Obstetrics from a Pediatric Perspective

March 19, 2013
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by Lindsey Wimmer, MSN, CPNP

A frequent frustration of families who have endured a stillbirth is the feeling that their OB or midwife wasn’t worried about the baby until the actual delivery, or until it was too late.  The health professional in me defends these providers and wants to believe this isn’t true.  However,  I also understand that “perception is reality”.

So, why do so many families have this perception?   I believe the answer is easy if we look at obstetrical care from a pediatric perspective.

I’m a pediatric nurse practitioner.  Most of the information I need to do my job comes from the parents (especially with infants and young children).  I was thinking about this recently as I heard stories from several different moms and their experiences with their OBs.

Example 1: Many women report that they were not told about kick counting.  Even if they were, they were not given information about how to do it, why it is important, when to be concerned, or what if they are concerned.  When I ask OBs and midwives about this, the most common answer is that they don’t want to scare their patients.

I can appreciate this – but I also would argue that this is their job!  I don’t enjoy talking to new parents about trying to protect their child from SIDS – but it’s my professional responsibility.  OBs and midwives don’t like to make their patients think about breast cancer, but they overcome that discomfort to teach women about self-breast exams.  Education is a significant part of the job description.  Every pregnant couple needs to be told about stillbirth risk factors and how to observe their unborn baby for signs of distress.

Example 2: A woman who is 34 weeks pregnant comes to the OB office and reports that her baby isn’t acting like she usually does.  The mom feels like something isn’t right.  She can’t put her finger on it and she doesn’t have any of the symptoms listed in her pregnancy books (fever, bleeding, cramping, etc).  The nurse’s response is that this is a common feeling toward the end of pregnancy and the woman shouldn’t worry about it.  She mentions it again to her OB who listens to the baby’s heartbeat with a Doppler, reports that it is normal, and reassures her that all is well.

As a comparison – A mother brings her 8 year old child into the pediatrician’s office because she isn’t acting normally.  No specific symptoms exist, but the mom says she just isn’t herself and mom is worried.  As a pediatric provider,  I need to do a complete physical exam and consider multiple tests to identify what could be going on.   If all I did was listen to this child’s heart and send them home, I’d meet some very angry parents and setting us all up for the potential of something important to go unnoticed!  It’s hard to reassure concerns parents that all is fine because the baby’s heart is beating at a normal rate.   Obstetrical providers need to thoroughly investigate every concern that a mom mentions.  Falling back on old wives tales isn’t good enough with the technology available today.  Yes, there may be false alarms, but I like to remember that the fire department doesn’t dismiss any of their alarms as ‘probably nothing’ – they treat every alarm as though it were a four alarm fire until proven otherwise.

Example 3:  If an obstetrical  provider is concerned about a baby’s growth, measurements may be taken during an ultrasound to estimate the baby’s size.  If these results are plotted on growth charts and found to be below the 10th (or sometimes 3rd) percentile for gestational age, the diagnosis of Fetal Growth Restriction (FGR) or Intrauterine Growth Restriction (IUGR) is made.  Many providers will tell you that this can be a ‘false positive’ because there are some babies that will be smaller and this particular size is their ‘normal’.  This is true.  However, the reverse is also true.  There are many babies that genetically are bigger babies, and a percentile above the 10th may represent abnormal for them.

In pediatrics, we follow growth charts using similar percentile calculations.  However, we track them every time the child is seen for a well-visit (and sometimes more often).  We watch the trend.  If a concern is found, a diagnosis of Failure to Thrive might be made or there will be additional evaluations completed to identify any problems.  In general, we are concerned about a child who has been following a specific percentile and suddenly or consistently drops down.  For instance, if a 6 month old child has been at the 75th percentile for weight for the last 6 months and is suddenly at the 25th percentile – we are concerned.  Using the definitions of IUGR or FGR, we wouldn’t need to be concerned about this child because he is above the 10th percentile.

The biggest difference here is that in pediatrics these measurements are taken with every visit.  This is not the case during prenatal care.  OBs monitor baby’s growth by measuring the size of mom’s uterus with a tape measure and tracking mom’s weight gain.  Yet, it is widely acknowledged that these methods are affected by many other factors and are only minimally helpful.  The practice of growth charting for every unborn baby should be routine part of prenatal care utilizing more than a tape measure.  In addition, the threshold of 10% should be abolished in favor of trending for that particular baby.

Example 4:  A pregnant woman has a Doppler at home to monitor her baby’s heart rate.  At 36 weeks, the mother calls the OB concerned that the baby’s heart rate is 20-30 beats per minute lower than his usual and the number of fetal movements is also decreased.  When she arrives at the hospital for evaluation, the monitor reveals that the baby’s heart rate is normal and the mother is reassured and sent home.

