33 weeks, 6 days: Close calls, interdoctor discord, and THE PLAN

February 13, 2014 § 34 Comments

Still pregnant! But holy, cow.

Crazy days, my friends.

Last Wednesday, I got my rankings submitted for the next phase in my clinical training. In 9 short days, on Match Day, we’ll know where our little (all of the sudden not so little) family is going to be living next year.

And then on Friday, we very nearly met the new members of that not so little family.

Friday was one of the most stressful days of my life. It was the first day I have had to make a serious decision for these children. My children. It was the first time I felt the weight of that – of being someone’s mother. The mother to two particular someones. Two small humans who have only me and The Artsy Engineer and who need us to make the right choices. It was so heavy. My throat closes up a bit thinking of it.

Since the last time I updated, things have fluctuated considerably. A few days after I wrote that post, they sent me home to continue bed rest there, because baby boy’s cord blood flow was consistently showing continuous (but still reduced) end diastolic flow. That lasted for under 36 hours. I got home on Monday evening and was readmitted a week ago today on a Wednesday morning after they saw intermittently absent flow again on the Doppler ultrasound. We were disappointed, but I knew the respite from the hospital would be temporary. I was just really really hoping for another couple of nights of dog snuggles and home cooked meals that my husband doesn’t have to unpack from a cooler. The good news about that Wednesday (32+5 weeks) was that we had the growth measurements taken again (as they only do it every two weeks to minimize error), and both babies had pretty solid growth estimates. Baby girl had gained a full pound and was estimated to be 4lbs 4oz and baby boy had gained 3/4 of a pound and was estimated to be 3lbs 6oz.

Then on Friday, my friends, it got real. The flow went back to absent end diastolic flow and the proverbial shit hit the proverbial fan. If you peek back at that last update, absent end diastolic flow is what was going on when I was admitted in the first place. The exact same issue. I was only 31 weeks then, but the data was the same. I had a particular protocol that the perinatologist (MFM doc) recommended and that my OB implemented. It involved 3x/day NSTs and 3x/week ultrasounds, bed rest, and steroid injections. However, I am situated at a major academic medical center, which has a lot of really excellent benefits but which also means that there are LOTS of people involved on my team. It’s a big freaking hospital with the highest ranked NICU and perinatology program in the state. But on Friday, the perinatologist who I had been seeing all along was out for medical treatments and that meant that I would be passed along to the others, depending on who could squeeze an inpatient into their schedule. There are 7 of them. This is apparently how it typically goes for people, but my OB had arranged it so that this particular perinatologist  would see me whenever he could. With him out of commission for 2 weeks, I saw this new guy. This new guy was described as “excitable” by several people before I met him, and I wasn’t sure what they meant. It could be demonstrative excitable, which is not a bad thing at all and was frankly what I was picturing, but it turned out that they meant more of the high-strung, impulsive, temperamental flavor of excitable. Bummer for me, apparently. Because he walks in, and with no further ado, he says, your baby has absent flow and you’re past 32 weeks and so there is no sense of waiting around until reversed flow because of risk of stillbirth so I am recommending that we deliver your babies today. BAM. Just like that. I’m all alone, sitting in his outpatient clinic office on the exam table, and I can’t walk anywhere or escape (which is strangely what I wanted to do) because if I look like I’m going to pass on the wheelchair, people get all concerned like.

By the time I got back to my room, my OB was there waiting for me, and he was not pleased. Pacing, fired up. He had to lecture to medical students, so he said that he was going to leave but that he’d be back 2 hours later to have a conversation about what we wanted to do. He had me call Bryan in and stop eating and drinking in case we decided that we wanted to proceed with the c-section that afternoon. Apparently, he had asked the perinatologists to speak with him before speaking with me and especially before making any specific recommendations to me, because he knew how different their opinions regarding what to do with absent end diastolic flow at 32, 33, 34, etc weeks.

When he came back, the three of us talked it out and decided to wait and try to squeeze out a little more time. We just felt as though this was the SAME DATA we’d had when I was initially admitted. Babies continued to look great on monitoring, BPPs were excellent, and there was absent flow. The only difference was that I was now past 32 weeks, so this doctor decided he thought the risk of leaving him in was now greater than the risk of taking them out. To appease this doctor, we’d increase monitoring to daily ultrasounds to look for reversed flow and do continuous fetal monitoring except when sleeping and eating (although I was woken up between 1-2 in the morning for a briefer monitoring session). The trickiest part was that my OB was leaving town for the weekend and was unreachable until Monday night and thus could not act as an advocate. He left saying that he’d tried to tie down all of the loose ends he could, but that he couldn’t control it once away. If whatever perinatologist did my scan on Saturday or Sunday or Monday suggested delivery and the OB on call agreed, we’d be delivering. He spoke with all of the OBs who were on call over the weekend to try to tell them the situation, but he wasn’t sure it would be enough.

