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.

Dad’s first kick

Craig felt spudlet kick for the first time last night. He’s tried to feel it a few times before but spudlet is notably bad for kicking on cue.

Yesterday I was at the dentist and spudlet was kicking harder than I’ve felt before. I’m not sure if he was reacting to the sound or vibration of the cleaning tool or something else. My lovely dentist said he was just saying hello. 😀

Funnily enough when Craig finally felt a kick, I think he was expecting a gentle flutter. Instead spudlet let fly a hefty thump to the vicinity of Craig’s hand. Craig’s response “whoa!” and he felt a few more after that too. Nice for him, but I was very tired and in need of sleep. It felt like spudlet was having a dance party in there which made it harder to relax.

Mostly it’s reassuring to feel spudlet moving but sometimes it startles me and sometimes it’s a bit painful, especially when he kicks low down. It feels particularly weird when he rolls. I’m sure that will get more uncomfortable as he gets bigger. I’ve started singing to him to soothe him and this is something I plan to do more of. He’s big enough now to be able to hear sounds so I’m hoping that by singing and humming to him now, I’ll be able to use the same methods to soothe him after he arrives in the outside world.

Pregnancy by numbers

Here are some numbers from my pregnancy so far:

Number of weeks pregnant: 23

Number of double strength Mylanta consumed (approximately): 45

Number of first names currently on the shortlist: 3 (no, I won’t tell you what they are)

Number of unwanted belly pats so far: 1

Number of completed items knitted by me for spudlet: 8 (I will blog about these soon)

Number of knits currently in progress: 2 (Tiling Fish and Turtle Butt)

Number of ultrasounds (chances to see spudlet): 3

Number of onesies acquired: I don’t know, lots! Mostly from op-shops

Number of times I have burst into tears in front of a medical professional: at least twice

Number of kg gained: 3 (give or take 0.5)

Number of months I’m planning to take off work: 12

Reflux

As my pregnancy progresses, most of my symptoms have been easing off. One which has reared its ugly head recently though is reflux. This happens in pregnancy when the growing fetus squashes your stomach, but also because of the hormone relaxin flooding the system. Relaxin makes muscles loosen in preparation for birth, unfortunately one muscle that is typically affected is the sphincter at the top of the stomach. This is the one that stops stomach acid from flooding your oesophagus.

I’ve been having mild to moderate reflux for some weeks now, but it worsened around the time I left Perth. I had been taking Mylanta which is an antacid to help relieve symptoms and it was helping a fair bit. I was also doing the usual dietary things such as having smaller meals, avoiding chili (sob) and leaving plenty of time before dinner and bed. By a few days before christmas however, it was no longer cutting it. In addition to the considerable pain and discomfort, I was also getting concerned about the effects on my throat and teeth.

My next effort to control the reflux was Gaviscon. This was quite effective but absolutely disgusting to take. It’s a thick liquid, some of which floats on top of your stomach contents, helping stop the acid get to the sensitive throat tissue. Gagging it down was difficult and the floppy sphincter made me concerned about it coming back up too easily.

Finally after a bit of reading and research, I decided to give Zantac a try. The active ingredient in Zantac is ranitidine which inhibits the production of stomach acid. This means that it helps to prevent reflux rather than just treating the symptoms. It’s available over the counter and is a pregnancy category B drug. It’s pretty widely used by pregnant women and I had a chat to the pharmacist about contraindications. I also bought the generic brand after checking the ingredients.

Deciding which (if any) drugs to take during pregnancy is a bit of a fraught issue for many people. I know of plenty of women who will take nothing at all in case it could hurt their growing fetus. I prefer to take a risk-benefit approach which acknowledges that my health and wellbeing is also important, both to myself and to Spudlet. This is a  situation where my scientific training, research ability and effort to make informed decisions becomes very useful.  It’s good to be able to go to the doctor, midwife, chemist etc with specific questions having already done some reading on a given topic or topics. It means that I’m much likely to get useful, detailed information rather than general assurances.

I’m planning to make an appointment to talk with my doctor about reflux management when I get back home. In the meantime however, I’m glad to report that the Zantac is working beautifully and for now, the reflux is under control.

Pregnancy – The Quickening

In Highlander, the quickening is like being hit by multiple bolts of lightning. It’s, powerful, visual and impossible to ignore or miss. In pregnancy, quickening (the first detectable movements of the foetus) are tiny, subtle and leave you wondering if you imagined it.

I’m fifteen weeks along at the moment and the last few nights I’ve been feeling faint movements. I only really notice it when I’m lying on my side getting ready to sleep. The lack of other distractions is what makes it noticeable. The first few times, I wasn’t really sure but last night it was more obvious. I think spudlet was doing somersaults in there!

I pointed it out to Craig but of course there’s nothing to feel from the outside yet. I told him that if you shine a light at the foetus it will often move away from it. He was amused and unconvinced but fetched a torch and gave it a go. I’m pretty sure that I felt movement on the other side of my abdomen at one point.

