Thoughts on inductions before 39 weeks of pregnancy

I've been out of the blogging for awhile. Life kind of got busy. But today seems like a good day to share some thoughts.

The American College of Obstetricians and Gynecologists (ACOG) recently released a bulletin discussing inductions. Here we are referring to inductions of labor by the use of medications or mechanical devices that stimulate labor to deliver a baby. The new recommendations are that there should be no inductions of labor before 39 weeks of pregnancy unless there is a medical reason. "Tired of being pregnant" doesn't count on the mom's side. "It will interfere with my time off" doesn't count on the provider's side. In other words there needs to be something like a problem with the baby or a medical problem with the momma.

Here is where it gets tricky. There is politics involved. Some providers follow this standard very aggressively. After all the March of Dimes, a wonderful organization in the U.S. that is dedicated to healthy babies, has made it very clear that before the due date, at 40 weeks, there is a lot of brain development that still happens even when the baby is considered term at 37 weeks. I see pregnant women every week who think their 35 week baby inside is just as ready to be born as the term baby at 40 weeks. They imagine that the baby will be fat and healthy and feel nothing could possibly be gained by waiting another 5 weeks. Once I explain to them how much more growth the brain still has to do many of these moms then come to understand that waiting on Mother Nature is the right thing to do. But not all providers share this information with their moms. If it is more convenient to schedule an induction of labor because it makes their clinic time flow better or because they want their time off on the weekends not being bothered by having a laboring woman show up to care for, they will just schedule the induction. If that provider has some political clout in the setting they are delivering these babies in, they often get away with it. But that doesn't make it right.

What is new on the horizon? There are many hospitals now looking at implementing strict rules for when a woman can be induced. They will insist there be good dating criteria for how a pregnancy is calculated to be 39 weeks before an induction is scheduled. For example, how early was an ultrasound done in the pregnancy? The earlier in the pregnancy the ultrasound, generally the better the measurements can tell exactly how far along a pregnancy is and when the baby is likely to be due. Another measurement might be done by an amniocentesis at the end of pregnancy to see if the baby's lungs are mature. This is done by sticking a needle in the woman's abdomen and withdrawing some fluid from around the baby. An amniocentesis has its own potential risks such as accidentally nicking the baby with the needle or accidentally going through the placenta and causing bleeding. Most of the time an amniocentesis is done with an ultrasound to guide where to place the needle, but that still doesn't make it risk free.

Evidenced based care for pregnant woman and their babies is clear: inductions of labor before 39 weeks of pregnancy is not good care unless there is a medical reason or a reason such as the woman lives 2 hours away from a hospital. There are other reasons that make sense for induction, and this should be left to the provider and to the woman to figure out. The one piece I think is missing in the system of care we have now is who is double checking if this induction is good for the baby? Nobody. There is nobody in place as the system is set up now who will question this prior to the induction. I think the piece that is missing in the current system is the baby's advocate, be that the pediatrician or neonatologist or some other party that would have the baby's best interest at heart. I wonder if this will ever fall into place in our country? I wonder if there is anywhere out there that has this in place? I would love to know.

My lastest theme

Life has a way of bringing a certain thought or a certain theme and then playing it out in several ways. It is as if life wants you to look at the various angles of a theme and learn from it. My theme of late seems to be meeting patient expectations. I feel like I have succeeded wonderfully at times, but I have occasionally missed the mark leaving unfulfilled desires for what they want.

An example of what I am talking about happened recently when a patient came in and started talking about how another midwife has told her things were going to be done a certain way. In this particular case the patient was referring to a plan of care I didn't feel was actually what would or should be done. However, the patient was adamant that the other midwife said this was the plan of care. I wasn't argumentative, but I did try to correct and set expectations realistically. Patients don't want to hear it when you don't agree with what they have in their head about what is going to happen, and this put me in a bad spot this week. I don't think the patient was mad at me, but I think she now doesn't feel I met her expectations for her care. It makes me sad to think I can't make everyone happy all the time. This patient is also sure another midwife will be coming in to care for her when the time comes for the baby. I wish we could promise things like that, but it isn't realistic to promise that if there is no guarantee it will happen that way. So again, I did not fulfill what this patient has set in her head will be the story of her future birth experience. And again, this makes me sad to know this expectation will make her unhappy if I happen to be the one on call that day. Well, actually I might not make her unhappy, but her expectation is that the other midwife will be there and if it isn't fulfilled then when I walk in I will feel awkward and it will be a hurdle to get past.

