The intuitive mind is a sacred gift and the rational mind is its faithful servant. We have created a society that honors the servant and has forgotten the gift. ~Albert Eistein
Empowerment of Mother's Intuition: One Prenatal Nurse's questions
A guest Blog by Clare Thorwick, RN
Now in her 90s, Clare's passion for mothers and their babies remains as strong as ever!
According to Clare's friend and former work colleague, Dr. Joann O'Leary, "“Clare Thorwick was the antenatal testing nurse at ANW for 15 years and NEVER had a loss with the many patients she interacted with. She helped women to trust their bodies as a safe place for their baby, helped them learn how to know their baby and, along with the perinatologist, helped save many high risk babies. How: Because the mother’s knew when movements had changed and came in immediately for help.”
"I graduated from Fairview hospital school of nursing in 1953", says Claire. I worked Labor & delivery there until my first pregnancy ended in the death of my 3 day old premie following surgery for a bowel obstruction. My husband was drafted into the army the day she died, 2 months before he would have earned his degree. Two years in Tokyo I worked L&D in the US Army hospital there. Discharged from the Army we came back to MN, had 4 babies in 4 1/2 years. When they were all in school I went back to L&D for 12 years at Fairview Southdale, a brand new suburban hospital. We were busy! Fetal monitoring came to MN then. Roche Medical Electronics offered me a job in Chicago, I became a consultant for their customers. Then I was recruited to be head nurse at Abbott Northwestern as they began a Perinatal Center in a private hospital. Two years later I was asked to start an Antepartum Testing department which I did and retired from there after 15 years in 1996. A week in Winnipeg soon followed, learning the Biophysical Profile from Dr. Freeman. I have no access to the numbers of tests or patients I tested in those fifteen years but the statistics of failure to predict wellness of the fetus for a week were roughly 1/1000. To have had no false negative tests in all those years I give credit to our team approach. Our perinatologists were very sensitive to the mothers’ intuitions and made decisions accordingly. We had a very good thing going but the stillbirth rate today is very troubling to me. I’m now retired after working 20 years in labor and delivery and 15 years in antepartum testing. I kept notes during that time that demonstrate the vital importance of a mother's sense of her baby’s well-being. Our ever-increasing reliance on technology can undermine a mother's part in monitoring the wellness of her baby. This disempowerment is negative in its own right and can be dangerous to her baby. I’ve seen many cases where a mother was right, the machine was wrong, and the baby was endangered or died.
A pregnant mother, near term, reported diminished movement to her health care provider and was promptly sent for Antepartum Testing (APT). The test is designed to be used in “High Risk” pregnancies. Its purpose is to predict the well-being of the fetus for one-half or one week depending on the particular risk factor. That makes it possible for the birth to take place at the optimum time for the baby instead of waiting for spontaneous labor to begin. This mother’s test was negative, so, according to the technology, there was no distress, and the baby should be safe for a week. So, she was sent home. The next day, the mother was still worried because she knew something had changed, maybe was wrong. She was asked to come back for another test; she did, and the same thing happened, she went home again. The third day she was still worried and came back yet another time. By then, tragically, her baby had died. She wept as she said, “I knew it!”
This is a clear case of trusting technology over a mother’s intuition. Why is this still happening in 2022? I am a retired registered nurse with a 20-year career in Labor and Delivery, then a final 15 years in APT. The development of technologies such as electronic fetal monitoring and ultrasound led to the development of this system of prevention of stillbirths.
APT has been enormously helpful in many pregnancies that might not have ended with healthy babies otherwise. But it isn’t perfect, and one failure is one too many. It seems counterintuitive, but the use of these technologies and Perinatal Medicine, first practiced in the 1970’s and 1980’s, has made “High Risk” pregnancies safer than normal pregnancies. When risk of prematurity is present, the advantage of growing in the uterus is very significant; roughly, for every day in the uterus, there are three days fewer in the NICU for a premature baby. But, waiting for spontaneous labor to begin when the mother has diabetes or high blood pressure, e.g., once the baby is mature, can increase rather than reduce risk. Birth, not too soon and not too late, is the key. Perinatal care focuses on fetal health both before and after birth and APT is part of that system.
Electronic fetal monitoring (EFM) first used only during labor, and ultrasound, made possible the development of this fetal surveillance system. Promising, as it seemed at first, stillbirth statistics haven’t improved much in recent years. Many new technologies are being added: umbilical artery ratio, measurements relating to gestational age, placenta size and other ultrasound applications, but the stillbirth rate remains about 6/1000 in spite of so many studies and approaches. Our statistics regarding stillbirth rates are not what they should be compared to other countries.
