- Obstetrics and Gynecology
- Breastfeeding Medicine
- Patient Safety Quality Improvement
Clinical Professor, Obstetrics & Gynecology - Maternal Fetal Medicine
Residency: Kaiser Permanente Northern California GME Programs (1998) CA
Internship: Kaiser Permanente Northern California GME Programs (1995) CA
Medical Education: Loyola University Stritch School of Medicine (1994) IL
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2000)
Independent Studies (5)
- Directed Reading in Obstetrics and Gynecology
OBGYN 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Obstetrics and Gynecology
OBGYN 280 (Aut, Win, Spr, Sum)
- Graduate Research in Reproductive Biology
OBGYN 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
OBGYN 370 (Aut, Win, Spr, Sum)
- Undergraduate Research in Reproductive Biology
OBGYN 199 (Aut, Win, Spr, Sum)
- Directed Reading in Obstetrics and Gynecology
Idiopathic granulomatous mastitis diagnosed during pregnancy associated with successful breastfeeding experience.
BMJ case reports
2021; 14 (8)
Idiopathic granulomatous mastitis (IGM) is a rare benign breast condition with a course that is often rapidly progressive and slow to resolve. There is no consensus on management, especially during pregnancy and lactation. A 30-year-old at 33 weeks presented with mastalgia, induration and galactorrhoea in the left breast. There was no improvement with antibiotics. Initial workup was negative, and a core needle biopsy showed findings consistent with the diagnosis of IGM. She was treated with steroids antepartum. She was co-managed by rheumatology and her obstetrician/breastfeeding medicine specialist postpartum. She was treated with azathioprine, breastfed exclusively for 6 months and continued breastfeeding through the first year. A multidisciplinary team approach is crucial in diagnosing, treating, and facilitating successful breastfeeding in patients with IGM.
View details for DOI 10.1136/bcr-2020-241232
View details for PubMedID 34413030
What's in a Name? Enhancing Communication in the Operating Room with the Use of Names and Roles on Surgical Caps.
Joint Commission journal on quality and patient safety
2021; 47 (4): 258–64
A pilot study was conducted in a tertiary referral center to assess whether wearing caps labeled with providers' names and roles has an impact on communication in the operating room (OR).Two obstetricians observed surgeries for name uses and missed communications. Following each case, all providers were given a short survey that queried their attitude about the use of labeled surgical caps, their ability to know the names and roles of other providers during a case, and the impact of scrub attire on identifying others. They were also asked to rate the ease of communication and their ability to recall name and roles of the personnel specific to the case. Patients were asked how they perceived the use of labeled caps by providers.Twenty scheduled cesarean deliveries were randomized to either labeled (10) or nonlabeled (10) surgical caps. A total of 129 providers participated in the study, with 117 providing responses to the survey. Providers reported knowing the names and roles of colleagues more often with labeled caps vs. nonlabeled caps (names: 77.8% vs. 55.0%, 95% confidence interval [CI] = 64.4%-88.0% vs. 41.6%-67.9%, p = 0.011; roles: 92.5% vs. 78.3%, 95% CI = 81.8%-98.0% vs. 65.8%-88.0%, p = 0.036). Name uses increased (43 vs. 34, p = 0.208), and missed communications decreased (16 vs. 20, p = 0.614) when labeled caps were worn. Providers and patients had an overwhelmingly positive response to labeled caps.This pilot study demonstrated that wearing labeled caps in the OR led to more frequent name uses and less frequent missed communications. Providers and patients embraced the concept of labeled caps and perceived wearing labeled caps as improving communication in the OR.
View details for DOI 10.1016/j.jcjq.2020.11.012
View details for PubMedID 33384215
Use of Hand Expression of Breastmilk Within First Hour of Delivery to Increase Exclusive Hospital Breastfeeding Rate
LIPPINCOTT WILLIAMS & WILKINS. 2020: 167S
View details for Web of Science ID 000554572900590
Epigenetic signatures of attachment insecurity and childhood adversity provide evidence for role transition in the pathogenesis of perinatal depression.
