fetal morbidity

Mamas on Bedrest: Common Sense Isn’t Very Common

September 24th, 2012

My dear friend Renee has a saying that is so apt, “Common sense isn’t very common”.

The first time she said this, we both busted out in laughter and shook our heads at whatever crazy occurrence had just transpired. Since that time, I have said to myself time and time again regarding various occurrences, “Common sense isn’t very common.”

But when I see the lack of common sense in medicine and science it really gives me pause. I recently got a MedScape alert in my e-mail inbox entitled, “Prenatal Diagnosis: What About the Mother?”, and it was a short video commentary by Jack Rychik, MD, Director of the Fetal Heart Program at the Cardiac Center of the Children’s Hospital of Philadelphia. Dr. Rychik was explaining how medicine has progressed to where we can now make diagnoses of congenital heart abnormalities in fetuses as early as 14-16 weeks.  In his video he states,

“Making the diagnosis of congenital heart disease before birth provides multiple benefits. We can offer education to families. We can, most importantly, make a plan. When these babies come to term and they are ready for delivery, medication, care, and management can be offered to optimize the overall outcome for these patients.”

Dr. Rychik goes on to say.

“What we have appreciated of late is that, by offering these fetal echocardiography services and making a diagnosis [of congenital heart disease], we create a potential for maternal stress. In essence, these are mothers who have been given this diagnosis in their fetus but then there are months that elapse before actual management takes place. This is a period of time with potential for significant stress.”

At the risk of seeming snide, can we all give a collective, “Duh!” How can one not realize that if you tell a mother that there is something wrong with her child, she is going to be upset? How can one not realize that if you tell a pregnant mama that there is something wrong (and as serious as a congenital heart abnormality) with her unborn child, that she’s going to be upset? When I read his statement, “we have appreciated of late…” Really?? You’re just getting this?? Once again, common sense isn’t very common.

I am as appreciative as the next person of the advances that have been made in science and technology that enable advances in diagnosis and treatment in medicine. But I am even more concerned that medicine and science have forgotten that for all their ease of knowledge and function, technology and science are being used on and for people. Medicine and science are not just fascinating and interesting disciplines. At their core, and I am speaking specifically about medicine here, they are about improving the human condition. Medicine is (or should be) about making people feel better, easing their pain and restoring them to a state of good health. This should always be the guiding principle whether we are talking about improving the lifestyle of a diabetic, improving mobility and function in a paraplegic or making an early diagnosis and treatment plan for a pregnant mama and her unborn baby. To forget the human element in favor of medical science is a travesty. We cannot lose the human element to medicine.

When I first started Mamas on Bedrest & Beyond, I was (and continue to be) adamant that the focus be on mamas. So often with obstetrics and pregnancy the focus shifts to the baby and mamas seem to be relegated to ‘gestational carriers’. While I don’t believe that any obstetrician or women’s health care provider ever intends for this to happen, many mamas begin to feel secondary within their pregnancies and this becomes even more pronounced when the pregnancy becomes high risk.

The goal with Mamas on Bedrest & Beyond has always been to be a support and resource for mamas. For mamas locally, that can mean home visits to perform personal care services such as grocery shopping, running errands, light housekeeping, etc… For mamas online, that means support via answering questions, social interaction, workshops and webinars and teleseminars.  Having had 2 high risk pregnancies, I know what it feels like to be spoken of in the third person or to have the baby and pregnancy made tantamount with you feeling as if you’re “just there”. We know that you are doing the absolute best that you can and our goal is to provide as many tools and resources as possible so that you can continue your pregnancy as far along as possible.

Mamas on Bedrest: I’m Pro-Action!

August 27th, 2012

I “shared” the image at the right on our  Facebook Page last week because I thought that it was an interesting statement and one that we all need to consider. Needless to say, it created quite a bit of controversy.  At first, I was dismayed by the negative comments. Not because they pertained directly to the image, but because the insinuation is that we here at Mamas on Bedrest & Beyond don’t care about women and babies and how best to help mamas have healthy babies. I thought for awhile about the comments and then replied directly on the post. But the more I thought about it, the more I had to say.

When it comes to reproduction, the issues are much more than pro-life or pro-choice. At the heart is the fact that a woman has become pregnant and she may or may not want to be, and she may or may not have the resources to adequately care for herself and her unborn child. I think that rather than having a philosophical debate about whether or not she should be made to keep the child, I think that our first obligation is to mama herself because after all, if mama is well cared for, her baby will be well cared for.

