Wednesday, October 24, 2012

Baby III Week 24: Danger

24 Weeks

I changed my hair this week, we went purple! I feel like my face is starting to get puffier so I thought darker hair would be more slimming... or distracting.

Robin Smitherman at Platinum Salon in Monterey is a magician, or of the devil... her skills are simply not of this world.

Baby is so active, I love it. When I'm busy and don't notice him or her for a while it freaks me out, I'm so used to almost constant movement!

I weigh exactly the same this week as I did at 24 weeks with Ash, only I've gained 21lbs and not 11lbs. It's weird, I've actually been gaining almost the same number of pounds each week as last time for the last month. My mom said that no matter what weighed she started pregnancies at she pretty much ended up at the same weight. Maybe that's happening.

I wish I was able to run more, or at all, I miss the definition in my legs. But I'm still able to keep up at nearly the same pace at kickboxing. I just tried piloxing, and loved it. It's pilates and kickboxing. I wish I could go every week... but with work it's almost impossible. Maybe I can find some piloxing youtube videos or something!

We likely have about 14 weeks to go. We still don't have a boy middle name locked down. Eric seriously suggested Danger last night. Suggestions very welcome. Please no one back Eric up on Danger.

Baby is about 12 inches long an weighs around 1.3lbs, approximately cantaloupe sized according to my sources.

Tuesday, October 23, 2012

The VBAC conversation I keep replaying over and over in my head

I don't have time to write this. This is stupid. I have tons more coursework to complete before my Birth Boot Camp certification in 15 days, and if I was going to write this post I should put a lot more time putting together statistics and studies, but I can't concentrate until I put this out here.

Last Saturday I received the text I have praying for: my friend is in labor. I've needed one more birth to observe before my BBC certification and her's was my last hope! She labored at home, we met at Salinas Valley Memorial Hospital, I got there and she was already pushing. Her sixth baby and first natural delivery. She did amazingly.

I was also thrilled with the attending OB, my OB during my first pregnancy and still the doctor I choose to see for all gynecological appointments, Dr. Gilbert. He didn't deliver Milo, but I've heard such wonderful things about him in the delivery room and I was glad to finally have the opportunity to see him work. I wasn't disappointed, he taught through much of the birth, pointing out the baby's unusual cord, the hand delivering up by her little neck, and the aspects of the placenta. I love his personality, but then another of those moments happened that reminded me while I don't deliver with this practice or that hospital.

A comment was made about me heading up to Santa Cruz for my birth, I mentioned that I actually think I will be going to Natividad.

"Just so you know, they say you can have a VBAC, then there tends to be some reason why you can't."

"I'm not having a VBAC (he seems to always forget that I delivered a 10lb baby vaginally, as if it cannot be done), but a 40% VBAC rate is better than 0%."

Cue the uterine rupture story.

I'm curious how many local women have heard this story, Gilbert has told it to me at least twice now. It's extremely sad, I don't want anyone to think I'm trying to lessen this incredibly tragic event. An OB from CHOMP was attending his daughter's VBAC in the bay area. Her uterus ruptured, she was rushed to surgery, the baby died. This has happened once at SVMH as well.

No disrespect is meant to the families who experienced loss in these scenarios, but this is like reminding someone about 9/11 when they are getting on a plane... these events are incredibly rare.

"The risk of rupture during a VBAC is less than 1% (actually 0.47%)"

"It may seem rare, but 1 in 100 babies is too much, all those babies add up."

I didn't want to start a debate in the delivery room while a mom bonds with her new baby, but I was stunned, and so upset, all at once. Did he really believe VBAC was that dangerous, or did he feel obligated to support the hospital's policy of not allowing VBAC (as nurses listen in) by playing up the risks and playing down... the truth? One in a 100 babies? Who has reported those kinds of perinatal mortality (death of a baby around birth) rates?

The perinatal mortality rate for VBAC is reported to be 3 out of 10,000. (The Thinking Woman's Guide to a Better Birth by Henci Goer)

The risk of infant death after a repeat, planned cesarean just like they do every single day at Salinas Valley Memorial Hospital and Community Hospital of the Monterey Peninsula, is 3 out of 10,000.

