Today is my last day home with my family before I go back to the office.
I can hardly believe how fast the time has gone and that Tomorrow I will be returning to work – armed with a new breast pump and the faint hope that my brain will function.
I am blessed that I have been able to spend ten weeks at home with my new little one, my toddler, and my husband. The U.S. Military gives new moms six weeks of paid maternity leave. After the end of the six weeks, I used a combination of regular vacation time, and 13 days of convalescence leave after my Thyroidectomy.
The time has been a bit surreal in many ways. There’s so many things that I was able to do that would normally never happen. Like wearing colored nail polish for 8 weeks straight (I’m only allowed clear polish when in uniform). Sleeping in and snuggling with my kids on weekdays. Taking our time to get ready for the day. Going to the Chiropractor as a family. Running errands in the middle of the day. And exploring the city more than ever before, including trips to the Zoo and Children’s Museum too.
As I sit here, listening to my baby girl breathing as she sleeps on my chest, it is hard to believe that it’s over. My days have been filled with such joy! And soon I’ll only be able to spend half as much time with my little ones again.
I am so thankful that my husband is a stay at home parent. I can’t imagine how emotional I would be if tomorrow I had to take the kids to a daycare facility. We are blessed to have one of us at home, and he does an amazing job, but sometimes I wish I could be the one to do it. For a variety of reasons, it has made more sense for my husband to stay home. But I fear that my kids will somehow be upset about that decision someday. That they’ll feel angry that I chose to work instead of taking care of them. I think a lot of working Moms face this fear.
How do I explain to a child all of the very logical reasons why it makes more sense for Mommy to work? When at the same time my heart aches to be able to give them exactly what they want?
I don’t think there’s a good answer to this. But for now, I will work hard and give them the best life that I can so that they are taken care of and feel loved. I will try hard to treasure every moment we have together to make it through the times when we are apart. And someday I hope that they understand that we’ve done the best that we can for them.
But for just this moment I’m going to soak in this baby snuggle.
This past week I went to my local ICAN meeting, as I have monthly for the past year. The ladies there have been a fantastic group that have helped me in so many ways. They are supportive and knowledgable about VBAC and the local medical community in ways that have really helped me prepare for our upcoming birth. This month they also did a blessing way for me!
I’ve topped off my hospital bag with eleven amazing notes filled with affirmations and encouragement as I go through this birth and a necklace to remind me of their words when I am in the midst of my birthing time!
Thank you so much to everyone who has been there through this time of preparation. We are only a couple of weeks away from our estimated due date!
ICAN The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).
The next topic that I really wanted to dig into for our birth plan was Fetal Monitoring. It’s come up a few times this pregnancy at some of my appointments, and the policy at my hospital is that all VBAC patients have continuous Electronic Fetal Monitoring during their time at Labor and Delivery. As I started to look into the research about fetal monitoring, it became clear that this is a HUGE topic! So, if you have the time to get through this I think you’ll learn a lot and be able to make a great informed choice for your own birth plan too.
My main concerns regarding continuous fetal monitoring during labor includes the accuracy of the monitoring and the affect it may have on my ability to stay mobile during labor. In this post, I’m going to go through a few different topics including the types of monitoring used, the various heart rate patterns that they are watching for during monitoring, and how that relates to VBAC specifically.
Types of Monitoring
There are two types of fetal monitoring used: Electronic Fetal Monitoring (EFM) and also Manual Auscultation. EFM is much more common, and enables providers to measure the response of the baby to contractions. It does this using two receivers, one for the fetal heart rate and one for measuring the strength on contractions. EFM has become much more popular since the 1980s, with original hope being that they could decrease the incidence of Cerebral Palsy. Although EFM is used in over 85% of hospital births, the rate of CP has not changed since WWII.
Manual Auscultation is when providers use a handheld device to listed to the fetal heartbeat while feeling for contractions using their hands. This type of fetal monitoring is most commonly used during care provided by a midwife, and usually more common in home birth and birthing center situations. There is no continuous monitoring when this is the method used.
What are they looking for?
A normal fetal heartbeat varies between 110 and 160 beats per minute, and potential problems with the fetus can be signaled by a heart rate that doesn’t vary, is too high, or too low. According to ACOG, there are three levels of classification for the print-outs, or tracings, generated by the EFM. Category 1 FHR Tracings are normal and no specific action is required. Category 2 tracings are considered indeterminate and evaluation, surveillance and possibly other tests should be used to determine if there is a problem. Category 3 tracings are abnormal and this may require additional actions like providing oxygen, changing positions, discontinuing labor stimulation (Pitocin), or treating maternal hypotension. If the providers aren’t able to get the tracings to return to normal, ACOG recommends that the baby be delivered as soon as possible.
