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So your daughter comes to you and says, "It hurts to pee." Is it automatically a urinary tract infection? Not so fast. Girl parts are super-sensitive, especially between the ages of potty-training to puberty, and there could be a few things going on. So how do you know what the problem is?
Diagnosing UTIs in Children

First, your daughter would need to be seen. We cannot diagnose urinary tract infections in girls over the phone. We need them to actually come into the office and pee so we can do a urinalysis test. That will show if she has a UTI or if she's dehydrated and her burning with urination is due to concentrated urine.

It will also show if there is blood in the urine or any signs of diabetes as well, which doesn't cause burning with urination, but does cause frequent urination, which is another sign of a possible UTI.
Treatments for UTIs in Children

If your daughter does have a UTI, we can treat her with antibiotics while sending her urine off to get a culture at the lab and find out what type of bacteria is causing her UTI and make sure she's on the correct antibiotic.

If your daughter does not have a UTI, then we need to ask a few more questions, like is she drinking enough water? Does she take bubble baths? Is she wiping too hard? Is she wiping at all? Is she wiping in the right direction? Does she have any vaginal symptoms? And yes, we have to ask if anyone has touched her inappropriately down there.

Based on those answers, we can talk about treatments. Will drinking more water help? What about cranberry juice? Which may or may not help, depending on what's going on. Does she need any special creams for her private area? Does she need to work on better hygiene? If she is sexually active, do we need to test for chlamydia or gonorrhea? Is this not a urinary issue but more a vaginal issue?
What NOT to do for Your Child's UTI

Everything is in such a small space in that area that it can be hard to figure out what is going on and what the correct treatment is.

I've had parents ask me about certain home remedies that I can tell you, you should not do. Don't do the following. Don't have your daughter douche to clear out the UTI.

Similarly, I had one mom tell me that she was told to soak a tampon in probiotic kefir and insert it in her vagina to treat a UTI. Neither of those will help because a UTI is in the urinary system and inserting something into the genital system won't help. Just because they're in close proximity doesn't mean that they are treated the same.

Don't put random creams in or on your daughter's privates without finding out what the main cause of her symptoms are. Sometimes, that will make the problem worse.

And don't give antibiotics that were left over from a previous infection, because not all antibiotics will treat urinary tract infections.

So if your daughter has girl-part issues, please bring them in to be seen by their pediatrician. We can help you figure out exactly what is going on and what is best to help them feel better.

Interviewer: When it comes to issues of infertility, it's important that both members of the couple are involved in the diagnosis and treatment of the issue.

To find out why that is, we're joined by Dr. Kelli Gross, a men's health specialist and assistant professor in urology at University of Utah Health.

Now, Dr. Gross, why is it so important that both partners are involved when we're trying to, say, diagnose why a couple can't get pregnant?

Dr. Gross: It's incredibly common that men come to see me and they've never been considered at all in their fertility workup. We find that up to about 40% of the time, there is what we call male-factor infertility or an abnormality in fertility in the male partner. So it can be greatly underdiagnosed.

With all of the technology that we have in fertility, things like in vitro fertilization can make it so that optimizing the male partner is not as essential as it once was. But it can be a lot more expensive and have its own set of downsides.

Interviewer: So when you say that it's 40% of the time, does that mean that it is often misdiagnosed, or do we often deal with the female issues more often?

Dr. Gross: It wouldn't necessarily be that it's misdiagnosed, more that it's ignored. With couples, they may be experiencing infertility without having any major health issues or causes. It can be both sides things are a little bit abnormal. So having things that are less than optimal in one partner can still lead to issues, but sometimes we just get around these by other sorts of things.

Interviewer: And what kind of things are those?

Dr. Gross: So it would be things like intrauterine insemination or in vitro fertilization. So what that is, for intrauterine insemination, is we put the sperm directly into the uterus. So it bypasses some abnormalities if there are low counts in the sperm or if there are issues on the female side.

We can also do things like in vitro fertilization, which is where the egg and the sperm are joined outside of the body. And that can, likewise, overcome a lot of issues on both sides, such as having very low sperm counts or issues from a female partner side.

Interviewer: So if a couple is trying to identify what is causing their infertility, why is it more economical to have both partners involved from the start?

Dr. Gross: So there are things that we can improve from a male side that can make it easier to get pregnant either naturally or with help. So, for example, there are certain procedures that we do that can improve sperm counts in certain men.

So if we have somebody who has very low sperm counts, then doing something like that where they previously would not be a candidate for something like intrauterine insemination, which takes a certain amount of sperm, by raising those counts, we then make them a candidate for that, or they are able to get pregnant naturally because the sperm counts are higher. So they can save a lot of money from the cost of, for example, in vitro fertilization.

