Interventions

Our “birth plan” is extremely short.  It basically says “we prefer to minimize interventions.”  This is kind of ironic considering the number of interventions we submitted to in order to get knocked up in the first place.  But our interest in minimizing interventions is not because we think childbirth has to be “natural” but because there are so many secondary risks that the interventions themselves can pose… and it seems like the US obstetrical system seems to be optimized to minimize the “risk of a lawsuit because we didn’t do anything when we could have,” rather than the actual risk to the baby.

Today I had an appointment with the midwife, which I had been dreading all weekend.  Our practice has multiple midwives, so you see different people every time you go.  Today’s appointment was with the super interventionist midwife, she of the “you have a DE baby, so we will be more likely to do a c-section” fame.  I knew she was going to get on my case about being post-dates (5 days and counting).

At the last appointment, she told me she would want to “sweep my membranes” at this appointment.  Sweeping the membranes is a very, very common procedure where they use a finger to separate the bottom of the amniotic sac from the uterus; it is supposed to trigger labor.  This weekend, I went on-line and did some research into sweeping the membranes to see if I should consent.  Here is what I found out.

First, there is no scientific research that shows that sweeping the membranes as a routine procedure actually makes any difference in how quickly labor comes.  Second, there are a few risks to the procedure, including that your bag of waters could break (in which case they have to induce you if you don’t go into labor within a day), and that they may introduce bacteria from your vagina into your uterus and thus increasing your chance of infection.  The procedure is often very painful and it is not uncommon to have bleeding afterwards.   All in all, it didn’t really sound like the benefits were worth the risks.

I took Mr. Nishkanu along with me to the appointment because I was pretty sure that the midwife was not going to be receptive to me turning down this procedure and I thought I could use some help fighting off the tidal wave of doom and gloom she likes to spread.  First, we had our non-stress test.  Baby passed with flying colors, not only doing all the right things with its heart accelerations but also kicking 15 times during the 15 minute test, at one point kicking the contraction monitor so hard you could see it bump off of my belly.   Hooray!  Everything is great, no need to worry… right?

We then went to the midwife’s office where the Big Fight ensued.  I was so glad that I brought Mr. Nishkanu because the midwife pulled out all the guilt stops.   The thing was, a lot of what she said just didn’t seem logical.  For example, she told me this was my last chance to avoid an induction, since it was practice policy to induce at 41 weeks (which I know it isn’t, since I talked to all the other midwives about it).  When we asked about risks and benefits of the procedure, she only talked about benefits and did not discuss risks.   She said it was very dangerous to be post-dates, that the placenta starts degrading… although she admitted that according to the test my placenta was in great shape.  But, she said, they prefer to induce before there is a problem… leading me to wonder, why did she bother doing a non-stress test, if her plan was to induce if there is a problem, and also to induce if there is no problem?

She also assumed that the reason I did not want to have my membranes swept was because I was “afraid to go into labor,” so she started trying to talk me into having courage to face the inevitable.  One thing I can tell you, lady, is that after 5 years of infertility treatment and 8 IVF cycles, I am not afraid of labor.  The hell in my past is much greater than the suffering in my future, even if the raw pain of the latter is much greater.  After all I have been through to have this baby, labor is just a minor bump in the road.  And actually, although I know this might be a bit weird and I might regret saying this in retrospect, I am kind of looking forward to the athletic challenge.

Fortunately Mr. Nishkanu had taken over the conversation at this point.  He is good at not getting upset by this stuff.  Finally he got the midwife to the point where she said “if you really insist on not sweeping the membranes, then the only option is for you to come in in a few days for more tests.”  Mr. Nishkanu said, “that sounds good, we’ll do that.”  Fortunately, our next appointment is with a different midwife.   If she continues the “must get this baby out now (despite no evidence of problems)” bandwagon we’ll listen; as is, I feel like this particular midwife has an induction ax to grind.