So, who determines what category the tracings are? Your providers. This opens the door to a large variety of interpretations. In fact, according to a press release from ACOG, “The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.”1 ACOG recommends that women who have high-risk conditions such as preeclampsia, type 1 diabetes, or suspected fetal growth restriction (IUGR) be monitored continuously during labor.
Fetal Heart Rate during VBAC
I really want to focus more on how this impacts mothers who are going through a VBAC birth. Understanding how providers use these tracings to monitor VBAC patients can give us some insight into why they have policies in place that require continuous EFM for those patients. When speaking to my provider, they said that fetal distress is often the first sign of Uterine Rupture, and that is why they have their policy.
“In a larger study, Leung et al. analyzed the FHR and uterine contraction pattern immediately prior to 78 cases of uterine rupture. Prolonged deceleration was defined as a FHR less than 90 beats per minute that exceeded 1 minute without return to baseline. Prolonged deceleration (alone or proceeded by either severe late or variable decelerations) occurred in 71% (n = 55/78) of the cases of uterine rupture. In addition, prolonged deceleration occurred in 100% (n = 36/36) of the FHR tracings in which total fetal extrusion occurred. If more than one type of periodic deceleration, in addition to a prolonged deceleration was present, only the most ominous pattern was recorded. Late decelerations were considered most ominous, followed by variable and early deceleration. Although late decelerations were more common preceding the prolonged deceleration that heralded uterine rupture, this finding may be an artifact of the study methodology.”2
I know that a lot of that is some very technical language, so now lets explore what some of those heart rate patterns mean.
Fetal Heart Rate Patterns
- Fetal Tachycardia, defined as a baseline heart rate greater than 160 bpm and is considered a nonreassuring pattern. Between 160 and 180 bpm it is considered mild and over 180 bpm is considered severe. Over 100 bpm is usually due to fetal tachyarrhythmia or congenital anomalies. Some causes of fetal tachycardia include maternal fever, hyperthyroidism, maternal or fetal anemia, Chorioamnionitis, and prematurity. Fetal tachycardia may be a sign of increased fetal stress when it persists for 10 minutes or longer, but it is usually not associated with severe fetal distress unless decreased variability or another abnormality is present.3
- Fetal Bradycardia is defined as a baseline heart rate less than 120 bpm with 100-120 bpm range not associated with fetal acidosis. It is common in post-date gestations and in fetuses with occiput posterior or transverse presentations. A FHR below 100 bpm is usually associated with babies with congenital heart abnormalities. Moderate bradycardia of 80 to 100 bpm is a nonreassuring pattern. Severe prolonged bradycardia of less than 80 bpm that lasts for three minutes or longer is an ominous finding indicating severe hypoxia and is often a terminal event. Causes of severe bradycardia include prolonged cord compression, cord prolapse, tetanic uterine contractions, paracervical block, epidural and spinal anesthesia, maternal seizures, rapid descent, and vigorous vaginal examination.
Both Tachycardia and Bradycardia are considered longer term patterns to watch for. There are some short term or periodic FHR changes that should also be noted.
- Accelerations are usually associated with fetal movement, vaginal exams, contractions, umbilical vein compression, fetal scalp stimulation or external acoustic stimulation. They are considered a sign of fetal well-being, and are the basis of the nonstress test (NST) that many providers recommend to women who are past their due date. The presence of at least two accelerations, each lasting for 15 or more seconds above baseline and peaking at 15 or more bpm, in a 20-minute period is considered a reactive NST, which is a good thing.
- Early Decelerations have a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Meaning that the heart rate will decrease at the start of the contraction, and then return to baseline after the contraction. Early decelerations are reassuring, and not an indication of fetal distress, but they need to be identified to avoid confusion with other nonreassuring decelerations.
- Late Decelerations are caused by uterine contractions and are associated with uteroplacental insufficiency, which means that there is a decrease in uterine blood flow or there is a placental dysfunction. Some causes include postdate gestation, preeclampsia, chorinic hypertension and diabetes mellitus. A late deceleration starts at or after the peak of a contraction and the heart rate doesn’t return to baseline until after the contraction ends. According to the Association of American Family Physicians (AAFP), all late decelerations are considered Category 3 situations and a pattern of them is nonreassuring.
