• Fetal Monitoring: What Parents Should Know
• Renovations and New Obstetrical Wing Planned for Saint Barnabas
• New Program Offering: Prepare for Surgery, Heal Faster
• Update On Ovarian Cancer
• Healthy Eating During Pregnancy
• Physician Helps Battered Women
• Infertility and Mind/Body Groups
• Update on The Women's Center for Gynecological Surgery

Fetal Monitoring: What Parents Should Know

Electronic fetal monitoring was first introduced in the late 1960's. Prior to that time, a baby's heartbeat could only be evaluated during labor with a special stethoscope, called a fetoscope. It was thought that by monitoring a baby's heartbeat during labor, complications such as cerebral palsy could be eliminated. At that time, cerebral palsy was thought to result primarily from lack of oxygen to the fetus during labor. Since then, however, we have learned that the majority of cases of cerebral palsy do not occur during labor, but long before labor begins.

While external fetal monitoring did not help to decrease the number of cases of cerebral palsy, it has proven useful in a number of other ways. Information can be gained from the monitor strip that can predict intrauterine infection, fetal heart arrhythmias and even fetal anemia. The main strength, however, of fetal monitoring is in confirming the well being of the fetus. When a fetal heart rate pattern is deemed normal or "reactive" by the physician, the baby is receiving enough oxygen in more than 99% of cases.

The monitor is actually an ultrasound machine that listens for the opening and closing of the baby's heart valves. It works in conjunction with the tocodynometer, or contraction monitor. The latter device detects changes in the curvature of the mother's abdomen during a contraction, then translates this signal into a printed curve onto the machine's paper. The physician or nurse then sees both the fetal heart rate pattern and the contraction pattern in relationship to each other.

There are times when tracing the fetal heart rate is difficult or when more precise information is needed. In these cases, once the bag of water, or membranes, have broken, a small metal clip can be attached to the fetus' scalp through the mother's open cervix. This is not in any way a painful procedure for the mother or the fetus. The device is called a fetal scalp electrode, and rather than listen for the heart valves, it works by detecting the electric cardiac rhythm, similar to an electrocardiogram.

Similarly, there is a monitor used internally to detect contractions. It is called an intrauterine pressure catheter, or IUPC, and it is placed between the baby and the wall of the uterus. Unlike the external contraction monitor, which only gives information about frequency of contractions, the IUPC can reveal the strength of a given contraction. contraction. This information is used by staff members to determine if the contraction pattern is normal and if the contractions are of sufficient strength to result in normal labor progress.

Special Care at Saint Barnabas

At Saint Barnabas Medical Center, the Labor and Delivery Unit employs a monitoring protocol that is individualized to the patient. Low risk patients who have had an uncomplicated pregnancy and who have no medical problems may undergo intermittent monitoring as described by the American College of Obstetricians and Gynecologists. This allows the patient to have some freedom of movement during labor, returning to her room to be monitored for a part of each hour during the early stage of labor. Monitoring becomes more frequent as delivery is nearer. High-risk patients, on the other hand, have either maternal or fetal issues that make closer, continuous monitoring more desirable.

The biggest drawback to fetal monitoring is that it is not as efficient at detecting a fetus in trouble as it is in confirming fetal well being. Also, fetal heart rate patterns that most would view as abnormal are associated with a normal baby in the vast majority of cases. It is with this in mind that a new tool in the obstetrician's repertoire has been developed.

The Fetal Pulse Oximeter is a new monitor that uses an infrared sensor that detects the level of oxygen in the baby's tissues. When the fetal heart rate monitor suggests a problem with the baby's oxygen level, the fetal pulse oximeter can provide more exact information about the baby's condition. This technology is still in its initial phases of clinical application, and more studies are underway to establish further establish its utility in a clinical setting. At this point, we believe the pulse oximeter decreases the need for Caesarean deliveries for "fetal distress" without jeopardizing the baby's well being.

At Saint Barnabas Medical Center, our Labor and Delivery nurses and obstetrical physician staff are highly skilled in the interpretation of fetal monitoring strips. Although the tools available to us are not perfect, the availability of new technology promises even more success in attaining our goal: delivery of healthy babies.

For a referral to a Saint Barnabas Medical Center obstetrician, please call 1-888-SBMC-DOC.

