How do midwives diagnose IUGR? - Mothering Forums

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#1 of 13 Old 11-28-2002, 04:15 PM - Thread Starter
 
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Where can I find specific information on the standards midwives use to diagnose IUGR?

I am very upset about the prenatal care I received, but the only guidelines for midwives I have found is the "midwifery model," which states that midwives refer clients when necessary. I'm trying to figure out why my midwives didn't think it was necessary to refer me. I've already had an OB and L&D nurse (the nurse is a close friend) review my midwives' notes from my prenatal visits. They have both stated that for an OB, the failure to get an ultrasound to investigate poor growth consitutes "gross negligence", based on the specific numbers in those notes. But what I want to know is whether the standard for midwives is different? At what point does a midwife suspect poor growth? Is there a web site that specifically outlines the criteria a midwife uses to diagnose IUGR? Or that outlines when an ultrasound should be obtained because of poor growth?
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#2 of 13 Old 11-28-2002, 05:49 PM
 
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Hi! Diagnosing IUGR really depends on a few factors. It depends on when you began seeing your midwife- the earlier into the pregnancy the more likely a good fundal height growth assessment can be made. It also depends on how certain you were of your dates, this helps lower the leeway for fundal height variations. Then your own anatomy/build plays a bit of a role in assessing "normal", because it will vary from mother to mother considerably. There may be other factors nutritionally and livestyle wise that cause an allowance for a smaller measurement (usually something like smoking, high caffiene intake, poor nutrition habits, or such). The midwife also has to take into account the volume of amniotic fluid, if there is a lot of fluid it can make gauging size a bit more challangeing.

There are two types of small size baby also, and both tend to get lumped into the same catagory medically unless premature birth was an issue. Some babies are "Small (or light) for Gestational Age", this means that the baby's growth rate was normal in regards to meeting expected increases in size, and when born the body grew symetrically and in correct proportion, the baby was healthy, but small. This is usually just a genetic variation. Or there is the actual "Intrauterine Growth Retardation" where the growth rates did not meet the usual rates of growth consistently when measured, and the baby actually fails to achieve the size that was expected, often (not always) the condition of the placenta at birth can reveal reduced performance/health.

I know one mom who is extremely anemic, she has never been counseled by her doctor to rectify this problem, but it is probably because of a racial and socialeconomic connection. Anyway, her babies are all SGA at 5lb, they are normal in all other regards, but tiny at birth- they look like dolls. Health wise they are always well enough to take home right away. The anemia causes her to have a small placenta, and the reduced blood flow feeding the fetus from the beginning causes a small baby from the beginning. If a mother has a relatively normal size placenta at the beginning, the baby will begin its growth at a normal size and rate, but if later the health of the placenta or maternal circulation deteriorates, the baby will begin growing at a slower/impaired rate, resulting in IUGR.

Other than ensuring good quality nutrition intake and hydration, there is not alot that can be done to reverse IUGR. If a mom has hypertension or diabetes mellitus, that can effect the health of the placenta/circulation also.

You can read a fair bit about this in Holistic Midwifery, pp.400, 409-413, 990-994. This book is one of the main texts in midiwfery coursework.

Many midwives do not order routine Ultrasound, but if they suspect something may be amiss, they will discuss the need for an ultrasound with their client. If there are no obvious indicators, as in SGA babies, then it is less likely that they will call for an ultrasound. Ultrasounds are standard in the medical model of care, and many mothers will have between 1 and 3 before delivery- even then it really depends on when they are done as to accuracy, and who is doing the reading as to how reliable the result is- I'm sure that there are many moms on this board who have been told that their baby would be really small, or really huge, or have some condition, that at birth did not occur.

I'm sure that other midwives here can (and will) add to this from their knowledge and experience.

It is hard to say with any birth, in retrospect and as someone who wasn't there and has no access to your charts, what the signs and causes of a particular experience may have been.

Since you are not comfortable with the prenatal care you recieved, you may want to bring this to your midwife's attention, either meeting to discuss the experience, or writing a letter?

