Beloved Holistics Radio

Microdose J - The One About the C19 Injection May 06, 2022

"To help you further understand why we did not get the vaccine, what follows is my assessment of the C19 situation so far. Like I said, there is no doubt that many people were getting very sick over the first half of 2020. What is most challenging for me is the narrative that ensued thereafter, which seems at best misleading and at worst nefarious."
www.ObgynoWino.com

Microdose G - This is Not an Article about Coronavirus: Birth, Death, and our Grapple with Safety May 06, 2022

"If I could live for another twenty years loving, laughing and touching in the ways that I could before this pandemic, would I choose this over fifty years of living in a place of fear, where I'm forced to question the safety even of hugging my own mother?"
www.ObgynoWino.com

Goodbye! Here's to new beginnings... Sep 09, 2021

I have left the conventional medical model for good in search of brighter pastures! With the amount of painting, dancing, and kissing my baby and wife that I've been doing over the past several days, I encourage you all to try living a life free of the medical industrial complex! I have been liberated, and now I've got the bandwith the shake things up and create the life of my dreams.

The new iteration of my podcast will be titled The Holistic OBGYN
Find me at: www.BelovedHolistics.com

Microdose K - Lead With Love and Compassion Aug 14, 2021

Important PSA for healthcare professionals...
Theme music by Evan Handyside

Ep 82: Management of AUB Associated W/ Ovulatory Dysfunction Aug 11, 2021

Practice Bulletin #136 - Published July 2013 (Reaffirmed 2017)
1. Know your reproductive endocrinology like the back of your hand!

2. AUB-O is classically associated with cycles that differ in length by `10 days or more. Patient with AUB-O also generally don't experience the classical cyclical breast tenderness, mucoid cervical discharge, premenstrual cramping, or bloating seen in ovulatory bleeding.

3. Anovulation is the most common etiology of AUB in 13-18-year olds. Transfusion or hospitalization is rare in this age group, but, when it happens, you should investigate coagulopathy.

4. AUB-O in patients >18 years of age should prompt investigation for hyperplasia/malignancy.

5. Hysterectomy or hormonal contraceptives are the mainstays for treating AUB-O, but neither address the underlying endocrine abnormality.

6 .SIS + EMB is a sweet combo: if both are negative, the likelihood of pathology is extremely low and conservative measures are be offered without you losing sleep
Show Notes
Theme music by Evan Handyside

Ep 81: Second Trimester Abortion Aug 09, 2021

Practice Bulletin #135, Published June 2013 (Reaffirmed 2017)
1. It's none of your damn business why a woman desires a 2nd trimester abortion. There are also a lot of scenarios in which 2nd trimester abortion skills are necessary but that have nothing to what many perceive to be a seemingly easy decision to terminate a pregnancy.
2. If you don't feel confident in your skills as a provider to perform 2nd trimester abortions, do your patients the service of developing a referral relationship with another provider who does.
3. Inducing fetal demise prior to 2nd-trimester abortion does not improve safety or decrease procedure time in case of D&E, but he it does shorten induction time for medical abortion.
4. Misoprostol + mifepristone = the most effective protocol of medical options
5. All methods of contraception are effective on the day of 2nd-trimester abortion apart from cervical cap, diaphragm, or hysteroscopic sterilization (including IUD)
Show Notes
Theme music by Evan Handyside

Ep 80: Management of Endometriosis Aug 08, 2021

Practice Bulletin #1114, Published July 2010 (Reaffirmed 2018)
1. Pelvic pain and infertility are characteristic. Severe dyspareunia and dyschezia are indicative of deeply infiltrative disease.
2. The etiology is unknown, but currently thought to be due to the implantation of endometrial glands and stromal cells outside the uterus within the peritoneal cavity due to retrograde menstruation
3. Histologic evaluation of a surgical specimen is the gold standard for diagnosis. Visualization of endometriotic lesions has a high false positive rate. The finding of an endometriomas on imaging studies can alone be highly predictive, though.
4. Excision of endometriosis can improve fertility rates, particularly with the excision of an endometrioma.
5. NSAIDs, COCs, GnRH analogues, and progestins are all great alternatives to surgery for managing endometriosis-related pain
Show Notes
Theme music byEvan Handyside

Ep 79: Journal Club, July 2021 Aug 07, 2021

July 2021 Journal Club
I'm joined by Emmie Sturgess, DO, an OBGYN, MFM, and friend of the show to review relevant articles from the major OBGYN journals. I promise it's not as boring as it sounds...
Show Notes
Theme music by Evan Handyside

Intro to Beloved Holistics Radio Aug 03, 2021

Welcome to Beloved Holistics Radio, a podcast for the holistic OBGYN! Expect summaries of ACOG's practice bulletins, important voices with birth keepers and birth warriors, and discussions around the most up-to-date research and publications.
www.BelovedHolisticsRadio.com

Ep 78: Postpartum Hemorrhage Jul 30, 2021

Practice Bulletin #183, Published October 2017 w/ co-host Sara Rosser, CPM (@sararosser)
1. PPH is defined as 1000 mL for either vaginal or cesarean birth.
2. Go with your gut in diagnosing PPH, and do it fast! You can't rely on vital signs or lab work to make the call to action in the acute setting.
3. Uterine atony is the most common cause of PPH. Manage through uterine massage, uterotonics, tamponade, and UAE. Opening up her abdomen to place compression sutures, ligate the uterine vessels, or perform hysterectomy are last resort!
4. Remember the triad of the amniotic fluid embolism: respiratory decompensation, hemodynamic instability, and DIC.
5. As soon as you feel that she's lost too much blood activate your institution's transfusion protocol. Remember that you can never get pre-screened blood fast enough when you actually need it.
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Theme music by Evan Handyside

Ep 77: Ultrasound in Pregnancy Jul 28, 2021

Practice Bulletin #175 - Published December 2016 (Reaffirmed 2020) w/ co-host Sara Rosser, CPM (@sararosser)
1. US may be harmful if overutilized.
2. Important uses include pregnancy dating/viability, fetal growth, and amniotic fluid assessment.
3. US pregnancy dating is most accurate in the 1st trimester. If significant discordance exists between US dating and LMP dating, it may be appropriate to adjust due date.
4. Fetuses at risk for FGR should be monitoring by serial growth ultrasound. It's not recommended to repeat growth ultrasound more frequently than q2 weeks.
5. Growth-restricted fetuses can be monitored through umbilical artery Doppler velocimetry as a means of avoiding bad perinatal outcomes.
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Theme music by Evan Handyside

Ep 76: Journal Club, June 2021 Jun 20, 2021

June 2021 Journal Club
I'm joined by Emmie Sturgess, DO, an OBGYN, MFM, and friend of the show to review relevant articles from the major OBGYN journals. I promise it's not as boring as it sounds...because...I mean...come on...WINE.
Show Notes
Wine pairing: 2016 Primitivo di Manduria from Antico Sigillo
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 75: Osteoporosis Jun 14, 2021

Practice Bulletin #129 - Published September 2012 (Reaffirmed 2016)
1. In any hypoestrogenic state, resorption begins to overwhelm building, leading to decreased bone density.
2. Treatment is warranted if T-score ≤ 2.5 on DXA scan or if patient has history of vertebral facture or other type of fragility fracture
3. FRAX tool can be helpful in determining usefulness of treating patients in the osteopenic range (T-score < - 1 to ≥ -2.5). It predicts risk of osteoporotic fracture over next 10 years .
4. Bisphosphonates are first-line therapy for all-comers, though raloxifene is also reasonable first-line in younger postmenopausal women.
5. HRT is a great alternative to bisphosphonates in younger women at risk for osteoporotic fracture: ~35% decreased risk of hip fracture (estrogen alone or estrogen + progestin)
Show Notes
Wine pairing: 2017 Tempranillo from Baron de Ley Varietales
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 74: Antiphospholipid Syndrome Jun 12, 2021

Practice Bulletin #132 - Published December 2012 (Reaffirmed 2017)
1. The clinical diagnosis of APS is made through a careful clinical history that takes into account thrombotic events, history of pregnancy loss, and development of preterm preeclampsia.
2. Lab studies to detect specific antibodies can confirm your diagnosis, but these lab studies are not indicated when clinical criteria are not met.
3. The three relevant antibodies on your board exam are: lupus anticoagulant, anti-β₂-glycoprotein, and anticardiolipin
4. The worst consequence of APS is thrombosis.
5. In pregnancy, thrombotic risk is EVEN higher. APS patients with history of thrombosis should be treated with prophylactic heparin throughout pregnancy until 6 weeks postpartum.
Show Notes
Wine pairing: 2018 Sonoma Zinfandel from Seghesio Family Vineyards
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 73: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women Jun 11, 2021

Practice Bulletin #128 - Published July 2012 (Reaffirmed 2016)
1. "Normal menstruation" is classified by ACOG as: 5 days of bleeding with cycle length of 21-35 days
2. PALM-COIEN is a classification system for abnormal uterine bleeding.
3. Get good at SIS and hysteroscopy! A meta-analysis found intrauterine cavitary anomalies in roughly 50% of women with AUB
4. Fibroids tend to present as heavy periods. Polyps tend to present as intermenstrual bleeding. Adenomyosis presents with painful and heavy periods.
5. Accuracy of blind endometrial biopsy is great if (a) an adequate sample is collected and (b) the endometrial process is global. A blind EMB can miss cancer if less than 50% of the endometrium is involved.
Show Notes
Wine pairing: 2018 Cabernet Sauvignon from Los Vascos
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 72: Multifetal Gestations May 15, 2021

Practice Bulletin #169 - Published October 2016 (Reaffirmed 2016) w/ co-host Sara Rosser, CPM (@sararosser)
1. Multifetal gestations have overall increased risk of morbidity for both mom and baby.

