Childbirth educators could save women’s lives

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US maternal mortality has rightly captured the nation’s attention. Perhaps the most shocking fact about it is that so many of the women who die during and in the aftermath of pregnancy die from preventable causes.

Why?

Everyone involved in the care of pregnant women seems to have forgotten the single most important thing about childbirth: it is inherently dangerous and has always been a leading cause of death of young women. Not surprisingly, providers can’t diagnose a complication if they don’t think of it.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]What if normal birth meant avoiding complications not avoiding interventions?[/pullquote]

Obviously obstetricians and midwives need to do a better job of warning women about postpartum complications. Healthcare websites need to do a better job, too.

As Nina Martin reports in the latest installment in the ProPublica/NPR series on US maternal mortality, Trusted Health Sites Spread Myths About a Deadly Pregnancy Complication, most trusted healthcare websites are failing to provide accurate information about postpartum preeclampsia.

The large majority of deaths occur after delivery, often from strokes.

But you’d never know it from the incomplete, imprecise, outdated and sometimes misleading information published by some of the most trusted consumer health sites in the country.

What’s especially disturbing about postpartum preeclampsia is that it often occurs when women are no longer being monitored: after discharge from the hospital and before the 6 week postpartum check. That’s why it is critical that women themselves know how to recognize the symptoms. What do leading internet health websites have to say on the topic?

After reading reports about Beyoncé, ProPublica took a look at how top health sites discuss preeclampsia. We sent screenshots and links to Tsigas, one of the leading experts on the condition in the U.S., for review last week.

Virtually every site we asked her to look at contained some problematic language, Tsigas noted in her written comments. Her biggest area of concern: A number of sites flubbed how they explained postpartum preeclampsia — sometimes mentioning it only in passing, or sometimes failing to mention it entirely…

ProPublica only looked at mainstream medical sites that are presumably maintained or overseen by physicians. But many women often look to natural childbirth websites for information about pregnancy. How do they do?

1. The Childbirth Connection, which describes itself as promoting “safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families,” has NO information on postpartum preeclampsia.

2. Lamaze International, which claims its “education and practices are based on the best, most current medical evidence available,” has NO information on postpartum preeclampsia.

3. Evidence Based Birth, which claims to offer “evidence that empowers,” offers NO information on postpartum preeclampsia.

They aren’t offering women the information they need, either.

What if we used childbirth educators, the people whose job it is to educate women about childbirth, for that very purpose? At the moment, most childbirth educators think their job is to promote “normal birth.” But what if normal birth meant avoiding complications not avoiding interventions?

At the moment, childbirth educators teach women about what to expect during labor and delivery. That’s entirely appropriate. They also spend an inordinate amount of time teaching women that they should avoid epidurals, C-sections, and other childbirth interventions. But if we truly face a crisis in maternal mortality, shouldn’t they be spending that time in trying to avert it?

Let’s reform childbirth education to include the information that women need to protect themselves and their babies from death and serious disability.

Let’s give women:

Information on pregnancy complications like preeclampsia and premature labor. What should they worry about and what should they ignore? Who should they contact when they are concerned?

Information on stillbirth. How much should the baby be expected to move? When should they be concerned about lack of movement? What can they do to encourage the baby to move when they are concerned? When should they insist on fetal monitoring to assess the baby?

Information on postpartum complications like hemorrhage and postpartum preeclampsia. How much bleeding is too much bleeding? What should they do if they begin to hemorrhage? What are the signs of postpartum preeclampsia? Where can they go to get their blood pressure checked besides the doctor’s office? When should they insist on being seen by an obstetrician instead of a midwife or nurse practitioner?

Information on heart complications. Cardiac complications are the leading cause of maternal mortality and women should be taught to recognize their onset. What should they do if they feel unusually weak and short of breath? How quickly should they be seen and by whom?

Information on blood clots. Blood clots are a major, often preventable cause of maternal death. They typically arise in the leg. What are the signs and symptoms? What can women do to prevent blood clots? A blood clot can kill if it breaks off and reaches the lungs (pulmonary embolus). What should women do if they feel chest pain or sudden onset of shortness of breath?

Everyone has a role to play in preventing maternal deaths. Obstetricians and midwives have the primary role, and purveyors of childbirth information have a role, too. Up until now childbirth educators have not been recruited to the effort despite the fact that their mandate is to educate women. Let’s change that. Let’s train childbirth educators to prevent death rather than to prevent interventions!

  • Shawna Mathieu

    I had absolutely NO idea this was a thing. My feet swelled up after I gave birth. I just went “Huh, that’s weird,” and went on with my day. Headache? I had a newborn and a preschooler, who wouldn’t have a headache? Took some Tylenol, went on with my day.

    I went to a (non-OB/GYN)doctor for a routine medication refill appointment about a week after I gave birth. They took one look at my BP, freaked, and said, “Yeah, forget the refills, go straight to the hospital.”

    It horrifies me to think of what could have happened if I hadn’t had that appointment. It’s very possible I would have just gone about my business, then dropped dead of a stroke.

    I knew what pre-eclampsia was. I’d known women who’d had it, one nearly died and her baby spent NICU time because of it. I knew the symptoms. If I’d had them before birth, I’d have been at the doctors’ immediately.

    The pregnancy book I had had ONE small paragraph about postpartum preeclampsia. It did not mention you could have a stroke or heart attack. I did not mention you could die. The childbirth class I took didn’t even mention it.

  • EmbraceYourInnerCrone

    OT but still important given the amount of anti-vax information otherwise reasonable people seem to believe now

    Number of measles cases in Europe skyrockets: https://www.bbc.com/news/health-45246049

    “More than 41,000 people have been infected in the first six months of 2018, leading to 37 deaths. Last year there were 23,927 cases and the year before 5,273. Experts blame this surge in infections on a drop in the number of people being vaccinated.”