My question is, “Has the mother’s intuitive sense about her baby when she reports a change played a big enough role in this area of pregnancy care?” This writing is addressed to parents awaiting the imminent birth of their baby. The purpose is to highlight the importance of your role in keeping your baby safe, not to add onus. No one else has more at stake and your voices need to be heard.
The UK has developed a “Saving Babies’ Lives Care Bundle,” a protocol to address this issue. It includes many good suggestions about what to teach mothers. Smoking, diet, prematurity, fetal movement counts, etc., are included but, in my opinion, not enough about listening to and empowering parents, the mother’s important role of parenting during pregnancy and the father’s role of support and affirmation. As one father said, “He’s the doctor, I’m just the Dad.” Later he revised his thinking and realized, “I’m the Dad and he’s just the doctor. Who will live longest with these vital decisions?”
When parents interact with their unborn great things happen; they get to know one another before birth. Once fetal movement is perceived by a pregnant mother, the most important “monitor” of the new life begins developing. Fathers/partners can strengthen her perception with affirmations of their own. Even when her attention is focused on other things (a job, other children, responsibilities totally unrelated), when fetal movement patterns change, she notices. It somehow emerges from some subconscious place into her awareness. We know because even very busy mothers report diminished fetal movement. In my experience, this has been life-saving for unborn babies time and time again. How does that happen?
“When the IT (the pregnancy) becomes YOU, (our baby) the dialogue begins,” was the opening remark at a conference of the Association of Pre- and Perinatal Psychology and Health (APPPAH) in Krakow, Poland in 1992. APPPAH is an organization that focuses on prenatal cognition and communication between a mother and her baby during pregnancy. More and more we are learning about the fetal experience; they have the ability to communicate and remember. The unborn clearly are not “blank slates.” A three-year-old was asked what it was like when he was inside his Mommy’s tummy. “It hurt my head when you walked too fast.” “And when you peed it was really loud!”, he responded. A three-year-old could not make that up!
It seems to me we have made a mistake by destroying a mother’s intuition with our technology. With a reassuring test after reporting diminished movement, a mother can believe she’s wrong unless we teach that she is more sensitive than the test. Continuous fetal monitoring over some time may be needed to determine fetal status when a mother’s perception doesn’t agree with test results. That isn’t always a part of our protocols or practice. We, health care providers, need to teach mothers they did the right thing to report the change from what she’s used to. She is more sensitive than technology and it is critical that she should continue paying attention and report concerns. Otherwise, it’s easy for her to feel mistaken and suppress her intuition/perception at the peril of her pregnancy. Continuous monitoring can sort it out when technology and a mother’s intuition disagree.
Teaching pregnant women the risks of stillbirth must become a part of prenatal care. Avoiding this so as to not frighten mothers is patronizing and needs to stop. Using positive language is a better approach, e.g., “Prenatal care is about keeping you and the baby safe and finding the best time for birth. That could be when you are due but if not, the baby, or something else, will show when it’s time. Affirming her role as the only constant attendant to her baby’s well-being is important and a partner’s support is invaluable. I was told by one father that after his wife went to sleep, he put his hand on her tummy to feel the baby’s movement for himself. That seems to me to be a great example of co-parenting.
Obviously, the process of dying is extremely unpredictable depending upon causation and timing can vary enormously. (It seems too simple a fact to even mention.) Cord accidents are fast. Other causes of death take more time. To be fair, drawing that line of when to intervene is not easy and differences of opinion were not rare in the past nor are they now.
People who work in hospice care, first developed as recently as 1963, have many stories to tell that belie science, “Out of body experiences,” to mention just one. Janis Amatuzio, MD, a coroner, has written two books about “Unexplainable things” she’s learned as she was giving autopsy reports to families. She also gives lectures about those strange incidents, (“sometimes received skeptically by her peers”), one I attended. The stories are amazing but, even more convincing, she asked her audience to raise a hand if they had experienced something similarly mysterious. At least ¾ of the audience raised their hands. Who can explain “scientifically” why these are such a common phenomenon? We clearly have more to learn, and we need to be open to taking into account things we may not completely understand. New discoveries have made possible many advances in perinatal care in recent decades. As satisfying as that is, certainly, the trend will continue. There are many nuances, to be sure. My purpose in bringing this issue forward is to share stories that include the interaction between the mothers and babies I encountered in my work as an obstetric nurse. There have been many unexplained outcomes and surprises that defy “Science”. I think access to the dialogue between the sentry (mom) and the hidden (fetus) can, and should, be a much larger part of the decision-making in pregnancy care. And the father or other support person can be a powerful advocate/supporter day in and day out which strengthens the mother’s trust in her intuition. Can we bring that sacred gift into a more prominent place in our care involving new life?
