My birth mindset

If it hasn't come through already in my posts to date, I'm really passionate about birth. I think it's just the coolest experience ever! That said, I'm not planning on becoming the next Michelle Duggar, so my personal birth experiences will be limited. But I love talking birth with other women who are passionate about it -- or, even better, with women who are interested but maybe not so passionate, and helping them understand that birth doesn't have to be what they see on "A Baby Story" or "16 and Pregnant."

Obviously, I started this blog to talk about homebirth specifically, which I particularly love discussing because it's so different from the "Baby Story" view of birth and because so few people have any direct experience with it. But I also have a lot of thoughts on birth in general. Since you've wandered onto this blog, I assume you have some sort of interest in birth :) So forgive me if I jump up on my soapbox every now and then, and talk about stuff that isn't specific to homebirth -- or even related to homebirth at all.

Starting... now :)

One of the places I love to hang out is The Bump's Natural Birth board, because it's full of women who are passionate about birth! A few weeks ago, a woman asked about the "mindset" going in to a planned natural birth. How do you truly commit to avoiding an epidural -- because from what I've seen, most women who go in saying "I'll try to avoid an epidural but I'll see what happens" end up getting one -- without feeling like a failure if you end up really needing one?

A lot of people liked my response, so here it is, slightly modified to make some pieces more clear.

About a year before I got pregnant with Littles, I did an Ironman triathlon. It's probably the experience in my life most analogous to labor, in a variety of ways. The morning of the race, my dad told me something along these lines: "You've done the hard part. All the training and preparation. Today is the easy part. All you have to do today is get out of the way, and let your body do what you've trained it to do."

That was precisely my mindset going into labor. I lined everything up... I did the classes, I did the exercises, I talked over my preferences with my doctor, I hired a doula. I did all that because I needed to know going in that I had done everything possible to achieve the birth I wanted. I didn't want to look back and think, "If only I had sprung for a doula..." That preparation meant that on the day of the birth, all that was left to do was get out of the way and let my body do what I had trained it to do.

As for changing my mind, well, I didn't line up at the Ironman start line thinking, "I'll try to finish, but we'll see." After nine long, hard months of training, there was no doubt in my mind that I was going to finish. But -- this is hard to explain -- ultimately, finishing wasn't the important thing. It was the journey to get there. On the bike, I watched a guy 10 feet in front of me fail to make a left turn and go crashing over a ledge. He probably didn't finish, but he also didn't "fail." Just getting to that start line took more guts, more hard work, than most people are willing to give. He might not have gotten a finisher's medal around his neck at the end, but he still got the really important things. The improved fitness level. The discipline it takes to train for an event like that. The knowledge that his body was capable of doing way more than he ever thought possible. Those things come from the journey, not from the race at the end.

Again, this was my mindset going into labor. There was no doubt in my mind that I would do it. But if the unexpected happened, I'd know that ultimately, avoiding an epidural wasn't the important thing. It was the journey -- preparing, learning about birth, learning about my options, and setting myself up to make the safest, most informed decisions for myself and my baby. In some labors, the safest, most informed decision is an epidural, or a c-section, and that's not a "failure." In fact, it's anything but.

So. That's my mindset.

Kids at appointments

With Littles
At the time, I didn't have any other kids, so this topic never came up!

With Noob
It was very important to me that Littles be included in Noob's birth, if she wanted, in a way that was completely comfortable and very meaningful. In my eyes, birth is a transformation for our entire family, and it would feel odd if a member of our family weren't there for that transformation.

But throughout the pregnancy, I opted not to include Littles in my midwife appointments, ultrasounds, etc. I wasn't sure that she would be welcome, or that the environment would be welcoming to her.

Finally, at my 34-week appointment, I figured it was now or never. My husband was able to come to that appointment, so I didn't have to worry about amusing Littles myself. I figured she could meet J, one of the two midwives who could possibly deliver Noob, so that she wouldn't be a stranger to Littles on the day of the birth. Afterwards, we could wander over to the hospital, which was right across the street from the midwives' office.

Littles is normally outgoing, talkative, a lot of fun. But I don't think she said a single word the entire time we were in the midwives' office. It got even worse when we went over to the hospital. We were just in the waiting area, not even in one of the rooms with bright lights and funny machines -- but Littles turned to me and said, "I don't like it here. I want to go."

I thought, "Well, J is a stranger to her. Maybe that's why she was so quiet at the appointment. And maybe she was just tired and cranky by the time we got to the hospital."

We went straight home, as we had a meeting with another key component of our birth team: M, our fabulous doula.

