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Breast-feeding and birth control

Is it safe to use oral contraceptives, birth control pills while breastfeeding?

 

There is some controversy about this.

The American Academy of Pediatrics recently stated that it is perfectly safe to use one of the low dose oral contraceptives while breast-feeding once the feeding pattern has been well established.

Use of hormone contraceptives before the body has had time to heal from the pregnancy may increase the risk of blood clots in the legs or lungs.  It is usually recommended to wait at least 6 weeks before starting the medication.

Starting hormone contraceptives before 6 weeks may also interfere with the milk production or dry up the milk completely.

The various pharmaceutical companies that sell birth control pills, still state that it is not a good idea to use the estrogen containing oral contraceptives while breast-feeding.  They describe a decreased quality of the breast milk produced if the mother is taking birth control pills.  Some studies have reported small decreased amounts of protein and lactose in the breast milk of these mothers.

In the past, the “mini-pill” was used.  This is a birth control pill that contains only one hormone, progestin, and no estrogen.   Many doctors are returning to this birth control pill in their breast-feeding mothers.  Only a small amount of the progestin passes into the breast milk.  There have been a number of reports of complaints of decreased breast milk production even with this pill.  There have not been any reports of long term harm to infants that were breastfeed while the mother used progestin contraceptives.

The “mini-pill” is not as effective as the estrogen containing pill. It might be safer to use condoms with the pill as a backup.  Some studies have found that this pill may only be up to 92% to 95% effective versus up to 99% with the other estrogen progestin pills.

The pharmaceutical companies that sell progestin only contraceptives still recommend caution when breastfeeding however.

The Mirena IUD, a device placed inside the womb that releases progestin hormone or Depo Provera, an injectable form of progestin that lasts 3 months, are other options also.

 

So, to answer the question: A breast feeding mother could use a progestin only contraceptive and starting 6 weeks after breast feeding. She may consider using a backup method along with the pill to ensure 99%+ protection.  If there is a decrease in the milk production, she may consider stopping the medication if she plans to continue breastfeeding.

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The Affordable Care Act/Obamacare

What is this Obamacare?  What if I have a pre-existing condition, such as diabetes?

 

The Patient Protection and Affordable Care Act or Obamacare was signed into law March 2010.  The aim of the law is to increase access to medical care and ensure high quality care. The estimates are that there were about 65 million people in the US without healthcare coverage when this became law. Texas had the highest rate of uninsured people followed by Florida.

 

The health law is rolling out in phases through 2018.

 

  • Young people can be covered under the parent’s insurance up to age 26.

 

  •  Preventive care (well woman exams, mammograms) is covered without co-pay.

 

  •  Insurance companies must publicly justify rate increases of 10 percent or more before raising premiums.

 

  • Insurance companies are required to spend at least 80 percent of customer premiums on healthcare and quality improvement or issue a rebate to policyholders.  Quite a few people have already received a rebate check from their insurance carrier.

 

  • Insurance companies are no longer allowed to place lifetime limits on coverage and they’re not allowed to rescind coverage except in cases of fraud.

 

  •  And starting next year, insurance companies can no longer deny coverage to individuals based on preexisting medical conditions such as diabetes, or heart disease.

 

The centerpiece of the healthcare reform law, the online health insurance exchanges unveiled Oct. 1 where Americans can shop for health insurance plans at http://www.healthcare.gov/

 

On the exchanges, people will find out if they are eligible for federal subsidies to help pay for insurance premiums and out-of-pocket costs such as deductibles, or if they are eligible for Medicaid, the federal-state health insurance program for the poor.

 

For the physician the great part of the Affordable Care act is the incentives for people to get preventive services, get checkups, find things early, get it taken care of, fill their prescriptions and follow the doctor’s advice so that you don’t end up back in the hospital. Physicians see people come in to the office or ER with advanced stage diseases/ problems that there may be little or nothing that can be done.  If these people had the ability to afford healthcare or had come in earlier, the problems could have been taken care of simply and completely. It breaks your heart to watch someone suffer, die of a problem that with all the technical advances in medicine could have been avoided.

 

It should be pointed out the Affordable Care Act does not mean the government will be doing your pelvic exams or the cost of insurance will be going up for the people who already have insurance.  As millions more people enter the healthcare market and purchase insurance with or without government subsidies, the overall cost of insurance is spread out over more individuals.  Right now, when a very sick person is admitted to the hospital without insurance coverage, the cost of that care is eventually passed on to everyone else who does have insurance in greater costs overall.  The sick person is not working, is not contributing to society.  Healthy people obviously do not utilize as much healthcare, so costs for everyone goes down.

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Epidurals in labor

What is an epidural?

 

An epidural is anesthesia used during labor or for a cesarean section. It delivers continuous pain relief to the lower part of your body while allowing you to remain fully conscious in labor or during surgery.  Medication used is delivered through a catheter inserted into the epidural space just outside the spine.  The discomfort of placing an epidural is minimal.

The anesthesiologist will have you sit up on the edge of the bed or curled on your side.  She then cleans your back, injects the lower back with a numbing medicine, and carefully guides a long skinny needle into the proper space. The anesthesiologist then passes a catheter through the needle, takes out the needle, and tapes the catheter in place.  Intravenous fluids are given prior to the epidural to hydrate you. Usually you’re given a small dose of medicine to test your response and test placement.  Then a full dose will be administered.  Medication is administered by a continuous pump while you are in labor.  There will be continuous monitoring of the baby’s heart rate and your blood pressure is checked frequently to watch for any side effects.

