Associative Memory Gone Wrong

[First things first, for those who just need a tachlis update: had an excellent visit with BMA and her eldest three kids up in Portland. I’m worried about her and the kids, but there isn’t anything I can do at the moment, and I’m not worried about the pregnancy or having the adoption disrupted. I’m going back to visit on the due date, which is also BMA’s birthday. I’m going to bring a cake.]

I don’t think of myself as having a good memory. In fact, my piss-poor memory is something of a defining feature. But I do have an associative mind (it’s one of the things that makes me a good librarian), although sometimes it steers me in unhelpful directions. My visit on Thursday with BMA brought up some associations that really aren’t true, but loom over my thought process in bad ways.

The first is about scheduling. I thought I was going to be taking BMA to an OB appointment on Thursday. That I might get to meet the OB she’d be laboring under and ask a few questions about the whole thing. Instead, I arrived to find she’d had the appointment that morning. I’m not sure where the miscommunication happened, and I know the circumstances are totally different, but I recently listened to this RadioLab back episode, and the association of the broken OB appointment was a pall over the whole afternoon. The afternoon was lovely, though, with a late lunch out and talking and going to the park and dealing with I9, who has a horrible cold.

The second is about BMA going overdue. What she told me is that the OB may let her go all the way to the 4th of December before inducing. On the one hand, this is something I would like to talk directly to the OB about, so I know the message isn’t getting garbled and I can get reassurances as to the reasoning. On the other hand, that’s exactly one month before I go back to work, which is troubling. Hovering over all of this is the baggage I bring to an overdue pregnancy.

Some background: although for religious reasons I grew up not going to doctors, both my biological brother and I were born in hospitals. The reason (at least, the one I remember being told as a child) was that our mother did not produce the hormone to begin labor. We were delivered right on time, because she and her OB picked our due dates and induced her in the hospital. The reason we know that our mother didn’t produce this hormone is that she lost her first pregnancy: a full-term stillbirth because she was allowed to go overdue. The doctors didn’t induce her until the baby was already dead. She and my father never held or named the girl they lost, and they went home to explain to their almost three-year-old son that the baby sibling he was expecting was not going to be coming home with them.

It may seem odd that I knew about this child who was born dead long before I was conceived, but I recognized from an early age that her death created the shape of our family. If she had lived, would my parents have adopted my sister? Would I have been born, since my parents had decided on four kids? I remember not being able to figure out how I should name myself in Latin class: third (birth child), fourth (living child), fifth (child of any kind)? This is not to say my parents talked to me a lot about this stillbirth during my childhood, since most of what I’ve learned about how it really affected my parents as people I’ve learned in conversations I’ve had with them in the last five or so years, but this is my strongest association with overdue pregnancy and induction.

BMA similarly has had to be induced for all five of her previous labors, and knowing this, I assumed that her OB would induce on the due date, but it looks like they are going to let her go overdue. And I know that this is 2011 and not the mid-1970s, that her OB is not going to go on vacation and leave her unattended, that BMA is cared for and monitored to the degree considered appropriate, but it still scares me. Today, I ran into the person who will be this child’s nanny, and when bringing him up to date on what’s going on, he said “Well, it’s not like the kid can be overcooked,” and I had to respond, “Yes, they can.”

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2 thoughts on “Associative Memory Gone Wrong

  1. What gestational age does 12/4 put her at? This is from up-to-date, describing the approach to managing post term pregnancies & deliveries. It is from http://www.uptodate.com/contents/patient-information-postterm-pregnancy.
    POSTTERM PREGNANCY TREATMENT
    Antenatal fetal monitoring — In most cases, a healthcare provider will recommend tests on the fetus if the pregnancy extends beyond the due date. These tests give information about the health of the fetus and about the risks or benefits of allowing the pregnancy to continue.

    The American College of Obstetricians and Gynecologists has stated that it is only necessary to start antenatal fetal monitoring after 42 weeks (294 days) of gestation, although many obstetric care providers will start fetal testing at 41 weeks. Many experts recommend twice weekly testing, including a measurement of amniotic fluid volume. Testing may include observing the fetus’ heart rate using a fetal monitor (called a nonstress test) or observing the baby’s activity with ultrasound (called a biophysical profile).