A mother came to APT at 29 weeks, the perinatologist thought the ERM strip looked OK for such a young fetal brain. “But the mother is worried,” reports the nurse. “Admit her,” he said. Continuous monitoring was started in the labor room. The baby’s condition deteriorated at midnight, about 14 hours later, and was delivered by C/section, Apgar 4-8. The mother was concerned, the nurse reported to the decision-maker, he changed his objective analysis, contradicting the technology, acted on the mother’s intuition and changed what would have been a disaster to a good outcome.
Just out of nursing school, working in Labor and Delivery, one night I was assigned to care for a woman in active labor. Then listening and counting fetal heart rate with a stethoscope was our only means of ensuring fetal well-being during labor. I don’t remember why, but my own intuition about the fetus was of concern so I listened and counted much more often than usual. No matter how I counted and multiplied by 4,3,2, or counted for 60 seconds, the result was always 140 beats per minute, (BPM), normal. Upon delivery, the baby was pale, totally limp, did not breath or cry for a very long time and not without help. It was shocking then, unforgettable, and it prepared me for learning everything I could about continuous fetal monitoring when, years later, it became available.
I now know what that baby’s monitor strip would have looked like: no variability so the heart rate printout would have been a straight, flat line. The baby’s brain controls its own heart rate according to her need even before birth. That produces a squiggly line on the monitor strip, called variability, a powerful demonstration of healthy fetal brain function. If anything interferes with the lifeline, the umbilical cord, the heart rate may speed up to compensate. When the shortage of blood flow becomes more than the baby can tolerate the print-out becomes flat. This print out can also take place when the baby is in a sleep cycle (as in Case 15) , so again, time will tell.
Continuous EFM became standard practice in hospital Labor and Birthing units in Minnesota in the mid-1960’s. After hours and hours of watching fetal monitor strips, day in and day out, we began to learn the patterns of a healthy baby and the early signs of stress. A normal rate of 140 beats per minute (bpm) we knew from listening but there was more, obviously. Variability of the heart rate, beat by beat, and, at term, huge accelerations of FHR when the baby moved, showing the central nervous system (CNS) is well oxygenated and functioning well. Babies born with those patterns were pink, had good muscle tone and began breathing and crying on their own right away. Continuous monitoring during active labor also showed us the surprising variation in fetal stress/distress/recovery patterns printed out on paper in real time. A lot of those patterns were “variable decelerations”. The baby’s heart rate would go from 140 bpm to a very scary 40-60 bpm for a whole minute during the contractions. These were caused by umbilical cord knots, twists around parts of the baby, often the neck causing a temporary slowing of blood flow to the baby. Usually this happened during the contractions and causes a reflex defense mechanism. When the contraction ends, the FHR pops right back up again, and the fetal status remains strong. Variable decelerations were very obvious; at first, because they were so obvious, we thought they always meant fetal distress, and they sometimes do when too many, too long or strong. But this built-in defense system of the fetus allows for much more tolerance of cord problems than we knew at first! We had no idea about this when we started fetal monitoring so there were many unnecessary Caesarean births. After a while we learned, by watching the print-out and comparing the condition of the baby at birth, that variable decelerations could be tolerated for quite long periods of time. Now we could see in retrospect that if the rate returned to 140 or so, and variability returned after the deceleration, the fetal well-being was still excellent. Who knew? The dynamics of pregnancy are well designed for the safety of both mother and baby, and we may not appreciate the whole spectrum of that yet. The learning continues.
We learned that even the fetus has a lot it can do to participate in its own well-being both before and during labor. A simple example is, if long-term blood flow to the baby is less than desirable, growth is slowed, especially to the baby’s abdomen, but not to the more vital brain. That results in Discordant Growth. The baby may need to be born earlier than her due date for the best outcome. So, induction of labor will be safer than waiting for spontaneous labor. But when? The baby decides with APT testing results. Amazingly lung maturity speeds up in preparation for an early arrival so breathing is more efficient for that baby even though very small for its gestational age. The need for NICU care is usually much less than it would be for a baby that size or weeks gestation.
Fetal wellbeing is dependent upon blood flow between the mother’s circulation and the placenta that grows with the baby in the uterus, obviously, but nature can create some variations, as we know and see all the time. We’ve been able to recognize more of those variables with our prenatal care by utilizing ever newer technologies along with old tried and true methods. Measuring the height of the top of the uterus, and comparing it with averages for weeks of gestation is one easy, old, way of checking the growth rate. Before continuous monitoring, we had no idea of intermittent stresses that the fetus could tolerate but that sometimes led to serious problems. We found that distress in labor can abate with some simple interventions: changing the mother’s position, especially turning her on her side can almost instantly improve blood flow and the monitor strip demonstrates recovery.
