Week 38 Appointment: Induction TONIGHT

Well, it's finally February 10th and that means no more guessing and no more waiting: Baby will be here and in my arms by tomorrow.  

The appointment at the Antenatal Testing Center this morning showed a reactive NST and that it'd be necessary for the doctors to administer several doses of Cytotec tonight before beginning Pitocin and actual, active labor tomorrow morning.   I'm excited and glad to have answers to all of my "what if," "when," and "how" questions.  

We're heading home now to have an afternoon full of GW and GV before we head back up to the hospital at 6 PM tonight.  Not sure how long it will take me to get updates up after delivery, but it'll happen :) 

Wish me luck!

Week 35: Right now, right now? Maybe later, later?

Well, my 35 week check up was yesterday morning and I can’t even begin to understand where my head is today as things are just all jumbled.  Going into the appointment, I was anticipating all sorts of doom and gloom due to my weight gain this past week, a four-day headache that acetaminophen just wouldn’t shake and the knowledge that we’d be repeating fetal measurements (in other words, just how huge are we talking? And is vaginal delivery even still an option?);  but having hopped in the car almost two hours early to learn that the inner-loop of the Capital Beltway was closed due to a turned over vehicle blocking both the two Hot Lanes as well as all four of the regular lanes, I began to think my pessimistic expectations of the morning’s happenings were a bit too cheery for what was actually in store…  

Taking just shy of those two hours to get to the hospital due to knock-on accidents and residual area-wise back ups, I arrived just on time to go straight from the ATC reception into the ultrasound room for my exam.   Running a biophysical profile, checking my amniotic fluid index levels and measuring Baby’s overall growth, Tamara - the wonderful sonographer I’ve worked with through both of my pregnancies with this doctor’s office - was comforting, yet frank about where things currently stand: 

Biophysical Profile: 8/8

Amniotic Fluid Index: 29.6 

Estimated baby weight:  7 lbs 3 oz (85% percentile)

Abdominal Circumference:  34.2 cm (+18 days)

Head Circumference: 34.1 cm (+19 days)

Showing me the 3D pictures of his (practically identical to GW and GV) face, Tamara and I couldn’t help but notice the chubby cherub cheeks that Baby’s acquired in the last few weeks.  Suggesting that I cut even more carbs than I already have (okay, I’ve been cheating on my protein only diet some, but not terribly excessively… I’m dreading the idea of three more weeks of omelets…) to ensure that Baby doesn’t continue to put on excessive weight and break through that magical 9 lb 4 oz threshold that would ensure a doctor mandated delivery by cesarian, she encouragingly said that things were by and large looking good before sending me down to another nurse, Kaye, for my weekly NST. 

Delivering me to my reclining blue chair with waiting goo, padded belly straps and monitor, Tamara provided a report summary of the ultrasound which I promptly scrutinized for the twenty minutes Baby's heart accelerations and movement were monitored.  Passing this go around with no-prompting (thank you!) I was relieved to hear that, in spite of his large size, the NST and ultrasound were exactly what the doctor would be glad to see.  Setting my pessimism aside, but not out of reach, my meeting with the perinatologist was all that remained of the morning's flaming hoop session. 

Surprised not to be seeing Doctor Bronsky as he's typically the go-to in office practitioner at the ATC on Tusesdays (apparently Doctor Nies, along with everyone else in NOVA, is down with the flu so he was off covering for her on the L&D floor), Doctor Khoury called me back to his office in a flourish of compliments: "look at that belly!" -- "you look wonderful!" -- "it's so great to see you, dear!" Having dreaded my next appointment with him since my early November given the zero tolerance, minimal wiggle room estimation he made of me, my weight and my macrocosmic baby I acknowledged his praise with a half-hearted "thank you" and began throwing up as many emotional barriers as possible to handle whatever read he'd make of my test results.  

