G3

In the OBGYN world we describe a woman’s pregnancy history in terms of G’s and P’s.  There is an alpha numeric code that tells the story- “GTPAL.”

G stands for gravida. It’s the number of times a woman has physically been pregnant.

T is for term- the number of term pregnancies a woman has had.  Any baby born at 37weeks or after counts here.

P is for preterm births, those babies born after 20 weeks but before 37 weeks.

A is for abortion. This is a medical term, not a political one.  Medically we call any end of pregnancy before 20 weeks an abortion.  It may be spontaneous, aka a miscarriage. It may be elective, aka a termination.  A also includes ectopic pregnancies.

L is for living children.  No further explanation needed.

To make it even more confusing we shorten the the GTPAL to G_P_ _ _ _.  In this instance G still stands for gravida and P stands for para- para meaning the number of births (term or preterm). It might be better to explain by example:

A woman who has had one term living child with no other pregnancies would be a G1P1001 versus a woman who has had one living preterm child would be a G1P0101 versus a woman who has had one miscarriage and no other pregnancies would be a G1P0010.

It can be used to describe a pregnant woman too.  My friend who is pregnant for the first time is expecting twins.  She is currently a G1P0000.  When she has the babies, if she has them at term (fingers crossed) she would be a G1P1002.

Make sense?

So why does this matter?

As of late, I have recently added a new G to my history.

After Mabel I became a G1P0100.

After Felix I became a G2P1101.

I am now a G3P1111.

My loss story continues.  I’m having a very early miscarriage.  So early I barely became attached. But it has still stolen the breath out of me.  Did I take five pregnancy tests just to be sure? Did I figure out my due date? Sure did. Think about maternity leave? Toss around baby names in my mind? Imagine telling Felix he’d be a big brother? Dream of a living sibling for me son? Did I get excited? You bet. So when it turned out to be just a shadow of a pregnancy, a whisper of something I’ve been wanting and trying for since Felix was born, I grieved. I am still grieving. I feel broken in so many ways, untrusting of my body, unsure of my ability to be happy.  I know I will find my way out of this darkness- I have crawled out of deeper holes.  But in the meantime, I will mourn my little whisper…

 

 

So much sadness.

She stared up at the ceiling, eyes welled with tears, while I stared at the screen, searching, looking for anything that would give me better news. Moments before we were in another exam room chatting cheerfully about the latest developments in her pregnancy. She had just started feeling movement and her fundus was a few fingerbreadths below her bellybutton, just where it should be for 17 weeks. I searched with the doptone for the classic “thud-thud-thud” of her baby’s heartbeat but all I hear was static and artifact.

“Baby’s being stubborn,” I said, a sinking feeling already settling in my gut. “Let’s go take a look instead.”

I looked and looked, feeling helpless- the machine was old; I’m not a trained sonographer- but I couldn’t see the telltale flicker that told me everything was alright. Everything was not alright.

“I’m having trouble finding a heartbeat. “ I put down the probe as tears filled my eyes. I didn’t hide them- they were no match for hers as she let out a panicked and woeful “No, no, no!”

I sat her up and hugged her hard. I told her I couldn’t tell for sure- old machine, needing a formal ultrasound- but I was worried. I had to send her to the hospital. She called her husband, forty minutes away and I repeated my uncertainty- it seemed what she wanted to hear, what would get her through that endless wait for her husband and then the drive to the hospital. I sat with her for a bit and then had to go see more patients. Between each one I checked back in with her, not having any words to say to would ease the pain, because there are none.

Husband arrived, off to the hospital they hurried and everything was confirmed. Her baby had died.

Here I am, a babyloss mom myself and I was still at a loss. I thought of all the awful experiences people have had with their providers (and remembered the good ones too). But I had a sudden empathy for the bumbling providers. Some behavior is inexcusable, but there are many other clumsy caregivers who just wish they could take away the pain, but know they can’t. Stupid words fall from their mouths, medical processes are focused on- all because they were helpless. Their pain is nothing compared to the patients, but I had a little more insight. It had been a long time since I had to say the words and it was my first time since my own loss. It sucked. It was terribly heart wrenching for me and even more so for my patient.