2020; 10 (1): 48
Early life adversity and insecure attachment style are known risk factors for perinatal depression. The biological pathways linking these experiences, however, have not yet been elucidated. We hypothesized that overlap in patterns of DNA methylation in association with each of these phenomena could identify genes and pathways of importance. Specifically, we wished to distinguish between allostatic-load and role-transition hypotheses of perinatal depression. We conducted a large-scale analysis of methylation patterns across 5*106 individual CG dinucleotides in 54 women participating in a longitudinal prospective study of perinatal depression, using clustering-based criteria for significance to control for multiple comparisons. We identified 1580 regions in which methylation density was associated with childhood adversity, 3 in which methylation density was associated with insecure attachment style, and 6 in which methylation density was associated with perinatal depression. Shorter telomeres were observed in association with childhood trauma but not with perinatal depression or attachment insecurity. A detailed analysis of methylation density in the oxytocin receptor gene revealed similar patterns of DNA methylation in association with perinatal depression and with insecure attachment style, while childhood trauma was associated with a distinct methylation pattern in this gene. Clinically, attachment style was strongly associated with depression only in pregnancy and the early postpartum, whereas the association of childhood adversity with depression was time-invariant. We concluded that the broad DNA methylation signature and reduced telomere length associated with childhood adversity could indicate increased allostatic load across multiple body systems, whereas perinatal depression and attachment insecurity may be narrower phenotypes with more limited DNA methylation signatures outside the CNS, and no apparent association with telomere length or, by extension, allostatic load. In contrast, the finding of matching DNA methylation patterns within the oxytocin receptor gene for perinatal depression and attachment insecurity is consistent with the theory that the perinatal period is a time of activation of existing attachment schemas for the purpose of structuring the mother-child relationship, and that such activation may occur in part through specific patterns of methylation of the oxytocin receptor gene.
View details for DOI 10.1038/s41398-020-0703-3
View details for PubMedID 32066670
- Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping CHILDREN-BASEL 2019; 6 (4)
Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping.
Children (Basel, Switzerland)
2019; 6 (4)
Delayed cord clamping (DCC) is endorsed by multiple professional organizations for both term and preterm infants. In preterm infants, DCC has been shown to reduce intraventricular hemorrhage, lower incidence of necrotizing enterocolitis, and reduce the need for transfusions. Furthermore, in preterm animal models, ventilation during DCC leads to improved hemodynamics. While providing ventilation and continuous positive airway pressure (CPAP) during DCC may benefit infants, the logistics of performing such a maneuver can be complicated. In this simulation-based study, we sought to explore attitudes of providers along with the safety and ergonomic challenges involved with safely resuscitating a newborn infant while attached to the placenta. Multidisciplinary workshops were held simulating vaginal and Caesarean deliveries, during which providers started positive pressure ventilation and transitioned to holding CPAP on a preterm manikin. Review of videos identified 5 themes of concerns: sterility, equipment, mobility, space and workflow, and communication. In this study, simulation was a key methodology for safe identification of various safety and ergonomic issues related to implementation of ventilation during DCC. Centers interested in implementing DCC with ventilation are encouraged to form multidisciplinary work groups and utilize simulations prior to performing care on infants.
View details for PubMedID 31013884
Breastfeeding Duration and the Risk of Coronary Artery Disease.
Journal of women's health (2002)
BACKGROUND: Previous studies have suggested that prolonged breastfeeding has beneficial effects on the health of the mother including the reduction of long-term risk of coronary artery disease (CAD). The mechanism of this association remains unclear.METHODS: We surveyed 643 women aged 40-65 years receiving outpatient care at Stanford University Hospital on their reproductive/lactation history, including 137 women (cases) with clinically confirmed CAD. Survey data were supplemented with traditional risk factor data for CAD obtained from the participant's medical record. We then conducted logistic regression analyses to assess the relationship between breastfeeding duration and case-control status for each of the two separate definitions of duration. The first was based on the participant's single longest duration of breastfeeding considering all live births reported and the second was based on a participant's total duration of breastfeeding summed over all live births. For each of these two definitions, we ran three sequential models each with a different reference group-(1) nulliparous women, (2) parous women that never breastfed, and (3) parous women with a short duration of breastfeeding-successively excluding women in the reference group of the previous model(s).RESULTS: Just over one-half (51.6%) of the women surveyed reported a history of breastfeeding. We found nominally significant associations (p=0.04-0.12) for our multivariate analyses that modeled maximum duration of breastfeeding. When compared with nulliparous women, parous women who either never breastfed or always breastfed for <5 months had approximately double the risk of CAD. Among parous women, women who breastfeed for ≥5 months at least once in their lifetime had a 30% decrease risk of CAD compared with those who did not initiate breastfeeding. Among parous women who breastfed ≥1 month, women who breastfed ≥5 months had 50% decreased risk of CAD. We found similar point estimates of effect for analogous analyses modeling maximum breastfeeding duration but p-values for these analyses were not significant. Unadjusted analyses demonstrated higher valued odds ratios and lower p-values suggesting the presence of some confounding by traditional risk factors.CONCLUSIONS: Parous women who breastfeed ≥5 months in at least one pregnancy seem to be at decreased risk of CAD later in their life, whereas parous women who either never breastfed or discontinued breastfeeding early seem to be at increased risk. More research is needed to more reliably quantify and determine the nature of the relationship between parity, breastfeeding duration, and risk of CAD.
