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Heather Zeidler, CNM, MSN PDF  | Print |  E-mail


Heather Zeidler is excited to bring her ten years of experience in obstetrics to Triangle OBGYN.  As a top graduate from East Carolina University's Masters in Nurse Midwifery program, Heather provides full-scope midwifery care to low and moderately high-risk women.  As a Certified Nurse Midwife, Heather enjoys working in Triangle OBGYN's positive, collaborative and open-minded clinic environment.  Originally from Iowa, Heather earned her Bachelors of Science in Nursing at the University of Wisconsin and has practiced at hospitals in Iowa and Illinois before coming east to North Carolina.  Her professional interests include: non-pharmacological therapies, deep-relaxation labor techniques, postpartum depression, and teen pregnancy.

Heather has two children and enjoys North Carolina's coast, the farmer's market and the local parks and recreation.

 
New VBAC Guidelines PDF  | Print |  E-mail
The cesarean delivery rate in the United States has increased from 4.5% in 1965 to 32.3% in 2008 (Guise JM, 2010). Meanwhile, the rate of Vaginal Birth after Cesarean (VBAC) has decreased from its peak of 28.3% of all women with a prior cesarean delivery in 1996 to the most recent rate of just 8% in 2006 (National Institutes of Health, 2010). The reasons for this decrease are numerous and complex involving fear of potential dangers of VBAC, lack of access to facilities that offer VBAC and fear of litigation among providers.  In March 2010 the National Institutes of Health (NIH) held a consensus conference to examine the safety of VBAC and repeat cesarean for women with prior cesarean deliveries.  Following the NIH consensus statement, the American College of Obstetricians and Gynecologists (ACOG) released a new practice bulletin outlining their guidelines regarding the mode of delivery for women with a prior cesarean delivery (American College of Obstetricians and Gynecologists, 2010).
New Recommendations regarding VBAC
The best current evidence available supports that women with one prior cesarean delivery with a low-transverse uterine incision (the most common kind performed) are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.  In addition, there is good evidence to support that epidural anesthesia is a safe option for women attempting a VBAC (American College of Obstetricians and Gynecologists, 2010).

Based on limited or inconsistent evidence, ACOG supports offering the following women a VBAC: those with two prior low transverse uterine incisions, those with a current twin pregnancy who are otherwise good candidates for vaginal delivery, and those requiring an induction of labor for maternal or fetal indications (as long as prostaglandin preparations are not utilized).  ACOG supports offering VBAC to women with an unknown uterine scar unless there is a high suspicion of previous classical (up and down) incision on the uterus. Women with a prior cesarean delivery and a current pregnancy complicated by a breech presentation can be offered external cephalic versions (a procedure of trying to turn a breech baby).  
Who should offer VBACs
ACOG also outlines that VBACs should be attempted only in facilities capable of emergency deliveries. Surveys of hospital administrators found that 30% of hospitals do not offer VBACs due to the lack of emergency delivery services (National Institutes of Health, 2010).  Providing care for women who desire a VBAC is within the scope of care for Certified Nurse Midwives who practice in facilities that have the ability to perform an emergency delivery (American College of Nurse-Midwives, 2000). The Certified Nurse Midwives at UNC work closely with our obstetricians and anesthesiologists and have a VBAC success great of greater than 80%.


Based on the best available data, the newest guidelines from ACOG increase the number of women that should be offered a VBAC. The benefits and risks of VBAC should be discussed with each woman based on her individual history and desires. Because the greatest risks of VBAC occur when they are not successful and a repeat cesarean delivery is required following labor, attempts have been made to predict a woman’s likelihood of success at VBAC. Caution should be used when trying to predict the likelihood of individual success at VBAC based on programs that calculate likelihood of success:   “VBAC calculators” have only been studied at the population, not the individual, level (National Institutes of Health, 2010).

The decision about whether to attempt a VBAC or schedule a repeat cesarean is complex and multi-faceted. It can only be made by the woman and her family with appropriate, thorough counseling by her health care provider. More research is needed into the risks and benefits of VBAC and repeat cesarean and what factors influence these harms and benefits.
 
