Sunday, October 31, 2010

Birth Story #2: Braveheart


My second son was born at 10:25 p.m. on October 22, 2010.

The story actually begins well before the birth itself. In fact, it really begins in September of 2008 when I found out I was pregnant with my first son, but maybe that's a different, longer story about motherhood. We'll just start a couple weeks from this baby's birthday.

My doctor first suggested induction at my 38 week appointment. It was actually a question: "When would you like to schedule it?" I was unprepared for the question, since I never intended or wanted to be induced. So I deflected and bought myself another week. At my 39 week appointment, we scheduled the induction for 2 days past my due date, but I was still not resolved to do it. I kept just hoping I would go into labor on my own.

The night before my scheduled induction, after all sorts of "natural" induction methods had failed, Jenn called and wanted to make sure that I was comfortable going forward with a pitocin induction. I wasn't, so her call forced me to the point of fully accepting whatever choice I made. I even spoke with my doctor the next morning - the morning I was supposed to show up for my induction - and he (without his typical warmth) affirmed that the choice was, in fact, mine (but that he had already made enough of an exception for me by letting me go to my due date and did not approve of my hesitation). Still unconvinced by his heavy-handed warning about the statistical doom that awaited my child and my pregnancy, I told him that he may or may not see us at the hospital in an hour.

After a three minute discussion with my husband, we decided to go for it (in reality the conversation had been ongoing for weeks and involved many more people than this, but for the sake of brevity, I must cut it off here. Will post more on that discussion later). So we hopped into the car.

We arrived at 8:00 a.m., were admitted, and met our nurse. And after meeting our nurse, I knew that God had prepared this ahead of time for our good. We had a lot in common, and she seemed very excited to help us bring our baby into the world. We even invited her to our son's anticipated baptism.

The pitocin started at 10:00 a.m. I was already dilated 4 cm and 90% effaced, but had similar stats at the beginning of labor with Symeon, so I was not convinced that this didn't have the potential to be a 24-hour ordeal. Contractions gradually gained regularity and frequency, but were weak. I wasn't doing any real work. We read, checked e-mail, talked with each other and with our nurse. We were pretty excited to meet our little man, but I was having doubts about how it would all go down. One bit of luck I had is that one of the residents did an ultrasound before they started the pitocin and she was able to print a picture of my baby for me...and his eyes were open! I can't tell you how much it helped to get me excited to be able to look at a picture of my baby during these waiting moments.

Around 5:00 p.m., I was maxed out on pitocin with not a lot happening. My doctor checked me and I was "5-6 centimeters." In plain English, that means I was probably closer to 5 cm but they wanted to make me feel better about my progress. He wanted to break my water but I wasn't ready. I was still not convinced that I was actually in labor, and if I was, I wasn't sure I was ready for the intensity that would likely follow an amniotomy. I asked them to wait. He stripped the membranes, grudgingly agreed to wait, said he was going home, and told me to let the residents know when I was ready.

Over the next two hours, the contractions became more intense (but I was still talking through most of them). Now I knew I was in labor, so the only obstacle to them breaking my water was whether I was ready for it to go quickly and get hard? After some deliberation, my husband and I decided it would be best to have them break the water.

At 7:30 p.m., when the resident went in with the amnio hook, I was still only "5-6 centimeters." Which meant that no measurable progress had been made. Still, I knew I was really in labor now, and I was emotionally ready to get to work and meet my baby. These are not measurable indicators, but it was still extremely important progress.

Within one or two contractions, the intensity came on strong. I was still on the maximum pitocin dose, so our nurse began to turn it down. After another half hour, I asked her to turn it off, since I did not have ANY break in between my contractions and really needed some time to recuperate. Half an hour after the pitocin was all but removed, I had the peace that I needed in between contractions, but they were still fast, long, and strong. I told my husband I wasn't sure how much longer I could do this. He told me I was doing great.

At 9:30 p.m., I was feeling a lot of "pressure." The experienced reader may understand the difference between "pressure" and "urge to push," but I sure didn't, and thought maybe I was ready to give it a go. I asked the resident to check my dilation, but I was only at 7 cm. Oh, wow, did that news hurt. Like, even more than the contractions did. She told me to continue to try to breathe through the contractions, since my cervix was not really ready to let my baby through.

