Special Feature

Journal of Perinatology (2012) 32, 325–327; doi:10.1038/jp.2011.183; published online 16 February 2012

An exploration of connections between a mother and her unborn in preterm labor

J M Milstein1 and A Jain2

  1. 1Division of Neonatology, Department of Pediatrics, University of California, Davis, CA, USA
  2. 2University Pediatric Associates/Department of Pediatrics, University of California, Davis, CA, USA

Correspondence: Dr JM Milstein, Division of Neonatology, Department of Pediatrics, 2516 Stockton Boulevard, Ticon II, Room # 354, Sacramento, California 95817, USA. E-mail: jmmilstein@ucdavis.edu

Received 6 September 2011; Revised 31 October 2011; Accepted 14 November 2011
Advance online publication 16 February 2012

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Abstract

The purpose of this special feature is to elaborate on a unique physician–patient interaction between a neonatologist and a pediatrician established during the pediatrician's personal experience with the onset of labor between 22 and 23 weeks’ gestation. As the two are both versed in conventional aspects of neonatal care including prenatal counseling, the neonatologist thought that he had more to offer the expectant mother holistically. Thus, he decided against approaching her as an information source and contribute to the customary data-dumping format that can be both frightening and dehumanizing. Instead, he wanted to focus on her individual experience of pregnancy and the healing aspects of care. The most important lesson received from the interaction is the value of being present with another. This sense of ‘being with’ applied to the neonatologist and the mother from their initial phone conversation to their in person times, and to the mother with her unborn permitting interaction in a meaningful way. Fostering each of those connections in alternative ways was valuable in this prenatal experience.

Keywords:

preterm labor; compassionate presence; connections; being with; alternative therapies

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Introduction

To the chagrin of practitioners and families, premature labor remains a major basis for morbidity and mortality in modern obstetric practice.1, 2, 3 As a neonatologist and pediatrician, our exposure to these families is generally in relation to the care of their infants. The purpose of this vignette is to elaborate on a unique physician–patient interaction between the two established during the pediatrician's personal experience with the onset of labor between 22 and 23 weeks’ gestation, a period when the unborn is at the limits of viability.

Several years ago, a former pediatric resident, now a member of our faculty, contacted me from an outside hospital when she entered labor between 22 and 23 weeks of gestation. Her initial request was to meet me once she was transferred to the University of California (UCD), Davis, CA, USA, where I am a senior neonatologist. As we are both versed in conventional aspects of neonatal care including prenatal counseling, I thought that I had more to offer her holistically. I decided against approaching her as an information source regarding curative aspects of care, which could contribute to the customary data-dumping format that can be both frightening and dehumanizing. Instead I wanted to focus on her individual experience of pregnancy and the healing aspects of care.

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Recollections of our initial encounter

In the text to follow, we will share our perspectives on the experiences that we each had over the remaining duration of the gestation and beyond.

I agreed to meet her once she was transferred, and we continued our phone conversation. Even though she was at bed rest, her voice reflected her current state that was anything but relaxed. She spoke in a rapid, intense fashion highly focused on the medical aspects of her condition. At this point in the conversation, I decided to shift her focus from her finely honed medical data bank to a quieter mindset. I asked her to indulge me in my effort to help her relax and follow my verbal guidance. I instructed her to change to a speakerphone if possible or prop the phone if necessary. I then had her lie on her back, legs uncrossed, as best she could (with the imposed restrictions), and to put her arms at her side with palms upward. I was spontaneously trying to generate a relaxing shift in her focus. I then asked her to close her eyes and, as she would breath in, imagine waves of relaxation enter through the crown of her head. These waves would bring a sense of warmth and heaviness to her arms, hands, legs and feet and a sense of relaxation throughout her core. I was mixing autogenic suggestions with other mindfulness techniques.4 I could detect a change in her demeanor. Her voice softened and her previous perpetual chatter markedly decreased then actually disappeared. I could feel her relax. I stayed on the phone and followed her breath as she settled into a state of repose. It is an interesting experience to shift from the role of physician to patient. When I entered preterm labor at such an early stage of my pregnancy, the most prominent feelings that I had were significant stress, fear, anxiety and apprehension. These emotions recurred intermittently throughout the remainder of my pregnancy. After the preterm labor began, my most prominent thoughts included a fixation on the medical facts and potential adverse outcomes. I emotionally disconnected further from the fetus as a protective mechanism to avoid disappointment if the pregnancy would terminate prematurely.
After our first interaction, I felt less anxious and fearful. For the first time, I began considering the fetus as an actual living being that I could connect with emotionally. Prior to this, I had been so busy with work and life that the pregnancy took a backseat. The complications and imposed bed rest provided a wake-up call demanding my attention.