A nurse practitioner I knew had the responsibility of making hospital rounds on postpartum mothers at our perinatal center. Every day she saw the difference in recovery time between women who had had vaginal births and those who had Caesareans. Now, pregnant with her own first baby at term, she knew, better than most that a vaginal birth would be much preferred. In time, active labor ensued for this healthy mother with an uncomplicated pregnancy. Before long her fetal monitor strip began to show variable decelerations with every contraction. Consultation with a perinatologist and discussion of a strategy resulted in his staying in her labor room or very nearby for the rest of her labor. She was determined to have a vaginal birth. He was prepared to intervene with a Caesarean at any moment if needed. Decelerations to 60 bpm for up to a minute with every contraction were dramatic and could not be ignored. But the rapid return to 140 bpm between contractions with good variability and a baseline which did not increase over time, showing decompensation, were all reassuring signs the fetal status was remaining stable. Hour after hour they watched for the changes that would mean it was time for intervention. But no changes ever came! The decelerations just kept coming throughout her whole labor. And when it was time to push, she did what mothers do and had a normal vaginal birth. The baby was pink, vigorous, cried right away, and grew up with no after-effects from his scary birth. The umbilical cord was around the baby’s neck which caused the decelerations during contractions.
This can be seen as nature’s way of protection because of a pretty high probability of the umbilical cord becoming entangled or obstructed in some way. Many are born with the umbilical cord around the baby’s neck mostly causing little or no trouble. Before ERM we didn’t even know that protective mechanism was there because we listened for FHR between contractions. Part of my work included teaching fetal monitoring to nurses in our area. At one of these classes, I used the monitor strip from the Case 4 story to show the amazing extent of fetal compensatory capability. A different perinatologist, waiting for her turn to teach, privately shared her opinion with me that she would have done a Caesarean with a monitor strip that looked like that. Another example of “there is no one right way” but these are not easy decisions! A parent’s perspective/intuition is not out of place in difficult decisions like these, I believe and have observed.
“Late decelerations,” are more serious to the fetus. They are described as a symmetric, slight slowing of FHR about halfway through the uterine contractions during labor. As earlier described, these are much more subtle but indicate not enough oxygen to the brain, obviously a much more serious sign of distress. Loss of variability of the baseline heart rate is also dire but easier to miss because the rate could still be 140, or so. Heart rate baseline gradually creeping up over time is also compensatory but, similarly, not so easy to notice. Learning all this took time and a lot of experience. No to mention, there was also a lot of subjectivity involved in reading the monitor strips.
The question becomes, when is the right time for intervention? Caesarian section is not reversible. Our medical system is strongly affected by our legal systems, as well, and that imposes another onus. I heard one obstetrician say, “That monitor strip is the ultimate retrospective tool.” He felt vulnerable legally because of the poor outcome from one of his deliveries. Timelines of fetal distress and especially fatality can vary enormously. Drawing that line of when to intervene continues to be a conundrum and differences of opinion will most likely be part of the perinatal/obstetric scene indefinitely. Roger Freeman, MD published books on fetal monitoring in 1935, 1991, and 2002. The title of his last book is, “A disappointing story.” This speaks powerfully to the nuances in this technology.
With the advent of Perinatal Medicine, maternity care became focused on outcomes of pregnancies both before and after birth. Timing is of the essence in terms of the long-term optimum health of the newborn. Could we extend the prediction of wellness we learned in labor rooms? That question led to the development of Antepartum Testing. Once viability has been reached in pregnancies when risk factors have been identified it seemed possible. With that idea, the innovation in about 1975 by Dr. Roger Freeman of the Non-Stress Test (NST) and the Oxytocin Challenge Test (OCT) became a focus of development. The NST required accelerations of heart rate with fetal movement and the OCT required not even the slightest deceleration during or after contractions. Since these women were not in labor contractions were induced by IV Pitocin. That made this test very labor-intensive and time-consuming. But it was needed when the NST was not reassuring. These tests were very successful in predicting safekeeping a whole week at a time. The next week, another test, etc., until the test failed and evaluation for delivery would take place. “The baby chooses his or her own birthday because of the heart rate patterns on the monitor strip!”, I taught parents. Preventing tragic late pregnancy losses by induction of labor or Caesarean birth, rather than waiting for spontaneous labor to begin, was life-saving!
Rigorous studies found that a fetus in a high-risk pregnancy could safely grow one week at a time as long as the tests were OK, or negative. This method of management of high-risk pregnancies is what made them safer than normal pregnancies at that time. The rate of false-negative tests then was .009/1000, meaning that there had been a prediction of well-being for a week, (a negative test) but instead the baby had, tragically, died before the week was over. False-positive tests meant that it looked like there was a problem with the baby but with repeated testing, the babies met the criteria and were ok. These false positives were numerous, made a lot of work for staff but had no other consequences. The false negative tests were rare but the huge impact they create has kept the search for better predictors continues to this day.