2. Chorionicity is an important piece of information for managing these pregnancies. Monochorionic pregnancies carry higher risks than dichorionic pregnancies.

3. Outside of dx of cervical insufficiency: available data doesn't support cervical cerclages, bed rest, tocolytics, or pessaries decrease morbidity or mortality associated with preterm birth in setting of multifetal gestation.

4. NIH recommends administration of corticosteroids for any pregnancy, irrespective of GA, at risk of birthing from 24-34 wga within 7 days

5. Unless monoamniotic, twin pregnancy is not a preclusion to vaginal birth
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: 2017 Red Blend from King Estate Winery
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 71: Obesity in Pregnancy May 14, 2021

Practice Bulletin #156 - Published December 2015 (Reaffirmed 2018) w/ co-host Sara Rosser, CPM (@sararosser)
1. Women with obesity are at increased risk for fetal congenital anomalies, c-section, preeclampsia, fetal macrosomia, childhood behavioral/developmental issues, and other bad outcomes.
2. Pre-conception weight loss to normalize BMI improves maternal and neonatal outcomes.
3. Weight loss while pregnant is not recommended.
4. There are a variety of special considerations intrapartum and postpartum for women with obesity.
5. If your patient undergoes c-section, a thick subcutaneous fat layer should be well-irrigated and approximated with sutures in multiple layers if necessary.
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: 2017 Bourbon Barrel-Aged Cabernet Sauvignon from Ménage à Trois
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 70: Management of Late-Term and Postterm Pregnancies May 01, 2021

Practice Bulletin #146 - Published August 2014 (Reaffirmed 2019)
1. When pregnancy goes beyond 41 wga, there are increased risks for mom and baby, but absolute risk is overall still very low. these risks are still low in absolute.

2. Pregnancy dating by LMP combined with early ultrasound is far more reliable than LMP alone.

3. "Membrane sweeping" decreases the chance of a pregnancy going beyond 41 wga, but consent your patient first!

4. If fluid checks out, particularly if BPP is otherwise reassuring, it's reasonable to continue pregnancy

5. IOL at or beyond 41 wga does not improve fetal or neonatal outcomes apart from a possibly lower risk of meconium aspiration syndrome. NNT = 410 to prevent one perinatal death.
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: Dark Side Red Blend from 7 Moons Wine
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 69: Management of Gynecologic Issues in Women With Breast Cancer Apr 22, 2021

Practice Bulletin #126, Published March 2012 (Reaffirmed 2016)
1. Rapidly dividing cells - like those in the gonads - are the most susceptible to chemo, so suppressing with GnRH analogues prior to chemo may be protective against ovarian toxicity, but data is mixed.

2. BRCA mutation carriers are at increased risk for both breast and ovarian cancers, therefore prophylactic BSO is recommended at age 40 or after childbearing is complete

3. 5 years of tamoxifen use decreases the annual risk of recurrence by 40% and annual mortality risk by 35%

4. Women treated for breast cancer are at higher risk for bone fracture because chemotherapy, ovarian suppression, and, especially aromatase inhibitors all lead to bone loss and osteoporosis.

5 .HRT has a bad rap historically due to concern that it may predispose women to de novo breast cancer or recurrence, but the findings have been mixed and generally not statistically insignificant.
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: 2017 Perlita Malbec-Syrah from Bodega DiamAndes
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 68: Shoulder Dystocia Apr 03, 2021

Practice Bulletin #187, Published May 2017 (Reaffirmed 2016)
1. Neonatal complication risk is overall low (5%), including brachial plexus injuries, clavicle fracture, humerus fracture. HIE/death are also possible, but extremely unlikely.
2. The faster that a shoulder dystocia is resolved, the less likely HIE/death.
3. It's nearly impossible to predict shoulder dystocia, but risk seems to be higher with larger fetuses and diabetic mothers.
4. Insufficient evidence to conclude that early induction of labor when fetal macrosomia is suspected decreases the risk of shoulder dystocia.
5. Steps to resolving shoulder dystocia per ACOG: stop pushing, McRobert's maneuver w/ head traction, suprapubic pressure, rotational maneuvers, then posterior arm delivery. My advice? Get her on all fours way before any of the other maneuvers (Gaskin maneuver).
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: 2017 Central Coast Red Blend from Smith & Hook
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 67: Noncontraceptive Uses of Hormonal Contraceptives Apr 01, 2021

Practice Bulletin #101, Published January 2010 (Reaffirmed 2016)
1. Most COCs combine a progestin (i.e. synthetic progesterone) for contraceptive effects with 10-35 mcg of an estrogen (usually ethinyl estradiol) to stabilize the endometrium and reduce unwanted spotting
2. COCs are a safe bet for management of heavy menstrual bleeding. If patient responds to COCs, they are most cost-effective for the first year, then it's more effective to switch to a levonorgestrel intrauterine system
3. The levonorgestrel intrauterine systems work better than progestin-only pills (e.g. norethindrone acetate) to reduce heavy menstrual bleeding and patients report greater satisfaction.
4. DMPA and the progestin IUD can regulate the menstrual cycle over the long haul, but will initially increase the irregularity of bleeding.
5. Before prescribing any hormonal contraception, review the US Medical Eligibility Criteria for Contraceptive Use.
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: 2018 Pinot Noir from Tres Palacios
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Microdose I - The Self-Destructive Nature of Being Human Mar 31, 2021

"How can we reimagine our relationship with Mother Nature? This seems like a privileged luxury of the few, but it's far more important than a philosophical suggestion. Based on the preceding examples found through the challenges of monocultural farming and efforts to sterilize the human body, it should be obvious that we are a part of a variety of ecosystems that rely on us reciprocally. As such, in allowing the Earth to deteriorate, we are inadvertently corrupting any possibility for the survival of our own species."
www.ObgynoWino.com

Ep 66: On Surrogacy and the Tribulations of Nuance Mar 25, 2021

SPECIAL EPISODE - Interview w/ Sara Rosser, CPM (and my dear sweet friend!)
In episode 66, Sara Rosser, a CPM at the famous Farm in Summertown, TN, is joining the Obgyno Wino team to co-host coverage of future OB-related practice bulletins. She is also anticipating her second surrogacy pregnancy on behalf of a gentleman who is otherwise unable to start a family. Between her choice to offer herself as a surrogate and her family's adoption of their beautiful son, Silas, from Ethiopia, Sara has been forced to navigate a wide range of criticism (amidst an equal amount of support!) for her decisions around pregnancy, surrogacy, and adoption. Fortunately, Sara is a beautiful unicorn of a woman guided by intuition and morality, two principles of which we could use a little more in this world.
Show Notes
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Trailer to the Obgyno Wino Podcast Mar 24, 2021

Show Notes
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 65: Bariatric Surgery and Pregnancy Mar 21, 2021

Practice Bulletin #105, Published July 2009 (Reaffirmed 2017)
1. Combined oral contraceptives may be poorly absorbed in patients who have undergone malabsorptive bariatric surgery (e.g. Roux-en-Y)
2. Micronutrient and macronutrient deficiences are common in pregnancy after Roux-en-Y. These include iron, calcium, vitamin B12, protein, folate, and vitamin D. It's reasonable to screen widely for nutrient and micronutrient deficiencies pre-pregnancy or early in pregnancy and supplemental as appropriate.
3. For patients who underwent a banding procedure, early consultation with a bariatric surgeon is recommended in order to actively manage the band
4. Dumping syndrome is caused by ingestion of refined sugars that are rapidly dumped from the stomach into the small intestine; this causes hyperinsulinemia -> hypoglycemia -> tachycardia; otherwise characterized by bloating, nausea, abdominal pain, n/v, and diarrhea.
5. Patient with dumping syndrome can be screened for GDM by regular glucose fingerstick checks at 24-28 wga
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**
Wine pairing: 2017 Pinot Noir from Ferrandière
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 64: Shared Decision Making in Maternity Care Mar 18, 2021

