labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Sunday, November 22, 2009

Multip End Point

This morning I get an email from an old friend who is pregnant with her fourth child. This pregnancy was more challenging than her others, with more aches and pains, preterm contractions, questionable blood pressure issues, and then a few episodes of premature rupture of membranes. Everything has always turned out fine whenever she went in for an evaluation, whether at her doctor's office or the labor and delivery triage unit. Her most recent labor and delivery triage visit prompted a nurse to say to upon arrival, "Oh, I would have thought you would have delivered by now!" This made my friend feel a bit like a multip reject...like she should have been able to know exactly the right times to actually present for triage evaluation or have had something requiring her to stay instead of being discharged still pregnant.

Her previous three babies were all delivered between 36 and 37 weeks after spontaneous rupture of membranes and a fairly quick spontaneous onset of labor shortly after. So at 36 weeks we were all waiting for her water to break. And she reached 37 weeks. During the 37th week, she went in for several evaluations of varying concerns, all panning out just fine. She was feeling quite anxious at this point, given that she had never gone past 37 weeks.

And then 38 weeks...

Now, at just 39 weeks, and still chugging along, she tells me that she is going in for induction tomorrow. Just because. The reason her doctor gave her was basically a "What the hell...you're a multip and your cervix is 2 centimeters dilated and I know you want this over with."

And you know how I read this? "ACOG says it's ok to induce at 39 weeks, you've had 3 normal vaginal deliveries without problems, your Bishop score is favorable, and we are sick of you calling us everyday and I am on call tomorrow."

Why do I think this? Because my friend reports that her doctor had said it was fine for labors to be induced once a woman reaches 39 weeks in all women; that her doctor's office staff have said to her that she "got the award for the most phone calls from a multip ever", and he said routinely started checking her cervix at 37 weeks to see if she was "ripe" should she ever need an induction. Oh, and when she requested to postpone the offered induction by one day for childcare reasons, the doctor said it couldn't be done because he wasn't on call that day and it would just be better for all involved if she came in when he was there.

Now, I am not sure if my friend sees it this way, as she was delighted to be able to have an end point to her pregnancy that has been an anxiety provoking experience for months.

And it gets better...the reason my friend contacted me to discuss her induction was because the doctor ended her visit with saying, "Well, this all should go fine, but I think your baby is big so you might end up with a c-section."

Sigh......

12 comments:

Mrs. Spit said...

Well, if she is at all pre-eclamptic, evidence based medicine says that those babies, and certainly those women do much better with inductions at 37 weeks.

Jillian said...

Hi there. I just started following your blog and really enjoy it. I am a graduate NM hoping to take my boards very soon, but put off my career for a bit after having a baby of my own this past February. I love living vicariously through you as you start this new journey.

Anyway, about your post: Ugh...that is terrible, and I am sure you are right about her doctor's motives. I really wish women were more educated about the risks/downside to induction and the cascade of interventions, but I know I am preaching to the choir here. Unfortunately, it is her doctor who should be educating her, and instead he is pushing for an intervention that is not considered best practice. Yes, ACOG says it is okay at 39 weeks for medically indicated reasons, but it doesn't say it is recommended! And I HATE the big baby threat! Hopefully, for your friends sake, things go smoothly, but if she does end up with a C/S for failure to progress I bet it will have more to do with her induction than the size of her baby. Of course, there will be no way to prove that so you know her doctor will tell her, "see, good thing we induced when we did or your baby would have been even bigger." He may even say that if she ends up with a vaginal birth. I have heard that line given to so many women.

When my son was born (my first) I was 11 days past my due date. Thankfully, I had a CNM who was very trusting of nature and trusted that I was educated enough to make my own decision, even though the policy in her practice was induction at 10 days past due date. I went into labor on my own the day I would have been scheduled for this induction. I had biweekly NST and AFIs in that week and they estimated his weight at 9 lbs on the final U/S and still my midwife reassured me and made no attempt to change my mind. He was born weighing 8 lb 10 oz and I only pushed for 40 minutes as a primip! I had a beautiful natural delivery wherein the nurses worked around my contractions allowing me freedom of movement and I spent most of active labor in a jacuzzi tub. I know that if I had been under the care of a different provider at a different hospital my story would have been drastically altered.