Stating that he didn't feel like a c-section is required at this point, he began by stating that the issue with diabetics with large babies - regardless of previously successful delivery histories - is that even if the baby doesn't measure above the weight threshold requiring surgical assistance for delivery, there is a significant risk for shoulder dysplasia that we'll need to  address mindfully.  Moving on to look at my AFI numbers and wishing to alieviate his concern with the possibility of preterm labor, he called down to the nurse practitioner, Laura, to have her check for effacement and dilation before sending me on my way for the week.   Running the Group B Strep test while at it, Laura made the ambiguous comment "oh yeah, you're super soft" before returning to her other patients.  Knowing that this generally meant things were heading in the correct direction for delivery, I gathered my things and began to walk out to reception with the intent of asking "anything else?" when Doctor Khoury practically tackled me in the hallway preventing my hasty exit. 

"Sit, please!"   (Uh oh...)

"You're moving quite a long - 80% effaced, 1 CM dilated and baby is at -2 station - so really he could come at any time.  I want to see you sooner than seven days, come in next Monday for your next appointment and we'll check you again.  In the mean time, if things progress at all - even if you aren't sure - get to the hospital immediately... subsequent babies tend to come quickly, but with the higher risk his size presents for delivery, we really can't afford to have you have this baby in the car.  Okay, dear?" 

Knowing that the numbers he rattled off are definitely a sign delivery is coming (but not necessarily imminently - darn AFI levels making "any minute" something that could last from right now-right now through induction in February), all I could do was nod my head and attempt to process the morning's events.  So I am looking at a large baby.  I am looking at a large baby that may or may not be premature.  I am looking at a large baby that may or may not be premature and is potentially going to be ill effected by my diabetes (sugar level or lung development wise). I remember with GV we did the amniocentesis at week 37 to determine if she could be delivered that week or would require more time for lung maturity, so being mid-week 35 with a large baby that may or may not be premature and is potentially ill effected by my diabetes has me freaked by "what-ifs" of his sooner rather than later arrival.   I mean even with waiting for 38 weeks to induce her, GV still wound up in the grow-box for a few days due to her jaundice and she suffered from post-birth hypoglycemia even though my sugars were tighter than the jeans on any one of those Hollywood film stars (at least they're wearing jeans, right?).  

Feeling excited, anxious, nervous, terrified and completely unsure of what is to come, I am flat out overwhelmed by yesterday's appointment.  On one hand, GW was a 36 week 5 day baby and he was just fine with a mild case of home-treatable jaundice... but he was born well over a year before I became a diabetic.  On the other hand, GV was born over a year and a half after I went on the insulin pump and, despite all of the terrible placentra-related complications of that pregnancy, was considered a perfectly healthy, completely normal newborn within four or five days following delivery - no NICU or micro-management required by the pediatricians.  So, optimistically speaking, things could go well even if Baby decided to come early...  would things be better if he arrived following induction the week of February 9th?  Yeah!  He'd get more lung development time, he wouldn't run the risk of being delivered on the side of I-95 in a traffic jam and I'd have another few weeks to button up the house into the home it's supposed to be.   Of course, he'll likely be so huge by then that that adds more cons to the mix, but hey, there is no one perfect way to have a baby and only God knows what's actually in store. 

On that note, I'll end my weekly blathering and hope that the next update I have for you is a clear-headed one.  Fingers crossed. 

Week 34: Not so much.

I am completely drained.  Yes, I have been staying up until well after midnight every night for the past few weeks.  Yes, I have been getting up early and fight the good fight to have two fully dressed children at the breakfast table by no later than 7:20 each morning.  Yes, I am eight and a half months pregnant and being tired is just a way of life.  But, no, these reasons have nothing whatsoever to do with the bottom of the barrel, running on empty, complete exhaustion that my day today introduced.

For the second week in a row, HB couldn't make it to my perinatal appointment at the hospital due to his looming work deadline.  Having overcome the oddity of this mommy-only situation last week, I pouted momentarily this morning when looking at the traffic reports before leaving just early enough to arrive twenty minutes prior to my "we don't actually have appointments available, but we'll schedule you for 8:45 and least know you'll be seen" time.   Skipping the waiting room in favor of the conveniently located bathroom at the nurses station, the nurse I bumped into on my way out decided to have me start my non-stress test immediately since I was already back in the exam room and it didn't matter scheduling wise where I was fit in so long as my NST occurred.  Reassured by my old-hand-at-this attitude toward the procedure, she quickly took my weight (down 1 lb from last week) and my blood pressure (118/79) before hooking my belly up to the various monitors and letting Baby, my book and me be for the twenty minutes of monitoring.

