"Normal" pregnancy aches and pains

With Littles
It was around 30 weeks that the pain started to kick in.

At first, it just felt like I had a bruise right on my pubic bone. Annoying, but tolerable. I asked my OB about it, and she said, "Sounds like public symphysis pain. Totally normal."

While that was reassuring, it didn't help it go away. Over the next few weeks, it got progressively worse. Walking became difficult, especially after I'd been seated or lying down for a while. I started to dread rolling over in bed, or lifting my legs to put on pants. Climbing stairs was nearly impossible. I remember getting up one morning when I was about 33 or 34 weeks along and thinking, "I can't do this anymore."

But I knew I had to keep doing it, so I turned to the Internet, and found this link: http://www.plus-size-pregnancy.org/pubicpain.htm

It described my symptoms perfectly. And unlike my OB, it offered some suggestions for lessening or even eliminating the pain.

I started sleeping with a pillow between my knees, and whenever I needed to roll over, I concentrated on keeping my knees together. Those simple steps helped somewhat.

But one of the biggest recommendations was to look into either chiropractic or acupuncture. I asked my OB about it, and her response was, "Well, it's safe. It probably won't help, but it won't hurt."

I asked my doula for recommendations, and she referred me to a nearby acupuncturist who specialized in treating a variety of women's issues. I had never tried acupuncture before and was pretty skeptical. I walked out of my first appointment feeling no different, aside from a wallet that was quite a bit lighter. (My insurance doesn't cover acupuncture at all.)

Within 24 hours of that first appointment, I was feeling 90% better. I still had some pain, but it was quite tolerable. I could walk upstairs again. I no longer dreaded getting out of bed in the morning.

I kept going weekly for the remainder of my pregnancy. I didn't see much improvement after the second or third appointment, although the pain also didn't get any worse, which was a blessing in and of itself! Within a day of the fourth appointment, I saw more improvement, to the point where I was feeling close to 100%.

So much for "it probably won't help."

With Noob
I started feeling the familiar twinges of SPD (symphysis pubis dysfunction) much earlier, before 20 weeks. I'm not sure if this was because the pain actually started earlier than it had with Littles, or if it was just because I was more aware of it.

Thankfully, the pain didn't get as bad as it had with Littles. I was already under the care of a chiropractor, where I got regular massages and adjustments, so perhaps that had something to do with it. (As a bonus, chiropractic is fully covered by my insurance. Hence why I was already seeing one, even before I got pregnant: It was a way to get free massages!)

As the final months of my pregnancy approached, I did start feeling it more, so I started working with a chiropractor who specializes in treating pregnant women and children. That helped keep the pain at bay and also ensured that I was properly aligned for a smooth delivery.

Noob's birth was a lot easier than Littles, and while there are many possible reasons for that, I do wonder whether those adjustments helped.

With Q
Again, I started feeling the familiar twinges much earlier, around the start of the second trimester. I started seeing a chiropractor at around 20 weeks. My previous chiropractor had returned to teaching exclusively, but my midwife gave me a recommendation for another one who also specialized in pregnant women and children. In fact, as it turns out, my new chiropractor was a student of my previous one :)

I'm currently just shy of 35 weeks, and feeling wonderful. The SPD pain does kick in more some weeks than others, but even at its absolute worst, I'd say it's where it was at after my first acupuncture appointment with Littles. At its best, I hardly feel it at all.

In talking with other women, I find that many of them have suffered from SPD during pregnancy, and have had it dismissed as "normal" by their providers. My chiropractor and I often talk about the fact that so many women think that pregnancy has to be uncomfortable and painful. I'm sure some women will struggle with discomfort regardless -- putting on 25+ lbs in a short period of time and putting a watermelon where various internal organs used to be does have its effects -- but many women probably put up with discomfort as being "normal" when it's not.

What happens at a typical appointment?
A lot of people are unfamiliar with or even scared of "alternative" medicines like acupuncture and chiropractic. I think they also get a bad rap from people who think they can be used to treat everything, e.g. the stories of cancer patients who forego chemotherapy in favor of chiropractic and it doesn't work.

Using them to treat pregnancy pain is much different. In most cases, Western medicine offers no solution for this pain. So it's not like you're foregoing a treatment known to be effective in favor of alternative medicine. Worst case scenario, it doesn't work, and then you're no worse off than you were if you didn't try it.

