Doctor vs. midwife

The differences in care provided by a doctor vs. a midwife (especially a homebirth midwife) were on full display at Q's follow-up ultrasound today.

When C scheduled the appointment on Monday, she warned me that she might not be able to come, as it was at prime school pick-up time (3:45 pm) and she lives all the way on the other side of the city. I was a little worried, because my husband couldn't come, either, and while I had a feeling everything would be fine, I really didn't want to face bad news on my own. Well, C called me last night to say that she had made arrangements for her kids so that she could be at my ultrasound! I was so relieved that I almost cried.

The ultrasound was with the same perinatologist who did Q's NT scan. C beat me to the office. When I arrived, I checked in, and the receptionist said that they had no record of my appointment. Say whaaaaa...? Luckily, they were able to just add me to the schedule.

Perhaps due to the appointment confusion, we had to wait about 30 minutes to be seen, so C and I passed the time chatting in the waiting room.

Finally, we went back to the ultrasound room. (No Barbie cars in this one.) The nurse asked me if I knew the baby's sex yet and I said no. She asked if I wanted to find out and I said no. She said, "OK, well, the doctor will look anyway and it will be in the ultrasound report." Sigh.

The perinatologist breezed in. He appeared to have no clue who C was and why we were there -- again, perhaps due to the appointment confusion, or perhaps because he just didn't care. So, he basically repeated the entire anatomy scan from Monday. He did explain what he was looking at, but was very businesslike about it.

When he got to the right kidney, he noted that it was dilated. Duh. He asked the nurse about my Down's syndrome risk from the NT scan. I guess this problem can be a soft marker for Down's, but since I had the NT scan done and my risk was very low, we know it's highly unlikely that the baby has it. He explained that the extra fluid doesn't look serious, and will likely resolve itself in utero as the baby grows. We'll continue to monitor it via ultrasound, and if it doesn't resolve itself, we'll just need to follow up with our pediatrician to get the baby examined after the birth. It could eventually require surgery, but it might also resolve on its own post-birth.

Then he asked (again) if I wanted to know the sex, and I said no (again). He said, "OK, we'll, I'm going to scan that area now, so look away." He did this at the NT scan, too. I'm not sure why he's so obsessed with my baby's genitals.

He concluded by reminding me to schedule another ultrasound in three weeks and to follow up with "my doctor" to do the AFP test (a second trimester blood screening for Down's and other chromosomal abnormalities, which I have no plans to do). Clearly, no clue who C was. Oh, and he asked once again if I wanted to know the sex... seriously? NO! C quietly said, "Surprises are the best." Love her.

And then he and his nurse left. The entire visit lasted perhaps 15 minutes. Maybe it would've been 14 minutes if I hadn't been asked about finding out the sex three separate times.

C told me that she could give me some more information, so I checked out and got the next ultrasound scheduled, and then we stepped out in the hallway.

C started off by saying, "That's the best possible outcome!" We spent about 15 minutes discussing it all. In short, even if the issue doesn't resolve in utero, I can still do homebirth. The only thing that would necessitate a transfer of care would be if my amniotic fluid gets low, which can happen when the kidneys aren't processing properly. But my fluid levels have looked great at both ultrasounds, and so C thinks it won't be an issue, especially since the left kidney is fine. We both laughed at the perinatologist's genital obsession... C knows we don't want to know the sex (I don't have to tell her multiple times per appointment) and so she has taken care to look away at the appropriate times as well. Because if we don't want to know, she doesn't want or need to know, either.

Once all my questions had been answered, I thanked her for taking the time to come, she said she was happy to and gave me a hug, and we went off to pick up our respective kids.

And that, in a nutshell, is why I'm thrilled that I'll be able to stick with midwifery care.

Anatomy scan

The anatomy scan, or "big" ultrasound, is usually performed between 18-22 weeks. It's an in-depth look at every aspect of the uterus and the baby's anatomy, attempting to identify any abnormalities or other concerns. This is also traditionally when parents find out the baby's sex, if desired -- although these days, a lot of people do elective gender ultrasounds around 16 weeks, or even get a gender guess at the NT scan.

With Littles -- January 16, 2007 (20 weeks)

Although my OBs had ultrasound equipment and were able to use it, they sent me to a different office to get the anatomy scan done with an ultrasound tech. I don't know if that was for scheduling purposes (since the anatomy scan typically takes a lot longer than the average OB appointment) or because the ultrasound equipment in that office was better or what.

Anyway, I didn't mind, because the ultrasound tech was fantastic. He really took a lot of time to explain what he was looking at, which was helpful because I don't know about you, but even after three pregnancies, ultrasound pictures usually remind me of those "hidden picture" books where you have to really squint and turn your head just the right way and then bam! oh OK, I see it now :)

We did choose to find out the sex at this time. I'll probably do another post on that whole decision.

