Providing Effective Prenatal Care: Focus on the Vision
Editor’s note: This article first appeared in Midwifery Today, Issue 59, Autumn 2001.
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Nine years ago, age 18 and single, “Cassie” prepared for her first birth. With the help of state-sponsored medical assistance, she received routine prenatal care by nurses and physicians in a maternity clinic. She kept her appointments and followed instructions. Labor started with spontaneous rupture of membranes at 36½ weeks. She was admitted to the hospital, where she progressed to complete dilation. After she pushed intermittently for two hours, her records state: “fetal heart tones were reassuring, the fluid was clear, and the patient is afebrile.” Nevertheless, the baby was only +1 station, and this “proved that she was unable to deliver vaginally.” Arrested descent and cephalopelvic disproportion (CPD) were diagnosed, a cesarean performed, and an 8-pound, 7-ounce baby delivered. The baby spent more than a week in the hospital due to infection concerns. Discharged on the third morning after the surgery, Cassie returned to the hospital later that same day in considerable distress. She was reprimanded for feigning illness to be close to her baby and instructed to return home. She persisted in her complaints and was reluctantly examined. Her temperature was documented at 102.6, hemoglobin at 9.7, and she had a 29.9 hematocrit. She was re-admitted and spent another five days in the hospital. The bill cost taxpayers more than $20,000.
Pregnant again, a few years later, married now to a new man and living in a different state, she engaged a physician’s services. Her prenatal course was relatively uneventful, and a VBAC was planned. Labor began at 36 weeks. In the hospital, she soon reached full dilation and began pushing. Descent was slow, so a decision was made to perform an instrumented vaginal delivery using a vacuum. The procedure was prolonged and difficult, but finally the 8-pound, 1-ounce baby was extracted. Cassie’s postpartum course was complicated by lingering pain and dysfunction resulting from a severe tear requiring 38 stitches. She endured this while caring for her toddler and worrying about her newborn, who suffered life-threatening head injuries as a result of the procedure. He coded, required resuscitation, and was then immediately airlifted to the regional high-level care NICU, where he remained for some time. He eventually recovered, the parents declared bankruptcy, and state taxpayers assumed medical bills approaching $60,000.
Two years later, living in another state and pregnant a third time, Cassie had several doctor visits before learning that the local rural hospital had a strict policy against VBACs. Unless she arranged prenatal care elsewhere and planned to travel to a distant hospital during labor, she would be scheduled for a repeat cesarean. Cost wasn’t what worried her, as the state-funded medical assistance program she enrolled in would pay the anticipated $20,000 (or more). There were other problems. She didn’t have a car, and since she was intermittently estranged from her husband (who hadn’t fathered this baby), she didn’t feel she could depend on him for transportation. She was also very concerned about how her body would handle major surgery and a hospital stay, since her chronic respiratory condition was aggravated by anesthesia and chemicals and worsened with immobility, and her severe varicosities greatly increased her risk of thromboembolism. Plus she was allergic to latex, a fact she found necessary to repeat over and over to medical staff who approached her as they donned latex gloves. Further, she needed her full strength right after the birth to care for the new baby, her toddler and her older child, plus several more children who attend her in-home daycare on a daily basis (her sole source of income). At 20 weeks, she contacted me.
Taxpayers had already paid about $80,000 to provide maternity care in the medical model for Cassie’s first two births. Both experiences were disempowering and traumatic, leaving her marked by physical and emotional scars and in pain. Neither baby made it to term, both had prolonged hospitalizations, and one almost died. A third hospital birth would bring the taxpayer total to $100,000, but what would be the personal consequences for Cassie or the baby this time? It seemed like a lose-lose proposition. We couldn’t turn back the clock or undo damage already done, but we had 20 weeks (or maybe only 16, given her history) to turn things around. Could a midstream change to midwifery care really make a difference? We needed a new vision.
Providing Effective Prenatal Care
Conceptualizing the ideal outcome is an essential first step in providing effective prenatal care, as it helps determine which subsequent actions will support (or detract from) the realization of your aspirations. Working backward from the desired conclusion, form intermediate goals and step-by-step plans to reach them. If the challenges seem insurmountable, consider a “plan B” and “C” without losing your focus as you continue to work hard toward your original dream. Consider the big picture as well as the details. What are your client’s strengths? Her challenges? Your concerns? In striving for excellence, there’s no room for “routine” care. Each person has a unique array of individual circumstances that merit personalized responses. Even if all the concerns cannot possibly be resolved, you always can at least improve something—probably many things.
