Sunday, September 9, 2018

The Big Cut: Circumcision Information

What Is Circumcision?

Circumcision is the surgical removal of the foreskin from the penis.  In the United States, this procedure is routinely performed on males within the first few days of life for various religious, cultural, and aesthetic reasons. 

At birth, the foreskin is firmly adhered to the glans of the penis, like a fingernail is attached to its nail-bed.  The procedure requires that the foreskin be forcibly broken away from the glans.  After all of the adhesions are broken away, the foreskin is then surgically removed or a circumcision device is placed to cut off blood flow to the foreskin, causing it to become necrotic and to fall off in a few days.  If the procedure is done as an adult, the patient will be placed under general anesthesia and the foreskin will be surgically removed.  There is no need to break away any adhesions since most males have fully retractable foreskins by the time they reach sexual maturity.  

Risks VS Benefits

There are many risks to circumcision, the greatest of which are infection of the circumcision site, accidental damage to the penis, and post-operative hemorrhaging.  

Other side effects of circumcision include adhesions to the surgical site (which can cause irritation, discomfort, and pain) and urethral stenosis (a narrowing of the urethra causing urinary tract health issues and pain).  These types of issues typically require additional surgeries to be corrected.  

While there have been studies showing that circumcised males are at less risk for UTIs, phimosis, and for certain cancers none of these studies have shown significant improved outcomes.  The American Academy Of Pediatrics issued a statement that while the benefits of circumcision may outweigh the risks of the procedure, they do not recommend the routine circumcision of all infants as a preventative measure, while the American College of Obstetricians and Gynecologists published a statement that circumcision is an elective procedure and that parents should weigh the risks and benefits before making an informed decision about circumcising their sons.***
***American Academy Of Pediatrics Task Force On CircumcisionACOG Newborn Male Circumcision FAQ


It is very important that you keep your son's surgical site clean after his circumcision to prevent complications from infection.  The glans will appear to be very red, irritated, and is likely painful to the touch due to the forceable removal of the foreskin from the glans prior to the surgical removal of the tissue.  Any urine or stool will burn the skin of the glans until it has properly healed.  Using warm soapy water, wash the penis gently (do not use wipes or a washcloth).  Pat the area dry.  Apply vaseline liberally  all over the surgical site and penis.  It is important to make sure the skin on the shaft of the penis is not adhering to the surgical site.  Gently (but firmly) break away any forming adhesions at each diaper change.  

Other Considerations

Most insurance companies view routine circumcision as an elective and aesthetic procedure and as such do not cover the cost.  Depending on the area you live in and where you deliver, the cost of the procedure can run anywhere from $200 to $500.  

Intact Information

Intact Myths

Intact penises are dirty.

An intact penis is no dirtier than one that has been circumcised.  Proper cleaning of an intact penis is as simple as gentle SELF retraction in the shower and rinsing the glans with clean water (no soap needed).  After putting the foreskin back over the glans, wash the penis with mild soap and water - just like you would a circumcised one.  

It is harder to care for a newborn if they are intact.

Actually, it's easier.  There is no post operative care and no need to break adhesions to the surgical site routinely during diaper changes.  Remember two simple steps:  DO NOT RETRACT (not even a little) and wipe what you can see from base to tip, just like a finger.  

You need to retract your son to make sure he doesn't have issues as an adult.

This is very important:  IF INTACT, DON'T RETRACT.  Misinformed healthcare providers and outdated information still suggest that you should start retracting during diaper changes or when your child turns three years of age to prevent an issue called phimosis.  Phimosis is when the opening of the foreskin becomes to tight to allow for full or partial self-retraction to occur.  This can be very painful for adult males and can impact sexual pleasure and function.  We have now learned that most cases of phimosis are actually caused by forced retraction from care givers and health care providers.****  At birth, the foreskin is actually fused to the glans of the penis.  As your child grows, these adhesions gently break away on their own, allowing the foreskin to become retractable between the age of 6 through to the late teens.  Forced retraction causes damage and leads to the build up of scar tissue, which greatly reduces the natural stretch of the skin and tissues and can lead to phimosis.  
****It is important to note that even "a little" retraction from a care provider or parent is still considered forced retraction and can cause irritation, pain, and/or damage to the glans or foreskin.