  • demodocus

    Waaay OT: What age do you think it’s appropriate to have a kid’s bedroom on a different floor? My little escape artists are sharing one on our floor and there’s a 3rd bedroom upstairs. No railing, though

  • Aine

    Dr Amy, is there a problem with Disquis removing comments? I posted a lengthy comment last night that seems to have disappeared, although I could view it fine yesterday evening.

    It related to my experience of developing post-partum blood clots directly as a result of listening to the advice to sit and cluster feed for endless hours in order to increase milk supply. I had zero other factors for blood clots. Nobody ever mentioned they could be a complication post-partum. It is an area that desperately needs more awareness. The elevated risk of clotting was never mentioned by my obs, my paediatrician, my nurses/midwives or my lactation consultant. It’s so dangerous that women are encouraged to sit under their babies for hours in the name of increasing milk supply / cluster feeding.

    Thank you for the work you do on these important issues.

    • Chi

      It could just be trapped in the spam filter because I think disqus automatically sends comments to moderation if they’re over a certain length.

      If you have links in there, that could be a reason as well.

    • That’s a really scary complication I had never thought of. Thank you for sharing.

    • Sarah

      Gosh, is that why women are meant to be encouraged to move around soon after delivery?

    • Amy Tuteur, MD

      They seem to have changed the spam algorithm and it is sending perfectly reasonable comments to spam. Sorry!

    • MaineJen

      Yet another difference between the health care of men vs women. Within days of major abdominal surgery, my husband was encouraged to do laps around the floor each day, and had pressure cuffs around his ankles constantly to prevent blood clots. In contrast, blood clots were NEVER mentioned during my hospitalizations with either child.

      It seems that, in the name of not wanting to treat labor and delivery as a ‘medical condition,’ the tendency has been to ignore common and easily preventable complications.

      Thank you for this comment!

      • Sue

        Good point – it`s actually the immediate post-partum period when women are most at risk for clotting – we make ourselves hypercoagulable – presumably to survive bleeding during birth.

  • mabelcruet
    • Kelly

      I like how they have some high award for breastfeeding and think it’s important when they encouraged unsafe breastfeeding practices that led to a baby’s death.

      • mabelcruet

        The other issue that worries me here is the report that the baby had pneumonia. I can’t work out how long the baby survived after the collapse. If they were resuscitated and ventilated for a while before death, then that could have predisposed to infection, but it says that the baby was born with pneumonia. Congenital pneumonia is caused by the baby being exposed to intrauterine infection. Mostly this is ascending bacterial infection coming up from below, but if this was the case, then it was missed at delivery. Did mum or baby have signs of infection/chorioamnionitis or was it missed? If it was missed and untreated, then the baby was even more susceptible to hypoxia and the midwives even more negligent.

        • Kelly

          Very true. It sounds like there may have been a lot of negligence than just telling her to co-sleep.

      • Mari

        Yes, it was SUCH an inappropriate comment, and just betrays such ignorance as to the nature of the problem. Also, there was an attempt at victim-blaming, as the MW quoted here said accidents were a result of women wanting privacy while feeding.

        https://www.netmums.com/baby/coroners-warning-over-feeding-technique-after-newborn

    • Anna

      The callous response screams Team Byrom and RCM to me!

      • mabelcruet

        Typical tone deafness. Who cares about dead babies when you’ve got your shiny tinpot medal of accreditation?

        • Mari

          I was horrified by the response from the hospital’s HoM who was asked to comment on this story, as I mentioned on my Twitter feed. Not only did she gush about it being a ‘Level 3 UNICEF accredited baby friendly unit’, she also felt the need to point out what a ‘prestigious award’ this was. How callous and tone deaf is that?

  • mabelcruet

    The saddest clinical histories I get are very stereotypical. It starts about 35 weeks-mum is typically considered low risk but she starts coming to the unit complaining of decreased fetal movements. Midwife has a listen-fetal heart heard. Occasionally a CTG is done. Mum is reassured. Comes back a couple days later, similar presentation, same treatment. I’ve had cases where mum has come back 3,4,5 times with decreased movements and its never been escalated. She’s been ‘reassured’, told she’s too sensitive, given explanations about baby engaging and movements naturally decreasing. No one ever thinks it’s a baby in trouble. Typically they present at 38+ weeks with no fetal movements, and intrauterine death is diagnosed.

    They come to me and its usually a scrawny little baby, small for dates and a scraggly little knackered placenta that was just about coping earlier, but when it comes to the final few weeks, the demands on it are too much and it gives up the ghost. If a woman comes back again and again, they are being written off as over anxious, or inexperienced and can’t tell what normal movements are. There’s no thought that perhaps this is a baby with missed growth restriction, or sub optimal growth and a failing placenta, and perhaps if the mum had some more detailed biophysical profiles done, and there was a lower threshold for thinking ‘this isn’t normal’ rather than ‘mums a worrier’ then maybe I and my colleagues wouldn’t have to do so many autopsies on babies who shouldn’t have died. About 70% of my term stillbirths are either growth restricted or sub optimally grown with a placenta that’s too small. The more hands off we are, the less medicalised we are, we are just going to miss more and more of them. Honestly, I’m glad I’m only part time now-I’ve had an entire career of seeing the same story over and over again and its bloody depressing. And it’s not changed in 20+ years. And the more total arseholes like Byrom and that fuckwit Hill push their twinkly fairies bringing babies souls earthside crap, the more blood they will have on their hands.

    • fiftyfifty1

      “Either growth restricted or sub optimally grown with a placeta that’s too small”

      A wave of nausea passes over me whenever I think of how skinny my second child looked as a newborn, how lucky I am it turned out fine, how easily it might have gone the other way. She was all head attached to a scrawny body, gruesome looking really. The labor nurse asked me if we were sure about my dates because the placenta looked “way postdates and all calcified.” No, I was sure about the dates, only 38 +4. I’m so thankful I went into labor early, a week before the CS was scheduled. Would it have turned out fine if I hadn’t? I don’t even want to think about it.

