Thursday, May 31, 2012

The Feast of the Visitation, and a Happy Birthday!

Today is the Feast of the Visitation, when Mary went to visit her cousin, Elizabeth, prior to the birth of John the Baptist. You probably remember how John, the infant in Elizabeth's womb, leapt for joy upon encountering Mary, who was carrying Jesus in her own womb, as John's mother greeted Mary with the words: "Blessed are you among women, and blessed is the fruit of your womb!"

When my husband and I were received into the Catholic Church in 2010, I chose Elizabeth, mother of John the Baptist (also called the Kinswoman, owing to her blood relationship to Mary), as my patron saint. I wrote about it a little bit at Christmas time, but basically, what impressed me so much about Elizabeth is the following.

She was six months pregnant when Mary, her young cousin, came to visit. She was probably just starting to get uncomfortable. She was aware that the son in her womb was to have a special purpose in God's plan of salvation. She was probably spending most of her time thinking about that, because her husband had been struck mute, so she hadn't had much of a conversation partner for a while. She had been unable to bear a child all her married life, so she finally had the child she had desired for so long. She was of "advanced maternal age," which I can imagine means everything hurt just a little bit more than it would for an average pregnant woman.

And then her young cousin, Mary, comes for a visit. Mary comes to visit unmarried and pregnant. Besides her piety, the facts of Mary's pregnancy appear to completely one-up everything that is special about Elizabeth's. Elizabeth is pregnant with the Prophet of the Most High, but Mary is pregnant with the Most High. Elizabeth is pregnant with a great Servant of God, but Mary is pregnant with God.

So, Elizabeth is one-upped by her kid cousin and has plenty of reasons for self-pity. Remember the mute husband and the advanced maternal age? In light of the visit, she could have grumbled inwardly about her surpassed fame and glory. She could have shut her eyes to Mary's piety and believed the most obvious natural explanation (Mary made a big, premarital mistake) rather than the miraculous one (Mary was visited by an angel and conceived by the Holy Spirit).

But Elizabeth does not do these things. In fact, to me, her reaction is truly astonishing. "Praise and blessing! I am so honored that you came to visit us! Who am I that the Mother of my Lord should come to serve me me and enter my home?"

Fitting for the mother of the greatest prophet that ever lived, but completely counter-intuitive to my petty, backbiting, envious, competitive, selfish self.

St. Elizabeth, ora pro nobis! Help us to greet the Christ child and the Mother of God as you and your son did once, long ago!

Three years ago, I apparently gave birth to what has grown into a walking, talking, question-asking, running, laughing, praying, eating, thinking, dancing, singing, jumping, bike-riding, loveable little boy. Amazing. I've told and re-told his birth story so many times now that I've forgotten the reality of what it was like, and each time I remember it, it seems to change a bit. I have revised it according to different themes on multiple occasions throughout the last three years. But what persistently comes to the fore is that it was scary, it changed everything, and now, as a mother, I know what it means to "bear fruit that is eternal."

We had one of the priests from our parish over for dinner last night (who happens to share a birthday with this special little boy, and who happens to be one of the special little boy's favorite non-family members), we will go to the zoo this morning and have his favorite meal for dinner tonight, and we may or may not have a birthday party with cupcakes and balloons on Saturday, since the only invitee (at his request!) is his cousin, whose mother just gave birth to another baby, this afternoon!

We love you, little boy!

Friday, May 25, 2012

Week 37: Full-Term and Full-o'-Baby

My belly feels like it's about to pop.

Literally, it feels like my belly button is pulling apart at the seam. I'm not sure if that's normal, but it's a searing pain that I live with every day and it gets worse every time I bend over to put on my shoes or pick up food off the floor. Good thing I don't drop food on the floor very often (because it lands on my belly and sits nicely on top) and spend most of the day barefoot...!

Yesterday, a woman asked me, "how are you feeling?" and the only thing I could think to respond was, "37 weeks pregnant?" She's a mom, so she understands. For those of you who haven't had children, let's just say, it's complicated.

I am so fortunate that everything is looking good. NSTs are normal, fundal height measurements are normal, amniotic fluid is normal, blood pressure is normal, weight gain (this week, anyway) is normal. The maternal-fetal specialist was concerned that the amniotic fluid had dropped from 10.1 to 8.2 or something like that, but apparently above 5 is normal. Besides, it's apparently nearly impossible to get a good amniotic fluid reading when the baby is moving around a whole lot. And this baby moves as soon as he can sense the probe coming closer!

My doctor hasn't mentioned induction yet, and despite my discomfort, I'm OK with that. I think part of the reason my induction went so well last time was because I was already so far along (40w2d) and because I was already dilated nearly 5 cm, 90% effaced. I'm happy to give it as much more time as he feels comfortable giving it. I'm sure the maternal-fetal specialist would be happy to deliver on Monday, but fortunately it's not her call.

Happy Memorial Day weekend, everyone! I hope that, should my boys choose to serve in the military some day, they will give honorable service following the tradition of their grandfather and many thousands of our nation's soliders, and that they will be properly honored by the citizens of the country they serve.

Thursday, May 24, 2012

"The High-Risk Outcast"

Holly, a Type I diabetic who blogs over at Arnold & Me, wrote the following about a month ago, regarding her pregnancy. It's well worth a read. She talks about being labeled as a diabetic, and consequently having her birth story written for her, before she'd even gone into labor.

A different way of getting at the same thing I talk about here all the time.

Holly gave birth to her baby a few days ago, and you should also check her blog obsessively for more information about that story (I have no idea whether she will be inclined to share it, but I plan to be the first to read it if she does. :)

Wednesday, May 23, 2012

Welcome, Baby Girl!

Jenn was induced this morning and I got word via Facebook that she has given birth to a healthy, 9 pound, 9 ounce baby girl today. Thanks be to God!

UPDATE: I've gotten word that Jenn successfully delivered her baby without the use of an epidural. Not that this makes her inherently better than anyone who does, but it's certainly an accomplishment, especially following an induction! Also, several pictures posted to Facebook show that her daughter may, in fact, be the cutest baby born yesterday.