So much sadness.

What was your experience hearing bad news? What was done well? What do you wish could have been done differently?

Future midwives

I’m sure I received some training on loss when I was in midwifery school. I don’t remember the specific lecture or chapter in the books, but there had to be some educational experience I received. I remember more the on the job learning. I worked as a Labor and Birth nurse while I was in midwifery school. I helped woman as they worked hard laboring for a baby that was extremely premature, that was unlikely to live, that had already died. I was scared at first- I think scared of saying the wrong thing, of not knowing what to say, of doing something that would make the situation worse.

During school, while I was working as a nurse, I remember caring for one woman who was being induced around 24 weeks, the cusp of viability. Her uterus and amniotic fluid were infected, meaning the baby who already faced significant life threatening struggles that came with extreme prematurity, also faced life threatening infection. Truth was, this baby had very poor chances of survival. The neonatologists knew this and gave her the option of resuscitation or comfort care. As her labor was induced she talked and cried with her family, with her healthcare providers about what was best for her baby. She had a family member who had extremely preterm twins who suffered many long term effects from being born so early. She was unsure if she wanted that outcome for her baby, but also could not imagine not doing something for her child. When my shift was done, she was just getting into active labor and had not decided what to do. I found out later from the nurse who relieved me, that her baby came suddenly, without the doctor even in the room, and she still had not decided. Her baby did not survive. The worst part of being part of her story, was not knowing how to help her. I know, even with all the training and experience in the world, I still might not have been able to help her decide, but maybe I could have. I’ll never know.

I have since been with mothers as the doctor couldn’t find a heartbeat on the ultrasound. I’ve had mothers whose babies come prematurely and die sometime after birth. I’ve had mothers who choose to terminate for a fatal diagnosis and a mother who has carried to term despite one. I helped mothers through subsequent pregnancies and subsequent miscarriages. Each woman I have cared for, I have learned from- more so than in any class in school. Ultimately I have learned most from my own experience.

This week I’ll be joining the program director of my local pregnancy and infant loss non profit in a guest lecture about loss to the local midwifery students. It is at the school I went to, I worked at and I still (though rarely these days) precept at. I sort of invited myself when the program director mentioned it to me- how could I not? This is what I do- I’m a midwife and I’m a babyloss mom.

As we talk to the students, I want to give them all I can. I want them to remember the talk and I hope, being given by someone who knows both sides will help. But I need your help too- I only have my own experience. I’ve come up with some points I wish to make- I know it’s not a perfect list, and so I encourage you to give me your suggestions to. I also know that these do not apply to everyone’s situation and it’s not a comprehensive list encompassing nearly everything- I am trying to look at it from both perspectives- a provider and a patient.

Tell me: What did you want your midwife or doctor to do? What did they do that was great? What did they do that you wish they didn’t?

 

Stillbirth

  • Be honest. There is no good way to say your baby is dead. Don’t sugar coat; just be clear.
    • I was with a mom with a stillbirth at term. She had been sent from the office to OB triage when the midwife couldn’t find a heartbeat on the Doppler. I sat by this woman as the APRN did a scan looking for a heartbeat. We were waiting for the Maternal Fetal Medicine doctor to come and make it official. Since he was tied up, the APRN started scanning, all of us hopeful she’d find something with the ultrasound that the Doppler could not. The room was silent as she scanned, the parents on edge, the nurses and I staring at the screen. It felt tortuous for me- I can only imagine what it felt like for the parents. Finally, because no one was saying anything, I said simply, “they don’t see a heartbeat. I’m so sorry.” I explained how we had to wait officially for MFM doc and I stayed by her side until he came. There were a lot of “whys?” and I was honest there too “We don’t know. We may never know. But here’s what we can do to try to find out…”  
  • Describe the process- let the patient know what happens next (do they want to go home, gather things, wait at all? Induce right now?) Discuss induction and pain management. Discuss the baby coming out- mention about skin color changes and bruising that might be apparent. Offer to call NILMDTS

 