I won’t go into all of the details of the weekend, because this is getting long enough (and confusing enough) as it is. But I was essentially told that my plan of care was being changed by every single doctor who came in the room, which amounted to about twice a day. One said that using a different set of norms our boy was actually not growth restricted at all (that he was at the 20th percentile rather than below the 3rd) and put me back to 3x/day monitoring. The next told me that babies were doing great and they’d deliver me at 34 weeks unless something changes before then (this is the first I’d heard of a 34 week cutoff). The next said that she wanted me back on continuous monitoring (even though nothing has changed) and that there was talk again about delivering that day. The next said that there was no way continuous monitoring made sense and that I would also be changed from full bed rest to modified bed rest but that our boy is, in fact, IUGR based on the set of tables that they just switched over to using and that is used in much of the recent research. I did my best to let it go in one ear and out the other and to just hold down the mental fort, so to speak, but it was tough. Without my OB here to be the ringleader (and he is, in fact, the ringleader), I was left to the devices of a group of practitioners who practice as individuals. We didn’t know how to gauge our fear and anxiety. Should we be as concerned as doctor number 1? Did I want continuous monitoring because any minute my baby could die? Or should I be as concerned as doctor number 3, who was clearly confident that there would be indicators of fetal distress leading up to something catastrophic that we could catch using less frequent monitoring. Etc etc. It was a nightmare, my friends, and I think I am just coming down from it.

Nobody signs up for randomized clinical trials and signs on to put their babies at risk, so there isn’t a lot of research for these doctors to go off of. There is no standard of practice for absent end diastolic flow in the umbilical arteries, here at this hospital or anywhere else. My OB pushed the 7 perinatologists to meet and come up with some guidelines that they all agreed on, and yesterday, finally, they did.

So. The plan.

Before 34 weeks: Either absent or intermittent end diastolic flow mean closer monitoring but not delivery. Reverse flow, less that 200g growth in 2 weeks, or indicators of fetal distress on the monitors or on the BPPs mean delivery.

After 34 weeks: Intermittent or forward mean I get to stay pregnant (provided that indicators and growth are okay). Reverse flow OR absent flow mean delivery.

Regardless, delivery no later than 36 weeks. Which means that my OB scheduled our c-section for Friday, 2/28. Two weeks from tomorrow (and one week after Match Day).

So, essentially, if they see absent flow after 34 weeks (which, ahem, is tomorrow), they will choose to deliver me that day. My ultrasounds have gone like this intermittent, absent, intermittent, forward, forward, forward, intermittent, absent, absent, absent, intermittent, intermittent.

Tomorrow I am at 34 weeks. From here on out, every Monday, Wednesday, and Friday are scan days and are going to be the decision points. If you look at the list above, I received a round of betamethasone (the steroids to help with fetal lung development) on the first day there was absent flow. Flow then improved and did not go back to absent for 10 days. If you ask the perinatologists, they’ll tell you that there is no research in support of betamethasone improving flow but that they see it in practice often enough to notice it. They would never give it for that reason alone, but because I was due for a booster (it had been two weeks since the last injection and I was still before 34 weeks), they would be interested to see if it might buy me an extra week or so before I would go back to absent and need to deliver. I got my booster on Tuesday and Wednesday, and baby’s flow was improved to intermittent on Wednesday’s scan. If the steroids are part of what helped the last time and it follows a similar trajectory, perhaps I can make it to the 21st (Match Day and the day I turn 35 weeks) before it turns absent again. I’d love to make it through the weekend and buy just a few more days.

But I could also go in tomorrow and see absent flow and deliver two tiny babies, one estimated to be just under 4 pounds and the other estimated to be just under 5 pounds, within a couple of hours.

I’m on the scan schedule for 7:10 AM. Wish us luck, friends.

_____________________________________________

* That was going to be an earlier post, because it was a very, VERY upsetting development for me. Apparently our baby girl, who is closest to the cervix, is footling breech, and because of the way our boy’s bag of waters has settled in around her, we have known for about a month that it is highly unlikely that she’ll be able to turn. My doctor will deliver vaginally so long as Baby A is vertex, regardless of the position of Baby B. He will happily do a breech extraction for Baby B. Baby B is moving all around still, flipping vertex to breech to transverse to breech to transverse to vertex daily (I know because I get ultrasounds ALL THE TIME). But it’s Baby A who makes the decisions here, and she’s not turning for us. I cared A LOT about this a month ago. I could care less now. I’d be thrilled if she shocked us and turned after 6 weeks of being in one position, but it ain’t gonna happen. And now, with all of this, I just want some healthy babies to come out of me – through vagina or uterine incision or nostril. I don’t love it. But I have bigger things to fret about.

