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July 14, 2016

A mother’s body is more than just a home as her baby grows: it is protection, sustenance, and strength. When a mother eats well, exercises, and takes care of her body, she is also helping her baby grow healthy and strong. Vaccines can help both mother and baby stay healthy during pregnancy and the early postpartum months. But not all immunizations are safe for pregnant women. If you’re trying to expand your family, here’s everything you need to know about vaccines during pregnancy.

Pre-Pregnancy Vaccines

If you’re trying to become pregnant, you likely have a list of things to eat, avoid, measure, and track. Moms-to-(Hopefully)-Be can add “vaccinations” to the list. Vaccines that contain traces of live viruses aren’t safe for pregnant women. Get these immunizations at least one month before trying to become pregnant. To prevent illness and infection during pregnancy (for both yourself and your baby), make sure you’re up-to-date on these vaccines.

  • MMR (Measles, Mumps, and Rubella vaccine)
  • Chickenpox vaccine

Safe Vaccines During Pregnancy

mom holding baby's handAccording to the CDC, some vaccines are safe for pregnant or breastfeeding mothers. The flu shot is recommended for pregnant women during flu season (November-March). The flu shot, which is made of dead strains of the virus, is safe for both mother and child. Vaccines that contain live viruses, such as some flu nasal sprays, are not safe during pregnancy. The TDAP vaccine, which protects against whooping cough, is made with toxoids (bacterial proteins which have been chemically altered), and is also safe for pregnant women. Other low-risk vaccines, such as the Pneumococcal vaccine and Hepatitis B vaccine, may be recommended by your physician based on your individual risk of contracting the disease.

Post-Pregnancy Vaccines

If you weren’t able to get up-to-date before welcoming your bundle of joy aboard, the postnatal period is the time to get caught up on your adult vaccinations. Parents should get immunized to protect their infants while they’re still too young for some vaccinations. Breastfeeding mothers can follow a normal adult vaccination schedule.

For more information about which vaccines are safe during pregnancy, call Cherokee Women’s Health.

Mother and Child

What Is Fecal Incontinence?

Fecal incontinence is a condition where one lacks the ability to control bowel movements. In some cases, even the sensation associated with the need to move one’s bowels is not felt. In these cases, stool or mucus may be impossible to hold back and can oftentimes result in mortifying accidents.

fecal incontinence photoNormally, strong healthy muscles and nerves in the anus and rectum cooperate with each other, working together to keep stool in the rectum where it belongs until it’s time to have a bowel movement.

This works much the same way as a garden hose with a fitting attached to a spray nozzle. When the tap is turned on, the water remains contained in the hose until the trigger of the nozzle is squeezed, releasing water spray. If the nozzle or fitting is faulty, depending on the extent of the damage, water will either dribble out slowly or gush uncontrollably. Fecal incontinence is similar. There is either some uncontrolled leakage or full incontinence.

Fecal incontinence can be occasional or chronic. Most of us suffer from gastric issues from time to time and can experience some loss of bowel control. But sometimes, what we presume will be simple flatulence may result in an unwelcome surprise of anal leakage.
Urge bowel incontinence is the need to defecate without warning. Those who have it know they need to get to a toilet, but usually cannot get there in time. Passive incontinence is being completely unaware of the need to defecate. The sensation is simply not there, and stool is passed with no warning.

Because of humiliating factors such as sound, odor and visible staining associated with this condition, it can often draw unwanted attention. In time, psychological issues like humiliation, depression, shame and even self-disgust may arise, causing those afflicted to withdraw and isolate themselves from society.

Who is Affected?

Fecal incontinence affects one in 12 adults in the United States alone. There is no age limit, however it affects older adults more often, and slightly more women than men. To put this ratio into perspective, at least one person at every family reunion or five people at any moderate church gathering may be suffering from fecal incontinence. It’s not uncommon.

What Causes Fecal Incontinence?

• Inactivity: Bed or wheelchair bound individuals, the elderly who lead a less vigorous lifestyle and those who spend most of their day in a sitting or prone position are more susceptible. A sedate lifestyle is more likely to cause stool retention in the rectum. Softer or more liquid fecal matter can leak past the harder stool causing fecal incontinence.

• Constipation: Hard, thick stool can develop with constipation, stretching the rectum and relaxing sphincter muscles. More watery fecal matter forms behind this stool and may leak out. Subsequent straining to relieve constipation may weaken pelvic floor muscles.

• Diarrhea: We’ve all had it at one time or another and know how hard it is to get to a bathroom in time. Accidents often result because watery fecal matter is harder to hold in than firmer stool and fills the rectum faster.

• Loss of rectal elasticity: The rectum stretches to allow room for fecal waste, however scarring, sores and irritation caused by such things as radiation, inflammatory bowel disease and rectal surgery may cause the rectum to stiffen and no longer expand.

• Childbirth via vaginal delivery: Giving birth vaginally, especially if forceps are used, can cause damage to nerves and muscles in the pelvic floor. So can surgically cutting (episiotomy) in an effort to minimize vaginal tearing during birth. Fecal incontinence may occur years later or immediately after giving birth.