General Loss Guidelines

  • Say “I’m sorry”
  • Use the baby’s name…. over and over.
  • It’s ok to cry- in front of the patient too.
  • Get familiar with the process- offer autopsy, karyotyping, TORCH titers, thrombophilia workup. Talk to the hospital social worker to learn what happens to the baby, how parents arrange services (cremation, burial?)
  • Sit. Be with patient.
  • Coo at the baby- talk about all the aspects of a baby you would otherwise- the hair, whose nose she has. Encourage parents to explore- undress baby, open eyelids. I never opened Mabel’s eyes- I wish I did, just to see the color (likely dark gray as most newborns are, but now I’ll never know)
  • Be a photographer- take photos, encourage parents to take photos. Call professional photographer. Since no one from NILMDTS was available for me, my nurse and midwife took photos- so many photos and I am so grateful they did.
  • Let parents stay with baby as long as needed. Encourage patient to call and invite any support they choose.
  • Send patient to a floor without babies for PP recovery
  • Early discharge
  • Prevention of lactation (also milk donation)
  • Offer sleep aids
  • Referral to resources- counseling, local bereavement groups, books, websites.  Go through your hospitals bereavement box, so you know what’s in it.

 

Follow up

  • Call patient- some potential questions beyond “how are you doing?”
    • How are you sleeping?
    • Who is around to help you?
    • Are you eating?
    • How are you spending your days?
    • Services?
    • Have you looked through bereavement box yet?
  • Postpartum visit
    • Plan first morning appt- so pt does have to wait in waiting room with other pregnant patients
    • Plan extra time for appt
    • Be prepared to go over autopsy
    • Discuss birth control or preconception- no judgement on whether it is “too soon”
    • Ask about photos- ask to see if she has some and wants to show
  • Remember due dates- good time to call or send a card
  • Anytime you are reminded of that patient, tell her-call or text her- she would love to know she is not forgotten
  • Attend services if you are invited and can go

 

Fatal diagnosis (if carrying to term)

  • Frequent appointments if pt desires
  • Listen to FHR first thing
  • Plan for longer appointments
  • Consider frequent ultrasound if pt desires
  • Help patient with birth plan
  • Coordinate care with specialists- NICU, pediatric specialists to discuss immediate care of baby
  • Encourage special plans- blanket, outfit, photographer for baby
  • Discuss logistics- funeral home, cremation, burial
  • Connect- give resources
  • Help patient celebrate pregnancy

 

Subsequent Pregnancy

  • may need more frequent appointments, reassurance of FHR
  • If previous stillbirth- testing (level II, NSTs, early delivery)

 

Miscarriage (also applicable with fatal diagnosis choosing to terminate)

  • Say “I’m sorry”
  • It’s ok to cry
  • Discuss logistics- expectant management, miso, D&C, D&E
  • Discuss “why” (most common known cause- chromosomal, but often we have no idea why…)
  • Listen
  • Discuss future fertility if patient desires
  • Call patient for emotional follow up (“just wanted you to know I’ve been thinking about you)
  • Referral if indicated (recurrent pregnancy loss, genetics)

What am I missing?

A little glucola, a little Mabel

“Ugh I don’t want to taste that syrupy gross glucola again,” she said adamantly.  A long discussion ensued, where I reviewed her risk for diabetes- her size, her family history, and where I went over the risks of undiagnosed diabetes, including stillbirth.  I often have patients complain about the diabetes test.  It’s gross, but it’s necessary.  I offered her a jellybean test or referral to do finger sticks to assess blood sugar.  She didn’t seem interested.  I tried to instill how important the test is.

“I won’t sleep well at night until I know you don’t have diabetes.  I want to make sure your baby is okay,” I pleaded.  She reluctantly agreed to go before her next appointment, though I wasn’t convinced.  I knew this patient well- she’s generally jovial, educated and opinionated.  She had been my gyn patient before pregnancy and was seeing me exclusively for her prenatal visits.

“You better be there when I deliver!” she coaxed me.

“You know I’m not doing deliveries right now, right?”

“Well you’ll do them by January 1st, right? In the new year?”

“We’ll see. When I’m ready.  I’m taking it day by day right now.”

“Why aren’t you ready now?”

“My baby died.  It’s too sad for me right now.”

She stood up and gave me a big hug.