About 15 minutes later, she came in with a concerned look upon her face.  Looking at Baby's heart rate on the chart, she asked me to roll to my left side and down a large cup of ice chips to encourage him to show proper heart accelerations.   As I have previously explained with GV's pregnancy, a non-stress test is a way for a MFM to look at the fetal heart rate to see if it increases to a certain level for at least 15 seconds for a minimum of two times over the course of twenty minutes.   When this kind of acceleration is seen, the baby is considered to be "reactive" and in good health; but when this acceleration criteria isn't met within the appropriate time window, the baby presents "non-reactive" concerns that require additional testing.  Well, today, my coffee didn't rial him up, my movements didn't change his agenda and the ice bath I gave him must have been soothing because Baby wasn't having any of it.   Much to the concern of my nurse who continually went back and forth from my monitor to Doctor Bronsky's office, Baby showed marginal accelerations within a thirty minute window - reactive enough for Dr. Bronksy to take me off that particular monitor, but non-reactive enough to require a previously unplanned biophysical profile to be completed on Baby.

Sent back to the waiting room to fret over the "I guess you passed" (aka "I'm trying not to say you failed") results of the NST, it was only a brief moment before the extremely informative sonographer, Sandra, came out to collect me for my ultrasound.  Explaining every little thing she was looking at as she clicked with the mouse and slid across my swollen belly with the probe, Sandra went out of her way to praised the "precious/adorable/sweet baby" each step of the way through the 8 part biophysical exam as if trying to boost his ego and put my parental concerns at ease.  Stating that "it's no wonder why you guys failed the NST with how squirmy he is and how much fluid you have," my heart sank as she reported my amniotic fluid index levels had increased to 29.6 cm.  Reassuringly trying to indicate that this increase should be "no problem, as long as ..." she ended her pick-me-up speech with a rushed "but, the doctor will talk with you more about that...  Want to see the baby in 3D and color?" 

Nice try to distract me, honey, I'm still going to obsess about it. But, yes (duh), I want to see him in 3D and color.  

Left: 01/13/2015 Baby #3 at 34 weeks gestation.  Right:  10/31/2012 GV at 34 weeks gestation.
I think they'll likely look alike.  

Ushered directly from that non-sequitur into see Dr. Bronsky, I sat down and immediately noticed the oddly stiff straightness of my posture - there was absolutely no denying my concern about the changes from last weeks glowing reports to this week's failure to respond and abnormal AFI levels.  Looking over my chart - and once again not providing me with a take-home copy of the ultrasound report - he automatically launched down the "how are your sugars?" worm hole.  Explaining that my A1C is slightly elevated, but likely more as a result of fewer hypoglycemic episodes than otherwise, I braced myself for what I assumed would be a sink-hole of criticism to engulf my chair and self-esteem. 

Frankly stating that he wasn't pleased to see that my amniotic fluid levels increasing at this point, Dr. Bronsky used the magical word "however" when reviewing Baby's biophysical profile results: 8/8.   Indicating that this doesn't necessarily replace the non-responsive NST but provides him with significant more confidence that Baby is still looking good, he requested that I begin daily kick-counts and expect a more comprehensive work up next week rather than the week after. 

Feeling quite a bit battered around the head by the appointment, I took one final emotional blow as I left the hospital:  as I walked over the catwalk from the Women's & Children's Hospital to the parking garage a friendly hospital volunteer handed me a flier about the campus' new visitation policies.   Taking a gander over the bold face type as I approached the car, I stopped dead in my tracks and had to actively fight back tears as I read that "all children under the age of 16 (including siblings) are not permitted as visitors on hospital premises for the duration of flu season."  In other words, when baby comes and we're left in the maternity ward for hopefully a brief stay of two to three days, GW and GV will not be permitted to come see me or to meet their new baby brother as GW did when GV was only an hour old.  Granted, I understand the medical necessity of trying to decrease the spread of infection and control the rampant spread of the flu across the DC metro area, but they've had their flu shots and we know better than to take a sick child to a place full of depressed and/or brand new immune systems!  I just... I just was really looking forward to that moment when we could all share the newness of Baby together.   