- Variable Decelerations. These are shown on the FHR tracings in “U”, “V” or “W” pattern and may not have a constant relationship with the uterine contractions. They are common in patients who have experienced premature rupture of membranes (PROM) and decreased amniotic fluid volume. They are caused by compression of the umbilical cord. Variable Decelerations can be complicated, “Variable decelerations may be classified according to their depth and duration as mild, when the depth is above 80 bpm and the duration is less than 30 seconds; moderate, when the depth is between 70 and 80 bpm and the duration is between 30 and 60 seconds; and severe, when the depth is below 70 bpm and the duration is longer than 60 seconds. Variable decelerations are generally associated with a favorable outcome. However, a persistent variable deceleration pattern, if not corrected, may lead to acidosis and fetal distress and therefore is nonreassuring.”3
- Sinusoidal heart rate patterns are associated with high rates of fetal morbidity and mortality, and is considered a Category 3 FHR pattern. It indicates severe fetal anemia, which can happen in cases of Rh disease or severe hypoxia. On the FHR tracings it looks like a regular, smooth, undulating wave that happens two to five times per minute and has a range of 5-15 bpm. It is also characterized by a stable baseline heart rate between 120 to 160 bpm, and doesn’t have variability between the beats.
How to Decide
Now that I know more about the different types of heart rates that they can see using the EFM and what they can indicate, I understand more why my hospital would require this for VBAC patients. However, my main concerns with continuous fetal monitoring haven’t changed. How can I be sure that the providers are accurately reading the FHR tracings? I have to have trust in those that are there and that they have the experience and knowledge to interpret them. How can I preserve my ability to stay mobile during labor? I am going to request that they use a wireless model of the EFM so that I can be comfortable while being monitored.
During my 35 week appointment, I talked to my midwife about my concerns and we talked in detail about how they ensure that multiple people are looking over the tracings before initiating the decision to have a cesarean section and that they work hard to try other options before resorting to surgery. She also explained how they have installed wireless receptors for their monitors throughout the birth center so that whether I am in my room or walking the halls they will be able to find me if they need me and I will still be able to have the mobility that I really want.
Although it’s not ideal to me to have continuous monitoring, I think that it will be something that I can work with. If during my labor I change my mind, we will cross that bridge when we get there. Did you have continuous monitoring during your labor? Were you able to have a wireless version? What was your experience like? I’d love to hear from other mamas about their experience!
- American College of Obstetricians and Gynecologists, June 22, 2009. (31 December 2014) (http://www.acog.org/About-ACOG/News-Room/News-Releases/2009/ACOG-Refines-Fetal-Heart-Rate-Monitoring-Guidelines
- O’Brien-Abel, Nancy, RNC, MN. “Uterine Rupture During VBAC Trial of Labor: Risk Factors and Fetal Response” (31 December 2014) http://www.medscape.com/viewarticle/458963_5
- Sweha, Hacker and Nuovo. Association of American Family Physicians. “Interpretation of the Electronic Fetal Heart Rate During Labor” (31 December 2014) http://www.aafp.org/afp/1999/0501/p2487.html
Thank you all for making 2014 a great year for Combat Boot Mama! It means so much to me to be able to share my story with all of you and help spread awareness for issues like natural birth, birth trauma, cesarean sections, gentle parenting, and Thyroid Cancer. The WordPress.com stats helpers prepared a 2014 annual report for this blog, and it blows me away! Go and check it out!
Here’s an excerpt:
The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 23,000 times in 2014. If it were a concert at Sydney Opera House, it would take about 9 sold-out performances for that many people to see it.
I’ve gotten a lot of feedback on my Visual Birth Plan post, and I love hearing from my readers! An important part of making your birth plan is being informed of your choices. I am starting a series of posts in which I look into the benefits and risks of different procedures throughout the birthing process that you can include on a Visual Birth Plan.
We are going to start the series by learning more about the umbilical cord and what our options are for cord clamping.
The umbilical cord has a key role during pregnancy: It carries nutrients and oxygen to the baby from the placenta. It has one vein that carries oxygen and nutrient rich blood from your placenta to your baby, and two arteries that return deoxygenated blood and waste products, like carbon dioxide, from your baby back to the placenta. After birth, two clamps are placed on the cord and it is cut in between them, leaving a small stump that is about 1-2 inches long on what will become the baby’s belly button. 5-15 days later, the stump will dry out, turn dark and fall off. It’s important to keep the area clean and dry while it is healing to prevent infection.