To counter this theme, I had a patient I saw recently who I had cared for in a previous pregnancy in a previous practice. Her mother was with her and in the hallway as I prepared to go in to see the patient. When I walked into the room the patient said that she remembered who I was. I wasn't sure I could remember her until she told me her story of why she remembered me. She had had a long induction of labor; it was over a couple of days. When I took over her care she was exhausted, tired, and had given up. She told me she just wanted a c-section. I encouraged her, tried to help her recover some energy and push forward through the labor. At one time I told her firmly that "no" she was not going to have a c-section. She delivered vaginally. She shared with me that at the time she was mad at me, but now she is happy to know I am going to care for her this pregnancy because I helped her through such a tough moment in her life by telling her "no" and helping her through. So again, here was a story of how I had failed at the time to meet an expectation by the patient; the expectation being that I should have helped her give in and get a c-section, but I was not doing that and I made her mad. I was so happy to hear that in the long run the fact that I didn't meet her expectation at the time turned out to endear me to her because it was what she needed at the time. She saw after the event that though I didn't give her what she thought she needed, in fact I had given her exactly what she needed.

And finally, to add to the theme is a case in which it wasn't me who failed to meet a patient expectation, it was another provider who failed to meet an expectation. However, I had to repair the damage done. This past week a patient came to our practice full of questions, angry at another provider, and suspicious of what kind of care we could offer her. I spent a lot of time with her answering her questions, asking questions of her, trying to find out what the worries and concerns were that she was having. We found a lot of common ground. She had something in her history that I wasn't sure how to proceed with during this pregnancy, but I spent some time and looked up what care we needed. I then arranged it with her. She was amazed that I took extra time to do this, that I took the time to address concerns, and that I was not doing the things that had failed her in her past experiences. It was wonderful to try and meet someone's expectations and then to exceed their idea of what they are looking for. It is exhilarating when that happens as a midwife.

As I ponder this theme of meeting, not meeting, or even exceeding patient expectations for what I will provide for them I come away with a few thoughts. Women want someone who is caring, but who is also able to draw the line when that is the best thing for her and her baby. This means sometimes we are not going to be liked by the patient or the family. Sometimes the decisions we make are unpopular with the patient or family. It isn't fun for me when this happens. But then expectations have to be realistic and it is my duty to try to set realistic expectations. Some women have very unique ideas of how they want things done and sometimes I don't "get it" but as long as nobody is unsafe I can go along with supporting it. I wish everyone loved my care and wanted me as a midwife, but it isn't the way life works. Personalities sometimes don't mesh. Top of the pile for me with this discussion though, is that I can't own everyone's problems and still remain healthy and helpful. If I tried to make everyone happy all the time I would burn out and be useless to those women who need me there with them. So it is a matter of balance. I have to balance what is reasonable for them to expect of me, what is reasonable to expect for their experience in pregnancy and labor, and try to dislodge anything totally off the mark and unrealistic.

Maybe all this thinking on this theme this week is why I am in a very thoughtful mood tonight.

The Swine Flu downgraded for me

I think I have the Swine Cold. It isn't the Swine Flu...I'm not that sick. But I have had chills, body aches, a sore throat, a mild headache, sneezing, and runny nose. No fever. Yesterday I had a few dizzy spells. I haven't been sick in the bed. I have decided I have single-handedly down graded the Swine Flu to the Swine Cold all by myself...I just hope I don't have to wear that mask, it makes it so hard to breathe through those N95 masks.

Wanna know why you can't help yawning when you see this guy?