Interviewer: We spoke about why it's so important to have both partners involved in diagnosing and treating infertility. How long should a couple be trying before they technically are dealing with infertility issues, or when should they start to see a specialist?

Dr. Gross: So we usually define infertility as trying for one year. And that's kind of just because 90% of couples will get pregnant within one year.

It's kind of arbitrary. So, for example, if you've been in a long-distance relationship and you haven't been having intercourse, of course, a year may not mean that there's anything wrong biologically. And at the same time, if there's any sort of history or medical concerns that make you seek treatment earlier, there's nothing wrong with that at all. We don't say, "Keep trying," necessarily. We would typically evaluate to see if there was anything that we can improve, no matter what time it is.

Dr. Jones: The mammalian miracle of growing babies inside you is amazing. Yeah, that's a lot of M's in one sentence, but what do we know and what don't we know about implantation? And what do couples do and doctors do to try to make it work better?

Announcer: Covering all aspects of women's health, this is the "Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: In humans, eggs are sort of squished out of the follicle, and that's the cyst that has the egg in it in the ovary when ovulation occurs. Okay. It usually works. It's not too hard to understand, and we can study it in other mammals like lab mice. The fallopian tube picks up the egg, which is surrounded by a cloud of sticky cells, and moves the egg and its cells into the tube. Okay. I got that.

Sperm, which were deposited in the vagina, swim up the cervix, uterus, and out the tube and meet the egg. Okay. That seems hard and a long way for the tiny guys, but there are so many of them. The egg and sperm recognize each other as human, and only one sperm gets in the egg. Now, that's amazing, and there are so many of them. And the egg gets fertilized.

Okay. We understand that mostly, and we can watch it happen in the IVF lab with human eggs and sperm. We do know that a lot of eggs and sperm and a lot of fertilized eggs are not normal, so there are lots of time that the process doesn't go much farther than this. But if things are normal enough, the fertilized egg starts to divide, wanders down the fallopian tube with a little help of tiny little fingers on the cells of the fallopian tube and arrives in the uterus at the time that the embryo has developed enough to have over 100 cells and specialized cells that can settle into the uterus lining and start to burrow under the lining. And, after that, we really don't have a clue as to what happens at all.

The human process of implantation is not necessarily like mice or cows. We actually are much less efficient. Removing the uterus of women at various stages of implantation to study what's going on is not going to be done. The primates that we share our genes and our reproductive biology with are increasingly rare and are protected from this kind of research. Implantation, the process of the embryo burrowing under the uterus lining, capturing some of the blood supply of the uterus lining, and growing enough to make a placenta, which then grows to feed the embryo and fetus, is mostly a mystery.

It is thought that about one in five fertilized eggs goes on to make a baby to viability in fertile couples. In infertile couples, it doesn't happen that often, and sometimes we don't know why or what to do about it. So many couples who are not getting pregnant move to in vitro fertilization. It is thought about 1% of all the babies born in the U.S. were conceived with IVF, and that makes about a million babies in the U.S. over the years. Hundreds of thousands of cycles of IVF are done each year in the U.S. But you can put lovely looking embryos into the uterus of a woman and not get pregnant for no good reason.

This leads doctors and patients to try to come up with strategies to increase the chance of implantation. In the old days, we had a woman in bed tipped upside down for a day after putting the embryo in her uterus with hopes that it wouldn't fall out. Then we had women rest for hours, then an hour, then 15 minutes, and then not at all because randomized trials showed that laying down flat after an embryo transfer didn't seem to make a difference in implantation. Some people have tried acupuncture with the hope that it might help implantation through some ancient wisdom that we understand about as well as we understand implantation. Randomized trials showed that acupuncture didn't work better than fake acupuncture and implantation, but doctors and patients were desperate to make this very expensive and life-consuming process work.

Some years ago, someone came up with the idea that if you disrupted the uterus lining the month before IVF, maybe it would cause a reaction in healing that might increase the chance of implantation. Given that we have no clue about implantation, it seemed like an idea. And some early studies suggested it might have a small effect, increasing the likelihood that the embryo would successfully implant and grow. Now, this isn't like gardening where you scratch the earth and then put the seeds down in hopes that they will grow better than just dropping the seeds on the ground, although it sort of sounds like that.

The endometrial disruption called endometrial scratching actually happens the month before the IVF cycle. It can be done in several ways, but the most common is to put a small tube with a sharp edge at the tip into the uterus, through the cervix, and move it around back and forth, sort of scuffing up or scratching the uterus lining. So does it work? Some people thought it did. Some studies suggested it might, and patients and doctors were desperate.

