On May 16, the American Congress of Obstetrics and Gynecology met to discuss several matters with regards to their practice. One of the topics that were discussed was recommending routine induction at 39 weeks for all women. The birth community was rather in an uproar about several of their more controversial statements, including
“This is a no-brainer. Why are we even having this debate?”
“Nature is a lousy obstetrician.”
“39 weeks is the solution. Rescued by birth.”
“Think like a fetus. There is no benefit to staying in after 39 weeks.”
The general conclusion of the meeting was that recommending induction across the board at 39 weeks was a good idea, though no official recommendations have been made as a result of their discussions. Many in the birth community are now nervous about what may happen to the field of obstetrics and how this recommendation if made official, is going to change the way obstetric practice is done.
There are a few things to note about ACOG. It is merely a private member organization, though indeed a LARGE one. It is not a government entity, though its name would suggest such. The recommendations that are put out by the organization do not dictate the way a member practice. (Hospitals and insurance companies do that). Furthermore, if a physician recommends a procedure just because ACOG recommends it, that does not mean that it is good practice. Only one-third of the recommendations put out by ACOG are based on sound evidence. The other two-thirds are based on either limited evidence or “consensus and opinion.” See here to read about this review of ACOG practices.
Evidence has shown time and time again that waiting until a baby is ready to be born, while carefully monitoring the mom and baby in the final weeks is generally the safest route. In addition, a woman is not clinically considered to be “post dates” until she is 42 weeks. An induction performed at 39 weeks could potentially cause a baby to be born three weeks before they were ready which can be dangerous for a baby. Due dates can be wildly off, and a 39-week induction could be very risky to a baby whose lungs are not yet developed. Induction itself also carries many risks for both mom and baby and those too numerous for this post.
One thing that evidence is clear on is that a baby should gestate for at least 39 weeks. That does not mean that 39 weeks is the magic date that a baby should be evicted from the womb. Stillbirth risks go up after a baby has reached 42 weeks, and most care providers consider the 39 weeks to 41 weeks time frame to be an optimal window for birth. Still, even though the stillbirth risk rises, the incidence is still extremely low, and a baby may still have crucial development happening at 39 weeks. You may read a great Evidence Based Birth (R) article detailing the research on due dates and stillbirth here.
So what is a woman to do if she finds herself with a provider that recommends induction at 39 weeks – just because?
First, understand that you can always change your care provider. ALWAYS. Women have changed doctors or midwives in the final days of pregnancy. It can be done. If your care provider is not practicing with the standard of care that you desire, or they are not answering your questions to your satisfaction, switch right away. In general, midwives tend to practice with a more hands off approach. Simply switching from a doctor to a midwife may change the entire outcome of your birth. Learn the difference between active management and expectant management and find a provider that lines up with the one that fits you best.
Know that you have the right to informed consent, but you also have the right to informed refusal. Informed refusal is not a term that is widely known, but it should be. Informed consent usually amounts to “I inform you and you consent.” Informed refusal simply asks the question, “What may happen if I choose not to move forward with this plan?” That is a viable option for you.
Hear the advice of your providers. Do your own research. Take an independent childbirth class. Make what you feel is the best decision for you and own it. At the end of the day, you are the one that deals with the results of decisions about you and your baby’s health, not your care provider.
That baby there is me, in my mother’s arms on Tuesday, April 16, 1985. Her name is Kathleen, and she died in my arms on Tuesday, August 18, 2014, at 10:33 pm in room 2410 of a local hospital.
I’ve always been “Mommy’s little girl.” On the weekends when I was still young and my older siblings had all left the nest, I would stay up late nights watching “I Love Lucy” and chatting with my mom as my dad worked the night shift. After the lights turned off, we’d become delirious with laughter, sing songs and pray. Pray in thankfulness. Pray for our loved ones. Pray for our health. And pray for the world.
We charted hurricanes and watched storm chasers. We’d sit outside on the covered porch and watch the thunderstorms as they rolled by. She encouraged me to jump in puddles, to rearrange and sow the materials of my clothing so I could represent ME, to pull apart electronics and write songs on my guitar. When I struggled with my history homework, she’d stop everything to help. When I had school projects she’d stay awake helping me assemble them. When I was falling asleep placing all our hand cut glow in the dark stars inside my mini planetarium, she sent me off to bed… and when I awoke, not only was the Planetarium complete, but there was a special message in hand cut glow in the dark letters, “Jesus loves you!”
