15 Weeks - Prenatal Visit and Plans

Midwife Ina May Gaskin at a prenatal visit.

I keep meaning to blog about my first prenatal visit, and it turns out I have more than that to talk about. Things are coming together, and I'm very excited.

I'll start about prenatal care.

I intentionally waited to schedule my first prenatal visit. Because of my two miscarriages I didn't want to try to find a heart rate at any point when being able to find one would be questionable. For instance, at 10 weeks with a doppler it's possible to get fetal heart tones, but it doesn't always happen. I didn't want to set my hopes up for something that might not work out even if things were still fine. If I hadn't been able to hear a heart beat at that point, it would have only caused more questions and doubts about the viability of my pregnancy, and I couldn't deal with any doubt. I was focusing on the positive and moving forward without fear. There were other factors in choosing to put off my first prenatal visit, but it was mostly that I felt things were OK and I didn't feel a need to have an official visit. I was already consulting with my midwife over the phone, and she had already helped me with some of my needs by offering advice, information, and alternatives I might not have considered myself. That shifted in my 14th week. Out of the blue I felt it was time to call my midwife and schedule a prenatal visit, so I did.

I took all my kids with me to Sherri's house, thinking they'd be happy to play there and that they could all gather around to hear the heart beat when it was time. Not so much. My toddler had just woken from a short nap and was grumpy. The other kids were fine, but the toddler refused to calm down. We didn't know where his pacifier was - I thought we'd left it at home - and he was MAD. Sherri and I were trying to start the prenatal visit and he just screamed at me. About halfway through the visit he found a Spiderman mask, and from that moment on he was Spiderman and he was happy. Phew! I had to laugh when Sherri's 5 year-old (her youngest) who owned the mask kept asking for it back and telling me how "crazy" my toddler was. Yes, welcome to my life.

On to the more important things. My weight was good, and exactly where I knew it was. I had bought a scale when I was thinking I'd have an unassisted pregnancy, so I'd been watching my weight. My blood pressure was nice and low (108/69 - normal for me), and the urinalysis was perfect! When I was pregnant with my youngest I had problems spilling ketones in my urine, meaning I wasn't getting enough nutrition, probably because I was still trying to breastfeed my fourth child at the time and it was such a struggle to meet my body's demands. My midwife counseled me endlessly during that pregnancy about eating more and eating healthier. I was so glad to have avoided that whole conversation this time!

She was able to find the baby's heart rate immediately, and it was 158 beats per minute.

Ina May Gaskin checking FHT with a fetoscope.

I don't remember everything we talked about. She asked if I was taking my nutritional supplements (yes) and how I was feeling. When I told her that I was still fatigued she asked about my sleep schedule and suggested more naps and going to bed earlier. 

Sherri was about to wrap things up and I said "Oh yeah, one more thing!" I told her about how I'd originally wanted to plan an unassisted birth for this baby, and how my husband hadn't felt comfortable about that and we'd decided to hire her again. I explained my reasons for wanting a UC and she listened and promised me that she would be as hands off as I want her to be. At the end of the visit she reminded me of her fees and asked me to talk with my husband and figure out how we would be able to pay her. I told her we would and thanked her, and we scheduled the next visit in 4 weeks. Then I gathered my kids and cleaned up the mess they'd made, and we went home.

I was happy about how the visit had gone, with the exception of the angry toddler. I was grateful for my midwife's support and felt very reassured that all was well with both me and the baby.

And here's where there's more.

About a week after the prenatal visit Sherri called me. She said she'd been thinking about what I told her about wanting an unassisted birth, and about our financial situation. She's a dear friend to us, and she knows our circumstances and has always been willing to work with us. She told me she thought that part of my motivation for wanting a UC was because of finances. She was right, but I had been afraid to admit that to myself until she pointed it out. She agreed that I have a lot of knowledge and understanding about pregnancy and birth and understood that I felt comfortable moving forward without outside support. She also pointed out that at my home birth there was a lot happening behind the scenes that I wasn't aware of. I had thought about that before and realized it was wonderful to just focus and be in labor la la land without worrying about setting up, cleaning up, and all the nitty gritty.

Sherri then offered an alternative plan.

She had talked with one of her midwife assistants and had made arrangements for this assistant to work with her in giving me 5 prenatal visits through my pregnancy, attend the birth, and provide one postpartum visit. They would also provide phone consultation throughout the pregnancy. She offered me this for a significantly lower cost than what my midwife normally charges.

The visits would be at the assistant midwife's home, which is closer to my home and a shorter drive than to Sherri's house. They would expect me to be responsible for my own prenatal care between visits, including tracking my own blood pressure and doing my own urinalysis. I was already comfortable with that, because I'd been considering doing it all myself to begin with. She suggested I get an automatic blood pressure cuff that would take the reading for me, since she wasn't sure if taking my own blood pressure would be accurate. She also told me where I could order the urinalysis strips from, and suggested I could also get my own doppler to use for fetal heart tones. She also asked that I commit to come to her monthly forum throughout the pregnancy, which was something I really enjoyed last time and was already planning on doing.

I'm very happy about this plan. I feel it shows trust in me to tune in to my body's needs and stay healthy and take care of myself, with minimal visits to the midwives themselves. I feel it's a really good compromise between an unassisted pregnancy and one with the full 13 prenatal visits that are typical. I feel very comfortable doing most of my prenatal care myself, and I love the idea of having my midwife and one of her assistants available as consultants. I feel this is a good way of utilizing them as valuable resources but not depending on them for everything. I'm really glad I spoke up and told my midwife about my desire to be unassisted, and that she really listened and seriously considered my wishes and my needs. It also takes some financial strain off by offering us a more affordable alternative.