Avoiding Lows? Or Managing Them?

For a few years now, I've been hearing a "buzz" among medical professionals (mostly endocrinologists) about the danger of low blood sugars. I was invited to participate in a research study through Washington University about low blood sugars in Type I diabetics; there have been a slew of personal stories on low blood sugars causing car accidents, including two articles in scientific journals synthesizing some of the data on car accidents following low blood sugars; and CGMs are targeted to individuals who are no longer able to feel low blood sugars coming on ("hypoglycemic unawareness"), and justified to insurance companies on that basis.

It's certainly a problem. Low blood sugar causes people to be stupider, and people do stupid things when they're feeling stupid. While death is frequently mentioned as a "worst-case scenario" for people with a low blood sugar, as far as I can tell, most people who have died from hypoglycemic incidents were actually trying to commit suicide.

Here are a few stupid things that I've done (actually ranging from hilarious to hazardous to my health) while my blood sugar is low:
  •  Lie down on the sidewalk at a bus stop. I was in late middle school, maybe high school, and I didn't have anything with me for a low. I stumbled up to the bus stop, with my knees collapsing underneath me each step on the way, and laid down. The bus driver kindly got out of the bus, helped me to my feet, and helped me get something to eat.
  • Yell and fight whoever is trying to help me. A few times, and most notably when I was being force-fed cake frosting from a tube (that stuff is nasty). This one time, at band camp (hold the snickers), I kept protesting the juice and granola bars offered to me at 6:00 in the morning, claiming that I "have to be on my flute at 12. I have to be on my flute at 12!" (Yes, I played flute at band camp. And yes, I have been fielding offensive jokes ever since.)
  • Hit my husband. I took the juice rather submissively, but seriously resented the fact that he woke me up to treat it. I smacked his arm to register my displeasure.
  • Take a Sunday afternoon nap that ends up in a sweaty, subconscious state from which I am revived with cake frosting from a tube. Did I mention that stuff is nasty? Anyway, I woke up with a tube of cake frosting in my mouth and immediately hoped that it was a bad dream. Unfortunately, it wasn't. This was the closest my husband came, about 4 or 5 years ago, to calling an ambulance for help.
  • Break a dish in the kitchen at my office, collapse on the floor in a heap, and gratefully accept the help of another Type I diabetic who happened to work in our small office. That one is pretty self-explanatory. It happened after I took a longer-than-average run on my lunch break. Bad idea, because I was already running on empty and a suspended basal rate just wasn't enough to keep the low away.
  • Take a bath. You can read about that here. It was horrible, and the closest I have ever been to dying from stupid behavior secondary to a low blood sugar. In fact, it gave me a serious dose of humility (I didn't even need the harsh treatment provided by my endocrinologist!), and I have treated low blood sugars much more cautiously ever since.
So there's the problem. Low blood sugars make you do stupid things. If you happen to be driving a car when your blood sugar gets low, you might get into an accident. If you happen to be lying in bed, you might get really sweaty and mad when someone tries to wake you up to help you treat the blood sugar. If you happen to draw yourself a bath, you might pass out and drown. If you happen to be pregnant, you might do something stupid that hurts both yourself and your unborn baby.

I've had endocrinologists fret over the fact that lows happen at all, but as far as I can tell, I think it's more important to face the reality that they WILL happen, and do our best to arrange the circumstances of our lives to protect ourselves against the serious consequences. According to my mother, who is an emergency room physician, "everyone knows that people who control their blood sugar well are at greater risk for lows." It's apparently common knowledge among medical professionals. They want us to control our blood sugars well, and they are aware that sometimes, in the effort to avoid highs (which are well-known to cause long-term damage to blood vessels in the eyes, feet, heart, and elsewhere, as well as damage to kidneys), we dip low.

As you can tell from the title of the post, I don't think that avoiding lows is the whole answer. Endocrinologists and I can adjust my insulin rates until we're blue in the face, but every now and then, I'm going to have an exercise session that sends me lower than expected. Or I'm going to overestimate my carbs and give a too-large bolus. Or I'm going to have an unexplained change in my metabolic rate (weight loss of even just 3-5 pounds, as during postpartum breastfeeding, often has this effect), resulting in a few more lows than normal and requiring wholesale changes to my basal rates and bolus ratios. Or I'm going to get a stomach bug that makes it impossible for my stomach to absorb anything I eat to bring the blood sugar up. Every diabetic knows these things happened, which means that low blood sugars cannot be absolutely avoided.

First of all, because this is a blog about pregnancy, let me just say that pregnancy is only tangentially related to low blood sugars. If you work harder at tight blood sugar control during pregnancy, you may experience lows more frequently. But that doesn't mean pregnancy is the problem. Because if you did what you were supposed to and kicked your butt into gear to get tight control when weren't pregnant, you'd have the same problem!

