Essential facts about midwives

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Certified nurse midwives provide care for pregnancy and well woman care beyond pregnancy. Here are a few interesting facts about midwifery in the US from the American College of Nurse Midwives.

There are thousands of midwives in the US delivering hundreds of thousands of babies a year.

  • There were 11,194 CNMs (certified nurse midwives) and 97 CM (certified midwives without a nursing degree) in the country as of May 2014.
  • There were In 2014,  332,107 midwife-attended births in the US, slightly more than in  2013. The vast majority ( > 90%) were attended by CNMs.
  • Midwives account for 12.1% of all vaginal births, and 8.3% of total US births.

Midwives also provide womens health care outside of pregnancy

  • CNMs are independent health care practitioners who are licensed and able to write prescriptions in all 50 states, including  DC, Samoa, Guam and Puerto Rico.
  • Federal law considers CNMs to be primary care providers
  • Over half of midwives considered reproductive health care to be their primary responsibility and a third consider primary care as their main role.

Most midwives work in a hospital setting in collaboration with obstetricians

  • Over 94% of midwife attended births occur in hospital settings
  • Over half of midwives are employed by physician groups or hospitals

Midwifery care is usually covered by health insurance 

  • Medicaid programs as well as most states are required to cover deliveries attended by midwives 

Midwives hold graduate degrees and are required to go through an accreditation process

  • There are 39 training programs for nurse midwives in the US and they receive their accreditation from the Accreditation Commission for Midwifery Education (ACME).
  • 82% of CNMs hold a master’s degree; a graduate degree has been an entry requirement into midwifery since 2010.
  • Almost 5% of CNMs hold doctoral degrees, the highest proportion of all groups of advanced practice nurses.

Dr. Gamburg talks about endometriosis surgery

Princeton NJ gynecologist discusses endometriosis surgery with the daVinci robotic device.

In the video above, one of Dr. Eugene Gamburg's patients describes her experience undergoing a combined robotic surgical procedure with a surgeon at the University Medical Center of Princeton at Plainsboro, and how it saved her wedding day.

 

Dr. Seth Derman, our practice's fertility specialist also answers some frequently asked questions  about this disease.

What is endometriosis?

Endometriosis is a disease in which tissue similar to the endometrium is located in places in the body where it normally does not belong. Endometrium is the layer of tissue that lines the uterus. It is where a pregnancy will implant, and part of it sheds monthly during the menstrual period. Endometriosis is typically found on the surfaces of organs near the uterus, the ovaries, the fallopian tubes, bladder and intestines, although it may also be been seen in distant parts of the body.

What are the symptoms of endometriosis?

The most common symptoms of endometriosis are pelvic pain, painful menstrual periods and painful intercourse. Because the implants of endometriosis respond to hormones similarly to normal endometrium, which fluctuate throughout the month, the symptoms of this disease are are often cyclic.

How is endometriosis diagnosed?

Endometriosis can only properly be diagnosed using surgery to directly inspect for it, and possibly confirm the diagnosis by biopsy. Routinely subjecting women to laparoscopy or other surgery is not practical, so oftentimes, the diagnosis of endometriosis is presumed without confirming the diagnosis.

How is endometriosis treated?

Your doctor may treat endometriosis in a number of ways. Sometimes this involves surgery, but it usually involve medications that suppress ovulation cause the implants to shrink down. This may include progesterone like drugs (progestins) and birth control pills that create a pregnancy-like hormone environment or drugs like Lupron, the create a temporary menopause-like situation. These medications often work because Endometriosis symptoms typically improve with pregnancy and menopause.

What is daVinci robotic surgery about?

Laparoscopy which involves a inserting a telescope into the abdomen is commonly used to diagnose and treat endometriosis. The daVinci surgical robot is a device often used to complete surgeries laparoscopically that are difficult to do without open surgery. Because it enables the surgeon to see far greater detail and operate with greater precisions, many gynecologists will use robotic surgery to treat the disease. Our team of gynecologic surgeons is among the most experience in DaVinci and minimally invasive surgery in the area.

Does endometriosis affect fertility?

This answer to the this question is a bit more complicated. Advanced staged endometriosis (stages 3 and 4) can clearly cause infertility. With early stage endometriosis (stages 1 and 2), it is a little less straightforward. While there is reasearch to suggest that treating early stage disease helps to improve pregnancy rates, there are other data which shows women with early stage endometriosis have similar outcomes to those with unexplained infertility. Either way, it is important to understand that even in couples with endometriosis-related infertility, there may be other reasons for not conceiving, so it is still important to see a fertility specialist for a testing.

 

Dr. Pierce brings minimally invasive procedure to Princeton

YOUR HEALTH: Princeton Doctor performs single-site robotic hysterectomy

By Stephanie Vaccaro

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This article previously appeared in the Princeton Packet  

Single site robotic hysterectomy in Princeton NJ

Dr. Bruce Pierce, the medical director of the robotic surgery program at Princeton HealthCare System, was the first doctor in the northeast to do a single-site robotic hysterectomy with the da Vinci Xi system robot. The surgery involved removing the uterus and both tubes and ovaries.   This surgery is frequently done with a larger incision that is similar to that of a C-section.   ”And that requires a two- to three-day hospital stay followed by a six-week recovery period,” Dr. Pierce said. “Since I do it minimally invasively with the robot, I’m able to make one tiny incision in the belly button and because of that, my patient goes home the same day. And basically in two weeks they’re back to work. They’re back to their normal routine.”