• Hemorrhoids: Hemorrhoids that develop around the anus may prevent sphincter muscles from closing completely. Since this muscle keeps feces in the rectum, any small portal can allow leakage to escape.
• Rectal prolapse: Sometimes the rectum can descend through the anus, causing the sphincter to not do its job properly.

• Rectocele: The rectum and vagina are separated by a thin layer of muscle. If that layer weakens, the rectum may jut down into the vagina forming bulges. In more severe cases, it can visibly hang outside the vagina, resulting in possible retention of stool in the rectum. It is speculated, though not certain, that this may cause fecal incontinence.

• Diet: Certain drinks such as dairy products or caffeine beverages may have a laxative effect, aggravating fecal incontinence symptoms, as can spicy, greasy foods.

• Overuse of laxatives: Sometimes mother nature may need a little medicinal nudge, but chronic use of laxatives poses a higher risk for developing fecal incontinence.

• Muscle weakness or damage: Circular muscles called sphincters located in the rectum contract tightly to prevent feces from passing through the anus (similar to the concept of aperture on a camera). These muscles can be damaged or weaken with age, losing strength and tautness.

• Nerve damage: Impairment of the nerves in the sphincter muscles, and those that sense the need to pass stool can also result in leakage.

Damage to both the sphincters and nerves can be caused by childbirth, cancer or hemorrhoid surgery. Additionally, nerves may be damaged due to stroke, constant forcing of stool, head trauma, injury to the spinal cord and diseases that affect nerve function such as multiple sclerosis and diabetes.

How is Fecal Incontinence Diagnosed?

After questions are asked, symptoms charted and a physical examination is completed, your doctor may order a series of tests to correctly diagnose fecal incontinence. These tests may include:

• Anal Ultrasound: This test specifically pinpoints the anus and rectum. Sound waves form an image of the sphincter muscles.

• Anal Manometry: An inflated balloon and pressure sensors check rectal sensitivity and function, along with sphincter muscle tightness.

• Magnetic Resonance Imaging (MRI): Magnets and radio waves produce images of soft internal issues and organs.

• Anal Electromyography (Anal EMG): This checks the health and electrical activity of the pelvic floor nerves and muscles, translating those into images and sounds.

• Defecography: An x-ray of the area surrounding the anus and rectum indicates the patient’s ability to hold and void stool. It also shows any structural damage in the rectum, pelvic floor and anus.

• Flexible Sigmoidoscopy or Colonoscopy: Similar to a regular colonoscopy, this test concentrates only on the lower colon and rectum to check for fecal incontinence. In some cases, if necessary, a small piece of tissue is harvested for a biopsy.


• Diet: About 20 to 25 grams of fiber, along with plenty of water should slowly be introduced into the diet to counteract diarrhea and constipation. It’s always best to get fiber from natural sources, but there are plenty of flavored and unflavored fiber supplements on the market. We’ve come a long way from the phlegmy, thick, pasty drinks. Keeping a diary of foods that can aggravate incontinence is always a good idea too.

• Bowel Training: It can take a few weeks to several months, but training your body to obey you by having bowel movements at certain times of the day can help minimize fecal incontinence.

• Medication: If chronic diarrhea is a problem, bulk laxatives can help for more controllable and solid bowel movements. Antidiarrheal medications may also be prescribed.

• Pelvic floor exercise and biofeedback: Exercises targeted to strengthen the muscles on the pelvic floor by squeezing and relaxing can help with bowel function and control. Biofeedback, using sensors can make sure the correct muscles are pinpointed.


Surgery is usually reserved as a final option, but when all other forms of treatment prove ineffective, it may be necessary. If so, you’ll receive a detailed description of all you need to know about the procedure and any possible risks associated with it.

You don’t have to suffer with fecal incontinence. It can almost always be corrected with non-invasive methods. Sometimes, a more aggressive approach may be needed, but in almost all cases, the problem CAN be fixed.
Our doctors are here to help. Call today to schedule an appointment so you can get your life back on track.

vaginal discharge photoWhat is vaginal discharge and what causes it?

The vagina is similar to a corridor that leads from outside of woman’s body to her inner reproductive organs. The vagina and cervix contain tiny internal glands that create and secrete fluids. The purpose of these fluids is to wash away bacteria and dead cells. This natural cleansing process protects the vagina, and prevents infection– much the same way a kitchen sieve holds strawberries while a good rinsing flushes away harmful dirt, grit and anything else those berries might have been lying in as they grew.
While vaginal discharge can be annoying, often staining and occasionally ruining those favorite, overpriced panties, it is a perfectly natural bodily function and should not be tampered with unless problems arise. If something interferes with the delicate balance of vaginal secretions, uncomfortable, painful and even serious infection may occur.

What is normal healthy vaginal discharge?

The color of healthy vaginal discharge can range from clear to milky white, the latter usually occurring during ovulation. It may also be clear with white stringy flecks. When dry, white discharge may turn yellow on underclothing.
A bloody discharge is also perfectly normal during a woman’s period and is no cause for alarm. At times, droplets of blood can be mingled in with discharge between menstrual periods and this is known as spotting. Unless excessive, or accompanied by discomfort, this is also normal.