So after adjusting my insulin rates to avoid at least a few lows, here's what I do to work around the fact that lows will happen, and how I prepare for them.
  • Carry Gatorade, and I mean, everywhere. At times, I've looked in my purse and the kids' diaper bag and between the two, I had 3 bottles of Gatorade. I'm packing a lot of extra weight, but it's saved my butt on dozens of occasions. Gatorade is GREAT because it's absorbed in your stomach (instead of juice, which is absorbed in your intestines), and so I feel better in 5 minutes. That means I can start driving, changing my kids' diapers, and keeping us moving throughout our day a whole lot faster. It doesn't last me beyond an hour, but an hour is usually plenty of time to find some real food.
  • Figure out what the best way to bring up a low blood sugar is, and fast, and not too high. I've heard Starbursts and lemonade works well for some. :) You'll probably need to stop eating before you feel better. Wait 15 or 20 minutes, and check again. It will only take you a few weeks to figure out what and how much you need to eat to raise a low, and then you can be confident that food will work every time (or at least, most of the time) without giving you a rebound high, even when you don't feel better right away.
  • If I'm having lows persistently at one time during the day, I try to avoid going out of the house at that time, or at least making sure I have a snack AND Gatorade with me, or eat a meal right beforehand. This happened during the second trimester of this pregnancy. After a heart-to-heart with my brother and sister-in-law, I decided I needed to hang around the house more after breakfast, because my 2-hour post-breakfast was very consistently low and still dropping. After a week, I figured out what was wrong, and was able to resume my normal morning activities. Staying home had the added bonus of giving me time to pay attention to what I was feeling, and I was even able to detect not just when my blood sugar was already low, but when it was dropping!
  •  Eat smaller meals. I'm trying to keep it less than 60 carbs. The problem with high-carb meals is that if your carb count is off, your insulin bolus is going to be waaaay off. Especially when you're pregnant, and your bolus ratios are very low. That means an overestimation of 10 carbs will result in a low that's even harder to bring up. If your meals are small and you need to eat a snack in between meals to bring your blood sugar up and stave off hunger, so be it. Isn't everyone always saying that eating frequently throughout the day is healthier, anyway?
  • Check your blood sugar all the time. Every two hours and more frequently if you think you're low.
  • Check your blood sugar every two hours.
  • Check your blood sugar whenever you think it's low.
  • Check your blood sugar before you get in the car, especially if you're going to be on an interstate or in the car for more than 15 minutes.
  • Check your blood sugar whenever you think you might not have a good opportunity to do so in the next hour.
  • Check your blood sugar when you wake up in the middle of the night, even if you don't feel low.
  • Check your blood sugar whenever you're worried about it.
  • Just suck it up and ask for help. Especially because this is a blog about pregnancy, do this one especially when you're pregnant. When I'm lying in bed at night, and I'm just about the fall asleep, and I can tell that I'm not just tired but that my blood sugar is, in fact, low, I ask my husband to get up and get me juice. It pains me, because I hate not being self-sufficient, but you know what? He's never said "no." And if your spouse does, then maybe you should let him or her read my post about taking a bath with a blood sugar of 20. That's what happens when you test-drive self-sufficiency with a low blood sugar, and it can have ugly consequences.
I'm apparently not the only diabetic who is skeptical about the hysteria over low blood sugars. So my recommendation is: avoid lows as best you can, which may involve working with your doctor, diabetes educator, and so forth. But in the end, it's equally (and possibly, more) important to manage them when they do happen.

What are your tips, especially you pregnant diabetics out there?

Saturday, May 19, 2012

Week 36: Cow, or Whale?

I think I have mentioned it a few times, but I was attempting to keep my weight gain down during this pregnancy to see if it would help with blood sugar management. Things had been going very well on this score for...well, basically the entire pregnancy. By week 34, I had gained something just shy of 25 pounds. With the Pious One and Braveheart, I gained some number rather closer to 50 pounds by the end of the pregnancy. So I was feeling pretty good about myself, thinking, "If I gain just one pound per week for the rest of the pregnancy, then that will be just about 30 pounds. Perfect, healthy, we'll see if it makes a difference in my blood sugars and blood pressure during these last few weeks, and in fitting back into my clothes after birth."

Then, I stepped on the scale at my doctor's office.

Eight pounds and two weeks later, my hopes of keeping weight gain modest during this pregnancy have taken a big hit. I am really having a hard time believing that I have put on ONE QUARTER of the additional poundage I acquired during this pregnancy in a period of TWO WEEKS. How is that even possible? I figure 1 pound of baby, perhaps 1.5 pounds of amniotic fluid and extra blood volume and... Yeah, that's still about 5.5 pounds of fat right there. I expect the jokes about looking like a whale or a cow to start really stinging now!

In any case, I visited with my OB and the maternal fetal specialist again on Friday. Everything looks fine. I'll get the results of my strep B culture next week. I think that the maternal-fetal specialist, realizing that she was going to have a hard time convincing me and my OB that I need to be induced at 38 weeks, decided to call the pediatric urologist to see if she could get him on her side. When I spoke with him a few months ago, he didn't seem to think that the hydronephrosis would warrant any special treatment of the pregnancy, including early delivery, unless amniotic fluid levels got wacky (which they are not).

My blood sugars are quite good. I tend low more often than I tend high (not surprisingly, I suppose), but even the lows are not terrible. I only have a few blood sugars during the week that are below 55, which is where I tend to draw the line and call a blood sugar "low" rather than "on the low side." I've gotten better at detecting a low before it happens, which means I can check and treat before the situation gets too serious.

I've slowed down my activity a little bit. I guess I've finally learned that the last few weeks of pregnancy is not the time to go full-steam ahead, particularly since there will be an abrupt halting of the engine at childbirth, anyway. I'm getting used to hanging out around the house, accepting the help of others, acknowledging my physical limitations, and budgeting more time for pretty much everything than I used to.

And, I'm going to see Brian Regan tonight! He has a sketch on what it's like to be a middle/younger child in a large family that is just laugh-out-loud funny. While you won't be able to watch his hilarious slapstick from the previous link, you will be able to listen to him make jokes about "finding a good activity" as a 4-year-old, at the direction of his mother, sibling conflict, breaking it to his mom that there had been an accident in the driveway, and calling the hump seat in the car. Hilarious. Happy early birthday to me, from my dad. :)

Wednesday, May 16, 2012

HypnoBirthing and The Futility of Fear

I recently learned that a friend of mine is a "follower" of this blog (Hi, Adele!). She is a HypnoBirthing instructor, has delivered all three of her children using the method, and has had two homebirths. She is very savvy about the physical and psychological aspects of childbirth, and we've often chatted about pregnancy and childbirth. At Adele's recommendation, I read the HypnoBirthing book a few months back, and partly because I'm so fond of Adele, and partly because I've been thinking a lot about fear and pain lately, I thought I'd share my thoughts about the good things HypnoBirthing offers to every woman who is in the process of becoming a mother (for the first or the twenty-first time).