The whole thing made me think again about the difference between RE practices and ob-gyn ones.  The REs I have been to are compulsive about collecting statistics about most of their procedures.   If you say, “what difference will it make if we do assisted hatching?” they can tell you what the numbers, on average, for their practice are (of course, this may not apply to your case, but that’s another story).   In fact, this is one of the things that I think kept Mr. Nishkanu on the DE wagon rather than going to adoption… adoption agencies don’t hand out statistics, they work more with relationships and emotions, things Mr. Nishkanu does not derive as much comfort from.  But ob-gyn practices seem to do much of their practice because “this is how we’ve always done it.”  The national evidence-based standards for induction from the American Council of Ob-Gyns is to not induce until 42 weeks unless there is an indication of a problem.  But many, many practices across the US start haranguing people to be induced much earlier than that… “just in case.”

Part of the difference, I guess, is that REs are trying to stay on the cutting edge.  They acquire patients by having better stats than the competition, and in order to keep the stats up, they have to keep innovating.  They keep pushing to see if they can get the numbers better.  Ob-gyns are in a different position, their methods are established and they get more patients than they need even if they don’t do anything better (for example, in our town, there are two ob-gyn practices; one has twice the c-section rate of the other yet neither hurts for patients).

But, Mr. Nishkanu pointed out, another issue is the question of bad outcomes.   Ob-gyn practices are optimized to avoid the worst outcome, not to optimize the average outcome.   The risk of waiting may be small, but over the patient population our clinic sees, eventually they will see the bad outcome.  And the bad outcome can be really, really bad.

Now,  the fact is that REs have bad outcomes which are just as bad as ob-gyns… after all, they are causing the pregnancies that the ob-gyns eventually handle.  If their patients have multiple pregnancies, there are very real, serious risks for the babies that come out of the treatment.  If we look at higher order multiples, these are very high risks.  But… REs generally don’t actually see the bad outcomes.  The perinatologist is the one left holding the bag when the babies don’t make it home, or have serious disabilities.

OK, time to go back to thinking positive.  The baby is doing acrobatic leaps and bounds tonight, so the good news is: happy and healthy, nothing bad has happened so far!

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The Wait

The conventional wisdom is that the period after your due date is one of total impatience.   You’re uncomfortable, the story goes, sick of being pregnant, you want your baby to be there.  Certainly, that’s what everyone around me is telling me… “you must be so tired of waiting!”

In actuality, that’s not how I feel at all.  There are some things that make me nervous about being postdates, one is that something could happen to the little one still at the last minute (and as I typed that it squirmed around inside as if to say “no worries, everything is fine!”) and the other is that I will get increasing pressure from my care providers to induce.  But otherwise?  I am fortunate that I don’t feel too uncomfortable, I have been spared the swelling and backaches that are common in late pregnancy.  I waited a long, long time to be pregnant and at this point a week or two more doesn’t seem like a big deal.

In fact, this time feels like a special, magical time, “the time that was not supposed to be.”  Every day that I get up and go to work, I think to myself, “what shall I do today that I didn’t expect to be able to do?”  And there is no pressure to do anything since, for the same money, I could be not working any more – everything I do is just a little unexpected bonus.  In the evening?  “Honey, what do you think about going out to dinner?”  “Sure, it might be the last time…” (we have now had many “last time” dinners and several brunches… and I’m not complaining about it).

The people around us seem to have more problems with it.  The only people who don’t bug me about “can’t you not wait to have the baby out?  don’t you feel anything? are you having any contractions?” are the ones who have, thankfully, forgotten when my due date was supposed to be – one of the advantages of having your due date early in the month is that a lot of people only remember “some time in December” and so they haven’t joined the bug train yet.

My mom is great, she sent me an email on my due date saying “I just want you to know I am not going to bug you every 5 minutes about how the baby is doing.  I know how annoying that is.  We will wait to hear from you that something has happened.”  I replied with effusive thanks and asked her if she could please spread the memo to everyone I know…

My MIL, on the other hand, is a different story.  Yesterday she called me at work…

MIL: What’s going on?  Is anything happening?