SPECIAL EPISODE - Interview w/ Brad Bootstaylor, MD, OB/GYN and MFM (and all-around awesome guy!)
Dr. B is back on the show to talk about the unfortunate turn of events that forced him to leave his collaborative OBGYN practice in Atlanta, GA. At the hospital where Dr. B worked for 20 years and even served as chair of the Department of OBGYN, a non-clinical professional committee determined - apparently arbitrarily - not to renew Dr. B's hospital privileges, essentially forcing him out of practice. Perhaps the silver lining of these very unfortunate circumstances is that he has more freedom to explore creative avenues for changing U.S. maternity care from outside of the hospital system. Dr. B is a hero to many of us in the OBGYN community, and in conversation with him, I still have a great deal of hope that his legacy will live on through his book and his engagement directly with birthing people, the true keepers of birth.
Show Notes
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 63: Anemia in Pregnancy Mar 17, 2021

Practice Bulletin #95 - Published July 2008 (Reaffirmed 2017)
1. Normal physiologic changes in pregnancy that are relevant in anemia include increased blood volume, increased red blood cell mass, and increased iron stores.
2. Low serum ferritin is the most sensitive and specific single lab finding in iron deficiency anemia.
3. The CDC recommends universal screening for iron deficiency anemia in pregnancy along with universal supplementation.
4. B12 deficiency and folic acid deficiency are common causes of macrocytic anemia; folic acid deficiency much more likely than B12.
5. Blood transfusions are almost never indicated in pregnancy, apart from the rare case of a large, concealed placental abruption (Hgb <6 g/dL is associated with abnormal fetal oxygenation --> non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death)
Show Notes
**Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!**

Wine pairing: 2018 Red Blend from Horse Heaven Hills Wine Growers
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 62: Trauma-Informed Birthkeeping Mar 11, 2021

SPECIAL EPISODE - Interview w/ Tracey Vogel, MD, OB anesthesiologist
In Episode 62, Tracey Vogel, MD, an OB anesthesiologist, is on the show to talk about her very unique path into trauma-informed birth keeping. Tracey is a practicing anesthesiologist at West Penn Hospital in Pittsburgh who has taken a unique interest in tendering women through their hospital-based birth process. When she's not training medical students and residents in OB anesthesiology, you can find her lecturing at ACOG, writing books, and devoting a portion of her time Pro bono to counseling women who have suffered through past personal trauma, whether birth-related or otherwise, in the context of pregnancy and birth planning.
Show Notes
Wine pairing: PInot Noir from Nicolas Idiart
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 61: Treatment of Urinary Tract Infections in Non-Pregnant Women Mar 08, 2021

Practice Bulletin #91 - Published October 2009 (Reaffirmed 2016)
1. E. coli are the most common bug in UTI.
2. Presence at at least 1,000 CFU/mL on culture or presence of leukocyte esterase or nitrite on UA, particularly if bacteria 2+ or greater in a symptomatic patient is pretty much a slam dank for UTI diagnosis
3. 3-day antibiotic course is sufficient for uncomplicated acute cystitis (trimethoprim-sulfamethaxazole is the preferred agent)
4. Treatment of pyelonephritis can be done as outpatient unless patient is very sick, in which hospitalization w/ parenteral antibiotics may be warranted
5. If symptoms persist beyond 7 days of antimicrobial therapy or if clinical condition worsens, further evaluation through repeat cultures and contrast imaging may be warranted.
Show Notes
Wine pairing: 2018 Cabernet Sauvignon from La Freynelle
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 60: Asthma in Pregnancy Feb 16, 2021

Practice Bulletin #86 - Published October 2009 (Reaffirmed 2016)
1. Poorly controlled asthma is associated with prematurity, preeclampsia, growth restriction, and maternal morbidity and mortality.
2. Nonselective β-blockers, carboprost, ergonovine, indomethacin, misoprostol, and dinoprostone can trigger bronchospasm, and they are all commonly used agents in pregnancy/postpartum.
3. Short-acting β2-agonists (e.g. albuterol) are the mainstay for acute asthma exacerbations
4. Long-acting inhaled corticosteroids and inhaled long-acting β2-agonists are the mainstays of maintenance asthma therapy. Oral corticosteroids may be required in the most severe cases.
5. For pregnant patients with poorly-controlled asthma or asthma classified as moderate or severe persistent, fetal growth should be monitored by serial ultrasound beginning around 32 wga.
Show Notes
Wine pairing: 2019 Chardonnay from Sean Minor
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Microdose H - The Journey of an Unorthodox Allopath Feb 02, 2021

"The restructuring of my healing practice affords me the opportunity to ask the bigger questions, to challenge dogma, and to truly heal people, communities, and the planet. I have the same skillset as most physicians: laboratory analysis, expertise in interpreting medical literature, medication, antibiotics, imaging studies, and surgery. The difference is in how I use these powerful but limited tools. Healing begins with your story, and it grows outward from there in concentric circles. This approach has been called 'slow medicine' by author Victoria Sweet."
www.ObgynoWino.com

Ep 59: An Unassisted Hospital Birth (Story) Jan 30, 2021

SPECIAL EPISODE - Interview w/ Maryn Green, CPM, independent midwife and author
Maryn is a midwife, midwifery instructor, and a mom to now 10 children, all of whom were born vaginally, most of which were born at home. The birth of her most recent, Rumi Sol, happened in the hospital as the result of Maryn acting on her intuition while in labor and transferring herself to the hospital when she sensed things weren't right. The most surprising part of her story is that she ultimately had an unassisted birth in the hospital. Maryn is a unicorn is more ways than one, and every OBGYN could learn a great deal from her experiences.
Show Notes
Wine pairing: 2018 Valpolicella Classico from Ca' La Bionda
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 58: Prevention of Deep Vein Thrombosis and Pulmonary Embolism Jan 21, 2021

Practice Bulletin #84 - Published August 2007 (Reaffirmed 2018)
1. Most patients who die from PE do so within 30 minutes of the event, so prevention is key.
2. If a patient is known to have Factor V Leiden mutation or prothrombin gene mutation 20210A, they should be considered high risk and managed appropriately intra- and post-operatively and in pregnancy
3. Compression stockings, pneumatic compression devices, and pharmacologic prophylaxis are all safe and useful in preventing VTE
4. Highest risk patients benefit most from a combined approach of mechanical or stocking prophylaxis combined with pharmacologic prophylaxis
5. Platelet inhibitors should be stopped 14 days before spinal or epidural anesthesia, unfractionated heparin or twice daily low molecular weight heparin 8-12 hours before, and low molecular weight heparin 18 hours before
Show Notes
Wine pairing: 2019 Les Quatre Cepages from Domaine de Pajot
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 57: Endometrial Ablation Jan 19, 2021

Practice Bulletin #81 - Published May 2007 (Reaffirmed 2018)

1. Both resectoscopic and non-resectoscopic techniques are safe and effective.
2. Size and shape of the uterine cavity and the presence of fibroids may impact efficacy of non-resectoscopic techniques
3. With resectoscopic techniques, careful monitoring of distension medium fluid is important. If too much fluid intravasates, dilutional electrolyte imbalances can have serious consequences.
4. Ablation is not recommended for patients who wish to preserve fertility.
5. Sample the endometrium before performing an ablation to evaluate for hyperplasia or malignancy.
Show Notes
Wine pairing: 2017 Nero d’Avola Cabernet Sauvignon from Barone Montalto
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 56: Hemoglobinopathies in Pregnancy Jan 16, 2021

Practice Bulletin #78 - Published Janury 2007 (Reaffirmed 2018)
1. Sickle cell trait (heterozygous for the mutation) is generally asymptomatic; sickle cell disease can have severe consequence
2. Sickle cell disorders are more common among individuals of African descent, whereas the thalassemias are more common among individuals of Southeast Asian and Mediterranean descent.
3. Alpha thalassemia results from deletion of any number of the four genes that code for the alpha chain. The more deletions, the worse the presentation.
4. Beta thalassemia results from mutation of one or both of the genes that code for the beta chain. Severity of disease is determined by presence and degree of functionality within intact genes.
5. Sickle cell disease is a risk factor for preterm delivery, IUFD, IUGR, etc., therefore, antepartum fetal surveillance is recommended
Show Notes
Wine pairing: 2018 Sainte Marie Corbieres from Domaine Faillenc
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 55: Medical Abortion up to 70 Days of Gestation Jan 09, 2021