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§ 34 Responses to 33 weeks, 6 days: Close calls, interdoctor discord, and THE PLAN

  • Steph Mignon says:

    Dude. I am sooooo vying for those little babies to stay in there as long as possible. Wow. Wow. AND WOW. What I definitely take from all of this is how medicine is definitely a “practice” and no where near an act of “perfection.” Data can be interpreted differently. People can over (and under) react. How totally frustrating and confusing and frightening! Thank God you guys have come up with a plan that to me sounds coherent AND safe. Here’s to 36 weeks! Also can’t wait to hear where you’ll be moving. Maybe Los Angeles and we can be real life friends! haha!

    • Yes. Medicine is so very much a practice. The gray area is vast, leaving so much room for interpretation. I’m with you, though. I like this plan. It’s a tough position to be in – to just wait for your baby to be at greater risk – but we’re weighing the benefits to both babies here, and I think it’s the safest plan there is. Plus it took 7 very smart and experienced minds to come up with it and they argued and discussed before coming to this conclusion. You can’t beat that.

  • Amber says:

    That is crazy how much the doctors weren’t on the same page, or working together. It makes me grateful for how the MFM doctors and OB’s all worked together at my hospital. I’m so glad they finally came to an agreement, if only for your own peace of mind! I never wanted a c-section either, but was glad when the decision was finally made and I didn’t have to worry about which way it would go. I’m wishing you all sorts of luck Lentil! They might not be able to agree on protocol, bu at least you know your babies are being watched very closely.

    • Yeah, the c-section thing made me sad. I just had this weird animalistic desire to push my babies out. But I think it won’t matter so much in the end. Because I’ve been here for so long, I was able to tour the OR and picture our birth happening in that setting. It really helped.

  • Kimberly says:

    Oh my goodness. You guys have been through a lot. All of these varied and changing opinions sound like a nightmare! I am so impressed with how you are handling it! I hope you get to keep them insid as long as possible but it sounds like the new plan actually makes sense! Thinking of you!!

    • Yeah, I’m pretty okay with the new plan. Frankly, I think sometimes I’d rather take them out now to be sure we have two living babies, but my confidence waxes and wanes so often. It’s tortuous.

  • nickeecoco says:

    Man. I will definitely be keeping you all in my thoughts during these next few days (and hopefully weeks!) You are so strong and going to be a great mother to these babies!

  • jebhow515 says:

    My brothers twins who were delivered at about this time in his wife’s pregnancy were just under 4 pounds and just over 4 pounds. And have I mentioned that they are 2 1/2 now and quite gifted :). Hehe. You are in such a good place now. I am glad you made it to 34 weeks!!

  • Wha…..Can’t breathe after that post. And of course spit out my coffee laughing at “nostril.” Out the nostril. I mean, at this rate, it wouldn’t surprise me if some doctor came in your room and said: “In my opinion, we should deliver both by nostril in week 67.” You are doing great! Keeping the zen on for babies, who will soon be here. Hold steady…

    • Ha! I know. Frankly, I would not be shocked, either. My OB has been absolutely incredible and stable and by my side, but he’s trying to make sense of and suggestions based on all if their conducting information, too. I think I’ve fallen in love with him a little bit, in fact, in that weird way you sometimes do when someone goes above and beyond their typical duties to care for you.

  • jesselyn6585 says:

    Holy stress Batman! However, you’ve made it to 34 weeks! *happy dance* Sending gymnastic flippy vibes to Baby A and grow vibes to Baby B. Sending you and Artsy Engineer lots of love, strength, and patience.

  • Amanda says:

    Eeeek!!!! Girl, you are handling this so well! So well! You deserve a big high five and cake… can you have cake? You should definitely treat yourself at your first opportunity! I’m guessing since you’re commenting and it’s after 7:10am, that you passed the ultrasound test today… hoping for continues good news! Even if the babies are born (hopefully not through the nostril) next week, I hope you feel really good about the great start you’ve given them. 4 and 5 pounds for twins is something to be proud of… well done my dear! We’re all rooting for all four of you!

  • Hold tight mama, you’re almost there! And you’re in the best place, getting a lot of attention and monitoring for those little babes. I know it’s scary, not knowing what tomorrow will bring, but you have a good plan, and you’re in good hands!

  • J o s e y says:

    Phew, thanks for the update. What a rollercoaster you have been on! I’m glad you at least have one director trying to get all of the docs on the same page for you, but that has got to be such an emotionally trying development to not be sure whose opinion to trust — b/c of course when it comes down to it, nobody knows for sure what’s best. At least it sounds like they have a good plan moving forward, and how exciting that you’ll be holding these littles in your arms soon! My girlfriend delivered a baby boy at full term last fall that was only 4#4oz (they have no idea why he was so small – no IUGR), and he was definitely TINY, but oh so adorable and healthy. I hope the same for your babies!