The epidural provides a good deal of pain relief and also numbs your lower abdomen, pelvis and legs to a certain degree.  After the baby is delivered, the catheter will be removed.

You will want to be in active labor before getting the epidural to reduce the chance that it could slow down your contractions. Active labor is usually at least at 4 cm. dilated with regular contractions.

When or if you get your epidural is a decision you’ll make while you are in labor.  You will probably want to get it before the baby’s head is crowning, or showing at the perineum.

There have been a few cases, up to 3% of patients who experience a severe headache caused by leakage of spinal fluid after an epidural.  This may be treated with liberal amounts of oral fluids and pain medication. If symptoms persist, a procedure called a “blood patch”, which is an injection of your blood into the epidural space, can be performed to relieve the headache.

If labor continues for more than a few hours you will probably need a catheter placed in the bladder because your abdomen will be numb, temporarily making urinating difficult.

If the labor progresses quickly, you may need the attendant to tell you when to push because the lower half of the body is still numb.  Sometimes the mother may rest with the epidural turned off to allow enough sensation to return to allow effective pushing.

In some case the woman in labor may not be able to have an epidural administered because of a low platelet count, an infection of the skin of the back, or infection in the blood, or labor is progressing so fast there is no time for the medication to be administered.

If you are coping well with labor you may choose not to use any medication for relief.  Some women may use just a shot in the IV periodically and find that this gives adequate relief. Some women may use both the IV medication and later the epidural.  It is always completely up to the laboring mother.  We always remind our laboring mothers that there is no medal given for not using medication in labor and certainly no disgrace if analgesia is used.  The focus is on having a safe delivery and healthy mother and infant.

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Sexually transmitted diseases: Chlamydia

Should we use condoms until my partner is treated for Chlamydia?

Frequently, patients ask if it is ok to still have intercourse with a partner who has not been treated as long as the couple uses condoms.  A visualization technique to consider would be imagining having intercourse with the partner with a condom right after he has rolled his member around in fresh wet mud mixed with animal droppings.  That romantic image should cause at least some hesitation.

Chlamydia is a sexually transmitted disease (STD)  that can infect both men and women and can cause permanent damage to a woman’s reproductive organs. It is known as a ‘silent’ infection because most infected people have no symptoms.  It can be easily treated and cured with antibiotics.

Persons with Chlamydia should abstain from having sex for seven days after a single dose antibiotic, or until completion of a seven-day course of antibiotic, to prevent spreading the infection to partners.

Even if you have been treated, you can get infected again if you have sex with an infected person. It is a very common STD, especially among young people.

Some infected women have an abnormal vaginal discharge or a burning sensation when urinating. Untreated infections can spread upward to the womb and fallopian tubes (tubes that carry the egg from the ovaries to the womb), causing pelvic inflammatory disease (PID). PID can be silent, or it can cause symptoms such as abdominal and pelvic pain. Even if PID causes no symptoms initially, it can lead to infertility (not being able to get pregnant) or ectopic pregnancies (pregnancies that settle in the fallopian tubes.)

In pregnant women, untreated Chlamydia has been associated with pre-term delivery, and can spread to the baby, causing eye infections or pneumonia.

There are laboratory tests to diagnose Chlamydia. Specimens for testing are obtained from swabbing the cervix or collecting a urine sample.

Persons with Chlamydia should be retested about three months after treatment of an initial infection, regardless of whether they believe that their partners were successfully treated.

Using latex condoms correctly, and with each episode of sexual intercourse. can reduce the risk of getting or giving Chlamydia. The surest way to avoid Chlamydia is to abstain from vaginal, anal, and oral sex or to be in a long-term monogamous relationship with a partner who has been tested and is known to be uninfected.

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Fever during Pregnancy

Is a fever dangerous during a pregnancy?  Will a fever harm the baby?

 

A high fever (over 101 F) for a long period of time during an early pregnancy can be harmful to the fetus.  The exposure to high temperatures is most damaging between the fourth week after the last menstrual period and the fourteenth week.   In the second 3 months and the last 3 months of pregnancy, high temperatures are much less likely to cause any problems for the baby.

A brief episode of high temperature is unlikely to cause any problem and is usually treated with an over the counter medication like acetaminophen (Tylenol.)

Fever may indicate an infection in the womb which could also be harmful to the fetus. Such infections could be from the cytomegalovirus (CMV,) parvovirus, or toxoplasmosis.

Some researchers think that when the mother has a high internal temperature from fever or even soaking in the hot tub early in pregnancy there may be a greater chance of development of neural tube defects such as spina bifida-an opening in the spine.

There have been reports that there could be up to 3 times the chance of a child being diagnosed with autism by 3 years old if the mother had fever for a week or the flu during pregnancy.  The Center for Disease control says that there needs to be more research in this area to be certain.

There have been questions about other birth defects resulting from fever and infection but again more research is needed.

An ultrasound after 20 weeks may be used to look for any obvious birth defects.

Of course if the increased temperature is controlled, there would be little risk to the fetus.  If a woman develops a fever during pregnancy she should follow the instructions given to her by her health care provider.  If she is unsure, it is best to call her doctor or her nurse practitioner for further information and instructions.