View details for PubMedID 30523760
ACOG Committee Opinion No. 756: Optimizing Support for Breastfeeding as Part of Obstetric Practice.
Obstetrics and gynecology
2018; 132 (4): e187–e196
As reproductive health experts and advocates for women's health who work in conjunction with other obstetric and pediatric health care providers, obstetrician-gynecologists are uniquely positioned to enable women to achieve their infant feeding goals. Maternity care policies and practices that support breastfeeding are improving nationally; however, more work is needed to ensure all women receive optimal breastfeeding support during prenatal care, during their maternity stay, and after the birth occurs. Enabling women to breastfeed is a public health priority because, on a population level, interruption of lactation is associated with adverse health outcomes for the woman and her child, including higher maternal risks of breast cancer, ovarian cancer, diabetes, hypertension, and heart disease, and greater infant risks of infectious disease, sudden infant death syndrome, and metabolic disease. Contraindications to breastfeeding are few. Most medications and vaccinations are safe for use during breastfeeding, with few exceptions. Breastfeeding confers medical, economic, societal, and environmental advantages; however, each woman is uniquely qualified to make an informed decision surrounding infant feeding. Obstetrician-gynecologists and other obstetric care providers should discuss the medical and nonmedical benefits of breastfeeding with women and families. Because lactation is an integral part of reproductive physiology, all obstetrician-gynecologists and other obstetric care providers should develop and maintain skills in anticipatory guidance, support for normal breastfeeding physiology, and management of common complications of lactation. Obstetrician-gynecologists and other obstetric care providers should support women and encourage policies that enable women to integrate breastfeeding into their daily lives and in the workplace. This Committee Opinion has been revised to include additional guidance for obstetrician-gynecologists and other obstetric care providers to better enable women in unique circumstances to achieve their breastfeeding goals.
View details for DOI 10.1097/AOG.0000000000002890
View details for PubMedID 30247365
- Attachment Insecurity and DNA Methylation in Risk for Postpartum Depression ELSEVIER SCIENCE INC. 2017: S298
Opportunities to Foster Efficient Communication in Labor and Delivery Using Simulation.
2017; 7 (1): e44-e48
Introduction Communication errors are an important contributing factor in adverse outcomes in labor and delivery (L&D) units. The objective of this study was to identify common lapses in verbal communication using simulated obstetrical scenarios and propose alternative formats for communication. Methods Health care professionals in L&D participated in three simulated clinical scenarios. Scenarios were recorded and reviewed to identify questions repeated within and across scenarios. Questions that were repeated more than once due to ineffective communication were identified. The frequency with which the questions were asked across simulations was identified. Results Questions were commonly repeated both within and across 27 simulated scenarios. The median number of questions asked was 27 per simulated scenario. Commonly repeated questions focused on three general topics: (1) historical data/information (i.e., estimated gestational age), (2) maternal clinical status (i.e., estimated blood loss), and (3) personnel (i.e., "Has anesthesiologist been called?"). Conclusion Inefficient verbal communication exists in the process of transferring information during obstetric emergencies. These findings can inform improved training and development of information displays to improve teamwork and communication. A visual display that can report static historical information and specific dynamic clinical data may facilitate optimal human performance.
View details for DOI 10.1055/s-0037-1599123
View details for PubMedID 28255522
Obesity and Tobacco Cessation Toolkits: Practical Tips and Tools to Save Lives.
