Preterm Labor: Understanding Treatment Protocols

Birth Quest doula attends lecture with Obstetric residents about preterm labor.

On August 22nd, 2017, Sandy Parker from On the Path Yoga and I drove to the New Holland Brewery in Grand Rapids to hear Dr. June Murphy, DO, Maternal Fetal Medicine Fellowship Director at St. Joseph Mercy Oakland Hospital, talk about “Advances in Management of Preterm Labor: Achieving Optimal Practice.” The lecture was at an event that combined the journal clubs of obstetric residents at Mercy Health Hackley in Muskegon and Metro Health (University of Michigan) in Grand Rapids. The event was sponsored by Hologic, the makers of the fetal fibronectin test.

Understanding the ever-changing standard of care involving preterm labor is important for maternal and infant health advocates, like doulas and childbirth educators. People who experience preterm labor are often confused about why treatment varies so much between patients. Not understanding the standard of care can lead to anger when it appears that patients have not been treated equally. While unequal care can occur, protocols can prevent bias and reassure patients that everything possible is being done to protect them and their infant.

While preterm labor is the leading cause of infant mortality in the US, it is very common and often harmless. In fact, I learned that as many as 1 in 4 women will experience four contractions per hour prior to 32 weeks! However, 30% of preterm labor resolves spontaneously, without treatment. Only 1 in 10 women who are diagnosed with preterm labor will give birth within 7 days. In other words, uterine contractions poorly predict whose baby will be born too soon!

To complicate matters, steroids given to mothers with preterm labor improve newborn outcomes when given as late as 34 – 36 weeks, but can be harmful when given unnecessarily.

So, what are providers supposed to do? Fortunately, the March of Dimes created the Preterm Labor Assessment Tool (PLAT), an algorithm, or decision tree, based on the Rose et al study (2010), to assist healthcare providers in deciding whether to admit someone in preterm labor. Dr. Murphy explained how the cut-offs for cervical length combined with the fetal fibronectin results best predicted who would deliver early. Unfortunately, the protocol does not prevent preterm birth, but does save money, time and stress from unnecessary hospitalizations.

In addition to the lecture, residents reviewed two articles, one comparing the efficacy of vaginal progesterone to an injection. Studies in the last decade have shown that progesterone treatment to prevent preterm birth is effective. Barriers to this treatment include problems with insurance reimbursement and compliance with office visits to receive injections. Vaginal progesterone has the advantage of being cheaper and easier to administer. Although the study was small, it showed promise for an alternative, but effective, treatment to prevent preterm delivery and save lives.

Dr. Murphy said that if a woman presents to a hospital in preterm labor and there was a thought bubble above her fetus, if would say, “Follow the protocol!” The causes of prematurity are complex and interrelated. Clinical providers have a limited role in addressing the underlying causes of prematurity and the infant mortality that results. Standardized care based on the latest research can reduce treatment influenced by bias and help achieve equity.

Black Infant Mortality in Muskegon More than Doubles in Eight Year Span

Available here: http://www.mlpp.org/wp-content/uploads/2017/08/Muskegon-2017-Right-Start.pdf

Source: Michigan League for Public Policy, 2017 Right Start Annual Report on Maternal and Child Health, Muskegon Community Report

According to Kids Count data, released August 9th, 2017, the Black infant mortality rate, or B-IMR, in the City of Muskegon has more than doubled in an 8-year time span. The infant mortality rate measures the number of infants who died per 1,000 infants born. This makes it possible to compare places with different population sizes, or groups within a population. The data in the report compares a “rolling average” or the average of a 3-year time span, 2008 – 2010 and 2013 – 2015. For a relatively rare event like an infant death, years are combined to get enough numbers to make sure the statistics are not related to chance.

The community report for Muskegon points to the Maternal Infant Health Programs (MIHP) at Muskegon County’s two Federally Qualified Health Centers, Muskegon Family Care (MFC) and Hackley Community Care (HCC) and several programs through Catholic Charities of West MI as examples of efforts. Policy recommendations in the full report include:

  • Reducing disparities by race and ethnicity
  • Protecting the Affordable Care Act and the Healthy Michigan Plan
  • Expanding home visiting programs to support vulnerable women and infants
  • Addressing the social determinants of health

Here is a timeline of some significant events that impacted reproductive, maternal and infant healthcare services in Muskegon during the time covered in the report:

Important Events Impacting Reproductive Health in Muskegon County from 2008 to 2016

Muskegon County experienced a 131% increase in infant mortality during the time these events occurred. Did they have an impact?