My pleas for pain relief became more urgent. Thank God that neither my husband nor the nurse believed me when I said I couldn't do it. My husband reminded me that an epidural could make it take even longer, I was already so close, and as much as I wanted to avoid the pain, I mostly just wanted to get it over with and meet my son. So I metaphorically gritted my teeth (but in fact tried to relax my jaw, like all advocates of natural childbirth recommend!), remembered Bradley's advice ("5 more contractions"), and offered my pain to God.

Within 30 minutes, I grabbed my husband and said with urgency: "Tell Jen [our nurse] I can't not push anymore." With calm that did not mirror my urgency, I heard my husband whisper quietly to Jen. "Beth told me to tell you that she can't not push anymore." It made me chuckle because I was fairly certain that neither of them comprehended immediately what I already had: that THIS was the urge to push, this baby was ready to be born now and I was ready to assist.

Jen came over and checked my dilation and lo and behold! I was fully dilated after only 30 additional minutes! I quickly absorbed the good news, which I had intuitively surmised already, and with my next contraction I pushed hard. "OK, I can see baby's head, so I'm going to go get the residents."

Pushing felt good, but getting the baby out did not. Just 20 minutes later, at the very end, there was a lot of screaming and "ow, ow, ow, ow OWWWWW!" My husband said it was hard to watch me in so much pain and he even shed a few tears because of it. But every woman who has ever been there knows that there's no turning back. So you give one last big push and welcome to the world, baby!

He weighed in at a whopping 9 pounds, 8 ounces and 22 inches long. Everyone exclaims what a big baby I have and wow, that must have made labor hard? I laugh and tell them that the size of the baby matters very little to me - as far as I'm concerned, it's probably going to hurt whether you push out 6 pounds or 9 pounds - the biggest obstacle to pushing out babies for me is my own anxiety about it. And I'm not just talking about anxiety over the pain of labor, I'm talking anxiety about being a mother, a parent, responsible for one more new life plus holy living, even after your crankiest, most sleepless nights.

My blood sugar was right around 110 at delivery, but sky-rocketed shortly afterwards. I suggest you keep a close eye on it while pushing, because that's when mine rose last time around, too. It's just that this one came flying out so fast that my rising blood sugar didn't have time to affect him! His was 63 at birth and dropped down into the 40s over night, but his condition was stable and no supplemental feeding was necessary. Breast-feeding has been a huge success.

That being said, I highly recommend a second child to any one who experienced a lot of anxiety with their first. I can't believe how much fun I missed out on during the newborn period the first time around! Labor was faster, recovery has been much easier, and my perspective on babies and being a mother is larger, longer, and growing every day. And I'm sure loving the baby snuggles...

Sunday, October 24, 2010

Mom and Baby Doing Great!

More good news from Beth today... She and baby are home and doing well. Baby is nursing well and baby's blood-sugars have been just fine since delivery!! What wonderful news!

Induction was successful and Beth delivered with out any pain medication as she wished!

So thankful to pass on great news from Beth! ~jenn

Saturday, October 23, 2010

Baby's Here!

I know that many of you have followed Beth's story as she has carried her second child and wanted to let you know that as of 10:25pm, last night, she has a healthy baby boy! I haven't heard her story just yet and am so excited to over the coming days! We are praising the Lord for a healthy baby today though! Congratulations, Beth! ~jenn

Friday, October 8, 2010

Induction

So, here it is. This is the post where all my unresolved issues about the risks of induction compared to the risks of stillbirth come out.

My doctor asked me on Friday, at 38 weeks and 2 days, whether I wanted to be induced Wednesday or Friday of next week. Um, is neither an option? How about I go into spontaneous labor before then. That would be great. Yeah.

I was actually surprised by his recommendation, since at my first visit I had thought he was OK with me going to 41 weeks. My first son was born at 41 weeks. Last week, I thought I heard him he wanted to induce at 40 weeks, but I chose to ignore it and assume I had misunderstood, and see if he brought it up again this week. But today it was 39 weeks, and well, that surprised me. I used the "I need to talk it over with my husband" line to give myself some time to think and avoid an awkward, flat-out refusal (to be fair, I have done some serious thinking about it today).