Obstetrics and gynecology
Both obesity and smoking are public health burdens that together contribute to approximately one third of the deaths annually in the United States. In 2015, under the direction of Dr. Mark DeFrancesco, the American College of Obstetricians and Gynecologists convened two workgroups with the purpose of creating toolkits that bring together information that the obstetrician-gynecologist can use to address these preventable health problems. An Obesity Prevention and Treatment Workgroup and a Tobacco and Nicotine Cessation Workgroup developed toolkits on Obesity Prevention and Treatment (www.acog.org/ObesityToolkit)andTobaccoandNicotineCessation(www.acog.org/TobaccoToolkit). The toolkits contain specific talking points, counseling methods, and algorithms to address these health concerns in a supportive, efficient, and effective manner. By including these methods in practice, clinicians can help prevent the tragedy of early deaths caused by obesity, tobacco, and nicotine use.
View details for PubMedID 27824751
- Maternal attachment insecurity is a potent predictor of depressive symptoms in the early postnatal period JOURNAL OF AFFECTIVE DISORDERS 2016; 190: 623-631
Maternal attachment insecurity is a potent predictor of depressive symptoms in the early postnatal period.
Journal of affective disorders
2016; 190: 623–31
View details for PubMedID 26583352
Optimistic outlook regarding maternity protects against depressive symptoms postpartum
ARCHIVES OF WOMENS MENTAL HEALTH
2015; 18 (2): 197-208
The transition to motherhood is a time of elevated risk for clinical depression. Dispositional optimism may be protective against depressive symptoms; however, the arrival of a newborn presents numerous challenges that may be at odds with initially positive expectations, and which may contribute to depressed mood. We have explored the relative contributions of antenatal and postnatal optimism regarding maternity to depressive symptoms in the postnatal period. Ninety-eight pregnant women underwent clinician interview in the third trimester to record psychiatric history, antenatal depressive symptoms, and administer a novel measure of optimism towards maternity. Measures of depressive symptoms, attitudes to maternity, and mother-to-infant bonding were obtained from 97 study completers at monthly intervals through 3 months postpartum. We found a positive effect of antenatal optimism, and a negative effect of postnatal disconfirmation of expectations, on depressive mood postnatally. Postnatal disconfirmation, but not antenatal optimism, was associated with more negative attitudes toward maternity postnatally. Antenatal optimism, but not postnatal disconfirmation, was associated with reduced scores on a mother-to-infant bonding measure. The relationships between antenatal optimism, postnatal disconfirmation of expectations, and postnatal depression held true among primigravidas and multigravidas, as well as among women with prior histories of mood disorders, although antenatal optimism tended to be lower among women with mental health histories. We conclude that cautious antenatal optimism, rather than immoderate optimism or frank pessimism, is the approach that is most protective against postnatal depressive symptoms, and that this is true irrespective of either mood disorder history or parity. Factors predisposing to negative cognitive assessments and impaired mother-to-infant bonding may be substantially different than those associated with depressive symptoms, a finding that merits further study.
View details for DOI 10.1007/s00737-014-0446-3
View details for Web of Science ID 000351476400006
View details for PubMedID 25088532
Lean management system application in creation of a postpartum hemorrhage prevention bundle on postpartum units.
Obstetrics and gynecology
2014; 123: 45S-?
Postpartum hemorrhage is the leading cause of maternal death worldwide. Lean management principles incorporate a family-centered improvement system making work more effective and safer.Application of lean management principles in development of the Postpartum Hemorrhage Care Bundle and the Postpartum Hemorrhage Prevention Bundle is an innovative approach to improving patient outcomes. Implementing a bundle with high reliability requires redesign of work processes, communication, infrastructure, and sustained measurement. A lean process is a set of interventions, each of which creates value for the customer. Lean is not a new concept, but relatively new to health care.Through simulation training over a 6-month period 100 registered nurses, physicians, and family representatives simulated the innovative approach developed by a multidisciplinary local improvement team (clinical microsystems methodology) in the maternity department of Lucile Packard Children's Hospital at Stanford. Simulation training was held at the nationally renowned Center for Advanced Pediatric and Perinatal Education. The local improvement team was able to demonstrate significant decreased response time for emergencies.Supply retrieval time decreased by 99.9%, physician response time decreased by 81%, and family-centered care increased by 100%. The Postpartum Hemorrhage Prevention Bundle could become the first national standard in prevention of postpartum hemorrhages on a postpartum unit.
View details for DOI 10.1097/01.AOG.0000447328.58883.1e
View details for PubMedID 24770195