So many of my friends and family did not understand my desire to refuse induction. They were the ones getting anxious and commenting to me in pity as my due date came and went about how I must be so sick of waiting to go into labor. I wasn't. I was patient and enjoying those last speical days with my baby kicking inside of me. I knew he would come when he was ready. He did, and I strongly believe that it made labor so much easier on us both.

Anyway, sorry to leave a comment as long as your post, but I get pretty fired up about this topic. I need to get back to catching babies sooner than later!

Jillian said...

Mrs. Spit,

Yes, if she were preeclamptic, this would be a different story, but it was my undersanding that she isn't. "Questionalble blood pressure issues" does not = preeclampsia. Obviously we would need to know her current BP and labs to diagnose that.

Carol said...

Mrs. Spit, there's nothing to indicate in this description that this is the case. And if it was the case, why wasn't she induced two weeks ago?

Jill said...

:facepalm:

momstinfoilhat said...

Mrs. Spit, if she was preeclamptic, the physician would have mentioned that in his "what the hell" reasoning. She doesn't seem to be based on the information given. Blood pressure fluctuation is not the same thing as preeclampsia.

And, preeclampsia does not indicate an induction at 37 weeks. It completely depends on the patient and the severity of the symptoms, combined with the date of onset.

Some women may need to be induced earlier than that date, and some later, depending on the gestational age at which the symptoms began.

SuSuseriffic said...

"if she is at all pre-eclamptic" Even a little? Even the AACOG says there is a range to care for those with smaller levels of that....not to mention that there is no hint of this in her post.

Muse said...

When did we become a society that trusts what people say with out doing our own research? I'm guilty of it, but how did it become this bad? Maybe I'll figure it out during my upcoming years of psychology...until then...thank you for your blog! I enjoy it immensely and it has allowed me as a person to sit back an question and research!

Mama to Monkeys said...

So I'm dying to know what you told her....

MyOBsaidWHAT said...

Well, my grandfather always used to say: "Liars figure and figures lie!"

For shame on this OB and how sad that this poor mama, who has done a great job birthing her three other babies is falling for his statement hook, line and sinker!

this should be submitted to submissions@myobsaidwhat.com!

Labor Nurse, CNM said...

It's taken me some time to weigh in on the comments here....

as far as pre-eclampsia- she never developed this. She had some questionable symptoms but her blood pressures remained below the diagnostic level of 140/90 and never had proteinuria (protein in her urine). In regards to induction if she was pre-eclamptic- there is no one specific way to go with it. MomsTinFoilHat explains this well.

Muse, I think that when it was expected that people become self advocates in their health care was when it was best for our own health to research what the evidence shows. I think that there is even a campaign put out by some government organization that encourages people to "ask the right questions". If anyone knows what I am referring to, please post a link because I can't think of what organization it is!

And what did I say to her? This was a tough situation. She was so excited to have this induction that I briefly just said that she doesn't have to go along with the induction if she was concerned. I reassurred her that, yes, this baby was likely bigger than her 3 others only because she went further along, but that there was no indication that the size of the current baby was concerning. She said her fundal height measurements were always normal, and the doctor had never even suggested getting an ultrasound for an estimated fetal weight. So, my interpretation of that is he had no real concerns about fetal size and ability to have a vaginal birth...why he said what he said in regards to a possible c-section is beyond me!

And...she went on to have a normal vaginal birth 8 hours after Pitocin was started, pushed for about 30 minutes for a baby girl weighing 8 lbs 11 oz in an occiput posterior position!

womantowomancbe said...

I think the "ask questions" campaign you're talking about is from this group; but the AARP also has a page with lots of questions on it as well.

-Kathy