Rising Maternal Mortality Rate Causes Alarm, Calls For Action

"Each day in the U.S., two women die of problems related to pregnancy or childbirth. The numbers have been rising, for reasons that are not entirely clear."

"Nationally, the rate, defined as deaths from obstetrical causes within one year of giving birth, rose from 7.6 per 100,000 to 13.3 per 100,000." (emphasis mine)

Rising maternal mortality rate causes alarm, calls for action

This excellent article discusses the rising problem of maternal mortality, and some of the possible causes including: the rising c-section rate, increasing use of medical labor induction, and the changing profile of American mothers (more older women having babies).

The problem is baffling for experts, because high death rates are common in poor countries where women don't have access to adequate prenatal care. The United States, however, spends the most money on health care, yet has one of the highest rates of maternal mortality.

"Though the U.S. spends more per birth than any other nation, maternal mortality is higher here than in 40 other industrialized countries, including Croatia, Hungary and Macedonia, and is double that of Canada and much of Western Europe."

"That the United States is backsliding in this most basic of healthcare measures has triggered attention and alarm in medical circles. In January, the Joint Commission, an independent organization that accredits and certifies healthcare organizations and programs, issued a "sentinel event alert" warning of the rising maternal mortality rates.

"In March, the human rights organization Amnesty International released its own report, 'Deadly Delivery,' calling for sweeping changes in maternal healthcare in the U.S."

"The California Department of Public Health has commissioned a statewide review of medical charts in maternal death cases to identify reasons for the rise and seek ways to improve."

"'Mothers shouldn't die in childbirth,' said Dr. Elliott Main, chief of obstetrics at Sutter Health and director of the ongoing California review. The trend, he said, may signal a much larger problem with U.S. maternal healthcare."

Here are some more articles on the subject:

It's Now More Dangerous to Give Birth in California Than It Is in Kuwait or Bosnia

Revealing the Real Risks: Obstetrical Interventions and Maternal Mortality

New Moms at Risk - Maternal Death Rates Increasing

Maternal death rates are on the rise, and it's getting some well-deserved attention. In our world of modern obstetrics with advanced technology, one would think that fewer mothers would be dying during or after childbirth, but the opposite is true.

It's Now More Dangerous to Give Birth in California Than it is in Kuwait or Bosnia

That article caught my attention. It was a bit shocking to see the statistics and realize the real impact this is having on real mothers and their families.

According to the statistics from California, the increase in mothers dying is the result of the overuse of interventions such as c-sections and medical induction.

C-section rates are higher than ever. The US has an overall c-section rate of about 33%, with hospitals in some areas boasting rates close to 50%. That means that in the United States, 1 out of every 3 babies is born by c-section. The World Health Organization recommends a safe c-section rate for developed countries (like the United States) is 10-15%. They also state that when the c-section rate is more than 15% the risks outweigh the benefits and more mothers and babies are at risk for complications. Complications that are completely avoidable.

Amnesty International is concerned and advocating for changes in maternal health care:

"According to Amnesty, which gathered data from many sources, including the Centers for Disease Control and Prevention, approximately half of the pregnancy-related deaths in the U.S. are preventable, the result of systemic failures, including barriers to accessing care; inadequate, neglectful or discriminatory care; and overuse of risky interventions like inducing labor and delivering via cesarean section. 'Women are not dying from complex, mysterious causes that we don't know how to treat,' says Strauss. 'Women are dying because it's a fragmented system, and they are not getting the comprehensive services that they need.'"

"In the U.S., we spend more than any country on health care, yet American women are at greater risk of dying from pregnancy-related causes than in 40 other countries."

(Amnesty International Report on U.S. Maternal Health)

ABC has reported about the statistics in California and brought some much-needed attention to this problem. One thing they recommend in this video: avoid unnecessary interventions during pregnancy and birth. This means avoiding induction, scheduled c-sections and other interventions unless they are medically necessary.

What do you think? What else can women do to protect themselves from the dangers of overaggressive obstetrics?

Informed Consent

When a woman goes to the hospital to have a baby she is given forms to sign, and is usually immediately placed in a hospital room with a bed and hooked up to all kinds of gadgets and strange machines. In the throes of labor does she read through all of the forms and know exactly what she is agreeing to when she signs them? When a doctor, midwife or hospital staff want to intervene somehow with her labor and birth, do they explain all of the benefits and risks associated with that intervention? By law, physicians are required to provide full disclosure to the patient, and this is called "Informed Consent".

The American Medical Association has laid out requirements for Informed Consent as follows:

“Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.

In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

• The patient's diagnosis, if known;
• The nature and purpose of a proposed treatment or procedure;
• The risks and benefits of a proposed treatment or procedure;
• Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
• The risks and benefits of the alternative treatment or procedure; and
• The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states.”

Informed Consent is required by law, yet I don't recall being given informed consent for every intervention done on me or my baby in any of my 4 hospital births. This is of grave concern, as I believe all women should be fully aware of the reasons, risks and benefits of what is being done.

I urge every woman to take charge of her own care and insist on having informed consent. After all, it is her legal right and her doctor's legal obligation.

AMA - Patient Physician Relationship Issues - Informed Consent