Sunday, November 20, 2016

Baby is here!

Our newest little man flew into the world last night in what I can only describe as both a very short and a very long labor! His blood sugar is a little low (as almost always seems to happen to my babies), but he's nursing like a champ to bring it up and cute as a button regardless.

You'll get a birth story when you get one, which probably won't be very long from now, because I love writing it.

Happy Feast of Christ the King! Baby picked his birthday well. Viva Cristo Rey!

Monday, November 14, 2016

Google is Celebrating the Inventor of Insulin Today!

I had no idea that this guy first had the idea to try insulin to control diabetes in humans. I actually know precious little about the development of insulin therapies except the fact that I'm grateful for them. Thanks to Google, now I also know this little tidbit. Apparently the Canadian Sir Frederick Banting was the first person to try isolating insulin from cows and pigs to use in human beings.

In other news, Sir Frederick Banting was the youngest of five children. Hey, I'm pregnant with our fifth! I guess I can always hope that this baby of ours, growing healthy in utero as a result of the insulin that fifth child Sir Frederick Banting discovered, will grow up to "pass it on" and do something great for his generation and posterity. (But even if he's not the youngest and turns out to be a middle child instead, we can all rest assured that I'm populating the world with middle children. Apparently they are the most well-adjusted adults).

Sunday, November 13, 2016

Week 37: A Week Full of Contractions

I had a lot of contractions this week! There's still always something new to experience with each pregnancy, I suppose. I've always had a good number of contractions towards the end of each pregnancy, but the firsts this time around were 1) contractions that lasted all day but didn't result in a baby at the end of said day, and 2) contractions that woke me up in the middle of the night but didn't result in a baby the following morning. Late last week the contractions had been so consistent for two whole days that we did make a visit to the hospital, where we learned that dilation had not progressed from last week. Contractions petered out and we were sent home. So we're going to call that hospital visit a practice run. Our neighbors and friends now know that they could be receiving a call from us at any time of the day or night in the next two weeks, and they also know where the extra bagels are kept...

The contractions I've experienced lately have not, for the most part, been what I would call "painful." In fact, I haven't really tended to experience "painful" contractions until transition, and that's just the last few contractions (I read somewhere that it's only about 10-12 contractions, all told) of first stage before you begin to push baby out during the second stage of labor. If I were to wait until the contractions became painful, my babies would for sure be born at home or in the car on the way. The only reason I really woke up at all was because I had to time them. Then I began remembering my third son's birth, which went kind of fast, and then I got kind of anxious and had trouble falling back asleep. 

The most consistent theme of this pregnancy seems to be anxiety. True to form, I had a lot of anxiety this week. I worried about whether we'd get to the hospital on time. Everyone has heard of other women who have accidentally delivered at home without a caregiver or on the side of the road. I personally know five such women, and I'm not anxious to join their ranks! I worried about my blood pressure and blood sugar readings once we got there, and whether the doctors would think they were bad (From the desire of being approved, deliver me, Jesus). As everyone knows, worrying about your blood pressure is probably the best way to be sure they'll show up higher than normal. I worried about the pain of labor, especially after I heard another woman enter the triage stall next to me in such obvious pain with her contractions. It's funny how three centimeters dilation can feel so different to different women... After the doctor sent us home, I worried that all the people we had told about our departure would think I was a drama queen (From the fear of being despised, deliver me, Jesus).

So how do I cope with the anxieties of the last few weeks of pregnancy? A few helpful suggestions:

1) Cry. Because you're allowed to, and it doesn't mean you're doing it wrong. It also might very well be better than getting mad. It also might make someone pity you enough to help you out. There's seriously no shame in crying for help when you are about to go through one of the most intense experiences of your life. I guess the Litany of Humility prayer might be working, because I really find it hard to care if people around uncomfortable about the fact that I'm weeping uncontrollably, and I also don't feel the need to explain myself to anyone. I cry at Mass, I cry in the grocery store, I cry while talking to friends, I cry while cooking dinner, I cry when no one is around and I'm lying in bed. I woke my husband up when I started sobbing early this morning, loudly proclaiming my desire for contractions that would either just STOP or SPEED UP. 

2) Drink wine. I know the Surgeon General's warning as well as anyone, but...I'm having a hard time caring. I mean, as long as it's moderate. One doctor I spoke to said the only case of fetal alcohol syndrome she saw during her medical school education was brought about by a woman who was actually trying to cause a miscarriage in herself by drinking. In light of that anecdotal evidence, I figure a glass here and there is probably not going to do a lot of harm. Also, I've had more than a few glasses of wine during the second and third trimesters of this and my last three pregnancies, and no abnormalities have popped up so far with any of them.

3) Drink tea. Whatever kind makes you feel good. Put some honey in it if your blood sugar is low!

