Author name: Diane

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High-Risk Pregnancy Education, OB

Fetal Distress

Fetal distress is the term used when the baby is compromised in labor or during delivery. It is a medical condition which generally refers to “hypoxia”, or low levels of oxygen in the baby. It’s possible to occur before labor, but more commonly occurs during the delivery process. Oxygen deprivation can result in decreased fetal heart rate and requires immediate action to protect your baby. While pregnancy can be a joyous time in a woman’s life, not all pregnancies are the same, and some women may have a healthier journey than others. Among the common problems that can occur throughout pregnancy, delivery, and after, is fetal distress.   Learn about common problems throughout pregnancy, delivery and after. What Causes Fetal Distress? Fetal distress may be caused by several factors, including: Preeclampsia Placental abruption Too much or low levels of amniotic fluid Labor complications Umbilical cord prolapse Pregnancy-induced hypertension An overdue pregnancy Uncontrolled diabetes Anemia What are the Signs? Sometimes, mothers notice signs of fetal distress on their own. These symptoms include: Decreased movement in the womb Vaginal bleeding Excessive weight gain Inadequate weight gain Fetal distress is diagnosed based on fetal heart rate monitoring, which is monitored throughout pregnancy and taken at every prenatal appointment. The fetal heart rate should be between 110 and 160 beats per minute during the third trimester of pregnancy and labor. Heart rate abnormalities that are signs of fetal distress: Bradycardia- An abnormally slow heart rate Tachycardia- An abnormally fast heart rate Variable decelerations- Abrupt decreases in heart rate Late decelerations- Lat returns to the baseline heart rate after a contraction Help for Fetal Distress Your doctor must closely monitor all pregnancies — especially high-risk pregnancies — and continuously assess the health of the mother and baby. If your doctor recognizes or is alerted to signs of fetal distress, they will monitor the baby and decide the safest way to proceed. If there are signs of fetal distress on the fetal heart rate monitoring, the main goal is to return the baby to an oxygen-rich state as soon as possible. In some cases, the best way to alleviate fetal distress is to remove the baby from an oxygen-deprived environment and deliver. A C-section delivery may be the safest way for this to occur. Lasting Effects of Fetal Distress Babies who experience fetal distress are at a greater risk of complications after birth. Lack of oxygen during birth can lead to very serious complications for the baby, including brain injury, cerebral palsy and even stillbirth. Can I Prevent Fetal Distress? While you can’t prevent fetal distress, your odds of it occurring are lower if you are going to all your prenatal appointments and following your doctor’s recommendation for a healthy pregnancy. Monitoring is the key to identifying fetal distress, treating it before it leads to irreversible complications, and preventing it in the first place. If you have been diagnosed with a condition that increases your risk of fetal distress, like gestational diabetes or preeclampsia, it is especially important to remain closely monitored. Many women don’t necessarily notice when a baby is in fetal distress, so an increasing number of prenatal appointments towards the end of your pregnancy allow your doctor to monitor your baby’s heart rate. If you’ve noticed a change in fetal activity or your kick count is off and you’re concerned, call us right away. Our Board-Certified OB/GYNs are Here For You Fetal distress can be a scary medical condition and maintaining an open dialog with your OB/GYN throughout your pregnancy can help alleviate some of your fears. Don’t hesitate to contact us with any questions or concerns regarding fetal distress or any other pregnancy-related condition. A trained staff member will be happy to answer any questions or schedule a consult. Call us today at 770.720.7733 or request an appointment online.