“So this is why you want me to do the glucose test, huh?”

“I know what it’s like to not take a baby home from the hospital.  I don’t want anyone else to have to do that.”

She did her glucose test right after the visit.  She passed. I’ll sleep better.

Mabel came up organically in this conversation, but I worry some people might view me a using her to guilt people.  I don’t usually bring her up under these circumstances, but it just came out naturally- and frankly, it felt right.  What do you think?  Am I using my experience in the wrong way?  Have you had a similar situation?

Spanish

Today I perfected a phrase. I figured out how to say “my baby died” in Spanish.
I speak Spanish- sort of. I’m not fluent, more like conversational and I know all the key phrases for female body parts, pregnancy related terms and I can describe vaginal discharge like a boss. I took a year of high school Spanish, a semester in college and a medical Spanish course in grad school. That piecemeal gave me the basics, but I learned how to converse with native speakers. I spent a month in Nicaragua during nursing school, living with a family, working in prenatal clinics and getting Spanish tutoring. Once I was a full fledged midwife, I spent a week volunteering in the Dominican Republic at a poor public hospital. I perfected my obstetrical Spanish while working my first job in a hospital clinic that catered to a lot of undocumented immigrants. When I moved into private practice a few years later, my Spanish speaking population shrunk, but I maintained a small panel of Latino women who sought me out for my bumbling Spanish. I felt terrible at first because since I wasn’t fluent; I felt they ween’t getting as good care as I thought they deserved. But they kept coming back and I came to realize my clumsy Spanish was better than English to them.
Today, I had two Spanish speaking patients back to back. Each congratulated me on the baby.
“Tengo noticias tristes sober la Bebe,” I warned them. “Ella morio.”
I was unsure if my grammar was correct and I wondered is morir was a reflexive verb, but I got my point across.
Spanglish “I’m sorry”s followed and I’m pretty sure one said something along the lines of “trust in God; he has a plan.” I smiled a sad smile, nodding and moved the conversation forward.

Do you ever feel like you’re speaking a different language?

Day 10: Support

My grief journey started well before Mabel was born.  I grieved the original vision I had of a typical baby when I learned she had Down Syndrome.  I grieved the potential risk of miscarriage and stillbirth that came with that diagnosis.  I began grieving the death of my child when we learned it was a real possibility at 27 weeks.  My grief wander high and low as I crept week by week, my baby still alive inside me and then hit hit full force in the days, weeks and months after she was born and died shortly after.

“Down Syndrome children are born without malice,” one of them told me and I began to celebrate the new vision of the child I was going to have.

“You need to meet with this doctor,” another told me, encouraging me to seek out a well respected neonatologist on the medical ethics board.  With that meeting I began to plan how to best help my baby.

She didn’t put me on bedrest, like many would have done, simply because no one knew what to do to help my baby.  “Exercise,” she said, “is good.”  She gave me a little sanity.

She came with cabbage leaves and breast pads to soothe the raging milk that kept reminding me there was no baby.  She put me on a sitz bath, reminding me that my body needed to be cared for too.

“Parents aren’t supposed to bury their children,” she cried unabashedly, sitting in my bed with me in the days after.

My OB team- my midwives, my doctor- was and still is a huge support for me.  It’s national Midwifery Week.  So it’s well timed that today I thank my midwives (and my M.D., my Midwife Doctor).

#CaptureYourGrief

IMG_3083

 

oh

As I put my stethoscope up to her back to listen to her lungs, the thin paper gown shifted, revealing the inked skin of her shoulder. I paused and put my finger up to the faded tattoo of a tiny footprint flanked by angel wings.

She’s part of the club, I thought. She knows loss.

“Who’s this for?” I asked in a voice that was almost a whisper, ready to share my secret, to envelope her in this cloak of grief with me.

“For him,” she said, pointing to her living child in the room with us.

“Oh.”