Your son needs to look like his dad.

This is a common concern amongst circumcised men who are considering leaving their sons intact.  They worry that their son will question why their penises look different, or that it may somehow impact their son's body image or self-confidence.  However, these concerns are needless.  It is a simple enough thing to explain to your son that you chose to keep him intact while his father's parents chose to circumcise him and the difference in appearance will not impact potty training, self-confidence, or your son's body image.  

Your son will be bullied for having an intact penis.

This is known as the Locker Room Myth.  A study in 2015** showed that out of the 10% of boys who were teased about their penises in middle or high school (90% of boys were not teased about their penises at all), 83% were teased about penis size while only 17% were teased in relation to being intact or circumcised.  Finally, 97% of the boys polled who were intact reported that they were happy with their penis and would not change it's appearance.  
**Alexander, Cooper, Storm.  2015.  "Teasing In School Locker Rooms Regarding Penile Appearance" Journal Of Urology, 193:3, 983-988 

Intact Care

Intact care is SIMPLE!  Wipe any stool or urine off the exterior of the penis from base to tip, just as you would a finger.  Never retract, not even a little.  

If you are interested in more information about circumcision, why circumcision rates are so high in the United States, information about intact care, and functions of the foreskin I recommend watching the YouTube video Child Circumcision: An Elephant In The Hospital.

Monday, September 3, 2018

Cesarean Sections: You Don't Have To Miss Out On A Natural Birth Experience

New mother smiling after a cesarean section as a nurse lays her newborn across her chest
Whether having a medically elective cesarean section for the first time or having a repeat cesarean for medical reasons or personal choice, many mothers feel that they must give up on having a natural birthing and immediate postpartum period with their newborns.  Due to the clinical nature of a cesarean it may be shocking for you to learn that you don't have to miss out on as much as you may think, even within the surgical setting.  Just like mothers who labor and deliver vaginally, you have choices that you can discuss with your obstetrician and your surgical team to get the birth you want to experience.

Traditional Cesarean Practices

Before we discuss how you can achieve a more natural experience during a cesarean section, also known as a c-section, we should review a traditional cesarean procedure.  Unless you are having a "crash" c-section, meaning a true obstetrical emergency has occurred and they must deliver the baby immediately, the mother will be prepped in the operating room prior to surgery by having an IV and a spinal or epidural block put in place.  During a crash c-section, general anesthesia may be used since that is much faster than placing the spinal.  

While your surgical team is waiting for your spinal to take effect, you'll be further prepped for surgery while lying on the operating table.  A nurse will scrub your belly and may even clip your pubic hair if need be, and a surgical drape will be hung up above your belly to keep the surgical site sterile and keep you and your partner from becoming light-headed from watching the procedure.  Your arms may be strapped to the table to ensure you don't accidentally bump someone holding a scalpel and you will have electrodes placed on your chest so that the anesthesiologist can keep a close eye on your heartrate.  After you are prepped and numbed, your partner, who will be in a surgical gown and mask, will be invited into the surgical suite to join you.  

Your surgeon will ensure you are properly numb before beginning the procedure - keep in mind numb means no sharp pain, you will still be able to feel tugging and pulling.  After checking to make sure you are numb, your surgeon will make a horizontal incision very low across your abdomen and will cut through the skin, fat and other tissues layered over the uterine wall.   After moving the muscles of the abdomen aside, your surgeon will make another horizontal incision into the uterine wall, simultaneously breaking the amniotic sac.  At this point, they will deliver the baby's head by pushing on the top of the uterus while manipulating the incision and the head.  After the head is delivered, the rest of the baby is pulled through.  The umbilical cord is then clamped and cut and the baby is handed to the partner, nurse, or pediatrician.  

After the delivery of the baby, the surgeon will administer a shot of pitocin, which is a synthesized version of the naturally occurring hormone oxytocin, to help deliver the placenta as well as to encourage the uterus to start contracting back down to it's pre-pregnancy size.  Once the placenta has been delivered, the surgeon will begin sewing up the incisions to the uterus, abdominal muscles, tissues and skin.  Prior to suturing, an IUD or other means of birth control may be placed if so requested.  