As a comparison – a father of a 2 year old child notices the child has a temperature of 102 degrees and is complaining of ear pain.  He gives her a dose of Tylenol and takes her to the pediatrician’s office.  By the time they arrive, the little girl is smiling, playful, and her temperature is down to 99 degrees.  This child will still be evaluated as if the symptoms that Dad noticed at home were still present.  I can’t dismiss Dad’s report just because the child’s status has changed.  Obstetrical providers need to assume the issue was present and do a thorough evaluation over a number of hours of more than the baby’s heart rate to see if the reported issue will repeat itself.

As a medical professional, I know that there is much more that goes into medical decision making than usually meets the eye.  But these stark differences between how we monitor, evaluate, and treat children before and after birth represents a problem.  The amount of credit we give to maternal instinct and parental intuition before and after birth discredits the relationships that parents build with their unborn children.

In decades past, providers were very limited in how much they were able to monitor, evaluate, and treat babies before birth.  Fortunately, technology today gives us many more options.  Unfortunately, the standard of care during pregnancy has not kept up with technology. 

When the information that parents bring to the table is ignored, it is easy to see why they think their child is being ignored.  Obstetrical providers must always remember they have TWO patients!

I encourage all obstetricians and midwives to treat their unborn patients as aggressively as pediatricians or pediatric nurse practitioners would treat the same child after birth.  I encourage parents to express your observations and concerns.  Ask that your unborn child receive the type of care he/she will receive after birth.

Babies, before they are born and after, will receive the best care when parents, providers, and technology all work together!


So true!

Annaya was my third pregnancy and it wasn’t until nearly a year after her death that I learned about kick counting. When I asked my OB about her chronic hiccups, I was told that it was the sign of a healthy baby and she would instinctively know to drink fluid. I think most expectant moms must learn to be better advocates for themselves.

It would be wonderful if OBs would treat babies while in utero like the human beings they are.


I’ve felt like example 4 with my son Marcos who was stillborn at 34 weeks in 2011. I went in to my regular doctors visit and his heart rate wasn’t normal. This was my first pregnancy to get that far along so I didn’t know what to expect. But the OB doctor who has been a doc for 14+ years should’ve known to do an ultrasound or something for me! Two weeks later I had another regular visit and the doc couldn’t find his heart beat. She sent me to the hospital for a better ultrasound and they confirmed that my sons heart had stopped. So they induced me, I had him the next day. When he went for an autopsy, the medical examiner said that his body was decomposing and his heart hadn’t stopped a day or two before my visit, it had stopped over a week and a half ago!! So, sometime after my visit where his heart rate wasn’t normal he passed =(
I’ve also felt like example 2 with my daughter Aubree who was stillborn at 33 weeks in 2012. I wasn’t feeling her move like she normally does and the OB doc said that she’s growing and there isn’t enough room in my tummy for her to move like she use to, so it was normal!! I was upset, because 2 days later her heart stopped!!! =( I had no signs of anything, no bleeding, discharge, headaches, nauseous, nothing!!
I feel like I didn’t get the best care after both my children were born. Til this day I don’t know exactly what caused my sons death and with my daughter, our tests came back but nothing abnormal and her autopsy isn’t back yet… or not that I know of!

Why aren’t the drs. Doing anything. If they put half as much energy into keeping wanted babies alive instead of trying to keep unwanted babies (abortion) alive maybe stillborns would be a thing of the past. The cord accidents are preventable if they were told what to watch for my grandson would be with us. My daughter was 37 weeks and had low bp, high heart rate, her baby had low heart rate, extreme movement for two days and hiccups very often. We have done a lot of googling and read these were symptoms of cord accidents. The Dr said she was low on fluids Monday, Tuesday my daughter sent me a text of baby being very active, Wednesday evening she said she hadn’t felt movement drs checked and he was gone they induced her and he was born still on Thursday. This not wanting to scare the mothers is crap being scared for 9 months beats, the heck out of living the rest of their lives without that child.

Joann O'Leary

Lindsey, this is a wonderful article and the comparison of prenatal to pediatric care is right on! Your stories of mothers intuitive knowing and not being listened to I found in my research as well. I also agree their is a difference between monitoring “fetal movement” and knowing your baby so when there is a change parents can go for help–it’s not just about hearing a heart beat! Yes, there are two patients!

Thank you so much for this article!