The amount can vary anywhere from 20 mg to 60mg a day (yes, it feels like much more!) This can increase to about 600mg during ovulation. Increase in discharge can also occur during exercise, breastfeeding, contraceptive use, sexual arousal and even emotional stress. Vaginal discharge decreases at menopause due to lower estrogen levels.

The texture of normal discharge also fluctuates. During ovulation, it can be thin and watery. This texture is Nature’s way of enabling sperm to pass into the uterus allowing a better chance of fertilization. At other times, it is thicker, more acidic, and less hospitable towards sperm. This is temporary, just like a mild marital spat.

Discharge texture varies depending on the body’s levels of the hormones estrogen and progesterone, both found in birth control pills. This is why women who take oral contraceptives produce thicker discharge, thus preventing unwanted pregnancy.

During pregnancy, a thick mucus plug (operculum) forms inside the cervical canal. Containing antibacterial properties, its function is similar to that of a cork or safety seal for the uterus, protecting it from uterine fluid leakage or pathogen invasion. When dilation begins to occur before childbirth, the plug loosens and drops out, resembling discharge tinged with blood.

Discharge odor can vary depending on medication, menstrual cycle, diet, activity, personal hygiene, pregnancy, lubricants, and hygienic cleansing products, but usually a slight musky, though not unpleasant odor is normal. Receiving oral sex can sometimes produce a different odor.

When should you see your doctor?

Although vaginal discharge is vital in maintaining optimal health of the reproductive organs, the delicate Ph balance can sometimes be compromised leading to infection. Infections may occur at any time, but are more likely to happen when the Ph balance is less acidic, right before or during menstruation.

If you experience any of the following symptoms, see your doctor. These can possibly be indications of infections or sexually transmitted diseases such as Bacterial Vaginosis, Yeast Infection(Candida), Pelvic Inflammatory Disease, Human Papillomavirus, Trichomoniasis, Gonorrhea, or Chlamydia –to name a few:

• Pain or inflammation accompanying discharge
• Redness in vulvar or vaginal areas
• Strong unpleasant smelling discharge immediately after intercourse
• Burning or itching
• Rash
• Burning while urinating
• A cottage cheese like texture.
• Thick, lumpy, or pasty discharge
• Foul smelling green, yellow, grey, or cloudy discharge
• Excessive or recurring brown or bloody discharge, especially when not on your menstrual cycle
• Strong, foul, fishy odor
• Watery discharge
• Any unusual discharge accompanied by abdominal pain, uncommon fatigue, fever, sudden weight loss, and increased urination.
• Blisters or sores in the vaginal or vulvar area.
• Painful intercourse


After a brief medical examination which is usually enough to identify the problem, your doctor may request additional tests to analyze skin, cervical or discharge samples.
When the problem is identified, most vaginal discharge abnormalities can be treated with prescription medications such as antibiotics, creams, antifungals, or suppositories. These should always be taken for the full amount of time prescribed by your doctor, no matter how much better you feel.
In some cases, it may be necessary to treat both the patient and her sexual partner, and both may be asked to refrain from sexual intercourse until treatment is successfully completed.
If symptoms persist after medication is completed, a follow up visit may be necessary.
Over the counter medications are available for common yeast infections, but should be avoided if pregnant unless approved by a physician.
Abnormal discharge may be indicative of some cancers, but this is rare.

How you can help prevent problems

• Use condoms, especially with new sexual partners.
• Have an annual pap smear to screen for possible cancer. It’s only uncomfortable for a minute
• Keep the genital area dry and clean with regular bathing, showering and gentle wiping from front to back after urination or defecation.
• Avoid harsh soaps, feminine sprays, powders, chemicals or douches around the vaginal area. They can may upset the Ph balance and kill important bacteria. Being field flower fresh can sometimes do more harm than good
• Avoid deodorized pads and tampons, especially those discount store brands that can be smelled before you enter a room.
• Wear absorbent cotton underwear, and save the sexy, synthetic ones for special occasions unless they have a cotton crotch piece.
• Be vigilant when you wear tampons. Anyone can forget, especially near the end of a period when there is little or no blood. It happens more often that women think.
• Use products designed specifically for vaginal lubrication. Avoid petroleum jelly or other household lubricants your grandmother suggested.
• Eat a healthy, well balanced diet and drink plenty of fluids. Yogurt containing live cultures helps to prevent yeast infections.
• If treating an infection, use sanitary napkins instead of tampons and avoid intercourse if advised by your doctor.

Normal vaginal discharge is essential good pelvic health, but any unusual symptoms should be addressed immediately. Speak to your doctor honestly and frankly to alleviate the problem as soon as possible. There’s no need for embarrassment. Open dialogue is vital to an accurate diagnosis and effective treatment.

June 29, 2016

Every expectant mother has heard jokes about pregnant women running to the bathroom all the time. Overactive bladder is one of the most common symptoms of pregnancy in the first trimester, and it only gets worse as your pregnancy develops. But for some, overactive bladder causes an even more embarrassing symptom: pregnancy incontinence.

What to Know about Pregnancy Incontinence

pregnant woman laughingPregnancy incontinence, or bladder leakage, gets less press than overactive bladder syndrome (possibly because fewer dads-to-be find it a funny road trip joke), but many pregnant women suffer it. Bladder leakage most frequently occurs when coughing, laughing, sneezing, or straining, but it can happen almost anytime. The good news is that pregnancy incontinence is usually temporary. When your hormone levels go back to normal and your body heals, your bladder should return to normal too.