So that brings me to the most important point, which is, why is it that doctors recommend induction for pre-gestational diabetics at 39 weeks? Nothing has changed about my health since I recovered from the migraine at 35 weeks. Blood pressure is slightly high but within an acceptable range. Blood sugars are great and stable. Baby is moving and growing. So what gives? Well, a lot of you probably know that epidemiological studies have shown an increased risk of stillbirth in pre-gestational diabetics. To boot, the risk of stillbirth also increases with gestational age beyond 37 weeks. Statistically speaking, it is more likely that my baby will die before he ever takes his first breath.

So some of you might then ask, why are you complaining about being induced? Seems like a no-brainer for something as serious and terrifying as stillbirth. Well, not so fast. A patient-friendly Mayo Clinic site describes the risks of induction, which include increased risk of fetal distress (due to unusually strong, long, and frequent contractions on pitocin), increased risk of c-section, greater risk of maternal or fetal/newborn infection, and risk of umbilical cord compression. More and more caregivers are recognizing these risks of induction. And while none of these seem all that bad compared to stillbirth, any of these risks may result in further complications or interventions that hurt me or my baby and may impair my ability to have more children in the future. Unfortunately, the possibilities for problems associated with these interventions are endless, which is why standard protocols such as "induce diabetics at 39 weeks" don't always serve mom and baby best.

So I'm trying to process all of this stuff for myself, and decide which risks I am more comfortable with, and which risks apply to my situation. Here's what I discovered.

RISK OF STILLBIRTH FOR PRE-GESTATIONAL DIABETIC WOMEN

This study, published in 2003, describes the rate of stillbirth in 130 pre-gestational diabetic births. Twenty-five ended in stillbirth, which is a rate of 19.7%. That is almost 4 times higher than the rate of stillbirth in a normal, non-diabetic population, which I read elsewhere as hanging out around 5.5%. Several notable things about this study, should give us some hope about our chances:

In half of the stillbirths, the cause was explainable. Fortunately, it was not a complete mystery why some of these women lost their babies. And furthermore, some of these situations may be preventable and/or detectable. Fetal malformations would likely have been detected at a 20-week, comprehensive ultrasound and possibly at growth ultrasounds after that (which are both recommended for diabetics). Intrauterine growth retardation can also be detected by growth ultrasounds, maternal weight gain and fundal height measurements. Ketoacidosis can be prevented by maintaining good, tight blood sugar control. Chorioamnionitis (infection, usually occurring after rupture of the membranes) can be prevented and monitored for, by limiting vaginal exams and cervical checks after the membranes have ruptured and keeping a close eye on mom's body temperature. Tobacco use is apparently associated with placental abnormalities, and those caused some of the other stillbirths, so not smoking may be another way to keep the risk of stillbirth at bay.

The women who experienced stillbirth had suboptimal health compared to the women who did not. Examples of suboptimal health included maternal obesity, smoking, and poor glycemic control. I've got a leg up thanks to nutritional habits I've learned, the terror of tobacco instilled in me from childhood, and an insulin pump (isn't modern medicine awesome sometimes?).

RISK OF STILLBIRTH FOR WOMEN PAST THEIR DUE DATE

It is actually quite common for doctors to recommend that even low-risk pregnancies don't go past 41 or 42 weeks, and for them to recommend induction at that point. This research debate, on the issue, from the year 2000, is quite informative about the risk of stillbirth in women whose pregnancies last until late-term and beyond their due date.

I am not entirely sure, based on the highly technical discussion, but I think that one point made here is that more pregnancies end in stillbirth between weeks 24 and 38 than between weeks 38 and 42 or 43. Which means that I am patting myself on the back for making it to 38 weeks without losing my baby, since my risk of stillbirth is reduced by this mere fact.

The other thing I learned from nosing around in the debate is that the risk of stillbirth increases most dramatically between 40 and 41 weeks. The risk of stillbirth increases from 0.2-0.4/1000 births to 1.2/1000 births during this single week of gestation (I think this is usually presumed to be from placental insufficiency...it gets kind of old and stops supplying the baby with nutrients).