I've found less conservative estimates too:
"The risk of neonatal death from cesarean section was found to be nearly three times higher than from vaginal delivery." Marian F. MacDorman, Eugene Declerq, et al., Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” 33 Birth 175 (2006). 
The way it was being presented, there was no risk to cesarean, and this is not the first time cesarean has been presented to me in this light from an obstetrician at Healthcare for Women. Not even the third time. I wonder what mothers needing accurate, unbiased information are getting? Not only do routine planned repeat cesareans not protect the baby, they put the mother in considerably more risk of death:
"The risk of maternal death from cesarean section is higher than for vaginal birth (in one study, four times higher), the rate of maternal complications is significantly higher with c-sections, and long term risks must be considered." Zelop & Heffner, The Downside of Cesarean delivery: Short- and Long-Term Complications Clinical Obstetrics and Gynecology, Vol 47, No. 2, June 2004, pp. 386-393.   
"The risks of severe maternal morbidity associated with planned cesarean delivery are  higher than those associated with planned vaginal delivery." Shiliang Liu, Robert M. Liston, et al., Maternal Mortality and Severe Morbidity Associated with LowRisk Planned Cesarean Delivery Versus Planned Vaginal Delivery at Term, Canadian Medical
Association. Journal. Ottawa: Feb 13, 2007. Vol. 176, Iss. 4; pg. 455.
A meta-analysis cited in Optimal Care in Childbirth by Henci Goer that included 380,000 women, at term, showed that 9 more women out of 100,000 died by opting for the planned repeat cesarean. A very large study showed that 21 more women out of 100,000 died. Not 21 out of 100,000... 21 MORE women died.

These are repeat cesareans, that means the mothers die leaving behind other children.  The complications associated with cesarean are so incredibly real yet are so consistently ignored. I'm so confused by educated, intelligent people who deny and downplay them, people that I like, that I want to recommend.

Truth be told, the nursing staff at SVMH were wonderful during and after the birth. The OB delivering did a fantastic job... but nothing went wrong that would require the mother to trust the judgement of the staff or her doctor, that's when having the best care counts. Considering that this practice and this hospital are not basing their VBAC policies on what is safest for women or babies, I'd be afraid to be in their care, even if I'm birthing with an unscarred uterus. They are either ignoring or not informing themselves in the science, studies, statistics, facts... of repeat cesareans; what else are they ignoring or have outdated information in? That makes me scared. It frustrates me that this information is there, the stories of hundreds of thousands of women... but they keep passing this one horror story on to women turning to their doctor for information they need to make a truly informed decision not just about their birth experience, their health, their future fertility, but about their LIFE, and their baby's life.

This keeps me up at night. I've considered writing letters, passing along books and studies... maybe when I'm done writing papers and working through this pile books and studies I'm required to read I will. There's just a slight nagging "I'm just one person, I'm not a doctor, I'm just a (perhaps overzealous) student, what will people think of me?" in my head.

Back to work.

Tuesday, October 16, 2012

Baby III Week 23: As long as we're pointing fingers...

23 Weeks

Body stuff: It's getting fat. That's all you really need to know. My wideness in particular has been commented one THREE times this week.

Birth stuff: I had a prenatal appointment with my midwife this week. We went over my birth plan to make sure it wasn't too hardcore. I'm not trying to be an asshole or control freak in the delivery room... but my births are like my Super Bowls and every aspect is exciting and super important to me. It's not just about the end result, it's the whole experience, and I'm running through plays and little details because I love it, and I'm so stoked, and I'm so worried that my enthusiasm comes off as obsessive. Also, because in the past my "we prefer..." and "if possible..." requests were ignored, I definitely used stronger language just because I want it clear that I am an informed mother capable of being an active participant in the birth of my baby.

My midwife agreed it was a great tool for interviewing a potential OB to make sure my expectations matched both his practices and hospital protocol, but to cut it down some for the nurses on the birth day... and I agreed.