(I am so very sorry for your loss. )
The Lord bless you,
Zoie
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#3 of 13 Old 11-29-2002, 02:10 PM - Thread Starter
 
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Zoie,

Thank you so much for responding to my post so thoroughly. I appreciate the time you took. Your suggestion about talking to my midwives is a good one. We had a brief conversation a few days after my son was born. One midwife said the critieria for diagnosing poor growth is four consecutive weeks of poor growth, and I had a growth spurt in the middle, so she thought I was fine. The other midwife said, "Your growth wasn't good at your last appt., but I thought we'd check you again the next week."

(By then, he had been born, and we discovered that there was no way he had just died. My husband and I could tell from the way he looked that he had been dead longer than two days. There was no blood in the cord, the amniotic fluid was completely gone ("bone dry" is a term one nurse used, and my water had never broken-it was all reabsorbed), and he was only 4 1/2 pounds, at 38 weeks. The doctor thinks he had been dead for two weeks. That means I had two prenatal appts. where my midwives heard a heartbeat, but he was already dead. That also means I didn't realize that the movement I was still feeling was only him bumping up against me, not actual kicking--and that's a whole other issue I have to deal with.)

I'll include my numbers, that might be helpful:

At 32.3 I measured 30 cm.
At 33.6 I measured 31 cm.
At 35.6 I measured 34 cm.
At 37.2 I measured 33.5 cm.

BTW, we are sure of my dates. Two days after that last appt. my labor started, and that's when the midwives realized they weren't hearing his heartbeat. Anyway, meeting with them at this point would be very awkward, because the doctor who was on call at the hospital is considering filing a complaint against the midwife who is licensed, and my husband and I are waiting for the autopsy report to decide if we are morally obligated to file a complaint as well. I don't want this to get messy. I just want to understand what a reasonable standard of care is for a midwife. Would the average midwife have suspected a problem with those numbers? Would most midwives have realized my baby wasn't kicking back as they checked his position during those last two appointments? How did they hear a heartbeat for him? Is this type of prenatal care acceptable under the midwifery model, or do I owe it to other women to file a complaint? These are all questions we're considering. We are not even remotely interested in legal action, simply wondering what our responsibility might be to other families. Anyway, it's obviously a little touchy right now between the midwives and me. After we have the autopsy report and decide what we should do, that might be a better time to talk with them.

I've been searching midwifery sites, but I can't find any specifics in terms of numbers, and what constitutes a growth problem that needs investigation. I'll try to track down the textbook you mentioned, that's a great idea.

Thanks again for responding,
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#4 of 13 Old 11-30-2002, 12:54 PM
 
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Hi Katherine, first off I am so sorry for your loss, I've been following you other thread in complete tears.

I don't have much info. but w/ my 1st preg. I was planning a homebirth and my midwives deteced a problem w/ my measurements. I measured fine the first few times but then began to measure 2 cm. small for @ 3/4 times and they recommended I go for an ultrasound. We started to meet w/ a CNM in the hosp. too. Then the heartbeat was low at one visit and I was still measuring small. Anyway I went for another ultrasound then a non stress test. Ended up in the hosp. 4 days before her due date found almost no fluid.

I was still meeting w/ my homebirth midwife and talking w/ the CNM. I was very impressed w/ how my midwife detected the problem. But my situation could have been easily detected too. There was never a growth spurt & I was gaining enough weight.

W/ my last pregnacy I measured great the whole time but towards the end my measurements became screwy and they all freaked out it was happening too, also I had low amniotic fluid. Anyway there were 3 different midwives who were measuring me at diff. appts. so I think this is why the got different measurements. One Of the midwves told me they can get diff. measurements because the same person isn't measuring each time. Did the same midwife measure you each time? How about the time the time you measured 34 at 35.6 weeks? It seems to me, I am in no way an expert, that your measurements were showing a warning sign. HTH

My thoughts and prayers are w/ you & your family on your journey to healing.


