Hands Full of Rocks

April is anniversary time

Mid-April would have been the due date for one of the babies I miscarried. Mostly, I don't have any blips over that - the losses were mainly early, and I generally had a sense of peace over them, eventually.

But I still miss her, sometimes. She being the one whose laughter I could hear, whose smile I dreamed about, whose loss and my subsequent silence about the ongoing grief caused the biggest train wreck in our marriage.

Now, if I have faith in what Mr G has said, I'll meet her again - she was not mine, but was instead meant to be with him. He told me that she was born to another mother, and that he would marry her when he grew up. And that she loves earrings.

My dreams of her were all of someone of mixed race heritage - dark skin, curly hair, deep brown eyes, and that ready smile and somewhat dry sense of humor. I dreamed of her more during that very short pregnancy than I dreamed of any of my other kids, or that's the way it feels, anyway.

It's been a while - nine years. Some of the information fades. But April always gets to me. August gets to me on another loss, but April is hers.

I never notice until I'm knee deep in it, feeling unaccountably weepy, volatile, like I'm waiting for something that might never come. It's that feeling of nearly holding my breath, or of worrying about ep if I'm waiting for him to come home - trusting that he's fine, but anxious anyway until I see the headlights of the car.

For extra fun, I usually end up mentioning miscarriage to someone, without warning. This time it was a coworker. Totally tangential comment to the conversation, out of the blue. I had no idea where that came from (I opened my mouth and the words fell out). I recognized that they weren't relevant and shifted the conversation on to the next topic (he fortunately tends to shrug odd stuff from me right off - it's either a Me thing or an American thing, whatever) - it was only this morning that I realized it was a week past her due date, which is right when it usually reaches surface for me.

Bleah. And I have a busy day today, and no time to process.

Musings on pregnancy and birth and evidence-based medicine

I am well past most of the baby and pregnancy stuff, for myself. But I still have friends who are having kids or might still have another. So I try to keep an eyeball out for items of interest.

A major item of interest for me is my flat-out favorite evidence-based medicine for maternity care site, Childbirth Connection. I originally found them as MaternityWise.org, and that group merged with Childbirth Connection later. Regardless, they're all about understanding how the entire process works - and not just in our bodies, but interpersonally (with support staff and medical providers), and also at that third level that takes into account culture and institutions. Their evidenced-based maternity care report came out last year, and I forgot to mention it. It's worth a read if you're pregnant.

It is the institutional culture process that has some major issues at the moment, when it comes to childbirth, at least in the US. Maternity care likewise, but there's less of an obvious disconnect there. Consumer Reports even did an article on the issue of overuse of technology in pregnancy and birth. They pointed back to the report that Childbirth Connection released (linked above), which has some very important points about maternity experiences and care.

I'm not going to go into the details here, but I'll note that they're not anti-hospital or anti-OB, and they don't think we should decline every possible intervention under any circumstances - they're genuinely evidence-based, they rely on the Cochrane Collaboration (renown for examining the evidence for all sorts of medical practices) and do similar work themselves. Some things get the thumbs up, some get the thumbs down, and a lot of things get the 'there is just not enough evidence either way on this one' (hint, hint, please somebody do a quality study on that topic!). Y'all can read the link.

When it comes to pregnancy and birth, I tend to go both personal and philosophical.

I'm a fan of natural childbirth - born and raised that way, since my mom did it long before it was at all even counter-culture trend. Like, in the 50's. She even (gasp!) breastfed her kids. Tsk, tsk. I was raised with a regular retelling of my own birth story as a personal history of power, determination, passion, spine, and humor. I just assumed that women can do this.

And I also am a fan of Western medicine. My eldest brother survived three years because of surgical intervention, and died only because medicine had not yet advanced as far as it has now. If he'd been my son, he'd have lived a much longer time, and might not have even suffered much brain injury on the way. Western medicine gave him a fighting chance, and a childhood, that he would not have had otherwise.