One defining feature of HypnoBirthing is its claim that childbirth can be painless, under the right circumstances. The way to eliminate pain in childbirth, according to HypnoBirthing, is to reduce fear, eliminate tension, and re-train ourselves to think of the sensations of normal physiological birth as healthy events in the life of mother and baby. From their website:

The method teaches you that, in the absence of fear and tension, or special medical circumstances, severe pain does not have to be an accompaniment of labor.

And, from the author of the method, Marie F. Mongan:

When you change the way you view birth, the way you birth will change.

If you've been reading over the last few weeks, you'll notice my as-of-late preoccupation with fear and pain. I am 35 weeks pregnant, and once again coming to grips with the reality that this baby will come out one way or another, and it's bound to be a serious shock to my system. I blame the shock and the resultant fear on our first mother, Eve. But I don't really have an excuse for indulging in the fear when I contemplate the perfections of the Blessed Virgin. As I get closer to my due date, it becomes increasingly shocking to me that, even and especially from the perspective of the one who gave birth, the Nativity is one of the joyful mysteries, not one of the sorrowful...!

So there I sat, preoccupied with my fear, blaming Eve, praying the rosary and trying to move past it to achieve some pre-birth resolution. And, not surprisingly, one thing that came to mind is the HypnoBirthing admonition against fear. For the most part, HypnoBirthing advocates draw a strong connection between fear and the downward tension created within the body because of it. I completely track with that. I think most midwives, natural childbirth advocates, and other methods of natural childbirth track with that.

But what is most striking to me about fear in pregnancy and childbirth is not the failure to resolve the downward tension created in the body, but a failure to resolve the upward tension, as fear is reflected from the soul.

Fear results in bodily tension. But fear results from tension with regard to our purpose as a human being, our relationship to God, our relationship to our spouse and our children, our relationships with our doctors, and often, a failure to understand the true nature of life and death. Fear will continue to rear its ugly head unless we address very seriously the top-down reasons that fear arises in a woman preparing to give birth. In other words, fear creates tension, which can cause or augment pain, but what causes fear? I can think of a few things right off the top of my head: death, pain, and getting a large-ish baby out of that teeny-tiny little hole...!

Unfortunately, I don't think HypnoBirthing does a very good job of addressing the top-down source of fear. In fact, I don't think any of the methods do a very good job at addressing the top-down fear, except for making some mention in passing about resolving childhood sexual abuse, which is a tragically common but not universal source of fear for women facing motherhood. I think it's all too easy for natural childbirth advocates to say, "well, it's natural, so we just need to learn all about how it works, how the 'pressure' is really just your uterus working hard to peacefully evict the child within, how it more often goes right than wrong, and then we won't be afraid of it anymore." It's a good start, but it won't get you all the way there. Because, for example, no natural childbirth advocate denies that horrible things can happen during pregnancy, childbirth, and postpartum recovery. So what about when it DOES go wrong? What about when you do still experience pain? What about when you have a miscarriage? What about when you do need a c-section? What about when your baby is stillborn? What about when you're so depressed after your baby is born you can barely get out of bed to take care of the child? What about when the mother dies?

So there are good reasons to be afraid. For me, I am afraid of pain and I am afraid that my baby will die, and I am afraid I might need a c-section. I am afraid of what my doctors will say about me and my future childbearing potential if something goes wrong. I guess those things probably make my body tense, but making my body un-tense will not make them go away. Learning more about how birth works will not make those questions go away.

I touched on it a little bit in my last weekly post, when I wrote about facing the pain of childbearing, but it boils down to this line from one of those great Easter hymns we've been singing for a few weeks: "Ours the cross, the grave, the skies!"

Ours the cross. Christ lovingly prepares a burden that is not one ounce too heavy, which includes all the pain we experience in childbearing - back ache, contractions, c-section recovery, frustrating toddlers and all.

Ours the grave. Sometimes we die, and sometimes our children die. Fortunately for us, these realities are infrequent, but it is good to remember them and be prepared to meet them, because they do come to all of us at some point.

And ours the skies! If you have never had a baby, I can tell you that there are definitely moments that will feel like heaven, as often as there are moments that feel like the walk to Calvary. It may not be in the delivery room. It may not be when you're up in the middle of the night rocking a crying baby that just can't or won't fall back asleep. It may not be when you're changing diapers. It may not be when you're feeding them green pea slop out of a little jar...or it might be. Or it might be when your baby nurses peacefully. It might be when your baby smiles at you for the first time. It might be when your baby falls asleep contentedly in your arms. It might be when you're watching someone else hold and enjoy your baby.

And motherhood carries its own special eternal reward, after death. You are, after all, caring for some of the least of Christ's people. There's a reward in heaven for that! Didn't one of the epistles say that women will be saved through childbearing? There's a reward in heaven for that! I'm pretty sure Christ said something about letting the little ones come to Him, too. There's a reward in heaven for that!

Even if you are not a Christian, rage against pain and death is utterly futile. Fear is futile. "Who of you, by worrying, can add one single day to his life?" Death comes to us all, tomorrow or 60 years from now. Better to make your choices with a level mind, unswayed by fear. If that means talking to your friends and family about what might happen if you die, so be it. If it means asking your doctor every possible question about the complications that might occur so you can prepare to handle them on the other side of birth, so be it. If it means crying really hard and then acknowledging that you can't do more than your best, come what may, so be it. If it means praying to a God that you do not know, so be it.

At some point, you will come to the end of your power to prevent pain and tragedy (even if you have an epidural). Your doctor will come to the end of his or her power to remedy illness (even if he or she does a c-section). Your parents, friends, spouse, and everyone else will come to the end of their power to help you and relieve you of the burden of pain and death (even if your husband takes on all middle-of-the-night diaper changes). There's no sense in tormenting yourself with "what ifs," because pain and suffering come to all at the end of our power, and Christ meets us right there. Do not be afraid, and do not let yourself rage against pain and death. Fear is futile, because pain and death come to us all. Be strong and courageous, for your work is good and noble. Pregnancy and childbearing is hard with or without diabetes, but children are worth it.

