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88 3 WomanwithPregnancyComplications A Case Story In her fourth month of pregnancy, Mrs. Thor sought prenatal care at the midwifery clinic for the first pregnancy of her second marriage. A twenty-five-year-old woman, Mrs. Thor had lived in a Thai refugee camp for twelve years before coming to the United States with her family when she was fourteen years old. She attended high school for three years but did not graduate. She had a son from her first marriage who now lives with her ex-husband and his new wife. Three years ago she married her present husband, who is the youngest son of a large family, and they live with her husband’s parents. She and the family had been concerned about her apparent difficulty with becoming pregnant and they attributed this pregnancy to the successful combination of shaman ceremonies, Hmong herbal medicines, and Western infertility treatment including pills and shots. Mrs. Thor was dedicated to making her marriage a success and was excited about this long awaited pregnancy. Prior to coming to the midwifery clinic, Mrs. Thor sought prenatal care from an obstetrician. The doctor ordered five tubes of blood for a variety of tests, but Mrs. Thor refused, stating she was too weak and tired to have any blood drawn and she questioned why they needed so much blood. During the prenatal pelvic exam, the doctor wiped her cervix with a wooden spatula for a Pap smear and her cervix began to bleed. Seeing the blood, Mrs. Thor became frightened that the doctor’s exam was causing her to miscarry. Despite reassurances that the bleeding was not related to a miscarriage, she left the clinic concerned about the viability of the pregnancy and did not return. Afterward, on the advice of her sister, she sought prenatal care at the local midwifery clinic. There the midwife and Hmong nurse heard her story, listened to her concerns, and tried to reassure her that the examination had caused no harm to the fetus or to herself. They explained why a blood sample was desired and negotiated to draw a single ten-milliliter syringe of blood. They also recommended prenatal vitamins , but Mrs. Thor declined to take them, stating she did not want a large infant. A test revealed that Mrs. Thor had an elevated level of alpha-fetoprotein (AFP) and she was called by telephone and asked to come to the clinic for further testing. Hearing the nurse’s explanation that a high value may mean that the baby has a birth defect, such as a spina bifida, Mrs. Thor reluctantly agreed to a repeat blood test, the result of which was also high.A fetal ultrasound revealed no evidence of an abnormal 3. Woman with Pregnancy Complications 89 spinal formation and the midwives explained the option of seeing a specialist who could test the fluid around the fetus for genetic abnormalities (amniocentesis). Mrs. Thor and her husband were horrified at the thought of using a needle to draw fluid from around the fetus and declined to consult the specialist. Mrs. Thor did not keep her prenatal appointment at twenty-two weeks. One of the Hmong clinic staff called to schedule a new appointment and to ask whether she had any concerns. Mrs. Thor said she was fine and the baby was moving strongly. At twenty-four weeks, Mrs. Thor experienced labor pains every three minutes and called the clinic.At the clinic the midwife found that Mrs. Thor was in premature labor with regular contractions and her cervix was dilated to two centimeters. She was admitted to a hospital’s labor and delivery unit, where obstetricians took over her care, placed her on strict bed rest, and gave her parenteral medication to stop the contractions (tocolytics) and to help the baby’s lungs mature more quickly (corticosteriods). The next day she refused to receive any more medications because she was feeling quite ill, her contractions had stopped, and her cervix had stopped dilating. The doctors and midwives were very concerned about the welfare of Mrs. Thor’s baby and tried to explain the risks of pre-term delivery to her, her husband, her husband’s parents, and her father, who was visiting from out of state. Mrs. Thor’s father was the most vocal family member, explaining to the doctors that taking the medicine was unnecessary because his daughter’s contractions had subsided. He explained that he had helped his wife deliver six healthy children without any...

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