In a widely read medical journal, the "New England Journal of Medicine," a large randomized trial of endometrial scratching versus no scratching before an IVF cycle reported that it didn't help. There was no difference. Not exactly a surprise. At least it didn't hurt. Well, actually, it did hurt. Putting a tube in the uterus and swirling it around is uncomfortable to most women. And for doctors who charge for this procedure, it could be 200 to 600 bucks, so scratch that. Well, no, don't scratch that.

Lots of things have been tried. Word gets out on the web, and patients request some intervention or another that might increase the chance of getting pregnant. I will admit to some magical thinking of my own that I did after putting embryos back in the uterus of patients undergoing IVF in my years as an IVF doctor. There are a couple of minutes between putting a tiny drop of fluid with embryos, or better one embryo, into the top of the uterus. And when the embryologist in the lab checks the tube and makes sure that the embryos are gone, it's a couple of minutes. I would practice deep breathing and imagine the embryo in the uterus happy and implanting, and growing, and seeing children at our IVF picnic. I didn't tell patients that I did this little exercise, but it seemed like a good use of a few quiet minutes. Magical thinking. What I really wanted was some kind of tissue super glue, but somebody actually tried that, and it didn't work.

So what do we do when we don't know what to do? The world of infertility and early pregnancy loss has been filled with well-meaning therapies to try to help people have the children that they hope for. Most, at least, haven't been harmful -- acupuncture to increase IVF implantation, aspirin to prevent miscarriage, and many others. But before we suggest it or offer it to patients who want it, we should at least know that it won't hurt physically, emotionally, or financially. Large, well-done randomized trials are very expensive, and in the IVF world, usually not funded by our government, but they need to be done. As patients and consumers of reproductive health care, we should try to get the best information from our physicians and take a deep breath and do the best we can. And thanks for joining us on The Scope.

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Interviewer: Considering a career in medicine, but aren't sure exactly what area would be right for you? We'll discuss what it's like to be an OB-GYN, next, on The Scope.

Announcer: Thescoperadio.com, focus on Careers in Health Care.

Interviewer: Each field of medicine comes with its own challenges and benefits. We have Dr. Kirtly Parker Jones, an OB-GYN at University of Utah Health, here to talk about a career in Obstetrics & Gynecology. First, how did you get into reproductive medicine?

Dr. Jones: Well, it's a long story, and students who are anxious because they don't know exactly what path to take, you need to realize, I didn't ever think I was going to go into medicine until I was a senior in college. So it's often someone who shines a bright light on a choice. A job as a basic biology scientist was probably not going to be very well-funded. So my mentor, who was a chairman in the department said, "Go to medicine." And so I was going into medicine thinking I was going to do genetics, but issues at the beginning of life are so compelling.

So I think medical students often, as they're thinking about a career, are looking for something that is egosyntonic. It's a wonderful word that means "sings with their soul." Some people are great with their hands. Some people like to play video games, and they like to do things with images. Some people are really bonded to the storytelling of individual patient care. And so people tend to find, as they go through medical school, the topic or the area that sings with their soul. And for me, as a biologist, as someone who loved the beginnings of life as a biologist, OB-GYN was a natural. A lot of drama and a lot of blood, but I was okay with that.

Interviewer: So what do you like most about your job?

Dr. Jones: Well, it turned out that what I liked wasn't what I thought I was going to like. So I thought I was going to like fixing things because I used to sew for a living, and I thought, "I can cut and sew, and so the surgery's going to be fun, and the baby thing is fun." As I grew in my work, what I really loved was women's stories. I loved the stories about their lives and anything I could do to help them be happier with themselves. Women carry a burden of inadequacy. They don't think they're pretty enough, or smart enough, or, you know, sexy enough, or whatever enough they may not be, but they actually are all those things.

So helping women be happy with their stories or get over a really hard story, that ended up being the most rewarding in the long run and the thing that I remember most. Of course, I remember the days that someone nearly bled to death and our team saved them, but I remember my ladies and how brave they were, and how funny they are, and how beautiful their stories are. And that's the best.

Interviewer: So what's the hardest part then?

Dr. Jones: Well, the hardest part is when you can't help someone get over a bad story. So there are women who feel that they are victims, and they had been victims. But moving past that victimhood, just survivorship, whether they're victims of rape, or emotional abuse, or cancer, or infertility, helping women move with the love in their heart for the thing that they lost, but helping them move beyond that. And women who can't do that, women who are addicted and can't move beyond, women whose grief is so long, then I need help. I need a professional. I need a psychologist.

