Dating the pregnancy

"Dating" a pregnancy is the process of calculating the estimated date of delivery (EDD). Typically, the EDD is set at 40 weeks after the mother's last menstrual period (LMP). This assumes that all women have a standard 28-day cycle with ovulation on day 14.

In many cases, this assumption isn't valid, and then, the EDD should be determined by other means. Doctors like to use early ultrasounds to date pregnancies, since embryos grow at a very well-defined rate during the first few weeks of pregnancy.

In addition, women can "chart" their cycles and identify their personal ovulation date with a great degree of accuracy. I'm not going to get into a whole explanation of charting here, but if you're interested in learning more, I highly recommend the Fertility Friend site or the book Taking Charge of Your Fertility.

With Littles -- October 2007
My own cycles have always been on the long side, suggesting that I likely ovulate later than day 14. I explained this to the nurse at my first appointment after getting pregnant with Littles. I was not charting, but based on this and some other signs, I suspected that my actual EDD was about six days later than my EDD per LMP.

The nurse got me set up with an ultrasound, at what was 8 weeks 4 days per LMP, but 7 weeks 5 days per my suspicion. Littles measured 8 weeks 0 days -- so, closer to what I suspected based on my cycle history.

But Dr. K said that since Littles measured within a week of my EDD per LMP, she would not adjust my EDD. At the time, I thought this was great! Six fewer days of the miserable first trimester to put up with!

I came to regret it at the end of my pregnancy. My OBs would not let me go past 42 weeks gestation, because the risks to the baby increase past that point. Since my EDD had been set based on my LMP, this meant 42 weeks from my LMP.

I ended up having to be induced. Of course, if my suspected EDD was actually correct, I was really closer to 41 weeks at my induction date. We could have allowed Littles to keep baking for another six days before she got into the increased-risk territory.

As I've explained previously, I ended up having a very positive induction experience anyway. But I still felt a little deprived of the experience of spontaneous labor. I still believe that Littles would have come on her own had she had those extra days that she rightfully deserved.

With Noob -- June 2009
I started charting after my pregnancy with Littles, so when I got pregnant with Noob, I knew that I had ovulated nearly two full weeks later than "expected." This was another reason why I insisted on an early ultrasound (in addition to wanting some peace of mind after my previous miscarriage).

The ultrasound was at 8 weeks 2 days per LMP, but only 6 weeks 5 days per my chart. It came as no surprise to me that Noob measured 6 weeks 3 days. I didn't quibble over those two days, since I knew it gave him two more days to bake at the end!

As it turns out, he arrived two days "early" -- that is, precisely on his EDD per my chart. Of course, had we not accurately dated the pregnancy, he would have been considered 11 days "late." Many doctors would have induced him by that point... wrongly, because he was not at all overdue.

With Baby Q -- December 2011
I charted again, and so I know that I ovulated late again. But my midwife, C, does not routinely induce for being overdue. If I reach 42 weeks, as long as everything is fine with Q and me, we'll keep waiting. This is another reason why I didn't insist on an early ultrasound with this pregnancy: I'm less worried about accurately dating it, because I know there's no induction looming at the end.

(By the way, you might be curious as to why my OBs with Littles felt that it was too risky to continue past 42 weeks, but C is fine with it. I'll address that in another post, at some point.)

Also, unlike many doctors, C trusts my chart. When we went through the initial paperwork yesterday, she asked me not only what my LMP was (as all my previous providers have done), but also if I knew my ovulation date and my actual EDD -- both of which I do know, thanks to my chart. That's what we're using for dating purposes. Neither of my previous providers ever asked me about these two key pieces of data.

Houston, we have a heartbeat

I don't think any parent ever forgets the moment when they first hear their baby's heartbeat. It's truly magical.

With Littles -- October 2007
Our initial appointment was with a nurse, to do paperwork, go over do's/don'ts, etc. I wasn't entirely sure of my conception date, so the nurse got me set up with an early ultrasound at 8 weeks to date the pregnancy.