How to Treat Pregnancy Incontinence

Before trying home remedies, make sure you’re leaking urine. If the liquid is clear and odorless, it may be amniotic fluid. It’s rare, but if you are leaking amniotic fluid, contact your obstetrician immediately.

Okay, you sure it’s urine? Here’s what you can do to treat pregnancy incontinence.

  • Do Kegels to strengthen your pelvic muscles.
  • Train your bladder to behave by slowly extending the amount of time between trips to void your bladder.
  • Monitor your weight. Unnecessary weight gain during pregnancy puts undue pressure on your bladder.
  • Try to avoid constipation, which also puts pressure on your bladder.
  • Keep drinking water! Limiting your water intake doesn’t minimize pregnancy incontinence, it only dehydrates your body and increases your risk of UTI (another cause of bladder leakage).
  • Avoid foods that irritate the bladder such as citrus, tomatoes, coffee, and alcohol (which you shouldn’t be having anyway!).
  • Use pads in case of accidental leaks.
  • Brace your pelvic muscles before laughing or sneezing by crossing your legs or doing Kegels.
  • Pay attention to any patterns. If you notice a specific behavior causes bladder leakage, stop that behavior.
  • Talk to your practitioner. Your OB or CNM does this for a living, so you can be sure they have some good tricks for minimizing bladder leakage.

Pregnancy incontinence may be frustrating, but it’s a normal part of pregnancy. If your incontinence lasts up to six weeks postpartum, speak to your physician about treating incontinence before it becomes a long-term issue. For more information on pregnancy incontinence, call Cherokee Women’s Health.

Laughing Mom-to-Be

June 24, 2016

breastfeeding mother

Breastfeeding is probably the first most intimate bond a mother will ever create with her child, but sometimes it can take a little while to get it right—both for mother and baby. Much like picking up rice with chopsticks for the very first time, breastfeeding requires patience, practice, time and effort. Although babies are born with a natural instinct to suckle, and mothers usually produce the colostrum and milk they need immediately, sometimes getting the two natural occurrences to cooperate with each other can be difficult.

Apart from the time and discomfort needed to recover from childbirth, baby’s constant demands for food, cuddling, changing– not to mention possible colic- the first few days can be overwhelming on a new parent. Lack of sleep can also cause impatience, which in turn is something a baby can easily sense. No matter how many decibels you attempt to lower your voice after drowsily walking into walls during that three o’clock feeding, your baby will still pick up on your irritability and react accordingly with fussing, flailing or crying.

Compounding all this with a difficulty to breastfeed could easily leave the mother experiencing feelings of failure, shame and anxiety. Rapid hormonal changes on her part add to the melting pot of emotional stew.

Latching Problems
Breastfeeding can be a painful, uncomfortable experience during the first few postpartum weeks. Although hungry newborns may not have teeth, their gums can certainly clamp on well enough to make a new mother wince, even yelp at times. Until tender, engorged nipples become accustomed to the sensation, it can be highly unpleasant for the first little while.

If pain persists after this adjustment period, however, it may possibly be caused by a bad latch. A bad latch may occur for a number of reasons, such as cradling the baby’s head at an improper angle, positioning your breast incorrectly, flat or inverted nipples, or an infant who hasn’t quite yet grasped the intricacies of sucking and getting tasty results.

Learning to latch may take time. If you look down and see that your areole or nipple are visible, your baby may not be latching correctly. Both serve a purpose similar to a bull’s eye on a target. Baby needs to zone in and clamp on the center to achieve proper suction. The sensation of the nipple, and in some cases the tiny bumps surrounding it on the areole serve as a type of braille to baby’s sensitive mouth. Nursing pillows may facilitate finding the correct angle, thus gently coaxing your child to a better position.

If you can’t resolve the latching problems on your own, there is no need to get frustrated or to feel badly about it. At your next appointment, ask your obstetrician or certified nurse-midwife for information on overcoming breastfeeding problems. They are familiar with the problem and will gladly help to make breastfeeding a more enjoyable nurturing time for you and your infant.

Inverted or Flat Nipples
1 to 3% of all women have flat or inverted nipples which can create a challenge when breastfeeding. Speak to your obstetrician about breastfeeding with inverted nipples. Some methods he or she may recommend would be to pump before breastfeeding to stimulate milk flow, or using a silicone shield to help your baby latch.

Some women with flat or inverted nipples may require the help of their spouses to get a good latch going. In a way, this can also be a pleasant bonding time for their partners.

Breast milk provides babies with vital nutrients to help them grow and develop into healthy, strong little people. It is recommended that mothers try as much as possible to introduce their infants to not only this beneficial form of nourishment, but the resulting closeness and warmth both mother and baby can derive from it.

For more information on lactation, Northside Hospital-Cherokee has a center dedicated to lactation and their website offers lots of great tips.

June 23, 2016

happy baby picCommon Breastfeeding Problems
Apart from providing valuable colostrum and vital nutrition for babies, breastfeeding can create an intimate bond between a mother and newborn. Another plus is that breastfeeding requires more calories than pregnancy, Mother Nature’s way of rewarding a new mother by giving her a jump start on the road to ‘baby weight” loss.