After I wrote my last post about Mirror Neurons, I was reading a book about body language and ran across this interesting tidbit of information. I will now quote:

"We mirror each others body language as a way of bonding, being accepted and creating rapport, but we are usually oblivious to the fact that we are doing it. In ancient times, mirroring was also a social device that helped our ancestors fit in successfully with larger groups; it is also a leftover from a primitive method of learning that involved imitation. ...One of the most noticeable forms of mirroring is yawning--one person starts and it sets everyone off....yawning is so contagious you don't even need to see another person yawn--the sight of a wide-open mouth is enough to do it." p 250 (see citation below)

"Being "in sync" to bond with another person begins early in the womb when our body functions and heartbeat match the rhythm of our mother, so mirroring is a state to which we are naturally inclined." P 252 (see citation below)

"American heart surgeon Dr. Memhet Oz reported some remarkable findings from heart recipients. He found that, as with most other body organs, the heart appears to retain cellular memories, and this allows some patients to experience some of the emotions experiences by the heart donor. Even more remarkably, he found some recipients also assume the same gestures and posture of the donor even though they have never seen the donor. His conclusion was that it appears that the heart cells instruct the recipient's brains to take on the donor's body language. Conversely, people suffering from disorders such as autism have no ability to mirror or match the behavior of others, which makes it difficult for two-way communication with others."

---The Definitive Book of Body Language, by Allan and Barbara Pease, p 253.

As I read this I thought, "This is mind blowing! These authors are telling me that we not only mirror, but it is built into us on a cellular level and we learn this from the womb!"

We are supposed to be in sync with one another. If we weren't we wouldn't form families, tribes, nations. It is built into us to bond. From the moment we are formed we are bonding. We start by bonding to cells upon cells. We are then bonded to our mother's womb. We are bonded with our parents and family. We are bonded with our mate. We are bonded with our children, and our friends, and our communities. We are meant to bond. This is why we learn to mirror. It helps us have empathy with others. It helps us care about others. It helps others care for us. When we don't have this bonding, then this breaks the natural rhythm of humanity.

But I digress...for our little laboring couple that I care for as a midwife, I have to do what mirrors caring activities, behaviors, and words. I have to mirror what good care means and behaves like. As a midwife I need to assist a couple who is laboring the various ways they can support one another through this intense time. But now I will have a new perspective. It is helpful for me to know that the couple and the baby being born are bonded already and that I am a facilitator to help this new life being the bonding outside the womb.

Mirroring care using the mirror neuron system in our brain

I've been studying about mirror neurons. These little neurons in our brain allow us humans to understand the intent of motion, understand emotions of others, they help us have empathy, and it even can contribute to the learning of language. When we watch someone doing something, we use our mirror neurons to tell what the intent is.

Scientists learned about these little guys by hooking up some monkeys in a lab and discovering that when this lab tech walked by the monkey with something to eat the monkey watched him eat it. The neurons fired off telling them that the monkey knew the intention of the man was to eat and this made the monkey also want to eat. I am no scientist, but I think it is amazing anyone thought to check to see that special neurons in our brain are looking at what others are doing and then figuring out the intent.

As humans we can watch someone pick up a stick. We immediately have our mirror neurons fire off a message, "Hey, he picked up a stick." Then our brain does this quick process where several parts of our brain coordinate what is being visualized, we "feel" what the person is about to do with their actions, and in this way our mirror neurons help us figure out if the guy is going to use the stick to knock a piece of fruit off the tree, use the stick to carve something into, or hit at us.

Ever wonder why when you see someone you love hurting you can sometimes you also feel the pain? Voila...mirror neurons have told you, "Hey, your loved one is hurting. You see her hurting? Now to understand how she hurts I, your mirror neuron center, am going to help you "feel" this hurt so you will understand what is going on and you can decide if this is something minor or if this is a crisis." This in turn helps us decide if action is needed. Maybe we need to stop and help versus maybe we need to run away quickly from that man with a stick!

When we see a dancer we visualize this person dancing. Our mirror neurons fire off and we can start feeling our bodies want to move like that dancer. Sometimes we actually do move like that dancer. If we ourselves are trained as a dancer and we see the other dancer then our mirror neurons really fire off hot and heavy because our brain understands even better what is being done, versus someone like me who just enjoys watching a good dancer.