Practice Bulletin #225 - Published October 2020
1. Medication abortion is safe and effective (just slightly less effective than uterine evacuation).
2. The standard regimen is mifepristone 200 mg PO followed by misoprostol 800 mcg per vagina 24-48 hrs later
3. Patients who reliably report menstruation within 56 days of presentation for medication abortion do not require ultrasound confirmation
4. Patients at high risk for ectopic pregnancy based your clinical assessment should not be offered medication abortion.
5. Medication abortion has no adverse effect on future fertility or future pregnancy outcomes.
Show Notes
Wine pairing: 2017 Willamette Valley Pinot Noir from Chemistry Wine
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 54: Screening for Fetal Chromosomal Abnormalities Jan 05, 2021

Practice Bulletins #226 - Published October 2020
1. Cell-free DNA screening has the best sensitivity and specificity of all screening methods. But before you order it, it's best to get a prenatal ultrasound
2. Best non-cell-free screening modality is the sequential integrated serum screen (1st-tri serum + NT ultrasound + 2nd-tri serum)
3. Formal anatomy survey should be offered at 18 - 22 wga; can identify soft markers for T21 and T18
4. Prenatal genetic screening should be offered to all pregnant women regardless of risk profile
5. Anything that doesn't add up, it's best to just refer to a genetics counselor or even your friendly MFM for clarification.
Show Notes
Wine pairing: 2017 Garnacha from Las Rocas
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 53: Diagnosis and Management of Vulvar Skin Disorders Dec 20, 2020

Practice Bulletins #224 - Published July 2020
1. A systematic approach is required to evaluate and treat vulvar pain and pruritis.
2. In premenopausal women: contact dermatitis is most likely culprit.
3. In postmenopausal women: Genitourinary syndrome of menopause is your most likely culprit, and this relates to the natural increase in pH associated with the hypoestrogenic state.
4. Lichen sclerosus is best diagnosed through biopsy, because if left-untreated it can develop into vulvar squamous cell carcinoma
5. Topical steroids w/ topical anti-histaminic agents are the mainstay of therapy for inflammatory vulvar disorders.
Show Notes
Wine pairing: 2017 Chardonnay from Eighteen Eighty Three
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 52: Thyroid Disease in Pregnancy Dec 14, 2020

Practice Bulletins #223 - Published June 2020
1. Fetal brain development relies on adequate maternal T4 until the fetal thyroid gland takes over at ~12 wga
2. Fetuses who develop in environments deficient in thyroid hormone may suffer from impaired psychoneurological development of the newborn
3. Hyperthyroidism is most commonly due to Graves' disease, which is caused by antibodies that stimulate the thyroid gland
4. Screening for thyroid disease in pregnancy starts w/ TSH. More sensitive than thyroid hormone.
5. Propylthiouracil is generally used to treat hyperthyroidism in the 1st trimester because methimazole is associated w/ rare embryopathies
Show Notes
Wine pairing: 2016 Cabernet Sauvignon from Embrazen Wine
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 51: Management of Genital Herpes in Pregnancy Dec 09, 2020

Practice Bulletins #220 - Published May 2020
1. Herpes simplex virus (HSV) is transmitted directly from lesions to mucosa or open skin: this includes cold sores to mucosa, active lesions on the skin, or ulcers on or inside the genitals.
2. Infection of babies generally occurs during passage of the newborn through mom's GU tract, not in-utero.
3. Neonatal herpes infections carry relatively high mortality and morbidity.
4. Active or recurrent infections in pregnancy should be treated with antiviral therapy. Suppression therapy should be given to all women with history of HSV starting at 36 wga and continued until birth.
5. Women who have active genital HSV infections manifested as active lesions or prodromal vulvar symptoms at the onset of labor should be counseled against vaginal birth.
Show Notes
**Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!**
Wine pairing: 2017 Armando Bonarda from La Posta Vineyards
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 50: External Cephalic Version Dec 07, 2020

Practice Bulletins #221 - Published May 2020
1. Training physicians in external cephalic version (ECV) and encouraging the practice of this procedure could significantly reduce c-section rate
2. It's best to wait until 37w0d to attempt ECV due to high likelihood of spontaneous version prior to that but likelihood of success decreases with advancing gestational age beyond 37w0d
3. Risks to mom/fetus include: cord prolapse, fetomaternal hemorrhage, terminal deceleration, placental abruption, or demise but these risks are all <1%
4. Administration of a tocolytic agent like terbutaline can increase rate of success.
5. ECV is really f*cking easy to learn and perform
Show Notes
**Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!**
Wine pairing: 2018 Corbières Col des Vents from Castelmaure
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 49: Operative Vaginal Birth Nov 20, 2020

Practice Bulletins #219 - Published April 2020
1. Episiotomies should never be performed routinely, even if you were trained to do it routinely to assist in operative vaginal delivery. If you think it's absolutely necessary, counsel the patient so that she can make an informed decision.
2. Overall, operative vaginal delivery carries low absolute risk for baby and mom w/ comparable relative risk compared to c-section
3. Vacuum-assisted delivery carries higher risks to the fetus when compared to forceps and lower risks to mom.
4. Major benefit to operative vaginal birth is decreased risk of hypoxic injury to the newborn in the event of successful expedited vaginal delivery through operative means (assuming there is concern for fetal acidemia)
5. Forceps, even in trained hands, carries significantly higher risk of severe perineal injury compared to vacuum.
Show Notes
**Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!**
Wine pairing: 2018 Willamette Valley Pinot Noir from Inscription Wine
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 48: Chronic Pelvic Pain Nov 14, 2020

Practice Bulletins #218 - Published March 2020
1. Up to 33% of women with chronic pelvic pain will also meet criteria for diagnosis of major depression
2. An interdisciplinary approach is the way go to: gynecologist, physical therapist, and psychologist in the very least.
3. The physical exam should be approached very carefully and systematically
4. Yoga, acupuncture, and other complementary and integrative therapies should absolutely be considered.
5. Don't prescribe opioids for chronic pelvic pain. Go with neuropathic agents, SNRIs, and tricyclic antidepressants.
Show Notes
**Visit our friends at www.intimatewellnessshop.com for bushels of sex positivity, including toys, massage oils, self-care products, and more! Use code MOREWINE at checkout for 15% off your purchase!**
Wine pairing: 2017 Red Blend from Francis Coppola
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 47: Prelabor Rupture of Membranes Jul 03, 2020

Practice Bulletins #188 - Published January 2018
1. Management recommendations in PROM/PPROM is dependent on gestational age:

>37 0/7 wga => induction/augmentation
34 0/7 - 36 6/7 wga => expectant management or induction/augmentation
<34 0/7 wga => expectant management
2. Diagnosis of PROM is based on history and physical: pooling of fluid, pH of vaginal fluid, and ferning on microscopy.
3. Indications for induction/augmentation for both PROM and PPROM include abnormal fetal testing, evidence of intra-amniotic infection, and vaginal bleeding suggestive of abruptio placentae.
4. For PPROM (24 0/7 - 33 6/7 wga) --> antibiotics and steroids should be offered, and magnesium sulfate should be offered at <32 wga
5. The diagnosis of periviable ROM is best followed up with careful counseling around the risks and benefits. It can be managed with induction or expectant management, which, after hospital assessment, can be provided via home care until viability
Show Notes
Wine pairing: 2019 Malbec from Espuela del Gaucho
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 46: Changing the Culture of Hospital-Based Birth Apr 29, 2020

SPECIAL EPISODE - Interview w/ Hermine Hayes-Klein, JD, and Brad Bootstaylor, MD, FACOG
In this episode, we'll be discussing the problematic culture of hospital-based birth. We explore the physician-patient relationship, the responsibilities that come with the rights to informed consent and refusal of treatment, and how supercomputers in the hands of our patients have enabled them to view us as the enemy, and vice-versa. Most importantly, we discuss ways in which we may all begin to mend the physician-patient relationship in order to redirect the culture of hospital-based birth.
Show Notes
Wine pairing: 2017 Sauvignon Blanc from Psyche Wines
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 45: Nausea and Vomiting of Pregnancy Apr 18, 2020

Practice Bulletins #189 - Published January 2018
Five pearls:
1. The decision to treat should be informed by the woman’s perception of the severity of symptoms, her desire for treatment, and the potential effect of treatment on her fetus
2. Use of prenatal vitamins 1 mo before fertilization may reduce incidence and treating nausea and vomiting of pregnancy (NVP) can prevent progression from NVP to hyperemesis gravidarum (HG)
3. After dietary and nonpharmacologic options (e.g. ginger) have been tried, first-line pharmacotherapy entails trying vitamin B6 alone or vitamin B6 plus doxylamine
4. Antithyroid drugs are not recommended for abnormal maternal thyroid tests attributable to gestational transient thyrotoxicosis or HG
5 .Hospitalization for evaluation and treatment of dehydration and electrolyte imbalance is indicated when a woman can’t tolerate liquids without vomiting and hasn’t responded to outpatient management
Show Notes
Wine pairing: 2018 Pinot Noir from Hedgeline Vineyards
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 44: Midwifery is Under Attack Apr 01, 2020

SPECIAL EPISODE - Interview w/ Elizabeth Catlin, CPM, Melissa Carman, CPM, and Hermine Hayes-Klein, J.D.