Interviewer: What does your typical day look like?

Dr. Jones: Well, I'm in academic medicine. There is no typical day. So there are several days of the week when I have clinic in the morning, and I might have lectures with students in the afternoon. I might have one day a week where I operate. I have a week when I do administrative work, meaning I design educational programs for students and for residents. So, in academic medicine, you are never, ever bored. You're always steep on your learning curve, and students keep you that way.

For docs out in private practice, they might have three days a week when they do clinic, so they're in their clinic. They have one day a week when they operate. They have a day a week they try to catch up. And, of course, they're running back and forth to do deliveries which aren't always scheduled. So if you're going to be an OB-GYN, you have to tolerate a lot of chaos in your schedule. If you think you're always going to do this and get this done at a certain time, then you need to do something else.

Interviewer: Can you tell me a story or a favorite memory you have, being an OB-GYN?

Dr. Jones: Well, I would say there are a group of stories that come with patients who are going to have bone marrow transplants. So, for many years, I saw most of the women who were going to have a bone marrow transplant, usually for a life-threatening cancer. They were young women, and their future was going to be ending if they did not cure this cancer.

Bone marrow transplantation, at the time, is bringing someone almost to death with chemotherapy, and then snatching them back with someone else's bone marrow. And for these women, to watch them face a life-threatening cure from a life-threatening disease, watching their eyes as they hear that their fertility will be taken from them because the chemotherapy will take away their eggs, and seeing them afterwards, six months later and a year later, and watching them get on to their lives, they were the heroes for me.

There are so many women who've suffered from their infertility, from a rape, from abuse, from some awful surgery, but those women were, I think, examples of courage, and humor, and willingness to go forward in the face of uncertainty. And they shared it with me, and that was a privilege.

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Dr. Jones: So who really knows about women's health? Are the OB/GYNs just the specialists in the below-the-knees women's health? Are internists just the specialists for above-the-knees women's health? And why don't they talk to each other? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and we are doing that today on The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: For many OBs, women's health stops when the baby is born. For many gynecologists, women's health is above the knees and below the waist. For internists, they might cover the rest, but defer what goes on down there to the other docs. Of course, family physicians would probably rightfully claim that they can cover all the domains of women's health. But what should OB/GYNs and internists know about each other's territory to really take care of women?

Today in The Scope studio, we're talking to Dr. Melissa McNeil. Dr. McNeil is Professor of Medicine and chief of the section of women's health and Director of the Comprehensive Women's Health Program at the University of Pittsburgh. She's trained as an internist in medicine and in public health, and she's here to give grand rounds to the internists and to the OB/GYNs to tell them what they should know about each other's specialties. Let's start with this: What do you think women would want their internist to know about their womanly health?

Dr. McNeil: For so many physicians, they silo women. And increasingly what we . . .

Dr. Jones: Silo them by their body parts?

Dr. McNeil: Silo them by their body parts and the domain that they will take care of. So one of the things that are increasingly happening is that, for the internal medicine community, many of our patients don't see their gynecologist as regularly as they used to. As our Pap smear guidelines go to every five years, as our women move out of the childbearing age and they don't need contraception, for many women, they are not seeing the gynecologist on a regular basis. So the things that I think all physicians need to know, particularly internists, are the following.

I think the first thing is that the folks who are charged with your heart health and preventing heart disease need to understand your reproductive health history. What we know and are increasingly aware of is that women who have reproductive consequences, such as preeclampsia, such as hypertension during their pregnancy, such as small for gestational age babies, have an enhanced risk of cardio disease early in life. So, as an internist who sees, very much as my domain, the risk assessment of women for cardiac disease, I need to understand, I need to know about those birth complications, and I need to understand how it impacts cardiovascular risk.

The second thing I think that internists need to know and understand is breast health. I think the breasts . . . it's a little bit unclear who owns the breasts.

Dr. Jones: Oh, we don't. It's no man's land, sort of.

Dr. McNeil: It's no man's land, so to speak . . . no woman's land. And so one of the things that are increasingly becoming clear is that breast health is an area of precision medicine. We talk about the need to personalize the recommendations we make the patients based on their own individual risk factors, and then a one-size screening program for breast health does not fit all. So, therefore, internists need to know and understand the risk factors for breast health, family history, they need to know how to understand the reproductive parameters that change breast health, like time of first baby, time of onset of menarche, and how to understand things like breast density.