    Nonstress testing — Nonstress testing is done by monitoring the baby’s heart rate with a small device that is placed on the mother’s abdomen. The device uses sound waves (ultrasound) to measure the baby’s heart rate over time, usually for 20 to 30 minutes. Normally, the baby’s baseline heart rate should be between 110 and 160 beats per minute and should increase above its baseline by at least 15 beats per minute for 15 seconds when the baby moves.

    The test is considered reassuring (called “reactive”) if two or more fetal heart rate increases are seen within a 20 minute period. Further testing may be needed if these increases are not observed after monitoring for 40 minutes.

    Biophysical profile — A biophysical profile (BPP) score is calculated to assess the fetus’ health. It consists of five components, nonstress testing and ultrasound measurement of four fetal parameters: fetal body movements, breathing movements, fetal tone (flexion and extension of an arm, leg, or the spine), and amniotic fluid volume. Each component is scored individually, 2 points if normal and 0 points if not normal. The maximum possible score is 10.

    Amniotic fluid volume is an important variable in the BPP because a low volume (called oligohydramnios) may increase the risk of umbilical cord compression and may be a sign of changes in the feto-uteroplacental circulation. Amniotic fluid level can become reduced within a short time period, even a few days.

    Contraction stress test — A contraction stress test (CST) can also be done to assess fetal health. It involves giving an intravenous medication (oxytocin) to the mother to induce uterine contractions. The fetus’ heart rate is monitored in response to the contractions. A fetus whose heart rate slows down during a CST may require a cesarean delivery.

    Inducing labor — The optimal time to deliver a baby in a woman who is postterm is sometimes hard to determine. The healthcare provider and woman must consider the risks and benefits of continuing the pregnancy, the results of antenatal testing, and the condition of the cervix (the lower part of the uterus, which opens into the vagina). Normally, the cervix begins to dilate (open) and efface (thin) towards the end of a woman’s pregnancy. Inducing labor is more likely to fail in women whose cervix is not dilated or thinned (called ripe), which could require the woman to undergo cesarean birth.

    Most healthcare providers will induce labor if it does not begin spontaneously by 41 to 42 weeks of gestation. For a woman whose cervix is not ripe, labor can be induced with a medication applied directly to the cervix or in the vagina, which causes the cervix to ripen. Cervical ripening may also be accomplished using mechanical methods such as a Foley catheter bulb. Most women, including those whose cervix is ripe, will also require an intravenous medication, oxytocin, which stimulates the uterus to contract; uterine contractions further stimulate cervical dilation and effacement. If induction of labor does not completely dilate and efface the cervix, or if complications develop that require the baby to be delivered quickly, a cesarean delivery is usually performed.

    Some patients may choose to have a cesarean delivery, especially if the fetus is macrosomic (defined as an estimated fetal weight of greater than or equal to 4500 grams [about 10 pounds]), they have a history of previous cesarean delivery, or for reasons of personal choice. It is important to understand the risks and benefits of cesarean delivery, and to discuss these issues with the physician who will be performing the procedure. (See “Patient information: C-section (cesarean delivery)”.)

  2. Hi, Benjamin M asked me to look in on you. I’m a naturopathic doctor and midwife in Seattle. First, I’m sorry for your family’s loss. I understand how this experience can strongly affect how you approach this pregnancy. From a statistical perspective, stillbirth is rare and increases slightly as the pregnancy progresses. Most women are asked to have some kind of fetal surveillance after 41 weeks gestation, typically a combination of non-stress tests and biophysical profiles, which provide reassuring information about the baby’s wellbeing (a baby who scores well on these tests is unlikely to have a problem within a certain timeframe, but scoring poorly doesn’t necessarily mean there’s a problem). Many postdates pregnancies are as a result of inaccurate dating — the rate is 11% when you’re only using someone’s last menstrual period to calculate the due date, and it goes down to 2-3% when you have an early ultrasound to confirm dating. You might find it reassuring to find out how many weeks she was when she was induced the first time, and to know that 41 weeks and 3 days is a very typical duration for first pregnancy. Anyway, this issue is full of subtlety, but she will most likely receive some kind of surveillance, and she will most likely go into labor on her own. Feel free to contact me if you want to discuss.

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