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Through new construction and renovation of existing space, Saint Barnabas Medical Center has plans to develop the maternity services areas to create comfortable, elegant facilities dedicated to care of mothers and babies. The entire project, including existing and new obstetrical wings, will be renamed The James L. Breen Obstetrical Pavilion in honor of Dr. Breen, the esteemed emeritus chairman of the Department of Obstetrics and Gynecology. The anticipated $6 million construction of a new obstetrical wing on the sixth floor of the Medical Center will provide 21 additional patient beds. Of these beds, 17 will be private rooms and two will be semiprivate. These additional rooms will allow Saint Barnabas to provide the obstetrical population with private patient room accommodations.

The 13,000 square foot obstetrical wing will include two nurseries and elegantly decorated patient rooms that will be generously sized to allow significant others to sleep over. Construction is planned to begin January 2001 and expected to take approximately 11 months to complete.

Additionally, a new design and renovation plan has been created which will transform current third floor facilities into a comprehensive pavilion. The new pavilion will be a hospital within a hospital with many amenities for patients and family members. One such service, known as Baby Press Conference, will allow new parents to go online and announce the birth of a child on their own full color web page.

For ongoing information about maternity services at Saint Barnabas Medical Center, locate the website at www.saintbarnabas.com.

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To help women prepare for their surgery, all patients are welcome to take part in the Prepare for Surgery, Heal Faster™ program. Research shows that psychological preparation for surgery reduces anxiety, promotes a feeling of well being, lessens the need for pain medication and helps initiate a faster recovery. In the Prepare for Surgery, Heal Faster™ workshop, women learn mind/body techniques specifically tailored to their surgical and post-operative needs.

As an advocate of an integrative approach for patients undergoing surgery, my philosophy is that "where there is high tech, there must be high touch." Over the last few years, there has been outstanding advancement in new surgical techniques and successful outcomes available for patients. To enhance this technology, complimentary medicine modalities have moved into the mainstream of practice. For example, research has shown that psychological preparation for surgery is very beneficial.

Emotional support and genuine caring are holistic nursing values that I, along with Joanne Cambell, RN, HNC; convey to all our course participants in our role as workshop presenters. Holism is a wellness concept that helps patients create a balance of mind/body/spirit in their lives as they prepare for and experience surgery and recovery.

Ideally, patients participate in the workshop one to two weeks prior to their scheduled surgery. However, even if patients have only a day or two before surgery, they can still benefit from learned techniques. Mind/body skills are taught to help patients feel calm before surgery, which in turn strengthens their immune systems and helps promote a faster recovery. Workshop alumni have confirmed that there seems to be less pain post operatively, which means fewer pain medications.

The five goals of the program are to do the following:

• teach the use of guided imagery so patients can visualize their recovery and
  focus on positive healing thoughts.
• help calm patients' preoperative anxieties through the use of a relaxation tape used prior to and during surgery.
• encourage the love and support connection between patients and their family members.
• instruct a surgical team member to repeat healing statements.
• promote supportive physician-patient relationships.

Patients can register for a group workshop by calling The Siegler Center for Integrative Medicine at (973) 322-7007. The $35 registration fee includes an hour session, Peggy Huddleston's Prepare for Surgery, Heal Faster™ workbook and a guided imagery relaxation tape to be utilized prior to and during surgery.

As a mind/body nurse therapist and stress reduction expert, I see that this program helps to guide participants into an arena of healing which includes a suitable emotional environment. Patients' surgical experience and recovery is enhanced by providing them with ways to participate in stress reduction and self-healing.