Dr. Jones: Well, you know, this is . . . it turns out that internists don't even touch us, anymore. You know, they might wave a stethoscope sort of in the direction of your heart, but in reality, the gynecologists still take the clothes off and look at us all. But that now, it's not every year. It's maybe every five years, and even now, they're not doing that. So the concept being actually touched while doing a breast exam, now true, breast exams don't really help save lives, but they are a way of talking to your patients about their breast health. So . . .

Dr. McNeil: So that's interesting that you talk about that because I do think that the benefit of the physical exam in that arena has been called into question. Having said, that the benefits of a conversation have not. And so in a busy office practice, you get to decide where you spend your time. I still actually believe in the breast exam. I still do the breast exam on my patients for their annual visit, and certainly, if there's any complaint, an exam needs to happen. So . . .

Dr. Jones: Anything that we wish our internists would know about us?

Dr. McNeil: Yeah, and this is the last thing that I'm going to emphasize. I think that our internal medicine community needs to really become much more comfortable and savvy talking to women about the things that impact the quality of life as they age. And there are three that I think, again, fall into no woman's land. It's the management of the menopause and hot flashes, it's the management of vulvovaginal atrophy and the symptoms of dyspareunia that come with the menopause, and then, finally, incontinence. For many of our women, these things fall into the "don't ask, don't tell" category. And if you don't ask, you'll never find out.

Dr. Jones: Well, not only that. Women often switch off in terms of their healthcare. So when they get to midlife, they don't see their gynecologist, anymore. But if the internist doesn't ask, they figure the internist doesn't know and so they tend to hold those personal. They're often very personally held. And I encourage all of our listeners that if you've got a problem or concern, if you're waiting for your internist to ask you, you might need to buckle up and speak up.

Dr. McNeil: And I would second that wholeheartedly. I find that, in our Comprehensive Women's Health Program, if you ask, patients have the symptoms. I think some of the advertising we see on television has empowered women to come forward for it, but at the same time, you cannot wait, internist, non-internist, for your doctor to maybe ask about everything that might be bothering you. You need to put it forward.

Dr. Jones: And if your internist is your primary care doctor now, not your gynecologist, you need to hold them to the fire, and they can . . . if they don't know, they might be able to talk to somebody. So that gets the last question: How do our doctors talk to each other? Ideally, if we're in a healthcare system and most everyone is either a little system or a big system, why, and how can our doctors talk to each other, our internist talk to our gynecologist, and vice versa?

Dr. McNeil: I think that's a great question and I think it has both become harder and easier with our current practice structure. The idea, of course, is a multidisciplinary practice where you have internists and gynecologists practicing side-by-side so that you can just go next door and say, "Hey, I have a question. Can you come look at this abnormal finding?" Or, "What's the next test you would do with the symptom?" Or, "How do I prescribe vaginal estrogens?"

That's a luxury and doesn't happen very often. I think the next strategy, of course, is just to pick up the phone and call a friend, call a colleague. And it can either be a colleague who's actually sharing care of the patient or someone you just value who will work with you in solving those patients' problems.

The third strategy, which is increasingly being utilized, is communication through the electronic medical record. One of the benefits of a shared electronic medical record is that docs can talk to each other, docs can see what they're recommending, each specialist is recommending for the patient. And so there can be a dialogue about, "Ooh, I'm a little bit uncomfortable with this," or, "Wow! That's a great idea," or, "Maybe we should actually step out and talk about this." So the electronic medical record can be very helpful. And then the last thing I would add is that the way to make docs talk to each is patient-driven.

Dr. Jones: Right, you tell them.

Dr. McNeil: You do. As a patient, you say, "Well, you know what? My gynecologist said something different. What would you think?" Or, "Could you talk to my internist and sort out . . .?"

Dr. Jones: "You just got me started me on some estrogens. Would you talk to my internist about that so that they know?" You know, or, "My internist seems to be kind of negative about it. Would you kind of talk to them and share what you know?" I think it's in the domain of patients' rights to get their personalized care by having their doctors come together around their person.

Dr. McNeil: To make their personalized care coordinated care. And it's very hard for patients when different providers that they trust make different recommendations. So coming together with a consensus is incredibly important for the peace of mind and good-quality care that our patients deserve.

Dr. Jones: So for those of you who are listening, be brave because, now that we have electronic medical records so the other care providers within your system can be contacted easily, it's not having to look up a telephone number. So be brave. You can help coordinate your care. You can ask the questions and you'll be happier at the end of the day for it.