At first, however, to the dismay of many new parents, it isn’t always the warm fuzzy experience they imagined it would be. Breastfeeding does not always happen naturally. The milk is in the mother’s breast, and the baby instinctively makes sucking motions looking for food, but the act of successful breastfeeding itself is a skill that requires a little practice on both parts.

Motherhood can be challenging and intimidating enough, especially for first time moms who want to do the very best job possible. Even the sweetest, undemanding baby can be intimidating due to lack of experience, let alone a colicky fussy child. Encountering breastfeeding problems can raise stress and anxiety levels at the very best of times, and this frustration may result in abandoning breastfeeding altogether. Most breastfeeding difficulties, however, are easily remedied with minor position adjustments or a few timeless suggestions from your OB-GYN.

Solving Common Breastfeeding Problems
Low milk production. Many moms underestimate their milk levels, especially when first learning to breastfeed. But a few tricks can increase your supply: ensure your baby latches well and drains both breasts at each feeding, drink plenty of water, use a breast pump between feedings, and nurse at night when milk production hormones surge. You can also ask your doctor to modify your diet to include foods that encourage healthy milk production.
Latching pain. Latching pain is expected for new moms, but it shouldn’t last. If latching pain lasts longer than a minute, reposition your baby to an asymmetrical latch, where his mouth covers the nipple and the lower part of the areola.
Cracked nipples. A common result of latching problems, improper pumping, or thrush, cracked or bloody nipples can cause serious anxiety in new moms. But a little blood won’t harm the baby, and the solution is simple: lanolin cream. Other remedies include repositioning your baby’s latch, breastfeeding more frequently for shorter intervals, and letting some milk air dry on your nipples.
Thrush. A yeast infection that may develop in infants’ mouths, thrush can spread to the breasts, causing itching, soreness, and sometimes a rash. See your doctor, who will provide an antifungal cream to be applied to both your nipple and the baby’s mouth.

Every woman faces her own challenges during pregnancy and postpartum. We encourage our patients to take advantage of the rich resources in our health community, including the Lactation Program at Northside Hospital-Cherokee, where we deliver all our moms.

If you have concerns about breastfeeding, schedule an appointment with us today.

Every woman gains weight during pregnancy. For some, this is a positive experience: the healthy glow and rounded figure are a badge of honor, broadcasting her good news to the world. For others, it’s a struggle: dealing with the stress of weight fluctuation on top of the other body changes pregnancy brings. But all moms share the same question: how much pregnancy weight gain is too much?

Healthy Weight Gain During Pregnancy
stepping on scaleThe amount of weight gained during pregnancy isn’t an abstract question. It can affect the health of both mother and child during gestation. Gaining too much weight contributes to postpartum weight retention, but gaining too little leads to inadequate birth weight of your infant. If you’re worried about weight gain, discuss it with your obstetrician or CNM. Your physician can give you an individual assessment to make sure you gain a healthy amount of weight during pregnancy. To get you started, here’s a handy chart from the American Congress of Obstetricians and Gynecologists.

  • For underweight mothers (BMI of 18.5 or less), the recommended gain is 28-40 lb
  • For average weight women (18.5-24.9 BMI), there’s a recommended weight gain of 25-35 lb
  • For overweight (25-29.9 BMI) moms, doctors recommend a 15-25 lb weight gain
  • For obese mothers (30 BMI and higher), the recommended weight gain is 11-20 lb

How to Control Weight During Pregnancy
If you’re gaining too much or too little weight during pregnancy, ask your obstetrician about a personalized nutrition plan. Not only will a proper diet improve your weight gain, it will also provide necessary nutrients to you and your baby. Moms-to-be can also begin a pregnancy exercise routine to improve health and decrease the discomforts of pregnancy. Some conditions make exercising during pregnancy unsafe, so always speak to your doctor before starting a new fitness regimen.

Want to learn more about nutrition, fitness, and healthy weight gain during pregnancy? Visit Northside Hospital-Cherokee or make an appointment with one of our providers today at 770-720-7733

June 17, 2016

baby and storkWhen you find out that you’re pregnant, your world dissolves into a various shades of joy, curiosity, and worry. There’s a lot to learn about pregnancy and labor, especially if it’s your first child. One way many moms sort through the madness is to create a birth plan.

Birth Plans – Remember, it’s Just a Guideline

A birth plan is a short (typically 1 page or less) document that communicates your desires for labor and delivery to your medical team. It lets expectant mothers sort through their preferences and clearly articulate what type of childbirth they’d like. It’s important to remember that a birth plan is only a guideline. Delivery rarely goes as expected, and your medical team may be forced to make decisions that go against your written plan for the health of you and your baby. But if you’re trying to make sense of all the information you’re learning about labor, a birth plan is a good place to start.

What to Include in Your Birth Plan

Write your preferences clearly and concisely. It’s best to discuss your medical questions and preferences with your obstetrician and your family before writing anything down. Clearly communicate your preferences with your medical team ahead of time, before labor pains become the top priority.

