Update with our Birthing Plans

After a whirlwind last week, we're getting some plans in place and feeling a little more settled with our "game plan".

With the 34-week confirmation that my placenta was still covering my cervix, we decided to work with an OB at our local hospital to plan a cesarean birth in the event that the placenta doesn't move in the finals weeks of pregnancy.  We had an appointment planned last Monday (35 weeks) with the midwife at the local women's health center. (Even while planning a home birth, we do some prenatal care with her because 1. if a hospital birth becomes necessary, we have records and a contact there, 2. she is 7 minutes from us, as opposed to an hour drive to see my home birth midwife, so it's more convenient when we're just going for routine appointments, and 3. I really like her a lot!)  We talked to her extensively about our desires and concerns and who we wanted to put together for our "dream team" (I had an OB, anesthesiologist, and pediatrician all picked out in my mind.)  She wanted us to see the OB right away to start making plans and present our requests for the not-so-common-here technique of a "natural cesarean".  The OB happened to have an appointment open that afternoon, so we made plans to come back and talk to her.  I felt good and like things were falling into place.

About 32 seconds into our appointment, the OB told us that her biggest concern with our birth plans was the pediatrician.  So before our appointment, she had caught him and talked about our case.  He informed her that since our baby has a known heart-defect, they didn't want the liability of caring for and releasing him from the hospital.  And that if we did give birth here in Burlington, they would call in the neonatal response unit from the University of Iowa hospital to pick him up and airlift him to Iowa City.  And that's when I wanted to throw myself on the floor and have a tantrum.  I had this all figured out!  After several tough days of digesting placenta previa and Tetralogy of Fallot diagnoses, I had found peace with my plan!  The more rational part of me though, along with some extremely practical HypnoBirthing techniques to calm myself, smiled, thanked her for her time, and told her that if they were going to toss my baby onto a helicopter shortly after birth and take him to Iowa City, then I would just go up there to birth my child.

So Monday night I was a bit of a mess.  I felt overwhelmed and unprepared to navigate such a large hospital where I don't have relationships with care providers.  A place where, unlike here in town, I don't know the OB nurses, a fabulous anesthesiologist, and an OB and pediatricians that I know respect my choices, even when we disagree.  I had a good cry, did a whole lot of praying, and resolved to put on my big girl pants and move forward.

I spent the next couple days getting records transferred and trying to get an appointment with an OB at the University Hospital.  I wanted to get in within the week, and I wanted to see a female.  And that left me all of one option among the dozens of doctors up there.  And if I ever needed proof that God has this thing, our appointment Thursday afternoon provided that for us.

I wasn't sure how I would be received by the random OB with whom I had been given a time slot. I was walking in the door with a journal article about the technique I wanted used to birth my baby and a long list of questions/opinions about procedures before and after the birth.  Not everyone has an appreciation for assertive patients.  :)  She walked in, introduced herself, told me she had read through my records and was familiar with my situation, and then said, "So here's the punchline: I went ahead and got you scheduled for a c-section on Monday."  And then I proceeded to talk. A lot.  About my understanding of the preference to deliver at 36 weeks with placenta previa.  About my rejection of evicting my child with a known heart defect from the womb over a month early.  About my previous birth experiences and my preferences for this time around.  About my desire to give this little guy the best possible birth experience and strongest start that I possibly can.  And I was calm, and I held it all together, and I was polite and rational.  Eric was a great support and helped me to remember the things he and I had talked about needing to discuss with her.

And then really awesome discussion followed.  And at some point in there, the doctor was visibly fighting back tears.  She got it.  She understood me, my disappointment, and the challenge of trying to do the best thing for my baby.  And while she presented the medical view, she very strongly respected the research I had done and my opinions.  She reiterated several times that this was my baby and my birth and, while she is there to present the best evidence and medical opinion she has, it ultimately it is my choice and they will do whatever they can to accommodate my requests.