These events may impact infant mortality in the following ways:

Despite promises by administrators that reproductive health services would not be impacted, the hospital system, now operating under the Ethical and Religious Directives for Catholic Health Systems (ERDs), eliminated insurance coverage for family planning under its health insurance plans. Although some providers violate the ERDs by prescribing birth control for preventing pregnancy, there is now institutional support for providers who, because of their own religious beliefs, refuse to insert an IUD immediately postpartum, prescribe hormonal contraceptives, or emergency contraception; or perform a tubal ligation during a cesarean, for example. The merger also meant an end to all abortions, except to save the life of the mother, which, as the court case Means vs. the US Conference of Catholic Bishops shows, is up for interpretation by the local Bishop. The ban on abortions includes terminations for fetuses known to have birth defects incompatible with life, even when the pregnant person has health conditions that can make pregnancy dangerous for them.

As I stated this past May, when I was invited to speak to congressional staffers by the National Women’s Law Center (NWLC) on the impact of religious restrictions in healthcare in Washington, DC, unenforceable policies open the floodgates to discrimination based on provider biases.

Muskegon’s Fetal Infant Mortality Review (FIMR) findings showed an increase in both unintended pregnancies among women experiencing an infant or fetal loss and a sharp increase in Black infant mortality following the loss of Title X family planning services.

The new Muskegon Planned Parenthood clinic reopens inside of Public Health – Muskegon County , providing services in Muskegon for the first time since the Peck St. clinic shut down in 2007. Title X – funded clinics are unique in that federal guidelines prohibit discrimination, religious refusals on the part of the provider and can provide more confidential services to minors than state law requires.

The Birthing Center at the former Mercy Hospital was a favorite among local women. As an in-hospital birthing center, it was physically detached from the hospital, but still run by it. During construction, some women who gave birth complained to me of noise and crowding. Some women who had given birth prior at the Mercy facility and then had to deliver subsequently at the new facility, preferred the later.

Centering Pregnancy is an evidence-based group prenatal care model shown to decrease the incidence of preterm births, with the best improvements among African American women.

Regardless of the reasons of the clinic’s closing, Muskegon County women now must drive to Grand Rapids’ Heritage Clinic, currently the closest abortion clinic, to obtain an elective abortion. For those who lack transportation to Grand Rapids or the addition time for travel, this clinic closure creates an additional barrier to obtaining services. Research has linked increases in abortion access to declines infant mortality rates.

  • Oct 2013: Public Health – Muskegon County (PHMC) Eliminates the FIMR Program

Despite successfully reducing the B-IMR in Muskegon County, PHMC eliminates the FIMR program after a “Know Your Rights” event is held at Muskegon Community College. The event, co-sponsored by the ACLU of Michigan was held to educate local women about how other communities had been impacted by mergers with Catholic healthcare systems.

Planned Parenthood takes over the job of STD testing, despite being open fewer hours, when PHMC decides to focus on partner notification. At the time, we had the third highest rate of Chlamydia among all counties in the state of Michigan. Chlamydia and Gonorrhea are major contributors to prematurity and infant mortality.

Now, both of the FQHCs offer Centering Pregnancy group prenatal care, although the midwives at HCC stopped catching babies that same year, leaving MFC the only place in Muskegon to receive continuous care from a Certified Nurse Midwife throughout labor and birth.

Research shows that racially inequities in incarceration rates are directly related to racial inequities in STD rates. When the former jail was being used, the racial disparities was 5.9, meaning an African American in Muskegon County was nearly 6 times more likely to be in jail than a White resident. Muskegon County FIMR participated in at least two efforts to address this injustice: The Disproportionate Minority Contact (DMC) Coalition and a Health Impact Assessment (HIA) on the funding of the new jail. The DMC Coalition, which was making some progress in collecting data to identify key points in the juvenile detention system where discrimination occurred, had its leadership derailed by a vote electing Judge Pittman as the new president and never again convened. The HIA was sabotaged by inadequate funding and refusal to approve a research project initiated by a professor at Grand Valley State University to inform service providers of the unmet psychosocial needs of current inmates.

Muskegon is about to have its second birthing unit in five years built away from the city center to be more convenient to out-of-town patients. According to the head of obstetric nursing, community input for the birthing unit was obtained, although the public was not invited.