In this special episode, I speak with two midwives about their recently being arrested and charged with the "unauthorized practice of a profession" in the state of New York. They have served the Amish and Mennonites communities for years, and these charges are just another piece in the government's and medical profession's efforts to control a woman's right to choice in pregnancy and childbirth. We are joined by an attorney who specializes in human rights in childbirth.
Show Notes
Wine pairing: 2017 Merlot from Chalkboard Wines
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Microdose F: On My Departure From Hospital-Based Birth Mar 26, 2020

"Today is my final shift as an obstetrician. You'll find me breaking bread with the birth educators, doulas, witches, midwives, nurses, and other physicians who guide their patients to safety without failing to appreciate the beauty and majesty displayed by a birthing human."
www.ObgynoWino.com

Ep 43: Prevention and Management of Alloimmunization in Pregnancy Feb 08, 2020

Practice Bulletins #181 and #192 - Reaffirmed in 2019
Five pearls:
1. Risk of alloimmunization is around 15% after 2nd delivery of an Rh positive fetus to an Rh negative mother; this risk is decreased dramatically with administration of postpartum RhoGam
2. RhoGam is never indicated if both mom and dad are Rh negative or in women who are already sensitized (indirect coombs screen)
3. The KB test can used to determine if excessive feto-maternal hemorrhage has occurred in order to guide RhoGam administration in less obvious cases such as abdominal trauma in pregnancy
4. Alloimmunization can present as mild to severe anemia; if concerning antibodies are found, serial titers and/or peak systolic velocity of the middle cerebral artery ma be indicated
5. "Kell kills"
Show Notes
SIGN UP FOR LOUISVILLE BREECH WORKSHOP!
Wine pairing: 2017 Pinot Noir from Longford Estate Wines
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Microdose E: Senseless Acts of Sourdough Jan 31, 2020

We need more senseless acts of kindness in our world, in feeding the masses, in home repair needs, and particularly in medicine.
www.ObgynoWino.com

Ep 42: A Brief History of Midwifery w/ Rebecca Dekker, PhD Jan 29, 2020

SPECIAL EPISODE - Interview w/ Rebecca Dekker, PhD (Instagram, Twitter, and Website).

Rebecca also wrote a book called Babies Are Not Pizzas...you may have heard of it.
Show Notes
SIGN UP FOR LOUISVILLE BREECH WORKSHOP!
Wine pairing: 2017 Chardonnay from Montoya Vineyards
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Ep 41: Exercise is Safe and Should Be Recommended Before, During, and After Pregnancy. Period. Jan 24, 2020

SPECIAL EPISODE - Interview w/ Lori Forner BScH, MPhtySt, PhD Candidate, APAM, Physiotherapist (Instagram, Twitter, and Website)

5 Pearls:
1. Exercise with intensity in addition to strength training is non-negotiable
2. Exercise needs to be enjoyable in order to be sustainable
3. Pelvic floor health needs to be taken into consideration with exercise, and this goes beyond muscle strength and contraction
4. Risk factors for pelvic floor dysfunction exist (e.g. pelvic floor trauma, POP, family hx, parity, etc), but they shouldn't preclude exercise
5. Abdominal strengthening exercises are not dangerous, though the focus in pregnancy is different.
Show Notes
Mentioned in this podcast:
- ACOG CO#650: Physical Activity and Exercise During Pregnancy and the Postpartum Period
Wine pairing: 2018 Malbec from Alamos Wines
Theme music by Evan Handyside
Logo design by JD Dotson (jddotson1@gmail.com)

Microdose D: Death Through Birth Through Death Jan 14, 2020

With space, we pick ourselves up, in our new place - in some ways stronger, in some ways broken and in need of repair - and we move forward together, in love, through death, birth, and rebirth.
www.obgynowino.com

Ep 40: Prevention of Infection After Gynecologic Procedures Jan 10, 2020

Practice Bulletin #195 - Published June 2018
Four pearls:
1. Clean your hands, clean the skin, prep the vagina, treat remote infections and keep blood sugars controlled preoperatively to reduce infection rate.
2. Antibiotic prophylaxis is indicated for all hysterectomies, open surgery, and D&C for abortion, but it's generally not indicated in other procedures unless there's risk of entry into the bowel or a communication made between the abdominal cavity and the vagina.
3. Evidence is poor for antibiotic prophylaxis for indwelling foley or suprapubic catheters
4. For patients with penicillin allergy, switch to cephalosporin if allergy is mild, switch to metronidazole (or clindamycin) plus gentamicin (or aztreonam) if allergy is severe or if history of anaphylaxis
Shout-outs:
- Julie Duhon and Haddie Katz, CPM are looking for an OB to help them open a birth center in Bloomington, IN (email: hellomidwife@gmail.com)
SHOW NOTES
This episode pairs nicely with the Lot 1 Bonanza Sauvignon by Chuck Wagner Wine. Main theme music by my main amigo, Evan Handyside

Ep 39: Macrosomia Dec 30, 2019

Practice Bulletin #216 - Published January 2020
Five pearls:
1. Large babies come with a relatively higher risk to mom and baby, but absolute risks remain low.
2. Shoulder dystocia is generally difficult to. predict, but in diabetic patients with large fetuses, the risk is significantly higher, especially if vacuum or forceps is attempted.
3. Ultrasound is. notoriously inaccurate at predicting fetal weight (+/- 15%), and it's no better than using your hands or asking your patient to guess based on a previous pregnancy.
4. Diet, insulin and exercise are helpful in preventing macrosomia.
5. Inducing labor if fetus found to be macrosomic is not indicated. C-section reasonable if fetus measuring >4500 g in a diabetic patient or >5000 g in a non-diabetic patient
Shout-outs:
- Maryn Green, CPM (her podcast, on Twitter, Instagram)
- Sunita Puri, MD (buy her book on Amazon)
SHOW NOTES
This episode pairs nicely with the 2014 Restitution Red Wine Blend from Magistrate Wines. Main theme music by my main amigo, Evan Handyside

Ep 38: Birth Beyond the Hospital Dec 16, 2019

SPECIAL EPISODE - Interview w/ Maryn Green, CPM (Instagram and Twitter)
Five pearls:

1. The desire from home birth often stems from a desire to follow our physiology as mammals and is particularly focused on mom and baby connection.
2. Listening to women and supporting them, no matter what they desire, is the work.
3. “Radical informed choice” is the way many midwives support women in making choices. They assess their own benefits and risks along with research, intuition and more.
4. Transparency is key in serving women.
5. The world is not black and white (e.g. home vs. hospital) in achieving the best birth outcome.

Shout-outs:
- Indie Birth Association
- Maryn's home birth website
- Milo Chavira, MD
- Dr. Stu's Podcast (w/ Blyss Young, CPM)
- Felicia Sokol, doula (Instagram)
- Juli Anderson, CPM (Instagram)
- Nick Capetanakis, DO (low intervention OB/GYN in Encinitas)
- Madeline Murray, CPM of Believe in Midwifery
- Rebecca Dekker, PhD (her book and blog, Evidence Based Birth)
- Augustine Colebrook, CPM (Art of Birthing)
- Nicole Morales, CPM (Facebook)
SHOW NOTES
This episode should be paired with the 2018 Macon-Villages Chardonnay from Louis Jadot. Main theme music by my main amigo, Evan Handyside

Microdose C: The Devaluation of Birth Has Led to a Devaluation of Women Dec 16, 2019

When society values women, women won't have to prove their worth...The queen bee will be honored for being the queen bee, and birth will once again be trusted and embraced, not feared.
www.obgynowino.com

Microdose B: Know Thy Patient Dec 08, 2019

As at the end of life, this must become a priority in our care for pregnant women: know thy patient.
www.obgynowino.com

Microdose A: My Last Sound Dec 08, 2019

If we can't sit comfortably with the issue of a woman's experience in birth, beyond simply "healthy mom, healthy baby", we will continue to neglect the cries of our patients, like passing ships in the night.