Triangle OBGYNs Perform Surgery on Gorilla PDF  | Print |  E-mail

Triangle OBGYN Medical Team Performs Follow-up Cancer Surgery on Gorilla08_donna_2

September 10, 2008; Cary, NC - A team of medical
professionals from Triangle OBGYN and Duke University
Medical Center successfully performed a difficult and
intricate surgery August 27, 2008 on "Donna,"
a 39 year old, female Western Lowland Gorilla who
lives at the North Carolina Zoo in Asheboro, NC.

Senior Veterinarian Ryan De Voe, DVM at the
North Carolina Zoological Park contacted
Sameh Toma, M.D. and Gerald Mulvaney, M.D.
at Triangle OBGYN to assist his staff in doing a
total hysterectomy on Donna. This procedure was
a follow-up to surgery that Drs. Toma and Mulvaney
performed in November 2007 which resulted in a
diagnosis of endometrial cancer. Because of the
nature of Donna's cancer, the team from Triangle
OBGYN brought in Dr. Fidel Vilea, a
Gynecologist/Oncologist, from Duke University
Medical Center to consult on the surgery and
insure that all malignancies would be removed.

As of today, the 400 pound gorilla is nearly back to normal. "Donna is doing great. She recovered from anesthesia very quickly
and began taking oral fluids and some fruit the morning after surgery," says Ryan DeVoe, Senior Veterinarian at the NC Zoological
Park. "When I went to visit her I honestly couldn't tell anything had happened to her. She is one tough monkey."

Zoos around the world utilize the services of (human) medical doctors when dealing with great ape cases. The NC Zoo reached
out to Drs. Toma and Mulvaney at Triangle OBGYN for help since gorilla reproductive anatomy, physiology and pathology is
so similar to that of humans.

"For years, we have benefited from animal experimentation. Now we have had the opportunity to give back. Our vast experience
and deep fund of knowledge in human medicine has allowed us to provide assistance to our veterinary colleagues in difficult
surgical cases in which they are less experienced due to the rarity of this type of procedure in animals," says Gerald Mulvaney, MD
at Triangle OBGYN. "The anatomy of the female gorilla is close enough to the human anatomy, that it allows us to use our skills
that have been refined over years because of large volumes of human surgeries similar to this one. This has provided a cooperative
relationship between human and veterinary medicine that we encourage and hope to continue in the future."

"The zoo is buzzing with news of Donna's successful procedure and the great medical team that was here to pull it off. You guys
have no idea how thankful we are for your help," remarked Dr. DeVoe from the North Carolina Zoological Park.

News & Observer Article
http://www.newsobserver.com/news/story/1216168.html#MI_Comments_Link

NBC 17's MyNC.com Video:
http://cary.mync.com/site/cary/news/story/8688/loc

WFMY-TV - Greensboro, NC
http://www.digtriad.com/news/features/article.aspx?storyid=110641&catid=216

Greensboro News-Record
http://blog.news-record.com/staff/health/

 
Baby Gap Yields Unique Challenges and Rewards PDF  | Print |  E-mail

Courtesy of Carolina Parent Magazine
July 2011
Featuring Triangle OBGYN's Dr. Spyro Vulgaropulos

It isn't unusual to see moms in their late 30s and early 40s sporting a baby bump while cheering on an older child's athletic endeavors. Families raising children with large age gaps between siblings often have one foot in teenage tirades while taking baby steps with the other.

Kim Buccino, of Clemmons, N.C., is a busy mom. She and her husband, Michael, are raising a 17-year-old daughter and 13-year-old son. Buccino's car is the family taxi, shuttling daughter Tai and son Zavier to sports practice, school and other activities. She is also in school to earn her second degree. Michael is a police officer who works a hectic schedule, often leaving Kim to juggle family duties by herself. All of this, and the 40-year-old mom has a 2-year-old son, Giovanni.

Lori Eskridge also has three children: Andy Szoke, 17, Holly Szoke, 15, and nearly 4-year-old Sara Eskridge. The 43-year-old Charlotte mom says she and her husband, Lee, are looking at playground equipment one day and checking out college campuses the next.