Monday, May 14, 2012

Week 35: Swing Low, Sweet Blood Sugar

I didn't post last Friday about my week because. Well. I think I was just tired. Pregnancy insomnia strikes again.

Last week was one of really serious changes to my blood sugar levels. I had been giving those little extra boluses after meals because I was subconsciously remembering the last time I ate lunch I was high after it, or because last time I drank that small amount of juice to cover a low my blood sugar was actually high an hour later, or because no matter how low my bolus ratio is at breakfast I still seem to turn up high 2 hours later...

So after about 10 days of doing this, I had a few days of what I would consider unacceptable ups and downs, between 150-200ish down to 40. I realized that I needed to make wholesale changes to my insulin regimen, rather than trying to do some wacky compensation with my eating habits and manual boluses.

I increased basal rates across the board (adding anywhere from 0.6 units/hour to 0.4 units/hour), decreased my insulin sensitivity (from 1:25 down to 1:10!), and increased all my bolus ratios (down 1-2 grams of carb per unit).

So, swing low, sweet blood sugar. I am a happier person carrying a little bit of food with me everywhere, checking my blood sugar every hour to see if I am correctly feeling low, and sneaking a small amount of Gatorade from time to time, than biting my nails and forcing myself to wait until 2 hours after a meal to check what I anticipate will certainly be a higher blood sugar than I want it to be.

I'm hoping that will be the last set of major changes I have to make (but I think I said that last time, too), so I will keep you posted. :) Grow, baby, grow!

Monday, May 7, 2012

Fetal Hypoglycemia and Cutting the Cord

I've heard a lot about delayed cord clamping, but both of my boys had theirs cut within a minute after birth. I think the intention with the Pious One was to leave it until it stopped pulsing, but there was meconium when they broke my water and again when he was born, so they thought it might be better to begin looking him over for signs of distress right away. With Braveheart, I spent so much time thinking about how I felt about induction that I plum forgot about a whole lot of other natural things that I might have wanted to try.

A little bit of light internet reading turned up the following reasons for delayed cord clamping: support for the baby's iron stores, and extra oxygen to baby's brain, at least for preterm infants. I read a couple pages that suggested the white blood cells present in cord blood may benefit a newborn, also, which makes sense, but I didn't find the research.

As I understand it, blood continues to be supplied to the infant via the cord, as long as it has not been cut, for about 5 minutes after birth. The primary benefit is an increase in blood volume, which, provided that the mother's blood supply is healthy for baby (which it most likely has been for 9 months!), should be an added benefit to the baby.

What I know about fetal hypoglycemia for babies of diabetic mothers, however, is that it is precisely the mother's blood supply which stimulates an excessive insulin response in the baby, bringing the baby's blood sugar too low following separation from its mother.

So I guess the question is: will extra blood volume from the mother, especially if the mother's blood sugar is on its way up or high during and immediately following delivery, stimulate a more exaggerated insulin response from her baby? Will the baby's insulin response be changed such that it is more difficult to bring the baby's blood sugar back up? My gut says that the baby's insulin response WILL be more exaggerated, and that it will be more difficult to get the baby's blood sugar up.

But I could be missing something.

I suppose the baby's insulin response might be sufficiently insensitive that the total blood volume received from mom (and even the level of the mother's blood sugar) doesn't matter that much, but I think I would want to see something suggesting that before I put my eggs in that basket.

On the other hand, if my blood sugar is OK when the baby is born and in the few minutes following delivery, I actually feel pretty darn partial to it.

If, in the heat of the moment, the cord gets cut and I think it would have been OK to leave it, I won't be mad about it.

Unfortunately, I remember the final pushing stages with the Pious One (after nearly 4 hours...) saw a pretty sudden rise in my blood sugar, and even though Braveheart was out by the time it happened, my blood sugar also rose sharply following his birth (his blood sugar remained fine during recovery).

Don't you love it when I think out loud?

So I'm going to let the doctor make the call here, and as much as I covet the idea of giving my baby an iron boost at birth, I will bow to what seems, at this time, to be the better judgment and let other considerations take preference. I know what it feels like to have a low blood sugar, and wouldn't wish it on anyone - especially not my newborn baby.

Perhaps your pediatrician or OB has made a suggestion one way or the other, specifically as it relates to fetal hypoglycemia, and you'd like to share?

Why I Love My OB

I had another round of doctor's visits with my maternal-fetal specialist and the OB who will deliver my baby yesterday.

The day began with a fetal NST. The Statesman was not awake, so the nurse asked me to turn over on my side, hoping that the disorientation of a new position would get him moving so they could record changes in his heart rate. I did so, but found that, after a few minutes, the Statesman slumbered on.

But since I know how to get this baby moving, I tried a different trick. The good old-fashioned poke. (Oddly enough, this is what I think about every time someone pokes me or I poke someone else on Facebook). I tentatively tried poking in one spot. After a few moments, though, I got no reaction. So I poked a little harder in a different spot. Only a slight movement of a small limb registered a response to the stimulus, but no corresponding changes on the heart rate monitor. A third poke, the hardest of all, proved equally ineffective in altering the heart rate on the machine. So finally, I went for the poke-and-press. I pressed southeast of my belly button and poked, hard and long, to the northwest of it.

The poke-and-press did the trick! The Statesman swung his bum this way and that, and I smiled happily as I heard the heart rate come up and down following the compulsory dance moves. I did it a few more times and the nurse, who was completely unaware of the lovely little game I had just played with my baby, came back in the room and happily unhooked me from the machine.

I also had an amniotic fluid and anatomy ultrasound. Neither the tech nor the maternal-fetal specialist reported the numbers directly, but seemed utterly unphased by either the amniotic fluid value or the growth percentile. They reported that both were within a normal range. The hydronephrosis had increased somewhat, but the maternal-fetal specialist reported that this was almost certainly owing to the fact that the baby himself has increased in size. Also, baby is vertex now, so we'll hope he stays that way.