      • momofone

        My experience is very similar. I can’t even let myself give real thought to what could have happened with a less vigilant OB. I was old, with a long history of infertility and other issues, and I absolutely believe he saved my son’s life. A biophysical profile done at 38 w3 days showed significant calcification. He gave us two options-attempt, probably unsuccessfully, to induce, and likely end up with c section, or go straight to c section. We took Door #2 and found that the placenta was in much worse shape than the BPP showed. I was nowhere near labor. I shudder to think what could have happened.

        • mabelcruet

          It’s a frighteningly common scenario and it happens to mums who are technically low risk. Everything seems fine early on, the problems arise early-mid 3rd trimester when the placenta can’t keep up. But my general impression has been that if a woman is in the low risk midwife led care stream, it is entirely dependent on her midwife whether this is dealt with-some midwives seem extraordinarily reluctant to refer them over to consultant care. It’s like once you’re low risk, you’re always low risk, and it doesn’t work like that. Good midwives will appraise the situation, look at the mums presenting complaint, refer properly and ask for more specialist input. But there are definitely ones out there who don’t recognise the changing clinical picture (bump not growing, repeated episodes of decreased movements etc) as anything to worry about because they are so blinkered on the ‘low risk, natural birth is natural and normal and I’m the expert in normal birth’. If it’s lack of knowledge then that can be addressed, but attitudinal problems are more difficult.

          I go to the perinatal mortality meetings in various hospitals where each stillbirth is discussed-the hospital policy is that each stillbirth is considered a significant incident, so each is investigated (as well as being reported to national audit MBRRACE so we have accurate national figures). But for many it’s the same story over and over and it comes down to individual midwives. One of the fairly common things I’ve seen is that the estimated fetal weight going by the fundal height measurements is vastly different-bump was measuring at 75th centile, baby ends up with me and is actually 3rd centile. The discrepancy is so huge sometimes-I once asked about it, whether there was a training issue or if there was a policy that the person who had measured the bump were monitored to check on their standard and see if they were actually doing it correctly-i just got blank looks.

          • fiftyfifty1

            I agree, there needs to be a more standardized way of measuring growth. In medical school, we were taught that the fundal measurement had to occur with the tape held upside down so as not to bias us, and that only after could we turn it over and read the number. How often is this adhered to after training is complete?

            Also, should maternal perception be taken into account? I remember being told in an offhand way “this baby will probably be bigger than your last” and replying “Oh really? It seems smaller to me this time” and that was the end of the conversation. I thought nothing of it until a few days later when she was born significantly smaller than my first, even though she was further along in gestation. I would have blamed myself forever if she had died in utero–I KNEW she was smaller and yet I missed the significance. Are most mothers accurate with their perceptions this way and should it be routinely asked? (obviously, a first time mother won’t know.)

            Or maybe we should just realize that measurements and perceptions are never going to be accurate enough and just go to 3rd tri scans as routine.

          • RudyTooty

            There needs to be a more standardized way of measuring growth, and a method reponsive to our population’s increasing average BMI.

            With patients entering pregnancy with BMIs of 30-40-50, I don’t know how external measurement of fundal height with a paper tape is accurate at all. Especially among multiple clinicians.

          • mabelcruet

            But doing 3rd trimester scans is over medicalising childbirth. The cohort of skinny little growth restricted babies that it could potentially save are those babies ‘who weren’t meant to live’ anyway….

            3rd trimester scans supported by proper biophysical profiling would go a long way to improve the stillbirth rate I think. Get them out at 36-37 weeks. The risk of transient tachypnoea is there, but with the alternative being brain damage or death, what would you choose? Then again, l’m just a pathologist, there’s probably all sorts of neonatology issues and obstetric issues I don’t know enough about that would be against it.

          • RudyTooty

            Oh, I’m going to get confused because I can’t always tell what’s sarcasm or not. (I’d probably hear it in your voice! Harder with text.)

            I’m going with sarcasm with your first statement.
            Which is a statement I hear in earnest, on a somewhat regular basis. I hope you’ll forgive me if I get confused.

          • mabelcruet

            Sorry, yes, it was definitely sarcasm! I’m all in favour of doing whatever we need to do to get the stillbirth rate down, in the UK our stillbirth rate is horrific. I accept that financially making 3rd trimester scans routine and inducing early would be costly, but anything’s better than the seemingly endless line of sad little skinny babies I end looking after.

          • Anna

            This! Yes, it would be expensive but so is years of counselling and then high risk pregnancy care for PAL.

          • Anna

            I think so, I’m not a clinician but OBs don’t measure fundal height – they do scans. Why? I presume because they need it to be accurate! I never had a fundal height measurement in my last pregnancy but I had a solid growth pattern showing an LGA baby with a particularly LGA abdomen – so I was asked every time “are you sure you did and passed your GTT?”.

          • fiftyfifty1

            OBs definitely do measure fundal heights as part of routine care. Perhaps they didn’t in you because they were already doing ultrasounds to measure growth?

      • mabelcruet

        I’ve heard them referred to as ‘lollipop babies’-if the baby is struggling in utero they will adapt their circulation and redistribute cardiac output to the brain at the expense of the other organs. So brain growth is maintained whilst the body falls behind, and you end up with a disproportionately skinny body and a normal sized head. After birth they catch up eventually, but they do look a bit lopsided for a while.

