Overdue

Sure enough, spudlet has stayed put past his due date. I always suspected this would happen. I was two weeks late, my sister was late and my niece was ten days late.

He is also stubbornly still breech.

On the birth options side of things, much has been happening. Our decision to be as flexible as possible has paid off even though we’ve been bouncing between care providers like a yo-yo. Funnily enough, we’ve ended up with what was originally our worst case scenario – a birth at KEMH AND a private obstetrician. Only now it’s a great option and we’re really pleased!

Here’s how it happened: Armadale hospital referred me to KEMH because they weren’t comfortable letting me try a vaginal breech birth (VBB) there primarily because it’s my first baby. The first obs we spoke to at KEMH was happy for me to try a VBB but wasn’t comfortable with me going more than 10 days past my due date or with induction. He recommended an elective caesarian 10 days past my EDD at the latest. I wasn’t thrilled with that but was pleased to be able to try for a VBB.

The second obstetrician we spoke to at KEMH (on my due date which was Wed 14/5) further advised me that my chances of being allowed to try for a VBB were entirely dependent on which obs were on duty if I came in labouring. He said that not all of them were comfortable with delivering breech so I might still need a caesarian at that point. He also looked into booking an elective caesarian and told me that the only free slot was 8 days past my due date.  This is because apparently they do very limited elective sections on Monday and Friday (which were fully booked) and none on the weekend. I was not pleased and began to negotiate at this point. We were stuck at a bit of an impasse when Craig had the brainwave of asking about booking an elective caesarian at Armadale hospital instead. The obs seized on this idea with relief and I liked the idea because at least I’d be closer to home.

After some phoning around and the help of various midwives, I was booked in for a caesarian at Armadale instead. Frustratingly, it was still 8 days past my EDD (apparently the Fri-Mon limited sections thing isn’t just KEMH) but it still felt like a better option. I was however frustrated by the lack of appointments for four days out of seven every week. That’s a sad indictment of public medical care in WA in my opinion.

On Friday, mum and I headed back to KEMH to have a CTG done on spudlet to check that he was doing ok. He was stubborn and just wanted to sleep, so I ended up hooked up to the monitor for two hours. I got to chatting with the lovely midwife who was attending. She admired my knitting and we talked about that a bit, I also told her about the saga of trying to get a VBB. She said she had an idea and vanished.

A little while later, she came back and asked if I have private health insurance. She said there was a possibility of getting an obstetrician to take me as a private patient which would increase my options. I was delighted by this suggestion and told her to go for it! Shortly thereafter, another obs turned up, plonked himself down on the end of my bed and had a chat with me. We discussed my situation, he had a look at my notes and asked some questions and then agreed to take me as a private patient. He was friendly and willing to negotiate over details of labour but also made it clear where his boundaries were which I appreciated.

He said he was also willing to let me wait a bit longer, especially given my family history, and also consider induction (by prostaglandin gel) if I didn’t go into labour by a certain date. He advised me to cancel my other appointments and my elective caesarian (yay) and instead made some new appointments to discuss options further and keep an eye on spudlet’s health via further CTGs.

So this is where things stand at the moment. I never thought I’d be this happy to have a private obstetrician! I’ll still be delivering at KEMH and hopefully have followup care from the community midwifery program.  There’s still also a good chance I’ll end up needing to have a caesarian. I feel better about that though if I’ve at least had a chance to go into labour. By this time next week, we should hopefully have a spudlet in the outside world. That still feels surreal.

Physcially I’m doing ok. I get tired very quickly and can’t do as much as I’d like but I still go out somewhere most days. It’s good to have both mum and Craig around to help look after me and provide moral support. We’re looking forward to meeting the spud and bringing him home. The birth is going to be an adventure one way or the other but I’m trying not to focus on it too much beforehand. Here’s hoping it goes (relatively) smoothly from this point onwards!

Turn Around

I’m currently 38 weeks pregnant and physically feeling pretty good. The main issue at the moment is that spudlet is still breech.

What this means is that his head is up the top of my uterus, when it should be at the bottom by now so that he can be born head first. He seems to be wilful already and has refused all efforts to turn him thus far. These have included:

  • Inversion (kneeling with head down, bum up)
  • Breech tilt (lying upside down dangling off the couch)
  • Somersaults in a swimming pool
  • Putting an ice pack at the top of my uterus and a heatpack at the base
  • Talking to him, singing to him and poking him
  • Chiro (Webster technique)
  • External Cephalic version (having a obstetrician try to physically turn him from the outside at a hospital) x 2

I haven’t tried acupuncture/moxibustion because that strains my credulity a little too far.

Having the ECV done is pretty uncomfortable. I have some impressive bruises to show for it and I don’t bruise easily. Both times, the obs couldn’t find any obvious reason why he wouldn’t turn. Spudlet is a normal size, has plenty of surrounding fluid and my uterus seems to be a normal shape. The obs could turn him 90 degrees but no further and he soon shifted back.