It puts me in an interesting place. Kind of like I am with parenting - that there are many tools that can come to hand, and relying on only one is rather limiting. I rely on everything I can put to use. Everything can have a shot, I'm not picky (okay, I'm picky, but I'm not resistant). I view everything with a bit of skepticism, and everything with a bit of hopefulness, too. As long as the benefits and risks can be weighed and tip the right way, I'll consider it. If it is very low risk, I'm likely to try it and see what comes of it, even without a strong clinical basis.

So, birthing.

My general expectation was that birth would be as powerful, amazing, potent, fundamental, and physically engaged as my mom described it. She glowed, radiated, became focused when talking about it. She smiled, laughed, was warm with the memories. My expectations followed that lead. I thought I'd get there with an OB, but the OBs who are on that planet are somewhat few in number. I had one, first pregnancy - she was grand. Non-interventive, expectant management (watchful waiting), positive, not fear-based. Unfortunately her two partners in practice were unlike her, one being kind of middle-ish, and the other being very 'I am OB, I am a God, you are patient, you are an ant' in attitude. And then we moved, and I got to rethink my expectations, and had the opportunity to look into whether midwives were really actually scary people who didn't have a medically rigorous bone in their bodies (as I'd been acculturated to believe, though not by my mom), or if they had perhaps not been given much chance to state their case... which ended up being the truth.

Switched to midwifery care.

But. Still don't object to medical intervention. I have needed medical intervention with that first labor, and was grateful to it (despite the side effects, which I think I got every possible one except a spinal headache or catastrophic blood pressure drop from the epidural, and a lot of side-effects just from the IV fluids). Still, glad it was there, glad it was possible, glad I could choose without guilt or shame, and I don't even have regrets on that - it was what it was, labor was what it was, eh, whatever.

I like to choose, though. I like to be part of the team that decides what happens and what does not. I'm pretty easy going (despite my past comments on being a feral laboring mom - I'm totally compliant and a limp noodle easily bent in any direction by the merest glance, provided you don't engage my pissed-off-ness - I end up being a doe, not a wolf, unless I feel I need to be a wolf...). I'm more accommodating than usual in labor - I want intermittent monitoring, and you said I could do that, but ya know, it's not really bothering me right now, and I'm not really feeling like bothering to mess with it, so, eh, whatever, leave the monitors on (that was with the twins).

But my brain engages on the process, even for things like IV fluids. I know they make me swell badly and contribute to an uncomfortable recovery. But I can talk to the doc and discuss the issue of my minuscule unhelpful valvular veins (many of the little gate-keeper valves makes it really hard to hit me clean with an IV even under the best conditions), and dual placenta sites, and come down to - yeah, set me a hep lock, and if they're not working well, set me an IV with the lowest possible flow just to keep the line open. It's okay - that's my call, with their call, together.

Having the evidenced-based information to draw on is a help, for me. It allows me to engage in the conversation as a partner. I don't want someone else to do it all for me, really. I also don't want to do it all for myself. I just want to work in community and coordination with a team that is all on the same page. I did get pretty much that the first time (despite the long labor and the transfer to hospital). A few blips, but nothing major. And I got that the third go, with the backup OB unexpectedly assigned the double-vaginal breech natural birth that is going at a very precipitous pace. Kind of an eek on her part, but she dealt, stayed with me mentally even when I challenged her preferences in the middle of it, and we tuned to each other reasonably well. Being able to make note of evidence-based medicine for my preference (that is, not c-sectioning for second twin breech, especially after having done first twin breech) allowed me some standing even where she was the professional who was indeed having to do a lot of the work part of birthing the babies.

The evidence-based medicine information is also what made me decline the c-section scare tactics with Mr B. I knew that evidence showed that near-term ultrasound size estimates can be very much off (Mr B's estimate was more than a pound higher than he ended up being - as measured the same day he was born). It wasn't that the ultrasound was 'bad', it was that evidence shows that ultrasound at term is not very reliable (even within a 10% margin), though the trend is that if the baby reads very big, they're likely to be bigger than average (which was true, but there's still that missing pound-plus in there).