        The placenta in this sort of case is generally small, thin and flat, and usually feels really gritty when you dissect them, like cutting through a pear. And the texture is all wrong-healthy placenta feels like raw steak (even though there’s no muscle in it), kind of firm but with some moistness and ‘give’, but the IUGR placentas are dry and grainy and there are infarcts where some of it has died off. The placenta is like any other organ, there’s some built in reserve capacity so you can afford to lose a bit of it without much impact, but any more than about 10% infarction then you run into trouble. I explain it to parents using the analogy of a heart attack. At term, the placenta is coming to the end of its natural life span-its essentially like an old man. It still works, just like the old man’s heart might still be working, but its getting a bit knackered and there might be some underlying disease process which means its working right at the edge of its capacity, and all it needs a little bit of extra stress to push it over. So an old man with a old heart who then gets a chest infection or whatever, that additional stress is too much to cope with.

        • fiftyfifty1

          “lollipop babies”

          Yes, that’s what we sometimes call them here in the US too. So it was hard for me to look at because I knew what it indicated, asymmetric IUGR.

          Thanks for the info on the placentas. That is fascinating.

          • mabelcruet

            That’s the classic IUGR placenta due to maternal arterial malperfusion (the current name being used for all the maternal vasculopathies like PET). There are a few other placental conditions causing IUGR not related to maternal arterial malperfusion-chronic villitis and histiocytic intervillositis being two, and they can only be diagnosed microscopically-often the placenta looks OK on naked eye inspection. Massive pervillous fibrinoid deposition is another one-these are often heavy placentas and have a marbled appearance when you slice them
            Rare, but recurrent, as is chronic villitis and intervillositis. And then you have delayed villous maturation (previously called villous dysmaturation). Another tricky condition that can only be diagnosed microscopically, and the placenta can be small, normal or enlarged, but it causes fetal growth failure.

            Moral of the story-any issue with fetal growth at all, send the placenta to pathology. It’s potentially going to be important for future pregnancies.

    • Young CC Prof

      In the USA, there’s a sort of stumbling in the direction of a third-trimester growth scan as the standard of care. My OB had an unofficial policy of digging through medical records to find a risk factor to justify it, which is why my son’s growth restriction was diagnosed at 32 weeks rather than after the fact.

      Without that, I don’t know. There’s no way he would have made it to his due date, at 37 weeks his placenta was just about done for, but I might have gone into labor on my own soon enough to save him.

      I’m just glad we didn’t have to find out.

      • Anna

        I’m hoping the Stillbirth inquiry might get a routine 3rd trimester scan on the schedule in Australia too – even if its only partly funded.

        • AnnaPDE

          And this is why going private is not just for poshness — because when you’re having a $100+ appointment every 4 weeks (or more frequently as the due date arrives), the doctor is not faffing around whether or not to do another ultrasound, but will simply get it done as a normal part of the appointment instead of letting the ultrasound machine (which they have anyway) just collect dust.

          • Sarah

            Yeah, I wouldn’t go private now if I were to have another one, but I’d pay privately for a third trimester scan. In my first pregnancy I was pretty ignorant of all this and in my second I had a third trimester scan anyway as I was measuring big for dates. If none was forthcoming for a clinical reason, I’d pay.

        • Anna

          Going private isn’t an option for us but yes, I understand why a lot of women do. A lot of women in the PAL groups do because they want those extra scans and being able to go in whenever they like and get seen by the same people. I think surely even if everything appears fine for me this time I should get at least two third trimester scans. Given they really don’t know for sure what went wrong with my stillborn bubba, I’m 39, I always have nugget babies and the last two have both been breech at 35 and 36weeks. I’m ready to kick up a stink if I have to too, but I really shouldn’t have to.

      • guest

        I had my first baby at age 36, My care providers ordered four growth scans in the third trimester. Partly because the baby was measuring very large and they were concerned about that (she was 11 lbs at birth, and off-the-charts tall) and because I was considered high-risk.

        Luckily the baby was healthy, but I am grateful for those scans and the peace of mind.

    • Lilly de Lure

      Holy crap that makes my blood run cold – you have just described my final weeks of pregnancy (not to mention the state of my son and placenta when he was born – alive mercifully) perfectly, complete with the reassurance and the implication that I was an overanxious bed blocker because I insisted on staying in hospital for observation when my son’s heartbeat looked dicey on the EFM trace (given to me when I cam in for decreasing movements) and my 35 week ultrasound showed that he hadn’t grown at all since the 32 week one. All this despite my being older, ivf and flagged as at risk of IUGR – no one so much as mentioned your scenario as a possibility to me, even though it’s apparently a very common presentation for stillbirths. If I hadn’t found this site and knew to stick to my guns and go for the 37 week induction (developed into c-section) I shudder to think what would have happened.

      • mabelcruet

        It happens to so many women-I honestly think that some midwives are patronising these women and babies to death, writing off women’s perceptions and unease about a situation as ‘there, there-I’m the expert, you’re just the incubator, I’ll tell you when something is wrong’. In my medical training, we were told that a general rule of thumb is if a patient complains 3 times about the same thing, you get a second opinion, even if you think there is nothing wrong. It might be that a fresh pair of eyes is needed, just in case. I see more paternalistic and patronising behaviour from midwives like Byrom than I ever have from doctors.

        • Lilly de Lure

          I can well believe that last part. I can still honestly say that I received more basic human respect – to say nothing of the feeling of actually having my concerns listened too, never mind taken seriously – in the 3/4 hr or so I was with the surgical team for my c-section than I received in the entire two weeks I was being looked after by the midwives in the pre-natal ward.

      • Anna

        This scares me so much. If a woman has a good scan at 20weeks she won’t necessarily get another scan unless there is an indication. In the PAL group I’m in I’ve heard of women going in two, three times with reduced movement and being told by midwives they won’t consider induction till 41weeks. We always say “go back and ask for the consultant” and the woman ends up getting her induction at 37-39 depending on other issues but a standard care woman who doesn’t know any better is just going to go along with what shes told. Also hear of women going in with reduced movement and then get fobbed off with a quick doppler listen! I’m kinda glad my bestie has GD and I know that sounds awful but it means shes getting regular check-ups and scans and will be induced at 38weeks.