In St. Louis, I probably would have been attended by a maternal-fetal specialist during labor. Here, fortunately, maternal-fetal specialists only do consultations during pregnancy and make recommendations to the OB that does attend the delivery. Some OBs probably religiously accept the recommendations of the maternal-fetal specialist, but I am fortunate that my OB does not, as you will see:

First of all, I asked my maternal-fetal specialist if she would be willing to look at my blood sugars over the next few weeks before delivery. I explained what had happened with my endocrinologist: that I was on Medicaid and didn't think the office visits were worth the money, that he had been looking at my blood sugars at least weekly but that I felt very comfortable making changes on my own, that my last two A1Cs in early March and mid-April were both 5.7. She was only too eager to help, and told me that I was doing a better job than any Type I diabetic she had ever seen. As far as I can tell, she will let me hold the reins when it comes to adjusting my insulin rates.

Nevertheless, she made some troubling recommendations for the last few weeks of pregnancy. Firstly, she warned that the hospital may not permit me to stay on my insulin pump during labor. I was quite confident that she was misinformed, unless the hospital has changed its protocol in the last 18 months, since I was permitted to monitor my own blood sugars during labor the last time I delivered with the same doctor at the same hospital, and the first time I delivered at a different hospital in a different town.

Let me just say that "letting" a Type I diabetic monitor her own blood sugars during labor, if she feels comfortable doing so, seems common sense to me, and to do it any other way without the express desire of the laboring woman is just weird. She suggested that labor would be too intense, and I wouldn't be able to think about how to control my blood sugars at that time. I assured her that managing my blood sugars was second nature to me, I regularly did it while holding one baby on my hip and calmly trying to explain to my toddler how to put his shoes on, and that it involved a lot more than just numbers on a piece of paper. Not to mention, by the time the nurses communicate the number to the attending physician and they call the maternal-fetal specialist to make a decision about whether and how much insulin to give or withhold, the critical window to act may very well have passed, especially if it only takes you 20 minutes to push that baby out. No single blood sugar reading is just a number - it's always part of a longer and sometimes very complicated and rapidly-changing story. I have spent a lot of time trying to understand that story (which involves my body in such an intimate way that a doctor would truly be incapable of understanding it to the degree that I have), and make judgments accordingly. During this pregnancy in particular, since I have been hounded about it by my doctors so many times, I have had to not only observe the details of that story, but articulate it, and gosh darnit if I just go ahead and say I've been doing a pretty good job.

**NB: Not all women feel so comfortable adjusting their insulin rates. I am totally aware of that, and I appreciate the difficulty, and would not hesitate to tell such a woman that she can hand that responsibility over to her doctor if she chooses. But the fact remains that a woman who has studied herself, her physical sensations, her habits, and her blood sugars, and then experimented with it as much as I have is, in fact, more capable of knowing how to manage her blood sugars than any doctor. Period. No matter how good a doctor, no matter how many articles he's read, no matter how many research studies he's done, no matter how many patients he's seen, and no matter how long he has been seeing that particular patient. He may be capable of making some very excellent suggestions, which a woman would be wise to consider and experiment with, but it's just better if she does it herself.

In any case, the point is, I am not comfortable relinquishing the responsibility of managing my blood sugars to anyone else, and I would almost rather ask my husband to deliver the baby in the car in the parking lot if they refused me the right to keep my insulin pump on. If my baby's blood sugar is low at birth (which, by the way, I've never heard of being a life-threatening complication), I would feel much more comfortable knowing that it was my fault, since I think it is incredibly more likely that the nurses and doctors would err than that I would. If the doctors made a mistake, I would be bitter and resentful. If I made a mistake, I would be humbled and resolved not to let it happen again.

The second recommendation that the maternal-fetal specialist made is that I come in TWO TIMES EVERY WEEK from now until I deliver. Can we say OVERKILL? I did not do fetal NSTs two times per week with my first two pregnancies, now I have two toddlers for whom I have to find a babysitter, my blood sugars are better than they ever have been, and it's not like those tests have actually been proven to detect stillbirth before it happens. No way. Once a week is perfectly fine.

The third recommendation she made is that I be induced between 37 and 38 weeks. Whoa! Thirty-nine is plenty early as far as I'm concerned, and I'm planning to make a serious pitch for 40w4d, which will be the Monday following my due date. The short story of my reasoning, and I will share more with you about this later, is as follows: healthy pregnancies experience an increased risk of stillbirth beginning at 41 weeks. Since I have had a basically healthy pregnancy, I deserve to be treated like a basically healthy woman. Stillbirth is a horrible, awful fact of pregnancy, there's no good way to prevent it or anticipate it while the baby is in utero (even in an otherwise healthy pregnancy), but even though stillbirth is a horrible risk, there advantages to spontaneous labor at term for both the baby and the mother as well as risks of induction that should be considered, especially given that the statistical increase in stillbirth risk is not all that significant.

In the end, however, the maternal-fetal specialist said she would defer to my OB. What a relief! Next I went to see him, and I spent some time running the maternal-fetal specialist's recommendations by him.

Let me say now that the psychological difference between seeing my endocrinologist, at the very worst end of the spectrum, the maternal-fetal specialist somewhere in the middle, and my OB at the height of psychologically-affirming doctor's visists, is incredible. I'm pretty sure that my blood pressure, which was hanging out slightly high, 119/80, at the beginning of my NST, had probably dropped significantly by the time I left my OB's office.

I reported to him the results of the ultrasound, and he was pleased. He told me that under no circumstances would I be separated from my insulin pump during labor. He also told me that once weekly visits for fetal NST were fine. We didn't talk about induction, but I plan to do some serious thinking about it in the next two weeks so we can have a fruitful conversation about it.

He told me, and I quote, and furthermore, wish to forever brand these statements into my memory of this pregnancy:

"Some women just give up. But you, never."
"I hope you have the opportunity to share your experience with many other women, so they can learn from it."
"You know your disease so well, better than anyone."
"When they finally approve the islet cell transplant, I hope you will be the first in line."

Beyond just his words, however, I could tell that he was truly proud of me, and impressed with what I had been able to accomplish in spite of adverse circumstances.