What a freaking emotional roller coaster.  Let's just hope next week brings better news. 

Week 34, part freaking two

Hmph.  Double hmph.  And grump!

It has just been one of those no good, down right horrible, get off my back, leave me alone or give me chocolate kind of days.   I didn't sleep well last night because GW, who is usually the best snuggler in the world, kept trying to head butt me in the chest to make space for his legs to go sideways on the bed and that of course made the fact that the alarm went off extra early so that HB and I could get to the hospital on time for my bi-weekly testing all the more gruesome.  Normally an hour drive, we left an additional 30 minutes early to fight the in-bound morning traffic to NOVA and DC and managed to get to the valet parking at the hospital with a few minutes to spare before my 8:30 appt.  Of course the antenatal testing center was running a bit late and we wound up sitting for an additional 45 minutes, but whose counting? (Oh yeah, me).

So we finally get back to the non-stress testing area and it's beyond freezing -- and for those of you who do not know me personally, I do not do well with any temperature below 70 degrees F.   The nurse, who I'll admit was very nice, squirts the non-heated (gasp!) goo on the paddles and hooks it up to my belly.  About fifteen minutes into the test she grumbles about the sleeping baby, gets me cold ice water to drink (again, gasp!) hoping to wake up the baby.  After the next fifteen minutes she decided to shut off the monitor and get the doc's take on my NST since the accelerations were borderline to where they ought to be (ideally they should rise by 15 beats per minute over the course of 15 seconds or more, Baby's were going up for like 13 seconds).  Leaving me sitting there in frigid goo under an air conditioning vent for another while, she eventually came back to announce that the results were acceptable and she sends HB and I back to the waiting room for the next available sonographer.

Waddling down the hall back to the waiting room, we turn the corner and find that the formerly sparsely filled room is now as packed as it possibly can be with pregnant women and significant others.  We found ourselves a corner and, to fill the dragging time, I started counting...  at any given moment there were between 11 and 16 pregnant women in that dang room.  Some closer to popping than me, others barely showing -- but all obvious with their hospital band bracelets.  It's funny how pregnant women take on different shapes and how differently we all carry... at 8.5 months I look like the typical woman does at six months and one woman's jaw actually dropped when she learned my due date is only two weeks after hers since we look so drastically different.  Course she'll probably get lucky and meet her baby sooner than I will, so size - ladies and gentlemen - really doesn't matter.

Anyway, the sonographer finally calls me back and does the quickest sonogram of my pregnancy yet.  She absolutely knew what she was looking at and clearly took speed clicking classes because bang bang bang and "you can go sit down and the doctor will call you back shortly."  I think if I had been a normal pregnant woman and that this was one of the very few times I could see my baby on the monitor I'd have been annoyed, but since this was sonogram #15 and I wanted part two of breakfast asap it was perfectly fine with me.

So back out to the waiting room we march and waited among the collection of mamas.  We watched the third interview with Sarah Silverman on morning television, we cringed at a 3 year old little girl with horrible manners boss her mother around and we joked about our lapse in judgement at leaving our entertainment (GW) back at home.  Some time later, this random doctor comes out and calls my name and I have no freaking clue who this guy is.  His jacket says that he's a "MFM MD" which is at least one step in the right direction, but seeing as I'd never heard of him, he looked like he is 12 years old with facial hair and I admittedly have little to no faith in medical fellows I was not exactly thrilled to see a non-familiar face behind the desk.  After pulling out a phone book to sit on and figuring out which way is up on my several inches thick chart, Dougie Howser then reviews my tests says that things with the baby were fine with the exception that the AFI was a bit high (even though it was lower than Wednesday).   Understanding that it was in normal limits, I moved on from that comment and handed him a print out of my blood glucose charts from the last three days and that - my friends - began the worst part of my day...