While the causes of infant mortality and the inequalities expressed in rates are complex, one thing is clear, Muskegon stands out in Michigan as having the largest increase, 131%, in an eight-year time span at the same time as infant mortality statewide is decreasing. This is not an accident, nor are the multiple contributing factors a mystery. What remains unasked is why aren’t the home visiting and other programs in place not making more of a difference? And moving forward, if Public Health and Mercy Health aren’t doing a good job of ensuring the survival of our county’s Black infants, is anyone paying attention and will anyone be held accountable? Who will spearhead our efforts toward improvement? Whoever that is, I wish them the best of luck in their endeavors, will follow their lead and hope that they don’t become demoralized and without a job. The needed change will not come without stepping on a few toes.

Crying During Pregnancy and Labor: Breaking Through Barriers with Tears

Crying pregnancy labor

Person crying

I’ve wanted to write about this for years. The profound effect crying has on people has always fascinated me. How can something that must seemingly come from a place of hurt lead to what can only be described as relief?

Now, for some people, crying comes easily. Maybe they are just instinctively good cryers or were fortunate to have the support from others to cry; I’m sure there are many reasons. But for others, like me, crying doesn’t come so easily. For pregnant women, this makes breaking through barriers during their pregnancies and labors more challenging.

Crying has always been hard for me, even though I know I need to do it. I know how much better I feel, how much less cloudy my mind is. But I also know it takes a willingness to be vulnerable, something I seldom allow myself to do. I need privacy and safety, as many others likely do. Often, those two elements don’t come together and so the need to cry builds. At some point, there’s no moving past what’s causing the hurt and the only way out is to be honest and let the tears flow.

Possible Hang-Ups About Crying

I know what my hang-ups are when it comes to crying. As someone who was bullied all through school, I did my best to hide my tears because I didn’t want to be seen as weak or give them the satisfaction of seeing me hurt. Like many other kids, I also remember being disciplined or scolded at times for crying too much. It’s about safety for me; I’ll cry when I need to, but never in front of anyone…not if I can help it. I also fear that I’m “too much” when I do get emotional, and that’s embarassing to me. So finding the nearest bathroom, bedroom, or private place is a must if the tears are going to fall.

And doesn’t anyone else think crying hurts? I hate how I feel when I’m doing it. I also hate how sometimes, it’s like an earthquake with aftershocks that pop up out of nowhere in the hours after the initial round of tears. Despite how much I hate it, though, I can never deny how necessary it is. It’s freedom, it’s relief.

So, for women who are pregnant, what are some hang-ups they might have about crying prior to and during labor? Here are a few possibilities:

  • Fear of judgement
  • Fear of appearing weak
  • Fear of being vulnerable in front of others
  • A belief that crying is a sign of weakness
  • A belief that she’ll be “too much” for others to handle
  • Fear of being seen as overly emotional
  • Embarassment

The reasons for these hang-ups no doubt vary from woman to woman, based on her individual life experience. Some of these impactful experiences might include:

  • Abuse
  • Abandonment
  • Upbringing (cultural, religious, etc.)
  • Lack of privacy
  • Lack of support
  • Suggestion from others not to cry

The Benefits of Crying

 Believe it or not, even if it doesn’t always come easy, crying is good for you. The list of benefits include:

  • reducing emotional stress
  • ridding the body of toxins
  • improving mental clarity
  • moving past barriers
  • releasing tension

There is science behind the benefits of crying. One study found a difference in the make-up of reflex tears and emotional tears. While the reflex tears consisted primarily of water (approximately 98%), emotional tears included more chemicals. What I really thought was interesting is that one of the hormones found in emotional tears was prolactin, which is also associated with a mother’s let down reflex.

You can Google it all you want; the benefits of crying are real.

But what if you’re like me? What if crying doesn’t come so easily?

Practice is the Key

If you struggle to let those tears flow, consider the growing trend in Japan. I saw an article online that struck me a couple of years ago: Japanese men getting together to watch sad movies so they could learn how to cry. In a society where it’s considered a virtue to keep emotions in check, this trend is helping to “normalize” crying. Not to mention how much better the participants feel after a good cry!

Life is already stressful enough. Add to it the changing hormones, anxiety, and fears common in pregnancy. It’s very common for women to “get stuck” or plateau during pregnancy and childbirth. What isn’t so easy is giving in and letting it go with a good cry.