Statistics from our brant new APT service are no longer available but the expectation would have been, we should have had many losses, false negatives, in those 15 years when studies were reporting the rate was about 1/1000. I dreaded the day my turn would come when the numbers would catch up with me but, thankfully, they never did. The learning curve for me was huge, starting out in 1981 with only NSTs and OCTs. The perinatologists read every monitor strip before the mother was released to go home. Many readings were “Equivocal” so testing had to be repeated the next day. Our perinatologists were very influenced by the mother’s perception of her baby. “You’ve got to listen to the mothers!”, one said. And we did. When test results and the mother’s intuition didn’t agree, continuous monitoring was often used to sort it out.
The next development was the Biophysical Profile (BPP) which used ultrasound imaging and ruled in signs of wellness instead of ruling out risk. It required the presence of FM, good muscle tone, fetal breathing, and amniotic fluid volume, two points for each feature for a score of 8/8 or 10/10 if an NST was included. The time limit was 30 minutes or less, and the standard was set for once or twice weekly testing depending on the relative risk factor. It was a relief when the cumbersome OCT was no longer needed though spontaneous contractions were welcomed for the additional information provided about late decelerations.
There were losses during those years but none that I could attribute to the failure of testing. One example was of twins. Their growth rates were very different because of the uneven distribution of blood between the two babies. The smaller baby needed to be born prematurely to survive, but the larger twin, with no stimulus to get ready to breathe air hadn’t developed lung maturity yet. Hyaline membrane disease in the NICU was the cause of his demise. Another loss was from a mother who reported diminished movement on Friday, but testing was scheduled for Monday. It was too late. Another story of uneven blood flow: there was a triplet pregnancy with one baby smaller than the other two. We were doing daily testing of all three until the smaller one failed. That called for an emergency Caesarean. In the operating room, ready to begin the incision, one more check with ultrasound revealed the small baby’s heart had stopped. Surgery was canceled and the other two babies had a few more weeks to grow and became mature enough to survive in the NICU. That likely would not have been the case had the first intent to intervene been followed. The mother credits the baby who did not survive with saving his brothers’ lives.
Our perinatologists, who read all the monitor strips, honored mothers’ intuitions and so I learned to, as well. Experience, common sense innovation, and intuition cannot be replaced with standardization or protocols. We have tried to do that with APT but results have been less satisfactory than we could wish. Vital Statistics have not improved enough recently especially in the US despite new technologies and studies. Is the missing link Mothers’ Intuition? Could it make a difference if the mothers’ intuition/opinion were part of the protocol?
Lois had a tragic history of intrauterine fetal death (IUFD) at 29 weeks with four prior pregnancies and had been referred to our perinatal clinic at 25 weeks in yet another pregnancy. She had lost four babies who most likely would have survived if they had been in time. I began seeing her for testing. She learned right away about its purpose. She understood it was designed for the prediction of wellness and that when the test was not perfect, further evaluations would be done. Our constant goal was to determine if the baby would be safer inside or out. I explained, emphasizing, “But you may be more sensitive than the test, so don’t hesitate to call us if you are concerned. You are there 24-7 so if you get worried, call and come back any time.” Four weeks later, at 29 weeks again, Lois had another reassuring test so she went home one more time. The very next day she called to say the baby had become quiet, so she asked to come back. This time it was positive, so she was admitted to Labor and Delivery. Fetal monitoring showed the baby was in trouble so she had an emergency Caesarean Section. A placenta malformation was seen at delivery, but it could have been detected prenatally. It could be presumed that her prior pregnancies had been lost because of the same problem. So why was yesterday’s test not correct in predicting well-being for a week like it was supposed to? Exceptions happen. Without the mother’s full understanding of her role there likely would have been another stillborn.
Janelle was hospitalized at 23 plus weeks with a single amniotic sac but there were twins inside. Risk of cord entanglement is extremely high. She was just trying to get enough maturity for those babies so they could survive in the NICU. The plan was for testing every day with BPP. Unusual situations call for unusual measures of care. There had been many days in a row of breathing, movement, tone and fluid, perfect scores of 8 on both babies. They were healthy, the same size, growing and maturing every day. Janelle understood the great risk to both babies and she knew the difference between them by how they moved. She also knew the ratio of one to three, growing in the uterus one day more would mean 3 days fewer (on average) in the NICU. Janelle was more than committed to giving it her all. One morning she asked me to work her into my schedule early because she was concerned about changes she had felt during the night and she asked that they be tested sooner rather than later. Sure enough, one baby’s score was only 2. Points for amniotic fluid only, one of the babies was not moving or breathing for a full half-hour. Janelle was transferred immediately to Labor and Delivery and had an emergency Caesarean Section. The babies’ APGAR scores were 2/8 and 8/8. The cord had become entangled but both babies survived because of the mother’s vigilance and a perinatal team’s ability to respond quickly. Hospitalization with frequent testing and Janelle’s deep appreciation of her babies’ risks and intense attention to their activity saved their lives. In both of these cases, a mother’s understanding and vigilance clearly changed the outcome of their pregnancies. Maternal input is so very critical and these two cases so clearly demonstrate that important part of care.