With Noob -- September 15, 2009 (20 weeks)

The anatomy scan was done at my midwives' office, although not by either of the midwives, because they aren't able to do ultrasounds. Instead, it was done by the same ultrasound tech who did Noob's initial dating ultrasound. I was unimpressed by the tech's bedside manner at that first ultrasound, and the anatomy scan was no better. It was a lot faster than the scan with Littles, because the tech just did the scan, barely explaining what she was looking at.

We elected not to find the sex with Noob. I'm not sure how much that played into our experience. At certain points, the tech asked us to look away to avoid accidentally getting a peek at the genitals, so we weren't able to look at everything like we had with Littles. She may also have been reluctant to do anything beyond what she had to do, to avoid the chances of another accidental peek.

I'm also not sure if the tech could say very much. At some offices, ultrasound techs aren't really able to give the patients the results (good or bad) directly; they simply take pictures and pass them along to the OB for review. So that might have been the case here.

Regardless, it was fine, but definitely a bit of a letdown from our experience with Littles.

With Q -- February 20, 2012 (20 weeks, 6 days)

C sends her patients to a local women's center for the anatomy scan. Must be interesting for them to get C's patients in there, since I'm guessing that many of the scans they do are for women with an unplanned pregnancy who are considering abortion...

We decided to bring Littles along, and it was a really nice setup for her. Unlike the ultrasound rooms where we'd had Littles' and Noob's anatomy scans, this one was clearly designed with the idea that women might bring their kids along. There was a stool for Littles to stand on to get a good look, and lots of toys to play with if/when she got bored of watching the confusing images on the screen. Littles hung in there for a good 10 minutes or so, but she quickly discovered the hot pink Barbie toy car, and that occupied her for the remainder of the scan.

Another difference from the previous anatomy scans was that C was there. (For the other scans, it was just my husband and me with the ultrasound tech.) This turned out to be a good thing, as during the scan, there was a problem identified with Q's right kidney. C was able to look at the ultrasound side-by-side with the tech, rather than relying on pictures after the fact. She was able to discuss the implications with us immediately, in person, rather than waiting till our next appointment or calling us on the phone. And within 10 minutes of the end of the appointment, she had me scheduled for a follow-up ultrasound with a perinatologist to get a better look at the kidney and determine a course of action.

Of course, I would have preferred to have had a totally normal scan, as I did with Littles and Noob -- but if I had to pick one of the three anatomy scans to be abnormal, it would have been Q's for sure, due to C's calm presence.

The follow-up ultrasound is tomorrow, and I'm hoping to get some better answers as to what's going on and how big (or small!) of a problem it is. Right now, we just don't know.

A typical prenatal appointment

If you've never been pregnant, I'll let you in on a little secret: Prenatal appointments are boring. (At least, you hope they are.) At this point, on the third time around the block, my husband doesn't even come to most of the appointments, because honestly, there's no need. I'd probably skip them too if I weren't physically required to be there :)

Anyway. There are 5 things that are typically checked at prenatal appointments:

1. Weight
2. Blood pressure
3. Urine test
4. Baby's heartbeat via doppler or ultrasound
5. Later in pregnancy: fundal height measurement (size of your uterus) and baby's position (vertex vs. breech) via abdominal palpitation

Pretty basic, right? How much variance can there be between providers? Well... a lot.

Let's say I have a prenatal appointment at 2 PM. How would that appointment have gone in each of my three pregnancies?

With Littles
2:05 PM - I arrive at my OB's office. (My dad likes to joke that I was born two weeks late and I've been late ever since. He's right.)

2:15 PM - I'm called back. A nurse directs me to the bathroom to give a urine sample, which I leave at the lab for testing. She then checks my weight and takes my blood pressure.

2:20 PM - I go into the exam room.

2:30 PM - Enjoying a year-old issue of People.

2:45 PM - Since this is 2007, I don't even have a smartphone to use to surf the Internet. Sucks.

2:50 PM - My OB finally arrives. He or she lets me know that my urine test looked good, my blood pressure is excellent, and my weight gain is right on track. I'm asked a few questions, like whether I'm feeling the baby move and whether I'm having any contractions. I'm given the opportunity to ask questions, too. As a first-time mom, I usually try to come up with a couple, at least.

2:55 PM - I hop up on the table and the doctor examines my belly. They don't have ultrasound machines in the exam rooms, like some OBs do, so we listen to Littles' heartbeat on the doppler.

3:00 PM - Appointment done.

With Noob
2:05 PM - I arrive at my midwife's office.

2:10 PM - I'm called back. A nurse directs me to the bathroom to give a urine sample, which I leave at the lab for testing. She then checks my weight and takes my blood pressure.

2:15 PM - I go into the exam room.