Now, at the time, M was also a stranger to Littles; she had met her only once, about four months earlier, during our doula interview. But the difference in M's behavior was like night and day. The outgoing, talkative, fun little girl who had been missing all morning? She came out right away.

I had been thinking a little about homebirth prior to that day, but seeing the change in Littles' behavior made me think about it even more. I wanted her to be comfortable at the birth, and it was clear to me that her comfort level was tied to location, much more than to people. And, I mean, it made perfect sense. Of course a 2.5-year-old would be far more comfortable in her own home than in a strange hospital.

Furthermore, during our meeting with M, we discussed a lot of specifics about our birth preferences. A few things came up that would be more of a struggle in the hospital vs. at home. For example, M said that our hospital really liked all laboring women to at least have a hep lock. That's reasonable, but I was hoping to avoid one -- I had one during my labor with Littles, and the site hurt and itched for a few days afterwards. An absolute dealbreaker? Of course not, on its own. But all of those non-dealbreakers taken together, along with Littles' behavior at the midwives' office and the hospital, started making me think seriously about making the switch to homebirth.

That was the last appointment I had with my hospital-based midwives. By the time of my next appointment, at 36 weeks, I had officially made the switch.

I had four appointments with C prior to Noob's birth, and Littles came along to three of them. (I opted not to bring her to the very first appointment, as I knew we'd be doing a lot of talking and paperwork, which would be pretty boring for her.) Even though C was a new face and her office was a new place, Littles seemed instantly at ease with the entire situation. I knew I'd made the right choice.

She ended up being present for my entire labor, in a way that was very comfortable and meaningful. But I'll save that story for another post.

With Q

Littles at C's exam table

Since we didn't tell the kids about my pregnancy until after we heard the heartbeat at our first appointment with C, we couldn't exactly bring them along to any of the early appointments :)

But I did bring Littles along to my most recent appointment, at 14 weeks. Once again, she seemed instantly at ease.

It's even more fun having her along now that she's older and understands more of what's going on. For example, she was curious about the different colored squares on my "pee stick" (testing my urine for sugars, protein, etc.), so C patiently explained to her what they all meant. She loved hearing the heartbeat and was fascinated by a small model of a 12-week-old fetus that C showed her.

I think that the visit really helped "make it real" for her, too. Prior to that appointment, she knew I was pregnant, but didn't talk about it a whole lot. Now, she's constantly coming up to me and kissing my belly and saying hello to Q, she's picking out outfits for Q to wear, she's telling me how big my belly is :), etc. I can't wait for her to come to more appointments and learn even more.

I plan to do the same with Noob, but he is such a little tornado that I'm dreading it a little -- I worry that he's going to be into everything! But C sounded downright disappointed that he wasn't there last time, so I'll probably suck it up and bring him next time and hope he's not too much of a pain! At least I know he's welcome, and I know the environment is welcoming to him, and that is the important thing.

NT Scan

With Littles -- November 2006
Early in my pregnancy with Littles, my OB told me about what was then a relatively new test, known as the nuchal translucency (NT) scan. The non-invasive scan could detect Down syndrome (trisomy 21), as well as two lesser-known and more serious chromosomal disorders, trisomy 13 and trisomy 18. It was covered by insurance and it included an ultrasound :) So we decided to do it.

The NT scan requires high-powered ultrasound equipment that most OB offices don't have in-house. So on the appointed day, we went to the hospital where Littles would eventually be born. We first met with a genetic counselor, who went over a family history and explained the test in detail to us. Later that day, we had the ultrasound, and I also gave some blood for further testing. We got the results back within a week or so, which indicated that Littles was at low risk.

At the time, the NT scan was considered optional for women like me, who had no risk factors for chromosomal disorders. (Risk factors include advanced maternal age or a family history of chromosomal disorders.) A few months later, ACOG started recommending NT scans for all pregnant women, regardless of risk level. That recommendation still stands today.

In the years since, I've talked to lots of other women about the NT scan, and have been surprised to hear that many of them skipped it, mostly based on misinformation. Some of the typical reasons I hear for not getting the NT scan:

• "It gives a lot of false positives, and I don't want to worry for nothing." One of the things the genetic counselor explained to us was that you cannot get a "false positive" on an NT scan, because it is not designed to conclusively state whether or not the baby has a chromosomal disorder. It simply states whether the baby is at "high risk" for one. To give an example, one of my friends' babies was deemed high risk and given 1 in 200 odds of having Downs. He was later born perfectly healthy. But this was not a "false positive." 1 in 200 odds meant that he had a 99.5% chance of being born healthy, and indeed, he was!
  
  Even the high risk designation is relatively uncommon. It's given to about 5% of babies. Hardly "a lot."
  