That was when we first met "Dr. K." And that's when we first saw and heard the heartbeat, beating away steadily in a small object that closely resembled a gummy bear. She took her time, explaining how she did the measurements, pointing out when Littles "moved" (it looked like a quick shudder), listening to the heartbeat and mapping it on the screen. My husband and I were just awestruck by the entire experience.

I happened to be wearing my Ironman finisher's shirt that day, and Dr. K noticed it and commented on it. We chatted a bit about it, and she thought it was very cool that I had done that.

I might get into my Ironman experience more in a future post, but for now, suffice it to say that it's the only experience in my life that even comes close to mimicking labor and childbirth.  To know that I've gone through that, and to comprehend what it means, is to understand a whole lot about me: When I put my mind to doing something, I do it. I'm not afraid of a little hard work -- or a lot of it. And my body is capable of some pretty amazing things.

All qualities that have served me very well at both my births.

Anyway, I really think that Dr. K "got" that, right from the start. I always felt really comfortable with her. Not so much with her partner, "Dr. S," who came highly recommended but whom I increasingly butted heads with over the course of my pregnancy.

We couldn't know it at the time, but nearly eight months later, Dr. K would be the one to catch Littles. I credit her for playing a huge part in making Littles' birth such a positive experience. And I really think it all started in that little room with that little beating heart.

With Noob -- June 2009
After a previous miscarriage, my midwife was happy to get me set up with an early ultrasound. We went in at 6 weeks.

I loved my midwives, but unfortunately, they could not do ultrasounds themselves (only the OBs in the practice could do so). And as it turns out, their ultrasound tech's bedside manner left something to be desired. At this ultrasound, she inserted the probe and a little blob appeared on the screen. Silently, she messed around with the image a bit.

Where's the heartbeat? My stomach sank.

Then she made a few comments and mumbled something about a heartbeat. Wait, what? "So there's a heartbeat?"

"Yes. 120 bpm." Which is great for 6 weeks.

It was a very different experience from our first ultrasound with Dr. K. But regardless -- Noob had a heartbeat. That was enough to put a big smile on my face.

We had to wait over five more weeks to actually hear the heartbeat for the first time, at a regular appointment with one of the midwives.

With Baby Q -- today! December 6, 2011
This was my first pregnancy where I didn't have an early ultrasound. I probably could have asked Dr. C to refer me at any one of my appointments with her, but I didn't feel like hassling with the referral process. Plus, it goes against my overall philosophy of minimizing interventions as much as possible. There have been concerns raised about the effects of ultrasounds on developing fetuses, and while I don't find any of the arguments to be particularly convincing, it does seem prudent to minimize ultrasound use to only what's medically necessary. And really, I had no medical reason to need an early ultrasound this time around.

Anyway. Waiting also meant that we'd get to hear the heartbeat for the first time with our friendly homebirth midwife "C," rather than some random ultrasound tech.

Unlike my previous providers, C gave me the option to come in for my first appointment whenever I wanted. I opted to wait until 10 weeks, because I figured there wasn't much point in coming any earlier. C has no ultrasound equipment, and the heartbeat isn't usually audible on the doppler until around 10 weeks. Paperwork can be filled out anytime. I knew I could contact C via phone or email if I had any questions in the meantime.

Finally, 10 weeks rolled around, and I headed over to C's office. When it was time to listen for the heartbeat, C showed us a model of a 12-week old fetus and warned us that it can take some time to find the heartbeat of such a little being. Indeed, she had to poke around some, but finally she moved the wand a bit to my right side and there it was. Clip-clop. Clip-clop. Clip-clop. The unmistakable sound of a tiny heart beating away.

We all got big smiles on our faces. That sound was well worth the wait.

The role of my primary care physician (PCP)

With Littles -- 2006-2007
When I said that I chose the OB closest to my house... well, that wasn't entirely accurate. I actually chose the OBs who worked out of the same medical foundation as my primary care physician. (I had chosen my PCP years before because she was the doctor closest to my house :) It was a large office with doctors covering many different specialties. Littles' first pediatricians were out of the same group, as a matter of fact.