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GYN Problems

5 Symptoms Women Should Never Ignore – and Why You Should See Your OB/GYN ASAP

There are five health symptoms women should never ignore and as OB/GYNs, we have seen many cases where women have waited too long to take care of their own health problems, and often regret it later after a bad diagnosis. Do not let this happen to you. Following are five of the most concerning women’s health problems that you should never neglect. If you have any of these five symptoms, make an appointment with your OB/GYN as soon as possible. 5 Symptoms You Should Never Ignore 1. Heavy or Painful Periods When it comes to your periods, you know what’s normal for you. If you experience heavy or painful periods that are out of the ordinary, you need to be seen by an OB/GYN. These symptoms can signal gynecological problems that need treatment. Some could be very serious, such as cancer, but many women have noncancerous uterine fibroids or tumors that cause heavy or painful periods. There are treatments available for uterine fibroids and other gynecological problems known to cause heavy or painful periods. 2. Abnormal Vaginal Bleeding If you experience bleeding between periods or bleeding after menopause, see your OB/GYN. Although abnormal bleeding can occur for many different reasons, gynecological cancers like cervical or uterine cancer are among them. Endometrial hyperplasia happens when the uterine lining grows thick, and is a noncancerous cause of abnormal bleeding. Abnormal vaginal bleeding is what it sounds like – abnormal – and is nothing to take lightly. See your doctor ASAP for treatment or to rule out anything concerning. 3. Pain During Sex Pain during sex can be caused by many different issues. A serious medical condition would need to be ruled out. It also could be endometriosis, which can even lead to infertility. Endometriosis is when tissue similar to the lining of the uterus starts to grow outside of the uterus. In addition to painful intercourse, watch for pelvic pain, extremely painful periods, and pain when you go to the bathroom. There are treatment options available, but you need to know what is going on with your body to be proactive. 4. Lumps in or Around the Breast Regular mammograms and self-breast exams are a must. Do not put off getting regular mammograms and see your OB/GYN at least once a year for evaluation. With no family history, mammograms should begin for every woman at age 40. If there is a family history of breast cancer, your OB/GYN may recommend you start getting mammograms earlier. If you notice anything unusual or different during a self-breast exam, in your breast, around your breast, or under your arm, see your doctor immediately. As OB/GYNs treating thousands of women over the years, we have diagnosed breast cancer in all ages and types of women, even if it there is no family history. The earlier you are diagnosed, the better your prognosis may be so do not delay seeing your OB/GYN or regular mammograms – ever. 5. Nipple Discharge It’s extremely important to pay attention to your breasts. In addition to checking for lumps or changes in breast size or shape, watch for nipple discharge. Discharge, especially bloody or clear discharge, can be a sign of breast cancer. Don’t put off getting checked by an experienced OB/GYN who can properly evaluate you and order the appropriate images and tests. Listen to Your Body If you have symptoms that are not typical for you, or something doesn’t feel right, listen to your body. You know your body best and can sense when something may be wrong. Seeking treatment early can help ensure the best outcome possible. Make taking care of yourself a priority. You are too valuable to neglect. Make an Appointment Today Our board-certified OB/GYNs are here for you. Call us at 770.720.7733 or schedule an appointment online to make an annual exam appointment or to discuss any issues of concern.

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Hymen Repair Education, Vaginal Rejuvenation Education

Reasons Why Women Choose Hymen Repair

Hymen repair (hymenoplasty) is sought after for many reasons. They range from physical to cultural. Whatever the reasons, it’s a very private matter and always the woman’s decision. Our double board-certified urogynecologists are experts in female pelvic health and are here to help. What is a Hymen? The hymen is a ring-shaped membrane of human tissue that begins to form in females in utero, and partially or completely covers the vaginal opening. In simple terms, hymen repair, or Hymenoplasty, is the cosmetic restoration of the hymen after rupture. What Causes a Ruptured Hymen? The main cause of the rupture of the hymen is sexual intercourse, however there are other everyday activities that may cause the hymen to tear or rupture. These include strenuous athletics, horseback or bicycle riding, internal gynecological exams, or even tampon insertion. And in some instances, a woman may not be born with one. Why Would a Woman Choose to Have her Hymen Repaired? There are numerous reasons a woman may choose to have her hymen repaired. The reasons can be physical, psychological, and/or cultural. Physical Reasons Psychological Reasons Cultural or Religious Reasons It is important to understand that cultures differ, and social norms accepted by one culture or country may not be deemed acceptable to another. Virginity may be a requirement for marriage in some cultures and hymen repair will cause bleeding upon penetration, thus “proving” that the bride is a virgin. Engaging in premarital sex is not only considered dishonoring to the families, but in certain cultures it is even considered a crime and the consequences range from annulment, divorce, or death. Request more information now! Patients Share Their Hymen Repair Results “Due to the religious stigma of having in intact hymen, I had a hymen repair before my recent marriage. The procedure was a success and my marriage events passed off normally.” “The recovery was not bad at all.  I felt better the next day and I was walking around with very little pain. No one could even tell I had just had surgery, which allowed me to keep it private. The outcome and the experience were well worth it.” “Because of a separated hymen, I recently had a repair done. I was nervous about having this done but it ended up being the best decision. I feel like I got my life back.” Why Choose Cherokee Women’s Health for Hymen Repair? Our double board-certified surgeons are both urogynecologists and OB/GYNs, and are beyond question the most qualified experts in female vaginal anatomy. Your vaginal surgery results are only as good as your surgeon’s experience and skills. They are also certified in Female Pelvic Medicine and Reconstructive Surgery (FPMRS), a highly coveted accreditation which requires years of training while meeting strict requirements set forth by the American Board of Medicine (ABMS). Depending on why you might request hymen repair, this may be a delicate subject to discuss. Rest assured that our doctors are familiar with the many reasons patients ask for this procedure, and fully understand the discomfort and shyness regarding this subject. Your surgery is a private matter—it’s your body. We want to help make you as comfortable and confident with it as possible. To learn more about hymen repair or to schedule a consultation with one of our doctors, please call 770.721.6060.