www.obgynowino.com

Ep 37: Prediction and Prevention of Preterm Labor Dec 08, 2019

Practice Bulletin #130 - Published October 2012 (Reaffirmed 2018)
Five pearls:
1. Spontaneous preterm birth rates are decreasing with time (woohoo!)
2. Good thing, because PTD at <34 wga carries higher mortality and morbidity risk to the newborn at time of delivery as well as long-term morbidity
3. In pregnant patients with a history of PTD, 17-OH-P supplementation should be recommended at 16-24 wga and continued through 36 wga
4. In patients w/ singleton pregnancy and history of PTD, cerclage should be offered if CL <25 mm is detected on TVUS at <24 wga
5. In patients without a history of PTD, finding incidental CL of <20 mm at <24 wga may suggest benefit from vaginal progesterone supplementation
Shout-outs:
- Felicia Sokol, doula (on Instagram)
- Maryn Green, CPM (her podcast, on Twitter, Instagram)
- Rebecca Dekker, PhD (her website, on Twitter, Instagram)
- Esther Perel (her podcast, on Twitter, Instagram)
- Michael Fratkin, MD (on Twitter)
- End Well Project (website, on Twitter, Instagram)
SHOW NOTES
This episode pairs nicely with the 2018 Cabernet Sauvignon from 19Crimes. Main theme music by my main amigo, Evan Handyside

Ep 36: Urinary Incontinence in Women Dec 04, 2019

Practice Bulletin #155 - Published November 2015 (Reaffirmed 2018)
Special guest: Ryan Stewart, DO (his 2nd appearance!)
Ryan's four pearls:
1. Urinary incontinence is extremely common, but it's not normal. Screening for incontinence is vital for all physicians with female patients.
2. A correct incontinence diagnosis is of utmost importance. Treatment will only work if you know what you're treating.
3. Minimum evaluation for a woman presenting with incontinence: history, urinalysis/= (and maybe culture), physical exam, demonstration of stress incontinence, evaluation of urethral mobility, and post-void residual.
4. Behavioral therapy and pelvic floor exercises improve symptoms of incontinence and may be recommended as first line therapy
Shout-outs:
- Julie Wiebe, PT on Twitter (and Instagram)
- Julie's interview in Ep 35 "Hope for the Pelvic Floor"
- Lori Forner, PT on Twitter (and Instagram)
- Patagonia makes quality sh*t
SHOW NOTES
This episode pairs nicely with the 2017 Pinot Noir by Meiomi Wines. Main theme music by my main amigo, Evan Handyside

Ep 35: Hope for the Pelvic Floor Nov 23, 2019

SPECIAL EPISODE - Interview w/ Julie Wiebe, PT (website, Instagram, and Twitter)
Six pearls:

Low back pain, incontinence, and painful sex aren’t inevitable after pregnancy, we have new tools to help.
Kegels are not the beginning and end of what we can offer patients. Our new tools include a growing understanding that the pelvic floor doesn’t act alone to maintain continence.
The pelvic floor is part of the team of muscles that provide “core” stability”, that same system of muscles helps maintain continence.
Intra-abdominal pressure management strategies are critical for preventing pelvic health considerations, and need to be addressed in pregnancy recovery and return to fitness programs.
Returning to activity and fitness postpartum women need more parameters than “listen to your body”, they need to know what to listen for (pain or leaking are both signals that they need to modify a movement or allow for more recovery).
A place to partner between doctors/midwives and rehab/fitness is to help us get baselines in order to help women have more realistic expectations of what recovery looks like (ex: get a diastasis measurement early in pregnancy or pre-pregnancy).

Shout-outs:
- Chante Perryman, doula and birth educator
- Cassie Cunningham, doula, birth educator, and birth photographer
- Rebecca Dekker, PhD, and her website EvidenceBasedBirth.com (and buy her book!)
- Gail Tully and her program Spinning Babies
- Nicole Morales, midwife in San Diego and The Art of Opening
SHOW NOTES
This episode pairs nicely with the 2017 Serie A Malbec from Zaccardi Wines. Main theme music by my main amigo, Evan Handyside

Ep 34: Management of Preterm Labor Nov 17, 2019

Practice Bulletin #71 - Published October 2016
Five pearls:
1. Preterm labor carries significant risks to the newborn: the more premature, the worse the outcomes.
2. Given high risk for long-term morbidity in extremely premature infants, focusing on comfort as opposed to aggressive resuscitation at time of delivery is reasonable through a shared medical decision-making process.
3. Corticosteroids can improve outcomes for newborns at risk of preterm birth at <34 wga (and some as late as 36w5d) if delivery anticipated within the next 7 days
4. Latency antibiotics can improve outcomes for newborns in the setting of PPROM at <34 wga
5. Magnesium sulfate can improve outcomes for newborns at risk of preterm birth at <32 wga
Shout-outs:
- Felicia Sokol, doula, on Instagram
- Maryn Green, of Indie Birth
- Sara Rosser, CPM
- Deborah Flowers, RN, CPM
- The Farm
- Julie Wiebe, pelvic PT
SHOW NOTES
This episode pairs nicely with the 2017 Red Blend from Saved Wines. Main theme music by my main amigo, Evan Handyside

Ep 33: Pelvic Organ Prolapse Nov 13, 2019

Practice Bulletin #214 - Published November 2019
Special guest: Ryan Stewart, DO (a real life expert in Female Pelvic Medicine and Reconstructive Surgery)
We'll cover:
- risk factors for POP
- diagnosis and classification of POP
- conservative management options
- pessaries
- evaluation for occult stress urinary incontinence before surgical management
- the variety of surgeries
- the mesh controversy
- Nathan and Ryan spend far too long moaning about docusate sodium
-...and more!
Shout-outs:
- Ryan Stewart, DO on Twitter
- H Clark Distillery (Tennessee Bourbon)
- Things We Do For No Reason: colace blog post
- Daring Greatly, by Brene Brown
- Brene Brown's Netflix special
- Julie Wiebe, pelvic PT

SHOW NOTES
This episode pairs nicely with the 2017 Russian River Valley from Siduri Winery. Main theme music by my main amigo, Evan Handyside

Ep 32: Thromboembolism in Pregnancy Nov 07, 2019

Practice Bulletin #196 - Published July 2018
We'll cover:
- why are pregnant women at higher risk of VTE?
- risk factors for VTE in pregnancy
- who and how to treat and prevent VTE in pregnancy
- what to do for women on thromboprophylaxis who present for delivery
- thromboprophylaxis postpartum
-...and more!
Shout-outs:
- The Farm, the greatest place on earth to give birth for many people (my words)
- Sara Rosser, midwife at The Farm on Instagram
- Ilana Stanger-Ross and her pregnancy book "A is for Advice"
SHOW NOTES
This episode pairs nicely with the 2017 Tempranillo Viura by Casado Morales Winery. Main theme music by my main amigo, Evan Handyside

Ep 31: Evaluation and Management of Adnexal Masses Oct 25, 2019

Practice Bulletin #174 - Published November 2016
We'll cover:
- differential diagnosis of adnexal mass (there's a f*ck ton)
- which masses need to be removed
- signs of malignancy
- when to refer to gyn/oncology
- management of masses in adolescents
-...and more!
Shout-outs:
- Augustine Colebrook of the Art of Birthing and her new podcast Worldwide Midwifery
- Maryn Green, author of Indie Birth: A Story of Radical Birth and host of the Taking Back Birth Podcast (also on Instagram)
- Katya Nova and her podcast Honey Talks (also on Instagram)
- Sarah Leahy of Birth Uprising
- Ilana Stanger-Ross and her pregnancy book "A is for Advice"
SHOW NOTES
This episode pairs nicely with the 2016 Educated Guess Cabernet Sauvignon by Roots Run Deep Winery. Main theme music by my main amigo, Evan Handyside

Ep 30: Prevention and Management of Perineal Lacs at Vaginal Delivery Oct 21, 2019

Practice Bulletin #198 - Published September 2018
We'll cover:
- female anatomy
- characterizing perineal lacerations
- associations between vaginal birth trauma and sexual and pelvic floor dysfunction
- prevention and management of vaginal and perineal lacerations
- postpartum considerations
- long-term follow-up
- Nathan is clearly a feminist
-...and more!
Shout-outs:
- Ryan Stewart, DO, on Twitter
- Thom Knoles interview on the Under the Hood Podcast (Part 1, Part 2)
- Maryn Green, author of Indie Birth: A Story of Radical Birth and host of the Taking Back Birth Podcast
SHOW NOTES
This episode pairs nicely with the 2015 Pinot Noir from Franny Beck Wines. Main theme music by my main amigo, Evan Handyside