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Update on Ovarian Cancer

Ovarian cancer affects 25,000 women and results in 14,500 deaths annually. It ranks as the fifth leading cause of female cancer mortality in the United States, following cancers of the lung, breast, colon and pancreas. Ovarian cancer is the second most common gynecologic malignancy and is the most lethal; 1 in 100 women die of this disease. The majority of ovarian cancers arise from the surface cells, called epithelium, and a smaller number arise from the germ cells and stromal (support) cells. The five-year survival rate of the more common epithelial ovarian cancer is approximately 40%; however, there is emerging information to suggest that survival rates are approaching 50%. Survival is based on the stage of disease, and the stage determines the size and spread of disease. This means that the earlier the disease is found, the more likely the patient will be cured. As an example, the five-year survival rates for stage I and stage III disease are roughly 95% and 20% respectively. The presentation of ovarian cancer has been a source of concern due to a lack of symptoms of early disease. Generally, an ovarian cancer patient presents with vague, non-suspicious and non-gynecologic complaints. These complaints include fatigue, constipation, abdominal or pelvic discomfort, bloating, urinary frequency, and rarely, menstrual irregularities. If a large volume of cancer is present, the patient may complain of an early feeling of fullness when eating, nausea, increasing abdominal girth and loss of muscle mass. In the case of advanced disease, the physical findings may include ascites (excessive amount of abdominal fluid), pelvic mass, and omental metastasis (tumor invading the normal apron of fat attached to the stomach and transverse colon). Such an advanced disease presentation may arise despite normal yearly pelvic exams. Sadly, the majority (75%) of ovarian cancer patients present with advanced disease and this, above all, contributes to the poor survival rates associated with this cancer.

Treating Ovarian Cancer
The principle treatment of ovarian cancer is based on combining surgery and chemotherapy. Surgery, if performed by a gynecologic oncologist, affords the patient an accurate staging assessment. The importance of accurate staging directs what additional therapy is necessary. Surgery also offers the attempt to debulk (reduce) the tumor load. The importance of debulking procedures in ovarian cancer has been clearly shown to improve a patient's response to chemotherapy and thus her survival. A 1994 National Institutes of Health Consensus Conference issued a statement stressing the value of surgical exploration for staging and debulking whenever possible.

Since surgery is directed at staging and debulking gross disease, a partnership was developed with chemotherapy to treat the residual visible and microscopic disease. Response rates to chemotherapy and median survival have increased following the introduction of each new active chemotherapy agent. Currently, 80% of newly diagnosed ovarian cancer patients respond to prescribed chemotherapy which usually consists of six cycles of Taxol and Carboplatin. In general terms, if a patient responds to the chemotherapy, the disease is in remission and is not clinically apparent. Unfortunately, and despite excellent response rates, this disease often recurs and requires additional chemotherapy in an attempt to stop its growth. Given the need for chemotherapy and the well-known side effects, several advances have been made to reduce these toxicities. These include new anti-nausea medicines that help protect normal cells from chemotherapy toxicity. Also, genetically engineered factors are available which can stimulate the growth of white blood cells, red blood cells and platelets whose numbers are often reduced as a side effect of chemotherapy.

Risk Factors and Screening
Recently, media attention has focused on risk factors and screening for ovarian cancer. Risk factors include a genetic predisposition to cancer, familial history of ovarian cancer, personal history of cancer, age and possibly infertility. A large volume of interest involves hereditary risks for the development of ovarian cancer. Hereditary risks factors are shown in TABLE 1. In those families with a
genetic or hereditary risk, we believe that one or more specific gene mutations are passed to the next generation, increasing a person's susceptibility to developing cancer. Two of these specific gene mutations involve the BRCA 1 and BRCA 2 genes. We believe these genes are tumor suppressor genes, which can be thought to act as cellular brakes, preventing cells from uncontrolled growth. In the absence of a specific _ gene mutation, we can also see that having a first-degree relative with ovarian cancer increases a person's risk.

Given the knowledge of ovarian cancer risk factors, several attempts have been forwarded to screen for ovarian cancer using ultrasound and a tumor marker commonly associated with ovarian cancer called CA-125. Unfortunately, and despite screening over 40,000 women, we have found that our current ovarian cancer screening techniques are not appropriate. The cost of ultrasound and CA-125 screening and the multiple surgeries for enlarged benign ovaries far outweigh the very small chance of finding an early stage ovarian cancer. Hope is not lost though. These early screening attempts have laid the groundwork for research into newer ultrasound techniques and tumor markers which will certainly prove useful in the future.

In the absence of a successful ovarian cancer screening program, additional research has evaluated preventative measures. The prevention philosophy is based on either removing the ovaries or blocking the communication between the ovary and the outside environment. At the conclusion of child bearing, a woman with significant risk factors for ovarian cancer may consider having the ovaries removed. In these cases, the postoperative use of appropriate hormone replacement therapy is recommended and does not increase the risk of other gynecologic cancers. Although these women would not develop ovarian cancer, they still have a small risk of developing a related cancer formed from the lining of the abdomen and pelvis. In contrast to removing the ovaries, oral ontraceptives, tubal ligation and hysterectomy offer some protection against ovarian cancer. These either chemically or surgically block the ovary's exposure to the outside environment via the vagina, uterus and fallopian tube.

