multiple gestation
The Preemie Primer: Recommended Reading for Mamas on Bedrest
September 2nd, 2010When you are pregnant, you are bombarded with information and advertisements for everything from infant swaddling blankets, to formulas, to cord blood banking, to strollers. Much of the information that I received in my bag at each of my first obstetrical visits was useless. They were simply little leaflets trying to sell me things that I didn’t really want or need. How much better it would have been if I had received a copy of The Preemie Primer: A Complete Guide for Parents of Premature Babies-From Birth Through the Toddler Years and Beyond.
The Preemie Primer was written by Jennifer Gunter, MD, a board certified obstetrician/gynecologist, who is also board certified in pain medicine and board certified in physical medicine and rehabilitation. At a first glance it seems like Dr. Gunter is yet another “expert” telling you what the “scientific evidence” says you should do for your baby. While Gunter offers comprehensive information on caring for a premature infant, the book is far from dry and overly ‘jargoned’. At its best it is a deeply personal account of how Jennifer Gunter, wife and mother, navigated the peaks and valleys of caring for her markedly premature boys Oliver and Victor (born at 26 weeks) while also grieving the loss of their triplet brother Aidan, born at 22 weeks. She is simply sharing what she learned and knows with other parents and has created a powerful resource for parents of preemies.
Now I don’t want to discount Dr. Gunter’s knowledge. She has done a great job of pulling together the necessary medical information pertaining to preterm labor, prematurity and caring for mom and baby (ies) post partum. But the honest truth is that much of the “medical” information is freely available-on the web and in books and texts. But The Preemie Primer is for parents of preemies who, at a time when this information is in critical need, they dont’ have a nanosecond to spare seeking it out. Part of what makes it such an excellent resource is that not only is the medical information readily at hand in one place, Dr. Gunter also includes information on self care for parents (asking for help with post partum depression for example, deep breathing, meditating…) and navigating the complex US insurance system to get the care premature babies and children desperately need. Yes, the chapters on “The Mind-Body Connection” and “Making the System Work for You” were really helpful and informative and a welcome departure from the sterile statistics, instructions and definitions.
But far and away the “precious jewel” of this book is that it is written by Jennifer Gunter, wife and mother to two 
navigated the peaks and valleys of caring for her markedly premature boys Oliver and Victor (born at 26 weeks) while also grieving the loss of their triplet brother Aidan, born at 22 weeks.premature little boys and an angel in heaven. The success of The Preemie Primer results from the fact that as I read it, I felt as if I was sitting across from Jennifer Gunter, drinking coffee and chatting as she tells her story. I think the most powerful parts of the book are the gray insets that tell her personal story, her personal struggles to care for her living boys while at the same time grieving her angel Aidan. The times she was so overwhelmed with emotions that all she could do was cry. At those times her credentials were irrelevant. She was a mom, struggling for herself and for her sons, and as vulnerable as the rest of us.
One of my favorite vignettes was her conversation with the hospital representative as she disputed charges for Aidan. Anyone who has ever had the frustration of speaking with hospital representatives who are insensitive, unyielding and basically ignorant to medical procedures will totally relate to this conversation. Gunter was arguing to have charges made for Aidan’s “care” removed from her hospital bill. You feel the pang in your own heart as you hear Gunter tell this representative that Aidan died and did not receive care as is indicated on the bill.
While I like and highly recommend The Preemie Primer (Remember, I said it should be in every new OB bag!), I realize it is a tough sell. In the same way that obstetricians don’t discuss the possibility of bed rest until a woman is having it prescribed, I doubt The Preemie Primer will become recommended reading for mainstream pregnancy. And this is unfortunate. Having had a late preterm birth, I would have loved to have had even an inkling of what to expect. As high risk as I was, no one ever even mentioned that I was at risk for preterm labor. I was never counseled about the signs and symptoms of preterm labor. When I delivered my daugher at 36 wks and 6 d, I fully expected to have her put on my chest, to nurse her and then to have her in my room. Instead she was whisked away from me by nurses and neonatologists and then admitted to the NICU (which is never mentioned or visited in hospital tours). I was completely blind-sided by the entire experience.
Our culture likes to “stay positive” and always “look on the bright side”. But turning a blind eye to potential catastrophe is just plain stupid. No woman wants bed rest, a premature infant or, heaven forbid, to have a stillbirth. But the reality is that these events happen. Just because we don’t talk about them or “don’t have that in my family or medical history” doesn’t mean that they can’t happen to us. Obstetricians and midwives should talk about them (at the very least) and give parents tools and resources that they can readily access in the event that the most awful and unexpected happens. So yes, I do think that The Preemie Primer should be put in OB bags-or made readily available in OB offices, hospital gift shops, family resource centers and the like.
We have to face the fact that not everyone has the picture perfect pregnancy, labor and delivery. But things needn’t spiral completely out of control. Research shows that patients who feel that their health care providers are honest and up front with them, explaining every test and treatment and potential outcome are far less likely to come away with ill feelings or to sue their providers. We have to have the hard conversations. But if OB’s and midwives don’t want to do that, or feel uncomfortable or as if they are “scaring” their patients, then have resources readily available. As Dr. Gunter said herself during our podcast interview, “Plan for the worst but expect the best”.