So where does all this research leave me? Well, unfortunately, no one can tell me with certainty whether my baby will live or die, and no one can even tell me with precision what the risks of induction versus the risk of stillbirth is in my particular situation. Ultimately, I think I have good reasons to refuse induction or proceed, and I will just have to make the choice I am most comfortable with. I feel good that I have successfully delivered one healthy baby at 41 weeks, I feel good about the fact that I am generally in good health, including blood sugars that are well under control, and I feel good about the fact that I have already made it to 38 weeks. On the other hand, I respect my doctor and don't want to take a risk that is simply motivated by fear of the unknown (multi-faceted risks of induction and consequent interventions).

I guess all I can say is that I have some more thinking to do. Happy to entertain your thoughts, if you have any you'd like to share. Um, and not that anyone would take the blogosphere this personally, but just don't be offended if I decide not to follow your advice.

Wednesday, October 6, 2010

Saint Gianna Beretta Molla

I have recently read about the life of Saint Gianna Beretta Molla, canonized according to the Catholic Church in May of 2004. This woman gave the ultimate sacrifice - her life - to preserve the life of her child. You can read about the exact circumstances of her fourth and final pregnancy, after and because of which she died, here.

As diabetics, on average, pregnancy is harder for us. But we do it anyway because having a baby is an incredibly good thing. As a diabetic with good modern medical care, the sacrifices that I take on may never involve the sacrifice of my very life, but it will always involve smaller ones. These sacrifices are sure to include the inconvenience of checking my blood sugar every 2 hours, in the middle of the night, and any other time I feel like I need to; denying myself certain indulgences; going to extra doctor's appointments; exercising; bringing food with me everywhere to avoid lows; and even risking unknown long-term consequences to my health. I only hope that if it does involve as much as the sacrifice of my life, I will offer it willingly for the one(s) I carry within me, as Saint Gianna did.

So, the next time I feel like complaining about how hard pregnancy is, even if I decide to whine about it anyway, I will remember and be encouraged but the woman that sacrificed her whole life for her baby!

Tuesday, October 5, 2010

Blood Sugar Management During Delivery

When I gave birth to my first son, I had basically managed my blood sugars throughout the whole pregnancy, so it made sense for me to do it during delivery, too. I don't think my doctors even suggested otherwise. My husband helped me by checking my blood sugars every hour, and they let me drink apple and orange juice to keep it elevated when necessary. Unfortunately, my blood sugar rose during the pushing stage and was around 180-200 when I delivered, so my son was slightly hypoglycemic despite my best efforts. I attribute this rise to the extreme effort I had put forth and the extreme stress my body was under for so long on very little fuel (about 30 hours without eating).

Now that I am in a new city with new doctors at a different hospital, I am once again faced with the decision about how to do blood sugar management during delivery. If I don't do it myself, I will be on an IV glucose drip and IV insulin, administered by someone else (nurse or doctor?). Has anyone had a positive experience doing things this way (e.g., achieved better blood sugar management this way than if they had done it themselves)?

I'd like to do it again myself because I think I know myself better and will be able to respond to changes in my blood sugar more rapidly than a team of doctors and nurses that haven't lived with my diabetes every day for the last 17 years and two pregnancies. I won't have to wait for the nurse to come in to check my blood sugar or give insulin (since they have better things to do and don't always have time for it when the floor is active!). This time, as compared to last, I will be more vigilant when I see my blood sugar start to rise, and give higher boluses a little sooner to prevent the high from happening. As long as I can still drink Gatorade or juice, I should be OK even if I trend low. I will also try to eat at least a small meal before I go to the hospital and hope that I am not in labor very long after that! I might consider IV glucose and insulin only if I am nauseated and can't keep anything in my stomach.

I am learning that the more and more I rely on someone else to tell me what is going on with my body (e.g., why are my blood sugars doing this?), the more often I am disappointed. There are too many things about diabetes that we still don't understand, and every individual is too unique to explain according to the epidemiology. My experience has taught me that careful self-observation has led to the best results, since I am the only person in the world with my entire blood sugar management history in my brain. And sometimes that involves going with my gut, which even care based on the best epidemiological studies doesn't accomodate well.

Would love to hear if your experience during delivery has been different.