She ended up giving us well over an hour of her time.  She was in and out several times to consult with other people and make phone calls. At the end of the appointment, we walked away with these agreements:

-We have scheduled the cesarean birth for September 2 (38 weeks 1 day) with the hope and prayer that placenta moves and I can cancel it.  :)

-We will meet weekly and keep watching my placenta for movement (ultrasound) and confirm baby remains happy and strong (non-stress test.)

-She is arranging for me to meet with someone from neonatology to discuss my expectations of a healthy baby at birth and my intention to keep him with me and out of the NICU, regardless of the fact that he has a congenital heart defect diagnosis that will require checking out in the days after his birth.

-She is going to have the scheduled operating OB stop by at our next appointment so we can present my preferences for the birth.

-My appointment is Thursday this week.

-Meanwhile, if I begin to experience any bleeding or signs of labor, I am to go to my local hospital right away to be checked out and then head up to Iowa City if there is time.

I got started on writing my official birth preferences to have everything on paper and make communication easier for everyone involved.  And after all that, I am at peace.  It's a peace that I know only God can give.  I trust that however everything shakes out, it will be right for me, this little boy, and our family.  I am so appreciative for all of the prayers, and I hope you will keep them coming.

Besides praying that, if it would be His will, the placenta would move, for healing of our little man's heart, and for general peace and health, I would ask that you also remember the girls.  I had already talked to Gabriela and Lilian about how everything will be fine, but baby brother has a hole in his heart and he's going to born at the hospital now instead of at home so that the doctors can help fix it.  They expressed some disappointment that they wouldn't get to witness it like they did Makayla's birth, but otherwise they haven't said too much. (Although Gabriela did tell me that she heard me say that baby boy is going to go on a helicopter ride to Iowa City and she wanted to know 1. why, and 2. if she could go too!)  All of the out of town appointments and birth is going to mean we are away from the girls more than we intended and that, along with Gabriela just starting school and welcoming a new sibling, is kind of a lot all at once.  Gabi has mentioned our little guy's heart and the hospital in all of her prayers the last week, so even though she isn't talking about it a lot, I know it's on her mind.

We are so thankful for a God who cares and for family and friends who pray for us and support us both emotionally and with the physical needs of our family.  I appreciate all the notes, texts, calls, emails, and messages letting me know that we are in your thoughts and prayers and, even though I have not acknowledged each of them individually, please know that it means so much to me and has brought me so much comfort.

A Prayer Request for Our Little Guy's Heart and Birth

This picture captures the moment that most stands out in my mind when I think about Makayla’s birth.  It was so awesome.  She was born gently in a birthing tub, in our home, with Eric and the big girls there with me (along with my midwife, assistant, doula, and two dear friends helping to look after the girls and take photographs.)  I have never felt so surrounded by love and have never experienced so much love for all the people around me, as I did in that moment.  Being in labor and giving birth is, by far, my favorite thing to do.  I often tell people, in complete honesty, that if I could wake up and birth every single day, I would.  Really, seriously, I would.  I have no idea what I’d do with all those babies…but I love bringing new life from my body just that much.

While all three births have been great experiences and completely unmedicated and intervention-free, Makayla’s was definitely my favorite birth.  Being at home where I could curl up in my own bed with my baby and no one coming in every time I doze off to take my vitals or ask to mess with my baby was fabulous!  And I have SO been looking forward to that calm, safe beginning again for my baby, myself, and my family.  (Both Gabriela and Lilian have such good thoughts and memories from the day Makayla was born! And I think Eric liked leaving all the running around and getting somewhere to everyone else this time.)

When I had some bleeding at 19 weeks with this pregnancy and we discovered, through ultrasound, that my placenta was positioned over the cervix, I wasn't overly concerned.  Somewhere around 15% of pregnancies have some degree of placenta previa at 20 weeks.  That drops to less than 1% by full term.  The placenta pretty much always migrates up as the uterus expands.  I've taken several steps as prescribed by my Traditional Chinese Medicine Practitioner (Western medicine says there is nothing to be done but wait and see) to help ensure it moves (herbs, acupuncture, diet changes, plenty of rest, and yoga), and I've been sure it would do just that.