Compiling a thorough history and reviewing it together reveals vital insights to guide you. Your discussion may include questions such as: Why do you think you made that choice? What was most important to you under those circumstances? How did that make you feel? Then what happened? What has changed since then? Anything else? What matters most to you now? Describe how it would be—what it would look like—if everything went exactly right. Gradually the vision comes into focus. Repetitive weight, blood pressure, urine collection, and fundal height rituals provide structure around which you do your truly meaningful work. Leisurely visits, where discussions unfold without pressure, interspersed with friendly phone calls, uncover aspects of each woman that exemplify her strength, power, creativity, and one-of-a-kind grace and beauty. Everyone has a measure of these traits, and the midwife is charged with finding and magnifying them, helping a woman identify her resources and building her up for the journey ahead. Family meetings allow everyone’s questions to be addressed and a shared bond of trust to develop. One-on-one visits allow the privacy one needs to broach intimate topics. Problems are identified and tasks assigned. As goals are reached, they are highlighted and celebrated.
For Cassie, our vision was a wonderful, satisfying, uncomplicated, private homebirth. No cutting, tearing, or trauma. A vigorous, pink, reasonably sized, full-term baby kept warm on the breast while still wet from the womb. No resuscitation, separation, hospitalization. Icing on the cake would be: perfect timing (I had two previous birth commitments in another state posing a potential conflict), reconciliation with her husband (he’s a nice guy willing to parent this child as his own), and as long as we’re asking, how about swift, easy, tidy, fun? Maybe even before bedtime?
Our goals included doing whatever it took to support the vision, including physical necessities such as ameliorating the varicosities as much as possible and keeping the respiratory condition under control. We wanted a healthy prenatal period, free from infection, to increase the chances of reaching term. Yet in seeking to extend the gestation period, we also wanted to avoid creating a great big baby and repeating any of the emergence difficulties she’d had before. We would work at creating a nurturing birth environment and facilitating bonding and respect between all family members. It would be important to fully explore all paternity options and birth certificate matters, making a decision before the birth, so that all involved knew where they stood and were prepared to fulfill their chosen role with an open heart.
Part of the plan included consuming more fresh fruits and vegetables and fewer refined carbohydrates, with the aim of supporting tissue integrity and creating a healthy, not huge, baby. A comprehensive prenatal vitamin/mineral supplement was started, adding 400 IU vitamin E, 500-mg vitamin C, and 500–1000 mg mixed bioflavonoids specifically for the varicosities. This would also help with the bronchitis and generalized respiratory problems, and for allergies we added nettles, chickweed, peppermint and digestive enzymes. Warm steam from the shower, visualization, rest and infrequent small doses of herbal ephedra (only as needed) replaced dependence on an asthma inhaler. Cassie had respiratory flare-ups and periodic problems with sinus congestion, but we battled these with echinacea, berberines, garlic, grapefruit seed extract and myrrh. Contraction-inducing coughing was suppressed with an herbal cough compound and natural throat lozenges. (For the most part we used a quality naturopathic-style prenatal supplement, augmented by additional vitamin E and bioflavonoids, with various herbal combinations in tablet and capsule form, adding teas, tinctures, glycerites and fresh herbs as available.)
The only time we resorted to drugs was when she had an incident with her veins. I was concerned about possible thrombophlebitis and tried to get Cassie in right away for a medical evaluation. She finally was seen in the hospital emergency room, where she spent most of the day waiting around, receiving interrupted and distracted visits from several people. After a cursory visual examination, she was told it was probably nothing to worry about. Persisting, she had someone else tell her it could be serious. Finally another person conducted an ultrasound exam, but the examiner seemed more interested in Cassie’s pregnancy than the problem with her veins. The examiner moved the probe up Cassie’s leg until it was on her belly. “Just following the vein all the way up,” she said, before she swished the probe to and fro on Cassie’s abdomen and told her it looked like a boy. Disgusted, since she had not asked for, nor consented to, an obstetrical ultrasound, Cassie waited, frustrated, for someone to discuss with her the complaint she had presented with. Then, she recalled, a man came in, didn’t introduce himself or even look at her, walked over to the sink, and with his back to her, told her, basically, not to worry her pretty little head. Sent on her way, she asked for something in writing about the ER’s findings. Staff members wouldn’t release anything directly to her, nor would they send records to me, since I didn’t have “admitting privileges.” Truly, gaining admission was the last thing on my mind.