After the first ECV, spudlet was observed with the cord between his legs, clamping down on it. The second time, he visibly had it in his hand and was squeezing it as if to say “leave me alone”! Cheeky baby! Note that there’s been no sign of cord entanglement. The obs was clear that he didn’t have any cord around his neck.

The breech issue has been quite stressful, especially combined with the CMP issues that I wrote about last time. Some of the advice we’ve been given by obstetricians indicates that a caesarian section would be the best idea in this situation, especially as it’s my first baby.

Being the stubborn opinionated people we are, Craig and I decided to look into this a bit more. I started reading guidelines, journal articles and websites (see below) and collecting the opinions of midwives. I was pointed towards the AU/NZ breech birth group on Facebook who turned out to be a wonderfully supportive community. I got a bunch of information, suggestions and personal anecdotes and was also pointed towards more of the literature by them.

As a result of this, when I went in for my second ECV, I was feeling considerably more confident and able to discuss my concerns with the consultant obstetrician in a lot more detail. It really helped, he listened to me, respected what I had to say and was pretty honest about what (and where) my options were.

I now have a referral to KEMH to discuss options around vaginal breech birth (VBB). Armadale hospital where I had my ECVs done were hesitant to accept me for a VBB as they don’t have surgical teams in place at night for emergency caesareans. KEMH have more expertise with VBB and complex births in general, so hopefully I’ll get a better outcome.

We are aware that there are risks associated with a VBB and that there’s a good likelihood that I’ll end up needing a caesarean section anyhow. There are also considerable benefits to letting spudlet arrive when he’s ready and experiencing labour for both of us. If I can have a natural birth, that will also be greatly preferable in terms of recovery time, bonding and options for a future pregnancy.

Our appointment with KEMH to discuss options is tomorrow morning. I hope we meet their criteria for VBB (I believe we should based on their guidelines). Then we will wait to see what happens. One way or another, we should be meeting spudlet in a week or two!

 

If you are interested in learning more about breech birth, here are some of the resources I used.

Useful Groups/Websites:

Breech Birth Australia and New Zealand Facebook Group (this was invaluable to me – closed group, ask for an invite)

Breech Birth AU/NZ

Spinning Babies

Breech Birth Guidelines:

Royal AU and NZ college of Obstetricians and GynaecologistsManagement of Breech Presentation at Term

King Edward Hospital (WA) – Breech Presentation Guidelines and Breech Presentation Planned Vaginal Birth

Royal College of Obstetricians and Gynaecologists (UK) – Breech Presentation Management (interesting to compare with the AU/NZ one)

Society of Obstetricians and Gynaecologists of Canada – Vaginal Delivery of Breech Presentation

American College of Obstetricians and Gynaecologists – Committee Opinion Mode of Singleton Breech Delivery

Journal Articles (you’ll need access via an academic library with the appropriate subscriptions for most):

Term Breech Trial (2000) (there are also lots of follow up studies and commentary papers on this trial)

PREMODA (2006) also a followup analysis

Vistad (2013)

Borbolla (2014) – Australian study

Bergenhenegouwen (2014) – Review of literature for preterm breech delivery

Too fat to give birth here

I’ve been sitting on this post for a fair while now to give myself time to settle down. I think it represents the most stressful thing in my pregnancy so far even including the high risk result. It still upsets and angers me a great deal to think about. When I found out I was pregnant, even before we got back from holiday, I started researching birthing options. The Department of Health site on this topic came up very quickly. After a bit of reading, the KEMH Family Birth Centre started looking like a really good option. It’s a midwife led centre which provides a comfortable and low intervention place to give birth but is also right beside the best maternity hospital in WA. When we got back and started planning visits to check out some options, it was at the top of my list.

It wasn’t until just before we went on a tour that I found out about their body mass index (BMI) limit. We did the tour anyway, it was an amazing place with lovely suites and a huge bath you can give birth in. It looked practically perfect from our point of view. We hung around afterwards to talk to the midwife and ask about the limit. Sure enough, she confirmed that the centre doesn’t take women with a BMI over 35. Furthermore, if their BMI goes over that limit at any point during their pregnancy , they will be bounced from giving birth there! At this point in my pregnancy I was about 12 weeks along and hadn’t gained any significant weight (+/- 1kg). I was just under the 35 cutoff. She told me that if I wanted to give birth at the KEMH birth centre I would need to not put on any weight during my pregnancy. She thought this was doable despite it being essentially a pretty steep weight loss diet.

At birth, the combined weight of the baby, placenta, amniotic fluid, extra maternal blood, breast tissue and other fluids is somewhere around 14kg. This is the amount of weight I would have to not gain while still getting enough nourishment to keep me and the fetus healthy. It didn’t sound feasible to me and I was concerned about the effect of watching my weight so strictly on my anxiety which was already beginning to get knocked around by the stresses of pregnancy.

So after quite a bit of anger and tears and consulting with my doctor, I decided to explore the option of the Community Midwifery Program (CMP). We decided after some more research and consultation to sign up with the program and give birth at Armadale Hospital via the Domino program. This means that our midwife will accompany us to Armadale hospital and provide continuity of care throughout and after the pregnancy. Ironically, despite being effectively turned away from the KEMH birth centre, I am eligible for a home birth if I want one because the BMI cutoff for the CMP is a measure of maternal weight prior to pregnancy.

