"Q" is here! It's a girl!

Q was born on July 2nd, 2012, at 1:11 AM Central time. It's a girl!

I'm going to post Littles' and Noob's birth stories, followed (eventually) by Q's. I do have more blogging to do on some specific birth-related topics, but that will have to wait!

Group B Strep

Group B strep (GBS) is a bacteria that is carried in the vagina and/or rectum of about 25% of pregnant women at any given time. It normally doesn't cause any problems or symptoms in the mother, but when she gives birth, she has a higher chance of passing the bacteria along to her newborn than an non-colonized mother. This can cause GBS infection in the newborn, which can be very serious or even fatal.

Here is more information about GBS infection, screening, and treatment from the CDC. Here is an article that presents an alternative view regarding treatment, from Mothering magazine.

With Littles
I was screened for GBS at my 36-week checkup, via a swab of my vagina and rectum.

I tested positive.

I was devastated. This was the first real curveball thrown at my med-free birth plans. (It wouldn't be the last.) It meant that I needed to get IV antibiotics during labor -- ideally, at least two doses, at least four hours apart, prior to the birth. I didn't like the idea of having to get to the hospital early to ensure I got the first dose of antibiotics in time. I didn't like being required to get an IV. I didn't like that Littles would get antibiotics before she even took her first breath.

I talked it over with Dr. K at my next appointment. She made me feel a little better by saying that I could get a saline lock (also called a hep lock), rather than a constant IV. This would allow me to be hooked up to the antibiotics when needed -- that is, for roughly 10-15 minutes every 4 hours -- and then disconnected, to give me freedom of movement until it was time for my next dose.

She also wasn't overly concerned about changing when I left for the hospital. Since I was a first-time mom, she was pretty confident that as long as I followed the standard 5-1-1 rule for leaving for the hospital (contractions every 5 minutes, lasting for at least one minute, for at least one hour), I'd end up getting there in time for my two doses regardless.

I asked her about alternative treatments, such as a chlorhexidine wash or even declining antibiotics completely. (Even with no antibiotics at all, fewer than 1% of babies born to GBS+ mothers actually develop GBS disease.) She had never heard of a chlorhexidine wash. She said that I could decline antibiotics, but added that if Littles developed any symptoms of possible GBS disease, she would be treated very aggressively. "Spinal taps on a newborn are no fun," she cautioned. I decided that it made sense to do the antibiotics, rather than risk any unnecessary discomfort for Littles.

As it turns out, I had to be induced, and so the GBS thing was not a big deal at all compared to everything that came along with the induction. Induction eliminated any concerns about getting to the hospital in time, and since I had a constant IV for Pitocin, I barely even noticed when they added the bag of antibiotics to the mix.

And, of course, Littles was fine. Hardly surprising. The antibiotics cut her risk of developing GBS infection from about 1 in 100 to about 1 in 4000.

In retrospect, even if I had gone into labor on my own, the whole GBS thing really wouldn't have affected it much at all. I really had no reason to be as upset as I was when I first found out.

With Noob
Some doctors treat a mother who has tested positive for GBS in past pregnancies as being GBS+ for any subsequent pregnancies as well. Early in my pregnancy with Noob, I asked my midwives if they did this, and they answered no. So my history with Littles made no difference: I'd be screened at 36 weeks again, and as long as I tested negative, there would be no need for antibiotics.

When I relayed this to my doula, she told me about a regimen of vitamins and herbs that her own homebirth midwife suggested to fight GBS prior to the screening. It consisted of probiotics, echinacea, vitamin C, and garlic, starting around 32 weeks. All of these things are naturally antibacterial, so they can potentially kill off GBS bacteria in a colonized mother. They also carry no known risks. I figured it was worth a try.

Some people consider this to be "cheating the test." I disagree. If this stuff does in fact kill off the GBS bacteria in advance of the test, presumably it will keep killing off any new GBS bacteria for as long as you continue taking it. For this reason, I opted not to take garlic: It's a blood thinner, so you need to discontinue use of it at 37 weeks, to avoid any bleeding issues during birth. I started on everything else, fully intending to continue taking until I gave birth.