Wait... back up... potential OB? Yes, I've been considering straying from the CNM that I love, and the hospital that I also love, to birth in Monterey County. I know that I will probably have a wonderful experience at Dominican, but I know using an out of county hospital is a bit of a protest. You are a consumer when you are choosing a hospital. I don't like the service/product that Salinas Valley Memorial or Community Hospital of the Monterey Peninula provide and I will not give them my business even though, I know that because I'm prepared, I could have a good birth, I just may have to fight against policy. However, over and over I kept hearing about Natividad Medical Center... I always had this article, The Holistic Hole, in the back of my head. The OB's and nurses are working so hard (and the hospital is spending so much money) to provide evidence based care that is better for mothers and babies than what SVMH and CHOMP are providing (whose approaches are better for the staff/ hospital/ insurance co.). What kind of birth advocate would I be if I'm here calling out the hospitals to make these changes, but then I don't support them with my business? A bit of a hypocritical one.

In addition to my own personal conviction about where I was birthing, I also wanted to see if all the hype was true. I didn't like the idea of telling one of my students "I hear Natividad is the place to go," when I myself was not taking that advice. I much prefer being able to say "I've birthed here, here and here... this is what my experienced were."

So yesterday I had my appointment to have a consultation with Dr. Chandler, who practices in the hospital. I was shocked by how nice the hospital is. I didn't get a tour of the rooms, but everything else that I saw was as nice if not nicer than SVMH or CHOMP. The wait was long, but well worth it. When I walked in a passed a purposeful looking doctor that I just got a good vibe from, I kinda hoped that was Chandler. It was. He and a resident came in, unfortunately after an over hour long wait and the babies were on the brink of meltdowns.

If you've read a book on birth, you've probably read a list of questions that are suggested you ask a potential OB. I've never been a big fan of those lists, I tend to feel like the answer you want shows a little... like... "What is your c-section rate?" You are basically saying "I'm about to judge you on a number that is determined by about a bazillion factors that may or may not have to do with you as a caregiver... choose your answer wisely." Who isn't going to feel defensive? I put together a list, though most of these were just answered in conversation. I decided if we made it through this list and I didn't feel like the doctor was silently hating me, I'd pull out my birth plan.

Is it hospital policy to have an IV or hep-lock, can the mother waive either?

Does the hospital require a blood draw/bank?

Is it the hospital’s policy to requite continuous fetal monitoring? Are there telemetry devices available?

Is fasting during labor required?

Are there showers or tubs?

If my water breaks at home but contractions have not started, what are my options?

If the baby seems to be in distress with no other no other signs of complications, what actions do you take?

Who can I have in the room with me? Photography or video allowed?

If the baby is discovered to be breech, what options are available to me?

Can I deliver in an upright or semi-upright position?

Can I or my husband assist in catching?

How often do your patients require episiotomies?

When do you use forceps or a vacuum, do you require an episiotomy?

How do you manage the third stage?

Is delayed cord clamping an option if there are no complications?

If I require a c-section, do you manually dilate the cervix.

Of course I have personal feelings on all these points, but I tried to word questions so that whoever I'm interviewing wouldn't feel challenged, or blamed, like "how often do patients require episiotomies" vs "how often do you do episiotomies."

I made it to most of the questions and was super impressed. I never felt like Chandler was defensive or judgmental. Two doctors can say "you don't have to have continuous fetal monitoring" but one can make you feel like they are tempted to call CPS on you for it. I can sense a stifled eye roll!

I handed him my birth plan, prefacing that this wasn't what I planned to bring to the hospital, but that it would help me decide if I had found a good match. I said I wasn't trying to order spaghetti at Chinese food restaurant and I totally understand if these needs can't be accommodated here.

Here it is:

Gentry Family Birth Plan

Thank you for allowing us to summarize our wishes for the birth of our third child. We are experienced in birthing naturally, we believe this is the safest method for the mother and child. Thank you for helping us in achieving our goals.

Labor Wishes in Stage 1

·         IV Fluids – We do not consent to routine IV fluids. The mother experienced significant edema in her first delivery which complicated breastfeeding and caused considerable discomfort during the initial bonding time. The excess fluid in the blood stream can dilute oxytocin, slowing labor, dilutes the concentration of red blood cells potentially leading to anemia, decreased oxygen to the uterus and baby, and possible excessive bleeding in the third stage. If at any time fluids are necessary, please consult the parents before taking action.