To hopefully demystify these forms of treatment, let me explain a bit about what happened at each of my appointments.

At my first appointment with each provider, she (they all happened to be women) spent a lot of time asking me about my pain, my general pregnancy history (including prior pregnancies and births), etc. Then she talked to me about how she planned to approach my treatment and gave me the opportunity to ask any questions. As a result, this appointment was much longer than subsequent ones.

With acupuncture, the treatment consisted of sticking small needles into various areas of my body. Once all the needles were placed, which took maybe 5-10 minutes, my acupuncturist left me to relax alone, with the needles in, for another 15-20 minutes. The needles were not painful at all. In fact, I usually fell asleep during the relaxation time :) How a needle placed in my big toe alleviated pain on my pubic bone, I do not know, but it did!

As for chiropractic, each of my chiropractors had a special table for doing adjustments. They could change it to accommodate my growing belly, so I could lie on my stomach to get my back adjusted. They felt for any misalignments in my spine, and pressed on different areas of my back ("cracking" it) to fix it. Misalignments in my pelvis were fixed by rolling me on my side and pressing on each of my hips. I lay briefly on my back while my neck got cracked. Finally, each provider treated my pubic area specifically. The one I saw with Noob used a special tool, called an activator, that "shot" me in my pubic bone -- not real comfortable at the time, but it helped. My current one briefly massages me right on my pubic bone to get rid of any inflammation in that area. It's a little tender, so she's careful to not do it too hard.

After the initial appointment, each provider generally asked me about how I had been feeling since my prior appointment, then proceeded with the appropriate treatment.

Different providers do operate differently, and have different levels of expertise with working on pregnant women, so if you don't have a good experience with one provider (or have had a bad experience in the past), try another. I think the best way to find a good one is to get a recommendation from an OB/midwife/doula/other pregnant woman in your area. For chiropractors, in lieu of a first-hand recommendation, you can use this link to find a chiropractor: http://icpa4kids.org/Find-a-Chiropractor. Use the "Search for" drop down to select "Webster Certified Chiropractors," as this type of chiropractor has more experience with pregnant women.

I really can't say enough about the care I've gotten from my acupuncturist and chiropractors. I honestly think it's made the difference between tolerating pregnancy and truly enjoying it.

Gestational diabetes

What is gestational diabetes?
In short, gestational diabetes (often abbreviated GD) occurs in women who were not diabetic pre-pregnancy, but who have high blood sugar levels during pregnancy. This happens because pregnancy hormones can interfere with the production of insulin, which is what helps your body process sugar.

If your blood sugar levels remain high, the extra sugar gets transferred to the baby. This can potentially cause a whole host of problems with the pregnancy.

Here is a good article that explains more and also links to a short CDC podcast about GD: http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html

With Littles and Noob
With both of the older kids, at around 24 weeks, I had what is often called the "one hour" test. I had to drink a soda-like beverage with a certain amount of sugar in it. One hour later, I had a blood draw to check on my sugar levels. In my case, my sugar levels were low enough to indicate that my body had properly processed the sugar in the drink.

If they had been too high, I would have gone on to take a three hour oral glucose tolerance test (OGTT). Same lovely drink, except during an OGTT, the patient gets blood draws before drinking the drink and then every hour for three hours afterwards. Usually, having two out of the three draws above the acceptable thresholds results in a GD diagnosis.

Most women with GD are able to treat it successfully through diet, by eating regularly, eating more complex carbohydrates/fewer simple sugars, boosting protein, etc. This article includes some general guidelines for diets for women diagnosed with GD.

Still, in a typical hospital-based practice, women diagnosed with GD are classified as "high risk," even if their glucose levels remain well-controlled with diet. GD patients are generally subjected to more interventions, such as regular growth scans and NSTs, early induction (to prevent the baby from getting too big), etc.

With Q
C doesn't generally do the one hour test. Instead, at my 30-week appointment, she did a finger prick to check on my glucose levels. Mine were fine (actually on the low side!), so no GD concerns.

Why the different approach? Well, I'm sure part of the reason is that it's much simpler, given that the one hour screening generally has to be done by an outside lab, and C is not able to write lab orders. She can do the finger prick right in her office. Easy. And I just have to eat normally, rather than drinking that icky soda stuff. Easy, too.

