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 Gynaecologists – Management 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

Spanner in the Works

I’ve just started maternity leave. I’ve been planning to update this blog for a while, but work has been consuming so much of my brain and time and baby stuff the rest that it’s been squeezed out.

But today when I was just starting to adjust to the new normal, I got an unpleasant surprise. The official email states:

Dear CMP Client

Due to unforeseen staffing circumstances, the Community Midwifery Program regrets that if you are planning a hospital birth (Domino), or if you are planning a homebirth and are required to transfer into hospital during your labour, your Community Midwife will be unable to remain with you and will hand over your care to the hospital staff.  When you are discharged from hospital, your Community Midwife will continue your care at home.

This arrangement will continue until further notice.

If you have any questions or would like to discuss this further please contact <name and number redacted>

Yours faithfully

Community Midwifery Program

I also got an email from my midwife who I subsequently phoned about it. I’ve been planning a Domino birth (as suggested by my midwife incidentally) and one of the main reasons I chose the CMP was because of the continuity of care. I’m very keen to be able to birth with someone I know, and this pretty much negates that. Coming a month out from my due date, it’s a big unpleasant shock.

I haven’t had a chance to meet the midwifery teams at the hospital I’m planning to attend (why would I when I have a midwife?) and my experiences with the obstetricians have left me less than impressed. They have been for the most part impersonal, uninterested and poor on the details. The last one didn’t even take my blood pressure and tested my protein levels only when I asked about it.

My biggest fear comes down to the BMI issue. I’ve been eating fairly normally throughout my pregnancy and putting on more weight in my third trimester (most of which is going to the baby who is now ~3kg). Despite being otherwise healthy, I’m getting close to those scary cutoffs and that’s when I weigh myself at home first thing in the morning. The scales at the hospital are less discriminating, especially later in the day and wearing clothes. I’m really afraid that I’m going to be packed off to King Edward hospital for delivery sans midwife and lose any autonomy over my birth because I happen to be a kilo over the cutoff if they insist on weighing me.

Tomorrow I have an appointment with the backup CMP midwife and then another appointment at the hospital. I’m going to discuss my concerns with the midwife (especially in light of my anxiety issues around the BMI issue) and see if there’s anything they can do. I understand that they’ve had staff leave, but I’d like to hope they feel some sense of responsibility for people who are already in the system. At the hospital, I plan to decline to be weighed. I’m mostly going in to find out if spudlet is still breech and to get an anti-D injection so I’m hoping they don’t push the issue.

If we aren’t happy after the conversation with the midwife, I might contact the CMP manager and discuss it with her. I’m half tempted to see if I can switch to a homebirth even though it wouldn’t be my first choice as I’d feel safer with that than at KEMH. It’s distressing to have to consider these sorts of things when I thought it was all sorted. In the meantime, I’ll be eating salad so I can try to fit within the stupid BMI restrictions. I can’t help feeling sad and angry that the system is letting me down like this.

Pregnancy update

I haven’t been blogging much lately for a number of reasons. The main one is that mentally and emotionally my pregnancy has been somewhat difficult. There is a lot I want to say about this, but finding the time and headspace to write about it has been eluding me. I still hope to get there so stay tuned.

I’ve also been busy trying to balance full time work, getting everything ready for spudlet and managing my increasingly slow and ungainly body.

Today I’m 30 weeks pregnant so I’m well into my third trimester. Spudlet is very active, enough so that I’ve asked a few midwives if there’s such a thing as too much movement (apparently not). I’m also now having trouble sleeping because my hips are getting very painful at night in addition to all the kicking.

On the organisation front, I think we’re doing pretty well. The nursery is mostly set up and I’m very pleased with it. We have a cot and many of the sundries we will need. We’re still working on a name but we’re making progress there too.

I’m really hanging out for the weather to cool down. I’m still trying to walk as much as possible, but when the weather is in the mid to high 30s, that becomes really unpleasant. I’ve finally found a maternity swimming costume, so I’m looking to do more swimming in the coming months.

We are most of the way through our preparation for childbirth classes. While I still feel that there’s a lot I don’t know I at least feel more confident with the labour process and how to fold a nappy. It’s feeling increasingly like a waiting game, but I still have an awful lot to do at work before I start my maternity leave in six weeks time.

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.