  • Family: Who would you like in the delivery room with you?
  • Labor coach: What expectations do you have of the nurse who will coach you through labor?
  • IV: IV’s are typically not necessary during labor, but some women need them to receive fluids and prevent dehydration, or to quickly administer medications during labor. If you want an epidural, you will need an IV.
  • Blood tests: Though typically only necessary for high-risk pregnancies, blood tests may be needed to ensure labor goes smoothly.
  • Inducing or augmenting labor: Know how you feel about starting or speeding up the delivery process.
  • Pain relief: From breathing exercises to epidurals, there are plenty of natural and medical pain relievers for moms during labor.
  • Delivery positions: Positions vary from sitting or semi-sitting to lying on your side or squatting.
  • Episiotomy: Making a cut to widen the vaginal opening is not necessary for all women, though it may be necessary during difficult labor.
  • Cutting the umbilical cord: Waiting several minutes to cut the cord may help your baby receive more blood supply. Some fathers like to get involved by cutting the umbilical cord.
  • Skin-to-skin contact: This can help create intimacy between mother and child or father and child.
  • Cesarean section: Whether you’ve scheduled a C-section or you’re simply planning for an emergency situation, consider what types of pain relief you’d like in the event of a Cesarean birth.
  • Breastfeeding: Beginning breastfeeding is often most effective in the 30 to 60 minutes after birth. Skin-to-skin contact stimulates your infant’s impulse to breastfeed, making it more likely to be a success.

To learn more about creating a realistic birth plan, talk to your obstetrician or midwife at your next appointment.


May 26, 2016

An Interview With Michael Litrel, MD, FACOG, FPMRS – Part 1 of a 3 Part Series

One of your areas of specialty is Cosmetic Gynecology, especially vaginal rejuvenation. Can you expand a little on the subject of vaginal rejuvenation?
Originally, as female reconstructive surgeons, we would operate on the vagina or internal and external genitalia. We took care of medical issues such as bulges or weakness that prevented the organs from working properly.

Vaginal rejuvenation is a more recent elective surgery to enhance the visual appearance of a woman’s genitalia. Over the past twenty years, the field of Cosmetic Gynecology – especially vaginal rejuvenation – has become the fastest growing niche in plastic surgery. As the popularity increased, we began to see patients who’d been encouraged to undergo plastic surgery – from surgeons who don’t specialize in women’s pelvic anatomy. We’d find ourselves called in to correct whatever mistakes had been made in those procedures – but the problems were not always ‘fixable.’ It became obvious that the best thing we could do was to offer Cosmetic Gynecology ourselves, and at least insure that the women who came under our care could avoid the irreversible damage from inexpert surgery, and receive the benefits of surgery from Pelvic Reconstruction Specialists.

Apart from esthetic merits for visual genital distortions, or internal adjustments that restore tautness and sexual pleasure, what other conditions can be corrected, with these procedures?
When it comes to external cosmesis, which is surgery performed outside the body, we mostly treat conditions like elongated genitals or labia which may interfere with clitoral stimulation. It’s mostly anatomical—things are too long, getting in the way, disrupting sexual pleasure or causing orgasmic inability.

Vaginal surgery consists mostly of correcting “bulges,” be they bladder, rectal or intestinal bulging. We increase the caliber of the vagina to allow for better sexual sensation. Since the vagina leads to the internal sexual reproductive organs, if there’s pain or bleeding or scar tissue, lots of times those things have to be corrected surgically as well.

Sexual interest and gratification often diminish over time, due to a number of reasons such as lack of lubrication, the loosening of vaginal tissue and muscle, etc. Can pelvic reconstruction or vaginal rejuvenation give women a renewed sense of sexuality and confidence—and if so – how?
I think it’s a very individual thing. I’ve taken care of thousands of women and sexuality issues can vary. They can come from anatomical differences between partners, hormonal issues– even lack of awareness of proper technique. The list is endless, so I’m not going to say “have surgery and it will fix everything.” I’ve seen the full range of what causes problems, and I deal with them all on an individual basis.

As an example, I saw a patient recently who came from a neighboring state. After asking questions about the pain she was experiencing, I examined her and found there was nothing physically wrong with her. After speaking with her, I was able to pinpoint that the real problem stemmed from sexual abuse. I’m able to treat the anatomical problems, but a lot of these complaints simply must be addressed through counselling. I certainly wouldn’t recommend surgery in her case, but would guide her to other venues of help. It’s a complicated subject and doesn’t really have one answer.

Are the benefits of pelvic reconstruction and vaginal rejuvenation permanent, or does time eventually cause the original problems to recur?
I’ve seen patients I’ve operated on 10 years ago, and they’re doing great. For a lot of anatomical problems, if we fix them and they don’t suffer damage, they stay fixed. For instance, if a woman has a normal sex life and doesn’t have a baby, she probably won’t need surgery, and then, if it’s a cosmetic thing, such as labial elongation (hypertrophy), then once you fix that, it’s not going to grow back. It’s not common to have to re-operate.

For the cosmetic parts, however, sometimes you have to perform a few nips and tucks six months or a year later. But typically, that’s not necessary either. As for the tightening operations, once you do it, you’re done.