Due to the proximity, the OBs had a unique setup where patients who had a PCP in the same group alternated appointments between the OBs and the PCP, at least until the third trimester. So, I think I had three regular prenatal appointments with my PCP, at 12 weeks, 20 weeks, and 28 weeks, with OB appointments in between. I also saw her for an unscheduled appointment after a bad fall, when I wanted some reassurance that the baby was OK.

At the time, I appreciated that it was much easier to get appointments with my PCP, as compared with my OBs, and that PCP visits usually involved a lot less waiting time prior to seeing the doctor. I'm sure it was nice for the OBs too, as it allowed them to offload appointments that, frankly, do not demand the skills of a trained surgeon.

Looking back, I think it was also nice to have my PCP involved in that major transformation in my life. As it turns out, it didn't really matter, because we ended up moving twice in Littles' first year, so I never saw my PCP after that 28-week appointment. But had we stayed in the area, my PCP, not my OB, would have been responsible for my long-term health. (In that medical group, PCPs were responsible for all regular well-woman care. Aside from childbirth, I would have only seen my OB again if I had some sort of gynecological complication.) It just made sense for her to be involved in an event that changed me in so many ways, including ways that have had a direct impact on my long-term health.

With baby #2 and Noob -- 2009
After our move, one of our first priorities was finding a pediatrician for Littles. We got a recommendation for one, "Dr. C," who actually turned out to be a family practice doctor. By this time, my husband and I had both been without a PCP for over a year, so we figured we'd start seeing Dr. C as well.

By the time I got pregnant with baby #2, I had had a physical with Dr. C, and had met her a few other times at Littles' well-child checkups. Yet it never occurred to me to contact her during my miscarriage, even after I found out I couldn't talk to my midwives about it. I guess I just figured that pregnancy stuff was the exclusive realm of OBs and midwives. Same thing after I got pregnant with Noob.

She was aware of the miscarriage (the subject came up during one of my regular visits) and, of course, of my pregnancy with Noob (through Littles' well-child visits and because we eventually talked to her about adding Noob as a patient). But that was the extent of her involvement.

With Baby Q -- October-November 2011
As I mentioned previously, as soon as I found out I was pregnant, I knew I needed to get my progesterone tested, as I had done with Noob. My homebirth midwife was unable to do this testing, and I didn't particularly want to see a random OB just to get it done, so I tried Dr. C first.

At first, I considered this to be a disadvantage of choosing homebirth. I had to convince Dr. C's staffers (who surely don't deal with newly pregnant women that often and didn't seem to comprehend the importance and urgency of my request) to find a spot for me that week, in her always-jam-packed schedule. It sure was a lot easier with Noob, where all I had to do was call my midwife's office and I had an appointment for testing a few hours later.

But since I got that spot, the care I've received has been nothing short of exceptional.

For example, when we discovered that my progesterone levels were dangerously low, Dr. C immediately prescribed Prometrium (progesterone supplements), just as my previous midwives did during my pregnancy with Noob. Unfortunately, I soon discovered that Prometrium contains peanut oil. Noob is allergic to peanuts, so I've been peanut-free since his diagnosis earlier this year, because he is still nursing. Some doctors might have told me, "The kid is almost two years old. He doesn't need to breastfeed anymore. Deal with the peanut oil, or wean him." But Dr. C responded by giving me a prescription to a compounding pharmacy, who could make the medication without peanut oil. She is very supportive of extended nursing, and has a vested interest in seeing Noob stay healthy and happy -- because he's her patient, too!

It's funny. I started off thinking that having to involve Dr. C was a disadvantage of homebirth. Now, my thinking has flipped completely, and I consider it a wonderful advantage. She'll be Baby Q's doctor after the birth, and hopefully for many years to come -- so I love that she's been involved in his/her life practically from the start! And as with my PCP during my pregnancy with Littles, Dr. C is ultimately responsible for my own long-term health (she does my yearly physicals and well-woman care), so I'm glad she's been involved in this major event in my life.