At the time, I didn't know that I'd be switching to homebirth. I made the switch at 36 weeks, so I never did the GBS screening with my hospital-based midwives. Instead, I did the screening with C at 37 weeks. She handled it differently from the OBs I had with Littles:

• C left it entirely up to me as to whether I even wanted to do the screening. She gave me a paper with all sorts of information about GBS screening and treatment to ensure I could give truly informed consent. I opted to do it. In my eyes, there was no downside to screening: Even if I tested positive, as long as I birthed with C, I was free to choose my preferred course of treatment, including no treatment at all. And there was a potential downside to not screening: If I ended up having to transfer to the hospital for any reason and my GBS status was unknown, I'd be treated as positive regardless.
  
• C had me swab myself. It's really easy to do, no need for years of medical school to learn how, honest. And as far as I'm concerned, it's good to minimize how often I take off my clothes unnecessarily :)
  
• C instructed me to only swab my vagina, not my vagina and rectum. Rectums have more bacteria in general, so it's hardly a surprise that women who have both swabbed will be more likely to test positive than women who have only their vaginas swabbed. In case there was any doubt, this is backed up by studies, such as this one and this one. But those studies only looked at the number of women who tested positive from a vaginal swab vs. vaginal + rectal swab, not the actual incidence of GBS infection in their babies. And, well, last I checked, the baby doesn't come out your rectum. The reason generally given for doing the rectal swab is that a woman with GBS colonization in her rectum is more likely to develop GBS colonization in her vagina as well, but if that's the case, wouldn't a vaginal swab pick that up, at least the vast majority of the time?
  
• If I tested positive, C was not able to give IV antibiotics during labor. For better or worse. She offered a couple of alternative options, such as a chlorhexidine wash (which has been shown to be effective, e.g. in this study and this study), various herbal treatments, or no treatment at all, simply observation of the newborn in the early postpartum period. If I really wanted IV antibiotics, I would've had to go to the hospital myself.

C knew I was anxious about the results, so she called me as soon as they came in, even though it was just a day before my next appointment and she could've easily waited till then to let me know.

I was negative.

Of course, I have no way of knowing whether it was the vitamins/herbs that made the difference, or if it was skipping the rectal swab, or if I just wasn't carrying the bacteria this time around. (It does come and go.) Whatever the reason, it was a huge relief for me.

I continued taking everything until I gave birth.

With Q
Since I was with C from the start, I asked her for her preferred GBS-fighting regimen. Hers was similar to what my doula had suggested with Noob:

• Vitamin C (at least 500 mg/day)
• Echinacea (without goldenseal, following the dosage on the container)
• Optionally, garlic oil capsules (following the dosage on the container, stopping at 37 weeks).

Again, I opted out of the garlic, but took the other two, starting at 35 weeks. Again, I tested negative at 37 weeks.

Birth plans

Birth plans get such a bad rap. A common joke around L&D wards is: "When a woman comes in with an extensive birth plan, might as well start prepping the OR for her c-section." And many expectant mothers will scoff, "My 'birth plan' is to show up and have a baby."

Maybe it's the ridiculous name. Any woman who has been through birth will tell you that it cannot be "planned." The awesome (and totally terrifying) thing about birth is that you have to give yourself over completely to your body and your baby. "Plans" be damned.

But a (good) birth plan is not a minute-by-minute account of how you want your labor to go. It's more of a list of philosophies and preferences that you want to guide your labor. The value of a birth plan is not really the plan itself, but the research and discussion -- with your partner, your provider, and any other parties that might be present (e.g. your doula or family members) -- that goes into it.

In many cases, the problem with a birth plan isn't the birth plan itself, but the communication (or lack thereof) around this. It's like writing a plan for a party that includes a catered meal, but not talking to the caterers about what kind of meal you want -- and then being upset when they serve a five-course sit-down dinner, when you were envisioning a hamburger/hot dog buffet. You might conclude, "Party plans are stupid. Nothing ever goes according to plan." But the meal mix-up really wasn't the fault of the party plan...