The Preemie Primer is available on this website via our Amazon.com store in the Infancy/Childhood section. We respectfully ask that if you decide to purchase The Preemie Primer as a result of reading this blog post or listening to the podcast interview with Dr. Gunter that you do so via our store as it helps to fund the operation of this website.
Share your stories of preterm labor and caring for a premature infant below.
Bedrest: What’s The Point?
October 23rd, 2009This podcast discusses the rationale for the bed rest prescription, indications for bed rest and new advances in the treatment of high risk pregnancy.
Is Complete Bed Rest Best?
October 16th, 2009Recently someone made the comment that high risk pregnant women should not engage in any sort of physical activity while on prescribed bed rest. I cannot disagree more vehemently! When a pregnant woman is placed on bed rest, not only is she at risk for the usual complications of pregnancy (in addition to the particular risks that landed her on bed rest in the first place!) she then adds an increased risk for deep venous thrombosis (DVT) and embolism, pulmonary complications an muscle atrophy (wasting and loss of strength). This is why I produced Bedrest Fitness, a series of exercises pregnant women can do while on prescribed bed rest.
Numerous research studies have documented that prolonged inactivity is detrimental to health. For this reason, when a person has heart bypass surgery, as soon as they are taken off the ventilator and are breathing on their own, nurses are instructed to get them out of bed and into a chair. This sometimes occurs within in hours of open heart surgery! But the sooner patients sit in an upright position, the sooner they will begin reusing their muscles, taking deep breaths and recovering. The same thing happens for orthopedic patients. Once a hip or knee is replaced, within hours to days, physical therapists begin moving the new joint to aid in healing, range of motion and optimum utilization. Early movemtner lowers the risk of venous blood pooling in the legs , blood clot formation, embolisms (blood clots that dislodge and travel to other areas of the body), pulmonary (lung) collapse, fluid in the lungs and the development of pneumonia. So given these examples (and there are many more such as cancer patients and other surgical patients) doesn’t it seem strange that we tell pregnant women to go sit/lie down for weeks to months at a time???
I am sure that opponents and naysayers will chide me by saying, “Well then YOU take responsibility when a woman loses her baby!” I think that we can all agree that no one wants a pregnant woman to lose her baby (or babies as the the case may be). But I think that it behooves all of us, especially in this era of health care reform, to re-examine how we manage high risk pregnant women and to really ask ourselves, is complete bed rest really best?
In some cases, bed rest really is the answer. If a woman is actively bleeding from her vagina, experiencing contractions indicative of preterm labor or has severe high blood pressure and is at risk of pre-eclampsia then yes, bed rest is indicated and I think that inpatient hospital care is best in these settings. But once the bleeding stops, the contractions stop and her blood pressure is closer to the normal range is it still necessary to completely restrict a woman’s activities? Is it best to send her home without medical supervision? Is it in her and her baby’s best interest for her to remain immobile and inactive?
Researchers are just beginning to look at how high risk pregnant women are managed and are beginning to realize that perhaps restricted activity and modified bed rest are better options. If a woman is able to be up out of bed but sitting with her feet up she can work from home and engage in family activities. But some people still argue this isn’t enough, especially in the case of the incompetent cervix. They argue that the gravitational pull downward requires that a women stay reclined in bed. Again, this may not be the case.
The September 2009 American Journal of Obstetrics and Gynecology published a study, “Prediction of spontaneous preterm birth in asymptomatic twin pregnancies with the use of combined fetal fibronectin (fFn) test and cervical length”. Now first let’s qualify their findings by saying that the mothers in this study were in fact having twins but they were not otherwise high risk, i.e. they didn’t have incompetent cervices. The researchers found that in 155 twin pregnancies examined between 22 and 32 weeks gestation,
- A positive fFN test or a cervical length of <20mm increased the risk of spontaneous preterm birth at <37,<34,<32, <30 and <28 weeks gestation.
- The combination of a positive fFN test result and cervical length <20mm had a significantly higher positive predictive value for delivery at all gestational ages than either test alone.
- A positive fFN test result was a stronger predictor of spontaneous preterm birth than a short cervical length alone.
Although this is one test and on a fairly small, very specific population, we can’t ignore the potential indications. To date many women with multiple pregnancies are placed on bed rest to prolong gestation-regardless if they are having symptoms of preterm labor or other complications. While most mothers of multiples often lower their activity levels later in pregnancy out of necessity, those who wish to remain “restricted” but not “bedridden” may now have a way to determine their risk and potentially avoid bed rest.
Likewise, incompetent cervix is one of the most common reasons women are placed on prescribed bed rest. If a pregnant woman with an incompetent cervix can have a cerclage (sugical stitch placed around the cervix) and if the cervix is not effacing (thinning and shrinking), the fFN test may be used to establish which mothers actually need to be on bed rest because preterm labor is highly probable and which mothers may be able to be on modified bed rest, “house arrest” or simple modified/restricted activity.
Truly more research must be done in this area, but it is exciting to see that people are actually doing work for us high risk mamas. Maybe one day, we’ll be better able to tell who really needs to be on bed rest and who does not.
Mamas on bed rest, if you want to keep moving, try Bedrest Fitness! It’s simple yet effective at helping maintain muscle strength and mobililty. see a clip at www.mamasonbedrest.com.