So at 34 weeks when we went back in to check on the position of the placenta, I was both shocked and disappointed that it was still just barely covering the entire cervix.  You can’t too very well have the placenta (baby’s life-line) come out before baby.  And so the safest way for baby to be born with a complete previa is via Cesarean birth before you go into labor on your own.  The placenta still could move, and we would certainly look at it again before anyone starts slicing me open, but the likelihood of that happening is declining.

The other piece of news we received last Thursday, at that 34 week appointment, was that our little guy has Tetrology of Fallot.  It is a congenital heart defect consisting of 1. ventricular septal defect (for him, a  large hole in his heart between the ventricles), 2. overriding aorta (the main artery in a less than optimal position), and 3. pulmonary stenosis (in his case, this seems to be very a very mild narrowing of the right ventricle outflow tract.)  It will basically cause some blood to bypass the lungs and mix with the oxygenated blood being transported through his body, reducing his oxygen levels.  While this doesn't generally pose a risk to newborns, which have relatively low oxygen needs, as he grows and becomes more active, it is a serious problem.  The expectation is that he will require open heart surgery around 4-6 months to correct the malformations and afterwards he would be expected to lead a normal life with little-no restrictions.

That second piece of news complicates the first though.  OBs recommend a c-section at 36 weeks with complete placenta previa to minimize the risk of the cervix opening underneath the placenta and causing a major hemorrhage.  (Side note: Given that none of our babies have come before 40 weeks, we aren't comfortable with and would not consent to extracting this kid 1+ month early, regardless of the recommendation.)  Meanwhile, under normal pregnancy conditions, the pediatric cardiologist would prefer a spontaneous vaginal birth so that baby gets the strongest, largest start and doesn't have the breathing difficulties that so much more often accompany a non-labor Cesearean and/or pre-term babies.  Ultimately, since we’re the ones with the most at stake here, Eric and I have to look at all the evidence and decide where our comfort level is and at what point we feel the risks/benefits are most balanced. 

The big picture: the prognosis of placenta previa and Tetralogy of Fallot are both good in this day and age.  While both would have most likely lead to death of baby (the heart condition not right away, but eventually) and quite possibly mother 200 years ago, current medical technology has lessened the risks considerably.  

But the thought of my baby coming to me through major abdominal surgery (not to mention recovering from said surgery with four children 5 and under) is hard to wrap my mind around.  And then throw in open heart surgery with a 7-14 day hospital stay for my infant son and it all seems a little overwhelming. 

The reality check: I know other people suffer with much more.  I have friends dealing with infertility who would LOVE to be told, “you will have a baby, but he will need to be born via c-section.”  I have friends and family who have received terminal diagnoses and lost babies and others with children who will have life-long challenges and limitations, and “we’ll do a surgery at 4-6 months and after that all should be fine” would be the best news of their life.  And I do feel selfish and ungrateful at times to sit with the feelings that I have surrounding my situation.  But I also accept my emotions while praying for strength and serenity in all things.

I am incredibly thankful for the life I have, for the children God has entrusted in my care, for easy and uneventful previous births, and for this sweet little boy who will soon join our crazy family on the outside world.  We will handle whatever comes our way.  But I would be ecstatic if this placenta would slide a few inches up and over to open the path for baby.  And if God would see fit to stitch up our little one’s heart on His own, I can think of no greater miracle in my life.  I know He is in control.  He will give me, Eric, and the girls the strength to do what needs to be done.  And I know He answers prayers.  So if you would like to join me and my family in praying for this little guy and his birth, we would be most appreciative.

We have an appointment tomorrow afternoon with an obstetrician to start talking about the birth plans.  I'll update soon with more information.