With her oldest and youngest 14 years apart, Eskridge says she's had a few surreal moments. "When she (Sara) goes to kindergarten in August 2012, Andy will be going to college. It's so strange to be checking out an elementary school when it's been well over a decade since I've been through this."

Playing the numbers

The "whys" behind families with large age gaps between children are as numerous as the moms and dads heading them up. Careers, divorce and remarriage, secondary infertility and adoption are just a few of the reasons families choose to "start all over again" long after cribs and baby clothes have been put away the first time.

Both Buccino's and Eskridge's teenage children are from previous marriages. The women's interest in having another baby was renewed after marrying their current husbands.

Women who get pregnant later in life often face challenges they didn't experience the first time around. Depending on the mother's age and health, there is an increased chance of losing the baby during pregnancy or having a child with special needs. Women in their later reproductive years also have an increased chance of experiencing high blood pressure and gestational diabetes during pregnancy, says Dr. Spyro Vulgaropulos of Triangle OB-GYN in Raleigh. Having a baby later in life often becomes a numbers game. "There are very specific numbers attached to ages," he says.

But the mom's physical shape has a lot to do with how she feels during and after pregnancy. "Some 40-year-old women are in better shape than 25-year-old women," Vulgaropulos says. He advises that couples looking to add to their family later in life make a preconception visit to their doctor, especially if the mother is on any medication.

Buccino says she noticed a difference after delivering her third child more than 10 years after her last birth. "Recovery from the delivery was a lot slower than it had been with the other two," she says.

And if secondary infertility — when a couple who successfully had children in the past but are unable to achieve pregnancy after trying for a year — is preventing a couple from conceiving, doctors will often be quicker to start diagnosing and treating the problem, Vulgaropulos says.

Louise Bannon of Holly Springs struggled to conceive again after she married her husband, Greg. Her son Darius, from a previous relationship, was in middle school when the family decided to adopt.

"While we went over the infertility tests and option rollercoaster for some time, we finally asked ourselves, 'What matters more: biology or providing love to a child, any child, regardless of biology?'" Louise Bannon says. Darius, 13, welcomed home his little brother, Bryce, last September.

Preparing older children

For the Buccinos, the birth of Giovanni was a family affair. Daughter Tai was in the delivery room with her mom, and son Zavier came in soon after his little brother entered the world.

Siblings who are close in age often can't remember life before their new brother or sister. This is obviously not the case as the age gap widens. Carefully preparing children for the new addition makes a big difference, says Dr. Tracey Marks, a Duke-educated psychiatrist, psychotherapist and author of Master Your Sleep: Proven Methods Simplified.

"Have a talk with your child ahead of time to see how he or she feels about the new sibling," says Marks, who practices in Atlanta. "It's important to get a feel for what your older child expects, hopes for or fears around the new baby."

The Bannons included Darius in just about every aspect of the adoption process. "As old as he is, I didn't want this to just happen to Darius," Bannon says. "I wanted him to be part of this process." The family attended all the adoption classes together and fulfilled the process requirement as a threesome.

Bannon says she is proud of the way Darius has adjusted to the arrival of his brother Bryce, especially after being an only child for more than 12 years, although there have been challenges.

"He got accustomed to having things his way — having robust holiday celebrations with lots of gifts and being showered with all the attention all the

time," Bannon says. "Now, this is definitely not the case and it has taken him time to adjust."

The Bannons are very open with one other. Darius has the freedom to let his parents know when he needs time either by himself or with his parents. The Bannons continue to be involved and support Darius, and sensitive to where he is in his development.

Shortly after Bryce came home, the family took him to his older brother's football game. "It was important for my husband and me to both go to Darius' football games and show him — not just tell him — that he still is important to us," Bannon says.

Buccino says her teenage children have adjusted well and are very involved with Giovanni. "They don't mind helping out with him," Buccino says, adding that Tai is the nurturer and Zavier loves to play and read to his baby brother.

Balancing children's needs

Both Buccino parents try to carve out time for everyone. "We've had to make sure we've extended more patience, more hands-on time and more one-on-one time," Buccino says. This is especially necessary for Zavier, who went from being the baby of the family to the middle child. With no extended family in town, everyone pulls together to make it work.

