By Becky Yates, CNM

It is not unusual for me to encounter a woman in my exam room who has not had a Pap test in more years than she can remember. That always disturbs me because at least half of invasive cervical cancer is found in women who have never had a Pap test and 10-20% is found in women who have not had a Pap test in 5 years.

            Fortunately the causative agent for cervical cancer is now known- HPV or human papilloma virus. Knowledge of HPV and its affect on cervical health has changed methods of cervical cancer screening and management of abnormal Pap results. When a woman acquires HPV, abnormal changes can begin in the cells on the surface of the cervix and over time progress to cervical cancer if not detected and treated. Over 70% of woman will acquire HPV within 2 years of becoming sexually active because it is the most common sexually transmitted virus. Most women who become infected with HPV will get rid of the virus within a few years through their own immune system; women whose immune system fails to clear the virus are at greater risk to develop cervical cancer.

            There are over 100 types of HPV; some types cause the common warts that can occur anywhere on the skin. Over 40 types affect genital health in men and women; some types cause venereal warts called condyloma. Of the HPV virus types that cause genital disease in women some have been identified as a greater risk for causing cervical changes. Recently it has been noted that some cancers of the mouth and throat are caused by HPV. Babies born to mothers who have HPV may develop growths in their throats caused by the virus.

            Exposure to HPV occurs during sexual activity between partners; the virus may be acquired from skin to skin contact and use of condoms does not prevent transmission of the virus from one person to another. Females who initiate sexual activity in early adolescence increase risk of cervical cancer due to exposure to HPV and the vulnerability of the cervical cells at that point in their development. Multiple sexual partners or sexual activity with a partner who has had multiple partners increases risk. Women who are HIV positive are at increased risk for cervical cancer. Smokers have a higher risk of cervical cancer from HPV as smoking decreases a woman’s ability to clear the virus from her body. A diet low in fruits and vegetables which are high in antioxidants also decreases the body’s ability to clear the virus.

            How often should a woman have a test to screen for cervical cancer? The current guidelines say that women should begin Pap screening at age 21 and be screened every two years between the ages of 21-29 years of age. For women 30 years and older, it is recommended that a test for HPV be performed along with the Pap test; if both are negative the Pap test and HPV need only be performed every 3 years.  Annual exams for evaluation of the female genital tract are still necessary between the every 3 year Pap tests.  The reason that HPV screening is not recommended until 30 and after is because it is so common in sexually active adolescents and young adults and will usually resolve on its own in most women. In women in whom the virus persists, risks for cervical cancer increases.

            Women who have had a hysterectomy (removal of the uterus) are often surprised to hear that they no longer need Pap tests in most cases. Unless the hysterectomy was done for cancer of the cervix, there have been pre-cancerous/ cancerous cells in the vagina or external genital area, or the cervix was left in place at the time of surgery, a Pap smear is not necessary. Annual exams are still necessary to examine the genital area; if a woman still has her ovaries it is important that they be palpated as she still has a risk for ovarian cancer.

            When is it appropriate to stop Pap testing? Guidelines vary with different organizations but most women can stop Pap testing around the age of 70 if they have had regular Pap testing for the prior 10 years and everything was normal. The exception would be the woman who has a history of a prior cervical, vaginal, or genital cancer within the last 20 years.

            For prevention of cervical cancer and condyloma caused by four of the strains of HPV most commonly associated with these problems, young women have the availability of a vaccination called Gardisil to protect them. When a young woman receives the vaccine she has almost 100% protection from disease caused by the HPV strains in the vaccine. She still can develop HPV related cell abnormalities in the genital tract from other strains of HPV; therefore, Pap testing at recommended intervals is still necessary. The vaccine is best given before a woman becomes sexually active and is exposed to HPV; it is recommended that it be given to girls between the ages of 11-12 years of age. If it is not given at that time, it can be given later even if a young woman is already sexually active. Testing for HPV prior to administration of the vaccine is not recommended as it is unlikely that a woman would have been exposed to all four strains of HPV in the vaccine. A vaccine to protect women from cervical cancer is a real breakthrough for disease prevention.

            Since the introduction of Pap testing in 1940’s, death from cervical cancer has been reduced by more than 70%; however, annually in the US, there are over 11,000 new cases of cervical cancer diagnosed and almost 4000 deaths. Don’t be one of those statistics!! Make sure you are getting Pap testing as recommended.

