Lack of trust: the story of Lydia
Lydia fit a certain out of hospital mom profile. She was a thoughtful and educated mother. She was very careful about the food that her family consumed and about the way they lived. She was a committed Montessori teacher, believing in child led, developmentally appropriate education. Her husband, Mike, was also a Montessori teacher. It fit with their approach to life, to choose to give birth naturally and giving birth at home made the most sense of all. She was expecting her fourth baby. When I met her, I slid her effortlessly into the category of easy mom easy birth: fun, no-fuss for me. But midwives and all: Beware of Categories. Lydia started care at a birth center recently opened by a physician. (To me, out of hospital care from a physician rather than from a midwife is an oxymoron: doesn't make sense because they aren't trained to do it). She switched care half way through because she decided she wanted a home birth. Lydia's first baby was born in the hospital, her second at home with a naturopathic physician, her third with a CNM at the hospital, and now she was planning the home thing again. That is an interesting and somewhat unusual journey which might have alerted me that Lydia was not your typical bowl of granola.
Lydia always had the last appointment of the day (4pm) and she was always late: not just usually, not just a bit late, but 45 minutes late at the end of a demanding day of prenatals. We bend over backwards to serve our clients; service is what we are here for, so we worked hard to schedule appointments that would work. I remember one day at home chopping up vegetables, phone to ear, google calendar open on the table, scheduling three months of appointments for her at once, juggling her needs, the phone and the vegetable knife. One particularly difficult incident of need to reschedule followed by a late appointment, she arrived at 4:55 to find the midwife had left. Her explosive anger was another sign that Lydia didn't quite fit the category.
All may have worked out, if the baby hadn't measured consistently small using the tape measure for fundal height measurement. I believe that all data that we gather at prenatal visits has to be handled with a little wisdom. Throw it in the bucket, stir it around with all the information that you have about that person (her lifestyle, her other numbers: height, prior babies etc, the baby's position) add a touch of experience and a dash of intuition and make a call. Both Kristine and I, following Lydia over a few visits, thought that this baby was growing fine but probably smaller than her others. Being a proud 4'11 myself, I'm sort of into cute and little. Lydia was sort of OK with this judgement..... and sort of not. Anxiety is part of pregnancy.... comes with the territory. In fact, a large part of a midwife's job is listening to these anxieties and supporting the pregnant woman through them and out the other side. So, doing her job, Kristine ordered a reassurance sono. And the reassurance sono was reassuring.... which is what we want. Baby 7# 13 by sono. We know that sonos are not that accurate at size estimation so late in pregnancy but that is bang in the middle.... you can't get more reassuring than that. Fluid was adequate too (can also influence fundal height). Trouble was, Lydia was not reassured.
I forgot to mention that at this point, Lydia is 40+ weeks pregnant, baby coming any time. I received a message from Lydia that she had decided that she was probably going to have to give birth in a hospital because her baby had IUGR (stands for intrauterine growth retardation; sounds medical but really just means extra small baby don't know reason). I called her to follow up on her message. She also believed that the baby was at high risk of meconium aspiration and would need an intensive care team at the ready. Lydia sounded very rational. But really she was less rational, and more anxious. So I went through the data that we had and the options available. I offered a late (5pm) extra appointment to discuss the issue. If she really was unable to proceed with the home birth, I suggested that I transfer her care to one of the physicians who take my referrals. But Lydia had got herself into a pretty anxious swamp and seemed stressed by the laying out of options. It almost felt like she was more comfortable in the familiar swamp of doubt and anxiety than in taking a logical decision forward. I gave her till the end of the day to make up her mind. At 5pm no phone call, so I called Lydia. She had decided to go back to the physician that she had started with but with the intention of a hospital birth. I agreed to forward her records in time for her appointment and added "please understand that after you make this decision" (now at 40 weeks and 3 days) "you cannot transfer care again back to us". Lydia did not like that. She was still hesitant and hovering around in her anxious uncertainty. But giving birth at home, you need to trust your chosen care provider, you need to trust the process of pregnancy and birth, and you need to trust yourself. Lydia trusted none.