N: Nope.

MIL: Where is Mr. Nishkanu? [Aha, that explains why they called me… usually they bug him with this stuff.]

N: I don’t know, I guess he is at work.

MIL: Are you at work?

N: Yep.

MIL. Oh. Huh.  You know, you should go to the doctor.  They can tell you when your baby will come. [She has been bugging me for a while to find out how effaced/dilated I am… and tell her, of course.]

N: Actually, they can’t say it very precisely.  Anyway, the baby will come whenever it comes.

MIL: But we want to know when it will come.

N: It could still be a while, you have to be patient.

MIL: But we aren’t patient!  Anyway, do you know what the gender is yet? [My in-laws are semi-convinced that we have known the gender all along, just aren’t telling them… which in all honesty is something we WOULD do, but in actuality haven’t.]

N: Nope, no idea.

MIL: Mr. Nishkanu won’t tell us the names.  Will you tell us the names?

N: Nope.

MIL: He said you hadn’t agreed on a boy’s name.  Did you finally decide now?

N: I’ve decided, I can’t speak for him.

MIL: But you won’t tell us what it is?

N: Nope. We’ll call you when something is happening, until then there is nothing going on.

I have to say I was cracking up to myself over the course of this entire conversation.

Actually, that last thing I told my MIL was a lie.  We will not call them WHEN something happens, we will only call them AFTER everything has happened.  Because otherwise Mr. Nishkanu is going to get a phone call every 30 minutes in the delivery room asking for updates and if he can please post some photos on the internet of what is happening…

We have a solemn pact that No One gets to find out I am going into labor except for (a) the doula and (b) the midwives.  Mr. Nishkanu has been practicing his lies in case there are inconveniently timed phone calls.

Caller: What’s that moaning sound in the background?

Mr. Nishkanu: Oh, Nishkanu just stubbed her toe.

The wait continues…

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The due date

Today is a big day around chez Nishkanu.  It’s my due date.

Now, I had no illusions that this would be the day the little one comes.  After all, average day of delivery for first-time moms is 41 weeks 1 day, so we have plenty of time to go before even the average day arrives.  But still, it feels like a huge milestone.  The little one could come at any second, it is full term.  Who would have ever thought I would make it this far?

Now, could somebody please let my colleagues know that it is not unusual to go post-dates?!  I am now at the point where Every Time I see Any Colleague they feel compelled to say, “Oh, wow, you are still at work!” Yes, thanks for sharing, but I had already noticed.  And it isn’t really an interesting topic of conversation the first time in the day, let alone the 17th.   One poor colleague came into my office this afternoon and said (you’ll never guess), “Oh, wow, you are still in!” I said “Yes, I am aware of that.  I do not need you to point it out.  Or the other 15 people who have let me know that fact today.”  He said, “Are you tired?”  I said, “Yes, I am tired of people commenting on the fact that I am in!”  Then, feeling a little bad about my outburst, I added, “I am also a little cranky.”  I think he would have been well within his rights to respond “Yes, I am aware of that”…

In other news… had a bit of a scare yesterday. Normally, when I wake up in the morning the little one seems to wake up around the same time.  It seems to like getting in a little session of kicking Mr. Nishkanu in the kidneys before we get out of bed.  Mr. Nishkanu complains about these but secretly you know he likes it.  At least that’s my theory.  Yesterday morning, though, for some reason the little one was mellow or sleeping and didn’t kick around.