Any number of things can give a pregant woman reason to cry. From financial strain, physical changes, discomfort, to anxiety and fears surrounding birth and past trauma, it’s completely understandable to feel the need to cry. Pregnancy tends to be a time in the lives of many women where such issues emerge to be dealt with.

For a woman nearing the end of her pregnancy, it’s the perfect time to let the tears flow when she feels the need. Not only will it help her feel better, it’s great practice for labor. One of my favorite birth-related books, Natural Hospital Birth by Cynthia Gabriel, points out just how significant crying during pregnancy, and especially during labor, is. I was trying to come up with a good analogy to describe the way holding back from crying affects moving beyond barriers for pregnant and laboring women. All I could come up with was having to pee.

We all have to do it. We all know that if we hold it in too long, it’s all we can think about. There’s nothing else taking up residence in our minds when the need to pee has reached its nagging peak. Same goes for needing to cry. At some point, the dam will break.

I also think that Ina May Gaskin used a similar analogy that also applies here. She pointed out how most people have a hard time peeing in front of others. This, too, applies to crying. Having an audience, especially one that you aren’t sure supports you, is a real hinderance. Call it what you will (I think of it as a sort of stage fright), crying openly in front of others isn’t always easy.

As with just about everything else in life, practice is the key. Pregnancy is the perfect time to get in touch with your emotions and address any mental roadblocks you may be facing. Crying helps with this. A few ideas to help you with getting those tears to flow are:

  • Find time to be alone
  • Find safe people to talk to (your partner, a trusted friend, family member, counselor, or doula are excellent options)
  • Journal about your feelings
  • Watch a movie that makes you cry
  • Listen to music that helps you cry
  • Be honest with yourself about your feelings
  • Give yourself permission to cry

As challenging as it may be, even one good cry during pregnancy can help to straighten out jumbled thoughts and emotions. It also helps to set the stage for the transition to childbirth. If crying during pregnancy helped to move past emotional barriers, remember that it can do the same during labor. Physically and mentally demanding, childbirth is no time to hold back from crying, especially in the instance of a plateau or intense transition. Tips for crying during labor include:

  • Requesting privacy if there are too many people in the room
  • Letting your care provider know ahead of time you plan on crying as an aid to help labor progress
  • Making sure you have good support (your partner, doula, friend, or relative)
  • Shutting out negative comments or advice from others (a support person can help with this)
  • Practicing during pregnancy
  • Trusting that crying is purposeful
  • Reminding yourself of other times crying has helped you to feel better (a support person can remind you of this as well)

Facing Obstacles

There will always be obstacles to crying, though. Many people, even medical care providers (they’re people with feelings, too), are made uncomfortable by crying. It’s possible that they or others (your partner, friends, family, etc.) might tell you not to cry. They may or may not give you a list of reasons why you shouldn’t cry or tell you what to do instead. Odds are, they are simply just uncomfortable with it. Generally speaking, I don’t believe most people like to see others hurt. It’s also without question a learned response. I know I’ve heard it and hate to admit I’ve said it… “Don’t cry”. While no ill is likely intended by telling someone not to cry, it takes away from the validity of a person’s emotions.

But crying isn’t about weakness or defeat. So in spite of your own hang-ups, or what others might think or say about it, it’s important to remind yourself that crying is an essential release that leads to renewed strength.

It’s kind of like the difference between transition in labor and the pushing stage: considered the most intense part of labor for many women, transition is often the time women are pushed to the limits of what they think they can take. Those viewing on will inherently want to help. If a woman is encouraged and supported through this stage, pushing often yields a more focused and less distressed woman. With the pain and intensity of transition over, women can catch their breath and get ready for the purposeful work of pushing their babies out.

If, instead of receiving encouragement and support during transition, a woman is told not to cry or is offered other options, she may miss out on the relief and satisfaction that waits on the other side of safely expressing her emotions through tears. Anxiety, fear, and other pent up emotions that are not let out cause more physical pain, as well. This is often the point where women face decisions that will affect how their babies are born. This is a very tender period for the mother. Practice in supporting a woman in this delicate phase is essential. Not only does it reduce her risk of interventions, it increases her odds of reflecting positively on the birth experience.

Just like transition, crying is temporary. It’s simply a part of the process.

Seeking out the support of a doula is an excellent idea if you fall into the category of women who struggle to cry as a way of dealing with pent up emotions or who lack needed support. Trained to listen non-judgmentally, provide encouragement and a feeling of safety, doulas know the difference that positive support makes possible.

For information about resources in the area or to inquire about our services, please contact us.