When we found Dr. C, we weren't specifically looking for a family practice doctor, but now that I've experienced this model of care, I can't imagine ever going back to having separate doctors for us and the kids. I hope we'll all be with Dr. C for a long time, but if we ever do need to find a new practice, I'll definitely look for a family practice doctor again.

The nervous early weeks

With Littles -- October 2006
The early weeks weren't all that nervous. I was aware of how common miscarriage was, but just hoped for the best, and had no issues.

With baby #2 -- February 2009
My first appointment with the hospital-based midwives I had selected was scheduled for 8 weeks. But late one Friday night, when I was about five weeks along, a few hours after my husband and Littles left on a weekend trip, I started cramping and bleeding. I immediately called the midwives' office and was told that I could not speak with a midwife or with any of the OBs in the practice, because I was not "officially" a patient yet.

It was probably the worst experience I've ever had with the medical profession. I understood the liability concerns driving it, and I didn't blame the midwives themselves. But still, I was losing my baby, I was terrified, and I was completely alone.

With Noob -- May/June 2009
I did end up seeing one of the midwives the Monday after the miscarriage started, so after that, I was officially a patient.

I started having concerns about my progesterone levels -- along with the early miscarriage, I was charting my cycles and saw symptoms of low progesterone in my charts. So I talked to my midwife about it and she agreed to do some testing.

I was really happy that she took my concerns seriously. Many doctors won't agree to testing until a woman has had three miscarriages. I think that's ridiculous. After suffering through the heartbreak of one miscarriage, my goal was to not have two more.

As it happens, the cycle when we started testing was the cycle that I got pregnant with Noob. After receiving a positive pregnancy test at home, I requested beta HCG counts and another round of progesterone testing. My midwife complied, and prescribed progesterone supplements for me when my progesterone levels did indeed come back low. My HCG counts looked great, which was a huge reassurance.

Then I requested an early ultrasound (technically to date the pregnancy, but my midwife and I both knew it was more for reassurance) and an early first appointment. Again, my midwife happily complied.

That support helped make those early weeks a little less nervous.

With Baby Q -- October/November 2011
As soon as I found out I was pregnant, I started working on getting my progesterone levels tested again. Unfortunately, my homebirth midwife is unable to write lab orders for that testing or prescribe supplements to address low progesterone. So I had to go elsewhere.

At first, I was worried that I'd have to go back to my old midwives, or find a random OB to do the testing. I wasn't really looking forward to that, because I didn't want to get into the history of my previous births (specifically Noob's place of birth) or my plans for this one with someone who might not be supportive of homebirth.

Luckily, my primary care doctor was happy to order up the tests, and to prescribe supplements when my progesterone turned out to be low again. She is truly amazing -- she's family practice, so she sees our entire family, including the kids, and she has the most wonderful personality. She always makes me feel like I'm in good hands, and this was no exception. It is still very early and I'm still very nervous about everything, but as with Noob's pregnancy, having great support helps tremendously.

Choosing a birth attendant

In my opinion, choosing a birth attendant is the most important decision a woman makes during her pregnancy. Your choice of birth attendant influences not only where you'll give birth (which hospital, which birth center, or at home) but a whole lot about how your pregnancy and labor will be treated.

I strongly prefer getting personal recommendations for birth attendants. You do need to be careful of the source of the recommendation, though. For example, if you want a natural birth and your friend wanted an elective c-section at 38 weeks, you might find that her recommendation for an OB doesn't quite fit with what you're looking for. And vice versa.

I've been lucky to have wonderful birth attendants, despite finding them in very different ways.

With Littles -- October 2006
I used the OB closest to my house. No rhyme or reason. I just thought that's what people did when they got pregnant. It ended up working out OK for me, but that was pure dumb luck.

With baby #2 -- February 2009
I asked for recommendations on the Mothering.com "Find Your Tribe" group for my area and on a local attachment parenting Yahoo! group. I figured that the women frequenting those types of groups would likely share my perspective on birth.

From those recommendations, I interviewed a homebirth midwife, but didn't feel like I "clicked" with her. I set up an appointment with a hospital-based midwifery group, but miscarried a few weeks before the appointment.

