December, 2006

A NEW ERA BEGINS
BIRTH QUESTIONS TO CONSIDER
IODINE DEFICIENCY

A NEW ERA BEGINS

As of January 2007, I will discontinue attending home births. After 30 years of delivering babies at home, I have been unable to obtain medical malpractice insurance to cover home births any longer. During the past five years there has been a crisis developing for physicians who deliver babies in Illinois. The premiums for malpractice insurance have been skyrocketing. Several insurance companies have even terminated offering malpractice insurance at all, due to the large judgments that juries in Illinois have been awarding to plaintiffs in medical malpractice cases. Some women in rural areas of Illinois have to drive over three hours to find a doctor or hospital able to deliver their babies.

Malpractice insurance provides a defense for a doctor or hospital that is sued by a patient. This insurance also provides compensation for patients who are judged to have been injured by medical errors. A doctor is also required to carry medical malpractice insurance to maintain membership with his hospital staff and to participate in medical insurance plans. My case is an unfortunate example of how the decisions of insurance companies can control or limit the variety of medical care available to the public. It is the patients who suffer due to fewer available options.

I will continue to deliver babies at the birthing center at Highland Park Hospital. Fortunately this hospital is very mother and baby friendly. There are birthing rooms where a mother labors, delivers, and recovers in a private, spacious, home-like atmosphere. For mothers with normal labors, no IV is required, and fetal monitoring is intermittent. I encourage the mother to change positions and to ambulate during labor. I perform the birth on the bed without stirrups, the same way I have always done the home births: utilizing perineal massage; using gradual controlled crowning of the baby's head to minimize trauma to the soft tissues; placing the baby on the mother's abdomen after the birth; allowing the umbilical cord to finish pulsating before clamping and cutting; and encouraging early initiation of breastfeeding following the birth. Full time rooming-in is available; the baby does not have to go to the nursery. In addition, the father can stay overnight on a rollaway bed.

I have been delivering babies at this hospital for over 27 years-longer than any other doctor currently practicing obstetrics on the unit. The staff nurses know my patients well and respect their low interventional philosophy of birthing. There are several nurses on the staff who have had their own babies at home, or have attended home births in the past. An excellent team of certified lactation consultants is available. They can help your baby develop a good latch on the breast before you go home. An optional hearing screening test is available that can verify that the baby's hearing is intact. Since I am the attending physician for both mother and baby, we can decide upon discharge whenever you are ready to go home.

I am very thankful that I will be able to continue doing home-like births within the hospital setting. My nurses, who have been attending home births with me, will now be available upon request, to help and support women who wish to labor naturally within the birth center setting. To those more than 3,000 families that I have helped to deliver their babies at home, I offer profound thanks for letting me participate in that extremely special time. Every birth represents a miracle: a time of hope, accomplishment, and happiness that I will always remember with great fondness, respect, and awe.

BIRTH QUESTIONS TO CONSIDER

If you are considering having your baby at home, the following is a list of questions that you should ask a prospective birth attendant during an interview. The person should be able to answer these questions confidently and without hesitation. If the respondent answers these questions to your satisfaction, this indicates that he or she is knowlegable and experienced, and has already considered these important issues.

How long have you been in practice?
Where and how did you train?
How many births have you attended?
Do you come alone or with (an) assistant(s)?
What medical equipment and medications do you bring with you to the birth?
If I develop a vaginal laceration, will you do the suturing repair? Do you administer a local anesthetic to help with the repair?
If I develop a risk factor during my pregnancy incompatible with a home birth, how does my care then proceed?
If I develop a risk factor during my labor incompatible with a home birth, how does my care then proceed?
What are some pregnancy factors that would preclude me from having my baby at home? What should we do if the baby is not engaged in my pelvis or is in the breech position close to term?
What is the earliest date that I could go into labor and have my baby at home? What is the latest date that I could go into labor and have my baby at home?
What are some labor problems that would preclude me from finishing my delivery at home?
How do you assess and monitor the fetal heart tones during labor?
How would you manage a retained placenta?
Are there some tests that you recommend that I have before my due date? Will you test me for genital Group B Strep? What is your protocol if the Group B Strep culture is positive?
Do you wait for the umbilical cord to finish pulsating before you clamp and cut it?
What procedures will you recommend for the baby? (e.g. eye treatment, Vitamin K, PKU/neonatal screening, hearing screening)
What medical follow up will the baby and I have after my delivery?
Who will complete and file the baby's birth certificate?
What procedures do you use if the shoulders do not deliver easily following the delivery of the baby's head?
What happens if you have another patient in labor when I am in labor?
At what point will you come when I inform you that I am in labor? Where might you be coming from? How do I reach you?
What is your schedule for prenatal care, and what will you do at the visits?
Will you weigh, measure, examine, and assess the baby after the birth?
How long do you stay following the birth?
How do you attempt to prevent perineal tearing when the baby is born?
What will you do if my bleeding is very heavy following the birth?
What will you do if my baby is not breathing effectively following the birth?