Note that he did not try to say that I am perfectly healthy (diabetes, alas, prevents it from being so). He did not guarantee that he won't still want to induce me early. He did not guarantee that I will not have a c-section. He did not guarantee that things will not fall apart in the last 6 weeks of this pregnancy. But it doesn't matter. What he did do was confidently assert that I HAVE been trying very hard, my effort SHOWS, and I am a capable and responsible party to this pregnancy.

While my endocrinologist and the maternal-fetal specialist have given lip-service to the idea that good control over my blood sugars will permit me to have a healthy pregnancy, they have continued to act as though their judgments and interference are the most important contributions to the health of the pregnancy, and furthermore, that this pregnancy is a disaster waiting to happen. "I've been humbled by Type I diabetics before" was the line from the maternal-fetal specialist, and "pregnancy is just too hard for a diabetic" is the line from my endocrinologist. They're trained to look for the warning signs of an impending storm that will sink the boat, and unfortunately, they seem to have a hard time recognizing the blue skies of what are more likely peaceful waters. My OB, on the other hand, having seen the evidence of my blood pressure, my weight gain, my blood sugars, and so forth, is truly proud of me and my effort, and optimistic about the future of both of us, and rightly so, on the basis of such evidence.

Speaking of which, I had a slight headache this week and what do you know? My blood pressure has risen slightly (still normal at 110/86, but three weeks ago it was 90/60!), which I'm fairly confident is both related to the headache and a normal development in a healthy pregnancy. More of an interesting factoid than anything, particularly since I had a massive headache at 34 weeks during my second pregnancy, too, and I noticed my blood pressure rose weekly as I neared delivery. Additionally, my weight gain has continued to be modest. More about that later, but I have tried very, very hard to keep it low (for a few different reasons) this pregnancy, and it's working. I'm hoping it may make blood sugars during the last few weeks even easier to control, and when this is all over, I plan to share with you some thoughts about the difference between a pregnancy weight gain of approximately 50 pounds and a pregnancy weight gain of closer to 30 pounds.

Friday, May 4, 2012

Week 34: Doesn't It Make You Fear For Your Bodily Integrity?

This week of pregnancy was consumed by the answer to the question in the title of this post.

I did my absolute best to prepare for labor with the Pious One. In fact, I spent so much time learning about how to have a healthy pregnancy, labor, and delivery that I sort of failed to prepare for having a baby. As in, I didn't realize that I didn't know how to change a diaper until after we had selected "rooming in" for our new baby, all the nurses left the room, and my husband was passed out on the couch at 1:00 in the morning. Oops.

Whatever. The point is that I felt good about my preparation, but in hindsight, nothing really could have prepared me for the intensity of labor. It was frightening, painful, and I screamed the primal scream of an Amazon woman when I felt the ring of fire, and then it was over. There were many new and unusual sensations, most of which have only been repeated during subsequent pregnancy and labor. Nothing prepared me for it like doing it. I tried to memorize what it felt like to have a contraction, and still forgot after 3 weeks.

With Braveheart, I kind of remembered what I was up against. After all, it had only been a little over a year. Then, at 34ish weeks, it hit me: I have to do THAT. Again. As in, there is a very large infant inside me. right. now. And there is no pain-free way for that infant to come out. Gulp. In the end, Braveheart's labor felt hard, more like running a marathon, than scary, like someone wringing a baby out of my uterus like water out of a towel, so it was an improvement of sorts. But still, it was a physically demanding experience, and fraught with "I can't do this"'s and "Can I really handle this?"'s.

It's funny that it only occurred to me to face that reality late in the third trimester, but a lot of women I've talked to experience a similar, late-pregnancy epiphany. I guess late in the pregnancy, you can begin to visualize the dimensions of the growing baby inside you. Or say one day the baby is breech and you feel how large the baby's head is. Or you can imagine the child's outstretched leg as it tests the dimensions of the inside of your uterus. Or you see someone else's newborn baby, and you realize that one of those is inside of you, and only getting bigger as the days go by. Or you begin to take seriously those fruit comparisons the books are always making (pushing out a pineapple?!). Or you just remember what it was like last time.

So this week, I wrestled once again with the knowledge that I have to do THAT. Again. There is a large-ish infant inside me right. now. And there is no pain-free way for that infant to come out.

Before I had children, I guess I kept thinking that the more I did this, the easier it would get. But then again, no woman I've talked to with more than 3 children has ever said that it would. "Does it get less frightening?" From the woman with 8 children, smiling politely and shyly but not really wanting to scare the classroom full of doulas-to-be, "Not really." "Does it get easier?" From Simcha Fisher, the blogging mother of 9, "No, and in fact, in some ways, it gets harder." Daaaaang.

After pondering it this week, I think what it boils down to is this, for first-time mothers and women who have given birth more than a dozen times: doesn't it make you fear for your bodily integrity?

There are only two ways for a full-term infant to come out. In one, a very small hole has to stretch to dimensions it has hitherto not seen, or at least only seen a few brief times in its life. In the other, someone slices a hole in your abdomen and pulls the baby out. It's as simple as that. The potential for damage to one's bodily integrity is high, and reasonably gives one cause for apprehension!

I think this may be one reason why I and a lot of other women feel very strongly about avoiding a c-section unless it is truly necessary. Plain and simple, while a vaginal birth carries the possibility of an intact body (absent the all-too-common perineal tearing, that is), it is absolutely impossible for your bodily integrity to be maintained perfectly when you have a c-section. Surgery is sometimes necessary to preserve one's life or the life of one's baby, but it always sacrifices some bodily integrity for the sake of the greater whole. A c-section is a tolerable but undesirable sacrifice. Thanks a lot, Eve...

So when you hear someone say it doesn't matter because, "at the end you have a healthy baby," you can just tell them, "but what about my bodily integrity?" Then, of course, you should be prepared for an extended philosophical discussion related to risk, human nature, and the principle of double effect. Ha.

A vaginal birth, however, carries with it the possibility of maintaining such integrity perfectly. Not that it happens often, but there's at least hope. I think women know this hope, deep down, and cling to it, even when they can't explain why.