During the morning I was working and not really paying attention, but around 1 I started to think to myself, “Gee, I haven’t really felt a lot of movement today…” I grabbed some lunch to get the blood sugar up, then ate some chocolate for good measure (yeah, I swear, that was “for the baby”), then grabbed the belly to do an in-office kick count… one measley twitch, that was it.  The little one is usually a circus acrobat, so this was making me nervous.  I went home, drank some juice, and lay in bed and tried to do a real kick count.  Normally I polish off the 10 kicks in 10 minutes or under, this time in 10 minutes I felt two tiny squirms that maybe were baby movement or maybe my imagination.  I started to imagine all the dire scenarios… what it would be like if the little one had died…  coming home from the hospital with a small box and the house full of kid’s stuff… whether we would keep everything and try to adopt, or just give up altogether… then I snapped out of it and called the midwives to go in and have the heart rate checked and avoid the whole insanity, or do something about it if there was a problem.

Sure enough, as soon as I was in the recliner with the fetal monitor strapped across the dark side of the moon and a contraction monitor orbiting the top, the little one woke up and started getting acrobatic again.  I think some of the “contractions” that they measured were actually the baby kicking the contraction monitor.    That’s fine because the important point is, baby was A-OK and super healthy.  Thank god.

The midwife on duty that day was the super interventionist one – she offered to strip my membranes (to try to get labor going) and wanted to do a vaginal exam to see how dilated I am.  I said “No thanks, I am not in a rush, the baby will come when the baby comes” and that earned me a little lecture on the dangers of going post-dates and when they will start bugging me about being induced.  I listened politely and continued with my refusal of the in-my-opinion-totally-unnecessary vaginal poking around (my theory is, we can start thinking about interventions when I am post-average-first-mom dates, or have some other reason to expect that there is a problem).  But the whole incident did make me realize the temptation of induction and all its friends… it would be nice to have the baby on the outside where I can check at home that it is still alive instead of poking my belly and hoping it wobbles back.

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Killjoys

This morning, I was relaxing under a nice hot shower at the gym after my water aerobics class.  One of my classmates came up to me and said, “Better enjoy your shower.  Because you won’t be having any long, hot showers for a long time after the baby comes.”

Why is it that people who are parents, when they are confronted with a 9 month pregnant woman, go out of their way to tell said woman about how their joy in life is soon to be over?  My classmate is by no means the only one, for the last couple of weeks I have been inundated by parents telling me about how I will never know peace again and to enjoy everything I am doing now because the baby will make my everyday pleasures impossible.   I don’t get it.  Even if it is true, why would you go out of your way to make other people feel bad about a major life change that is about to come upon them?  Do they think that if they don’t warn me that things are going to s*ck, that I might not notice on my own?

What’s worse is even people who know that we have been trying to have a baby for years, have gone through all kinds of suffering and extreme treatments to get one, and were crushed and depressed for years at the thought that we would never have a family, now that we are about to be on the brink of finally having a kid, still say “better go to the movies now, because you won’t have time for anything like that after the kid is born!”  Who the h*ll cares, I have had 5 years of going to the movies and doing all kinds of adventures that would be impossible with kids, all while getting more and more sad and desperate that that was all my life was going to be.  In any case, I really don’t think one more shower or one more movie at this point is going to make much of a difference.

The whole thing makes me wonder.  Imagine that your neighbour has been unemployed for 5 years.  Through no fault of her own, job prospect after job prospect  has fallen through.  She got to the point where she despaired of ever being employed again.  It ate at her self-esteem and triggered a deep depression.  But then… a miracle happens… she tries “one last interview” and finally does land the job.   So what do you say?  “Better enjoy your last days of vacation, it’ll be h*ll from here on out” – “You’ll see, you won’t have any peace any more, they will be calling you at home when you are on your hours off” – “do you know how tiring it is to work 40 hours a week?  Well, you’ll soon find out!”?

No, you say “Congratulations, I am so happy for you!”  So why is it so hard for parents to say that kind of thing?  What’s with the sharing the doom and gloom?