·         Hep-Lock – We understand having a hep-lock in place is often standard procedure and that hemorrhage or dehydration can complicate getting vein access in an emergency. We still do not consent to having a hep-lock in place during labor and will sign a release if necessary. The mother suffers from vasovagal syncope and reflex anoxic seizures in response to needles and labor is not a time to be coping with either. IV’s have also caused considerable discomfort and bruising. We have successfully labored without a hep-lock in place.

·         Continuous Fetal Monitoring – We do not consent to continuous external or internal fetal monitoring; intermittent monitoring has been proven to be just as effective. The use of continuous fetal monitoring has shown an increase in instrument and surgical delivery without an improvement in fetal outcomes.

·         Fetal Distress – In the case of a nonreassuring pattern during intermittent EFM without other obvious signs of an emergency situation (excessive maternal bleeding, cord prolapse), we ask that a fetal scalp blood sampling is done before cesarean is considered.

·         Vaginal Exams – We prefer vaginal exams to be used minimally. If membranes have spontaneously ruptured before the mother has the urge to push, we may not consent to any vaginal exams to prevent the risk of infection in a prolonged labor.

·         Augmentation of Labor – We do not consent to the use of Pitocin in the first stage of labor. Pitocin causes the uterus to contract longer and stronger than natural oxytocin causing more pain for the mother and may deprive the baby of oxygen. Prolonged use can contribute to postpartum hemorrhage in the third stage. We are informed in natural methods to strengthen contractions, however we also respect the natural flow of labor which occasionally includes plateaus. We do not consent to active management of labor.

·         Artificial Rupture of Membranes – We do not consent to the artificial rupture of membranes. Amniotomy can increase instances of abnormal fetal heart patterns, some studies show that early amniotomy can increase cesarean rate by 20%, and vaginal exams after amniotomy can lead to maternal infection. Labor is less painful with intact membranes. If membranes remain intact in the pushing stage we ask they remain so until the birth of the baby’s head at which time the membrane can be removed.

·         Food and Liquids by Mouth The mother does not wish to have food/liquids by mouth restricted while in labor. We understand the reasons this is often hospital policy is to avoid aspiration if an emergency cesarean is necessary. However, fasting during labor does not guarantee an empty stomach or that the mother will not instead aspirate stomach acid. Fasting during labor can cause maternal ketone levels to rise, can cause unnecessary discomfort during labor and may negatively affect labor progress.

·         Pain Management – Please do not offer any form of epidural or narcotic pain relief during labor. Both pose serious risks that we are not comfortable taking during labor. The mother wishes to be able to move freely and have access to shower/tub if available.

·         Residents & Students – As long as they do not cause any unnecessary noise or distraction, we welcome residents & students to see a natural birth in progress.

·         Photography & Video – As long as is it does not interfere with the birth and there are no emergencies, we would like to have a close friend present to video tape and photograph the birth.

Labor Wishes in Stage 2

·         Pushing Positions – The mother would like to push in whatever position is most comfortable to her at the time. This mother’s experience has been that the lithotomy position increased the pain of contractions and made controlled breathing (and therefore pushing) more difficult. The lithotomy position can reduce blood flow to the baby, narrow the pelvis, and increase instances of tears. We will likely choose a semi-sit/squat position.

·         Mother Directed Pushing – The mother will push with urges.  Please do not count out loud for her, the father/coach has been trained to coach the mother’s breathing and pushing. Please offer us a mirror if available, and the mother would like to be reminded to touch the baby’s head at crowing if possible. She loved encouragement, but please no “get angry” or “push like bowel movement.”

·         Episiotomy – We do not consent to an episiotomy, which can increase instance of perineal injuries and blood loss. We would appreciate the birth attendant try perineal massage, support, oil and warm compresses to assist in the birth of a large baby. If a forceps or vacuum delivery is necessary we ask it’s done without an episiotomy.

·         Delivery – If the delivery is uncomplicated, the father may like to assist in catching the baby, we greatly appreciated this offer by the birth attendant in our previous hospital delivery. We do not know the sex of the baby, the father would like to announce it.