Many people might describe the procedures we’ve covered as “frivolous,” “unnecessary,” “a waste of money,” etc. Their assumption might be that you need to accept yourself “the way you are.” Can you describe the positive physical and psychological impact these procedures have had on some of your patients during your extensive career?
Fifteen or twenty years ago, I probably would have said the same thing. I remember I was very much against breast implants at one time, but over years of practicing, I noticed that women with these implants not only looked better, but felt wonderful about themselves. We all want to feel good about ourselves.

Now, in the field of Cosmetic Gynecology, with procedures such as vaginoplasty or, labiaplasty, the reason we, as female reconstructive surgeons are in this field, is because we know we’re the best at fixing it and we know that it’s not just about cosmetic surgery. It’s functional as well. Unlike a breast implant, face lift, or even a tummy tuck, none of which really have a function, internal and external genitalia are functional. Whether it’s sex, urination or defecation, there’s a biological function that’s dependent on the correct anatomical restoration of a woman’s body. So in terms of ‘frivolous,’ well, if you’re fixing a bulge here or there because a woman’s bladder is dropping or leaking, or you’re fixing the rectum bulging out, you can also do a tightening operation because the patient desires it for their sex life. I don’t think a good sex life is frivolous. I think it’s an important part of a relationship and it’s an important part of the way a woman feels about herself.

Real Self PicThe word ‘surgery’ can be frightening and intimidating. It usually sparks the fear of pain, long convalescence, operative and postoperative complications, etc. On average, what is the recovery period for most of your procedures?
Typically – because we do less invasive surgery with laparoscopes and robots – one to three weeks. Certainly some healing processes can go on for three months, but after one to two weeks, people generally feel pretty good.

At one time, the standard treatment for conditions related to pelvic prolapse was a hysterectomy. It’s now possible to treat Pelvic Floor Disorders with pelvic reconstructive surgery. How has the specialty of pelvic surgery changed since you began? What conditions are fixable that women forty years ago would just suffer with?
Nowadays, the biggest changes have been the minimally invasive laparoscopic surgeries. We can visualize things better. We can access things and also repair things less invasively. Additionally, surgery is less risky than it used to be—better antibiotics, smaller holes. Tumors and organs can be removed with much tinier incisions. We do a lot more uterine saving surgery as opposed to hysterectomies nowadays.

What diseases, conditions or illnesses prevent a person from being a suitable candidate for pelvic reconstruction or gynecology cosmetics?
We have office procedures so that we can make things look better and work better without doing any surgery. If someone is sick with underlying medical problems, I don’t think they’ll be presenting with issues of vaginal laxity or problems of cosmetic appearance. They have bigger issues such as being unable to breathe, walk, etc. Typically I don’t see patients whose medical problems prevent them from having surgery. We can do more minimally invasive things for patients today.

I had a patient recently from North Carolina who was convinced I would have to perform countless surgeries. As it happened, all I had to do was a ThermiVa, a procedure which is a low frequency energy treatment we deliver in the office. It requires (3) thirty minutes treatments over a period of three months. I also have an 82 year old patient suffering from diabetes, and I’m still able to do something to help her.

Other than natural processes in the body such as aging, giving birth, etc., can your procedures repair such things as birth defects, accidental injuries, or physical trauma—and can these things be corrected even years after the damage has occurred, or is time of the essence?
Birth defects occur during birth and we certainly have to perform reconstruction because of that. This is not done in childhood, but when the person is diagnosed as an adult. If you’re referring to something like an anatomical variance, for instance, something like size and shape, or a congenital problem such as not having a uterus, vaginal septums, having two uteruses, or a hymen that doesn’t allow blood flow, typically, we do not address these issues until a woman is older. In fact, we may not become aware of them much before 15 years of age.

Defects can also happen during such occurrences as miscarriages. Typically, injury is not common. Unlike breaking an arm or something like that, the uterus and a woman’s genitals are very well protected, because they’re in the midline of the body and the center of gravity. So if injury does occur, it’s usually quite easy to repair.

To prevent such problems as infections, flaccidity, sexual discomfort, or sexual disinterest, what can women do to maintain personal gynecological health, other than general cleanliness, yearly pap smears and Kegel exercises?
I think that probably the most important thing that women can do is limit their number of sexual partners and just be sexually active with people that are faithful to them, love them and want the best for them. I think multiple partners are the number one cause of the problems that women have. If you marry someone, and have a good sexual monogamous relationship with them, it would solve most of the problems we see.

I have a 22 year old patient who is beautiful. She’s had several sexual partners. I did cosmetic surgery on her and some tightening, but she hates herself because of things her partner said to her regarding her genital appearance. Had she waited for the right, committed partner, he most likely would not have said anything and accepted her the way she is.

Many physical issues also come with a related psychological issue such as fear, shame, religious inhibition, etc. As a women’s health specialist, how do you personally deal with the psychological deterrents to put your patients at ease?
I think we’re all a little inhibited. It’s just part of being a person. Inhibitions tend to disappear when you’re in the process of having a baby come out of your body. Nothing will stop you from pushing out that baby. My specialty is OB/GYN, and my subspecialty is reconstructive surgery, so I’ve delivered thousands of babies, and women are generally comfortable with that. Many of my patients have gone through a lot, and I’ve gotten very close to them, but I think that’s only due to good communication. People want someone to help them, and if you let them know it’s okay to feel a certain way, then it’s okay to feel and express the pain, etc. They just need to be nurtured in such a way that we can open up the lines of communication.