Parents should also consider how much they want, or don't want, to ask their teen(s) to watch the younger child. Having a "baby-gap" baby doesn't necessarily mean you also have a built-in babysitter.

Giving special attention to older siblings and remembering that teens should be growing more independent goes a long way toward creating family harmony, Marks says. "Make sure you don't put so much emphasis on the new baby that you neglect time with the older child," she says. "He or she still needs your time and attention."

Enjoying unexpected gifts

In parenthood, juggling is a top job requirement, and a wider age gap between children poses its own set of hurdles. "It has been more challenging than I expected," says Buccino, who says mornings in her house can get a little hectic.


Being there for both boys, as well as those important — and very different — life stages can be tough, she adds. On one side is the critical early-childhood learning and developmental stage, with teething and mobility milestones. On the other is "an incredibly active and athletic hormonal, moody and temperamental teenager, who sometimes pushes the limits," Buccino says.

But parenting the second time around usually brings with it calmness and a perspective first-time parents just don't have. And for those who find themselves back into bottles and onesies after a long hiatus, there can also be wonderful and unexpected gifts for the entire family.

"There were quite a few things I missed the first time around because I was making sure everything was 'right,'" Buccino says, adding that the birth of Giovanni sparked a renewed interest and excitement for the entire family. They all were proud of Giovanni's milestones, and holidays began to take on a more important meaning with a baby in the house.

"All that holiday fun and excitement you share with the little ones wasn't there anymore [with teens]," she says. "[The baby] brought such a joy to the house, that the older kids got caught up in the activities."

Bannon also enjoys being mom to a toddler once again, and she is holding on to every moment. "Looking back, I feel like [the first baby] was a whirlwind of moments and exhaustion," she says. "With Bryce, we've taken our time a bit more to remember, document moments and take photos."

Courtney McLaughlin is a Charlotte freelance writer and editor, and the mother of 5-year-old Isabella.

 
Urinary Incontinence PDF  | Print |  E-mail

Urinary Incontinence

Urinary incontinence (UI), or bladder leakage, is the loss of urine control, or the inability to hold your urine until you can reach a restroom. Incontinence can range from the discomfort of slight losses of urine to severe, frequent wetting. Millions of people experience incontinence and it can have a profound impact on their quality of life.  Incontinence is not an inevitable result of aging, but is particularly common in older people. It is often caused by specific changes in body function that can result from diseases, use of medications, and/or the onset of an illness. Sometimes it is the first and only symptom of a urinary tract infection. Women are most likely to develop incontinence either during pregnancy and childbirth, or after the hormonal changes of menopause because of weakened pelvic muscles.

Types of Female Urinary Incontinence

Urge incontinence, the inability to hold urine long enough to reach a restroom, is associated with a sudden, intense desire to urinate that cannot be resisted. It can be caused by neurological conditions such as stroke, dementia, Parkinson's disease, and multiple sclerosis, but it can also develop in patients without neurological diseases. Problems with bowel movements can also cause urge incontinence.

Stress incontinence involves the leakage of urine during exercise, coughing, sneezing, laughing, lifting heavy objects, or other body movements that put pressure on the bladder. It is one of the most common types of incontinence, particularly in women. In men, surgery on the prostate can cause stress incontinence.

Overflow incontinence is leakage that occurs when the quantity of urine produced exceeds the bladder's capacity to hold it. This type of incontinence generally develops when a person is unable to empty completely on a regular basis. Patients often complain of persistent dribbling, or urinating small amounts but not feeling empty.

Mixed incontinence usually refers to both stress and urge incontinence, but can refer to any combination of types of incontinence.

Functional incontinence is a medical condition that prevents a person from making it to the bathroom in time to urinate, resulting in incontinence. Common examples include physical impairments such as arthritis, which make it difficult to move quickly enough to reach a restroom in time, or mental impairments such as dementia, which prevent a person from realizing when they need to urinate.

Total incontinence is persistent, continuous incontinence that can occur as a result of anatomic abnormalities or injuries that develop during surgery.

