGB, can have severe consequences if not diagnosed. We present two cases of SBO due to IH during pregnancy after laparoscopic RYGB (LRYGB). Both patients underwent an antecolic, antegastric LRYGB...IH should always be ruled out in pregnant patients with previous RYGB and abdominal pain. Prompt surgical intervention is mandatory for a good outcome.

Taiwan J Obstet Gynecol. 2007 Sep;46(3):267-71. Strangulation of upper jejunum in subsequent pregnancy following gastric bypass surgery. Wang CB, et al.  PMID: 17962108

...CASE REPORT: After a Roux-en-Y gastric bypass surgery, a 32-year-old woman had unrelenting epigastria for one week at 36 weeks' gestation. An emergency cesarean delivery, followed by laparotomy, was performed. A female neonate was delivered with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Strangulation and gangrene of the upper jejunum caused by a fibrous band at the site of the Roux anastomosis were revealed. Segmental resection of the nonviable bowel was performed. The patient experienced a smooth postoperative course. CONCLUSION: The awareness of internal hernias and small bowel strangulation should be addressed when unrelenting epigastric pain is present in women after Roux-en-Y gastric bypass surgery, during their first subsequent pregnancy.

Case Reports in Obstetrics and Gynecology. Volume 2011 (2011), Article ID 415795. doi:10.1155/2011/415795.  Abdominal Pain after Gastric Bypass: Labor, Uterine Rupture, or Obstruction and Internal Hernia. Cross, SN et al. PMID: 22567508 Full text available here.

...CASE: A 26-year-old G4P1112 status post-Roux-en-Y gastric bypass required multiple urgent antenatal evaluations due to frequent episodes of abdominal pain. At 35 + 4 weeks, she presented with severe abdominal pain; initial evaluation was negative for gastrointestinal pathology. The patient was found to be in preterm labor and underwent a repeat cesarean section. The postoperative course was complicated by bowel obstruction due to internal hernia resulting in an emergent laparotomy and a prolonged hospital course....

Obes Surg. 2006 Sep;16(9):1246-8. Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery. Ahmed AR and O'Malley W.   PMID: 16989713

We report the rare case of a pregnant woman who had undergone Roux-en-Y gastric bypass 8 months previously, and now presented with subacute small bowel obstruction secondary to internal herniation of some of the proximal Roux limb into the lesser sac through the transverse mesocolon rent, which was widely spread apart. At laparoscopy, the hernia contents were reduced and the defect was repaired. The patient made a good recovery. Because of the changes associated with pregnancy, gastric bypass patients may be at an increased risk of internal herniation. It is particularly important not to delay surgical exploration, even in the absence of a positive finding on imaging, because delay may lead to potentially devastating bowel strangulation and sepsis culminating in loss of fetus and mother.

Hum Reprod Update. 2009 Mar-Apr;15(2):189-201. Epub 2009 Jan 8. Reproductive outcome after bariatric surgery: a critical review. Guelinckx I, Devlieger R, Vansant G.  PMID: 19136457

...METHODS: English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding. RESULTS: The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive. CONCLUSIONS: Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.

Incidence of Internal Hernias After GB

Obes Surg. 2003 Jun;13(3):350-4. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Higa KD, Ho T, Boone KB.   PMID: 12841892

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been shown to be a safe and effective alternative to traditional "open" RYGBP. Although lack of postoperative adhesions is one advantage of minimally invasive surgery, this is also responsible for a higher incidence of internal hernias. These patients often present with intermittent abdominal pain or small bowel obstruction with completely normal contrast radiographs. METHODS: Data was obtained concurrently on 2,000 consecutive patients from February 1998 to October 2001 and analyzed retrospectively...RESULTS: 66 internal hernias occurred in 63 patients, an incidence of 3.1%...20% of patients had normal preoperative small bowel series and/or CT scans..There was 1 death associated with complications of the internal hernia. The negative exploration rate was 2%. CONCLUSION: Internal hernias are more common following laparoscopic RYGBP than "open" RYGBP. Contrast radiographs alone are unreliable in ruling out this diagnosis. Early intervention is crucial; most repairs can be performed laparoscopically. This diagnosis should be entertained in all patients with unexplained abdominal pain following laparoscopic RYGBP. Meticulous closure of all potential internal hernia sites is essential to limit this potentially lethal complication.

Obes Surg. 2006 Oct;16(10):1265-71. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Iannelli A, Facchiano E, Gugenheim J.   PMID: 17059733

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) when compared to the open operation. METHODS: A search in PubMed MEDLINE from January 1994 through January 2006 was performed (keywords: obesity, laparoscopy, gastric bypass and internal hernia). RESULTS: 26 studies with a total of 11,918 patients were considered. 300 cases of IH occurred (rate 2.51%)...Mortality was 1.17%. CONCLUSIONS: IH after LRYGBP has an incidence of 2.51%. Closure of mesenteric defects with non-absorbable running suture and antecolic Roux limb are recommended. Surgical exploration for suspicion of IH after LRYGBP should be first done by laparoscopy.

Obes Surg. 2011 Dec;21(12):1822-7. Small bowel obstruction after antecolic antegastric laparoscopic Roux-en-Y gastric bypass without division of small bowel mesentery: a single-centre, 7-year review. Abasbassi M, et al.   PMID: 21656166

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed...Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH...Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.

Am J Surg. 2004 Dec;188(6):796-800. Internal hernias after laparoscopic Roux-en-Y gastric bypass. Garza E Jr, et al.   PMID: 15619502

...METHODS: A retrospective review of 1,000 retrocolic Lap-RYGB was performed to identify those who developed postoperative internal hernias. Clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiologic diagnostic accuracy (including computed tomography [CT] scan and upper gastrointestinal imaging). Subsequent independent review was performed to match operative intervention with radiologic imaging and interpretation. Operative outcomes, including the hernia closure technique, hospital length of stay, and mortality were obtained. RESULTS: Of 1,000 Lap-RYGB procedures, 45 internal hernias were identified (4.5%) in 43 patients...The most common clinical symptoms included intermittent, postprandial abdominal pain, and/or nausea vomiting (86%), although 20% had no abdominal tenderness. Initial radiologic imaging studies were diagnostic in 64%, although subsequent review of all imaging studies showed diagnostic abnormalities in 97%...The mean time to intervention for an internal hernia repair was 225 days (range 2 to 490), whereas hospital length of stay was 1.2 days (range 1 to 4). No deaths were noted. CONCLUSIONS: Internal hernias after retrocolic lap-RYGB are associated with vague abdominal complaints and limited radiologic imaging results. A high index of clinical suspicion should be used in this patient population, and surgeon review of radiology imaging studies should be performed. Prompt surgical intervention is successful and can commonly be performed laparoscopically.

Do You Know You're Overweight?

Another gem from My OB Said What?!?

I keep trying to swear off repeating these here on my blog, but they just make too many of my points for me to resist, plus it's just important to fully document incidents like this.  So here's another one:

“Oh my goodness! Do you know you’re overweight? Have you tried to diet and exercise??"
– OB immediately upon entering the room and meeting a mother for the first time. The mother was in the process of miscarrying a 16 week pregnancy

I'm not even going to start commenting on this one, it's so wrong on so many levels. Urgh.

Commenters, go for it.  What do you want to say to this doctor?