The benefits of robotic surgery 

The value of robotic surgery is clear.   ”Basically, it’s using technology to make a major surgery into a minimally invasive procedure, with the focus on quicker recovery,” Dr. Pierce said, adding that it involves less scarring. “Ninety percent of these surgeries can be done as outpatient.”   Earlier this year, a large study was published in the “Journal of International Gynecology & Obstetrics,” with thousands of patients with a variety of hysterectomies. “They found in surgeons who were experienced with robotics, meaning they had more than 60 cases under their belt, they found the robotic hysterectomy has less complications, less need for re-operation, less need for readmission, and less bleeding and infection,” Dr. Pierce said. “The main thing was the surgeons needed to be experienced.”   What makes a patient a good candidate for robotic surgery? “It depends on the surgeon’s level of experience,” Dr. Pierce said.   He also said that it’s important to note that there is a learning curve with robotics.

The importance of using an experienced robotic surgeon

   "It’s not perfect right out of the gate," he said. “With a beginning surgeon, you basically have to pick the easiest candidate, meaning somebody who is not overweight, somebody who has not had a lot of previous surgery, somebody whose uterus is small, a non-complex surgery. But the more experienced you get with the new technology, you’re able to expand the patient base to a more complex patient. So, all of a sudden these patients who used to be not candidates for robotics are now candidates with experienced robotics surgeons.”   How will this technology develop? “The future though lies with more women becoming candidates and more complex cases being done in a minimally invasive manner,” Dr. Pierce said.   What about the naysayers? “The detractors of robotics say it’s too expensive,” Dr. Pierce said, but he pointed out considerations as fewer hospital stays, and returning to a work a month earlier.   Dr. Pierce has done hundreds of robotic surgeries for the past eight years. He has also taught other physicians how to do it for many years now. When considering robotic surgery, experience matters, he said, “I want to emphasize that an experienced surgeon is crucial to improved outcomes."

 

Bed rest and pregnancy

Article in Harper's Magazine questions whether bed rest is helpful in pregnancy.

Is bed rest helpful or harmful for pregnant women?

For years, obstetricians and midwives (as well as grandmothers-to-be) have recommended bed rest to treat a variety of pregnancy related problems including premature birth, preventing miscarriage, poor fetal growth (IUGR) high blood pressure and pre-eclampsia (toxemia).  Even fertility doctors have gotten in on the game, recommending bed rest to improve IVF pregnancy rates. The question that pregnancy researchers have been trying to answer and the impetus for article above, recently published in Harper's magazine: is does bed rest help?

The science behind bed rest and pregnancy

The idea that bed rest is beneficial for pregnant women certainly makes sense to most people including most womens' health care professionals recommend bed rest. Most obstetricians and midwives have been trained to use bed rest as a treatment but now in the age of evidence based medicine that therapy is being called into question.The problem is that there are few if any studies that show any benefit to bed rest during pregnancy. To be fair, there is also little evidence to suggest that it is not helpful either.

In contrast, there are are a number of studies showing the benefits of exercise for pregnant women, and moderate exercise is now encouraged in healthy pregnant women by organizations such as the American Congress of Obstetricians and Gynecologists

So, why care about bed rest in pregnant women since it is harmless?

Bed rest is not harmless. Bed rest increases the risks of a number of complications including:

  • Blood clots
  • Depression
  • Low birth weight
  • Slower recovery from childbirth
  • Loss of bone and muscle mass
  • Loss of income
  • Stress at home

In fact the more strict the bed rest, the higher the risk and severity of these side effects are.

Discussing bed rest with your OB

Making decisions about your medical care is an individualized decision a woman should have with her Obstetrician or Midwife, and bed rest is no exception. Bed rest is neither a cure all for pregnancy complications nor something to be avoided at all costs. 

More confusion over mammography

The American Cancer Society changes mammography recommendations yet again

Mammograms, x-rays of the breast are routinely performed on women for the purpose of diagnosing breast cancer at its early stages when the chances for a cure are highest. While that goal certainly makes a lot of sense, the science behind mammography and its usefulness are turning out to be a moving target.

It seems that every year, mammography recommendations continue to change as we learn more about what breast imaging can and cannot achieve. Just this month, American Cancer Society has changed its mammography recommendations once again.

The new ACS Mammography guidelines are as follows:

  • 40-44: annual mammography optional
  • 45-54: annual mammography recommended 
  • 55+: mammography every 1-2 years
  • Screening should continue for as long as a woman is expected to live at least 10 more years
  • All women should learn about the risks, benefits and limitations of screening and learn their own normal breast anatomy through self examination.

So, does that mean my doctor (OR MIDWIFE) and I should cut back on how often I get my mammograms?  maybe, maybe not.

  • There is really no consensus. Other organizations that issue mammogram recommendations such as the American Congress of Obstetricians and Gynecologists (ACOG) and the US Preventative Health Task Force either have not changed their guidelines or offer different recommendations.
  • ACOG continues to recommend offering annual mammography after age 40
  • Women at high risk such as those who carry BRCA gene mutations and those with an extensive family histories of breast cancer (particularly at a young age) are usually advised to start screening much sooner.