Looking Ahead
In summary, the cornerstone to diagnosis and treatment of ovarian cancer is surgery followed by chemotherapy. Research continues to search for new and active agents as well as targets for therapy designed to further extend the lives of women with this potentially lethal disease. Additional investigation is also directed toward refining techniques of early diagnosis which will certainly be a major impact on the survivability of this dreaded disease.

To reach the Division of Gynecologic Oncology and Reconstructive Pelvic Surgery at Saint Barnabas, please call (973) 322-5280.

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Healthy food choices are important when you are eating for two. Your baby's health depends on you getting the right amount of calories and the full range of appropriate vitamins and minerals. What you eat during the next nine months can give your baby the best possible start in life.

Nutritional Needs for Mom and Baby
Pregnant women should eat about 300 more calories a day than they usually do. You may find that regular snacks and smaller meals are better than three big meals a day. The food guide pyramid is a great reference when planning your meals. Here you can find the number of servings you need each day from the different food groups. You should also drink at least 8 - 10 glasses (2 quarts) of liquid a day. In addition to water, good sources of fluid are unsweetened fruit and vegetable juices.

Appropriate Weight Gain
Gaining the appropriate amount of weight is an important part of a healthy pregnancy. Your weight status prior to pregnancy helps determine the actual number of pounds you should gain:

Underweight 28 - 40 pounds
Normal weight 25 - 35 pounds
Overweight 15 - 25 pounds
Carrying Twins 35 - 45 pounds

During the first three months of your pregnancy, you are likely to gain about three to five pounds. Then, you may gain one to two pounds each week in the rest of the pregnancy.

A breakdown of where all the weight goes is listed below:

Dangers of Dieting During Pregnancy
Pregnant women are sometimes concerned about their weight gain. No matter what you weigh prior to pregnancy, you should still gain weight during pregnancy. If a ten-pound weight gain is not achieved by midpregnancy, your nutritional status may need to be reviewed by your physician or a nutritionist.

Dieting during pregnancy may lead to inadequate weight gain. This may be associated with an increased risk of a lowbirth- weight infant (<2500 g or 5 pounds 8 ounces), lack of expansion of plasma volume and risk of intrauterine growth retardation.

Vegetarian Diets
Vegetarians may continue their diets during pregnancy. Meals need to be planned with care following the food guide pyramid to ensure you receive the necessary nutrients for you and your baby.

A strict vegan is a person who eats no animal products, including eggs, milk, and other dairy products, as well as meat. These individuals need supplementation of key nutrients during pregnancy, such as vitamin B12, vitamin D, folic acid, iron, zinc and calcium.

Conclusion
A new life is growing inside you. What you eat, or do not eat, can affect your developing fetus. Give your baby the best possible start in life by eating healthy during pregnancy.

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Saint Barnabas Physician Helps Battered Woman Through Face to Face Outreach Project

When she is asked to describe what happened, 43-year-old Elizabeth B., a Passaic County resident, recalls little about the incident. Just one image stays with her: seeing her then boyfriend against her door holding a metal pipe in his hand, and her bewildered and fearful question, "What are you doing with that pipe?"

The next thing she remembers is waking up in a hospital more than two weeks later. That she survived the beating at all was a miracle considering she experienced severe fractures to the skull and eye sockets. The attack caused blindness in her left eye, broke her teeth, necessitating the need for dentures, and also made her lose her sense of smell. During emergency neurosurgery, physicians replaced parts of her crumbling skull, resulting in an uneven forehead. The only eyebrows she has are those she applies herself with an eyebrow pencil. She also styles her hair to hide a lengthy scar on her hairline. Elizabeth looked polished during her meeting in late October with otolaryngologist and plastic surgeon Todd A. Morrow, M.D., of West Orange, an attending physician at Saint Barnabas Medical Center. But then, she has had 25 years to adapt to her "new" face. The beating took place in August 1975.