Evaluation for Female Urinary Incontinence

Incontinence is a common condition but one that should not be ignored. Women suffering from incontinence should see a doctor because there are a number of treatment interventions that can dramatically improve their urinary control. Doctors often ask patients to fill out a voiding diary, or a frequency/volume chart, to establish urinary patterns. Our physicians may perform a urinalysis to rule out an infection or other problems.  They may perform a bladder ultrasound or scan after voiding to ensure that the patient is emptying his/her bladder completely. They may perform a cough stress test to investigate whether stress incontinence exists.

More sophisticated testing includes multichannel urodynamic studies, which include complex cystometrograms (CMG), leak point pressures, urethral-pressure profile (UPP), and uroflow, and pressure-flow testing using the Lumax Cystometry System.  This highly sophisticated bladder function evaluation allows the doctor to determine the bladder capacity, whether the bladder is spasming while it is filling, whether incontinence is present, and if so, what type, and whether bladder pressures while it is filling are appropriate.

Incontinence Treatments

Treatment depends on what's causing the problem and what type of incontinence you have. If your urinary incontinence is caused by a medical problem, the incontinence will go away when the problem is treated. Kegel exercises and bladder training help some types of incontinence through strengthening the pelvic muscles. Medicine and surgery are other options.

In addition to effective drug therapy, Carolina Women’s Aesthetic Surgery Center is equipped with a state of the art operating room where IV sedation may be given for certain procedures. We utilize the services of Certified Registered Nurse Anesthetists who are experienced in both office and hospital environments. The procedure room is equipped with modern monitoring and resuscitation equipment.

Behavior Therapy

Behavior therapies for urge incontinence include bladder training and pelvic floor muscle (Kegel) exercises. Bladder training (i.e., learning to hold urine longer and longer between voids) can be more effective than medications, such as oxybutynin, and improves incontinence in more than 50 percent of patients.

Cystoscopy

This is a procedure which involves inserting a small scope into the bladder for evaluation of blood in the urine, and for evaluation of the inside of the bladder. A flexible fiberoptic scope is used for cystoscopies. This allows us to perform cystoscopies with the patient lying back without being in stirrups. It is also much more comfortable than using the older, rigid cystoscopes.

Urodynamics

In females, urodynamic evaluation is performed to check for bladder sensation, stability, and competence of the internal sphincter. These studies help decide if a surgical bladder suspension is required to treat urinary incontinence or whether medication should be used.

Monarc™ Subfascial Hammock

The Monarc Subfascial Hammock treats female stress urinary incontinence by placing a narrow strip of mesh in your body to support the urethra. The Monarc uses what is called a transobturator approach to place the supportive mesh. The transobturator approach avoids the retropubic space, the area of loose connective tissue between the bladder, pubic bone and abdominal wall. With this approach, narrow mesh carriers are passed through an area near the groin at the obturator of the pubic bone. The mesh is then attached and pulled into place under the urethra.

Once placed, the hammock cradles your urethra and gives it a point of support.

Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities within a few days.

Benefits

The Monarc offers several benefits:

•Patients generally recover quickly and experience immediate continence.

•It is minimally invasive and suitable for a wide variety of patients.

•Incisions in the groin area are small.

•Can be used in patients who have retropubic scarring resulting from prior pelvic surgery.

•The hammock can be loosened or tightened during and immediately after the procedure.

 

The SPARC Sling System treats female stress urinary incontinence by placing a narrow strip of material—called a "sling"—in your body to support the urethra. The SPARC system uses a suprapubic approach in which narrow sling carriers are passed from above the pubic bone to the vagina. The sling mesh then is attached to the carriers and pulled into place.

A self-fixating polypropylene sling cradles your urethra and gives it support during normal daily activities.

Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities within a few days.

Benefits

The SPARC provides many benefits:

•It is an outpatient treatment suitable for a wide variety of patients and can be performed using a minimally invasive approach.

•The sling can be loosened or tightened during and immediately after the procedure.

•Incisions in the abdomen and vagina are small.

•Patients generally recover quickly and experience immediate continence.
 
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