Becky Yates MN, CNM is a certified nurse-midwife and certified menopause practitioner at For Women’s Health in Albemarle, NC.

Vaginal Birth After Cesarean: Making an Informed Decision

By Becky Yates, CNM

Are you one of those women who had a cesarean section in the past? Are you expecting now or planning another pregnancy and wondering what to expect for your next birth?

            On March 8, 2010  an expert panel was convened at the National Institutes of Health for a 3 day meeting to examine concerns about vaginal birth after cesarean (VBAC).  The dramatic rise in cesarean section in this country from 21% in 1996 to 33% by 2007 is due in part to the decreased number of vaginal births after cesarean; for a variety of reasons more women who have had a cesarean section are giving birth by elective repeat cesarean instead of attempting to deliver vaginally. Beginning in 1980, after a prior National Institutes of Health conference recommended trial of labor (TOL) for possible VBAC as a viable option, the number of VBAC’s increased until 1996 then started to decline from 28% of births to 10% of births. In 2008, a joint statement by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists called for the immediate availability of facilities, equipment, obstetric and anesthesia personnel, and the presence of a physician qualified to perform an emergency cesarean section when a patient was laboring to attempt a vaginal birth after a prior cesarean. Since that joint statement, many hospitals and physicians have stopped offering VBAC due to inability to comply with that standard. The purpose of this recent meeting was to investigate factors that influence the utilization of VBAC, short and long-term benefits and harm of VBAC versus elective repeat cesarean, and the factors that affect a woman’s ability make an informed decision about VBAC and choose that option if desired.

            The potential for success of a vaginal delivery after a previous cesarean averages 74% (60-80%) depending upon a variety of medical and obstetrical factors. The most worrisome complication associated with VBAC is a separation or rupture of the scar in the uterus from the previous cesarean surgery; however, the actual risk of such an event is less than 1%. Only women who have had an incision that is low in the uterus and horizontal (low transverse uterine incision) are candidates for a TOL.

            Prior vaginal delivery either before or after the prior cesarean, spontaneous onset of labor, a cervix that has already begun to dilate when labor starts, and the baby’s head in a favorable position in the pelvis increase the likelihood for a successful VBAC. Induction of labor decreases the likelihood of a successful VBAC and increases risk of uterine rupture.

            There has been recent concern over the rate of maternal death in the US. A recent study shows that women in the US have a greater risk of dying in childbirth than women in 40 other countries. The risk is 5 times greater than in Greece, 4 times greater than in Germany, and 3 times greater than in Spain. The two conditions that account for the most maternal deaths are blood clots and hemorrhage; cesarean section increases risks of both of these events.

            How does the risk of maternal mortality compare between trial of labor (TOL) and an elective repeat cesarean section?  Maternal mortality rate for TOL is 3.8 per 100,000 births; for repeat cesarean the rate is 13.4 per 100,000 births. Risk of a childbirth related hysterectomy is higher with repeat cesarean than with a TOL; the risk of hysterectomy is increased if labor is induced for the TOL. The risk of a necessary hysterectomy at the time of cesarean is increased with each cesarean section (420 per 100,000 after one cesarean, 900 per 100,000 after two cesareans, 2410 per 100,000 after 3 cesareans and so on).

            As mentioned the greatest risk with TOL is the possibility of uterine rupture; the overall risk of such an event with TOL is 325 per 100,000. If a uterine rupture occurs during TOL, a cesarean section is performed immediately. For elective repeat cesarean, the overall risk of uterine rupture is 26 per 100,000.  The risk of uterine rupture is increased if the labor is induced instead of starting spontaneously. According to the NIH report, there have been no reported deaths from uterine rupture. Risk of rupture of the uterus is increased if a woman has had two or more cesareans. A hysterectomy at the time of childbirth may be the result of uterine rupture in some women.

            The baby’s well-being during the birth process is of equal concern to that of the mother. The risk of fetal death from rupture of the uterus during TOL is 20 per 100,000 births. The risk of perinatal mortality (death between 20 weeks of pregnancy and the first 28 days of life) between TOL and elective repeat cesarean is comparable to that of first time laboring women. Infants born by cesarean section have higher rates of respiratory problems in the early days of life. Cesarean section interferes with initial maternal infant bonding as there is a period of separation between mother and baby in the first few hours after the surgery. This prevents breastfeeding in the first few hours of the infant’s life which may have a bearing on breastfeeding success as it is known that breastfeeding in the first hour of life helps increase success with breastfeeding.

