Mild p-e and CNMs... or high-risk OB?

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Hi -- I'm not a nurse, but have a question for all of you. I'm 35, 30 wks pg with my second son. My first son was born at 40 wks via emergency c-section for I think what they call non-reassuring decells after 12 hrs of labor, thankfully he was fine, just perfect actually. I had been diagnosed at 39 wks with PIH, which progressed to p-e during L&D. I was on mag for 24 hrs. Two days after discharge, I was back in the ER b/c a home nurse took my BP and it was very high (I think around 180/100). I was put on nifidipine and bedrest for a week, and my BP came down and stayed down, weaned off the meds at 6 wks postpartum.

My BP was normal in the interim and up until my third trimester with this pregnancy. At 27 wks I had two readings of high BP (around 148/88, I think), and was put on bedrest. It has been lower since, around 120-135/70-80 at home, even lower at the office. I am continuing to see my CNMs, now weekly, plus are having weekly NSTs. I just had a biophysical profile (fine), which they want me to have monthly. I also completed my second 24h urine (first was a baseline at 26 wks), but this time my protein was elevated at 330. My MWs (and apparently the backup OB) weren't concerned. I am.

My question is - I love my MWs, and the care I have received from them. They seem much more attentive than the OBs. But I'm wondering if I should be seeing either the OBs, or even a high risk OB instead? I'm kind of nervous about switching caregivers this late in my pregnancy, esp. with these complications. I am a pretty pushy patient - for example, I was the one to request the second 24h urine - but I'm just not sure what to do here.

I should add - my CNMs have their own practice, but meet with their backup OBs twice weekly.

Thanks!

Mel

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

If you are concerned, you always have the right to a second opinion. Maybe you could ask another midwife or dr about all of this?

Other than that there is really no reliable advice we can give you here. Wishing you a healthy and happy delivery!

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I second the second opinion, but this is how I would suggest doing it....since you are familiar with and comfortable with your current midwives, I would start with them. Make an appointment just to talk about your concerns. Ask them what criteria they have for turning your care over to an OB, so you know what they are going to be looking for. Ask about co-managed care, where the OB and the midwife work more closely together, but the midwife stays actively involved in your pregnancy and birth. Do your midwives offer that?

Then, if you are not reassured, I would go to the backup OB for a visit, since he or she will likely have heard about you and will have some familiarity with your situation - and it shouldn't commit you to switching practitioners. See what they think.

I hope you find the answers you are looking for and have a safe and easy birth!

Becki, SNM

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

I have learned Midwives vary in their sense of comfort in dealing with various risk situations in pregnant patients.

Some midwives take NO "high risk" patients of any sort. Others will take certain ones w/the knowledge they have backup from a group of physicians they know and have a good working relationship with. It all depends. I have seen midwives handle fairly complicated patients in the hospital setting-----ones like you describe yourself to be. ......

Others would not assume your primary care at all--you would be referred to an obstetrician.

You have to know the comfort level and experience these folks have with patients with similar profiles and know their back-up physicians, too----I do think that is best.

Good luck to you.

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I'm just a student so this is not a professional opinion. But, if you are worried about questioning your midwives like I would be, you could say it in a non-confrontational kind of way. Like "Do you think I will have to see a back-up doctor?" or "Do you have certain cutoffs when I have to go to your back up doctor?" That way it won't seem like you're questioning your mw's judgement, you can get an explanation of what they do believe consititutes seeing the doctor and see if you're comfortable with that, and it will also cause the mw to take another look at your case and determine if you need to be transferred now. Hopefully that will either get you sent to the doctor or will calm your worries. You also shouldn't feel bad about asking questions, that's the mw's job!

HTH and a healthy baby!

Courtney

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My practice would probably allow the CNM's to "comanage" you. I would order labs and any testing and offer to send you and those results to one of my docs. You might see a doctor once a week or so... but if you really wanted a midwife we would try to make that happen.

If you went into spontaneous labor the doc and I would both be close by for the birth and care afterward.

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I am in two different midwifery practices right now, and the two have differing approaches to managing pre-e patients, so I know there is a lot of variety out there. My one practice (university teaching hospital) does not manage patients on magnesium, so anyone that would need mag goes to the residents. If they are not on mag, we'll keep them, but we consult with the attending to give them a heads-up in case things change. But my other practice (clinic associated with a community hospital) does manage mag patients with MD input to the management plan. So it just varies. But both places keep the MDs in the loop pretty thoroughly.

Becki, SNM

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Thanks everyone for the input! I met with one of my MWs yesterday, and I told her my concerns. I was surprised - she really listened and addressed each concern. It sounds like my care is very much being co-managed... the OBs are completely in the loop and they share my file with them weekly. They are concerned, but watchful. I guess I was taken aback initially by the thought that they weren't worried about my rising protein. But it seems like they are watching it, which makes me feel better.

My MW wants me to come in twice weekly after next week, and she ordered a repeat of my blood work. We'll do another 24h urine next week. My NSTs continue to be great, but my BP is still inching back upward. I know it's just a matter of time until my p-e progresses to the point where we need to deliver... I hope I can just make it a bit further so the baby doesn't have to go to NICU.

Thank you! Your insights really helped.

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