I'm meandering, I know.

Why am I thinking about this just now? Because the friend for whom I'm doula-ing is overdue. She's not happy about it, though she's glad that her daughter held out to after the end of the chemo/radiation treatment program for her husband. She's ready. Hello, ready! Baby? You can come out now! Like, now! Okay, today would be good...

They didn't opt to go for a midwifery center, but the hospital they chose is great. Warm in tone, supportive in atmosphere, and all over non-interventive-first stuff. Like, when I asked (at the hastily arranged private tour) about birthing balls, they said they had them, they really liked them, and there was NOTHING like a birthing ball for getting a posterior baby to turn, really opens the pelvis... they also have an advanced childbirth class that is all about the extra stuff you can do to support a mom in a no-meds labor. And it's cheap, so it's not prohibitive, either. They're all over breastfeeding (posters everywhere), and the breastfeeding class happens the first morning you're there after the baby is born, so they get you 'fresh' and can help with specific issues you have with your own baby and body, in real time. Kinda cool. 

I'm looking forward to working with them. I'm keeping my fingers crossed for a good, easy, smooth labor - it would be good after the rather lumpy late pregnancy dealing with cancer and all that. We'll follow where it leads, though. Waiting for the call... waiting, waiting... 

Research: Hold on those last few weeks if you can (eat your fish oil)

In the twin forums I've been involved with, there has always been discussion about the issues of 'term' - about half of all twins are born before 36 weeks. Many doctors think that twins should be delivered by 36 1/2 weeks, regardless of any other indication - it is just 'too hard' or 'too risky' to stay inside at that point. Research continues to not support that thinking - babies are really meant to stay in for 38 to 42 weeks, and while there are real and important reasons to take action sooner, the trend is toward increasing preterm births (many of them by c-section). Late preterm seems like it is safer - 34 - 36 weeks is 'close enough' ... but 'close enough' may not be as close as the doctors think.

Researchers seeing the trend (70% of preterm births are in the late pre-term period) have tried to determine what the impact of that gestational age of birth is - and it is definitely still a high-risk situation. Neurological impacts are particularly notable as major issues. Yes, their lungs are mature 'enough' and they usually have a suck reflex. But.

It is hard for the mom (dad, partner, family) to balance the risk profile effectively. And it is also hard for the OB to take a long-term look - the baby comes out 'looking healthy', and they are not the pediatrician or family doctor, so they do not have to deal with the long-term picture of developmental delays or neurological deficits. So it's important to make sure the care provider you have is aware of the issue, especially if you have a risk condition that might indicate pre-term birth as a potential offset to risks of a longer gestation (gestational diabetes being one issue that is tricky to balance - how big IS the baby, really? We don't have an accurate way to find out for sure, late term, so it becomes a guessing game).

In the twins research world, even 'near-term' (now effectively 37w - that last week between the end of late preterm and the start of term at 38 w - the terminology is changing, near-term used to have a different range, and was used interchangably, and is probably not settled even now) has been noted to have a laundry list of risks associated. 38 weeks really is the lower limit. It's really hard to reach that, though there's some indication that omega-3 fatty acids (especially DHA) can extend twin gestation (six days just by changing to DHA-enhanced eggs and eating a dozen a week).

Interestingly, the tie-in with DHA may be a contributing factor to both the preterm risk and the neurological factors. A diet low in Omega-3 fatty acids both increases your preterm labor risk and increases the risk of neurological issues for the baby. While this presentation is long and includes multiple factors, the discussion of DHA and other fatty acids is really important. (Someone ping me if you can't read it, I have a Medscape membership on the professional side, and I can't always tell if something is locked down to casual readership.)

It is reassuring that more doctors are being given access to the information about nutrition as an important factor. It is also reassuring that (as noted in that presentation) women are going to their doctors asking about nutrition, bringing it to the doctor instead of just waiting for the doctor to bring it to them. Keep doing that. They've noticed!