Using the test results to affirm the mother’s perception of her baby with a simple question, “Tell me about your baby,” is a good way to begin the conversation at the first visit for testing. When the test results confirm her opinion, affirmation of the mother’s knowing can become a most powerful influence to keep her focused on her baby throughout the rest of her pregnancy. If results of the test do not concur with her perception of the baby, she will need help to understand that, without doubt, she is more sensitive than the technology. This cannot be ignored when teaching mothers the purpose of testing. If she continues to feel concern, she should report it as many times as it takes to be seen. Maybe continuous monitoring will be needed to sort things out. Maybe repeated testing the next day; maybe a different kind of evaluation. There are no guarantees in life but together we can do a lot to stay out of trouble. Mothers need to be a bigger part of this truly vital conversation.
We were a budding Perinatal Center. Chaos was breaking out in Labor and Delivery. The one and only perinatologist in our center was accosted in the hall to read a monitor strip from a 29 weeker whose immature central nervous system (CNS) prevented clear and definite accelerations. Fetal heart rate accelerations with fetal movement are required to meet the standard of the test. There was variability, though, one reassuring sign. The doctor nodded and said, OK, then gave me eye contact with a question mark. A quick nod from me and we were both on to the next crisis. The nod meant I had learned from the mother she was not worried about her baby and there had been no other concerns discovered during the testing from her perspective or my findings (blood pressure, urine test, etc.), she came back a week later and had another good test. Intuition, teamwork, and science in accord, even in a big hurry.
It’s 1953, it was the night shift, I listened to report. My assignment was to attend to a woman with diabetes, in her 4th pregnancy. She had three children at home, all normal, live births at term. She was in spontaneous labor but making very slow progress. She was trying to sleep so I introduced myself and sat down quietly by her bedside and began feeling contractions with my hand. We had no fetal monitors in those days. An hour or so went by and her contractions could be described only as “piddly”. There was no point in checking her cervix. So, I started a little conversation by asking about her pregnancy. “My doctor told me to not get pregnant again because I might die because of my diabetes.” Labor nurse, just out of school, full of knowledge and confidence replied, “Oh no! You’re in the hospital now, there’s no way we would let you die. The dangerous part is done.” Her contractions strengthened and two hours later she delivered a healthy baby girl. Thank goodness I was so naïve as to be able to allay her fear so thoroughly that she could allow herself to go into productive labor. Clearly, her fear was legitimate because of her doctor’s warning, and it was impeding the progress of her labor. When her fear went away her body became available to take up the work of active labor.
All of these stories demonstrate the important part mothers play in their positive outcomes. Through the years of working with pregnancy, I never stopped learning but I struggle to find a way to bring forward more emphasis on the mother’s influence in order for it to become a necessary part of pregnancy care. We have the capability of electronically monitoring the fetus continually over time. Fetal monitoring in labor has certainly taught us to recognize patterns of distress that come and go. And it requires time to determine the need for intervention. Also, minor interventions can make a big difference. Repositioning a mother in labor is only one simple example. When the tests and the mother’s intuition do not agree it seems like the next obvious step is to give it more time. Why has this not become standard practice? I am convinced that that is why these stories need telling. Parents need to be heard. Even with all of our technology we cannot see/know everything.
Perhaps, most important of all, what NOT to teach: A BABY’S MOVEMENT SLOWS DOWN WHEN LABOR IS COMING SOON. This new addition to prenatal teaching, though sometimes true, has been lethal to too many babies. As the fetal head moves lower in the uterus, thinning and softening the cervix in preparation for the onset of labor, the mother’s perception of fetal activity may seem to decrease. Space available may also be a factor as well as other phenomena we don’t know about yet. Perception of movement can CHANGE but should not stop! A sudden increase in FM needs to be checked out as well as decreased FM. The struggle of a fetus in distress because of blood flow impairment can mean a crisis is happening. Rapid response may be the only way to avoid imminent demise.