Of course, easy isn't always better... but in this case, I think it is! For starters, it's exactly how women diagnosed with GD monitor their blood sugar levels. And again, most women diagnosed with GD are able to control their blood sugar levels with diet. So it makes sense that if your blood sugar levels are within normal range after eating your normal diet, then your normal diet is doing a good job of, well, controlling your blood sugar levels!

To that end, I've also found that C talks to me a lot more about my diet than any of my previous providers. At pretty much every appointment, actually. Really, a "GD diet" is nothing revolutionary; most pregnant women would benefit tremendously from choosing more protein and complex carbs over simple sugars, regardless of GD status. (Heck, most people would benefit from making those choices in general, regardless of pregnancy status :) C, and many homebirth midwives, tend to steer all of their patients towards that type of diet early on, rather than waiting till they fail the OGTT.

Also, C's more personalized approach to prenatal care shines through here. At every prenatal appointment I've ever had, I've had to do a urine test, which screens for sugar in my urine, among other things. Sugar in the urine can be an early sign of a woman whose body is having trouble processing sugar. With my previous providers, I always gave my urine sample to a lab person who never saw my face. With C, I give the dipstick directly to her.

This means that she quickly gets an idea of what is "normal" for me and what is not. For example, at my last appointment, she looked at the stick and said, "What did you eat for breakfast?" I told her: cereal, yogurt, and orange juice. (That's another way she can get a sense of my dietary habits.) She said, "OK. Your sugar levels are higher than normal for you. They are not too high, it's just that you're normally below the normal range, and today you're in the normal range. But it was probably the OJ." That is an analysis that an anonymous lab person who never saw my face never could have made.

(Interestingly, my previous providers never mentioned any concerns about the sugar levels in my urine. Not once. C has now mentioned something twice this pregnancy. The first time was a few months back, after I had a handful of gummy worms with my lunch. I don't know if her test is more sensitive, or if that just goes back to the fact that she knows that being in the "normal" range is not normal for me.)

So it all fit together: C knew my diet, and knew that it was generally good. She knew that I rarely spill sugar in my urine. And so when my blood sugar levels on the finger prick test were low as well, she was able to say pretty confidently that I don't need any further GD testing.

Of course, had she had any concerns, she would have asked me to get an OGTT. If that test diagnosed me as a gestational diabetic, I would have been able to stay in her care as long as I kept my blood sugar levels under control with diet. If I got to the point where I needed insulin to control my blood sugar levels, I would have risked out of homebirth.

Differing perspectives on GD screening and diagnosis
The 1-hour test is widely considered to be "the" way to screen for GD, so much so that I've heard many people say that it's foolish or downright dangerous to not do the 1-hour test. But the 1-hour test is just one of several screening methods that the American College of Obstetricians and Gynecologists (ACOG) recommends:

"All pregnant women should be screened for GDM [gestational diabetes mellitus], whether by patient history, clinical risk factors, or a 50-g, 1-hour loading test to determine blood glucose levels."

So, C's finger prick test is right in line with those recommendations.

For diagnosis, ACOG recommends the 3 hour OGTT. Again, C does recommend the same if she has concerns about one of her patient's blood sugar levels.

Furthermore, there is some disagreement over whether the OGTT is even an appropriate way to diagnose GD. On one side of the spectrum, there is Henci Goer, who argues that the OGTT and diagnosis of GD in general is useless: http://www.gentlebirth.org/archives/gdhgoer.html

It's an interesting read, but I should point out that 1) Henci Goer is not a doctor and is strongly anti-intervention, so she's hardly an unbiased source, and 2) the sources she cites are fairly old, with the most recent being from 1994.

On the other side of the spectrum, a large-scale 2008 study, called the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, suggested that the current diagnosis criteria may not be stringent enough! http://www.nejm.org/doi/full/10.1056/NEJMoa0707943

In short, the HAPO study followed women who were not diagnosed as GD under the current criteria. It found that the risk of a number of adverse pregnancy outcomes (such as macrosomia, primary c-section, shoulder dystocia, and pre-eclampsia) rose linearly in correspondence with the mother's glucose levels during a 2-hour OGTT.