She told me I could be anything I want. When it was a gymnast, she signed me up for gymnastics and brought me every week. When it was a figure skater, she made me a skating dress and surprised me with a set of skates. She took me to the rink weekly just to watch me fall on my tush over and over again. She’d take me home and bandage the blisters on my feet, massage my sore muscles and hold ice on my bruises. When I won first place, she’d smile and tell me, “I knew you could,” and when I fell short she’d always lift me up, “You did your best and I’m proud! Next time, kid. Keep practicing.”
When I was 9 years old I wanted to participate in the competitive Junior Bible Quiz team. My mom quizzed me and when I had difficulty remembering, she’d make Biblical quotes easier to memorize by putting them to familiar music. And when our church participated in an in house Bible Quiz, my mom and I both took home matching FIRST PLACE BLUE RIBBONS – even beating out the pastor who desperately wanted to trade out his “pretty yellow ribbon for a boy’s blue ribbon.”
She had a music ministry with my father, traveling the East Coast sharing the Good News and love of Christ. Her voice was truly anointed a powerful and beautiful gift.
I suppose, with any gift, comes a curse.
You see, my mom had always lived in pain. When she was 11 years old, a boy beat her so badly that it broke her hip and she needed surgery to repair it. As the years progressed, arthritis set in and the pins, which had never been removed, tore apart her muscle with each and every step she took. When she finally decided to do something about it on February 27, 1998, when I was just 12 years old, a big mistake was made during a “simple surgery” and it rendered her unable to walk.
Wheelchair and bed rode, pain plagued her, but she only smiled in its face. She soldiered on creating an online antiquity business with my father and uncle.
I grew up, moved out, got married, gave birth to a son… but I religiously called my mom several times a day, every day and visited her weekly.
The years took their toll on her body.
Looking back, I realize I was lucky to have another 15 years with my mom and blessed to have the last 2 years with her by my side in my home where she challenged me to games of Boggle, enjoyed our morning brew of coffee as we sat on the deck bird watching, where she cuddled my son watching Frosty the Snow Man for the umpteenth time, and where she held my minutes old daughter, Everleigh.
January 20, 2014, my mother was admitted to the hospital with what our family recognized as a bout of reoccurring cellulitis – a deep subcutaneous infection which was now brewing in her leg and hip. For THREE DAYS they refused to treat her for cellulitis and for three days she suffered a high fever, body aches, and skin lesions began to appear. If only I had a doula who would have advocated for our desires – a second opinion.
On the morning of the fourth day, doctors agreed and diagnosed my mother with cellulitis, but by this time, the infection was RAGING and not responding to several rounds of IV antibiotics. Finally, they found a compound of antibiotics which she began to respond to just in time!
“You had us frightened there for a moment, Mrs. Brindle. We thought we were going to lose you!”
Within 18 hours the hospital decided to send her home with a mid-line IV and orders for a visiting nurse who would show ME how to administer the antibiotic twice daily for the next week or so. I argued she hadn’t been on the antibiotic for even 24 hrs and should stay and be monitored to be sure she had no adverse side effects and the infection would continue to respond to the medicine. After talking with several doctors and several nurses including the department head, against our wishes, she was released from the hospital. If only I had a doula who would have reminded me to call for a patient advocate when our wishes weren’t considered.
Regardless, her smile beamed ear to ear as she came up the ramp and into our home. There is no place like home!!
For two days I administered the medication. By the morning of the third day, she complained of severe neck pain. Luckily, she had a great primary who offered to make a house call after office hours. He said she was suffering a form of whiplash, probably from laying in a hospital bed for over a week.
In the wee hours of the next morning, my mother called me from my bedroom to help her get to the bathroom. Tears streamed down her face as I carried her head for her. She couldn’t even lift it. A few hours later, her entire body was in severe pain and she barely had control. We called EMS services and she returned to the hospital via ambulance. After a few days, it was confirmed that my mother had a reaction to the drug interactions of Daptomycin and Pravastatin causing severe myopathy and renal failure. For a long time, I lived with that fact… that for days I dosed her body with a poison.
If only I had a doula who would have reassured me this wasn’t my fault.
She never came back home.
