Monday, May 7, 2012

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.

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