Sunday, September 21, 2014

possibly postmature

Possibly postmature
and
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 
  • the date of the first day of the last period
  • the normality of the last period
  • the date of quickening
And, if ultrasound is used, there are additional pieces to add to the puzzle.


Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.


A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.


A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?

Why?

          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?


With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 



There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.




No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable. 

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