With Noob -- May 2009
Initially, I went with the same hospital-based midwifery group that I had planned to use for baby #2.

Towards the end of my pregnancy, when I decided to switch to homebirth, I already knew exactly which midwife I wanted to use, based on my prior research. Had she not had availability, I don't know that I would have followed through with the switch. Luckily, she did, and she was amazing!

With Baby Q -- October 2011
I'm using the same homebirth midwife who delivered Noob. I can't imagine having anyone else take care of me and my new baby.

A journey of a thousand miles starts with a single step...

...and a journey through pregnancy starts with a pregnancy test. After that? The paths start to diverge fairly quickly.

With Littles -- October 2006
I tested on a Friday morning. It took a few days (and a few more pregnancy tests) for the news to sink in. Once it did, I called the office of the OB closest to my home. My first appointment was with a nurse practitioner to go over family history, pregnancy do's/don'ts, etc, so my first direct contact with my OB was at my second appointment, at 8 weeks.

With Noob -- May 2009
I tested on a Sunday afternoon. That Monday was Memorial Day, so I had to wait until Tuesday to call my midwife's office. Due to a prior miscarriage, I had bloodwork to check HCG and progesterone levels that afternoon. My first direct contact with my midwife was on Wednesday, when she called with the results.

With Baby Q -- October 2011
I tested late on a Sunday night. When the test came up positive, I immediately sent an email to my homebirth midwife to let her know. My first direct contact with her was precisely five minutes later, when she replied back to say, "WhoooHoooo!!!!!! So excited for you!!! Can't wait to see you again!"

How I embarked on this journey: The long version

(The short version is here.)

My birth -- June 19something (Yeah right. Like I'd tell you the actual year :) When I asked my mom about my birth when I was growing up, she described it like this: She went into labor early in the morning, precisely two weeks after my due date. She labored by herself for a few hours and then woke up my dad to go to the hospital. She did not receive an epidural or other pain medication. I was born about twelve hours later, weighing in at 9 lbs 6 oz.

What I wrote above is pretty much how she said it. No long drawn-out horror stories of the aaaaaaaaaaaaaaaaaaaaagony of waiting two looooooooooooooooooooong weeks to go into labor, or of laboring without an epidural for the better part of a day, or of delivering a nine and a half pound baby.

So I grew up thinking that delivering 9+ pound babies two weeks late with no epidural was just "normal."

Littles' birth -- June 2007

Throughout my pregnancy with Littles, I saw an OB and planned to deliver out of a hospital, with minimal interventions, including no pain medication.

Again, I believed that delivering babies two weeks late was "normal," and so I was not at all surprised when I went overdue. As week 40 turned into week 41 and started approaching week 42, everyone seemed to assume that I must be miserable and just done being pregnant. I really wasn't. I was eager to meet Littles, but I also loved being pregnant.

Finally, my OB said that she needed to be out by 42 weeks. I went in to the hospital on Sunday night to get Cervidil, and then started Pitocin on Monday morning. Littles was born that night, weighing in at 9 lbs 7 oz. Aside from the Cervidil, Pitocin, and antibiotics due to being GBS positive, I had no other medications.

I wouldn't say it was an easy birth. Mostly, it was just long. I was so tired by the end that I was falling asleep between contractions. But it was an absolutely amazing experience and I loved it. The next day, my nurse asked me if I'd do it without pain medications again, and I didn't even hesitate with my reply: "Absolutely."

I consider Littles' birth to be a very positive hospital birth experience. I'm not at all anti-hospital. I've learned over the years that having an experience like that, or like my mom's, may not be as automatic as it really should be, when you're birthing in a hospital -- but that doesn't mean it's impossible.

Noob's birth -- January 2010

We moved out of state when Littles was about a year old, so delivering future babies with my same OB was not an option. In a way, I was relieved, because although I had had a really positive experience, there were also some things I wanted to change, and our move gave me the opportunity to do that.

In particular, I felt that most midwifes would be more in line with my views on birth than most OBs. I considered out-of-hospital birth early in my pregnancy, but my husband wasn't comfortable with it. Instead, I found two midwives who delivered out of a hospital considered to be one of the most natural-birth friendly ones in my area.