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OB

Placental Abruption: Symptoms and Risk Factors

Placental abruption requires immediate care since the baby may not be receiving enough oxygen. Placenta abruption occurs when the placenta detaches from the uterine wall before or during labor. The placenta is an organ that provides nutrients to the baby in the womb. Placental abruption can cause vaginal bleeding and pain. Without prompt medical treatment, a severe case of placental abruption can have dire consequences for the mother and her unborn child. Symptoms When any symptoms occur, it is usually sudden. The main symptom of placental abruption is vaginal bleeding. However, vaginal bleeding doesn’t apply to all women, as 20 percent don’t experience any. Some of the symptoms and signs of placental abruption include: Continuous lower back and abdominal pain Painful abdomen (belly) when touched Tender and hard uterus Fetal distress Risk Factors While the exact cause of placenta abruption is unknown in most cases, certain factors make a pregnancy more at risk to placental abruption. Risk factors may include: Advanced maternal age Being pregnant with multiple babies Having a history of high blood pressure or previous abruptions Excessive amniotic fluid Uterine infection Substance use. In most cases, doctors don’t know the exact cause or causes of placental abruption. However, having one or more of these risk factors doesn’t mean you’ll experience a placental abruption. Diagnosis If you are experiencing any bleeding or abdominal pain, contact your doctor right away. Placental abruption can only truly be diagnosed after birth when the placenta can be examined. There are a few methods that are used to try to make this diagnosis during pregnancy so that proper treatment can be applied. Including: Ultrasound Blood tests Fetal monitoring Evaluation of symptoms (bleeding, pain, etc.). Complications In severe cases, complications of placental abruption can include: Stillbirth Decreased oxygen to the baby, which can lead to brain damage Maternal blood loss leading to shock Emergency hysterectomy Maternal death from severe blood loss. Placenta Abruption Treatment Unfortunately, there is no way to reattach the placenta once it’s detached, or no treatment plan that can stop it. The treatment depends on the severity of the separation, location of the separation and the age of the pregnancy. In the case of partial separation, usually less than 34 weeks, bed rest and close monitoring may be prescribed. In some cases, emergency treatment and hospital admission may be needed as well. In the case with a complete separation, usually more than 34 weeks, delivery is often the safest course of action. Depending on the stability of the baby, an immediate C-section may be necessary. The mother might also need a blood transfusion. We’re Here for You and Your Baby Call your doctor immediately if you experience bleeding in your third trimester. The outcome of a placental abruption diagnosis is improved with fast and accurate treatment. While placental abruptions can’t exactly be foreseen, here at Cherokee Women’s Health Specialists, our board-certified OB/GYNS are experts in high-risk pregnancies. Call us today at 770.720.7733 or schedule an appointment online.

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Mommy Rejuvenation Patient Stories, Vaginal Rejuvenation Education, Vaginal Rejuvenation Patient Stories

“Is This as Good as It Gets?”