In the meantime, I am fearing plenty for my bodily integrity, even though I believe I will probably have a vaginal birth this time, too. Pain is not equal to damage to bodily integrity, but it sure feels like it sometimes. I guess there's just no easy way to get a baby out!

Thursday, May 3, 2012

Surprise Ending

In my last post about my endocrinologist, I explained why I had decided not to see him since January, and the interaction that ensued over e-mail with the physician's assistant in his office.

The other day, I received another e-mail, from the physician's assistant at the office, letting me know that the doctor was "very insistent" that I come in to see him, because "as you are aware, pregnant diabetics should be seen every month."

This was puzzling to me, largely because during my first pregnancy, I wasn't seen every month (contrary to that oh-so-patronizing-'as-you-know'), only two or three times that I can remember.  My A1Cs were good, I had a healthy pregnancy and a labor and delivery with very few complications. The Pious One's blood sugar was a little low at birth, but I can hardly believe that a few extra office visits to the endocrinologist would have changed that. My blood sugar just rose unexpectedly during pushing phase, that's all. My doctors looked at my blood sugars every now and then, but only ever made suggestions, and I was basically left to my own devices to make changes to my bolus ratios and basal rates. So I was actually not aware that pregnant diabetics should be seen every month. Is this standard protocol elsewhere? Was my situation in St. Louis really exceptional?

When we moved here during my second pregnancy, I actually thought my local doctor was just uptight for wanting to see me every month, but I tolerated it and went to the appointments. I thought it was possible I might be missing something, and I understood that my doctor here didn't see how well things went the first time. I thought I would show him that I was capable, that I felt comfortable making changes on my own, that my approach involved more than just insulin rates, that there were good reasons for him to trust me with my own health, and that things would probably be fine.

They did turn out fine, so my first clue-in should have been when I went to see my endocrinologist when my Braveheart was 8 or 9 months old and he broached the subject of future childbearing with great disdain.

My second clue-in should have been when I returned three months later and he felt it necessary to reiterate his disapproval of my plan to have more children because, he told me, I don't need more children (of course no one NEEDS children, and if they do, they probably have some kind of co-dependency issues, so I'm not sure why that's a relevant measure).

I'm pretty dense, so I really should have gotten it when I turned up in his office, the Statesman was barely the size of an (no doubt adorable) peanut, and he was actually mad about it. No "congratulations," no "how have your blood sugars been?", no "do you need any help?" Just anger.

I guess I finally did get it when I went in, humbled by a difficult few weeks of blood sugar management, and I was mocked and bullied.

Please understand, dear reader, that I am emotionally over these personal offenses. Not that I think he's right, but I decided that he was a skilled and experienced doctor, and I wanted to see a skilled and experienced doctor when I needed help. So I just planned to tune out when he began to talk about how many children was too many and glean what good I could from our visits. I thought I *might* even be able to convince him that a diabetic could do pregnancy well without a lot of day-to-day meddling help, especially since I've known him for a long time. In fact, he mentioned that, of all his pregnant diabetic patients, he trusted me most (flattery only, apparently, as you will see).

So this pregnancy, as I mentioned, I'm paying out-of-pocket. I'm on Medicaid, which his office doesn't accept, and my open enrollment, last-resort-insurance-for-people-who-are-not-eligible-for-any-group-health-coverage-otherwise won't cover pre-existing conditions until June. I've done Type I diabetic pregnancy twice. I feel very comfortable making changes to my own insulin rates, in and out of pregnancy. Sometimes, when my blood sugars are off, it's not even an issue of adjusting my insulin rates. It's eating habits, blood sugar checking habits, sleeping habits, exercise habits, carb counting habits, and so forth. I make whatever changes I think are necessary, or I try out a new experiment. I'm constantly tweaking and mostly trying to stay on the safe side of 60 and 140. I feel very strongly that I am the final arbiter over my bolus ratios, basal rates, insulin sensitivities, as well as every other kind of habit that I adopt, and I refuse to permit someone else to make those decisions for me. I accept recommendations, suggestions, and discussions, not prescriptions and rules. I personally take 100% responsibility for my A1C and any other lows or highs that come my way.

For those reasons, I don't need to see my endocrinologist for day-to-day blood sugar management. Beyond that, my OB's office draws blood to check A1C and whatever else is needed, they check weight and blood pressure, remind me how important my blood sugars are for baby's health, and so forth. I am fortunate that I have no significant swelling, no pains that are not typical of pregnancy, and really, no complaints at all, except for the large bowling-ball shape that seems to be permanently stuck to my abdomen.

There has been no additional further reasoning from my endocrinologist, in this e-mail or any other, on what about ME and MY HEALTH and MY MANAGEMENT of diabetes needs to be treated with an office visit at the present time. I guess it's possible that diabetics as a group do better during pregnancy when they are seen by a doctor more frequently but...correlation doesn't equal causation? Just because one epidemiological study showed that the number of diabetics who have healthy babies is directly proportional to the number of times they saw their endocrinologist (if such a study exists, I'm not aware of it), it doesn't mean that "seeing the endocrinologist" actually made their babies healthier. Isn't that basic science?

I'm really, honest-to-goodness, wanting to hear about what I'm missing. In a return e-mail, I reiterated my reasons for not coming in, explained that I was healthy and comfortable as measured by my own assessment and that of my OB, and asked the PA to have the doctor call me to explain what he was worried about.

Well, I got a call from my doctor, alright. In the classiest of classy moves, my doctor, instead of trying to persuade me about the basis for his protocol or explaining his concerns about my health, had his receptionist call me to tell me that if I didn't come in for an office visit immediately, I was officially dismissed from the practice for the remainder of my pregnancy.

Dang, that's not a good feeling.

So Jenn and I are really on a roll here with our third pregnancies. I have six weeks to go and no one to bounce ideas off of or help me if my hormones get wacky. I hope you all will still help me out with your tricks, tips, recommendations, and suggestions...!