In this the second part in this brief series on cervical insufficieny/incompetent cervix, Bedrest Coach Darline Turner offers another potential cause of CI/IC- inflammation-and discusses the role of 17 Alpha-hydroxyprogesterone caproate (17P).
I was speaking with my mom the other day and we were chit chatting away about my work. My mom is really interested in “this bed rest stuff” as it was not really common when she was having us in the late 50′s and early 60′s. My mom asked me, “Is bed rest really that common?”
Bed rest is certainly more common now than when my mom was having kids and there are a myriad of reasons. Just to bring folks up to speed, according to the CDC the numbers are still holding at some 750,000 women going on bed rest annually in the United States. But my mom’s question is one that hounds me. Why are so many women going on bed rest? I tried to find a specific answer and while the literature is not specific, here is what I have been able to gleen.
1. Bed rest is more common right now because we have more diagnostic tools to diagnose conditions for which bed rest is recommended. When my mom was having my sisters and I, many of the ultrasound machines and fetal monitors that are used today to evaluate a mama and her unborn child simply didn’t exist. If a woman had a short cervix, she simply had a short cervix. Now I can hear the collective cyber gasp at that statement. But at the same time it makes you wonder, “How many women over the centuries had a shortened cervix during pregnancy and had a completely healthy baby?” One could give the opposing view, “Well how many women lost babies due to shortened cervix?” We don’t know the answers to these questions, but it does make for interesting mental gymnastics.
I am currently researching the life and career of my great grandmother, a “granny midwife” in the south from the late 1910′s to the early 1950′s. I hear tell that she had an uncanny way of knowing which women were going to have problems and which women were going to be “good breeders”. I also am learning that she had phenomenal clinical skills. I wonder if she was able to examine a woman and note if her cervix was shortened? Or if she would have preterm labor? I do know that she saw a lot of women through their pregnancies and advised them when to stop working (most were farm women) and to rest. It’s an interesting historical perspective and as I learn more, I will certainly share with you all.
2. Bed rest is more common because we have more women having children later in life. I don’t know if I completely agree with this. My grandmother gave birth to my dad at age 43 and he was her 15th child, 13th pregnancy (2 sets of twins, yikes!!) Now one could argue that her body was accustomed to having kids (one about every 18 months!). But one could also argue that her body was “worn out”. As far as I know, she had no problems during pregnancy, no bed rest and no still births. She did lose the twin boys to infant illnesses.
One thing that my reproductive endocrinologist told me when I was in the “height of my childbearing years” is that ovarian age can be uncertain. By that he meant that some women may be 20 yet have the ovarian age of a 40 year old, and some 40 year old women will have more youthful ovarian tissue and function than their much younger counterparts. There is no way to predict which women will have “youthful” ovarian function and which women will not. Likewise, there is no way to predict when a woman will cease to have ovarian function. When we speak of advanced maternal age, we know that in general, as a woman ages, her ovarian function decreases as well as the quality of her eggs. However, we all know of older women who have had completely healthy, unassisted pregnancies, labors and deliveries, and young 30 somethings who have struggled. The best that we can say for now is, relatively speaking, as a woman ages, her chances of having difficulty conceiving and having complications during her pregnancy are increased and continue to increase as she ages.
3. Assisted Reproductive Technologies (ART). Today there are thousands of women who become pregnant as a result of assisted reproductive technologies (IVF, GIFT, ZIFT, IUI, ICI, Surrogacy/gestational carrier). The use of ARTs is a relative risk factor for a woman being prescribed bed rest because women who use ART are often older and often have pre-existing reproductive issues that would predispose them to complications any way. Additionally, women who conceive via ART are at greater risk for having a multiple pregnancy which increases the risk of going on bed rest.
3. Stress. I have written extensively in previous blogs about the role that stress plays on a woman’s ability not only to become pregnant but to maintain that pregnancy. Today more than ever women are balancing the demands of a career, a family that they have created, caring for family members from family of origin (parents or even grand parents) or have other pressing responsibilities not common to women 30 or more years ago. The work of Kathleen Kendall-Tackett PhD and others shows that the stress response has a direct effect on the cervix and preterm labor. Women who are under stress are releasing neurochemicals that soften the cervix and “ripen” it in preparation for labor and delivery-even if it isn’t time. Stress also increases a mama’s blood pressure and may cause her not to eat or take optimum care of herself so her baby may experience Intrauterine growth retardation (IUGR). It is critical that pregnant women avoid stress as much as possible not only for their own health but also for the health of their unborn babies.
4. Litigation. I hate bringing this topic into the argument, but in our current culture, litigation is probably closer to the top as opposed to the bottom of the list of reasons some OB’s put patients on bed rest. Currently, there is not scientific or medical evidence that bed rest is beneficial in preventing preterm labor or preterm birth. In a review article published just over a year ago, I reviewed the current medical literature regarding the efficacy of bed rest and again found no solid medical or scientific evidence for the use of bed rest as a treatment to prevent preterm birth. But as a former clinician, I also understand why OB’s prescribe bedrest. If on the off chance an OB discovered an anomaly with the pregnancy, yet did not prescribe bed rest and the pregnancy had an unhappy ending, that OB can count on being sued and would likely lose his or her ability to practice as an obstetrician. At the current time, medicine in the United States (or globally) has not discovered any other, more effective ways to deal with the complications of pregnancy that often result in the bed rest prescription. Until that occurs, bed rest, effective or not, will remain a “standard of care” in the management of pregnancy complications.