    Also, I’ll be praying baby A flips head down for you. What a stinker! What a blessing to live in a time where a c/s is an option, but I sure hope you get to at least attempt a vaginal delivery since that is your preference.

  • missymakes says:

    Oh my gosh – things have been so crazy for you! I’m glad there’s a plan now and it sounds like you’re comfortable with it. I’m sending forward/intermittent thoughts your way for the big scan!

  • E. says:

    I’ve never commented before, but I’ve been lurking on your blog for a while now, and rooting for you and your babies. I’m in awe of your spirit and grit through all this. Your babies are lucky to have you. Anyway, just wanted to let you know you’re in this stranger’s thoughts!

  • Daryl says:

    Sending continued thoughts and good growing vibes for both babies your way! I’m glad you finally have a plan in place that everyone agrees on, but man, what a roller coaster to get there. You’re handling all of this beautifully, and I’m so excited for you to meet your two healthy babies soon (but not too soon)!

  • Isabelle says:

    So tough! Hope that everything goes well and no more fighting from the doctors.

  • Megan says:

    Gosh y’all have gone through so much in the last couple weeks, I hope you get to wait til at least 35 like you want- either way it goes I hope the babies do well whenever they are born!

  • Aramis says:

    Are nostril deliveries a thing now? I didn’t know that was a thing.

    Ok, now that my poor attempt at making you smile has failed, let me just say as an over analytical control freak I can begin to grasp what horrors the last few weeks must have been, especially with all the conflicting medical advice! I can’t do anything but send you love and hope for a safe healthy delivery.

  • L-you are an awesome mama already. Hoping for a safe and serene delivery however they arrive!

  • Oh.my.gosh. You poor thing. I can’t get over that doctors were coming in twice a day, everyone telling you something different. You’re amazing for not going crazy. I would have flipped. Stay strong and know that I’m praying for your little ones to hold on a couple more weeks!!! xoxo

  • Shannon says:

    With my twins, both babies were constantly flipping and the doctors kept trying to schedule me for a c section, to which I said only if it is absolutely necessary. I was so thankful when baby A turned somewhere between 37 and 38 weeks (b stayed transverse). So while I was induced at 38+4 due to the higher mortality rates after 39 weeks I got my vaginal delivery best of luck to you, no matter what happens.

  • mammacod says:

    I’ve been following your story only recently, but I wanted to let you know how much I’m pulling for these babies to get to 36 weeks! Sending lots of positive thoughts your way and also lots of admiration for your apparent complete cool during this whole situation and the fiasco with the doctors. No one should have to be subjected to such poor organization and communication, especially when needing to keep calm and focus on keeping your kiddos healthy. Way to go, mama! Hang in there. xoxo

  • nonsequiturchica says:

    Oh boy this sounds like it would be incredibly frustrating with all of the doctors saying different things. Update us when you can!

  • sarah says:

    Oh lentil, what a hell of a time. All of the different opinions, the competing medical minds – not the stress you need while growing two amazing humans. I’m sure you’ve heard these stories before, but FWIW, our downstairs neighbors have healthy, thriving six month old twins born unexpectedly and with great drama at 34 weeks. Everyone is doing awesome. Sending all kinds of positive vibes and strict orders for inmates 1 and 2 to remain healthy and inside of you for as long as they safely can. Can’t wait to meet these two! xo

  • Flicka Mawa says:

    What a journey you have been on! The Dr situation sounds really frustrating. Good luck! I also spent the last 2 weeks in that state of “each checkup had the real potential to lead to delivery that day”, although I was fortunate to be full term already.

    I am thinking of you and your babies often. Is there anything you will still need for them? Clothes for 5 pound babies?

    I’m sure you know this but be aggressive about pumping in the hospital if you plan to breastfeed; make sure the nurses know your wishes either way. Someone here that I know recently gave birth and I was surprised to hear that when her daughter was sent to the NICU it wasn’t automatic for the nurses to bring her a hospital grade pump and help her get her supply established. She now wishes she had pushed for that sooner.

    I’m sure you guys will continue to handle this will and make the best decisions for your children. Hugs!

  • notpregnantandpissed says:

    I am so hoping those babies cooperate and hold out just a week longer! And I hope those Dr.s chill the fuck out and stop stressing out a worried pregnant lady! It’s amazing to me how insensitive Dr. s can be! I am sending you lot’s of good vibes and I know everything will work out and soon you will be loving on those sweet babes! Good luck friend and keep us updated!

  • Hey Lentil. I’m hoping you’re still hanging in there and that booster bought you more time. Keeping you all in my thoughts.

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