Much love, Katie
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#5 of 13 Old 11-30-2002, 03:56 PM
 
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Not being a midwife, but having a stillbirth, and a stillborn twin myself, I am suspicious of your doc saying two weeks, the baby's appearance changes pretty quickly. My first baby, even after only being dead 24 hours was having quite a bit of skin breakdown and his cord was very very twisted, much of which could have happened post-mortem, it looked normal on u/s only a few days previous. I was on bedrest in the hospital. Yes, the midwives could have picked up your heartbeat instead of the babe, but they are usually pretty different in speed. Sometimes you hear the umbilical cord, but that stops when the baby dies, I believe. If the midwives heard a heartbeat twice, and you noticed no notable difference in babe's movement, I really think your child was not dead that whole time. The feeling of the baby inside me, especially with no amniotic fluid, is much different than live baby movement. When did you notice a change? I think it's probable that it was a couple of days, but two weeks, to me, seems not likely. Or did you feel there was some change then? I'm so sorry you have to even think about these things. I have found, from talking to many women with losses, that doctors cannot usually give us very good "answers", sometimes I think they make them up! (cord accident, etc.) They don't even understand much about how amniotic fluid generates, so fluid issues particularly, are complex.

I suspect you won't find any firm numbers, since it can be so subjective. As soon as I measured abnormally (large, too much fluid) my midwives sent me for a u/s and it was obs all the way after that. For the huge majorty of women with fluid abnormality there is no serious problem like you and I had..and I would hate for the normal women to be forced in to the O/B/perinatology system, not allowed to be with midwives, and having U/S if they didn't want them...and adding them to standards of care would probably do that. My sister got trapped in that, thanks in part to my pregnancy (genetic issue). She ended up birthing at home with an illegal midwife to try to stay out of the hospital when she didn't need it since her baby was unaffected. Around here anyway, a lot of midwives are very medicalized already, and still many can't treat women with a number of not very complicated conditions. It's a difficult dilemma...since most of all you should have been the one to make the choice, and it sounds like they didn't raise any flags with you that there was anything unusual.
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#6 of 13 Old 12-01-2002, 02:37 AM
 
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I want to state from the outset that I am not a midwife. I am an L&D nurse and an aspiring midwife. That being said, your measurements don't seem that off until your last one - they trend upward at a consistant rate and are only slightly off. There has been research that indicates that the "cm. per week" rule where past 20 weeks the fudal height in cms. should equal the number of weeks pregnant is highly subjective (differ often by person measuring and by what the person *thinks* they should be, i.e. a person measures a woman at 22 cms. when told that a 25 weeker is 22 weeks). And you were trending upward at a consistant rate. It would be hard to mistake your heartrate for the of a fetal heartrate - a normal fetal hr is 120 - 160 or so. Moms are usually in the 60 - 90 range. It would also be difficult, IMHO, to mistake the vigourous movements of late pregancy for that of a fetus bumping up against you - esp. considering your lack of amniotic fluid.

I feel very sorry for your loss. I can't imagine what you must be going through. I am worried, however, that you might become a political pawn in a "ob vs. midwife" type of scenario. It is very easy to say after the fact "oh, if she had been seeing an OB this wouldn't have happend". But, short of a lawsuit, rarely are OB's subject to the same type of hindsight reviewal, even when they seriously screwed-up.
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#7 of 13 Old 12-01-2002, 09:49 AM
 
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"Not being a midwife, but having a stillbirth, and a stillborn twin myself, I am suspicious of your doc saying two weeks, the baby's appearance changes pretty quickly. My first baby, even after only being dead 24 hours was having quite a bit of skin breakdown and his cord was very very twisted, much of which could have happened post-mortem, it looked normal on u/s only a few days previous."


Unfortunately, this is very true, skin breakdown begins to show within a few hours. A two week stillborn would also be very discolored. There are other characteristic changes also. This information can be a bit graphic and painful, so I will just post a couple links to some information on stillborn appearance vs. time of death. I have third, but unfortunately they have a photo of a stillborn in the article, so unless you request the site I won't post the link.

http://www.gblawyers.com/comm_fetal.html

http://www.obfocus.com/SanGabriel/guidelines/iufd.htm

If there were only numbers to go by, looking at the numbers you posted, honestly only the last measurement deviated from the normal growth pattern, and the timing of the drop in numbers could have been mistaken for the baby dipping into the pelvis toward the end of the pregnancy. It depends a lot on how much your midwives palpated the baby at the visits, they would know a bit more about the proportions and position of the baby. I wish that fetal growth were not such an involved process of variables.