Many people think that women who have abortions do so because they don’t care about their babies or that they are somehow loose and just want their freedom. In my experience, nothing is further from the truth. Women that I have spoken with who are either contemplating an abortion, having an abortion or have had abortions, at the time felt that they had no other recourse. Often at the ends of the age spectrum, many were young, under educated women without money or resources to care for themselves-let alone a child. Others were older women for whom another pregnancy would place undue hardship on them financially, emotionally and physically. And of course there were all the ages in between. But the one thing that I can say across the board is that not one woman that I ever spoke to ever had an abortion without great thought and consideration. Most women agonized over the decision.

I think that the image brought up such emotion because it asked, “Will you still be Pro-Life after she’s born?” It’s a really great question. We have to ask ourselves, if we save a baby girl’s life (or any baby’s life), are we as committed to her once she is here? Are we committed to making sure that her mama has a safe and secure place to live free from harm and/or danger (the questions of homelessness/poverty/violence)? Are we committed to making sure that her mama has adequate food to feed her at all stages of her life (starvation/malnutrition and poverty)? Are we committed to making sure that she has access to quality health care so that she will be properly immunized and have proper health, dental and vision care throughout her life (the questions of poverty and access to health care)? Are we committed to her education, and making sure that she will be a functioning and contributing member of society (poverty/economics)? Will we commit to keeping her safe (out of the ravages of war, rape and pillage)? Are we committed to making sure that she doesn’t end up in growing up and living in some of our country’s most impoverished and contaminated areas (Planetary Degradation) that are waste infested (and not just sewage. We’re also talking about chemical and industrial wastes as well as electrical and nuclear wastes emitted from industrial complexes residing beside some of the nation’s poorest communities)?  And are we committed to teaching her right from wrong so that she doesn’t end up in prison and, the worst case, on death row (capital punishment)?

When considering these questions, I realized that I am not pro-life or pro-choice. I am pro-action. Quite frankly, I don’t believe that either of the political parties in the United States are aware of the scope of the problems affecting women nor are they equipped to deal with them. I think that it is going to take a concerted effort on all of our parts to make sure that mamas and babies are provided with all the resources that they need not only to survive but to thrive. What good does it do if we save a baby from abortion yet can’t ensure its survival beyond its first year?

So to those who were offended by the post, I say this. Bring your offense. But also bring your ideas. If you believe that all babies, all people,  have the right to life (as I do) then come to the table and offer suggestions on how we are going to ensure that these babies have all that they need to survive. Better than that, come to the table and share what you are prepared to do-right here, right now-to save babies and mamas. (I say babies and mamas because bottom line is that an unborn baby is only as “viable” as its mama. If mama is malnourished, ill or ill equipped, that poor little baby really doesn’t stand a chance at a healthy life!). Are you willing to take a teen mama under your wing and nurture her not only through her pregnancy but also through motherhood? Are you willing to help mamas and their babies get the prenatal, intrapartum, post partum and childhood healthcare that they need? Are you willing to be a doula or birth coach to a mama without resources? Are you willing to house a pregnant, homeless mama? What are you willing to do?

Your moral indignation is not enough. We need action! Quite frankly it doesn’t matter if you are pro-choice or pro-life. What matters is what you do with your convictions. If you are pro-life, get out there a help provide the resources necessary for women to have a healthy pregnancy, and to raise a healthy and contributing member of our society. Provide baby clothes or diapers, offer to volunteer at a shelter. If you feel strongly that women should not have abortions, work hard to help them have access to birth control. Help them, if they are pregnant, to access prenatal care. Take them to office visits. Help them get vitamins. Get in there and do!

Likewise, if you are pro-choice, then be willing to sit with a woman as she mulls over her choices. Be able to share with her the pros and the cons (all of them, not just the moral ones!) of each of her options and be an unbiased support for her. Be willing to go with her to a clinic, cross the lines and sit by her side. Be willing to listen to her after if she is sad or depressed. Step in and help if she is struggling. Be willing to DO, not just speak!

I’m pretty sure that I may lose a few readers with this post. No matter. I don’t have time to get bogged down worrying about what some people may think of me. My focus has always been and will continue to be trying to help mamas on bed rest get the medical care, home care and personal care that they need to have healthy pregnancies and healthy babies. And if that offends people, so be it.

When is it better to induce Mamas on Bedrest?