• "I'd never abort a baby with Downs, so why bother testing? It wouldn't change anything for me." I wouldn't abort a baby with Downs, either, but I'd sure want to be prepared! This has become increasingly important for me in my subsequent pregnancies, because not only would I want some extra time to prepare myself for a child with special needs, but I'd also want some extra time to prepare the older kids.
  
  Also, the NT scan doesn't just test for Downs. It also tests for trisomies 13 and 18, which are often fatal in utero or result in a short (<1 year) and very painful life. I might consider aborting for those, and if I didn't abort, I would definitely want some time to prepare emotionally for carrying a baby who might not stick around very long, if at all.

I've also heard many more stories that have convinced me of the importance of getting an NT scan:

• The anatomy scan (an ultrasound usually performed at around 18-20 weeks) looks for signs of the same disorders that the NT scan identifies. These are called "soft markers" because they are usually present in babies with chromosomal disorders, but many healthy babies have them as well. If I have a clean NT scan and then have soft markers identified at the anatomy scan, I can take comfort in the knowledge that the NT scan rarely comes back as low risk for a baby who truly does have a chromosomal disorder, so the soft markers are almost certainly "soft" in my case. If I don't have an NT scan and then have soft markers identified at the anatomy scan, I have no such reassurance.
• Since the NT scan includes an ultrasound on high-tech equipment, it affords the opportunity to identify other problems with the baby (besides chromosomal disorders) very early on. One woman's baby was diagnosed with spina bifida at her NT scan. They were able to operate on the baby in utero at 17 weeks. The problem likely would have been picked up at her anatomy scan, too, but that would have been later in the pregnancy and the operation might not have been as successful.
• Tragically, another woman skipped the NT scan and then was diagnosed with amniotic band syndrome at her anatomy scan. By that time, the condition was so far advanced that it was fatal. Had she had an NT scan, the condition could have been diagnosed early enough to take steps to address it, quite possibly saving the baby.

With Noob -- July 2009
Because I knew all of this, I was a little surprised when my midwives didn't talk about the NT scan early on in my pregnancy with Noob. So I asked about it at a regular appointment at 10 weeks. F seemed a little taken aback, but had no problem giving me a referral to a nearby perinatologist to get the screening done.

He did a great job with the ultrasound, taking his time to not only get a good nuchal fold measurement (the entire goal of the ultrasound -- the thicker the nuchal fold, the higher the risk of chromosomal disorders) but also to take a peek at the rest of Noob's body and give me some good pictures to show my husband, who couldn't make it to the ultrasound.

And once again, when the bloodwork results were final, I got the reassurance of being deemed low risk.

With Q -- December 2011
Since I was planning homebirth, I was particularly keen on getting the NT scan done. If there are any medical concerns that might affect our homebirth plans, I'd want to know that as soon as possible.

I assumed, correctly, that most of C's patients weren't interested in getting an NT scan. As a result, she had no existing relationship with a perinatologist or other facility capable of performing it. So I went back to Dr. C for a referral. Of course, she doesn't do these types of referrals often, either, so this ended up requiring quite a bit of back-and-forth, further delayed by the fact that this was right around the holidays and so there were some office closures in there as well. Since the NT scan must be done by 14 weeks, it came right down to the last minute, but I finally managed to get the referral and get in for an appointment on the next-to-last possible day.

I was thoroughly unimpressed by the perinatologist who did the scan. It was the shortest of the three NT scans that I've had. The perinatologist quickly measured the nuchal fold and told me that the measurement looked good. Then he said, "Do you want to know the sex of the baby?" as I could see him moving down Q's body towards his/her bottom. "No! I don't!" I told him quickly. We don't plan to find out the sex. "Well, then look away," he said. I closed my eyes and he poked around for a minute or so and then told me that the scan was complete.

When I relayed this story to C at my next appointment, she explained that many perinatologists are trying to get good at early guesses as to the baby's sex. When I was pregnant with Littles, most ultrasound techs were reluctant to take a guess as to the sex at 16 weeks, nevermind in the first trimester. Now, a lot of women do walk out of their NT scans with a guess. Which is insane to me, because at 12 or 13 weeks, male and female genitalia look almost identical. But anyway, C thought that the perinatologist was using Q to practice his skills at distinguishing between the two sexes that early on.

It all happened really fast, but after the fact, I was rather peeved. I feel that the perinatologist should have explained why he wanted to look -- whether it was for medical reasons or for his own "practice" -- and granted me the opportunity to give or refuse consent. Normally, looking at a child's genitals for no good reason without the parent's consent is not just rude but is grounds for persecution. Why should it be any different on an ultrasound?