4) Pray. I always used to think that prayer was supposed to take the anxiety away, but ever since I became a praying person, it's never really worked like that. I used to think that meant that I was doing it wrong, and that made me even more anxious. But now I don't that's the case. Prayer doesn't take the feeling of anxiety away. It just helps me put words to the anxieties that I'm feeling, spend a little time figuring out how important they truly are, imagine how I might act if various worst-case scenarios came to pass, and then ultimately make an act of faith in God's providence. God's power and care for me does not depend upon my emotional state, so whether or not the anxiety remains when prayer time is over is becoming less and less important as time goes on.

Speaking of prayer, a friend of mine threw me a Birth Blessing party on Saturday. It was sort of last minute, pretty small, and almost got cancelled when we took ourselves to the hospital on Friday evening thinking baby could be coming soon, but it was really lovely. Obviously my level of anxiety about pregnancy speaks to this, but there's so much more to childbirth than just what's happening in the body. Caring for the soul in preparation for (and during!) birth is a great gift to give yourself and all the pregnant women around you. That's why I became interested in pregnancy and childbirth in the first place, why I went through doula training, why I followed a midwife around one summer, why I considered becoming a midwife, why I read birth stories at all. It's gotten somewhat lost in the diabetes numbers management of this pregnancy, but it remains a critical element every single time a woman becomes a mother. That goes for baby number one or baby number seventeen and every other one in between.

For now, I raise my glass (of wine, tea, sparkling water, Gatorade, or other beverage) to another week of waiting! (And I'll probably cry a little bit before I go to bed, too, because it's better than yelling).

Sunday, November 6, 2016

Week 36: Hello, Full-Term!

I am officially full term today. Should labor begin tonight, no one would try to stop it. Hooray!

I visited my OB on Friday. Over the last few weeks of pregnancy, I'll be meeting several of the doctors that work at the practice in the hopes that the face of the person who delivers my baby will be a familiar one. No matter, though. I think only one of my previous four babies was actually caught by the doctor treating me during pregnancy. I usually push them out too fast. Here's hoping for a repeat performance, because the pushing part is the one that makes everyone most nervous when you're looking at an increased risk of shoulder dystocia...

One lovely part of my most recent visit was all the detailed questions the obstetrician who examined me on Friday asked me about diabetes. She was so genuinely curious about the CGM, the pump, and my past experiences being pregnant and giving birth with Type I diabetes. Forgive me if I use the word too often, but the term "refreshing" comes to mind. At this point, though, I'm really looking forward to those first few hours after delivery when I can turn my pump way down and think about something other than my blood sugars for a while.

I also had a positive experience with my doctor's office when scheduling induction last week. At my 35-week visit, the doctor I saw then (a caregiver previously unknown to me) had recommended scheduling the induction for 39 weeks. When I pressed her on the point, citing my previous experiences with labor that begins spontaneously at 39 weeks or later and the ease of delivery, the health that my babies and I have had with all my labors, and the discussions I'd had with other OBs in the practice, she said we could schedule it "between 39 and 40 weeks."

Well it turns out that "between 39 and 40 weeks" is Thanksgiving Day, and hospitals and doctors don't like to schedule routine induction on major holidays. (Duh). So when the scheduler from the OB's office called me mid-week, I found myself having to negotiate the induction date once again. There were no appointments except on Monday that week, which would be only one day past 39 weeks and a few days earlier than any of my other labors began spontaneously. I once again explained that I'd done this before, had considered the risks (shoulder dystocia) in light of the facts on the ground (my previous labors, growth ultrasounds during this pregnancy), and that I'd really prefer to give myself a few extra days to go into labor spontaneously in the hopes that labor might proceed more smoothly if it began on its own. The best news of the week came about an hour later when the scheduler called me back after discussing the case with one of the practice doctors and they found it acceptable to postpone induction until the Monday following my due date (40w1d). One way or another, I should have a baby out of this weary body of mine and into my expectant arms on or about November 28. I hope it's on terms set by baby.

Also, I just came across this study in which the researchers are no longer recommending induction for diabetics until "approximately" 40 weeks gestation unless baby's weight on ultrasound is estimated to be greater than 4500g (9 lbs 14 oz). "Early delivery without maternal or fetal indication in women with diabetes is no longer the norm unless fetal lung maturity is documented." I have no idea where that recommendation comes from, but it's at least there in this study from India published in 2012. As far as I can tell, the recommendation for induction at 39 weeks was always somewhat arbitrary, anyway. 

In other news, contractions have increased in strength and frequency over the last couple of weeks. I have a few hours-worth of contractions every evening before going to bed, and cervical dilation so far confirms it. I was 3 centimeters dilated on Friday. Hoping for a baby this week (because who isn't excited for pregnancy to be over already?), but prepared to wait a few more. Come on out, baby. We're as ready as we're ever going to be!