Labor Wishes in Stage 3

·         Immediately Following Birth – We want our baby placed on the mother’s chest for skin to skin contact, even before the cord is cut. Any routine evaluations can be done on the mother or be delayed. If complications prevent the mother from having skin to skin with baby we ask the father takes the baby for skin to skin instead.

·       The Umbilical Cord – Please do not clamp the cord until the cord has stopped pulsing. Delayed cord clamping has positive effects on fetal iron stores, total red blood cell volume, and postpartum fetal blood pressure. The father would like to cut it.

·         Breastfeeding – The mother wishes to nurse her baby immediately. Breastfeeding stimulates oxytocin production which is aid in the delivery in the placenta and stop postpartum bleeding.

·         The Placenta – We do not want the placenta, but we would like to see it and take pictures of it.

Newborn Care

·         Rooming – We would like a private room. We want all medical procedures done at bedside. If our baby does need to be taken away for any reason, one or both of us would like to accompany him. We want our hospital stay to be as short as possible.

·         Eye Ointment – We would like eye ointment to not be applied until the end of the first hour after birth. We want erythromycin to be used, not silver nitrate.

·         Bottles & Pacifiers Please do not offer any bottles to the baby without parents' notification of a medical need. No pacifiers or artificial nipples please.

·         First Bath – We do not want our baby bathed.

·         Circumcision – If we have a son we will not be circumcising him.

Thank you for taking the time to help us achieve a natural childbirth for our third baby!

It went so well. Only issues, apparently fetal scalp blood sampling isn't really done anymore... so once again I made myself look a little dumb by having old information. Totally not as bad as the enema encounter at SVMH though. Also, they don't like video of the actual birth, like SVMH. I think we can work with that, but I will be bringing it up again because I really want that moment that we find out if we have a little boy or girl recorded.

I hope this wasn't all too good to be true, because honestly so many of his comments were shockingly fantastic. He asked if I had a doula and when I said no said "we really like our mothers to have doulas, but it shouldn't be a problem, you sound well prepared." He was totally fine with me delivering in whatever position I wanted (ie, not on my back). He mentioned having wanted to attend the recent Midwives Alliance of North America conference that I went to and that he recently watched and loved The Business of Being Born. Part of me wondered if he was reading from the "in case of natural mama" script... but with so many people saying to many wonderful things, I think this may be the real deal.

So, I think I'm sold. I still need to tour the hospital, but I feel really good about all this.

Here's my 23 week pic, all ready to go celebrate 5 years of marriage with Eric

Baby is grapefruit... or giant onion sized.

Monday, October 8, 2012

Baby III Week 22: Mid-pregnancy Nest Fest

22 Weeks

I'm on turbo drive and it's a fantastic change of pace from beached whale drive.

I decided that the bathroom neeeeeeeded to be remodeled before this baby gets here... most importantly, that it's demolded. It's gross, there's mold under the disintegrating sealant in the shower and the moldy walls are literally crumbling into the tub below. We typically would take on this job ourselves, but with Eric working so much there is no time, so we called Skip Wilcox at 3W Builders. I know his wife, they are super cool people, and I like giving business to cool people whenever possible.

So Skip comes out and we show him the bathroom, and decide as long as he's here, we'll show him the kitchen which needs to be done some time in the future. About 5 minutes into the conversation I decide the kitchen has to be done now. Like... can we demo tonight? It really makes perfect sense, my daycare is down to one kid until December, I don't have a newborn, the project should take 6 or so weeks...

I also show him where we want to move the laundry into the hall from the garage... it's If You Give a Cori a Cookie all over again... and yes I was pregnant when I posted that one... and yes I got my new front door.

Skip leaves and I'm pumped, because seriously, our oven could burst into flames any day now and occasionally our range actually does. Eric is less so.