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Dr. Jones: If the womb is such a safe place, how does the Zika virus get in? This is Dr. Kirtly Parker Jones from Obstetrics and Gynecology at University of Utah Health Care and this is The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: When I was a second-year medical student, I absorbed the idea that the womb was a perfectly safe place. I use the word absorbed because I don't think they taught that to me, I think I just figured that out. The placenta was the perfect mother, serving and protecting the fetus. Serving in that the placenta actively pumps some nutrients like to the developing fetus like oxygen and glucose. Protecting in that it keeps out large molecules and only smaller molecules can get in. Well, this was a rather romantic idea, but I was a rather romantic medical student.

By the time I was a third-year medical student, I was taught about congenital infections, infections in the child that start in the womb. Infections such as toxoplasmosis from uncooked pork and kitty litter, syphilis, well, from you know how. These aren't just molecules, these are whole organisms. They get through the placenta and into the fetus. We also learned about viruses such as chicken pox and rubella infecting the fetus. But in the dazed mind of a totally engaged but overextended third-year medical student, I never really questioned how they did that.

If the womb is a perfect mother protecting the fetus, how do those things get in? Well, first, it's important to remember that viruses are really sneaky. Here's a little bit on virus biology. They're just a little packet of DNA wrapped in a membrane. They don't have the ability to reproduce themselves. They get into cells and hijack the cell's energy and DNA and proteins and make the cell make more virus. The interesting part is that viruses are choosy. They have markers on their covering that attach to specific proteins on certain kinds of cells. Some viruses like the respiratory tract but not the skin. Some viruses like white cells, like the HIV virus.

The Zika virus, which has already found cells in the infected mother to turn into Zika factories, and the virus spreads throughout the mother's body. The virus then may specifically bind to the lining of the placenta, the amnion. Then the virus turns the amniotic membrane into a Zika virus factory. Then the Zika virus hatches out of the amnion cells into the fluid around the fetus and the fetus gets infected. Specifically, the virus likes nerve cells; it likes fetal brain cells. It binds the fetal brain cell, turns it into a Zika factory and then in the process it kills the brain cell.

There is another mechanism by which the Zika virus might get into the womb and that is through the leaky placental cells that are made early in development in the first trimester. The virus then seems to specifically attach to the stem cells of the embryonic brain. Destroying these cells, which have been infected by the virus, may explain why the findings of microcephaly, small brain, in some of the babies that were infected in pregnancy. The virus can get in at any time of pregnancy, but it's particularly successful and potentially damaging in the first trimester.

Researchers also found that different strains of the Zika virus were more infectious, more successful at hijacking placental cells than others. The earlier African strain was less infectious than the current South American strain, which is much more infectious and much more likely to infect the fetus. In fact, it seems it's not just spread through infection by mosquitoes, but it's spread sexually from men to women and now, we think, from women to men. There's the possibility that it might be spread from other body fluids as well.

Actually, it is remarkable that the placenta and the membranes can protect the fetus from as many viruses as it does. Only a few viruses that we know about specifically attack placental cells and then go on to infect and harm the fetus. The chicken pox virus, the measles virus and the cytomegalovirus are examples and we have vaccines for some of these. Understanding the mechanisms by which viruses can infect placental cells can help us develop anti-viral agents and other approaches to treatment.

Viruses are particularly successful and rapidly changing in their molecular appearance, meaning the way their face looks to different cells. So it may be difficult to make a vaccine. Or because the Zika virus belongs to a family of viruses that include Dengue yellow fever and we have a vaccine for some of those, we might be able to make a vaccine for all three or maybe not.

In the meantime, it's important to remember that a womb isn't a completely protected place. And the placenta isn't a perfect mother, letting in only the good in keeping out the bad. We need to remember to offer protection to pregnant women and women who might become pregnant from viruses, drugs and molecules in air and water pollution that can get through the placenta and affect the fetus. Thanks for joining us on The Scope.

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Dr. Jones: As human beings have evolved, our big brains evolved to be bigger than our pelvis has evolved to be bigger. So births have become a little harder with a few more long-term consequences for women. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare and this is the scope of the problem of getting the baby out.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: It has clearly been an advantage for humans to have a big brain. So with the big brain comes a big head. Today in The Scope studio I'll be talking to an expert on the pelvic floor, Dr. Ingrid Nygaard. She is a professor at the University of Utah and a urogynecologist, a gynecologist who specializes in pelvic floor problems. So what is the pelvic floor really? Not something you scrub with Ajax or something but give it to us.

Dr. Nygaard: No, definitely not. It's one of those important structures that we appreciate only really when it's not functioning as well as we wish it would. The pelvic floor is made up of the muscles, ligaments, connective tissues and nerves that support our internal organs, like the bladder, the uterus, the vagina, rectum. The pelvic floor muscles run from your pubic bone at the front to the base of your spine at the back. They're shaped like a sling and they hold your pelvic organs in place.