So why am I talking about mirror neurons? Because I think as a midwife I need to utilize these mirror neurons more. I think families watch what I do with women in labor. The father watches me to see how I comfort a mother. He assesses pretty quickly if I am there to help or harm. If I am doing something that comforts the woman in labor, maybe an action I do or have him do for her, then he can feel it is safe to do the same. In a crisis I mirror calm control, so that the family and staff around me also mirror that same calm control. As humans we watch one another. We assess the body language of others constantly and match it against their words. As the midwife I should be more aware of open body language, so that this is mirrored with the patient and the family I am working with.

Mirror neuron theory is relatively new. It has many applications but I propose comfort and caring for others is the biggest practical use for learning about this system in our brain. If we can use it for good purposes, i.e. helping others, then it is going to be a wonderful pearl in our treasure chest of things to use to care for others.

What makes midwives different, and what my patient taught me today

Why some patients choose midwives is interesting to me. Some just get referred to our site from their insurance company. Some patients hear about us from referral sites like health departments, friends, family. Occasionally advertising brings some new patients in to see us. And some women already know about midwifery care and seek us out.

Lately we are having a run on women who are saying things like, "They just didn't care about me at my last place." Or another comment I have heard a lot with our recent transfers is, "You talk to me. They never explained anything to me at the last place." Let me clarify, these are various other practices not just one previous provider.

However, today I had a patient come in who explained she didn't like it when someone touches her and doesn't explain why they are going to touch her. She wanted to know if we would touch her without talking to her first and explaining why we were doing something, because this was important to her. She said she didn't mind having exams, but it was the lack of respect for her need to have control over who touches her. Obviously there are boundary issues, but it did set me to thinking (as they say in the South). Why do providers, be they physicians, midwives, nurses, or anyone caring for people, automatically assume we can touch a patient? This patient brought home to me that just because I am a provider does not give me the right to touch her without explaining to her first what I am doing.

Let me say right now that I have always tried to explain things as best I can when I feel the need to do something. But here is my point. If I am going to measure a fundal height, that is measuring how big the baby is during pregnancy by measuring her belly, then I should ask first if it is ok to touch her before just assuming since she is lying on the bed that I can touch her. Some of you out there may be way ahead of me on this, but to me this is a new concept. I don't think about simple things like this. For example, now if I am going to do a Pap smear I ask the woman to lie back, put her feet up in stirrups, and then I explain how she can relax through the process. I tell her when I am going to touch her, and what is happening. What I haven't done up until this point is ask her permission to touch her. Specifically I haven't said, "Is it ok for me to touch you now so I can do this Pap smear?"

I think the fact that midwives are supportive of empowerment of women, this is the main reason our patients continue care with us. Caring for the patient as an individual is the hardest thing to do when you are in a busy practice, but it is what separates midwifery care from any other kind of provider.

Following the secret to its end; why I have to learn to keep them

Ever had a secret? It is hard to keep a secret. Mostly it is hard to keep because you want to tell someone so badly. When I have a secret I try to forget it, that way I don't get tempted. But not all secrets are meant to be forgotten. Some are so fun you want so badly to share them. Still, if you give in and do share them then they are not secrets anymore and now you have gossiped. Once you gossip the cat is out of the bag. The gossip becomes someone else's secret and they have a hard time holding onto that secret and before you know it they have gossiped. The gossip spreads. It might not be so very bad, however it seems that the more the gossip gets passed the less true it becomes. There is a grain of truth in there somewhere, but by the second or third telling of the secret it isn't enough of a truth to be accurate.
When the gossip is fanned out with enough people this non-truth becomes the unspoken truth. Everyone thinks they know the real story when they don't actually know anything at all except a tall tale. Or at least a short snippet of the truth. What happens next can ruin reputations. When reputations get smeared these become more important then knowing what the truth actually was to begin with and before you know it....the person that the secret was about has no idea why everyone is acting funny around them. Or the person goes on blindly acting like everything is OK, with everyone around them pretending it is OK, when it isn't.
So when I have a secret I have to remind myself why it is important to try to keep that secret. Too many times in my life I gave in to the temptation and too many times it came back around to bite me or someone I know in the butt. The lesson I want to learn as I enter my middle-age in life is to try to keep the secrets I know right where they belong, which is locked away tightly behind sealed lips.