Wednesday, November 2, 2016

CGM Trial and Error

At the beginning of pregnancy, I wrote a little bit about choosing settings for my CGM. What kinds of goals would I set for my blood sugars? Coming up with rules for diabetes management is not an easy thing, and I tend to rely on A1C values to tell me whether I'm pointed the right direction or not. But A1Cs only come once every three months, and something has to be done in the meantime.

When I chose those pregnancy settings for my CGM, I had only been on the CGM for about four months. Because we had just moved to a new town, I was still looking for a doctor and hadn't yet been for an A1C blood draw. My first A1C on the CGM was 7.1%, and that was taken in late April. I assumed it was a little high because I hadn't been as disciplined about my blood sugars before pregnancy started, and thought that keeping a tighter watch on the blood sugars and my food intake would bring it down below 6.0%.

My next A1C was taken in July, and it was 6.2%. Not quite as low as I'd hoped, but still good enough for baby, I assumed. I don't remember what all my A1Cs have been during all my pregnancies. I do know that I had a 5.2% which occurred during the months when I almost drowned myself in a bathtub with a low blood sugar, so that made me think that aiming for 5.5%-6.0% was probably best. I didn't want to be trying so hard for a low A1C that I was forced to suffer severe lows in compromising situations (driving, bathing, exercising, etc.).

My most recent A1C, taken in October, was 5.9%. The somewhat high number was a source of some dismay to me, because my monitor readings were really very good during the six months prior, yet I was barely inside my the target A1C that I'd been shooting for. In addition, my Dexcom clarity report indicated an estimated A1C of 4.7% for the same time period. Confusing and a little upsetting.

When I wrote about my growth ultrasound of 32 weeks, which showed a baby that was a bit on the large side, the anxieties I was having about the CGM readings and its apparent inaccuracy were very present in my mind. Evening calibrations were regularly showing up 20-30 mg/dL higher than morning ones, and that made me unsure of whether my blood sugar was being accurately reflected on the monitor the rest of the day. I assumed that if my blood sugar was actually 20-30 mg/dL higher for most of the day (and night?), that would explain why my true A1C was so much higher than Dexcom's estimate.

So my sensor receiver may tell me that my blood sugar is 55 when it is, in fact, 75 on my glucose monitor. Except that there are times when the monitor says my blood sugar is 55 and it actually is. No, I haven't figured out yet how to tell the difference. Also, I usually love being at 75, except when I don't. Sometimes 75 feels really terrible and lightheaded and weak and shaky. Likewise, I usually feel pretty junky at 55, except when I don't. Sometimes 55 feels as normal as 75 usually does.

So then comes the question: what to do? What are the rules for this situation? I have to write a whole blog post to explain it to myself and I'm still not sure I understand it. There's no way I can squeeze all this information into a 15 minute endocrinology or diabetes education exam. I've just got to make up new rules for myself as best I can. I've finally decided, as with other pregnancies, that I probably just have to be comfortable riding a low blood sugar line that most people are not used to and that most endocrinologists caution you to avoid.

The upshot of it is that I've lowered my target range considerably, hoping to squeeze out the last few weeks at a lower A1C than the first seven months. I have no low alert besides the built-in "Urgent Low" that appears when the sensor reads 55 mg/dL. I even sometimes ignore that if I feel OK and I'm at home and can get food quickly, should the need arise. My high alert is the very lowest the sensor will allow, at 120 mg/dL. I very rarely get above 130 mg/dL, because I begin treating with a modest 3.0 unit correction bolus any time my blood sugar gets to 120 mg/dL.

I was sincerely hoping that the sensor would allow me to avoid the worst pregnancy lows that I've suffered in the past, but the consistent margin of error with calibration simply requires that I assume my blood sugar is a little higher than the sensor is telling me and I have to hang out a little lower than the targets recommended by most endocrinologists (e.g., 80 mg/dL as the ideal reading on the sensor instead of 100 mg/dL as the ideal reading on a glucose monitor). The sensor does, at least, alert me at night when my blood sugar is dropping. That was information I did not have in previous pregnancies. But I still have to keep Gatorade with me everywhere I go, I still have to ask people to help me when my blood sugar gets low while I'm out of the house and I've run out of Gatorade, I still have to hang out at that junky-feeling 55 or 75 for a lot of the day, and I still have to give correction boluses with my fingers crossed, hoping that I'm just the right amount of low two hours later.

No one said having a baby with diabetes was going to be easy! But neither is going to medical school, and I'm pretty sure your endocrinologist thought that was worth it. Sometimes the hard stuff totally is.