Thursday, June 27, 2013

"Take Responsibility for Your Pregnancy and Birth!"

We welcome a guest post today from an anonymous midwife, who takes research and serving mothers safely very seriously. 

“Pregnant women need to educate themselves and take responsibility for their births.”

Women receive this advice, and admonition, from many quarters, but it does not usually mean what you would think it does.  It does not usually mean to educate themselves about their risks in pregnancy and childbirth, or how to know when intervention may be necessary.  What it usually means is to trust your midwife, and not to trust the doctors, nurses, hospitals, or medical advice.  

If your pregnancy and birth are completely normal and you don’t have any risk factors, that advice may work fine. But, what if your midwife tells you how to handle a condition or situation that seems contrary to your instincts and intuition, contrary to evidence based practices, or without safety at the forefront?  If women are told to take responsibility for their births then they should know when it is time to trust themselves that they may know more about about their pregnancy, labor, birth, and newborn than their midwife or doctor does.

Midwives attending women planning a home or birth center birth frequently quote the World Health Organization (WHO) which recommends that the cesarean section rate should not be higher than 10% to 15%. However, WHO also has many excellent midwifery educational publications that midwives may not be using, including

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

The overview for this publication describes the contents:
     “This guide provides evidence-based recommendations to guide health-care   

      professionals in the management of women during pregnancy, childbirth and 
     postpartum period, post abortion, and newborns during their first weeks
     of life.  It is a guide for clinical decision-making.  It facilitates the collection,
     analysis, classification and use of relevant information by suggesting key
     questions, essential observations and/or examinations, and by recommending
     appropriate research-based interventions. It supports the early detection of
     complications and the initiation of early and appropriate treatment, including
     timely referral, if necessary.

In other words, where ever midwives are providing evidence based care, this is what they should be doing.  The Institute for Clinical Systems Improvement (ICSI) also publishes two interactive healthcare guidelines. The first is for  Routine Prenatal Care, and the second is Management of Labor.  

Routine Prenatal Care pertains to the care of all women who are pregnant or are considering pregnancy, and the labor management guide is for all women who present in labor, including preterm labor.  

Management of Labor provides algorithms (charts) for decision making during labor, birth, and the newborn period.

The Hesperian Foundation publishes a number of books and guides for developing or low literacy countries, including Where There is No Doctor.  An excellent guide for pregnant women, simply written is A Book for Midwives.  You could purchase the entire book as a download, but the Hesperian Foundation has made the chapters available here, for free. The medical advice used in the book has been recently updated to reflect WHO guidelines for safe, evidence based care during pregnancy. This is the care your midwife should be providing using the best evidence available. 

If labor is progressing normally, watchful waiting and careful attentive monitoring are required. If your labor varies, or something feels wrong to you, your midwife should assist in assessing the situation and transfer you to the hospital.  A Cesarean is not automatic when you transfer to the hospital, but more careful monitoring may necessary to be sure you and
baby are safe and healthy.  Cesareans are also not the worst possible outcome should the need arise.  A safe and healthy mother and baby in end is what most mothers care most about.  At times we become so entranced with the "experience" of birth, we lose sight of what matters most. 

Links for each of these guidelines is included above, but they are summarized in the two tables below.

Safer Midwifery for Michigan has already discussed what should be included in Routine Prenatal Care at each visit.  The remainder of this post will describe the conditions that mean you should trust yourself that the pregnancy is no longer completely normal.  Unfortunately this list of signs and symptoms have been taken from the birth stories of loss moms.  Women whose babies died or were permanently injured because the midwives caring for these moms either didn’t know that these were signs of complications or did not believe the mothers.  If these things occur, please find answers.

Sometimes there are other explanations, but minimizing your symptoms and hoping they will go away is not the same as knowing these things are not problems.  Trying to manipulate the symptoms does not mean they didn’t occur. Using a different thermometer to get a lower temperature doesn’t mean you didn’t have a fever.  Resting on your left side for 10 minutes before having your blood pressure retaken, and getting a lower number the second time, doesn’t mean you don’t have high blood pressure.  It only means your midwife has found a way to get a lower number so she doesn’t need to make the diagnosis of hypertension or possible pre-eclampsia. Or, that she doesn’t need to transfer you to the hospital.

Although some midwives may say this chart is medical management and such precautions are not necessary with a normal pregnancy, if these things are happening with your pregnancy you need to know that they may be signs of complications or impending complications.  The midwife may tell you that she has seen this before, and everyone was fine, meaning it’s no reason to go to the hospital.  Dismissing or minimizing your concerns does not make the problem or the risks go away, and it may put you or your baby in danger if ignored.  A skilled, knowledgeable, and competent midwife will take your concerns seriously and will help you find answers. 