For months, it was a slew of battles. While she battled the delicate line of care between renal failure and congestive heart failure with dialysis, surgeries, medications, etc., we were fighting insurance to pay for care and hospitals and rehabs to make room for her. Shuttled here, there and everywhere.
While in the hospital, she caught a contagious disease… and we had to gown up just to visit. She wasn’t allowed to see her grandchildren and she hated having to hug yellow gowns and gloves when we said hello and goodbye. On one of these visits, I was stopped along my journey to her room, implored by a surgeon to sign a consent for surgery which she was already in; a CNA had dislodged the catheter access for dialysis and a large hematoma developed… she was essentially bleeding out underneath her skin.
Often our family would struggle for information. Some of the staff supported us, others battled us; they refused to acknowledge evidence or take the time to answer questions. They snickered when we offered alternative diagnosis – especially when they turned out to be the reason for an issue at hand.
A rehab center absolutely missed that my mother had become delirious, hadn’t consumed food or drink and had been awake for less than 2 hours in a whole day. She was transferred back to the ER where the medical staff seemed stumped. I sat beside my mother for hours thinking, contemplating why. Her oxygen levels were low from the congestive heart failure and I wondered if carbon dioxide was building inside her blood. For 24 hours, I pleaded for them to hear me.
If only I had a doula to remind me I could fire the doctor and ask for another.
Finally, at shift change, when I had become dehydrated from crying and my voice hoarse from lack of sleep the newly assigned doctor agreed to check blood gas. Sadly, it was true. She had a large amount of carbon dioxide in her body. She was transferred to ICU where they began a c-pap machine and increased the oxygen level and after another 18-24 hours, she began to wake.
Eventually, this delicate balancing of her kidney, heart and lung function became more and more unstable and on August 13, 2014, Kathleen was told she was dying. She had a fever, elevated white blood cells, tachycardia, high potassium and creatine levels, low oxygen levels…
My sister was sitting on my bed as I prepared to head to the hospital. When my father called me, I didn’t believe it. It didn’t seem real.
In her last days, I didn’t have a moment alone with my mother while she was awake. Those little moments we were all together. We loved on her, sang to her, prayed over her and tried to find ways to let her know we’d be okay. I spent my time analyzing her vitals… an escape from the reality of losing my best friend.
Suddenly, she stopped waking.
If only I had a doula to shake some sense into me – to tell me to forget about the puzzle and just be present in her last moments.
At that moment, I knew, I’d be her doula as she crossed to a new life. Somehow, I felt her soul tell me I’d be the one with her. I wouldn’t leave her side. I talked to her, hoping she could hear me. I held her hand, sang to her, moistened her lips and mouth, I suctioned the mucus which built up in the back of her throat. If only I had a doula to tell me about the death rattle I’d hear her breathing… what the normalcy of passing would bring.
Beside her, I fell asleep. Suddenly, I snapped awake. Something was different. Her breathing was different. My sister stood up and said she was going to grab something to drink. My eyes stared her down – inside I felt I was supposed to say “Don’t go”, but I couldn’t say the words even when she asked, “What?”
My father was finally sleeping in the recliner just behind the head of her bed. It was quiet. Except for her staggered breath. I reached my left arm around her shoulders and took her right hand in mine. I learned cheek to cheek and whispered in her ear, “It’s okay, mom. I’m here with you. I’ll breathe with you.” I took slow deliberate breaths. I could barely match hers. I knew. I just knew. I kissed her cheek and said, “It’s okay. We’ll be okay.” And I began singing, “Come, Lord Jesus. Come.”
Her last breath was after the second bar of the song. I looked at the clock. 10:33pm. I opened the door and called for a nurse. My father awoke. Not realizing she had passed, he attempted to lovingly remove the rings from her swollen fingers. “It is finished. She’s not here anymore.” My heart broke twice. Once for me and again for him.
If only I had a doula to help with everything else that came; telling family, making arrangements, preparing to pick up her ashes, and each day since.
I’ve come to realize that a mother is a doula; unbiased, compassionate emotional and physical support, always there for you. And in my mother’s last moment, I was hers.
My dearest mother,
You gave me life, but let me mold it. You’ve shown light on the path, but let me walk it. Though I stumble and fall, you have not thought me weak. Instead, you’ve lent me a hand and dusted me off so I might stand tall. And though you are no longer by my side, I know you are ahead, paving the path for every stride.
I love you with every beat of my heart.