After giving birth to three children, Carina was left with some challenges that she did not expect. While she absolutely adores her children and loves being a mother, she wasn’t prepared for the physical changes to her body, or the emotional changes. It not only affected her self-esteem, but changed her intimate relationship with her husband as well. Earlier in her marriage, she enjoyed an active and healthy sexual relationship with her husband, Keith. She thrived on being the “initiator” and she candidly shares that Keith quite enjoyed it. Like many women, her body changed after having children, but she didn’t realize how it affected her personality. Once very confident and outgoing, she became more emotional, moody, and withdrawn. The Breaking Point The breaking point for Carina was one day when her patient and loving husband sat down with her and openly shared his concern. He told her he loved her completely, but that it broke his heart to see the vibrant, sexy woman that he fell in love with fade into the distant past. She broke down in tears because she missed that woman too. After many more conversations and taking time for self-analysis, Carina knew she needed to make some changes. She felt assured that her relationship with Keith was strong, that this was more about her and her overall self-esteem and happiness. She longed for the confidence that she once had and was ready to make some changes. “There was something that happened after giving birth to my children. I felt like I had somehow given everything I had. My energy level was zapped, and I quit caring about my appearance. I lost my self-confidence, and I didn’t feel like having sex anymore. After three vaginal births, my vagina felt damaged, swollen, and made me feel unattractive. My labia became enlarged, and my vagina felt stretched out. As a result, sex with Keith was less enjoyable and very infrequent. It saddened me, and I hated that this was the way my future looked. It reminded me of a line in a movie, ‘Is This as Good as it Gets?’” – Carina on how her body – and mind – changed after giving birth Finding the Right Type of Surgeon It was then that Carina made the decision to see if there was a procedure that could help her. She assumed she’d need a plastic surgeon but after doing research, she knew she needed someone more specialized. After a long search, she found that she needed vagina and labia repair, which is also called vaginal rejuvenation. She read online reviews and was led to a doctor in another state, Michael Litrel, MD, FACOG, FPMRS. He was an experienced pelvic surgeon and was both a urogynecologist and an OB/GYN with many years of experience. Learn more! Download our FREE Vaginal Rejuvenation eBook. Making the Appointment with Dr. Litrel Carina called Dr. Litrel’s office and spoke with his Senior Patient Coordinator, Erica. They spoke several times and Carina had her many questions answered. She was finally ready to do a video consult with Dr. Litrel to see if this was the right decision for her. “Though I was somewhat reserved, Dr. Litrel immediately put me at ease. He gave me a full explanation of why my body was the way it was and assured me that what I was experiencing was completely normal. I was hesitant to discuss something so personal with a stranger, but I instantly felt a connection and could tell he was caring and professional. – Carina on her first consult with Dr. Litrel I shared with Dr. Litrel that my labia had scarring on it, was asymmetrical, and stretched out from the rough deliveries. He explained that during childbirth, the vagina, and vaginal opening stretches during a vaginal delivery, and while it typically returns to pre-pregnancy size, for many women, it never returns to 100%. He said that with his expertise in labia repair, he would make me look like a new woman. He gave me hope.” One Week After Vaginal Rejuvenation “All went well and it wasn’t even as bad as I thought,” Carina shared a week later. As Dr. Litrel had prepared me, the day after surgery was hard and uncomfortable, but the next day was better, and by the fifth day I had no more pain. I am very pleased with the outward appearance, even with some slight swelling. It looks fabulous!” Twelve Weeks After Vaginal Rejuvenation “Whoa! I got my mojo back! My confidence is nuts! My husband and I waited to have sex until it had been twelve weeks. I was a little scared the first time, wondering how everything would feel, but we both could tell a big difference. I felt like it did before we had our kids, not only physically, but my self-esteem was through the roof. The boost in confidence was life-changing for me. I feel like my old self — vibrant and sexy!” – Carina candidly shared just twelve weeks after her labia and vaginal repair procedure. Feeling Appreciative for Dr. Litrel Carina says she’s appreciative of Dr. Litrel for how he helped her restore her confidence. “Dr. Litrel completely understood my concerns and gave me assurance that all would be fine. He was right, and I am so thankful for his surgical skills and expertise. What an incredible doctor,” Carina shared. Vaginal Rejuvenation by Female Health Experts Carina decided to share her story, along with the intimate details, for one reason — she is hoping to help and encourage other women. If you can relate to her story, please schedule an appointment online to learn more about vaginal rejuvenation. Or call us today at 770.721.6060.

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Midwife Education, OB

Hospital “Home Birth”? Yes, You Can!