June 13th, 2012

Labor induction is always controversial. There are times when induction of labor is completely appropriate; when mamas are in crisis with pre-eclampsia or other obstetrical complications, when the baby is struggling or when progression of the pregnancy will put the life of the mother and/or baby at risk. But many mamas are induced for what seems like “convenience”; Mamas are tired, their OB’s want to schedule the delivery so that mama is not delivered by a partner, etc… While many obstetricians advocate for induction as a way to “prevent” adverse outcomes, we can’t ignore the fact that labor induction carries with it an increased risk of intervention in the birth process and adverse outcomes for mama and baby.

Recently in the British Medical Journal, researchers looked at elective inductions to see if they had any benefit on birth outcomes when compared to allowing labor to progress naturally. Sarah J. Stock, PhD, from the MRC Centre for Reproductive Health, University of Edinburgh in the United Kingdom was the lead researcher for the study.

Using Scottish birth and death records, they analyzed data for more than 1.2 million women with single pregnancies who gave birth after 37 weeks’ gestation between 1981 and 2007.

What Stock and her colleagues found is that

There was no significant difference in spontaneous vertex (normal head down) delivery rates between elective induction of labor and the expectant management groups (normal labor progression) for weeks 37, 38, and 39. However, a primary analysis showed an association of elective induction of labor with a reduction in spontaneous vertex delivery rates compared with the expectant management group at weeks 40 and 41. This difference was maintained for week 41, but not week 40, during secondary analysis. (so did more induced mamas have c-sections?? This is what previous data have stated.)

The authors estimate that for every 1040 women having elective induction of labor at 40 weeks, 1 newborn death may be prevented. This would result, however, in 7 more admissions to a special care baby unit (NICU).

The authors conclude that although residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery.

There are a couple of issues that I have with this study. First, while the sample size is definitely adequate, there was no way to control for confounding variables such as maternal size, number of pregnancies, pregnancy complications (i.e bed rest), prenatal state, etc… Additionally, the data has been run through a couple of multivariate analyses which controlled for possible confounding variables. I always wonder, if those “confounders” are incorporated into the data, how do they change the results and conclusions?

The authors conclude that elective induction of labour at term gestation can reduce perinatal mortality in developed countries. Is this reduction in mamas, babies or both? This was not clear to me.

The authors also state that they did not see any increase in operative deliveries.This is very interesting in that the United States has some of the highest c-section rates worldwide and the probability of having a c-section goes up with labor induction. Were these some of the variables removed a confounders?

Finally, the authors estimate that for every 1040 babies born, 1 would be saved from death while 7 would end up in the NICU. Now these aren’t huge numbers, but if you are the mama with the one baby who died, this number is significant. Likewise, it’s not good if your baby ends up in the NICU.

While the authors state that the intention of induction is to reduce perinatal morbidity and mortality in developing countries (and the United States certainly has some of the worst statistics for maternal and infant morbidity and mortality, i.e. maternal and infant complications and deaths, in the developed world) I don’t agree that induction is the way around these potential problems.

Induction of labor initiates a cascade of events that more times than not are not ready to begin. There is a delicate, yet complex interaction between the baby and mama that goes on as the baby begins to enter this world. Both mama and baby’s bodies have to transition from interdependence to independence and for the baby especially, there are several physiological mechanisms that must occur to prepare the fetus (inside baby) to become a neonate (outside baby). Induction speeds up these transitions and in some cases, certain transitions don’t occur (hence the NICU admissions for babies). While some may argue that babies may spend “just a few days” in the NICU, these babies have experienced a traumatic birth, their bodies have not had time to adjust to life on the outside and everyone involved (mama, dad and baby) are all traumatized. Is it really worth it? Further, we can only “guesstimate” gestational age. We really don’t know when the sperm fertilized the egg nor when the embryo embedded in the uterine wall. So a woman we may think is 40 weeks may really be 39  or even 38 weeks. Hence the induction is more of an intrusion. What if she is in fact 42 weeks?

I don’t know what the authors intend to do or recommend with this data, but I hope that they don’t use this data as a way to recommend elective induction as standard of care-especially in low risk uncomplicated pregnancies. I believe that human gestation is intended to be 40 weeks for a reason and that as much as possible, human babies should be allowed to gestate for those 40 weeks. If a baby comes at 38 or 39 weeks, so be it. But if the baby stays in until 40 weeks, are we to assume that there is something wrong or that something will go wrong and intervene?  I believe that babies should be left alone to gestate for a long as they need, and only in the situation of maternal/baby distress or markedly being post dates (say 42 weeks or more) should induction even be an option.