My current doula wrote an excellent post on birth plans that talks about this in general: http://bellyupbaby.blogspot.com/2011/04/birth-planning.html.

I'll talk about what I've done specifically.

With Littles
My husband and I had never heard of birth plans until we took our Bradley classes. As part of our class series, we had to write our own birth plan. This is what we came up with:

1. I am hoping to have a drug-free childbirth. Please don’t offer any pain medication. My husband will let you know if I need it.

2. I am GBS positive. I wish to have a hep lock for my antibiotics, not a constant IV. [This was added after I tested positive for GBS at 36 weeks.]

3. I wish to be allowed to drink freely and eat light snacks during labor.

4. I would like to be allowed to move around freely during labor. To this end, I prefer to avoid any IVs, with the exception of my antibiotics.

5. Please monitor the baby intermittently if possible. If constant monitoring is necessary, I prefer external monitoring to internal monitoring.

6. I would like to be allowed to give birth in any position that feels comfortable.

7. I would like to avoid having an episiotomy. If an episiotomy is necessary, I would prefer a pressure episiotomy with no local anesthetic.

8. I do not want time limits placed on labor and delivery (e.g. only two hours of pushing).

9. Above all, I want a healthy baby. If any of my preferences above conflict with this goal at any time, please discuss with me, my husband, and my doula prior to performing any procedures.

That's it. Hardly a minute-by-minute "plan" of my labor.

At my next OB appointment (around 30 weeks, I think), I went over this plan with Dr. K. I never showed her the written document. I just asked her questions, such as, "Will I be able to eat and drink during labor?" Thankfully, just about all of her answers lined up with my preferences, and so I went into labor pretty confident that my preferences would be honored, without having to make a big to-do about my "birth plan." In fact, I don't think I even brought a printed copy to the hospital with me. No need.

I'll eventually get around to telling Littles' full birth story, but in short, most of this "plan" went out the window, because I had to be induced at 42 weeks. Still, Dr. K did a fantastic job of continuing to honor the spirit of my preferences, even if she couldn't honor the letter of them due to the induction. For example, I had talked with her about wanting the option to labor in the shower. A few hours into my induction, she breezed into the room and asked if I had gotten in the shower yet. Um, no: I was hooked up to a constant Pitocin IV, constant fetal monitoring, etc. She said to the nurses, "Take her off all that stuff and let her get in the shower." And they did. I wasn't able to stay in there for very long, but it was just the break I needed to keep going. I don't think Dr. K would've given me that break if we hadn't had extensive discussions prior to the birth about my desire to go epidural-free.

With Noob
Prenatal care preferences, from when we were planning hospital birth:

· I want minimal cervical checks prior to starting labor. In fact, I’d prefer not to have my cervix checked at all. If you do need to check my cervix, you can note my dilation/effacement statistics in my chart, but please do not tell me what they are. The only exception is if we start discussing induction for any reason.

· I do not want any sizing estimates performed via ultrasound. My daughter was 9 lbs 7 oz, so I’m fully expecting this baby to be big as well, but I’m also confident in my ability to deliver a large baby. I feel strongly that sizing estimates will only serve to shake this confidence. If you do need to do a sizing ultrasound, please do not tell me the estimated size unless it dramatically changes our course of action.

· I want to avoid induction. My daughter was born (via induction) at nearly 42 weeks. I’m mentally prepared to go to 42 weeks again. Unless there is a strong medical reason (e.g. pre-eclampsia), please do not even mention induction until at least my 41 week appointment.

I started talking about all of these preferences very early on. I think I asked J about whether she'd wait till 42 weeks to induce at my 10-week prenatal appointment :) These were serious dealbreakers for me, and so it was good to confirm that I was on the same page with my midwives right from the start!