Remember how often your midwife told you that she was an “expert in normal birth”?  That she was also excellent at catching complications before things got serious, and would transfer you to the hospital if complications occurred?  The situations in these charts are some of the red flags they were talking about.  Is she living up to the expectations you had for the care you thought you would receive?

Care During Pregnancy

Sign or symptom
What it could mean
What may happen next
Bleeding, 15-42 weeks
Placenta previa or abruption.
May be a minor problem and could resolve on its own. However, you should have an ultrasound so you have better information for making decisions. The bleeding may occur on and off but may recur during labor. The bleeding you are seeing is almost never all the bleeding occurring, as the baby’s head may act as a cork at the cervix.
Severe pain in abdomen or uterus
• Any belly pain with fever can be a sign of womb infection.
• Constant belly pain in late pregnancy may mean the placenta is coming off the womb wall.
• Strong, constant belly or side pain in the first 3 months may mean that this is a tubal pregnancy.
The severe pain may be caused by an infection or problem not related to pregnancy. You may have a kidney stone, appendicitis, or a problem with your gall bladder.
Any of these things may cause problems for you and for the baby including the baby coming much earlier than it should.
Severe nausea
You should be concerned if you can’t keep water, or any other fluid or food down.
If the mother is unable to keep fluids down and stops urinating,
get medical help immediately. She may already have severe
dehydration, which is very dangerous.
Large amount of uterine (baby) growth
May be twins.
May be that your pregnancy is farther along than you think.
Could be a very large baby or an excessive amount of amniotic fluid.
If you decided not to have the glucose test at 24-28 weeks, you may have a missed diagnosis of gestational diabetes or diabetes that was present before pregnancy.
A very large baby may make it difficult for the baby to get in the best position for birth and lead to shoulder dystocia.
An excessive amount of amniotic fluid makes it easier for baby to float in the uterus which increases the risk for a cord prolapse or a baby that is breech, sideways, or otherwise in a poor position for birth.
Less  uterine (baby) growth than expected
Pregnancy may not be as far along as you or your midwife think, but baby may also be smaller than expected because the placenta is not working correctly.
Babies who are not receiving enough nutrients because the placenta isn’t working well will usually have problems with low blood sugars when they are born, which can lead to trouble breathing and maintaining their temperature. Low blood sugars can lead to brain damage that becomes permanent.
Can have a number of causes from an infection you have to an infection the baby has.
You should try to find the reason for any fever. If your midwife can’t help, seeing your family doctor might. It may be a kidney infection, but could also be an infection of the amniotic fluid, or  of the uterus. These infections require antibiotics. Untreated infections may lead to  the baby’s death from sepsis (severe blood infection).
High blood pressure, headache, dizziness, or blurred vision , especially with generalized swelling

Usually associated with preeclampsia.
The Brewer diet does not prevent or treat preeclampsia. Urine dip sticks are not an accurate way of finding protein in the urine. Preeclampsia labs need to be done and a 24 hour urine performed. Anytime the headache doesn’t go away with your usual remedies, you should have it investigated further at the hospital.
When a woman has high blood pressure during pregnancy, it is harder for her blood to bring food to the baby. The baby then grows too slowly. Very high
blood pressure can also cause the mother to have kidney problems, bleeding in the womb before birth, or bleeding in the brain.
High blood pressure can also be a sign of pre-eclampsia. Pre-eclampsia can cause premature birth, bleeding, convulsions, or even death for the mother.
Blood pressure elevated
Usually associated with hypertension, and pregnancy may make the high blood pressure more obvious.
Can also be associated preeclampsia.
(See headache with swelling above)
Women with pre hypertension or chronic hypertension are at greater risk for developing preeclampsia, but this may also indicate a need for lifestyle changes to prevent the development of chronic hypertension within a few months or years.
Labor doesn’t start by 42 weeks
Baby is in a bad position, the head is in a bad position and can’t apply the appropriate pressure to the cervix to assist the start of labor.
It can also be related to chronic medical problems like under functioning thyroid (hypothyroid).

If labor doesn’t start on its own, then the family should ask themselves how long they are willing to wait, and whether waiting  will make the birth more likely to occur.
As long as baby if moving the same number of times each day it is fine to wait for the baby past your due date.
However, at approx. 41 weeks a biophysical profile (ultrasound) should be done to check the amount of amniotic fluid and how well baby is doing with waiting. If the amniotic fluid is very low, there is a greater risk that baby will inhale meconium when it occurs because there is less fluid to dilute the meconium. A low volume of amniotic fluid also increases the risk that the cord will be “pinched” during labor, or that baby may not have gotten enough nutrients to tolerate labor well.