Like many domestic violence survivors, Elizabeth remained silent about her past. Her immediate family and intimate friends supported her after her ordeal, but she was never referred for counseling and never received assistance from social service organizations. That is, until she read an article about Face to Face in late spring.

Face to Face Assistance
Face to Face: The National Domestic Violence Project is a humanitarian, educational program staffed by medical personnel who donate their time and expertise to provide complimentary care to those who suffer from facial deformities caused by domestic violence. Supported by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) in cooperation with The National Coalition Against Domestic Violence, Face to Face was established in 1994. More than 275 AAFPRS surgeons nationwide participate in Face to Face, ten of them from New Jersey.

After calling the number in the article, Elizabeth was referred to a resource center for survivors of domestic violence where she received counseling, and then she met with Dr. Morrow to improve her appearance. Dr. Morrow recommended a new implant in her cheek area, scar revision on her upper and lower lips to reduce the puffiness, and scar revision on the temple beside her eye. He suggested the goal should be improvement rather than perfection. Elizabeth was optimistic about any changes for the better.

As an otolaryngologist and plastic surgeon, Dr. Morrow is sensitive about scars, especially for his patients who are survivors of domestic violence. His patients have numbered more than a dozen since he began donating his time, first to those who could not afford needed plastic surgery, and then through Face to Face when it was established.

"I can minimize scars to make them less obvious," he explains, "But I can't erase them entirely. The wounds and subsequent scarring are a painful reminder of what happened. I can help cosmetically, but there is the emotional scarring that needs to be addressed too."

Surgery at Saint Barnabas
Recently, Elizabeth became one of more than 1,250 women helped by Face to Face when she underwent cosmetic surgery at Saint Barnabas Medical Center. Face to Face relies on the pro bono work offered by its physician members who must arrange for all of the necessary medical resources free of charge. In addition to the services offered by the operating room staff, Robert Dorian, M.D., Chairman of Anesthesiology, donated his services as well. For now, Dr. Morrow hopes his contribution will make a difference in the lives of the women he meets through Face to Face.

In the physician's office before the surgery, Elizabeth pulled out an old, yellowed photo of she and her mother taken at her secretarial school graduation just a few months before her attack. In the picture, a pretty young woman with curly hair wears a formal dress with a corsage. Elizabeth looks at the photo fondly before putting it into her purse. It is a precious reminder, an image of someone young and beautiful that she is proud to recall from time to time.

For further information on Face to Face, please call the 24-hour toll-free number, 1-800-842-4546.

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Infertility and Mind/Body Groups

Jane* and John* have been married for six years and are both 38 years old. She is a lawyer and he is an accountant. They wanted to wait until they were financially ready before having children. They tried to conceive on their own for six months and then sought medical help. It has been two years since their diagnosis of "unexplained infertility" and multiple treatment rounds. Jane feels angry, disappointed and guilty for putting her career ahead of having children. Sometimes she thinks she is being punished.

Sue* is 30 years old and married to Steve*, 31. They each were married before and Steve had two children from his previous marriage. Sue has not had children yet. They have been married for two years. Sue wanted to start a family immediately, but Steve asked her to wait so his children could adjust to the changes. She agreed to wait, but when nothing happened as they tried to become pregnant, they sought medical help and were told they would need to use IVF to become pregnant. Sue became anxious, depressed and overwhelmed, feeling as if she were a failure.

Alice* is 25 and married to Jim* who is 30. They knew they wanted children right away. After one year of not conceiving, they sought medical help and discovered that Alice had "premature ovarian failure" and would need an ovum donor in order to become pregnant. They thought they were handling this news well until Jim became irritable most of the time and Alice started having panic attacks.

Approximately one in six couples experience some form of difficulty in creating a family when they wish to and require medical assistance. Infertility can have a powerful impact on one's life. Feelings of depression, anxiety, anger, shame, loneliness, isolation and despair are common. Not only are individuals affected by this emotional roller coaster, but marriages can also suffer under the stress of infertility.

It is well documented that stress and how we handle it affects our physical wellbeing. Couples who experience infertility report it to be very stressful. In one study where chronic medical conditions were compared, handling infertility was found to be as stressful as those dealing with cancer; and in another investigation infertility was rated to be more stressful than divorce. Stress affects how we think; how our bodies react and what we do.