            In deciding between a TOL for a possible VBAC versus an elective repeat cesarean, a woman needs to think about her future childbearing plans.  The location and attachment of the placenta in a future pregnancy can be affected by a cesarean section; the placenta may attach in an unfavorable location over the cervix (placenta previa) which can cause bleeding problems during the pregnancy and necessitate another cesarean section. Another placental complication is abnormal growth of the placenta such that the placenta grows into or through the uterine muscle. This can result in a necessary hysterectomy at the time of cesarean. Each cesarean section increases the risk of a placental problem in a future pregnancy.

            Since cesarean section is major abdominal surgery there can be long term problems due to the surgery. Scar tissue formation inside the abdomen called adhesions can cause chronic pain, increased risk for ectopic pregnancy (pregnancy outside the uterus), and problems getting pregnant in the future.

            Conclusions of the expert panel stated that “TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. One of our major goals is to support pregnant women with a prior transverse incision to make informed decisions between TOL and an elective repeat cesarean.” The panel further states that women should be provided with information about benefits and risks of TOL and elective cesarean section in a manner that they can understand and that the final decision for planned route of delivery should be a shared decision between the woman and her provider and “whenever possible, the woman’s preference should be honored.” The panel also suggested that the American College of Obstetricians and Gynecologists and American Society of Anesthesiologists re-examine their policy for an immediately available complete surgical team during TOL and “reassess the requirement relative to other obstetrical complications of comparable risk” for which such a requirement is not mandatory. As you can see, a woman who has had one prior low transverse cesarean and goes into labor on her own has a much lower risk than a woman who has had several prior cesarean sections or a woman whose labor is induced following a prior cesarean; in other words, every woman who has had a prior cesarean section and attempts a TOL does not have the same risk.  The statistics related to TOL versus elective cesarean section are hard to interpret. In general, it is safer for a woman who has only had one low transverse cesarean, whose labor starts on its own, and has no other risk factors to attempt a TOL for possible VBAC rather than choose an elective repeat cesarean for her second birth.

            So what should a woman who finds herself in this situation do to prepare for her next birth? Investigate the information about TOL and elective repeat cesarean. Talk with your provider to find out his or her opinions on birth options for women who have had a prior cesarean. Women who want the option of TOL have different reasons for their choice; some want the experience of a vaginal birth as they see this as the “natural” way a woman should give birth. Other women want their partner to have the opportunity to be actively involved in the labor and birth process while some want to experience the empowering feeling that labor and a vaginal birth can give a woman. Immediate maternal-infant bonding and an early start with breastfeeding are important to many women. The easier recovery after a vaginal birth versus another cesarean section is an important reason for a woman to choose a TOL. The birth of a child is one of the most significant and life-changing events in a woman’s life and deserves much thought, preparation, and planning to assure that it is not only a safe but satisfying experience in her life.

The 3 Year Birth Control Method

By Becky Yates, CNM

Since the first birth control pill was marketed in 1960, researchers have continued to look for other and perhaps better methods of contraception. The “new kid” on the block is Implanon which was introduced in the United States 2 years ago although it has been used in other countries since 1998.

            Implanon is a 1 ½ inch thin plastic rod about the size of a matchstick that is inserted just under the skin in the inside of the upper arm just above the elbow.  The procedure is performed in the healthcare provider’s office and only takes a few minutes. Contraceptive effect lasts for 3 years at which time it is removed and another inserted in the woman desires. Implanon works by slowing releasing a progestin hormone into the body that prevents the ovary from producing an egg and sperm from passing through the cervix to reach the egg. It is an extremely effective method; only 1 out of a 100 women will get pregnant each year when on Implanon.

            Implanon is a safe, simple, and convenient method because: there is no need to take a medicine every day; women who cannot use estrogen containing methods like some birth control pills; the patch, and the vaginal ring can use it; it lasts for 3 years; the ability to become pregnant returns as soon as it is removed; and one does not have to do anything at the time of sexual activity in order to prevent pregnancy.

            Every medicine, even non-prescription medications, can have side effects. With Implanon, the most common side effect is irregular bleeding which also occurs with other hormonal methods like the pill, patch, ring, and IUD (intrauterine device). The bleeding is most common in the first year; in most women, the periods become less and lighter and 1 out of 3 women stop periods completely.