      • Shawna Mathieu

        I read these and shiver.My son had IUGR b/c of severe food poisoning I had, and I remember being worried as hell because of all the “don’t let your baby be born early” stuff everywhere, not to mention there’s a lot of stupid, usually overly crunchy people on IUGR forums who tell you to refuse early induction/C-section b/c “they need all the time inside they can get to grow.” I remember listening to the doctors counting the clots in my placenta when putting me back together. I didn’t know how close it was.

    • Sarah

      This is why we have those stillbirth rates.

    • PeggySue

      This is a horrifying scenario, and I am sorry it is not uncommon. How awful to be the parent, how awful to be anyone involved in the care, including you.

    • Mel

      My nephew was a failed induction turned emergency C-section at 37 weeks. My sister-in-law had issues with pre-e through the pregnancy so they were keeping a close eye on the kiddo – but his placenta was done at 37 weeks. He didn’t handle contractions well at all and eventually had a decel that didn’t recover after the contraction.

      He’s a wonderfully healthy 2.5 year-old now – but I remember holding him when he was born and hearing about how calcified his placenta was and being insanely grateful that my sis-in-law used continual monitoring during delivery.

    • Mari

      Well said. It must be heartbreaking and utterly depressing to have to witness these preventable deaths time and again. The fact that something like this has not improved over time and in line with medical advancements suggests, IMHO, that the approach to maternal care has got worse over time.

      • mabelcruet

        Sometimes I think my view is inevitably skewed-paediatric pathology is a regional speciality so most of us will get babies from a number of different maternity units, not just from the hospital where we are based. That means I see far more stillbirths than an individual hospital would which gives me the perception that its more common than it really is. But yes, I do get frustrated when its the same problem over and over. I read through the clinical notes before I start the autopsy, and it makes my heart sink when I read about repeated self-referrals by mum worried about fetal movements-I just know what’s coming up.

    • Madtowngirl

      Thank you for posting this. I’m already concerned about this, as I am ~19 weeks, and I wrote my OB with a concern about the baby’s movement being decreased for more than 24 hours. I know it’s still way too early to get worried about decreased movements, but I just wanted to know at what point I should be concerned.

      A nurse responded with “we don’t do kick counts this early” message, and a few other comments basically blowing me off. I know you don’t do kick counts this early, this isn’t my first rodeo, and I even said that in my initial message. I want to know *at what point* I should be concerned and go in. I realize at less than 24 weeks, there’s probably nothing that can be done, but if they’re blowing me off now, what happens when I get to 32 weeks? My OB herself is quite good but, I don’t have a lot of faith in some of the nurses I’ve encountered in her office. It frustrates me that I should have to push and be *that patient* in order to get my questions answered.

      • guest

        I had reduced fetal movement at around 20-21 weeks and I ignored it for about a day until my husband convinced me to call the OB. I was sent to the high-risk hospital for monitoring. Of course, as soon as I got there, baby started kicking up a storm. I felt really silly, but the nurse kept telling me that I should always come in if I had any concerns, that they were happy to check on things, that this was their job.

        Like you, I knew there was probably not much that would be done at that early stage if there was a problem, but it was reassuring to me to know I could always call and be seen. I would definitely bring up your issues with some of the nurses with your doctor.

        Pregnancy was hard for me because I was always of the mindset to tough out injuries and illnesses. It was hard to change my mindset to be in tune with subtle changes in my body. For me at least, it was not obvious when I started labor for each of my kids. I had to get to a point of extreme pain or my water breaking for me to realize what was going on. And pregnancy was nothing but unfamiliar pain and body changes so it was hard to know what was normal. I just decided that I’m going to be *that patient* and screw what anyone thinks about it. I’m tired of having my concerns blown off and how a doctor handles my concerns is now a major decision point on whether I keep a doctor.

        • Madtowngirl

          Thank you. I actually ended up emailing the office back with a kind of snarky response, and got a much better answer about my concerns from a nurse that I’ve communicated with in the past. This is such a far cry from my OB that I had with my first – they would tell me to come in any time, they didn’t mind if I just wanted to hear a heartbeat for reassurance. But while the OB I have now is great, her support staff is leaving much to be desired, which is really disappointing given my medical history and AMA status. I guess I’m going to have to be *that patient,* with this staff.

      • space_upstairs

        Good luck! I’m only starting to feel too many “gas bubbles” when at rest to be convinced that they’re really all gas at 20+1, but this *is* my first rodeo and it is supposedly common to feel the kicks later in that case. My doctor at the 4-month checkup told me that I’ll probably get to a point by about 24 weeks where I think the baby’s kicking too much, but for now it was not unusual to not be able to feel kicks for sure or, with the mini machine, not to hear the heartbeat from outside without a proper scan. Thankfully he’s been very responsive to concerns I’ve had so far and he has a personal 40-week induction policy to avoid the overdue complications I’ve been reading about, even though in other ways the standard of care here seems to be pretty low-key, e.g., I’m AMA and they never ordered first trimester genetic tests for me, only all the cancer screenings before I started trying and the 6-8 week, 3-month and (in 2 weeks) 5-month scans. Also some basic blood and urine tests after the 6-8 week scan. Hopefully some way or another you’ll get the help you need if you start to have lower kick counts when it is a problem and when they can start doing something about it.

        • Madtowngirl

          Thanks! Your OB sounds great. I’m also AMA with a history of recurrent miscarriage, which is why I’m a bit disappointed with the “oh you’re just worrying too much” attitude that this nurse seems to have. Thankfully, I got ahold of a different nurse who gave me some better guidelines for when I should be concerned.