This is so true in so many ways. I am 42 years old, have been pregnant 4 times, three of which were with the same OB doctor I have known for over 15 years. My third baby was miscarried at 8 weeks in 2006, and our 4th baby, Presley Dean Wick, was born still at 37 weeks on Dec. 30th of 2012. I carried a total of 3 babies to full term. The whole time I was pregnant with our most recent little girl, it was different. I am no stranger to pregnancy obviously, have actually worked in and managed an OBGYN practice, and I am a college graduate. I accept some responsibility in our daughter’s death, but I also place blame on the passiveness and lack of attention paid to my pregnancy. Don’t get me wrong, I admire, love, and respect my OB doctor, but the field of OB HAS NOT kept up in my opinion. From the time I first felt my baby girl move, we nick named her our little “Ty Kwando Baby”. She was very active and towards the end would actually hurt when she decided to move around. Her movements were quick and sharp, rarely fluid like. I always had the sensation that she was going to just fall out at any time and my lower back hurt me constantly. I could even hardly lay down to be checked for her heart beat or be measured. My OB’s nurse was always the one to check the heartbeat, measure my belly, and ask if she had been active. Her heart beat was always hard to find because she was so low, I always held my breath until I heard it. I went in for a weekly check on a Wednesday afternoon, with the same complaints “No baby yet, my back is killing me, and she is so violently active at times it hurts”. I also had hardly gained any weight and on several prior visits had actually lost a pound or two, which always seemed very odd to me considering the amount of food I ate. All these things were dismissed as normal and acceptable for pregnancy and for my age. The weekend came and all was well when I went to bed around 11pm Friday night. She was VERY active and I even mentioned to my husband that she seemed MORE active. I had eaten ice cream though so I attributed it to the sugar rush. Saturday morning came and around 10 am it occurred to me that I had not felt her move. I knew immediatley something was wrong. After phoning the doctor and going to the hospital, we learned our little girl had no heartbeat. They didn’t tell us right away what they saw on the ultrasound, other than her heart had stopped. But when I gave birth to her, she had what they call a Nuchal X2, which is when the umbilical cord is wrapped around the neck twice. There were no other issues with her, she was healthy in every way, beautiful, and pretty much full term. Like I said, I totally agree with this article in that the focus needs to be on “both” patients and also needs to be narrowed when it comes to the dismissal of any type of complaint. In my case, I think because of my age and my prior child carrying experience, things were over looked by my OB and my self with the understanding that I had been through pregnancy before with no major complications so I should know. Well, I was in no way prepared for the end result and come to find out, even after 20 years of practice, my OB had never had a patient lose their baby in this way and at that gestational age. Even now, when I have gone into the office, there is NOTHING about stillbirth anywhere. It needs to be out there, we need not be afraid to discuss it. The statistics for still born annually are much greater than loss from the side effects of an amnio (which we did by the way) and I had no clue about its possibilities. Patients must be more educated, followed, and treated by their OB doctors, as well as listening to themselves when something doesn’t feel right. Regardless of how many other children they have, their age, and/or education. If we end up saving just (1) one life. It would all be worth it.

PS For those who don’t know about the STILL Project please google it, find it, be a part of it (stillproject.org) and also for those who have not heard of the move “Return to Zero” with Minnie Driver that is due to come out early next year, google it, find it, be a part of it too. (returntozerothemovie.com)

Lindsey, you have hit the nail on the head! Thank you, thank you. You should submit this blog to the NY Times and Mothering magazine at a minimum!
There ARE two patients here (or more if multiples) and doctors/midwives need to encourage moms to watch the patterns and come in whenever they feel the pattern has changed or their are sincerely worried.
THEN the medical professionals need to take this visit seriously. If they could assume a state of ‘concern’ – or at least trust (that all is okay) but VERIFY carefully, we might have fewer deaths. We also need to empower moms to put on their ‘mama bear’ attitude and do everything they can to protect their cubs.
Too many moms give their power and the decision-making to the doctors/midwives. We have much teaching and empowering to do.
Which brings me to the new Coalition that I wish everyone!!! would join so we can work together to change this system that is failing our pregnant parents. Go to http://www.StopStillbirthASAP.org and join for FREE so we can create a strong unified voice. I call this both an Awareness/Prevention Campaign and a Revolution!!! Will you each find 10 or more people and groups to join us??? Babies lives are at stake. What if you could help save ONE?????

It’s interesting to know that obstetrics and midwife professionals would be able to overcome some challenges in talking about breast cancer by telling women to get their bodies examined. Personally, I might already need to see a professional to get myself checked because of a lump in my left chest. Hopefully, it is nothing and will just be removed then it’s done.

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