I loved my midwives, but as the birth approached, I found myself turning back to the idea of out-of-hospital birth. My hospital was great, but it's still a hospital, and there were some things I really wanted that simply didn't work well with birthing in a hospital, such as allowing Littles (then age 2) to be an integral part of the birth.

I finally decided that my husband and I needed to meet with a homebirth midwife, "C." We did that just before New Years. I was 35 weeks pregnant. I fully expected my husband to walk away from that meeting saying, "I'm sorry, I'm still not comfortable with this idea." And then, I was fine sticking with our original plan of the hospital-based midwives.

To my complete and utter surprise, C was able to address most of his concerns. We decided to make the switch. Noob was born almost exactly four weeks later, two days before his due date, at home, weighing in at 8 lbs 11 oz. His birth was quick, easy, comfortable, peaceful. Incredible.

Hospital vs. home
When I switched to homebirth, obviously I knew that it would be very different from hospital birth. Still, I was surprised by some of the more subtle differences that came out, even in just the four weeks that I was under C's care. I quickly learned that homebirth is not just like hospital birth except you stay at home at the end. It is a completely different approach to pregnancy, birth, and the immediate postpartum period.

Take Group B Strep (GBS), for example. GBS is a bacteria that colonizes the vaginal tract in approximately 25% of women at any given point in time. It's harmless to the woman, but if she gives birth while colonized by GBS, her baby is at a higher risk of becoming infected with GBS. GBS infection in a newborn can be very serious, even fatal.

When I was pregnant with Littles, my OB followed standard American protocol for minimizing the risk of GBS-infected newborns: I was tested for GBS at 36 weeks. When I tested positive, I received IV antibiotics during labor, cutting Littles' risk of GBS infection. Of course, antibiotics carry risks as well, such as possible allergic reactions and an increased risk of acquiring other bacterial infections (since antibiotics kill off not only "bad" bacteria like GBS but also the "good" bacteria that naturally keep "bad" bacteria at bay).

With Noob, I switched away from my hospital-based midwives right at 36 weeks, but it appeared that they follow the same protocol: Test at 36 weeks, IV antibiotics during labor for women who test positive.

My homebirth midwife takes a different approach. She is not licensed to give IV antibiotics to GBS+ moms during labor. Some might point to that as an example of how homebirth is less safe than hospital birth... but that's not the full story.

Rather than simply treating GBS colonization when it's detected, my midwife tries to prevent it in the first place. She recommends taking probiotics and certain vitamins that have an antibacterial effect, starting a few weeks before the test. (With Noob, I was lucky that my doula had proactively passed along a similar GBS-fighting regimen to me when I was still under the care of the hospital-based midwives. So I had been following it even prior to my switch to homebirth.)

I ended up testing negative. So the lack of IV antibiotics was a non-issue, and I didn't have to worry about any negative side-effects of the antibiotics, either.

The difference between preventing and treating GBS is not something that I can quickly explain to the average person who looks at me in horror saying, "Giving birth at home? Are you insane? That's so unsafe!" But they're the kinds of things I want to document in this blog.

How I embarked on this journey: The short version

Late in my pregnancy with "Noob" (my second child, born January 2010), I decided to switch from hospital birth to homebirth. I thought I was just changing my provider and place of birth. What I didn't realize was that I was changing my entire approach to pregnancy, not just to birth, in ways that are hard to understand unless you've been through it.

I just found out that I'm pregnant again, due in July 2012, and I'm planning another homebirth. I wanted to document the entire experience, highlighting some of the differences between this pregnancy and my prior pregnancies with "Noob" (planned hospital birth with a midwife until 36 weeks), "Littles" (born June 2007 in a hospital with an OB), and "baby #2" (planned hospital birth with a midwife, miscarried in February 2009).

That is the purpose of this blog. My hope is that this will help women make more informed choices about hospital birth vs. homebirth, as well as help people who will never even consider homebirth to better understand us crazy homebirthers :)