A well-informed mother breezed in, at term, reporting diminished FM. She had read that that was normal when labor was soon to begin. She had learned she would have a test and if it was ok she would be sent home to await labor. She was totally shocked and stunned when it was discovered that her baby had died in utero. “Information” had damaged her intuition.
A history of prior loss, sometimes many, early, mid or late pregnancy, was a frequent reason for referring pregnant women to our perinatal center. Many of these losses had been of unknown causes. The extreme anxiety of these parents facing nine months of fear of another loss really called for additional care. Dr. of Family Education, Joann O’Leary and Lynnda Parker, OB/GYN nurse recognized the need, so they developed a program at our hospital. It included prenatal classes specifically designed for these traumatized Moms and Dads. It included a tour of the labor and delivery unit so parents could feel acquainted when it was time for the birth. This was even more important for couples who had been at our hospital with their prior loss. The trauma of “returning to the scene” could be devastating and needn’t be at the time of a new birth experience. There were home visits for some. A weekly support group for both parents at any stage of their pregnancy clearly demonstrated the help they could be to each other. A powerful closing of each session included a description of the size and stages of development specific to each couple’s baby’s gestational age. It helped parents differentiate this baby from the one who had died. Soon Lynnda moved on and I was fortunate to take her place. Listening to parents sharing their experiences of terror was eye-opening. Today this innovative work continues around the world and many other hospitals and organizations have followed suit. Star Legacy Foundation now offers this service to families across the nation via online platforms.
One evening a first-time attendee came to our support group. New, as a facilitator, I spoke up about the importance of the mother’s paying attention to their baby’s movement. I said that almost all the mothers whose babies had died in utero had said, after the fact, “I thought so, I knew something was wrong.” The newcomer suddenly got up, left the room and never came back. I can only surmise, but I fear my tactless words were too close to her former experience. If only I could have taken them back!
Another unintended painful experience: a mother was referred for testing because of a diagnosis of discordant growth. That means the fetal head measured the right size for its age but the abdominal measurement lagged. This can happen if, for some reason, blood flow to the baby is less than adequate. What had not been explained to her was the amazing compensatory mechanisms of fetal/maternal interaction during pregnancy. When the blood supply is short, something will cause more blood to flow to the most important part of the anatomy, the fetal head. Thus, the abdomen grows less but the head stays on track. The cause of inadequate blood flow is likely unknown but clearly the baby is protecting itself by some process we may not completely understand. Testing for that mother had begun at 32 weeks in case birth sooner than her due date would be necessary. In the meantime, the mother had this picture in her mind of an abnormality. She was terrified for two months expecting a monstrous-looking baby because of an abnormally large head. She was furious when her baby was born and looked completely normal, understandably! Here weeks of agony, worrying about deformity has been unnecessary. It was a smaller abdomen but normal size head. We were so remiss in not helping her understand the rationalle of discordant growth and why that is a reason for testing.
I was reminded of a statement I heard from Dr. Smith, the head of the Speech department at the University of Minnesota, “The normal result of communication is misunderstanding.” We were not careful enough with our teaching, obviously!
One young father came to the support group with his also very young partner and told his story with enormous rage. He had asked a question of the doctor making rounds: the doctor turned to the mother with his answer, infuriating this very young father. I suppose he felt dismissed.
So how can we health care providers, avoid misunderstandings and take advantage of parent’s strengths? Listening to their perceptions seems primal. There’s no better way to convey our respect and value of their part in reaching a positive outcome. Achieving the strongest collaboration possible between parents, physician, technical and nursing staff can become a powerful force for success.
So many poor outcomes have no explanation. A hospital or clinic can be intimidating and the ever-increasing advancements in technology even more so. Can we find a better way to empower and utilize mother’s intuition in our practice? Our decisions are for the day but for the family, the rest of their lives will be impacted. Empowering couples with full and complete understanding of their care and our reliance on their 24/7 parenting will pay off.
It’s not easy to tell parents “high-risk pregnancy is statistically safer than normal pregnancy,” but it is true. APT has been a big factor in getting us there. But nothing is perfect and the failure of greater improvement in our statistics in recent years has been disappointing in spite of lots of research with various technologies.
A mother of two children came to APT at 36 weeks because of her elevated blood pressure. By then most mothers are very tuned in to their babies from feeling their movements. “How is your baby?” I asked. She looked upward as though searching for an answer and finally said, “OK, I think.” Surprised by her uncertainty, “How about your other children?”, I asked. “Oh, they’re still in Africa with my mother and we’ve been working so hard to try to get them here.” A brief explanation of APT because of her elevated blood pressure and a gentle suggestion that this baby needs a bit of her attention, too. She knew her baby was OK, and the test agreed, giving her affirmation for the attention she had given her newest family member.