This afternoon, one of my colleagues came into my office to once again express the ritual astonishment that I have not given birth yet (although we are still pre-due-date).  He started, “I remember when my son was born…” and I braced myself for yet another h*ll story about the weeks after birth and the huge change in your life and the “you better enjoy your freedom while you have it.”  Instead he said, “It was so wonderful that finally I got to take care of him too, not just my wife.  It was such a great adventure.  You are in for a treat.”  Now that’s what I want to hear…

 

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To do list, adieu

Anyone who has been reading this blog for a while knows that I have a pathological attachment to my to-do list, which for the last few months has been both my primary method of coping (don’t have to think of the chaos which is the future and of the fears that something will still happen to the baby, because I can maintain control of my life by slavishly following the to-do list) and a primary source of stress (dang, the list doesn’t seem to be getting any shorter even though the delivery date is getting an awful lot closer…).

Wednesday I was at work, hacking away at the dang to-do list, and getting crankier and crampier by the minute.  I was chatting with a friend about my pathological to-do list, who said “and what exactly is going to happen if the to-do list doesn’t get finished?”  I said, naturally, “Are you kidding?  The world is going to come to an end!”  Then I said, “well, actually, it just means that things will be slightly less optimal than they would have been otherwise.”

Ain’t that the truth.

Somehow that one conversation was just what I needed to sever my affective ties with the to-do list.  Now my attitude is, if the stuff gets done great, if the stuff doesn’t get done, oh well.

This was just in time because I have gotten to the point in this pregnancy (39w2d) where all I want to do is crawl into my cave, stamp down my grass nest, and wait for the delivery to happen.   Not that I get to do that, thanks to my nation’s dysfunctional attitude to maternity leave.  But at least in my head, that’s what I’m doing…

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The resolution of the Great Name Dilemma of 2009

We’re done picking names at last.  Thank goodness.

I decided to take Chicklet’s advice and make our boy name list longer again. Maybe we couldn’t agree on “A” or “B” but  C through G would provide a breakthrough. I printed out a giant list of boy names and then started going through them with Mr. Nishkanu. By the time we got to the “N”‘s we still had no new names to add to the list – that’s right, Mr. Nishkanu had rejected every single one of them. At that point I started to realize how futile it was for me to be putting so much effort into finding an option that would be acceptable to him. Shouldn’t he be the one coming up with some alternatives?

I said, “Are there any names you can think of at all that you like?” He looked kind of blank.

I said, “Look, here’s the deal. I am happy to consider another name. But you have to come up with some options. If you can’t suggest anything, then we are going with (my favorite name).”

He did not look super thrilled about that but he was willing to admit that this was a rational solution.  If he really cares, he can put in the work to find another option.  I suspect that he cares enough to complain, but not enough to actually do anything about it.  Bingo, that means there is really no problem to be solved…

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Strange thoughts

Yesterday morning, on my way to water aerobics, a thought occurs to me… what if my water breaks while I am in the pool?  Would I even notice?  As a good post-loss pregnancy type my mind immediately races to the nightmare scenario… my water breaks in a big gush in the pool, I don’t notice, I walk around for days with my poor little one no longer having any cushioning for itself and its cord without realizing it, it dies of infection…

Then I realize, you sure as heck would notice if you pee in the pool, at least the feeling of warm fluid is a pretty key reminder.  If your water really broke in the pool you would for sure notice that too.  Phew!

Then, of course, my mind wandered to the next nightmare scenario.  If your water broke in the pool, how embarrassing would that be?  I mean, there is a sign that says “No urinating” and “No defecating.”  Even though there is no sign that says “No releasing a giant gush of amniotic fluid into the pool,” I’m pretty sure that people would put that in a similar category.  I can just see it in my mind’s eye…

N (raising hand tentatively): Excuse me, instructor?  I think it might be a good idea if we cancelled the rest of class.

A disembodied voice appears over the loudspeaker: “The pool is closed for maintenance.  Repeat: the pool is closed for maintenance.”

For sure it would be a water aerobics  class no one would ever forget…

Follow-up: I am happy to report I made it through class with no water breakage events.

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