Care During Labor and Birth

Sign or symptom
What it could mean
What may happen next
Bright red bleeding
May be an undiagnosed placenta previa or a placental abruption.
The amount you are seeing is not all there is, and baby has a lot less blood to lose than you do.
Very long labor

Close  or strong contractions with little progress

(Usually a sign of obstruction either because of the shape of the pelvis or the position of the baby’s head)
Once you reach 4 cms  (6 cms if you have had 5 or more births) you should be making steady, continuous progress in labor.

Active labor should not last longer than 24 hours for a first time mother, and no longer than 12 hours for a mother having another baby.
If you had a previous Cesarean for CPD, this may be an indication that the problem has recurred.
A very long labor may mean the labor is obstructed. Signs of obstruction include:
 Continuous contractions.
 Constant pain between contractions.
 Sudden and severe abdominal pain.
 Horizontal ridge across lower abdomen.
 Labour >24 hours.

Can lead to exhaustion for the mom, or permanent, serious damage to the baby.
Worst case scenario is a catastrophic uterine rupture which puts mom and baby at risk for dying.
Water is broken for a long time
A long time is 12 hours without signs of labor beginning
Consider going to the hospital, but at all times you should be watching for signs of infection.

Go to the hospital immediately if you notice
 Fever >38˚C  (100 degrees F)
 Foul-smelling vaginal discharge
A sign of dehydration or infection.

All infections in labor are dangerous for the mom and the baby.
The uterus doesn’t contract well if you are dehydrated. So you have an increased risk of prolonged labor and a large hemorrhage after baby is born.
If you have an infection, baby probably has an infection too. These can be life threatening especially for the baby.
Pushing without progress for longer than 2 hours in first birth, longer than an hour in subsequent births.
The mother’s genitals should be bulging within 30 minutes of when her cervix is completely open and she begins pushing.

If the birth is taking too long, go to a medical center. This is one of the most important things a midwife can do for the mother and baby to prevent serious problems or even death in women or their babies.
If you have tried different methods for bringing the baby down — better pushing, different positions, emptying the bladder, rehydration drink, acupressure, and any other methods you know — and you still see no progress after 1 hour of good pushing, you should go to a medical center. It is not safe to wait until more warning signs appear.
Severe abdominal or uterine pain
• Any belly pain with fever can be a sign of womb infection.
• Constant belly pain in late pregnancy may mean the placenta is coming off the womb wall.
Severe pain in the abdomen or uterus during labor is usually a sign of the placenta becoming detached (abruption), the uterus tearing (uterine rupture) or an infection in the uterus.

All are emergencies and you need to go to the hospital right away. Don’t wait to see if the pain goes away or becomes worse.

Dehydration can also make a woman feel exhausted. Signs of dehydration:
• dry lips
• sunken eyes
• loss of stretchiness of the skin
• mild fever (up to 38°C or 100.4°F)
• fast, deep breathing (more than
20 breaths a minute)
• fast, weak pulse (more than 100 beats a minute)
• baby’s heartbeat is faster than 160 beats a minute
Baby has a slow heart beat when the midwife listens
The midwife should listen to the baby’s heart beat at least every hour in early labor, every 30 minutes in active (hard) labor, and with every contraction while you are pushing.
These things can cause the baby’s heartbeat to drop below 100 beats a minute:
• Cord is very short or is being
• The baby is not healthy.
• There is not enough amniotic water.
  Placenta does not work well, usually because the mother has high blood pressure or the baby is late.
  • Placenta is separating from the womb.
• Contractions are too strong.
(This is rare for a normal labor. But too-strong contractions can easily happen to a woman who is given medicines or herbs to strengthen labor.)

If the baby’s heartbeat is slower than 100 beats a minute and stays slow until the next contraction or almost to the next contraction, the baby is in danger. This is especially true if there are other warning signs, like green waters or a long labor. The baby could be very weak at birth or have brain damage.
You must go to the hospital so baby can be watched more closely.
Baby has a fast heart beat-faster than 160 beat per minute.
The midwife should listen to the baby’s heart beat at least every hour in early labor, every 30 minutes in active (hard) labor, and with every contraction during pushing.
These things can make the baby’s heartbeat speed up to more than 180 beats a
• The mother is dehydrated
• The mother or baby has an infection
• The mother is bleeding.
• The mother has been in labor for too long.
• The mother’s womb is tearing
(uterine rupture).

If the baby’s heartbeat stays fast for 20 minutes (or 5 contractions), get medical help.


Related Posts: 
The Delicate Relationship Between Assessment and Safety
Women Deserve Not to be Their Own Midwife