The BMI issue has raised its head a few times since then. At one point, my midwife advised me that I was over the cutoff to have a water birth. This surprised Craig and I since we’d looked up the relevant policies (or thought we had) and it didn’t look like it would be a problem. I’m keen to have the option of a water birth and Armadale hospital has inflatable pools available for this purpose. That caused another emotional scene over stupid bureaucracy. We asked our midwife to double check the policy and fortunately it turned out she’d been looking at one which had been superseded and I can have a water birth if I want to.

I’m still extremely angry about BMI being used as a sole method of weight based risk stratification in pregnancy. I’m not going to go into the science of BMI here because there’s lots of information about it all over the internet (see here, here, here and here for some examples with varying degree of scientific rigour and readability). BMI can be a useful tool when used across populations, and a lot of dieticians and clinicians like it because it’s easy to calculate. When applied to individuals however, it can be extremely misleading. When using it as the basis of risk stratification (e.g. among pregnant women), it may fail to consider that some women are overweight and obese as a result of being unwell. This can skew both statistics and clinical experience of obesity.

I am obese according to medical definitions. I am also relatively healthy. My blood pressure and blood sugar are low, I’m reasonably fit (I walk an average of ~5km/day even in my 6th month of pregnancy). All of the risks that are supposed to be attendant on obese pregnant women have failed to materialise for me. I don’t have prenatal diabetes, it seems very unlikely that I will develop pre-eclampsia going by my blood pressure results. Also, my ultrasounds have shown spudlet to be in the 52nd percentile of growth for his gestational age meaning he’s bang on normal size. I see my pregnancy as low risk and don’t think my BMI changes that.

So why is BMI used in pregnancy? Especially when you’d be expecting women to gain weight as part of a normal pregnancy? It appears to be part of the increasing medicalisation of pregnancy which is predominantly coming from, surprise surprise, the United States (where medical care is big business). Caesarian section rates in the US and Australia have exceeded 30% of live births as more people see doctors for the birth of their children. Doctors/obstetricians view patients through the lens of pathology. Pregnancy and childbirth isn’t a disease, it’s a normal human process which like many processes can vary from person to person. Doctors however are trained to look for and treat anomalies. This can lead to a pathway of increasing intervention which more often than not results in a C section.

Don’t get me wrong, if anything goes awry with my pregnancy I intend to seek medical attention (and have done so to date). If something goes wrong during the birthing process, I’m not going to eschew medical treatment (including a caesarian if it comes to that). However I prefer not to borrow trouble. It concerns me sometimes that I’m being sent for so many extra tests based on my BMI (when by other measures I’m healthy) and I’m mindful that I don’t want any of this to snowball into unnecessary intervention just because a doctor who doesn’t know me or my medical history just wants to be extra careful.

I’m a person, not a number. I’m not stupid and I am capable of making decisions about my own health and that of spudlet. I am very glad that modern medicine exists, but I strongly prefer that medical decisions be made based on up to date evidence based research rather than out of date practices with little to no science to back them up. This is why I am, and will continue to be critical of the BMI as a individual measure of wellness.

Bad News

Pregnancy is supposed to be a time to relax and enjoy the natural processes of the body. For me this couldn’t be further from the truth. I have so many balls in the air right now, I feel like I barely have time to breathe. In reality, I do get down time in the evenings and weekends but work is very full on and I’m constantly thinking a few weeks ahead.

I commented to Craig on the train this morning on our way to our doctor to get the results of the first trimester screen that I couldn’t afford to get bad news with everything going on. So of course that was exactly what happened. Both she and Craig beat around the bush a bit talking about our choice to go with the community midwives for the birth, but I was keen to get the results back. She said, “well it’s not all good news”.

What it was in fact was a 1 in 141 chance that our fetus has Down Syndrome. High risk. Shit.

She asked me what I know about amniocentesis. I told her. I also said that we were very clear that we wanted to go ahead with further testing if we got a high risk result. She explained a bit more and said she’d fax through a referral to KEMH for the testing. She said they should call within a few days and the amnio should hopefully happen within a week.

So I get a big needle poked through my abdomen. I hate needles. Also, it means we now have to consider in more detail what we will do in the case of more bad news. Of course we will therefore hold off telling people until we get more news. I may not be able to have the amnio until week 15 and it can take up to 10 days to get all of the results back.

There are some good points however. The doctor said that she’d sent five high risk couples off for amnio and they’d all come back clear. Also, a clear result with an amnio is 100% reliable for chromosomal abnormalities. Plus you get to find out the gender sooner. 1:141 is actually less than a 1% chance, it still feels really bloody scary though.

It’s all still sinking in. I came in to work after the appointment, mostly to try to take my mind off things. That seemed to be working in the morning but it’s getting harder. My game face is slipping and people at work are beginning to notice that I’m upset.