This led the American Diabetes Association (ADA) to recommend revised guidelines for diagnosis of GD: http://care.diabetesjournals.org/content/34/Supplement_1/S11.full#sec-11

Again, to summarize: The ADA recommends getting rid of the two-step screening-diagnosis testing (the 1-hour and 3-hour tests), in favor of a single 2-hour OGTT for all women. While ACOG's standards only diagnose a patient as having GD if she has two or more blood draws indicating glucose levels above the defined thresholds, the ADA guidelines call for a GD diagnosis if there is a single draw with glucose levels above the defined thresholds. This would substantially increase the number of women diagnosed with gestational diabetes.

ACOG disagrees,

"because there is no evidence that diagnosis using these criteria leads to clinically significant improvements in maternal or newborn outcomes and it would lead to a significant increase in health care costs."

So what to make of all this? I actually think it can all be rationalized.

Let's start with the ADA guidelines. Despite calling for revised diagnosis criteria that would increase the number of women diagnosed with GD, they do concede that we don't really know exactly how these women with "mild" GD should be treated:

"Additional well-designed clinical studies are needed to determine the optimal intensity of monitoring and treatment of women with GDM diagnosed by the new criteria (that would not have met the prior definition of GDM). It is important to note that 80–90% of women in both of the mild GDM studies (whose glucose values overlapped with the thresholds recommended herein) could be managed with lifestyle therapy alone."

What kind of "lifestyle therapy?" Well, maybe the answer can be found in Goer's article, of all places:

"Pregnancy makes extra demands on insulin production; to minimize the pressure, pregnant women should eat a diet low in simple sugars, high in complex carbohydrates and fiber, and moderate in fat. Moderate, regular exercise also improves glucose tolerance."

In other words, the key isn't so much how we diagnose GD, but how we treat it. There is no doubt that there are some women with high sugar levels during pregnancy who need aggressive intervention. Even C concedes this, by risking women out of homebirth if they need insulin to control their diabetes. Heck, even anti-interventionist Goer concedes this: "Within the GD population lurk a few women who were either undiagnosed pregestational diabetics or who were tipped into true diabetes by the metabolic stress of pregnancy; a fasting glucose to screen for them might be prudent."

But most women with GD probably don't need aggressive intervention, just some form of intervention, such as nutritional counseling. Beyond that, they just need to be treated like the healthy pregnant women that they (mostly) are. As C puts it: "If you are diagnosed with GD, but you're able to control your glucose levels with diet alone, you don't really have GD."

Personally, I'd love to see the HAPO study repeated, with a twist: Rather than just following women after their 2-hour OGTT, divide them into two groups, with the control group just being followed and the test group receiving in-depth counseling on nutrition, exercise, etc. If my previous paragraph is correct, the outcomes among the test group should be better than the outcomes among the control group, regardless of the original glucose levels.

That would also be a fascinating confirmation of C's approach to GD screening and "treatment," too, since she essentially does that type of counseling with all her patients. As I said in my introduction to this blog, homebirth is not just like hospital birth except you stay at home at the end. It is a completely different approach to prenatal care as well, and this is a great example of that.

Hiring a doula

With Littles
We had never heard of doulas until we took our Bradley Method classes. It was our Bradley instructor who introduced us to the concept, and encouraged us to consider one.

I eventually decided that I wanted to look into hiring one. My big thing going into labor was that I wanted to have no regrets. I didn't want to look back and say, "Gee, if only I had hired a doula..." I talked it over with my husband and he was onboard. After all, neither of us had any experience with labor. It couldn't hurt to have someone there who had actually been through this before!

I started my doula search by utilizing a list provided by a local birth resource center. By this point, I think I was around 32 or 33 weeks pregnant, and quite a few of the doulas I contacted had no availability for my due date. Finally, I got in touch with "E," who said she could take me on. We interviewed her and felt very good about her, so we hired her.

A lot of people wonder about the cost of doulas. E's rate was $900. That's definitely on the high side, but this was in northern California (where everything is expensive!) and E also had a lot of experience.

I'll describe in more detail what E did for us in a later post, but for now, I'll just say that she was amazing and played a huge role in making Littles' birth a very positive experience for both of us.