Ep 29: Perinatal Palliative Care Oct 12, 2019

Committee Opinion #786 - Published September 2019
This is a different format from my own. This is a very heartfelt presentation on my part on the importance of incorporating principles of palliative care into our care of pregnant patients.
We'll cover:
- traditional versus palliative approach to managing complete prenatal diagnoses
- a protocol for delivering bad news
- the importance of establishing a patient's goals in order to help guide decision-making around birth
- labor and delivery planning to accommodate a family's goals for their newborn (even if this means opting for a comfort-focused approach)
- Nathan gets emotional ( and had to keep re-recording segments)
-...and more!
Shout-outs:
- On Death and Dying by Elisabeth Kübler-Ross
- Slow Medicine by Victoria Sweet, MD
- Vital Talks on Twitter (learn how to communicate better with patients)
- Nora McInerny's TED Talk on grief
SHOW NOTES
This episode pairs nicely with the 2016 Stephanie's Couvée Pinot Noir from River Road. Main theme music still by my main amigo, Evan Handyside

Ep 28: Inherited Thrombophilias in Pregnancy Oct 06, 2019

Practice Bulletin #197 - Published July 2018
We'll cover:
- review of the clotting cascade
- physiologic changes in pregnancy that affect clotting
- VTE risk in and out of pregnancy
- pathophysiology of inherited thrombophilias
- criteria for starting thromboprophylaxis in pregnancy
- Nathan's #1 fan made him new theme music
-...and more!
Shout-outs:
- Augustine Colebrook, CPM, founder of Wise Women Education and host of Worldwide Midwifery (her Instagram page also rocks)
- Nicole Nolan, MD, on Twitter
- Taking Back Birth podcast
- The Infertility Cure by Randine Lewis, PhD
- Guest theme music by Jake Curtis (@orangegemini on instagram)
SHOW NOTES
This episode pairs nicely with the 2015 Tempranilla from Las Almenas. Main theme music still by my main amigo, Evan Handyside

Ep 27: Vaginal Breech Birth Sep 28, 2019

SPECIAL EPISODE!! No practice bulletin or committee opinion this time. Instead, I interviewed Rixa Freeze, PhD, founder of Breech Without Borders, and David Hayes, MD, during a lunch break at a breech workshop that they hosted near Pittsburgh in September, 2019. I'M REALLY EXCITED ABOUT THIS ONE! We'll cover: - the Term Breech Trial's flawed methodologies, and the worldwide consequences of its publication - literature review of MANY other studies in countries where vaginal breech birth remains the norm - contemporary data on the risks/benefits of vaginal breech birth (it's far more reassuring) - counseling patients who desire breech or who present with breech presentation unknowningly - the difference maker in the safety of breech: experience of the birth worker in delivering breech - (and thus) why we need to re-teach breech birth skills - Nathan gets starstruck ...and much more! Shout-outs: - Rixa's personal website (Stand and Deliver) - Breech Without Borders - Find a breech workshop near you - Dr. Stu's podcast (w/ Stu Fischbein, MD, and Blyss Young, LM, CPM) - Indie Birth Podcast SHOW NOTES Theme music by my main amigo, Evan Handyside

Ep 26: Use of Prophylactic Antibiotics in Labor and Delivery Sep 09, 2019

Practice Bulletin #199 - Published September 2018
We'll cover:
- evidence skin/vaginal prep before c-section
- selecting the correct agent and dose
- PPROM antibiotic regimens
- are antibiotics necessary for preterm labor, cerclage, or manual extraction of placenta
- Nathan bores you with Burning Man stories (...or does he?!)
-...and more!

Shout-outs:
- Mountains Beyond Mountains, book by Tracy Kidder
- Daniel Ginn, DO, on Twitter
- Ryan Stewart, DO, on Twitter
- Jeffrey Sperling, MD, on Twitter
SHOW NOTES
This episode pairs nicely with the 2018 Pinot Noir by Cono Sur. Theme music by my main amigo, Evan Handyside

Ep 25: Early Pregnancy Loss Aug 16, 2019

Practice Bulletin #200 - Published November 2018
We'll cover:
- diagnosis of early pregnancy loss
- risks/benefits of expectant, medical and surgical management
- Nathan gets tipsy
...and much more!
SHOW NOTES
This episode pairs nicely with the Anew Pinot Grigio (in a can!). Theme music by my main amigo, Evan Handyside

Ep 24: Female Sexual Dysfunction Aug 09, 2019

Practice Bulletin #213 - Published July 2019
We'll cover:
- classification and diagnosis of female sexual dysfunction
- pregnancy-related and menopause-related sexual dysfunction
- estrogen and other medications that may be helpful
- psychologic and other non-pharmacologic interventions
- Nathan gets back up on his soapbox
...and much more!
SHOW NOTES
This episode pairs nicely with the 2017 Chardonnay from Chloe Wine. Theme music by my main amigo, Evan Handyside

Ep 23: Prevention of Group B Streptococcal Early-Onset Disease in Newborns Jul 30, 2019

Committee Opinion #782 - Published July 2019
We'll cover:
- likelihood of GBS colonization and transmission to newborn
- dangers of early-onset GBS disease of the newborn
- screening guidelines for GBS in pregnancy
- treatment protocols for GBs prophylaxis in labor
- more useless stories about Nathan's personal life
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Reserva Malbec from Bodega Norton
Theme music by my main amigo, Evan Handyside

Ep 22: Vaginitis in Nonpregnant Patients Jul 18, 2019

Practice Bulletin #251, Published in January 2020
We'll cover:
- understanding normal vaginal pH and flora
- role of estrogen in maintaining vaginal health
- infectious and non-infectious causes of vaginitis
- diagnosis and treatment of candidiasis, bacterial vaginosis, and trichomoniasis
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Pinot Noir from Carmel Road Winery
Theme music by my main amigo, Evan Handyside

Ep 21: Fertility Awareness Methods Jul 10, 2019

SPECIAL EPISODE!! No practice bulletin or committee opinion this time. Instead, I interviewed Lisa Hendrickson-Jack, the author of "The Fifth Vital Sign" about fertility awareness methods. This is an important part of women's health practice that you probably didn't learn in residency, yet I see it as a critical part of OB/GYN practice. We'll cover: - cervical mucus, basal body temperature, and cervical position fluctuations throughout the menstrual cycle - educating women on becoming aware of these things - utilizing fertility awareness for contraception and fertility - how abnormalities in the menstrual cycle reflect deeper-seated medical issues ...and much more! Lisa's website, book, podcast, Instagram, and Twitter. SHOW NOTES Theme music by my main amigo, Evan Handyside

Ep 20: (Part 2/2) Pregnancy and Heart Disease Jun 28, 2019

Practice Bulletin #212 PART 2 OF 2 - Pregnancy and Heart Disease, Published April 2019
We'll cover:
- identification, assessment, and management of patients at high risk of peripartum cardiomyopathy
- acute coronary syndrome and myocardial infarction in pregnancy
- management of cardiac arrest in pregnancy, including perimortem cesarean delivery and resuscitative hysterotomy
- antepartum, intrapartum, and postpartum management of patients with CVD
...and much more!
SHOW NOTES
This episode pairs nicely with the Criminal 2017 Red Blend from Truett Hurst Winery
Theme music by my main amigo, Evan Handyside

Ep 19: (Part 1/2) Pregnancy and Heart Disease Jun 19, 2019

Practice Bulletin #212 PART 1 OF 2 - Pregnancy and Heart Disease, Published April 2019
We'll cover:
- risk stratification of cardiovascular disease (CVD) in pregnancy
- prenatal counseling and workup
- workup of new-onset symptoms concerning for worsening or new-onset CVD in pregnancy
...and much more!
SHOW NOTES
This episode pairs nicely with the Pacific Redwoods Organic Red from Frey Vineyards
Theme music by my main amigo, Evan Handyside

Ep 18: Critical Care in Pregnancy Jun 07, 2019

Practice Bulletin #211 - Critical Care in Pregnancy, Published April 2019
We'll cover:
- indications for ICU consult
- why asking for help doesn't make you a sissy
- physiologic changes in pregnancy
- ICU mortality data for pregnant women
- ARDS and sepsis
- coding a pregnant woman
- mechanical ventilation considerations
...and much more!
SHOW NOTES
This episode pairs nicely with the E-6 Spanish Blend from Locations Wine
Theme music by my main amigo, Evan Handyside

Ep 17: (Part 2/2) Chronic Hypertension in Pregnancy May 18, 2019

Practice Bulletin #203 (Part 2 of 2) - Chronic Hypertension in Pregnancy, Published December 2018 .
We'll cover:
- guidelines for treatment of chronic hypertension in pregnancy
- management of severe hypertension in pregnancy
- other intrapartum and postpartum considerations
...and much more!
SHOW NOTES
This episode pairs nicely with the 2018 Malbec from Öko Winery
Theme music by my main amigo, Evan Handyside