IODINE DEFICIENCY

Iodine is an element that is utilized by various glands in the body to support their function. Most notably, the thyroid gland in the neck uses iodine to synthesize thyroid hormones. The thyroid hormones help to regulate the body's metabolism and temperature. If there is insufficient circulating thyroid hormone, a person may experience hypothyroidism with symptoms of sluggishness, fatigue, weight gain, dry skin, constipation, cold intolerance, or depression. Hypothyroidism is very common in the Great Lakes basin, and much more common among women than men. Doctors used to administer iodine supplements to treat hypothyroidism before synthetic thyroid hormone was available. After synthetic thyroid hormone became available, the use of iodine waned, although it is still an effective treatment. In fact iodine therapy can provide better results by improving the function of the patient's own gland to produce thyroid hormone. Administering synthetic thyroid hormone actually reduces the stimulation for the thyroid gland to produce its own hormones.

In our region, iodine deficiency is very common. Our soil is deficient in iodine, so the plants and animals produced in our area are also iodine deficient. Iodine is more plentiful near the oceans where the soil is much richer in this element. Sea foods and sea vegetables contain ample amounts of iodine. Beginning in the 1920's, iodine was added to table salt in order prevent goiter. A goiter is an enlargement of the thyroid gland caused by iodine deficiency. The Midwest was once termed the "goiter belt" due to the high prevalence of this condition here. At one time commercial bread was supplemented with iodine, but unfortunately, bromine has recently replaced iodine.

Bromine, chlorine, and fluorine are halide elements related to iodine, but they have no beneficial effects on the thyroid gland. In fact these elements can attach themselves to the thyroid gland and block the access of iodine to the gland. Chlorine and fluoride are added to the municipal water supplies in order to prevent bacterial contamination and dental cavities. These additives may thus exacerbate the current epidemic of hypothyroidism.

After the thyroid gland, the glands that absorb and utilize the most iodine are in the breasts. Iodine therapy is effective in preventing and treating fibrocystic disease of the breasts and breast cancer. Perhaps the reason that there are more women than men with hypothyroidism is that the breasts are competing with the thyroid for a limited iodine supply. The ovaries and prostate also utilize iodine to promote their healthy function.

Iodine levels in the blood can be tested, but this test doesn't document the level of severity of the deficiency. A more specific test involves a 24 hour urine collection following a 50 mg oral loading dose of iodine. If you have plentiful iodine stores in your body, your kidneys will excrete 90% or more of the loading dose (?45 mg) in the 24 hours. If the urine collection shows a lesser quantity of iodine, your body is retaining the iodine for utilization because your body stores are low. Most of us who live in this region are iodine deficient. A careful clinical trial of iodine supplementation for several months to see if symptoms improve would do no harm and might be beneficial. Please contact our office for further information.

The iodine supplement that I recommend is called Iodoral®. Iodoral® contains 12.5 mg of iodine: 5 mg of elemental iodine and 7.5 mg of iodide as the potassium salt. This recommended dosage regimen for supplemental iodine comes from studies that show the average Japanese person consumes 13.8 mg. of dietary iodine daily. The Japanese have a much lower incidence of breast cancer and thyroid dysfunction, and a longer life expectancy than people living in our area. For further information I recommend you read the very interesting book, Iodine: Why You Need It, Why You Can't Live Without It by David Brownstein, M.D.