I honestly believe that you were feeling your little boy kick, it takes a fair bit of muscle tone to produce noticeable movement in a uterus, especially as the space gets more cramped toward the end of the pregnancy. But I understand how you might begin to wonder whether it was really him moving or not, .

I wish I could be of more help, but I hope that some of this information is of help to you and your family.

The Lord bless you,
Zoie
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#8 of 13 Old 12-04-2002, 03:23 PM - Thread Starter
 
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Thank you so much for the kind responses.

Hawleyclan, I really appreciated those articles. I think I would like the link for the other article. Just understanding better what the autopsy report is looking for is helpful.

Thanks, everyone, for the input about my measurements. I posted on Midwifery Today, and someone responded that a 4 cm. difference is what to look for, which was only apparent at my last appointment. That actually helps me feel better about my midwives.

As far as the two weeks, I should have told the whole story when I originally posted. It wasn't until last week that I learned the doctor also suspected he had been gone for two weeks. After he was born, as I thought back on the end of the pregnancy, I realized it had been about two weeks since I had felt actual kicking. There were even nights when I went to bed and thought, "Something's wrong, he's not moving. He's gone." But then I would remember that movement slows down at the end of the pregnancy, and I would feel some sort of bumping, so I would think it was okay. After Kevin's birth, I realized I could feel his spirit still with me, so I started asking him how long he had been gone, and "two weeks" kept coming to mind. My Reiki practitioner is also very intuitive and I had her ask, and the answer she got was "weeks." So, I believed he had been gone for two weeks before I ever heard the doctor also believes that.

Now, along with all this is the conviction I have that we were not supposed to figure out there was a problem. I feel so strongly that he would have died anyway, and he didn't want an emergency c-section, time in the NICU, surgeries, etc. That would have been so traumatic for him and for us. I am being told so clearly (through spirit) that I wasn't supposed to know, and the midwives weren't supposed to know, because we would have interfered. (Doesn't this get complicated?) And after he had died, I believe we weren't supposed to know until the timing was right (in terms of the right doctor on call, and family support available, etc.). I guess I have been reluctant to tell the spiritual aspect of Kevin's story because I feel people won't understand, or won't believe me, etc.

Now, having said all that, I still have issues with my prenatal care. I wonder if part of the reason I was led to these particular midwives is so this would be a wake-up call for them. We never discussed fetal movement in my appointments, they didn't check to see if he was moving when they checked his position. I have two friends who are also going to them, and they have said that my midwives have totally changed their approach since Kevin died. Apparently they are much more thorough, paying attention to details, measurements, movement, etc. My friends also say they are working much better as a team, and that the more experienced midwife (the other is just finishing her schooling and applying for her license) is much more involved in the appointments and examinations. So it does sound like this has been a wake-up call for them. And that is what I have been needing to hear.

Again, thank you so much for the time everyone has taken to respond and share information and opinions with me. This is a pretty messy situation that will take a while to sort through.

Oh, have I even mentioned that my husband never wanted a homebirth/midwives to begin with, and of course this whole scenario has cemented in his mind how incompetent midwives are? It's so, so hard for him that I am not jumping on the band wagon and condemning homebirth/midwifery as a whole. He has not received any of the same spiritual experiences I have, so he doesn't share my conviction that Kevin's brief life happened exactly as it was supposed to. Even pursuing the homebirth, I felt so strongly that I needed to, and my husband never shared that conviction. So my husband is waiting anxiously for the autopsy report, and I am wondering what in the world it's going to say, and how we will deal with the ramifications.

Thank you everyone. Now it's time to get back to reality...taking care of my three precious living children, and desperately missing my baby who's not here.
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#9 of 13 Old 12-04-2002, 04:54 PM
 