Ep 16: (Part 1/2) Chronic Hypertension in Pregnancy May 18, 2019

Practice Bulletin #203 - Risks and Benefits of Sterilization, Published December 2018
We'll cover:
- definitions and diagnosis
- first prenatal visit
- maternal and fetal risks
- things to watch for throughout pregnancy
- superimposed preeclampsia
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Old Vine Zinfandel from Four Vines Winery

Theme music by my main amigo, Evan Handyside

Ep 15: Risks and Benefits of Sterilization May 12, 2019

Practice Bulletin #208 - Risks and Benefits of Sterilization, Published January 2019
We'll cover:
- counseling and alternatives
- male and female sterilization
- safety and efficacy of various techniques
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Red Blend from Rabble Wine Company
Theme music by my main amigo, Evan Handyside

Ep 14: Thrombocytopenia in Pregnancy Apr 24, 2019

Practice Bulletin #207 - Thrombocytopenia in Pregnancy, Published March 2019
We'll cover:
- etiologies
- work-up
- management
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Reserva Malbec from Bodega Norton
Theme music by my main amigo, Evan Handyside

Ep 13: Fecal Incontinence Apr 16, 2019

Practice Bulletin #210 - Fecal Incontinence, Published April 2019
We'll cover:

- epidemiology
- risk factors
- evaluation
- medical and surgical treatment options
...and much more!
SHOW NOTES
This episode pairs nicely with the Penfolds Koonunga Hill 2016 Shiraz Cabernet
Theme music by my main amigo, Evan Handyside

Ep 12: Uterine Morcellation for Presumed Leiomyomas Apr 07, 2019

Committee Opinion #770 - Uterine Morcellation for Presumed Leiomyomas, Published February 2019
We'll cover:
- leiomyosarcoma incidence and prognosis
- morcellation techniques
- choosing a surgical approach to myomectomy or removal of a fibroid uterus
- risk and benefit discussion around risk for spread of occult leiomyosarcoma by laparoscopic power morcellation versus morbidities associated with manual morcellation or "open" surgery
SHOW NOTES
This episode pairs nicely with the 2016 Cabernet Sauvignon from Chateau St. Jean
Theme music by my main amigo, Evan Handyside

Ep 11: Obstetric Analgesia and Anesthesia Apr 01, 2019

Practice Bulletin #209 - Obstetric Analgesia and Anesthesia, Published March 2019
We'll cover:
- opioids
- epidural/spinal anesthesia
- pudendal nerve block
- nitrous oxide
- general anesthesia
- risks to mother/fetus
- contraindications
- anesthesia and breastfeeding
- post-cesarean delivery pain management
- neuraxial precautions with anticoagulation
SHOW NOTES
This episode pairs nicely with the2016 Seven Oaks Cabernet Sauvignon from J. Lohr Vineyards and Wines
Theme music by my main amigo, Evan Handyside

Ep 10: Approaches to Limit Intervention During Labor and Birth Mar 22, 2019

Committee Opinion #766, Approaches to Limit Intervention During Labor and Birth, published February 2019
We'll cover:

- when to admit to the hospital
- pain management (pharmacologic and non)
- breathing techniques in 2nd stage
- the utility (or lack thereof) of fetal heart rate monitoring
- value provided by doulas
- to break the water or not to break the water
- the myth of laboring down
...and much more!
SHOW NOTES
This episode pairs nicely with the 2015 Gentleman’s Collection Red Blend from Lindeman’s Winery
Theme music by my main amigo, Evan Handyside

Ep 9: Fetal Growth Restriction Mar 08, 2019

Practice bulletin #204, Fetal Growth Restriction, Published January 2019
We'll cover:

- screening
- risk factors
- etiologies
- sonographic assessment
- management including delivery timing
- antenatal testing once diagnosed
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Central Coast Pinot Noir from Wild Horse Winery and Vineyards
Theme music by my main amigo, Evan Handyside

Ep 8: Use of Hormonal Contraception in Women With Coexisting Medical Conditions Feb 12, 2019

Practice bulletin #206, Use of Hormonal Contraception in Women With Coexisting Medical Conditions, Published February 2019
We'll cover:

- U.S. Medical Eligibility Criteria for Contraceptive Use (USMEC)
- VTE and stroke risk for various forms of contraception
- selection contraception for patients with co-morbidities (e.g. HTN, history of DVT, diabetes, obesity, etc.)
- how your practice might change in an older patient or a patient with migraines
...and much more!

SHOW NOTES
This episode pairs nicely with the 2014 California 37 Cabernet Sauvignon from Save Me, San Francisco Wine Co.
Theme music by my main amigo, Evan Handyside

Ep 7: Vaginal Birth After Cesarean Delivery Feb 03, 2019

Practice Bulletin #205, Vaginal Birth After Cesarean Delivery, Published January 2019
We'll cover:

- epidemiology
- risk and benefits counseling for patients
- diagnosis and management of uterine rupture
- risks to future pregnancies
- management of TOLAC
...and much more!

SHOW NOTES
This episode pairs nicely with the 2016 Apothic Crush Smooth Red Blend
Theme music by my main amigo, Evan Handyside

Ep 6: (Part 2/2) Gestational Hypertension and Preeclampsia Jan 22, 2019

Practice Bulletin #202 (Part 2 of 2) - Gestational Hypertension and Preeclampsia, Published January 2019
We'll cover:
- intrapartum management of severe preeclampsia
- magnesium toxicity
- management of acute hypertension
- management of eclamptic seizures
- postpartum considerations
- special consideration in HELLP syndrome
- long-term consequences
...and much more!

SHOW NOTES

Part 2 pairs nicely with the 2017 Unoaked Tempranillo from El Jefe. Yes...I had to consume two bottles of wine for this recording...aren't you nosy.
Theme music by my main amigo, Evan Handyside

Ep 5: (Part 1/2) Gestational Hypertension and Preeclampsia Jan 17, 2019

Practice Bulletin #202 (Part 1 of 2), Gestational Hypertension and Preeclampsia, Published January 2019

We'll cover:
- epidemiology
- risk factors
- prevention
- diagnosis
- maternal and fetal consequences
- inpatient versus outpatient monitoring
- expectant management versus delivery
- pathophysiology
- associated conditions (e.g. HELLP, PRES, eclampsia, etc.)
...and much more!

SHOW NOTES
This episode pairs nicely with the 2015 Lagrein Riserva from Glassier.
Theme music by my main amigo, Evan Handyside

Ep 4: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women Jan 04, 2019

Committee Opinion #577, Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women, Published April 2013 (Reaffirmed 2017)
We'll cover:
- defining and qualifying AUB
- differentiating between heavy menstrual and intermenstrual bleeding
- etiologies
- physical exam approach
- stabilization of patient in acute episode of heavy bleeding
- medical and procedural management options
...and much more!

SHOW NOTES
This episode pairs nicely with the 2014 Pinot Noir from MacMurray Estate Vineyards.

Theme music by my main amigo, Evan Handyside

Ep 3: Pre-gestational Diabetes Mellitus Dec 21, 2018

Practice Bulletin #201, Pre-gestational Diabetes Mellitus, Published December 2018
This episode is packed. We'll cover:
- epidemiology
- diagnosis
- patient follow-up and home glucose monitoring
- serum glucose goals prenatally and intrapartum
- how to prescribe insulin or oral antihyperglycemics
- management of nocturnal hypoglycemia
- risk of poor glucose control to mom, fetus, and newborn
- timing and mode of delivery
- postpartum considerations
...and much more!

SHOW NOTES
This episode pairs nicely with the 2015 Old Vine Zinfandel from Brazin Cellars
Theme music by my main amigo, Evan Handyside

Ep 2: Polycystic Ovarian Syndrome Dec 03, 2018

Practice Bulletin #194, Polycystic Ovarian Syndrome, Published June 2018
We'll cover:

- diagnosis and clinical workup
- etiology
- review of metabolic syndrome
- clinical manifestations of PCOS
- differential diagnosis
- associated co-morbidities and risks
- use of COCs to treat metabolic derangements and menstrual disorders
- ovulation induction and other management options for infertility in PCOS
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 Wintner’s Collection Merlot from Sterling Vineyards
Theme music by my main amigo, Evan Handyside

Ep 1: Tubal Ectopic Pregnancy Dec 01, 2018

Practice Bulletin #193, Tubal Ectopic Pregnancy, Published March 2018
We'll cover:

- epidemiology
- risk factors
- interpretation of serial ultrasounds and serum bHCG values
- follow-up for pregnancy of unknown location
- risks and benefits counseling for your patient when things aren't so black and white
- to aspirate or not to aspirate the uterine cavity
- medical versus procedural management of ectopic
- ins and outs of methotrexate
...and much more!
SHOW NOTES
This episode pairs nicely with the 2016 667 Pinot Noir from Noble Vines
Theme music by my main amigo, Evan Handyside

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