The Surgeon General first acknowledged the Mind/Body Model of health and illness in 1979. This term, mind/body, is used to describe the complicated set of interactions that take place among your thoughts and your body. Harvard Medical School has been studying this mind/body connection and its impact on infertility patients for a decade and has sought to reduce the distress and increase the emotional health and well-being of infertile women. Mind/Body infertility workshops are usually weekly meetings between 7 and 10 weeks in length, during which time participants are taught cognitive, physiological and behavioral techniques to feel better and manage their stress.

An example of a cognitive technique might be the "Pie." Women have many different functions and roles in life. When it comes to infertility, however, they narrow their focus and only see one. In this Pie technique, they are asked to draw a circle and divide it up into 8 or 10 sections, slices of a pie. In the sections, they are asked to label all the roles they play. Only one slice of the pie can be identified for the pursuit of motherhood. In this way, they see concretely that their lives are not only about infertility. Other mind/body tools are relaxation exercises. The focus of the mind/body group is to help women gain control over their lives and health by learning empowering tools through a combination of experiential exercises, shared group experiences, and educational presentations.

The Institute for Reproductive Medicine and Science offers several types of groups for woman and couples facing infertility. If you are interested in these groups, please call Claudia Pascale, Ph.D. of Psychological Services at the IRMS at (973) 322-5356.

*although the stories mentioned above are real, the names of individuals are not.

To help new parents in their transition to home and the acquisition of parenting skills, the Family Centered Care nursing team at Saint Barnabas offers new families a free informational meeting called Parenting Insights. Held every Tuesday, Parenting Insights is an informational gathering and an opportunity to meet other new parents, compare ideas about baby care and ask Saint Barnabas nurses a variety of parenting questions.

Sessions cover specific topics and an ongoing four-week program has been developed. New families may begin attending at any time during the course of the four weeks. A Breastfeeding Support Group is held from 1 to 2 p.m., followed by Parenting Insights from 2 to 3 p.m. Newborns in car seats or strollers are welcome to attend Parenting Insights,and refreshments are served. Free parking is available, but please allow plenty of time as space is limited. Reservations are required by calling The Department of Maternal Child Health, Saint Barnabas Medical Center, at (973) 322-2584.

First Ride Home In Safety

Saint Barnabas Medical Center continues a campaign to remind new parents of the importance of car seat safety beginning with the first ride home from the hospital. Expectant couples are given a pamphlet entitled, "Are You Using Your Care Seat Correctly?" Issued by the New Jersey Department of Law and Public Safety, the pamphlet covers issues such as the importance of placing infants in the back seat and properly installing the car seat. Parents should be familiar with the use of the car seat before bringing their infant home and the seat must be installed before discharge day.

For more information about car seat safety, please call the New Jersey Division of Highway Traffic Safety at 1-800-422-3750.

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Update On The Women's Center for Gynecological Surgery

The Women's Center for Gynecological Surgery opened January 2001 at 101 Old Short Hills Road (in the Atkins Kent Building) directly across from Saint Barnabas Medical Center.

This Women's Center for Gynecological Surgery represents a new standard in women's health care, offering the highest quality medical care, technology, patient satisfaction and comfort. The prestigious Saint Barnabas Departments of Gynecology and Anesthesiology combined with a superior nursing staff are dedicated to achieving optimal results for each gynecological surgery patient who does not require an overnight stay following surgery. The Surgery Center offers three surgical suites and recovery area.

Women coming to the Center enter an environment designed to put them at ease. The Center is complete with waterfalls, warm soothing colors and patterns and soft lighting. All elements are designed to create a tranquil atmosphere that fosters a relaxing setting. Attention to every detail, from restful music to a comfortable robe and a flower upon discharge, has been considered.

A comfortable waiting room for family members is also available, complete with many amenities. Family members have access to computer terminals so they can use their personal laptop computers and connect to their Internet service provider, while they wait. In addition, patients and families have access to extensive educational materials on women's health topics.

Patients using the Women's Center for Gynecological Surgery are invited to participate in a Prepare for Surgery, Heal Faster™ workshop offered at The Siegler Center for Integrative Medicine. For additional information or to register for the workshop, please call (973) 322-7007. There is a fee to participate.

For additional information about the Women's Gynecological Surgery Center, please call (973) 322-6200.