Can you have a “home birth” in a hospital? Yes, you can! As OB/GYNs, we help deliver a home birth experience while in the safety of a hospital. It’s the best of both worlds. We Want You to Have the Best “Home Delivery” Experience in a Hospital Home births have become increasingly popular among expectant moms, especially since the pandemic. Approximately 1% of all U.S. births are delivered at home, and statistics show that number is on the rise. But for the safety of pregnant moms and their babies, an “at home style” delivery in the hospital is the preferred option by OB/GYNs, especially by the doctors at Cherokee Women’s Health Specialists. The doctors and midwives at Cherokee Women’s Health work together with you as a team to accommodate your individual birth plan. The state-of-the-art facility at Northside Hospital Cherokee has a top-notch Women’s Center and a Level 3 NICU. We are fully equipped and ready for any dangers that arise, but ultimately, we desire to give you the closest type of birth possible to what you would experience at home. We believe each pregnant mother is special and deserves individualized family centered care. There are many options for a labor experience, and we will make every attempt to accommodate your preferences to make your labor desires come to fruition. It’s your body, your baby, and your birth – so we want and expect you to have your best experience for your pregnancy journey and birth. Why Should You Deliver in a Hospital? The American College of Obstetrics and Gynecology firmly states that the safest option for mom and baby are in a hospital or birthing center. The American Academy of Pediatrics concurs that babies are best born in the hospital to ensure the safest and healthiest outcome. The health and safety of mom and baby are of upmost priority — so taking the necessary precautions by being in a hospital are recommended by experienced doctors. James Haley, MD, FACOG, FPMRS of Cherokee Women’s Health has delivered nearly 10,000 babies during his career as an OB/GYN. He shares candidly about the dangers of home births: “We work together with expectant mothers to make all of the best plans for how a delivery will go. Childbirth, as we know, doesn’t always go smoothly or as planned. Occasionally, a medical crisis arises that causes the entire team of doctors and nurses to jump into immediate action, work together like nothing you’ve ever seen — all to get that baby out in 2-3 minutes to save its life, while also trying to take care of the mother and keep her safe. I have personally seen hundreds of babies that would have died, had the patient not been at the hospital just at that moment.” – Dr. James Haley on the importance of delivering in a hospital Preparing For Your “At Home Style” Delivery No one can tell you what your birth experience will be like, but we can help you feel prepared, confident, and ready for the birth of your baby. At Cherokee Women’s, we have an OB patient VIP program for all newly pregnant mothers, where you are given the opportunity to have all your questions answered and are given all the information you need to guide you throughout your pregnancy journey. You can create your own birth plan, unique to you and your wishes. We check on you often throughout your pregnancy – in addition to all the regular visits, to make sure that your pregnancy and birth plan are meeting your expectations. For those that opt for a natural birth, we offer unmedicated births. Our medical team is very willing to offer intermittent monitoring and variable laboring positions, among the many other requests according to your specialized birth plan. We also have the expertise of one of our physicians, Lisa McLeod, DO, FACOOG, who specializes in osteopathic manipulation to help women in labor and delivery. Her unique obstetrical training in holistic treatment has been valuable to patients wanting a natural approach to childbirth. As part of the planning process, we recommend attending maternity classes at Northside Hospital so that you can learn about the options available to make your childbirth as close to a home birth as possible. You will learn what to expect during delivery and all the options available to make your birthing experience your own. You also can learn what you need to know about breastfeeding, infant CPR, and you will be given answers to your questions through evidence-based education and support. It is important to educate yourself during pregnancy by attending classes, sharing with others who have similar concerns and learning what to expect so that during labor and after birth, you understand what’s going on and can make decisions with your doctors and midwives. Natural Hospital Birth: It Can be Done! You really can have the natural birth you are hoping for even if you must be at the hospital. You can enjoy the experience of working with your body to birth your baby in collaboration with your team of doctors, midwives, and nurses who are there to ensure you have a safe delivery.

Dr. James Haley Delivering Baby
Midwife Education, OB

Home Birth – Is it Worth the Risk?