      • mabelcruet

        I hope everything goes smoothly, but it does sound like you’re going to have to be ‘that patient’. You shouldn’t have to be loud and pushy and demanding in order to get answers and reassurance, but that seems to be the way things are going. I think sometimes we forget that whilst for us, as health care staff, we see the same thing over and over again so it becomes normal, but for the patient, its their first time, and we forget how worrying or upsetting it can be.

    • KeeperOfTheBooks

      I’m so sorry you’ve had to see that so many times. Just…I’m sorry. 🙁

  • Eater of Worlds

    Can someone help me with this? Someone said that the placenta stops “producing” oxygen within an hour of birth (assuming it’s still attached, I guess). I need a good explanation of why the placenta isn’t going to provide a baby with oxygen because it’s still in the mother. I need a good explanation of why just because you can see the umbilical cord pumping blood it’s not providing enough oxygen for a newborn that isn’t breathing. I know the reasons why but I can’t explain it concisely enough. Or maybe my explanations are wrong, I want to be doubly sure. I’m trying to explain this to someone else.

    • MWguest

      http://www.skepticalob.com/2011/05/ncb-stupid-pulsing-umbilical-cord.html

      No, it’s not providing enough oxygen for a newborn that isn’t breathing. But I’ve heard that claim many-a-time: “I wasn’t worried that my baby wasn’t breathing because the placenta was still attached!”.

      The additional blood and fluid volume from delayed cord clamping may be the beneficial action. Not oxygenation.

      And after the cord stops pulsating (a minute or two) there really is nothing going on in that cold white limp cord that is transferring anything from the placenta to the baby.

    • Young CC Prof

      If the placenta is still attached to the uterus an hour after birth, the mother needs medical attention to find out what’s up before she bleeds to death. That ain’t normal. Typical delivery of the placenta is within 15 minutes of the baby.

  • Kate

    I had extremely, extremely high blood pressure postpartum even with ramped up meds. I even went to the ER for monitoring at one point, but the entire time I had no idea that postpartum preeclampsia could be DEADLY. This is truly terrifying. We really do need more education about pregnancy complications. Wow.

  • FormerPhysicist

    I had post-partum pre-eclampsia. Even after having pre-eclampsia, I didn’t realize it was possible. I ended up back in the hospital two weeks after birth on another mag drip (I think I was at 180/150?). I realize I was foggy after pre-eclampsia, labor and a newborn, but … wtf? Why wasn’t I sent home with VERY explicit information to me AND to my husband that it could re-occur? We are both science PhDs, there was no question about not understanding what we were told. We weren’t told, unless it was so in-passing that it never registered.

    When I tell people – in my crazy over-educated part of the world – most of them have never heard of PPPE.

  • Aine

    Dr Tuteur, thank you so much for this. In particular, the mention of blood clots. I was not particulalry woo-ish but I did read several of the main websites when pregnant, including the more hippyish ones which I probably didn’t analyse critically enough. However, I also read avidly all the books I could get my hands on by reputable doctors etc. I am rarely ill and I am the type of person who ALWAYS obeys medical advice to the letter – probably because I so rarely need it that it isn’t a massive inconveninece to me to do exactly what the doctor advises.

    So, when my baby was born and rapidly developed jaundice, I took the doctor’s advice and combo-fed with formula top-ups. Thankfully with formula and blue-light treatment for a few days while we were in hospital, he recovered fully. Nonetheless, I felt like all “good” mothers exclusively breastfed and I wanted to return to exclusive breastfeeding. I engaged a lactation consultant (who was actually totally non-woo as it turned out – her priority she told me each time was ‘first feed the baby, if that includes formula, great, feed him what he needs to be fed, and we will continue to work on breastfeeding alongside that’) and, like the obedient patient I am, I followed her advice too.

    However, the more I read online about breastfeeding, the more I kept seeing “babymoon”, “plant yourself on the sofa and do nothing but feed, feed, feed” to increase supply. So I did. Not excessively I thought, but one evening, almost three weeks post-partum I held and fed my baby for about six hours on the sofa, in the hopes of increasing my supply. That six hours was enough to give me extended bloodclots in the knee and groin of one leg. I noticed some pain overnight when getting up for night feeds but fumbled along in the dark not paying too much attention to my leg. I woke the next morning with one leg that was purple-ish black and swollen to almost twice the size of my other leg. When I presented to my doctor, I was rushed to the ER and rushed to the top of the queue there. I was lucky to receive great treatment and was only in hospital and separated from my newborn for a few days.

    This is a long-winded way of saying NOBODY warned me about the risk of blood clots post-partum. I had a vaginal birth, with epidural and ventouse. It was never mentioned as a risk, not once. Indeed, I’d seen it mentioned as a specific risk of c-sections, which all the more implied it wasn’t a risk with VB. I absolutely know that there is no way I would have blindly followed the cluster feeding advice if I’d known anything of the risk. Luckily mine was caught before it travelled to my lung but I had months of painful daily injections, couldn’t walk more than a few yards for weeks, and more than a few hundred yards for months, couldn’t drive for weeks, wore a compression stocking for two years, had to take injections daily in subsequent pregnancies, years later my leg is still visibly more swollen than the other. I resent so much that the expensive childbirth education classes I paid for, and all the literature I read, never once mentioned this risk for VB. And I doubly resent that all of the advice around cluster feeding never once pointed to the need to remain mobile and active.

    Women need to be educated on the very real risks they are running. We definitely should not be encouraging the very behaviour that enhances yet further the risk of a blood clot in the name of breastfeeding.

    Breastfeeding remained a struggle, and I found your site in the dark days when I linked my failure to exclusively breastfeed to my worth as a parent. I thank you from the bottom of my heart for the service you and your wonderful online community provide to people like me. Please write more on post-partum blood clots, it needs huge awareness. Simple awareness can save lives.