Now whether or not a woman should be put on bed rest is still a heated debate. Given that there is no scientific or medical evidence that bed rest is effective in the treatment of preterm labor, one could argue that we are potentially creating more problems for mamas and babies than solving. But to mamas who have been on bed rest and now have healthy babies, there is no other route to go and no talking her out of the fact that bedrest saved her baby’s life.
I pass no judgement because I know that when I was having my kids, if my OB had told me to spin on my head and shoot marbles out of my nose, I would have done it. I think that high risk pregnancy is an emerging field and one in which there is still much to learn. I am very excited to watch what is emerging in the medicine and science, and I am very excited to be a part of the public health solution of supporting mamas on bed rest.
The first was on June 25, 2001 at just 6 weeks. The second was on November 1, 2004 at just shy of 10 weeks. By all accounts the pregnancies were not going to be viable, and each “fetal demise” occurred before 12 weeks. Yet, in my mind, I have lost two children and no one can convince me otherwise.
I realize that my early losses pale in comparison to mamas who have lost children much later in their pregnancies, at birth or shortly after birth. But a loss is a loss it must be honored.
There are no words to describe losing a child. It is a gut wrenching experience and one that you never forget. Even though I had my “children” for only a few short weeks each, for each precious soul I had hopes, dreams, ideas and plans. To have those hopes and dreams abruptly end was devastating.
The one thing that I regret with my losses is that I never properly mourned them. Because my losses were so early on, people tended to view them as insignificant. I was told things like,
“Well, it wasn’t really a baby yet” or
“Obviously it wasn’t meant to be, so be thankful that it didn’t progress and that you didn’t end up with a handicapped or deformed child.”
While I wholeheartedly acknowledge that people were trying, in their very uneducated and ill-equipped way to put a positive spin on my situation, yet their words stung and only further depressed me. I now realize in hindsight that I had post partum depression (most notably after my second loss), and my struggle to simply cope lead to my husband and I just never mentioning the loss at all. To this day, we have never discussed the losses of our children and the impact that it had on each of our individual lives and on our relationship and family.
Mourning the loss of a child-regardless of the (gestational) age-is one of THE most difficult things a mama may ever do. But it is hugely important to recognize that child. What I didn’t know at the time of my losses and what was never offered to me was support for my loss. There are numerous agencies and organizations that support parents grieving the loss of a child. Because I lost my children so early and because of many of the comments I received, I didn’t feel that I had a right to mourn the loss of my babies. But no matter how early or late your loss, you have the right and the need to grieve and mourn. Below are but a few organizations that I know of that support pregnancy and infant loss. This list is by no means exhaustive, but if you have experienced a loss and need help with grief, you can at least start here.
Share Pregnancy and Infant Loss Support, Inc. The mission of Share Pregnancy and Infant Loss Support, Inc. is to serve those whose lives are touched by the tragic death of a baby through pregnancy loss, stillbirth or in the first few months of life. The secondary purpose of Share is to provide information, education, and resources on the needs and rights of bereaved parents and siblings, enabling more effective family and community support.
Healing Hearts Baby Loss Comfort-Healing Hearts Baby Loss Comfort was created in response to the reality that some pregnancies do not end happily. Healing Hearts Baby Loss Comfort is a place for women to feel comfortable looking for real, physical comfort, herbal remedies and spiritual nurturing, as well as a space to find resources, honor their grief and express their loss. It is also a place for those looking to support someone who has lost a baby.
Before I close, I want to draw particular attention to the organization, Now I Lay Me Down to Sleep. This organization provides photographs of the precious souls that have gone on to heaven for their parents and loved ones.
When I first learned about this organization, my initial thought was, “Eeeww!” But parents with whom I have spoken who have utilized the service say that having a photo of their child, naming the child and acknowledging the life of the child-however short-helped them tremendously! The photographs are exquisitely done and the parents may choose photos of the child alone or photos holding the child. For so many parents, having the opportunity to hold their child and have a family photo is priceless and solidifies the child as a member of the family. While this resource may not be for everyone, those families I’ve spoken to who have utilized the service say that the tangible memory that they now have of their child is priceless.
Pregnancy loss is a heartbreaking reality for many couples. But it is not something that should be passed over or minimized. That child, that soul, was a part of you and came into you life for a reason. The reason may not be immediately clear and most certainly the loss may never make sense to you, but there is a reason. It is important that you honor yourselves as parents and honor, in whatever way is best for you, the life of your child.
September is National Infant Mortality Awareness Month and we’re celebrating the lives of our “Precious Souls in Heaven”
I”ll Hold You In Heaven By Jack Hayford A great book for grieving Parents.