challenging births 3
sara wickham
This article was originally published in
Midwifery Today.
Republished with permission.
This article is based on the 'Challenging Births' workshop which I lead at Midwifery Today conferences. In this class, I give a clinical scenario to two or three small groups of practitioners, who brainstorm the issues and debate what they would do, what other information they would look for in making decisions with women and the kind of issues this raises for midwives. The small groups then feed back to the larger group, who discuss the scenario and the issues raised. These articles have been written with permission of those who took part in the classes. The words of the participants have been transcribed, with only minor revisions for clarity and to maintain confidentiality. Many thanks to the midwives, aspiring midwives, childbirth educators, obstetricians and others who took part in this class.
You are a midwife doing an antenatal visit. Elaine is 42 weeks pregnant with her first baby and has planned a home birth. She is aware of the issues surrounding postmaturity but feels strongly that her baby will be born when it needs to. She is reluctant to consider any medical intervention in her pregnancy, but is interested in having your perspective and hearing about any evidence you can offer her. You can detect no problem with her or the baby. What issues does this raise for you, and what would you be saying to Elaine at this time?
“We sort of agreed that the first thing we would do is check her dates to make sure that the dates were correct, based on her last period, the date of her first visit, if the size matched and that kind of thing. We would discuss with her her fears and why she wanted to hold onto this baby, that kind of thing, just talk about the emotional issues and all that. And then we would go to a non-stress test which is where we put the monitor on (which, by the way is not an ultrasound thing, it's connected to a computer, it's not generally available). That would give us an idea of how the baby's doing in there in terms of accelerations, the variability of the heartbeat and when the baby moved if the heartbeat went up, those things that are normal. My colleague says that in her country an ultrasound could be done to check the end diastolic flow from the placenta, I wouldn't do that here in the US. I guess we could send them for an ultrasound and they would check the fluid levels and that kind of thing. Then we would go to send them home so they would have intercourse … lovemaking … one of us suggested nipple stimulation and castor oil but another does not like nipple stimulation because she's seen it cause really very strong contractions, so she does not recommend that at all … she would say lovemaking and rest and leave them alone.”
“At the first visit we would ask her how long was her period because it's very important to count when she is term.”
“We agreed with those things, we had a consensus that we were not sure that we cared that much that somebody is post-dates. Of course we would go over her dating, but three of us come from an era where 43 weeks was OK, as long as the mother doesn't have other medical problems, so that was interesting that we weren't blown away by the fact that she had reached this deadline. As part of the informed consent we would tell her the concerns, what the literature shows and maybe what the standard of care is in the community, for what's usually done, and then we would elicit feedback from her about what we were saying, it would be a two-way thing. That might lead to her willingness to go for a non-stress test, and we would review fetal movement counting with her. We weren't sure where it said that she wasn't interested in medical intervention whether that would include some of the other possibilities … castor oil, nipple stimulation (although we're glad to hear what you have to say about that!), having sex. Once we do informed consent it's a two-way street and you see what she is comfortable doing as an action.”
“Just also checking her cervix, where is she at, how 'induceable' is she, how ready is she, how far along?”
“I guess coming from the era where they didn't worry at 42 weeks and they just left people alone, I was forced to have a little discussion here about aren't we interfering by doing the, 'you know, you could be getting into trouble and you should be doing this, that and the other thing to get your baby delivered because I am starting to get worried as a midwife.' In the old days it was like, 'OK, your baby's not ready.' End of story.”
“I don't know if I'm very representative of my group, but that's OK! Both of these ladies with me come from personal situations … she had a sister who had a breech baby at 44 weeks very happily, and she had three c-sections for post-dates, 42 weeks, that kind of thing, and is dissatisfied with that. And I don't have a personal story and so I feel like they were very much of that 'that's fine, no big deal' philosophy, and I was more stuck with my stupid protocols! We talked a little bit about the pregnancy six, a mixture of herbs you can get in health food stores, most of them have black cohosh in them, some of them have false unicorn, they are varied a little in what they have but there are some commonalities. I always send women off with them, I don't know whether I should, maybe it's intervention. At 34 weeks I say to everybody, 'start these, if it makes you contract too much, stop them. Otherwise just keep going.' To prevent post-dates and I kind of believe it works. And also evening primrose oil 500mg every day, also from 34 weeks, and from 38 weeks evening primrose vaginally also. And that's my standard, I think most people around seem to do the same thing, I don't know whether that's too much intervention. And the other thing we did mention was reaming out the cervix, is this too much intervention for some people or not? I don't know.”
“I talked about a case where a lot of fear was developed in a woman that I was a Doula for, just because of the thought of going for a biophysical profile and that maybe they would find that there wasn't enough fluid and maybe they would make her get an induction. She was so scared of going for this test that she drank castor oil to induce her own labour and she ended up with a three day labour … she didn't sleep for the whole laborl she was totally physically exhausted for the whole labour and had nothing left and ended up in the hospital and had an epidural and everything and this was a home birth. So the fear of the test making her have to go for the induction led her to induce herself and a castor oil induction is pretty strong. Just because it's a herb doesn't mean that it's something benign, it's very powerful and you're taking it kind of into your intellectual hands instead of letting your body decide when it's going to come.”
“I believe in family history, and genetics play a very important part in my life. So the first thing that I would think of, I will try to get a generational history and all of my colleagues here thought the same way. They believe that if the grandmother went for 44 weeks and the mum went for 43 weeks why should we worry if she don't want to be interfered with at 42 weeks? But if you the midwife feel that you should be worried then the only thing that you try to do for her as a midwifery model is to tell her all of the modern things that you all spoke about, the kick chart, the flow chart, the ultrasound, they all are the paraphernalia's that we have to deal with this poor mum at 42 weeks. Who really I am not worried about because, as I tell you, her whole generation is that, so therefore her picture is perfect. And maybe she knows that this is what happens with her whole generation. Then my colleague says that suppose she did not come from that generation and she is a mother who should be ready at 40 weeks. But who are we to say that she is 40 weeks? Do we have her correct dates? What is the length of her period? Does she carry a good period? You know, we have to think of all these things when we do a chart on a mum and make that date become 42 weeks. There are a lot of things that go into that 42 weeks. I really don't believe too much in it and that's the truth. I don't like them to go to 44 and 45 and all of that but at 42 weeks we have no worry about it. We talk about castor oil, but - and I am talking personally now - I have had a terrible experience with castor oil that if I hear that word I shudder. Because of the fact that a patient went into anaphylactic shock almost. Thank God I was able to have another midwife with me so we could have given her intravenous medication and oxygen and all of that to revert, and we caught her just in time. So you know what happened eventually, we had to get the baby out just because of castor oil. So therefore this mum, I respect her if she doesn't want to have interference. I personally feel, if everything goes well with her, no interference. If you as a midwife feel that you should be handling her management and not her handling her management, well then you go ahead and do all the other little odds and ends and paraphernalia's that we have…”
“Please tell us what you mean by, 'does she carry a good period?'”
“Well I have run into problems, remember I'm 35 years in this business, and I've seen mums who have a three day period, I've seen mums who have a five day period, mums who have a seven day period. And when you have this type of mixture, when did she get pregnant? For you to evaluate and for her to evaluate that she's 42 weeks pregnant? So they are normal having a three day period, a five day period, a seven day period. You have some women who have a nine day period. So if you have a mum and her pregnancy, how does she arrive at that 42 weeks. She may be normally 40 weeks, or 39 weeks but by our calculation this is what happens.”