Disappointment

When I graduated college in California, I moved to the Washington DC area to live with several college friends. I imagined myself finding a job in a non-profit or a government agency involving healthcare. After a couple months of searching and interviewing in my brand new cranberry colored pinstripe skirt-suit (yup, I was hip) I found the job industry harder to break into than I thought it would, even with my shiny new Stanford degree. While my roommates started their more prestigious jobs at local papers, on the hill and in think tanks, I finally found work as a medical assistant in an OBGYN office. It wasn’t the glamorous job I had pictured, but I knew it would give me the experience I needed before applying to midwifery school.

I didn’t meet many people through work- those that I did had different lifestyles than me; they were older or had families. My job was also in the suburbs, not far from the house we lived in. While my roommates commuted into the city and stayed for happy hours with their new friends, I went to work early and often got out at 3:30p only to find myself home alone. So I started looking for ways to meet new people and make friends. I answered an ad on craigslist looking for women to join their indoor soccer league. I wrote tentatively, ensuring that the league was casual and disclosing that I hadn’t played soccer in eight years. Didn’t matter, he wrote, they needed women.

So I showed up, thinking I came prepared in my athletic shorts and sneakers, only to find out that the league was a bit more competitive than I had hoped. In my naivete, I didn’t even think to bring shin guards. Luckily a teammate had an extra pair and I was able to buy some socks there, allowing me to play with the regulation necessities. I was the warm body in female form that permitted them the gender balance for play.

I took a defensive position and found myself trying to makeup for my lack of skill with effort. I ran hard and fast, trying to beat other players to the ball, though I was rarely successful. The first time a ball actually rolled towards me, out in the open, I ran to it, pulled my leg back and swung hard, happy to have my chance to contribute.

I missed.

I also proceeded to basically score a goal for the other team, when the ball ricocheted awkwardly off my thigh, angling itself past my goalie and into the net. I was mortified. Yet, at the end of the game, I was asked to come back again- despite my ineptitude they needed me to be eligible for play. I left the game feeling embarrassed about my performance and walking tentatively because in all the hard effort I had put forth, I think I pulled muscles in both my thighs. I could barely maneuver the clutch to get myself home. I called my parents, as most young adults do when they don’t know how to fix something, and asked how to make my legs feel better. They suggested calling a family friend I grew up with who was a physical therapist. I told her what I had done and how I was worried I wouldn’t be able to work the next day because I could barely walk. She instructed me on the schedule of icing and rest that helped heal my sore muscles and put my in my job the next morning.

When I was recently relaying this story to some friends, I told them how I went back the next week to play again. They were both surprised after such an embarrassing show I had made of myself and the near injury I had caused to my legs. “I couldn’t disappoint them. They needed me,” I explained.

I don’t like to disappoint.

I recently did some soul searching and came to the realization that I’m not ready to do call- to deliver babies. I’ve had the conversation with work, asking to be taken off the call schedule…indefinitely. I do plan on going back to birth, I just need more time to figure out how much time I need. I am extremely fortunate that they are willing to accommodate me in this request.

Admitting that I’m not ready for birth six months after my baby died feels like a disappointment. I’m disappointing my practice partners- they’ll have to work more because of me. I’m disappointing my patients- the ones who were hoping I’d be there for their births will have someone else. I’m disappointing my nursing and midwifery colleagues who have tried so hard to bolster me up with comments like “You’re such a good midwife, you have to do birth,” and “It’ll be hard, but you’re so strong, I know you can do it.” I appreciate their efforts to build my confidence, but what they don’t realize is that I don’t need my confidence boosted. I just need time. These remarks meant to help me actually make me feel worse, because now I feel like I’m disappointing them- I’m not a good enough midwife or strong enough to get past the death of my daughter. I’m disappointing my friends who say they can’t picture me as anyone but a midwife, it’s such an integral part of my identity.

I’m not leaving midwifery and I hope to be back at birth- sooner rather than later- but I have to take care of me first. I will write more about the “why” behind my inability to face call right now, but that’s for another day. I know you all will tell me to not worry about it, to be gentle with myself, to know that I have to be good to myself before I can be a good midwife (and thank you in advance for such kind and supportive comments), but regardless of all the things I can tell myself, of the things you can tell me, I still feel like I’m disappointing everyone.

Do you ever feel disappointed in yourself?  Why?