Not understanding the charts or what information I was trying to explain to him, Dougie decides to take my print out down the hall to my normal doctor (why couldn't I just see him in the first place?) for his take on things.  The next thing I know is that we're being called into the principal's office for a serious parent-doctor sit down...  Thoroughly disappointed in my asking him for "input" (which I did not), the normal doc began a lecture about insulin care during pregnancy and how off my blood glucose numbers are and how poorly programmed my pump must be.  Looking specifically at my pump settings and seeing that my basal rate is no where close to 50% of my daily insulin usage (which it ought to be), he said that I needed to stop self-managing and start working more closely with my endocrinologist or that he'd need to take me off the pump and put me back on injections so that he could manage my glucose.

ONLY OUT OF MY COLD DEAD FINGERS WILL 

A DOCTOR PRY MY PUMP AWAY FROM ME. 
(Adapted from a Charlton Heston quote)

I attempted to explain that I've tried to work with my endocrinologist's office and that they typically aren't responsive or they just tell me to do what I'd otherwise do for myself, but that just seemed to result in more frustration on my doctor's part than understanding.  He then said that I needed to get into see my endocrinologist today for an emergency reprogramming of my pump or that I'd at the very least need to begin seeing a different NOVA based endocrinologist next week.  I tried to explain that my concern in bringing up my blood sugar with him isn't that I need external input in how to decrease my settings (that's straight forward and I've done it successfully for the last 34+ weeks without problem), but the cause of the lows -- to which he pretty much left me with no answer except "see you Tuesday."

Thus leaving the hospital in near-tears from the feeling of being completely misunderstood and the "you're a horrible mother" treatment, I immediately called the endocrinologist to pass the buck along.  Fortunately having space for me in the schedule once we got back from NOVA, I was able to get in and sit down with my endocrinologist to go through my logs with a fine tooth comb.  Agreeing with me - and the NOVA doctor - that my logs show far too many lows, she did exactly what I would have done on my own and lowered my basal rates even farther.  Cutting every single basal setting by 0.050 units, my total daily basal rates are down to 12.875 units!!  I asked her about the randomly high postprandial readings, but she said they weren't of concern to her because of the extreme prevalence of hypoglycemic lows and she lectured that those 40s and 50s should be my only concern as well.  When asked about how I should address the chastisement I received for the 50-50% ratio of daily bolus to basal insulin usage, she essentially told me that my perinatologist would just have to get over it since that's just how things are going.

So... my perinatologist yells at me for horrible diabetes care and my endocrinologist barely does anything to "solve" the problem AND neither have an explanation for why my sugars continue to drop but rather they each individually want to point the finger at the other and say, "well, that's their job."

AGH!

I don't know... I feel like my blood sugar control has been pretty good for the pregnancy all things considered.  These lows are definitely concerning to me and they make me frustrated and scared, but I can recognize them and treat them as they happen so it's not the worst case scenario of hypoglycemia I could face (knock on wood).  I'm angry that my doctor up north would blame me for the problem I am only trying to fix and I'm annoyed that my doctor down south is being so passive...   All I can say is that I am hella happy that the baby is due in 25 days or less (less, please God, let it be less) and that I can put this excessively hands on medical care out of my life for a while.  I'm looking forward to working with our pediatrician (aka a doctor for someone else, not me) for regular well-baby appointments and I cannot wait to get back into running.  Any outlet for frustration besides chocolate would be fantastic right about now, but hey, I'm a hypoglycemic, post-placenta abruption, 8.5 month pregnant woman on modified bed rest so that just isn't going to happen.

Pass the chocolate.

Hmph.

Week 34, part one

As an exciting post-Hurricane Sandy and Halloween outing, the whole family came along with me to the perinatologist office today for my week 34 non-stress test (NST), amniotic fluid index (AFI) reading and check up.  HB, who is the most wonderful, involved father I know, always comes but today was a bit of a treat because my Mom came along totting a very sharply dressed snowman.  I was quite flattered that GW received as many compliments on his home made costume as he did, but given the fact he is such a dang cute kid in the first place I give him all the credit for wearing the outfit with such success... course wearing a jumpsuit of 100% polar fleece inside a warm doctors office for two hours turned out to be a bit tricky (especially since he skipped his nap today), but he managed just fine and put smiles on several many faces.  Particularly mine.  