With Noob
I first "met" M early in my pregnancy with baby #2, through a local Yahoo! group for attachment parenting. I don't consider myself to be "fully" AP, but I knew the group was likely full of women interested in low-intervention birth, so I figured they'd be a good group to ask for recommendations on birth providers. And they were. It was M who pointed me towards the fabulous hospital-based midwives who ended up caring for me through my miscarriage of baby #2 and then most of my pregnancy with Noob.

After our wonderful experience with E, we both knew we wanted a doula again, so I also asked the group for doula recommendations. As it turns out, M was a doula, so once I got out of the first trimester with Noob, I gave her a call and set up an interview. Since we were starting our doula search earlier in my pregnancy, we did have a lot more options. We ended up interviewing four doulas.

People often ask me what sorts of questions to ask a doula. Honestly, the biggest thing for me is not asking specific questions, but just talking, and seeing if we "click." This time around, with one birth experience under my belt, I was able to walk through Littles' birth with each candidate, talk about what went well and what I'd like to change this time around, and see how they reacted.

The first doula we interviewed was M, and we both loved her. She has a calm presence and is incredibly knowledgeable without being pushy.

The second was a doula who came recommended by my midwives. She was very knowledgeable, too, but we just didn't "click." I think she might have been good for me as a first-time mom, when I needed a lot more guidance, but on my second time around the block, I had a good idea of what I wanted and needed support more than guidance. The last straw came at the end of the interview, when she went off on a little rant about how she is "absolutely a breastfeeding nazi," thinks formula is inferior, and insists that all of her clients at least try to breastfeed. Now, as it so happens, I breastfed Littles until she was 22 months old, including pumping at work, and fully intended to do the same with Noob. But she didn't know that. And many women don't feel that way. For her to exert such a strong opinion just rubbed me the wrong way, even though I was ultimately in agreement on that particular point. After all, who knew what other things might come up where I'd find I was not in agreement with her? I scratched her off the list immediately.

The third doula was very nice, but again, again, I just didn't "click" with her.

The fourth doula was a certified "hypnodoula" with Hypnobabies, which appealed to me because I planned on doing Hypnobabies. She was super nice and we had a great chat. She was the least experienced of all the doulas, but that wasn't of particular concern to me: A doula isn't a medical professional, so lack of experience isn't necessarily a problem, as long as we're on the same wavelength birthing-wise and she has enough experience to be useful.

There was just one odd moment in the interview. As we went through some of our birth preferences -- wanting to avoid an IV, eat/drink during labor, etc. -- she said, "Are you sure you want to birth in a hospital? Have you considered a birth center at all? There's a great one just down the street from your hospital." This struck me as strange, because we had never indicated any concern or dissatisfaction with our hospital. Indeed, it's well-known for being friendly towards med-free birth, and all the other doulas had spoken very highly of it. We said that yes, we had considered birth centers and still decided on the hospital (which was absolutely true), and she still spent a few minutes encouraging us to take a closer look at them.

She also mentioned that there was a Hypnobabies Yahoo! group, and encouraged me to join. So I did. And did some poking around in the archives. Eventually, I found her own birth story, which she had posted to the group after the birth of her son a year or so earlier. Long story short, she had been under the care of the same midwives at the same hospital as me. She ended up delivering via c-section, and vaguely blamed the midwives for it. She was also less-than-thrilled about some aspects of her postpartum care at the hospital, e.g. being woken up in the middle of the night to check on the baby. She said that she would go to a birth center for her next baby.

Suddenly, it made sense why she was so insistent about us looking at birth centers. I eliminated her immediately. I felt very comfortable with my midwives and hospital, and I didn't need anyone else bringing their personal baggage to my birth.

So, we hired M. I think I was around 20 weeks at the time. Again, I'll go into more details about the role she played in Noob's birth in another post (because this one is far too long already), but the short version is that she was wonderful, and we've hired her again for Q's birth.

On rates: I think M's was $400 for Noob's birth. (She now charges $450, which is still a steal for someone with her experience.) The hypnodoula was $200 -- as I said, she was the least experienced of the group, so that makes sense. The other two were in the $700 range, which is pretty typical for experienced doulas in this area.

Bradley vs. Hypnobabies

I concluded my last post by saying that it's important to choose a childbirth class that feels right to you, which may or may not be what feels right to me. I figured it might be helpful to talk a little more about the specifics of Bradley and Hypnobabies, to help other women figure out which one does feel right to them.