As these thoughts had not been verbalized but only revealed during this retrospective construction, we were not enticed to analyze them. This may have been fortuitous because the value of the experience, accepted with patience, could have been lost if analyzed at that time.

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Creating a compassionate presence

After 2 days, the mother, my colleague, was transferred and I was called to see her. She seemed quite anxious, manifested by increased talkativeness and, though confined to bed, a tension apparent in her facial expression and posture. At first, I wanted to establish a compassionate presence and the sense of being with (rather than doing to) her, foundations for a healing physician–patient relationship.5, 6 I began by exploring what her life was like before the onset of premature labor and how her life had changed. I then queried what she thought and felt, and how she and her husband related to the pregnancy, preterm labor and to each other. Although her husband was not present at this time, I asked her to consider the situation as if he were. I wanted her to consider where she and they might turn for support: inward, outward, to each other, anyone else, a spiritual path, a faith-based path or any other source of support.6 I urged her to consider any and all of these sources, as I attempted to invoke whatever support would help her cope. I suggested that she and her husband should be supportive of each other despite any differences in their reactions to the situation because such events can be extremely trying to the strongest of relationships. I told her more than once that I could repeat this conversation with him. The opportunity for that conversation never arose. Being characterized as a planner, her husband was quite stressed and anxious about the preterm labor. He was ‘fine’ with the approach introduced to his wife, but quite skeptical. Once she was discharged to home, he did not participate in any of the activities she continued.

Had a conversation occurred with the father, I would have covered most of the material noted earlier in this section that was directed towards him through the mother. In addition, as a simple entry into such a discussion with any patient encountering a life-altering experience, one can query what his/her life was like before—and after—an event, exploring the illness interruption imposed on his/her life's story.7 In order to further immerse in the patient's human experience—the cognitive, emotional and spiritual—rather than asking how one feels, generating a list of symptoms, asking how one feels about having a particular entity (asthma, cancer and preterm labor) can potentially open up dialogue regarding his/her human experience.

After the brief discussion following her transfer, I decided to repeat the guidance that I had given by phone earlier. I had her lie with her legs uncrossed, arms at her sides with her palms upward. I asked her to breathe in waves of relaxation. Then I shifted her focus to her breath and to the still point at the end of each outbreath.8 I gently guided her through a mindfulness meditation focusing on her breath, gradually shifting the focus to sound, touch and tactile sensations, as well as thoughts. If there were contractions among the tactile sensations, I directed her to gently breathe waves of relaxation into them. I suggested that she could resume these relaxation measures repeatedly during the day as well as whenever she sensed increased contractions. She could focus on whatever object of her attention seemed to resonate and generate the greatest state of calmness in her. She did not fall asleep but was very relaxed. I quietly departed to resume my other duties.