May 24, 2016

incontinence photoOveractive Bladder Syndrome, also referred to as OAB, is an uncontrollable need to urinate, often at the worst possible times.

For most of us, when the bladder fills to about half its capacity, the urge to void is triggered. Much like a snooze button on an alarm clock that lets us sleep awhile longer, we can hold off until we’re closer to a bathroom, or the timing is more convenient.

Not so for OAB sufferers. Their urgency is more like the constant demand of a malfunctioning alarm clock without that button—intense, shrill and non-stop until it’s turned off. OAB sufferers feel more like their bladders are overflowing. They don’t have the luxury of waiting, needing relief immediately. If they’re unable to void right away, leakage may occur.

OAB is unbiased. Whether you’re at work or play, it disrupts concentration, performance and pleasure, negatively impacting your life. In time, those afflicted with OAB may become depressed, withdrawing socially.

What Causes Overactive Bladder?

No one really knows, but it’s believed that involuntary contractions of the detrusor muscle in the bladder transmits false messages to the brain.


  • A sudden, inconvenient urgency to urinate that is difficult to control: Just as your child is about to blow out those birthday candles or receive that diploma, you suddenly you have to run, not walk, to the nearest toilet.
  • Frequent urination (more than 8 times daily): Your bladder seems to control your life. You need to know where every bathroom is located when you go out. Maybe you even carry a change of clothing, “just in case”.
  • Voiding two or more times nightly, disrupting sleep (nocturia): You awaken during a delectable dream or restful sleep more than once to urinate.
  • Involuntary, uncontrolled leakage (see also urge incontinence): You can usually hold it in, but just barely, and sometimes experience embarrassing drips.

Contributing factors

  • Overweight or obesity
  • Stress
  • Drinking large amounts of caffeine, alcohol and other liquids
  • Nerve related conditions such as Parkinson’s, Dementia, Diabetes, spinal cord injuries, Multiple Sclerosis, and strokes.
  • Chronic pelvic pain
  • Limited mobility (being unable to move freely or quickly)
  • Some medications

Age may contribute to, but does not always cause Overactive Bladder Syndrome. Never assume you’re doomed to live with OAB based on the number of years you’ve roamed the earth. Speak to your gynecologist. Don’t be ashamed. They’ve heard it before—often. They can help.


You will need to provide your doctor with your medical history, including all drugs, vitamins and supplements you are taking. A physical examination will also be necessary.
Sometimes, a urine culture, ultrasound, and neurological tests may be needed to rule out any sensory or reflex problems. If necessary, you might need more extensive analysis such as:

  • Urodynamic testing (studying bladder, sphincter and urethra performance; measuring urine flow, bladder pressure, and residual urine left after voiding)
  • Cystocopy (using a scope to study the bladder and urinary tract).

You may be asked to keep a journal that includes information like fluid intake, urinary outflow, any leakage, and a time chart of bathroom visits to assess your condition more accurately.

Treatment options

  • In milder cases, your doctor may recommend the following:
  • Drink less: Fluid is vital to the body, preventing dehydration and maintaining proper kidney function, but too much can exacerbate OAB symptoms. Try to cut back on diuretic beverages such as coffee, tea and alcohol, limiting yourself to eight cups of water daily. Avoid liquids too close to bedtime so you can finish those happy dreams.
  • Use liners or pads: Annoying, we know, but they help with trickles, stains and odor.
  • Lose a little weight: It’s not easy, but it can make a difference. Extra weight increases pressure on the pelvic muscles, causing more urination.
  • Teach your bladder who’s boss: Bladder re-education is a method that trains you to urinate at certain times, eventually allowing more time between bathroom visits. Your doctor can guide you, teaching your bladder to obey you–not the other way around.
  • Kegel exercises and biofeedback: Kegels strengthen pelvic floor muscles. Recommended biofeedback devices can help you pinpoint those muscles. Kegels can be done anywhere, are painless, sweat-free, and can be beneficial for OAB.
  • Double void: Sometimes trying to urinate again shortly after the first void may coax some shyer little droplets to make an appearance.

Medications and Treatments

Other treatments may include:

  • Prescribed Medication (Antimuscarinics, anticholinergics)
  • Gentle electrical stimulation (ThermiVa)
  • Bladder Injections ( botulinum toxin A)
  • Vaginal weight training

For more resistant cases, surgery, bladder augmentation, or the use of catheters may be necessary.

Overactive bladder does not have to isolate you. Help is available. Speaking to your doctor is always the first step to overcoming the problems associated with this syndrome, restoring your confidence, happiness, and quality of life.

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“Dr. Litrel was a fantastic doctor. I had my first exam with him, although at first I was skeptical about a male doctor for my GYN. But after I met him I’m glad I kept an open mind, and I couldn’t have dreamed up a better doctor. He cares about you as a person and not just a patient. The front desk ladies and nurses were very friendly and it’s a great office, very clean and not intimidating. I highly recommend Cherokee Women’s Health.”
– Vicki