Obstetrics from a Pediatric Perspective
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.