Dr. Jones: So it's kind of like a sling or a hammock but you don't want it too sling-y. You don't want it too hammock-y. You want it to be strong. So all these muscles and connective tissues keep our insides in. What happens when a baby comes out that way?

Dr. Nygaard: Well, as you can probably imagine, to allow the baby to pass through, the structures in the pelvic floor all have to stretch quite a bit. Luckily our body starts preparing for this long before labor even starts. But the pelvic floor muscles sometimes weaken after childbirth and then they weaken further as we get older.

Dr. Jones: Well, women give birth vaginally all over the world but why do some women have problems after vaginal birth and some don't?

Dr. Nygaard: Well, we know that weakened or dysfunctional pelvic floor muscles can cause problems down the road, like bothersome leakage of urine or pelvic organ prolapse where one or more of the pelvic organs bulges into the vagina. But for most women these conditions don't happen until they're middle aged or older. We don't know very much about how young women experience changes in their pelvic floor function after childbirth. It's probably fair to say that most women notice some minor changes after giving birth but the fact that most women who deliver vaginally don't have long lasting problems speaks, I think, to how amazing our bodies really are.

Dr. Jones: So as young women they may have the original insult or the original maybe even damage but that really doesn't show up until ageing and gravity and time adds its little mix to the potion. Is that how it goes?

Dr. Nygaard: Right exactly.

Dr. Jones: Right. So if women have a problem after vaginal birth, could it get better on? And so you're suggesting that these they don't notice it or maybe it gets better on its own?

Dr. Nygaard: No, absolutely it could get better on its own. A lot of processes go on in our bodies that encourage healing and recovery after childbirth. Over the first couple of months for example, the uterus goes back down to normal size and the pelvic floor muscles start regaining their strength, and this means that symptoms that some women notice after childbirth often go away within a few months. If it doesn't get better, is there anything we can do to help? Well, we're lucky that time alone helps many women recover well after childbirth but we don't know very much about other factors that might help women recover well after vaginal delivery. But one thing women can do to help get the pelvic floor back in shape after delivery is pelvic muscle exercises. Some people call those Kegel exercises. I encourage women who notice some urinary leakage for example, to do these. It's a good idea to have someone give you some guidance to make sure you do these correctly and effectively, and a great resource for this is a women's health physical therapist and you can also ask your doctor or nurse for tips.

Dr. Jones: Oh and they're really easy to do. I just did them. I can do them while I'm even talking on The Scope radio right now and I don't have to hold my breath and my face isn't getting red.

Dr. Nygaard: It's not getting red.

Dr. Jones: But someone in the studio is kind of laughing. Oh, okay, well let's talk about does childbirth cause any problems over the long-term? We talked about that a little bit.

Dr. Nygaard: Well, over the course of her lifetime about one in five women undergoes treatment, often surgery, for pelvic floor disorders. Childbirth is one thing that can contribute to this but there are many other factors too from ageing to nerve problems like strokes to obesity and genetics plays a role as well.

Dr. Jones: I read somewhere that female paratroopers had a little more prolapse but that's just an aside. So what kind of research are you involved with regarding these problems in childbirth?

Dr. Nygaard: That's amazing to consider the fact that even though nearly four million women deliver baby in the US every year, most of them vaginally, there really hasn't been much research about how to maximize recovery after childbirth in terms of pelvic floor health. So we are conducting a study called the MAPH study, which is short for Motherhood And Pelvic Health, and the goal of the study is to find out what we can recommend to help women recover well after vaginal delivery. We're specifically looking at how things like physical activity, intra-abdominal pressure and muscular strength influence pelvic floor support and symptoms during that first postpartum year. We see this research as an important step in crafting prenatal and postnatal regimens that will promote better pelvic floor health. We're planning to enroll about 1,500 women across the Salt Lake Valley. Our participants are all first time new moms and we're so grateful to them for lending us their time and involvement to help us learn about pelvic floor health after childbirth.

Dr. Jones: So for those of you who are still having babies or about to have your first, the good news is that it goes mostly just fine and for you ladies who have some long-term consequences of getting those babies out, there's hope and there's help, and thanks for joining us on The Scope.

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Interviewer: Have you ever watched those movies or TV shows where there's a woman in an elevator about to give birth and the elevator is stuck and you're stuck in there with her and you're panicking and you don't know what to do? We're going to tell you next on The Scope.