The baby is typically taken to the warming bed for newborn screenings while the surgeon is suturing and will be handed back over to your partner once the pediatrician and their team are satisfied that your baby is in good health.  After you are completely closed up from the surgery, you will be moved to a recovery room.  If you are alert and not shaking too much, uncontrollable shakes are a common side-effect of the anesthesia used for surgery, you can try to initiate some skin-to-skin time with your new baby or even nurse. 

Gentle Cesarean Practices

Provided that the mom and baby are both in good health and a "crash" c-section is not being preformed, there are simple changes to the routine procedures normally followed in the Operating Room (OR) to make your delivery a more natural experience.  Talking with your provider prior to your scheduled procedure will help ensure that you both are on the same page regarding care during delivery and immediately postpartum and will allow you to have realistic expectations for your birth.  It may also help to talk with your anesthesiologist as well, to see what they are or are not willing to do to help you achieve your ideal birth. 

  • Ask that your IV line and blood pressure cuff be placed on your non-dominant arm/hand.  This way your dominant arm is free to hold and touch your baby.
  • Ask that the electrodes be placed along your back and shoulders vs your chest so that you can facilitate immediate skin-to-skin and/or breastfeeding with your baby.
  • Ask if a clear surgical drape can be used and request that the table be elevated once your baby's head has been delivered so that you may watch your baby being born.  
  • Request that the baby be placed on your belly/chest for immediate skin-to-skin time.
  • Request delayed cord clamping.   
  • Request that the baby be left on your chest while the doctor sutures you.  You can also request that all newborn screenings be done on your chest as well. 
  • Delay newborn bath for a minimum of 12hrs postpartum.  Your amniotic fluid smells and tastes like your colostrum.  This scent encourages your baby to latch and suckle at the breast.  
  • Discuss the possibility of vaginal seeding with your provider.  This procedure simply uses a swab of your vaginal secretions that is then swabbed in your baby's nose and mouth, simulating the exposure they would have had during a vaginal delivery.  Studies indicate that this exposure to the mother's vaginal flora and fauna help establish the newborn's gut health and microbiome.  Vaginal seeding is NOT currently recommended by ACOG as most planned cesarean mothers have not had the routine STD and GBS screenings as mothers who were planning on a vaginal delivery.  This risk is mitigated if you a) take the screenings and have negative results and/or b) understand the risks associated with exposure.  

Other Considerations

Many women decide that since they are having a cesarean delivery that they do not need the traditional labor support of a doula or from their partners.  While it is true that you will not experience labor, you ARE going to experience birth - and as such you deserve just as much physical and emotional support as any other mother out there.  A doula can help you consider and become educated about your delivery options, help support you as you advocate for the delivery experience you want, can provide "in the wings" support during your surgery so if an emergency happens with your baby your partner can stay with your newborn and your doula can come and stay with you in the OR and the PACU, can help you hold and care for the baby in the first few hours postpartum while you recover, can aid in initiating breastfeeding if you are too incapacitated from the drugs to do it yourself, and will provide reassurance as well as physical and emotional support for both you and your partner as you recover.  

If you are planning on breastfeeding, consider making a prenatal appointment with a Lactation Consultant or and IBCLC a few weeks prior to delivery.  They can help set you up for the best chance at breastfeeding success after your surgery.  This also establishes a relationship with them in case you need more support after delivery.  

Set yourself up for your postpartum period in the weeks before you deliver.  Your recovery is going to take a little longer than if you had a vaginal delivery.  Ask friends and family to help stock your freezer with meals that can be thawed and thrown in the oven.  Have your partner help you set up nursing and changing stations by comfortable chairs throughout the house, complete with water bottles and snacks for you.  Consider hiring a postpartum doula for the first few weeks postpartum for extra support - not only will she be a welcome extra set of hands to help with the baby, she will also provide you with much needed physical support as you recover as well as encouragement and reassurance as you settle in to your new role as a mother.  

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