2:20 PM - My midwife comes in. She lets me know that urine/blood pressure/weight gain look good, and asks me questions about how I'm feeling. I'm given the opportunity to ask questions, too. Even early on, I usually ask at least a question or two about labor/delivery. It's important to me to make sure my midwives are on the same page as me regarding topics like induction for postdates, eating/drinking during labor, etc.

2:35 PM - I hop up on the table and my midwife examines my belly. No ultrasound machines here, either -- the midwives aren't able to do ultrasounds anyway -- so doppler it is.

2:40 PM - Appointment done.

(As an aside, I wondered if the promptness and the willingness to spend time/answer questions was simply a difference between the practices I saw with Littles vs. Noob, rather than a difference between OBs and midwives. Well, I had one appointment during my pregnancy with Noob where I was required to see an OB in the same practice as my midwives -- office policy. And it went pretty much identically to the OB appointment I described above, with Littles. The OB was about 45 minutes late and then was literally walking out of the room as I was asking a question. Ironically, I ran into my midwife in the hallway afterwards, and spent more time chit-chatting with her than I had spent during my entire appointment with the OB. So I guess it wasn't a difference between practices...)

With Q
2:05 PM - I arrive at C's office. She's there and waiting for me. She hands me a cup and a dipstick to do my own urine test. Littles comes with me.

2:10 PM - Urine test done. Littles is fascinated by all the colors on the dipstick and asks what they're for. I have no clue, so we both ask C when we get back. C patiently goes through each one with us. I knew from my previous pregnancies that she was looking for protein (possible sign of pre-eclampsia) or sugars (possible sign of gestational diabetes) in my urine, but C shows us that there are also tests for illness, healthy diet, etc. I have no idea whether my previous providers did all those same tests. I never asked and they never told me.

Everything looks good, except I do have some sugars in my urine. C notes that that's unusual for me and asks me what I ate today...

Me: I had yogurt and cereal for breakfast, and a cheese sandwich and an orange for lunch. Oh! And some crackers.

C: Hmmmm. I guess the sugars could be from the orange. Well, we'll keep an eye on it. *pause* No soda or candy?

Me: No. Oh wait! Yes. I had some gummi worms at lunch, too.

Busted :)

2:15 PM - C asks me how I'm feeling and then asks about our recent trip to China. "They have toilets you have to squat over!" Littles exclaims.

2:20 PM - Littles regales C with tales of our adventures on the Great Wall of China.

2:25 PM - Somewhere in there, C sneaks in a blood pressure and pulse check, and we also chat quickly about my nutrition.

2:30 PM - Littles entertains both of us with her theory on umbilical cords: "The baby can get ice cream through the umbilical cord, but not the cone. It's too big. It won't fit." C smiles. "That's a new one!"

2:35 PM - I make a coloring book for Littles to take to each appointment, with pictures of various pregnancy- and baby-related things. For today's book, she specifically requested a picture of a uterus. Okay. I found a picture online, so we spend a few minutes talking about the uterus, ovaries, and cervix. "My uterus is empty!" Littles proudly tells C. Thank goodness. I hope to keep it that way for many years to come.

2:40 PM - C directs me to the scale in her closet. I step on and call out the number to her.

2:45 PM - Littles has moved on to discussing the fact that Noob threw up this morning at the dentist's (hence why he wasn't at the appointment) and that she's seen two of her classmates throw up as well. "It's a potty humor kind of day, huh?" C remarks with a smile.

2:50 PM - I hop up on C's exam table. Littles stands right near my head. She told me last night that this is her favorite part. C squeezes blue ultrasound gel on my belly -- all the kids know about C's "blue goo," and so when her supplier stopped carrying it a few months ago, she found another supplier that did. She quickly finds Q's heartbeat, and follows Q for a minute or so as s/he moves around my belly. Littles listens intently, amazed by the sound.

2:55 PM - A little more chit-chat as we schedule my next appointment.

3:00 PM - Appointment done.

In summary
They all did the standard stuff, but...

• My OBs were much more likely to be significantly late.
• My midwives spent more time with me at each appointment. Especially C, my homebirth midwife. I joked that I probably spent more time with C during my pregnancy with Noob (after switching to homebirth less than 4 weeks before his birth) than I did with my previous hospital-based midwives during the first 36 weeks of that pregnancy, and with my OBs over my entire 42-week pregnancy with Littles. Well, it wasn't really a "joke;" I'm pretty sure it's the truth.
• Thanks to all the time spent together and random chit-chat, I have a much more personal connection with C than with any of my previous providers. She even came to Noob's first birthday party :) I know that some women don't want that personal connection -- they want their doctor/patient relationship to be more professional -- and that is totally fine. But it's something that's very important to me.
• Besides just giving me more time to ask my own questions, C also probes me more for information, going beyond standard baby-related questions ("Are you feeling the baby moving?") to ask about nutrition, sleep, stress levels, etc.

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?

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.