Now I'm the more frugal one in the family, so don't start thinking I'm one of those wives that goes crazy with my husband's money. Last night I had a significant meltdown in Costco because our tv broke, it would be $400 to fix it, and Eric said it would be $500 to get a new one of the same quality. So I think, new one for just $100 more, duh... Eric hears "new" and goes for the $1500 tv, which is his reasonable compromise tv by the way... He's shocked I'd consider the $500 (it's actually $599, so he falsely advertised it to me) tv and make us "suffer with a shitty tv" for another 7 years, I can't believe he wants to spend $1500 on a tv, which we have zero time to watch anyway, and does not serve any kind of truly important role in our family esp when we have an oven in menopause that seriously cannot make it through a batch of cookies without a hot flash. That tv is an oven and a half of a new fridge!

We are getting the cheap (cheaper, I don't think $600 is cheap) tv.

Back to after Skip leaves though. So Eric is skeptical over doing the kitchen, he is the one that sees our bank account after all... and he also is the only one who has seen it since we bought his new car (2008 Prius! Just in time for gas to hit $4.50). We went over what we have saved and I think we have a plan. Normally we try to pay cash for everything, so we take out of our savings and then replenish it, and since Eric should be working for a while, that should not be a problem. However, things happen, and I can see why he is concerned with taking out too much so I think to be super safe we are going to get a loan from our credit union, which should thrill the loan guy there because he loves Eric, he even stops him at Wal-mart to talk to him. Eric's charms are irresistible to all.

So now we are both happy and I can satisfy my need to prepare my nest. Some women paint and hang curtains, I rip out walls. It will be awesome.

In the meantime I am cleaning like crazy. I was cleaning in the garage until 1am. We are having a garage sale this weekend, purging is a big part of pregnancy for me.

So I think I'm up 4lbs from 20 weeks, kinda following the same pattern as the last pregnancy, it's not awesome but considering that I was training for a 10k last time and right now I'm not doing much more than walking, I feel good that I'm not gaining more. I guess no matter what my body just wants to gain in a certain pattern, which is kinda interesting.

Baby is a papaya this week. Fun fact, there are different kinds of papaya and some are very, very big. That's what Eric came home with... did he really think the baby was that big already? I should have held them both up so you can see the difference, but you can kinda tell how big the small papaya is, that's what I'm holding, then the comparison pic.

It's about newborn sized. Both are disgusting by the way...

Tuesday, October 2, 2012

Baby III Week 21: Surprises

21 Weeks

This week we got our ultrasound! We choose to go to Healthcare For Women for our ultrasounds because they have the best equipment and tech in my opinion. If there is anything wrong I'm confidant she will catch it. We would never go to one of those 3/4D ultrasounds that are done for entertainment purposes (those people are untrained, it's not considered safe, but it's not illegal), but it's an added perk that this ultrasound does 3D so we can get a better look at the baby's face. So meet Baby Gentry #3!

The ultrasound went great. Baby is measuring right on (a little big in the torso, we have a chunky baby) and everything looks perfect, even the placenta, which was a huge relief because my last placenta was huge with extra lobes and a velamentous cord insertion, all of which may have had to do with my postpartum hemorrhage+ after delivering Ash and the placenta. So, good news! 

No we don't know if baby is a boy or a girl, a few people (other than God and the baby) do though! My friend, Jasmine, that I visited in New York for her birth last month said I should send her what the baby is so she can make gender specific stuff for the baby (she sews, check out her shop, Cherished Style). Her suggestion was so crazy because for some reason I was thinking how fun and random it would be to send the results to her. I wont see her before the birth so I couldn't read it on her face, and she doesn't know my family so no one can get to her (though I realize they could always facebook harass her, don't please!). I love fun random things so I told the tech to write down the results and we literally drove straight to the post office and sent it before I could tear into it myself! I was afraid to even look in the direction of that little yellow taped up post-it. Jasmine didn't know that I had sent it, it was fun surprising her!

It will be fun to be able to bring whatever little gender specific thing she dreams up in a box and open it after the birth!

I had my first ever chiropractor appointment this week. He said I have inflammation in my back and now I've been icing. I feel a ton better... though I hate icing.

Baby is super active, his or her kicks feel like tiny little bombs going off that rumble my tummy, it's very different. Forgot to weigh myself, I say I'm probably up another pound or two though.

Baby is the size of a pomegranate, I guess we must be going by weight not length or something.