Interview

 Interview with P. Carson, RN

Below is the transcript of Interview with P. Carson, Boise School District RN, Former OBGYN RN and NICU RN.  I asked some questions but she offered so much more information with each question that the conversation just developed as we went along and I didn’t follow my script.

Q- What do you feel is the main reason for maternal and infant mortality in Idaho?

A- There is a lack of education among teenagers in Idaho and across the country. Many do not seek health care due to inability to pay or because they are scared to tell anyone about the pregnancy. Many teens are in denial about their pregnancy and try to hide it only seeking care later in the third trimester.  Teen pregnancies are higher risk and therefore early intervention produces the best outcomes.

Q- What has been your experience with educating teens?

A- Working in both a physician setting providing women’s health care and in the high school, I have been responsible for teaching sex education and providing birth control and abstinence counseling. Many parents are also in denial about children having sex. Many teens become sexually active at the age of 12 or 13 and I’ve seen girls pregnant at that age. It is important to realize that sex is occurring and try to develop methods to educate teens to practice safe sex. In Idaho, females can seek contraception and family planning advice without the consent of a parent.  When parents find out they want to place blame rather than address the issue that their son or daughter is having sex.

Q. Do you think only teens are at risk for complications and maternal mortality?

A. No. All women within childbearing age are at risk of complications. Any woman who is sexually active can become pregnant if she is not practicing safe birth control.  Women who are over 35 are considered advanced maternal age and the risk of complications and birth defects increases. Early pregnancy or teen pregnancy also increases the risk of complications.

Q. What have you witnessed as far as complications in pregnancy?

A. There are many complications during pregnancy, delivery, and the postpartum period. Many patients have a disease or illness that is aggravated during their pregnancy. Others develop conditions during pregnancy that they will recover from after delivery such as gestational diabetes or pregnancy induced hypertension. I have seen many complications and through my work in the Neonatal Intensive Care Unit I have seen many babies with a range or birth defects and prematurity issues. I have also experienced the loss of life which is very traumatic for the family as well as the staff. The hospitals provide counseling for all deliveries both positive and negative outcomes. Many women experience post partum depression after delivery and can even cause harm to themselves or their newborn.

Q-What do you think should be done to decrease infant mortality and morbidity?

A-I think that providing early prenatal care is the best way to prevent problems and making it affordable and accessible to everyone.  With proper diagnosis and treatment many complications can be prevented. Many diseases and illness can be treated during pregnancy and increase birth outcomes. There are new techniques available and operations can even be performed in utero. Most problems can be detected with blood tests and ultrasound or genetic counseling. At least if parents know prior to delivery, they are better prepared to handle the situation. Knowing that your child will be born with a birth defect gives a parent the opportunity to research and make informed decisions regarding health care.

Interview with B Schowalter, MD and Lelani,  RN

Below is the transcript of discussions with Dr Scholwater , an Orthopedic Surgeon, and his nurse Lelani  M. regarding congenital deformities of the foot and ankle such as clubfoot.  I asked some questions and gathered information regarding my topic over several visits, including diagnosis, treatment and prognosis. Dr Scholwater also presented me with a pamphlet that directing me to MayoClinic.com which provided me with a great deal of information.

Q- Do you see a lot of clubfoot cases?

A- Clubfoot is seen in about 1 in every 1,000 babies. I have so many clubfoot patients in the Treasure Valley I have a weekly 2 hour clinic.

Dr Scholwater also presented me with a pamphlet that directing me to MayoClinic.com which provided me with a great deal of information.

Q- What causes clubfoot?

A - The cause of clubfoot is unknown (idiopathic). But scientists do know that clubfoot is can be caused by the position of the baby in the womb (fetus). In some cases, clubfoot can be associated with other abnormalities of the skeleton that are present at birth (congenital), such as spina bifida, a serious birth defect that occurs when the tissue surrounding the developing spinal cord of a fetus doesn't close properly.

Q- Will it affect his ability to walk?

A- Clubfoot typically doesn't cause any problems until your child starts to stand and walk. If the clubfoot is treated, your child will most likely walk fairly normally. He or she may have some difficulty with:

• Mobility. Your child's mobility may be slightly limited.
• Shoe size. The affected foot may be up to 1 1/2 shoe sizes smaller than the unaffected foot.

However, if not treated, clubfoot causes more-serious problems. These can include:

• Arthritis. Your child is likely to develop arthritis.
• Poor self-image. The unusual appearance of the foot may make your child's body image a concern during the teen years.
• Inability to walk normally. The twist of the ankle may not allow your child to walk on the soles of the feet. To compensate, he or she may walk on the balls of the feet, the outside of the feet or even the top of the feet in severe cases.
• Muscle development problems. These walking adjustments may prevent natural growth of the calf muscles, cause large sores or calluses on the feet, and result in an awkward gait.

Q- What can we do to treat it?

A- Because your newborn's bones and joints are extremely flexible, treatment for clubfoot usually begins in the first week or two after birth. The goal of treatment is to improve the way your child's foot looks and works before he or she learns to walk, in hopes of preventing long-term disabilities. Treatment options include:

Stretching and casting (Ponseti method)
This is the most common treatment for clubfoot. The doctor will do the following:

• Move the baby's foot into a correct position and then place it in a cast to hold it in that position
• Reposition and recast the baby's foot once or twice a week for several months
• Perform a minor surgical procedure to lengthen the Achilles tendon (percutaneous Achilles tenotomy) toward the end of this process

After the shape of the foot is realigned, parents will need to maintain it by doing one or more of the following:

• Doing stretching exercises with your baby
• Putting your child in special shoes and braces
• Making sure your child wears the shoes and braces as long as needed — usually full time for three months, and then at night for up to three years

For this method to be successful, you'll need to apply the braces according to your doctor's directions so that the foot doesn't return to its original position. The main reason that this procedure sometimes doesn't work is because the braces are not used constantly.

Stretching and taping (French method)
This approach is also called the functional method or the physiotherapy method. Working with a physical therapist, parents:

• Move the foot daily and hold it in position with adhesive tape
• Use a machine to continuously move the baby's foot while he or she sleeps
• After two months, cut treatment back to three times a week until the baby is 6 months old
• Once the shape is corrected, continue to perform daily exercises and use night splints until the baby is of walking age

This method requires a much greater time commitment than does the Ponseti method. Some caregivers combine the French method and the Ponseti method.

Surgery
In some cases, when clubfoot is severe or doesn't respond to nonsurgical treatments, babies may need more invasive surgery. An orthopedic surgeon can lengthen tendons to help ease the foot into a better position. After surgery, your child will be in a cast for up to two months, and then need to wear a brace for a year or so to prevent the clubfoot from coming back.

Even with treatment, clubfoot may not be totally correctable. But in most cases babies who are treated early grow up to wear ordinary shoes and lead normal, active lives.

For Troy’s treatment we will first use the casting process to turn the delicate bones to a more correct position at that time we will assess the progress and determine if surgery will be necessary or if a brace will work.

Q- How long will he wear the cast?

A- We will cast the foot and position it in a certain way to correct the club positioning. We change it every week for 4-6 weeks and then see where to go.

Q- How long will the brace be necessary?

A- Troy will wear his brace 23 hours a day, an hour off for bathing, for the first 3 month and from there he will wear it only at night until he is 4 years old.