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Further connections

After 2 days, when I returned for another visit, I had a specific goal. In addition to guiding her through another meditation, I wanted to introduce to her some elements of a practice that I have utilized with occasional mother–infant dyads with critically ill infants to enhance their connections to each other; the practice, Sheng Zhen Qigong, is a form of Qigong with intention in both thoughts (contemplations) and movements.9 With the mother's permission, I asked that a visitor of her's allow us to have some time alone. Then I guided her through another meditation, but this time I asked her specifically to reach out to her unborn baby with her own voice, touch, thoughts and feelings, and become one with her unborn. I wanted them to commit to remain together as one, as long as they could, establishing a contract or commitment to remain as one. Her demeanor was favorably changed in moments. I suggested that whenever she would have breakthrough contractions, she and her unborn baby should relax and become one. I elaborated on the power of intention, in our thoughts and actions, potentially affecting our destiny and outcomes. This was the final experience that we had together prior to my discharge to home. I continued to have periodic contractions. I remained at bed rest until 34 weeks. There were no prompts or directives for me to stop bed rest at that time aside from my comfort level with preterm labor at 34 weeks’ gestation. I remained on nifedipine orally and progesterone intravaginally throughout the remaining duration of the pregnancy to 39 weeks’ gestation.
I began utilizing these relaxation and connecting techniques following our first conversation, the transfer to UCD and following my discharge to home when the anxiety would recur. It became a bonding time with my unborn child and validation that I could connect with him even if the pregnancy was not carried to term.
I experienced this as very stressful, of course, but also a good reminder of the fragility of life. The experience also provided me with a better perspective on patients I have seen in the past with similar situations and prompted me to reconsider previous biases of preterm delivery.

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Reflections on experience

In retrospect, my perspectives on communication with one member of a couple may have changed. Certainly, situations may arise that are best handled by timely communication with the patient present, even though other key family members are unavailable. Just as there are critical ‘teaching moments’ there probably are critical ‘connecting moments’ that may be lost if delayed for procedural or personal reasons. It probably is preferable to meet with key stakeholders at the same time. This would provide the caretaker an opportunity to witness and address differing reactions that may arise when either informational or directive material is transmitted. In addition, there may be inherent difficulties in relegating one member to pass on certain directive concepts to other family members, such as being supportive and accepting of each other, as opposed to concepts that are more informational in nature. In retrospect as a patient, my perspectives on informational as opposed to supportive communication with me alone and not with my husband and me together may have limited the shared positions that we held. Had we been together, the informational material could have been clarified for my husband who is not familiar with medicine and would have avoided putting me in the position of the primary information source. The supportive, more directive communication may have been more effective in generating adherence for both of us to follow throughout the remainder of the pregnancy as well.

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Lessons

The most important lesson we received from our interaction is the importance of being present with another. This sense of ‘being with’ applied to the mother and me from the initial phone call, to the in person times and to the mother with her unborn permitting interaction in a meaningful way. Fostering each of those connections in alternative ways was valuable to each of us and possibly to the unborn child in ways we do not fully or cannot begin to understand. Development of a compassionate presence that starts with a sense of being present may be helpful in this interaction.

Searching for lessons outside of ourselves, our experience combined with an earlier study that demonstrated favorable effects of a relaxation response on the duration of gestation and the rate of pregnancy prolongation 10 may provide the enticement to generate a study to further evaluate the effects of the relaxation response as well as contemplations enhancing connections between a mother and her unborn to prolong the duration of gestation in preterm labor. Finally, the approach described may satisfy the recommendation made in a recent review evaluating the effectiveness of medical interventions at preventing preterm birth on a population level.3 They suggested that alternative, holistic therapies may hold more promise to reduce preterm births in socioeconomically disadvantaged populations.3

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Conflict of interest

The authors declare no conflict of interest.

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References

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  2. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008; 371: 75–84. | Article | PubMed | ISI |
  3. Wisanskoonwong P, Fahy K, Hastie C. The effectiveness of medical interventions aimed at preventing preterm birth: a literature review. Women Birth 2011; 24: 141–147. | Article | PubMed |
  4. Benson H. The Relaxation Response, Chapter in Mind Body Medicine. In Goleman D, Gurin J, (eds). Consumer Reports Books: New York, 1993, pp 233–257.
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  7. Milstein JM, Raingruber B. Choreographing the end of life in a neonate. Am J Hosp Palliat Med 2007; 24: 343–349. | Article |
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  9. Li JF. Sheng Zhen Wuji Yuan Gong: A Return to Oneness. Lotus Press: Twin Lakes, 2004.
  10. Janke J. The effect of relaxation therapy on preterm labor outcomes. J Obstet Gynecol Neonatal Nurs 1999; 28: 255–263. | PubMed |
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Acknowledgments

We would like to acknowledge Debora Paterniti, PhD and Deborah Maciejewski for manuscript review and encouragement.