    • PeggySue

      OMG how awful for you, and what a risk and unnecessary at that. I am glad you made it through, and thanks for telling the story.

  • Anna

    Childbirth Education would have to be completely overhauled and regulated. Here in Aus a lot of CBEs are doulas or affiliated with Lamaze. Its pretty clear that most would only be interested in teaching women interventions are bad and to ne avoided at all costs.

    • Apart from everything else, few “childbirth educators” are themselves educated properly.

  • RudyTooty

    “Let’s reform childbirth education to include the information that women
    need to protect themselves and their babies from death and serious
    disability.”

    Really. Truly. You’re talking like someone who actually wants to improve outcomes for people. Instead of promoting your own (placenta-herbal-crystal-energy-healing-light-therapy-bullshit-in-a-candle) business interests.

    A legion of lay people who understood the importance of accurate information and timely intervention, and who had the flexibility and willingness to meet people in their homes – could go a long way to help others survive and avoid complications.

  • maidmarian555

    One of the things I found really difficult when I was pregnant with #1 was finding clear, factual information about anything to do with pregnancy and birth. I relied pretty much exclusively on the NHS website (which is great in places but does have a bias towards natural birth and doesn’t go into much detail on a number of things) because any time I Googled anything, I got reams of conflicting information and it just made me really anxious. For example, my midwife thought my son might be transverse so I tried to look it up but there was almost nothing on the NHS website, and Google threw up Spinning Babies (which is basically woo central) and Mumsnet (which only had horror-story threads which, when I just wanted data and facts, wasn’t really helpful). I just wanted the data on things like whether having a manual version was safe enough that I would consider it, and when we should be booking a CS if that wasn’t what I wanted to do. It was very frustrating.

    • Mimc

      I lucked upon the Mayo Clinic pregancy book. It has a great symptom glossery that helps you decided what’s normal, what you should ask about at your next appointment and when you need to call right away.

  • mostlyclueless

    Women don’t want to hear about complications. Look at any website where women discuss their birth stories. Happy and empowering stories are the most popular; no one wants to hear “fear mongering” from the women who were traumatized or permanently injured by childbirth.

    Telling women that birth is fun, easy, and nothing to be afraid of sells. And all of the orgs you mentioned exist to make money. Helping women, if it happens, is just a welcome side effect.

    • fiftyfifty1

      Some women don’t want to hear it, but a lot of them do. A lot of women have heard rumors about what can go wrong and are really eager for accurate info.

      • mostlyclueless

        That’s fair, I shouldn’t generalize. To be more precise, it has been my experience that the majority of first-time moms only want to hear about how magical childbirth is, and not any of the very real risks they are facing.

      • swbarnes2

        I wanted to hear stories about how things went wrong, and the docs fixed them.

        I was reassured to hear, for instance, that if the anesthesiologist punctured the epidural space, that this was fairly easy to fix.

      • BeatriceC

        It seems like there’s a fine line between giving enough information so that the gestational parents are educated enough for informed consent, and telling too many of the true horrible stories that the pregnant person becomes a bundle of anxiety. And since that line is different for everybody, it’s a tricky balancing act.

        My stepdaughters have heard about all the major complications I had during all my pregnancies. Now that one of them is pregnant, she’s got all that in the back of her mind, but she doesn’t want to hear any details anymore because it makes her too nervous. She’s good with knowing the broad details of the major complications but doesn’t want to hear the horror stories right now. I can respect that.

        Oh, and I don’t think I posted this here: MrC and I are going to be grandparents in a few months. We are beyond thrilled.

        • PeggySue

          Wonderful news!!! Thrilled right along with you!

        • demodocus

          Are you allowed to mention it openly, or just under your sooper sekret nom-de-disqus? Because I’ve been saving some grandma jokes 😉

          • BeatriceC

            They’re FB public now, but still keeping a low profile. I’m trying to keep a balance between being excited and not stomping on her mother’s memory.

            On that topic, I’m going through the gazillions of old pictures MrC has, trying to find pictures of the girls when they were babies and their mother, to make sort of a “welcome to the world” video, but from MrC’s late wife (their mother). I wanted to do something so the new baby can “meet” his/her grandmother.

          • demodocus

            Oh that’d be sweet! (in the old sense of sweet rather than the slang that also means cool)

            I can’t speak for your stepdaughters of course, but if my MIL had been able to do it, it would have me crying in a good way.

        • Lovely news.

        • Amazed

          What a lovely bit of news. Congrats!

    • HailieJade

      Some women, such as myself, might also decide it’s not worth it and just not have children. Or if they do, insist on an elective C-section. Both big no-nos in our current society. Keeping women uneducated and uninformed is in the best interests of pretty much everyone involved in the birth business, except the pregnant women themselves.

      • We watched a birth video in 9th grade biology class. The classmate who most passionately said, “I AM ADOPTING MY KIDS” was pregnant within five years.

        • HailieJade

          Well seeing as I had my tubes tied two years ago, that same fate is unlikely to befall me 😉

  • The Bofa on the Sofa

    I know that the What to Expect series gets a lot of criticism for overblowing every. Little. Possible. Issue during pregnancy. I haven’t looked at the WTE books in a while. Do they cover these issues?

    • AnnaPDE

      I didn’t find a lot about complications of childbirth, especially natural. They also don’t seem to be aware that these days most OBs have an ultrasound machine in their office and can just use it willy-nilly.
      But maybe I was already put off by the harping on about an exact 11.3 kg weight gain limit, the need for exactly measured vitamins and gram-accurate portions of vegetables, not to mention the advice to stick to sex that’s fun for hubby without having an orgasm myself because that’s risky.

      • Mimc

        This is why I prefer to the Mayo clinic book. WTE seems to include a lot of old wives tales. Plus the Mayo clinic book is truly nuetral on breastfeeding vs bottle.