            When Implanon is inserted, the health care provider numbs the area of insertion with local anesthesia prior to inserting the device. The insertion site will be a little sore for several days. When the device is removed, the provider will numb the arm again. After making a very small incision next to the end of the Implanon rod, the tip of the rod is grasped with an instrument and removed. No stitches are required because such a small incision is needed to remove the device. A new Implanon can be inserted at the same time if desired. There will be discomfort in the removal site for several days.

            The initial expense of Implanon is high but one has to compare it against the monthly costs of other methods like birth control pills over a 3 year period. Medicaid and some health insurance plans will cover the device.

            For information about Implanon, you may call For Women’s Health at 704-982-3400.   Becky Yates CNM, MN

¡Enhorabuena, usted está embarazada!! Ahora es hora de decidir  qué tipo de proveedor de asistencia Medica usted quiere para cuidar a  usted y a su bebé durante su embarazo y el alumbramiento. Las mujeres pueden elegir entre los obstétricos y las parteras en comunidades donde están disponibles. En muchas partes de Europa, las parteras entregan más  de 70% de nacimientos vaginales normales. En los Estados Unidos, las parteras entregan por lo menos el 10% de nacimientos vaginales normales. Mucha gente todavía no entiende cómo estan  entrenanadas las parteras y qué servicios proporcionan.

¿Qué clase de educación y formación tiene una partera? Las parteras de hoy tienen una educacion variada.El subtítulo que una partera utiliza indica el nivel de educación y el entrenamiento. La mayoría de las parteras americanas son las enfermeras-parteras certificadas (CNM) que ;

v Se han graduado de un programavHan terminado un programa del oficio de enfermera  del cuidado de-obstetricia credenciado por la universidad Americana, Han aprobado el examen nacional de la universidad americana devenfermeras-Parterasv obtengan su licencia en cada estado. Enfermera-Parteras son certificadas para tener una  relación profesional con los medicos, para consultar sobre pacientes y remisión o transferencia al médico si es indicado por la condición del paciente. Cerca del 96% de nacimientos atendidos por las enfermeras-parteras ocurren en hospitales. Una partera certificada (cm) no es enfermera registrada sino ha resuelto de otra manera las mismas calificaciones requeridas por la universidad americana de las Enfermeras-Parteras para la educación y la certificación. Puesto que este tipo de credenciales de la partera comenzó solamente en 1996 cm todavía no se autoriza en todos los estados.

El  certificado de la partera profesional (CPM) es certificado por el registro norteamericano de parteras, después de pasar exámenes escritos y evaluaciones,con abilidad en sus manos. Atienden generalmente en su  casa y los nacimientos del centro del nacimiento. Su personalidad jurídica depende de regulaciones del estado. Pueden no tener una relación formal con un médico para la consulta y la revision. Una partera que aprendio por medio de cursos o practicando  no tiene un grado de universidad o una certificación. Las parteras que aprendieron por medio de la practica pudieron haber entrenado con aprendizaje, talleres, la instrucción formal, o una combinación de éstos. No todos los estados  requieren trabajar conjuntamente con doctores, y practican generalmente en hogares de los centros del nacimiento  no-hospital. En todos los estados no se regulan ni se permiten a las parteras que no tienen creditos de la Universidad. Las únicas parteras que se autorizan en Carolina del Norte son Enfermeras-Parteras Certificadas como Rebecca (Becky) Yates y Rebecca Huneycutt. Ambas tienen una licenciatura en el oficio de enfermera y un amor en el cuidado de obstetricia. La universidad americana de las  Enfermeras-Parteras los certifican y se requieren obtener la formación permanente en curso para mantener su certificación como Enfermera-partera. Su oficina en Albemarle está para la salud de las mujeres situada en el teléfono 704-982-3400 de St. de 305 Yadkin. Becky y Rebecca  proporcionan cuidado a las mujeres embarazadas para el cuidado prenatal y el nacimiento. Realizan los ultrasonidos y la otra prueba para evaluar el bienestar del bebé. También proporcionan cuidado ginecológico a las mujeres no embarazadas tales como exámenes anuales, las pruebas de Papanicolado, problemas generales y menopausia menstruales, evaluación y prescripción de los métodos del control de la natalidad, y el tratamiento de infecciones femeninas. Becky es también clínica certificada de la menopausia y tiene maestría especial en osteoporosis.