By James P. Haley, MD, FACOG, FPMRS As an OB/GYN for over 30 years now, I feel the need to speak out strongly against home births. I have certainly delivered my fair share of babies, and what a privilege it has been to witness one of God’s greatest miracles, thousands and thousands of times in my career. I am honored to have shared with so many families one of the most special and intimate moments in their lives. One of my greatest blessings was being able to deliver my two children – memories that my wife and I will always treasure. Home Births Come with Extreme Risks There is a growing trend in OB that has me greatly concerned, and I feel the need to speak out strongly against it. It is the growing popularity of pre-planned home births. The trend seems to be gaining some momentum, and approximately 1-2% of all U.S. births are now delivered at home. According to recent statistics, that number is rising. The truth is, there are extremely serious risks involved with attempting to deliver at home, and women and their families need to be aware of these dangers. We have come a long way in modern medicine, especially in the field of Obstetrics. In the early 1900s when home births were the reality, one in ten babies died at birth. Sadly, many of these infants suffered trauma at birth resulting in complications such as seizures, paralysis, or brain damage. Death was common and the mother’s life was always at risk, as up to 1 in 100 mothers died giving birth. As OB/GYNs, We Have Seen it All With advances in modern technology, it is alarming as to why many would consider delivering at home without immediate access to a hospital. The American College of Obstetrics and Gynecology recommends that babies be delivered in hospitals. They want everyone to know that babies born at home are twice as likely to die, and three times more likely to have neurologic dysfunction or brain damage. The American Academy of Pediatrics concurs with ACOGs opinion and agrees that hospitals are the safest place to give birth. Even today, giving birth is one of the most dangerous things a woman can do. In the U.S., it is the sixth most common cause of death among women ages 20-34. These statistics are very troubling, and much research and study is being done to continually lessen the maternal death rate. OB/GYNs know with absolute certainty the risks of childbirth and the possible dangers that can go wrong. We have seen it all and there are often complications that can arise within a few minutes that no one saw coming. It is very humbling; and we have all seen multiple times where, had the patient not been in the hospital — in labor, being monitored and under close observation — the baby would have died. It happens quite frequently. Usually, with proper prenatal care, we can predict problems and future complications, treat them, monitor closely, and be prepared for those potential complications at birth. “I have personally seen hundreds of babies that would have died, had the patient not been at the hospital at that moment. After moments like that, you not only see the amazing hand of God, but also greatly appreciate the advances in modern medicine. And you are grateful you were there exactly at that moment – and in a hospital.” – Dr. James Haley However, childbirth as we know doesn’t always go smoothly or as planned. Occasionally, a medical crisis arises that causes the entire team of doctors and nurses to jump into immediate action, work together like nothing you’ve ever seen — all to get that baby out in 2-3 minutes to save its life — while also trying to take care of the mother and keep her safe. Common Problems that can Occur Throughout Pregnancy, Delivery and After: Following are just a few problems that can occur throughout a woman’s pregnancy, delivery and postpartum. Gestational diabetes High blood pressure Preeclampsia Preterm labor Anemia Infections Breech position Fetal distress Premature rupture of membranes Placenta problems Placental abruption Prolonged labor Perinatal asphyxia Shoulder Dystocia Excessive bleeding Malposition Placenta previa Cephalopelvic disproportion Uterine rupture Rapid labor Oxygen deprivation Umbilical cord prolapse Umbilical cord compression Velamentous Cord Insertion Chorioamnionitis (Infection) Fetal macrosomia (Extra-large infant) Postpartum hemorrhage (Bleeding) Postpartum preeclampsia Why Take the Risk of a Home Birth? Women that consider home birth typically want fewer medical interventions, they want to enjoy the comforts of home, enjoy a more satisfying and natural birth, and have control over all aspects of the birthing process. These are all valid wants and desires, and it is understandable how people are driven to choose this route. If you have had a home birth and all has gone well, that is great. However, I wouldn’t push your luck and do it again. You have dodged many, many bullets. There are medical offices and midwives that attempt to facilitate and “ensure” the safety of a home birth. Hospitals are nearby, and women are told that if complications arise, they can abort the plan and head to the hospital. In fact, the latest statistic shows that approximately 30-35% of planned home births end up delivering at the hospital after all. But at what cost? Do they make it in time? These actual statistics don’t often end up in the “home delivery” category. Once they are sent to the hospital, they are counted as hospital deliveries, so we don’t truly know if they had complications or even the worst possible outcome occurred. Working in the hospital and a busy medical practice, I have sadly seen some tragic outcomes. Just a few weeks ago, I personally saw a patient that had been going to the type of practice that is more “natural” and encourages and oversees home births. The mother suspected a problem and was referred to me for an evaluation. “Unfortunately, I confirmed their greatest fear, that the

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