 

 

So... the appointment.    Tam, the sonographer, did a partial sonogram for a basic biophysical profile (BPP) reading since they comprehensively looked at the baby's weight and my cervix thickness last week.  It is my general understanding that the doctors only do a full sonogram examination of the baby every three weeks because so many things can vary from one week to the next that it's not worth the extra stress if something may be a simple "water weight" change.   Any way, Tam spent the sonogram focusing on Baby's heart rate, her breathing patterns, her muscle tone, her movement and amniotic fluid levels (22.3) - to which I am happy to report Baby got the perfect score of 8/8.  She also did another 3D ultrasound and, for the third time this pregnancy, we got to see our little angel's face... granted she stuck her tongue out at the camera today, but hey she's supposed to be practicing that - she's got a big brother to contend with after all!
 

After the sonogram, the nurses had me do my second weekly NST.  Since she was more active after I downed Starburst last week to correct for a low, I checked my blood sugar before starting, noted I was trending low and did the same this week to try to save time.  Unfortunately Baby was set and determined to sleep through the Mommy-provided stimulus and after sitting there strapped by a belly band to a loud "wubba-wubba" machine for 45 minutes the nurse came in and gave her a vibroacoustic prod... Having never experienced this before, I must say it's kind of startled me when the nurse first pulled out this wand thing because I didn't know if I should expect a shock or what.  But essentially a vibroacoustic stimulator is a hand held machine that sends vibrating sound stimulus into the uterus to invoke a fetal heart rate acceleration - which is the whole point of the NST in the first place. After that the baby responded within the limits they look for at this stage in the game and I was taken off the machine after another 15 minutes.  

Bored out of his mind, GW requested to go read a toy book (pregnancy magazine) in the lobby with Grandma and so HB and I went back just the two of us for our meeting with the one and only Dr. Bronsky.  I gave him my blood sugar logs and for a matter of several minutes (which felt like several hours) he was dead silent as he looked at my numbers and began strategically flipping through my chart.   As I've previously shared here and outwardly complained about at all of my recent appointments, my blood sugar has been continuing to drop into hypoglycemic ranges that aren't normal or ideal for this point in the pregnancy. Since my last blog post where I indicated that my basal rate was decreased to the "low" daily total of 15.3 units I've had to further decrease it to 13.9 units - and I am still seeing numbers in the 40s and 50s! So, finally, he spoke up and said with a voice of mixed relief and concern that the results of my AFI and NST today are fantastic but that the lows in my blood sugar logs likely indicates a problem they're not seeing with the placenta.  As the implications of this can be dangerous and my diabetes is "very serious" (his words, not mine), these numbers warrant the doctors to be even more cautious as we finish out the pregnancy and Dr. Bronksy requested that I come in twice a week to the hospital for my testing so that they can monitor Baby more closely and "retrieve" her immediately as necessary.  

So as of this Friday morning at 8:30 AM, I begin my new routine of every Tuesday and Friday doctors appointments for the next several weeks of third trimester fun.  With any luck there wont be reason to justify more frequent appointments than that between now and delivery, but we'll see if we actually make it to the induction date - which YES we did set today. 

Drum roll please... 

If for whatever reason I do not go into spontaneous labor before week 38, the doctors have scheduled Baby to be born on Tuesday, November 27!  Dr. Bronsky explained that he'll have me come in the night before to be put on Cervidil and, depending on how things went with that, the morning of Nov 27 he'd would start Pitocin and artificially rupture the amniotic sac.  If things progress slowly, he said that we could expect to have Baby mid afternoon that day; but when HB mentioned how quick active labor was for my first birth, Dr. Bronsky said it could be much quicker than that.  

As I'd rather go into labor spontaneously than wait for this little whumpus to come out on a specifically circled date on the calendar (yes, I think that is weird), I am somewhat hopeful that she'll decide to pleasantly surprise me between now and then with an awkward gush and sharp twinge of pain.  Regardless, even if I don't go into labor on my own before then, it sounds like the docs are confident that I'll be able to have the vaginal birth that I've been hoping for and for that I thank God!  With how complicated things have been it's at least nice to know that Plan A is what I wanted all along and that Plan B is there as needed... 

Since my hands are shaking and my bg is probably low that is all for now. I'll be back again on Friday with another update from the land of the overly poked and prodded.  

Love, 

Diabetic Mommy of One, soon to be Two