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I know your DH probably won't go, but I encourage you to seek out in-person support groups for loss. Many people have the reaction that this is someone's "fault" and going over how things could have been done differently. I, for example, was hospitalised for 2 months under constant advanced care, and my ds died anyway. I still thought, maybe if this, maybe if that, maybe if i'd had an u/s that day, maybe if we'd tried removing some fluid, inducing the day I forgot to 28 weeks, etc. etc. My DH was so angry and kept talking about suing. I just though that it would keep us dwelling on our loss, and won't change the outcome. A lot of DH's seem to get angry. I don't think they have a good way to cope with it. It won't make him feel any better, but many obs only do one u/s around 20 weeks...and only another if they suspect a problem...so maybe your care wouldn't have been hugely different depending on your doctor. I am suprised the midwives didn't ask you about fetal movement, so I think it's reasonable that you want to discuss, within the practice, how this might have been prevented. You are right, a loss can be a very impressionable experience on a practitioner, and in modern midwifery, many don't get to see abnornal pregnancies, so it's easy to forget they can happen sometimes. My doctor, I think, still questions himself about how he could have proceeded differently, even though I both now and then, felt we were doing the best we could. I think your midwives will probably think about you quite a bit.

On the spiritual level, I felt my ds had a good death. If they had realized he was in distress, and tried a lot of intervention, it still was highly likely that he had some pretty profound neurological problems...he already looked cephalic, and would have died in noisy, cold, painful way. The day he died, he and I slept most of the day, and he died sometime that afternoon.

I hope for peace for you and you DH.
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#10 of 13 Old 12-04-2002, 06:31 PM
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I just wanted to comment on two things~

First, I too am walking carefully as far as any legal action in my case. In reviewing the files and doula notes, it is obvious that many mistakes were made in the management of my labor with Xiola. There were several that by themselves would have been a problem... together it is no wonder that my daughter died. However, as you all know it is a precarious time right now for the natural childbirth movement. So I am biding my time (in WA there is a 3 year statute of limitations) and will decide how to approach this in a way to ensure that these mistakes will not be repeated and those who made the mistakes will be held accountable, yet in a way that will not set a precident for limiting a woman's birth choices.

Secondly.... Katherine, you mention that you are sometimes hesitant to discuss the spiritual side of losing Kevin. I can understand this, I felt the same way. Granted, there were mistakes made, but I had a feeling in my bones that we were not going to keep her. I am pregnant again, and while I do get worried sometimes, and sometimes I am downright scared, I don't have that 'feeling' that we are going to be denied this child.

I have come to think that we lost her so that we could do something to keep other babies safe... I would like to make something good come of our loss. If your midwives are being more attentive to their patients, that is at least some good to have come from the loss of Kevin.

Things will get easier in time.

XM
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#11 of 13 Old 12-05-2002, 11:31 PM
 
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A week before Jacob was born/died I had what can only be described as a "sending". The image of a black haired, blue eyed newborn baby who was looking at me very intently and steadily. That was it. I thought at the time it was the baby saying "hello". After he was born, I realized he had been saying "hello" and "goodbye"

After Jacob died I wondered for a long time what the meaning of his life/death could be for me. At his memorial we celebrated the possibility of life and its fragility - love while you can in the here and now. Since no one had done anything "wrong" in my pregnancy or birth, and there was no explanation of why he started bleeding and died before he was born, it was easier in a way to look at the bigger picture, without the emotionally charged issues of "what-if"

Like you, XM, I somehow didn't believe we would be keeping this child. I hadn't made any plans for him, or imagined his future.

What came to me, slowly, was that his life and death taught me not to be afraid of birth and death. I am a homebirth midwife, (was in Washington state, not practicing now as I'm home with our two sweeties)and since the worst that could happen had happened to me, I could dispense with the anxiety that I might be the cause of some bad outcome. I tried to be the most careful practitioner I could be even before Jacob, but after his bith, I was freed in a certain unfathomable way from a fear of birth. Also, I felt that I could truly empathize with sad experiences and could then more truly be "with woman"

Anyway, that has been my journey.

Barbara
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#12 of 13 Old 12-06-2002, 12:23 AM
 
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First of (((Katherine)) I would like to express my sorrow for the loss of Kevin. I cna't imagine how hard it must be for you.
All the woman who have replyed to this thread are very wise. I ahve nothing more to add, but i hope you will read this thread carefully and take it all into concideration.

I think what you said about the spiritual aspects makes more sence then any of the medical input. Follow your heart.
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#13 of 13 Old 12-07-2002, 07:10 PM
 
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Katherine and XM, I just wanted to support you in choosing to share the spiritual aspects of your experiences with your sweet babies. Birth and death are more than physical phenomena; so is the connection a mother has to her child. The whole range of your experience is welcome here.
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