I have mixed feelings about this. On the one hand it’s quite amazing and a little bit wonderful. On the other, I’m afraid to bond too much with spudlet in case hard decisions have to be made. The pregnancy is becoming more real though. I’ve also ‘popped out’ and have what is (to Craig and I at least) a visible bump. It’s firming up and feeling more dense. One benefit of being overweight though is that people around me are less likely to notice or to comment if they do.

Until I can announce it, I guess I’ll just have to wear more loose clothing.

Patience, thy name is not Molly

It’s been half a week since we got the high risk result from the first trimester scan. We got the result on Thursday and our doctor said to email her if we hadn’t heard from the hospital by midday Monday. I stayed glued to my mobile (even during the very wonderful and excellently distracting RailsGirls event on Saturday) but sure enough, no call. I emailed my doctor as promised, but then got annoyed with the whole thing and phoned KEMH myself.

To my shock/disgust/horror I was informed that I had been booked in to an appointment and that they had SENT ME A LETTER to notify me. Seriously, WTF! They know women going through this are majorly anxious. How hard is it to make a phonecall, or even send an email?! One lady I spoke to was kind enough to point out that everyone going through it felt anxiety. Awesome empathy there . The other thing that threw me very badly was that the amnio wasn’t booked for this week, or the next even. It was booked for the 5th of December. The day of the Library Quiz. The one I’m organising and MCing. Yeah.

No, they couldn’t change the date. They only had so many people who can do the procedure and they had to triage in terms of urgency. Plus, they can’t do it until 16 weeks because it’s too risky before then (despite their own website saying that it’s done from 15 weeks). They could make it earlier in the day though, would that help? Well, not much really. Considering you’re meant to go home and rest after an amniocentesis, not run a quiz night.

Once again, I spent most of the rest of the day in deep shock, retreating into my headphones and doing some necessary but boring and mindless tasks. I was struck with the fact that I’m due to fly to Sydney 10 days after the amnio appointment. The full results take longer than that, not to mention that if a termination is decided on it needs to happen preferably by 18 weeks. Oh god.

Back at home in the evening, Craig and I started researching. I mostly hit the forums, I had heard a few mentions of a new blood test and I wanted to read more. The US forums were helpful for this one. There were a few new competing blood tests (with the makers predictably suing each other) that could be done using massively parallel PCR techniques (which sound pretty cool actually). They had just started being offered last year and were pricey but not overly so in the US. They generally tested for the main 3 trisomies (21, 18 and 13). So were they available in Australia? The answer appeared to be yes, but at a much greater price and the uptake was a lot lower.

I also got a few calls from my Midwife once I told her about the high risk result. She spoke to a colleague who advised that the Women’s Imaging service was a very good private practice for such thing. She suggested that I talk to them about alternative options or even a different date for an amnio. I phoned them this morning and it’s a good thing that I did. They gave me a whole bunch of information including options and costs. I was particularly interested in the blood testing options. They informed me that they use either Verifi or iGene which are pretty much the same in terms of cost, timing, technique etc except one is sent to the US and the other is sent to China. Craig and I decided that in spite of the high cost, this was a good option if it would give us an answer sooner and hopefully avoid the necessity for an amnio.

I decided to look into the Verifi option a bit more and found a brochure about testing in Australia. The cost was $900 and would give results in ~10 working days. However, in Perth, they only collect blood on Monday and Tuesday between 9am and 1pm. It was at this point a little after 10am on a Tuesday. I phoned them up to ask if I needed a referral from an obstetrician (as specified on their brochure) and found out that a GP referral was sufficient as long as they used the special form.

This put me in motion like a spring. I grabbed up my bag and headed out the door, phoning my GP’s office to ask if they could get me in to see her pretty much immediately. Fortunately they are champions and the receptionist said they would sort it out. At the doctors office I only had to wait briefly before Tracey saw me. She hadn’t had time to look up the Verifi test, but took my word that it was what I wanted and filled in the paperwork. She also bulk billed me for the appointment. She is a total sweetie.

On my way out the door of the doctors, I phoned the path lab to ask about bookings. The receptionist said that they had one available next Monday. “How about today?” I replied. She was a bit floored but seemed to cope with the idea that I was on my way (emphasising of course that I would have to pay at the time). I hopped on a red cat bus and made my way to West Perth. 10 minutes later I was in the path lab. The receptionist got me to pay (ouch) and then I had about a 15 minute wait before getting my blood drawn. Less than an hour and a half after deciding to go ahead with it, my blood was in a (special proprietary) tube destined for the US.

Now I feel a lot better having done something about it. It’s still a waiting game though and I’m anxious about the results coming back before the amnio appointment. The vampire at the path lab said they take 10-14 working days. My amnio appointment is on day 13 of that so I’ll be crossing everything. If we get a negative (i.e. normal) result, we will probably cancel the amnio.

It’s been a very exciting day and I’m once again grateful to have such a supportive manager. The whole thing including phone calls and racing around cost me under 2 hours of flex in the end. Totally worth it to get the blood taken and sent off. Now I hope I can let my mind rest a bit and focus on all the other things I need to think about. Oh, and wait for that letter from KEMH.

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.