Our children don’t always perform the way we want them to, when we want them to. This is true during pregnancy as well. A non-reassuring test is most commonly repeated the next day and usually is reassuring. But if the test is good and the mother is not convinced, her sense should not be ignored, I believe.
Barb was an insulin dependent diabetic who had a bet with her non-diabetic husband that she would outlive him. She was very focused on healthy living. With her first pregnancy she took on the task of APT with interest and enthusiasm and had a healthy two-year-old at home. In her new pregnancy she knew what to expect and was ready for testing when the time came for it. Not wanting to take too much time off from her full-time job, she asked to come in earlier than my normal hours. I agreed. So, she came in alone, applied her own monitor, she knew what constitutes a reactive NST, so when I came to work at 8:00 all I had to do was take her blood pressure, record her weight and urinalysis, have the test read and send her on her way. I could assume that she was very comfortable with the medical system because of her diabetes, she was committed to healthy living and confident about her ability to do the right thing and get good results. She was very pleased and proud of her accomplishment, once again, a healthy baby at term. I can’t help but think their successful pregnancy was related to her attitude.
My last and favorite story will be about Kim and her simple, sweet family. I met her the day of her third baby’s birth. She had been referred to APT because her baby’s growth was behind normal for her due date: (Intrauterine Growth Restriction (IUGR). The fetal monitor very soon revealed that her baby was in distress, so she was transferred right away to Labor and Delivery. Her baby was born with an APGAR of 2/8 but has done well. Two years later, more or less, she was back again with her husband and their three preschool children. She was a busy mom. Because of IUGR with her new pregnancy again, she was trying to do bed rest at home to enhance blood flow to the baby. However, reverse diastolic flow of the umbilical artery had been found at her weekly prenatal visit. This is evidence of a very serious decrease in blood flow to the growing baby. There was no BPP in those days, so the NST and OCT were our only tools. Kim and her husband had no reason to be concerned about their baby, there had been consistent fetal movements, reactive NST’s in all their prior tests, and they trusted their care providers. The whole family came in each time, so we all got well acquainted and knew what to expect. We were usually finished in half an hour or so, and they were on their way. Kim and her husband knew by now what a good test looked like, and they were confident. So, at 35 weeks, it’s time for another test. But this time the baby was quiet. Fifteen minutes passed, no movement, no accelerations; twenty-five minutes, the same. Siblings are getting restless. “Don’t worry, we can get a good test if you can just have a contraction, “I said trying for a spontaneous OCT. I was surprised when she actually did. Why not try for another one? She did! And one more, we needed 3 in 10 minutes, and we’ll have a perfect OCT. And again, she did and there were not FHR decelerations. A perfect test! “But now the contractions need to stop so you can go home.” I said. And in the next 20 minutes of monitor strip, not a trace of a contraction. Plus, a bonus: the baby woke up, gave a couple kicks and created two beautiful accelerations. I looked at Kim’s husband, we both looked at Kim and all three of us burst out laughing. “How did you do that”? I asked. “I just have to think about it now,” was her only explanation. She was confident in her baby, testing, and herself. Kim delivered a healthy baby in less than a week from that day and saved her whole family, but especially their baby the NICU experience.
There are many causes of fetal demise in late pregnancy when viability is so possible. These are the most tragic losses of all. And many of the causes are unknown both before and after birth. Where there are recognized risk factors such as diabetes, postdates, babies too big or small for their gestational age, and an ever-growing list of reasons for concern, we can intervene in a timely way with prenatal or perinatal care. Our technologies are also growing to meet these needs. Continuous monitoring in labor ultrasound measurements, antepartum testing, and induction of labor are only the beginning. Or, if prematurity is the issue, eking out just one more day of maturation can be life saving. The rate of the dying process can vary so much depending on the cause. Keeping vigil at the bedside of the dying is a cultural norm and should be brought into our prenatal care, I believe. Our imposed time limits of one week, or even a half week can seem very arbitrary. Yes, control factors for research purposes are necessary, but in real life, there are no absolutes. How does intuition work? Research of this phenomenon is still sparse. So, we need to be prepared for what we do not yet fully understand. We may not know, but when we keep an open mind, our chances of learning improve. The question: How can the voice of Mother’s intuition, the sacred gift, become strong enough to be heard?
I ask all these questions because, years ago, I read an article about a woman who had been the CEO of Southern States Power Company in Minnesota. She had been appointed to the Atomic Energy Commission in charge of testing atomic bombs in the US. She was new and the only woman on the commission, but she was brave enough to ask the questions, “Why do any more atomic bomb testing?” It was a ridiculous question to her colleagues, but, as a result, testing stopped. Since reading that, asking the right question has seemed more important than ever before. “How’s your baby today?” seems like a good one.