Considering the symptoms I referred her for (warmth, pain, swelling, a new “knot” above her worst cluster of varicose veins), there was ample reason for concern, and from her description of the assessment she received, I was less than reassured. But she had been seen and told everything was fine, and her medical program wasn’t keen to pay for duplicate examinations. In desperation I told her if it were me, I might try aspirin for several days, temporarily increase my vitamin E to 800–1200 IUs, and keep my leg elevated whenever possible. I explained the anti-platelet-aggregation rationale this was based on, along with the potential for bleeding and pregnancy complications it could lead to if continued too long. I also knew aspirin aggravates asthma symptoms in up to 20 percent of people who use it regularly. We were walking a fine line. I gave her a thorough rundown on the litany of danger signs she was to watch for and report to me immediately. Happily the situation resolved in a few days, she discontinued the aspirin, dropped her vitamin E back down to 400, and we carried on with our plans.
Physically there are some things I consider crucial in every pregnancy, let alone complex cases such as this one. Along with assuring sufficient reserves of maternal vitality, I want to know what position the baby is in and how big it is. Birth is surprising enough without finding feet, an elbow, forehead, placenta, or cord in the presenting position when you’re out in the boondocks and labor’s well along. Thus, palpation is a key aspect of prenatal care I spend plenty of time on. Plus it’s wonderful to have an excuse to play with the baby and provide nurturing hands-on contact. If I’m not sure of what I’m feeling, I may request a vaginal exam to add another dimension to my mental image. Thoroughly mapping out heart tone volume and distinctive sound qualities may help clear matters up. (With a sensitive Doppler and an attentive ear, one may observe that the cord hisses and whistles, the placenta whooshes, and heart tones heard over the baby’s chest through the limbs sound full and rounded; a probe located directly above the heart via the baby’s back produces a loud, crisp tapping and the sharp clicking of heart valves.) I’m not at all pleased with the trend toward routine and repeat ultrasounds (it seems like expensive laziness that does little to improve outcomes), and unless there is a specific problem that needs further investigation, I find the method I use usually provides plenty of information.
Malpresentations, or variations such as breech, can usually be rearranged with external version, preferably between 36 and 38 weeks. Certain cord or placenta problems need perhaps more help than you can provide, and you want as much lead time as possible to arrange for it. Less dramatic, but often just as big a problem (because surgery is often the result), is a posterior position. (Watch for these clues: maternal back pain, poor engagement, irregular fundal silhouette, heart tones a bit higher and off to one side, lots of movement, and palpable fetal small parts out front; vaginally—poor or uneven application to the cervix, unable to feel posterior fontanels, diamond-shaped anterior fontanel sometimes discernable.) Again, the time to find this out is during the prenatal period, while you still have the chance to adjust things. Have the mom enlist gravity: get on her hands and knees and do pelvic rocks, arch her spine, drop her tummy, shake and roll her belly, crawl around, scrub the floor, weed the garden—wear knee pads, use a pillow, stay on the bed and read a book, or have sex. How she chooses to enlist gravity doesn’t matter as much as consistently taking time to do it, in 15 to 30 minute sessions, several times a day. Repeat until the baby’s back drops around and stays forward.
At 35 weeks, Cassie’s baby had shifted from its preferred lateral and posterior positions to left occipital anterior (LOA) and felt to be just over 7 pounds. Backup plans in place, I was off to care for those previous commitments. We secretly nurtured our hopes and counted the days as milestones passed and we reached goals—36 weeks, 37 weeks. Melanie had her baby. Check. I called Cassie to let her know. (“Hang in there!”) Thirty-eight weeks. Walking on eggshells, afraid to call … then, Sarah had her baby. Check! We held our breath as I tiptoed through several days of joyful postpartum care, and zoom—I headed back down to be near Cassie. Thirty-nine weeks. She’d done it! We were watching the dream come true.
A few days later I was an evening guest in her home. Labor was swift, easy, tidy, and fun. Contractions seemed so mild and far apart that we discussed trying to get some sleep. After all, it was almost bedtime. Just then her membranes released. Cassie headed for the bathroom, where we gratefully accepted the gift of a wonderful, uncomplicated, private homebirth. A beautiful baby emerged, 8 pounds exactly with no cutting, tearing, or trauma, and snuggled up to the breast while still wet from the womb. Cassie sat (a princess!) sipping juice on the birth chair, as her husband embraced them both.
Occasionally in life there are those moments of unutterable fulfillment that cannot be completely explained by those symbols called words. Their meanings can only be articulated by the inaudible language of the heart.
— Martin Luther King, Jr.
December 11, 1964
Indeed, our hearts were full.