Birth preferences:

I understand that birthing a baby can be unpredictable. Ultimately, I want my health/safety and that of the baby’s to take precedence. In all non-emergency situations, please discuss all proposed procedures with my husband and me, so that we can direct the decision making with informed consent.

Labor:

· I intend to have as natural a labor as possible, including freedom of movement, intermittent monitoring, and a hep lock instead of a constant IV. I am hoping to birth without pain medication, but will let you know if I need it.

· I will be practicing self-hypnosis (Hypnobabies). Maintaining my positive frame of mind regarding birth is very important to this process. Please avoid using words such as “pain,” “hard work,” or other words with negative connotations in reference to birth.

· I’m a former Ironman triathlete and approach labor just as I approach an endurance athletic event. I know that keeping my energy levels up and staying hydrated is important in both! Please offer me clear liquids, such as juice and popsicles.

· I don’t mind cervical checks, but please keep them to a minimum.

· I have rented a birthing tub and would like the option to use it. I would also like a birthing ball.

· I hope to birth without the use of Pitocin. If it is required, I request that it be administered following the low-dose protocol, and increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each increase.

· If continuous EFM is required, I prefer external EFM to internal EFM.

· My husband and my doula will be present throughout labor. My two-year-old daughter may be present as well, along with one person (other than my husband or doula) to support her. Please turn away other visitors.

Birth:

· I want to “labor down” as much as possible and wait until I feel a strong urge to push.

· I hope to follow my body’s urges to push. Please do not count or otherwise direct my pushing.

· I would like to push in any position that feels comfortable. I welcome advice on positions that might be productive.

· Please allow any visitors present to take pictures and/or videotape the birth.

· We do not know the baby’s sex. Please allow us to see for ourselves, rather than calling it out.

· I would like to have the baby brought to my chest immediately for skin-to-skin contact. Please delay routine procedures (weighing, eye ointment, etc.) for as long as possible.

· My husband will cut the cord. We plan to donate the cord blood.

· I wish to nurse immediately after the birth and would appreciate assistance with this.

Emergencies:

· If the baby and I need to be separated for any reason after delivery, I want my husband to go with the baby and my doula to stay with me.

Again, most of this was discussed with my midwife ahead of time, to ensure I wasn't asking for anything that wasn't possible. For example, the reason I specified that I wanted access to clear liquids was that my midwife told me that hospital policy didn't allow for eating/drinking freely (which is really my preference). The hospital did have birthing balls and allowed mothers to rent birth tubs, hence why I included a reminder that I wanted access to both of those.

Of course, we ended up switching to homebirth. I didn't even bother showing this plan to C, because everything on it was either her norm (such as not calling out the sex of the baby) or not possible in homebirth (such as a constant IV or Pitocin).

With Q
I have even less of a need for a birth plan this time around, since again, most of my preferences are C's norms (assuming a non-emergency situation), and she also knows first-hand how I act and what I need during labor! There's also no need to write anything down; it's not like I'll need to inform some nurse I've never met before of my preferences.

We did do a brief "birth plan" during our home visit, including things like:

• Who will be present? (Me, my husband, midwives, doula, birth photographer. Also, probably both older kids, along with someone to care for them.)
• Water birth or no? (C assumed correctly that I'd like to try it again, although I don't have my heart set on it)
• Who will catch the baby? (Me! I gave first dibs to my husband, but he has no interest :)
• Who will announce the sex? (My husband)
• Who will cut the cord? (My husband and Littles)

Besides those things? My "birth plan" is to show up (well, really, for C to show up) and have a baby :)

In conclusion
If you're writing your own birth plan, feel free to steal from mine, either in pieces or in their entirety. There are also lots of online birth plan generators, such as this one or this one.

Just be sure that you research every point that's on your birth plan, and understand why you are asking for it. Don't copy my birth plan with Littles that talks about a pressure episiotomy if you don't know what that is and why you might prefer it. Remember, the value of a birth plan is not in the plan itself but in the research and discussion that goes into it. If you don't research a particular point, then you can't discuss it at an intelligent level -- and that doesn't help anyone.

"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 :)