Relating to my patients

I had a shadow with me in the office again this week. A doctor, new to our practice followed me around for a day last week to get familiar with our electronic medical records and the ins and outs of our office. This week our newly acquired midwife did the same. I’m apparently the go-to provider to show people the ropes. It’s interesting being shadowed, especially by people with more experience than me (as were both the doctor and midwife.) I felt the need to represent the practice well and to represent myself well. Last week I felt empowered at day’s end because I didn’t feel self- conscious being watched as I cared for my patients. This week, I felt pretty much the same, but I had a few moments of unexpected pain throughout the day too.

“Are you having a boy or a girl?” the new midwife asked the pregnant woman, in an effort to fill the void in conversation as I flipped though the patients chart.

We midwives become masters of small talk, chatting during potentially awkward times. I usually use the time I spend doing a breast exam to talk about the new pap smear guidelines with my patients. At the beginning of each visit I get a good social history from my patients (relationship status, job, what’s new…) and often use that to create conversation during a pelvic exam. “So what are your wedding colors?” or “How long have you been at your job?” are good time fillers. I often ask couples to tell me how they met while I’m in the labor room pushing with a woman.

Prenatal visits are quicker, having gotten the big chunk of the social history in the initial visit and so asking more “fun” questions about the pregnancy has been my fall back for conversation fodder. “What are you having?” or “Are you having a baby shower?” or “Does your younger child understand what’s happening?” are all non-essential questions but help support the bond between patient and provider.

I don’t ask those questions anymore.

They are too painful, too intimate. They make the pregnant belly in front of me more real and thus more of a reminder of what I have lost. If the conversation picks up from there, it’s hard not to try and relate to my patient. When someone tells me they are getting married in September, of course I’m going to say “Oh, how lovely! I got married in September, too. We had great weather, I hope you do too!” It’s human. Patients like it and it makes my job more enjoyable too.

If a patient replies, “We’re not finding out,” to the what-are-you-having question, I want to say “I didn’t either!” I did it while I was pregnant, so my natural inclination is to do it now too. But I hold my tongue, because then they might ask, “So how old is your child?” And then I have to disappoint them with the news that my baby died. Since I can’t seem to hold back my attempts to try to relate, I simply just don’t ask. I think my relationship with my patients suffer because of this.

Being observed, I wanted to tell my new colleagues, I’m better than this. I usually am much more chatty and ask those kinds of questions. I actually had the chance to exactly that last week, at the end of the day after a conversation about Mabel, and that made me feel better. But this week with my new shadow, I heard her have conversations with my patients that I should be having… if my baby lived.

“What do you have at home, a boy or a girl?” The new midwife asked my patient who was having back pain.

“A boy.”

“Oh, I have two boys! I know how they can be, running around…” she said laughing. “Make sure you bend with your knees and not at your waist, when you pick him up.”

My chest ached witnessing this conversation. Oh, how I wish I could relate to my patients this way! I don’t have living kids to bond with them over and I hesitate to bring even my pregnancy experiences into the conversation, for fear that they will lead to the words “my baby died,” bringing sadness and attention to me in the exam room, when the focus should be on them.

It’s the same kinship I feel with patients who have had babyloss. I’m sure many of you have felt it too- when you’ve met someone who either shares their story with you or when you’ve heard of someone else and you reach out to them. It’s natural to want to say “me too!”

This is just one of the many secondary losses we experience after our babies die. I have lost the joy I had in relating to my patients. What are some of your secondary losses?

Some people were raised well

She was a young woman. Some people do well at the gyn and for other’s it’s a struggle everytime to make it through the door. I had one patient tell me she’d rather come to me for a pap smear than go to the dentist (so true! Me too! Pelvics take 2 minutes, the dentists takes an hour!). Another patient tells me each time that she cant understand how I can do what I do. It all grosses her out.

This nervous young woman said in the middle of her visit- the visit that was focused on her and her issue and her nervousness around the exam- “I just want you to know I’m so sorry about your baby.”

In all her nerves and angst, she could take a minute a look outside herself and say something kind. That’s amazing.

I smiled. Thanked her. Thanked her for saying something.

It’s young women like these that make me want to hunt down their mothers and just say “Good job. You raised her well.”