Announcer: Covering all aspects of women's health. This is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Interviewer: We're talking today with Dr. Kirtly Parker Jones. Dr. Jones, I've never been in the situation and I hope I never have to be. But in case I ever do come across it, if I'm stuck in an elevator with a woman about to go into labor or if we're stuck on the highway and the ambulance isn't coming in time and I'm a bystander and I want to help, what are things I need to be doing? What advice do you have for somebody that's just standing there, panicking?

Dr. Jones: First of all don't panic.

Interviewer: Don't panic.

Dr. Jones: Don't panic. Well I'll tell you a story. Some years ago and it was probably late in night. I was on labor and delivery as the attending physician and the elevator door actually opens and it's an orthopedic resident and a woman who actually has given birth in the elevator. So she walked into the front door of the hospital, which is not really close to labor and delivery and was close to delivering. And she didn't know where to go and he took her, as he should, to the elevator and things then happened pretty quickly.

So he was strutting around. He was so proud that he had delivered the baby. But when we actually got to the woman her panties weren't really even off, so I don't think he did anything. So when he said, "I delivered this baby." I said "I think she delivered this baby." And in fact that's what you need to remember. If the baby's coming that fast you just stand back.

So you stand back, you can make sure that the mom maybe is on the ground so the baby isn't going to fall and you want to make sure that the baby if anything, if the baby comes out that the baby's put next to the moms chest. The baby needs to be warm.

Interviewer: Okay.

Dr. Jones: You do not have to cut the cord. Somebody else can do that. If you're in the elevator you can wait for that but mostly . . .

Interviewer: It's not an emergency.

Dr. Jones: It's not an emergency. You keep your hands off.

Interviewer: Keep your hands to yourself.

Dr. Jones: Keep your hands to yourself.

Interviewer: Got you. Okay.

Dr. Jones: If the baby's coming that fast and the woman is on the ground so the baby's not going to fall. Then all you do is you wait. If you have something that's relatively clean so that you can wipe off the baby's face and mouth and then put the baby on the mom's bare chest so that skin to skin so the baby can stay warm. Cover them up. Don't feel like you have to cut anything. You can just wait.

Interviewer: And the mom will be okay.

Dr. Jones: Yeah. The mom's going to be okay. Now the biggest risk to the mom who's having birth that fast is not the baby coming out, because the baby's coming out, it's, is the placenta going to come out. And normally the placenta comes out on its own. The uterus continues to contract after the birth and usually then it's expelled.

But if it doesn't come all the way out then the placenta separates and the mom can hemorrhage. That's where you need to make sure that you're getting help. So if the mom is hemorrhaging and you just see blood everywhere, the best thing you can do is put your hand on her tummy, below her belly button and try to massage this lump that's there and that's the uterus, so that the uterus will contract well.

Most people aren't going to feel comfortable doing that because they don't know what a uterus is. But after baby is born if the placenta isn't out yet, the uterus is still moderately big. It's below the belly button. It maybe just feel like a chubby tummy until you rub on it and then it should contract and become a hard ball-like melon size ball and keep massaging it so the uterus can contract. But hopefully someone's called for some help.

Interviewer: Right.

Dr. Jones: But remember women all over the world deliver their baby's by themselves. If it's coming that fast you don't need to put your hands in anywhere.

Now there is the baby coming that fast and its feet first and that's going to be difficult. My guess is if you have absolutely no experience, you should probably let things go and not tug on the feet.

Interviewer: Okay.

Dr. Jones: But if the head comes out first, that's the way it's supposed to and that's the biggest part of the body so if the head can fit, everything else is going to fit. If the feet come out first then the head may not come out and that can be a problem. But an inexperienced person should not be pulling.

Interviewer: So the rule of . . . Keep your hands to yourself still applies?

Dr. Jones: Right. So it's not like pulling a calf. Just put the baby skin to skin next to the mom and hopefully somebody will get in there who knows what they're doing.

Interviewer: So the takeaway is if you are bystander to a delivery, a birth delivery, keep your hands to yourself.

Dr. Jones: Right. Get the mom down on the ground. You can support her shoulders or head. She will push. If it's coming that fast her body will do the right thing. You don't know what size the baby is.

Interviewer: Stay above her head pretty much.

Dr. Jones: So stay above her head and then if someone can keep an eye so that when the baby does come all the way out that you wipe the baby's face a little, you can blow into the baby's face and make sure it takes a little breath. But then put the baby skin to skin next to the mom. The umbilical chord is still attached. Hopefully everything will go okay with the umbilical cord because that's the next risky time. But don't put your hands in there if you don't know what you're doing.

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