    • Mel

      I read the WTE series at the beginning of my pregnancy and found it rather dull. There’s a separate section in the back that covers major complications including my buddy HELLP syndrome.

      I read the entire WTE series when I was a teenager and I didn’t find their coverage of issues to be overwhelming. The series explained when something was normal – like having nausea that made you throw up, but you still could get enough calories during the non-sick periods – and when something was not normal like being so sick 24/7 that you get dehydrated and can’t keep any food down.

      I guess how people perceive the warnings depends a lot on their personality. I feel calmer when I know the warning signs of something bad happening and what to do if those signs appear. If people think that ignorance is bliss, they are going to find materials that I find calming to be deeply disturbing.

      Likewise, I don’t believe that thoughts and feelings cause bad things to happen (e.g., I don’t think I delivered at 26 week from HELLP syndrome because I thought about HELLP syndrome while pregnant or however “The Secret” works.

      • I don’t see any harm from learning the symptoms of common problems so you know to recognize them.

  • MaineJen

    But…but…midwives cannot treat pre-eclampsia or blood clots or hemorrhage or heart attack! Therefore, we should not worry our pretty little heads about those things. Right? Right??

  • Mel

    I’m alive today because a very detailed pamphlet sent home by my OB/GYN’s practice had an entire list of reasons to call the practice within 24 hours or immediately. I was having cyclic pain around by belly button that I couldn’t get to stop. It was the middle of the night on Thanksgiving and I was feeling anxious.

    The last line said “If you can’t decide if you should call us or not, call us.”

    I called. That set in motion a series of events that got my sudden onset severe pre-e and HELLP syndrome diagnosed prior to any major episodes of organ failure for me or my son.

    That same pamphlet had a postpartum section that explained amounts of bleeding and what normal hormonal issues immediately after birth felt like. It also included when you should call the same day or right away for things like difficulty breathing or suicidal thoughts.

    The last line said “If you can’t decide if you should call us or not, call us.”

    I suspect that line has saved other women from postnatal morbidity or mortality before.

    • demodocus

      i’m glad you and that little firecracker of a spawn of yours are doing well now

      • Mel

        Thank you!

        He’s amazingly adorable since he now wears glasses to help with an eye that kept turning inward. Since the glasses frames are blue circles combined with my son’s prominent forehead, hair that grows forward without a part and controlled smile, he looks exactly like Mr. Peabody from the “Rocky and Bullwinkle Show” short “Mr. Peabody and His Boy Sherman”.

        Spawn also began weekly PT since he’s almost 21 months/17.5 adjusted and shows no interest in walking and only a little interest in pulling up. Spawn’s still stand-offish with new people and places so I brought a pocket full of brightly colored pompoms which are his favorite toy right now – and one he only gets to play with when a responsible adult is with him. I sat down on the floor to give him a “safe” area where he could lean on my outstretched legs – and tossed the pompoms a few feet beyond my legs. Within 5 minutes he was crawling around after the pompoms despite the presence of a new adult – and he was so excited he started chattering. Spawn went a bit bonkers when she picked him up – but nothing too bad – and I realized that he chills out if he couldn’t see me so I suspect I’ll be hiding out of sight for at least a portion of each PT appointment until he lets the PT into the inner circle of trust.

        His PT realized quickly that Spawn likes to keep his legs sprawled to give him a wide base – but that position has allowed him to get away with not strengthening his stomach and hip flexors as much as he needs to get up and get moving – so she showed us a neat pair of shorts called Hip Helpers that restrains the outward flexibility of his hips – and I was amazed how much more natural his crawling was already. We’ve got a pair ordered for him. He’s also got some knee orthotics ordered that I think of as “Knee No-No” to help us help him get standing. The “No-No’s” let him keep his knees straight with a little bit of flex – but won’t let him bend them much. This will let us have both hands free to help him straighten his torso and hips instead of having to use both hands to pin his thighs and knees in place.

        • PeggySue

          He sounds just precious! I loved Peabody and Sherman!

        • Kelly

          My daughter screamed and cried all through PT and her therapist was freakin amazing. She would change what she was doing every few minutes and worked her butt off to help my child. Turns out, my daughter is a bit of a firecracker and doesn’t like people telling her what to do. She now walks and runs and you would never know she had issues. It sounds like you got yourself a good PT and he will be making significant strides because you are willing to work with him.

          • demodocus

            My pair were fairly easy going babies, but when they -really- want to do something, watch out.

          • Kelly

            My first two were like that, the third, is quite the handful. Come to find out the reason she didn’t want to sit up, crawl, etc. was because someone would help her out if she screamed enough. We are still working on getting her away from that tactic and she is almost three. We are having another one, I am not sure if we are sane but I am hoping that this fourth will be a bit calmer.

          • Mel

            I was in PT from when I was 4 until I was 10 or 11. I loved it! I had an hour of time where I got to talk to an adult.

            I’ve enjoyed watching Spawn have the more natural infant-toddler reaction to PTs of falling asleep as soon as he heard their name while in the NICU, followed by an entire act as a small infant that he really wanted to do PT…really he did….but *hack, hack hack*….but PT was making his multidrug resistant dengue fever act up *hack hack* and the only thing that would save him was cuddles *hack, hack , hack* (his fake baby coughs were amazingly dramatic – and palpably fake) , and now requiring quid pro quo of “High value toy I’ve never seen gets you 30 seconds of touching my legs before I fight back. Singing “The Wheels on the Bus” buys you another 30 seconds. I prefer Old MacDonald – but you better include cats, dogs and pigs quickly.”

    • That’s excellent. I am comforted by the existence of my practice’s nurse line and the help I’ve received for non-pregnancy issues.

  • demodocus

    But complications ARE normal! Just like death! But not taxes.