Bradley classes
A "classic" Bradley method course series is 12 classes. Many instructors compress it somewhat. Mine covered the material in 10 classes.

The classes include:

• Three classes on staying comfortable and healthy throughout your pregnancy (exercise, nutrition, etc.)
• Two classes focused on the coach's role (typically the husband)
• Four classes on the mechanics of first and second stage labor, as well as tips for pain management and coaching during each stage
• One class on planning (birth plans, packing the hospital bag, etc.)
• One class on unexpected situations (c-sections, etc.)
• One class on basic newborn care (breastfeeding, baby soothing, etc.)

A typical class for us lasted between 1-2 hours. We usually reviewed the material in the workbook we were given, with plenty of time to ask questions. We often watched videos related to the material we were covering. We also did relaxation practice, which typically involved me lying down, breathing deeply, while my husband rubbed/massaged me and helped identify any areas of tension. Later in the class series, we did some full-on labor rehearsals, where I tried different positions, our instructor pretended to be a nurse "interrupting" and my husband had to gently handle her so she wouldn't bother me, etc.

Homework between classes included keeping a food log, some pregnancy exercises (pelvic tilts, tailor sitting, squats, kegels), and relaxation practice.

Hypnobabies home study
The Hypnobabies home study class consists of a workbook, a quick reference/birth partner guide, and a folder full of CDs.

The workbook is divided into an introduction, five classes, and a maintenance program. Each class is designed to take one week, although I started early in my pregnancy (about 24 weeks with both Noob and Q) and often chose to take two weeks before moving on to the next class. The classes cover:

1. Positive childbirth (hypnosis and how it can help you overcome the fear/tension/pain cycle during childbirth)
2. Staying healthy and low risk (exercise, nutrition, etc.)
3. Birthing choices (risks and benefits of common interventions such as Pitocin, IVs, etc., birth plans)
4. First stage labor
5. Second stage labor and breastfeeding

So, basically the same topics as Bradley. The approach is a little different, e.g. the Hypnobabies materials remind you over and over again that birth is easy, and they replace the usual birthing-related words with more positive ones (birthing time instead of labor, pressure waves instead of contractions, etc.)

Each week, you read the appropriate section of the workbook. The section also gives you your homework for the week. It's the same as Bradley homework -- food log, pregnancy exercises, and relaxation practice.

The relaxation practice is another key difference from Bradley. The practice is guided by self-hypnosis "scripts" on the CDs. The workbook section tells you which tracks you should listen to each week -- there are two per week, which you listen to on alternate nights. It also includes the hypnotic suggestions that are on each track. This is nice for people like me who always fall asleep while listening to the tracks :) By reading the workbook, I'm able to find out just what I'm listening to while I'm sleeping!

If you want to get a sense of what the scripts are like, there's a sample track on the Hypnobabies website that you can download and listen to for free.

For the first week or two, the scripts walk you through deep breathing to relax and enter hypnosis. Later on, you learn to enter hypnosis by using your "lightswitch." You also practice self-hypnosis using your lightswitch 5 times a day, outside of your script listening. It only takes a few minutes.

On top of this, you also listen to the "Pregnancy Affirmations" track daily. This is not a self-hypnosis track, so you can listen to it while driving, working, etc. It's about 30 minutes of positive statements about childbirth, such as:

• Pregnancy is natural, normal, healthy, and safe for me and my baby.
• My changing body is radiantly beautiful.
• I will give birth in comfort and in peace.

Once you're done with the five classes, you enter the maintenance program until you give birth. No more weekly reading, but you keep up with the exercises, nutrition, and relaxation practice. For the scripts, there's a weekly rotation of tracks to listen to, plus the daily pregnancy affirmations.

If that sounds like a lot... it's really not. The workbook reading takes maybe 30-45 minutes per week. The exercises are maybe 20-30 minutes per day if you're religious about doing them, which I'm not :) As for the scripts, I always queue up the script of the day plus the pregnancy affirmations track at bedtime. I usually fall asleep within a few minutes, but that's fine: My conscious mind knows what's on the tracks from reading the workbook, and my subconscious mind is still listening even when I'm asleep.

Hopefully that gives you a better idea of what you're in for if you choose either Bradley or Hypnobabies. They are both great courses, so choose what fits your personality and mindset the best! You can't go wrong with either one :)