According to ACOG, the umbilical cord is usually clamped between 15-30 seconds after the baby is born, but the ideal timing for clamping hasn’t been established so there is a continued debate on what is best. 80 mL of blood transfer occurs by 1 minute after birth, reaching approximately 100 mL at 3 minutes after birth. This means that if the cord is clamped within 15-30 seconds of birth, the newborn is not receiving up to 140mL of blood. In one study, this accounted for a 61% increase in blood volume (2). So what are the benefits and risks of delaying cord clamping?
- Increased blood volume reducing the risk for blood transfusion; 30% increase in blood volume and up to a 60% increase in red blood cells (4)
- Increased iron levels, decreasing and preventing iron deficiency in the first year of life (3)
- Increased immunoglobulins and stem cells passed to baby (3)
- Decreased incidence of intracranial hemorrhage in preterm infants (3)
- Increased risk of jaundice requiring phototherapy in term infants (3)
It is also important to note that a 2008 Chochran review found that there was no difference was found in early/late clamping in regards to immediate birth outcomes such as Apgar scores, umbilical cord pH, or respiratory distress caused by polycythemia (3). The same review also found that delaying cord clamping did not increase the risk of maternal hemorrhage.
If delayed cord clamping sounds like something you would like for your providers to do for you, add this icon to your Visual Birth Plan:
There is not an “Early Cord Clamping” icon, as that is the routine time in which they perform this procedure and unless told otherwise, that is when your providers will most likely clamp the cord.
Did you have delayed cord clamping as part of your birthing experience? Do you think that it made a positive impact on your baby? I’d love to hear more in the comments!
1. NHS. (15 NOV 14) What is the umbilical cord? Retrieved from http://www.nhs.uk/chq/pages/2299.aspx?categoryid=54
2. Robert Usher, Michael Shephard, and John Lind. (15 Nov 15) The Blood Volume of the Newborn Infant and Placental Transfusion. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.1963.tb03809.x/abstract
3. American Congress of Obstetrics and Gynecologists. (14 NOV 14) Committee Opinion Number 543, December 2012 “Timing of Umbilical Cord Clamping After Birth.” Retrieved from http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Timing-of-Umbilical-Cord-Clamping-After-Birth
4. Gina Eichenbaum-Pikser, CNM, MSN, Joanna S. Zasloff, CNM, MSN. (15 Nov 15) Delayed Clamping of the Umbilical cord: A Review with Implications for Practice. Retrieved from http://www.medscape.com/viewarticle/708616
Lately, it has felt like the posts that I most want to see on Facebook – my friends and family – are the ones I have the hardest time finding. They are buried by all of these other pages that are vying for my attention: news outlets, random brands, non-profits, even the social media page from the base I was stationed at five years ago…
During my first pregnancy, I went through this big urge to really reduce the “drama” in our lives. We worked hard to really focus on the friendships that we wanted to nurture because they were fulfilling to us, and to let the ones that felt like a burden go. If I remember correctly, my friends list on Facebook went from over 1,000 to less than 200 over a period of a few days. Phew! It made such a difference! No more “random-person-I-met-on-that-trip- that-seemed-cool-freshman-year-of-college” keeping me distracted from those who are closest to us. I didn’t make a big fuss about it, no flourish of a post to say goodbye, I simply just clicked the button. If they missed me, they would send me a new request (in which case I would usually reconnect).
I think it’s a very normal thing to take a moment and re-evaluate what we allow ourselves to be distracted by in our relationships, especially when going through a big life change like expecting a child. Social Media has helped us to increase the interaction between those we care about, but it has also allowed us to become obsessed with knowing the latest and greatest information and also increased our distractions.
My husband and I were sitting at lunch today and he (who by all means does not use Social Media that much) even commented that he is going to be stepping back a bit by reducing the pages that he gets notifications from and sees in his news feed.
What he said stayed on my mind as I returned to work this afternoon. So I went into my FB (don’t tell my boss!) and out of curiosity looked at how many pages I had “Liked.” 367 pages! Whoa! It made me wonder how that compared to my friends list. 256 friends. It is no wonder I feel my friends are being drowned out! I have so many other things – random things! – taking my attention away from the people I care about.
I started looking through those pages and discovered many that must have meant something to me at some point, but now they don’t hold as much appeal. I decided to go through the list and “unlike” anything that I didn’t need to see every day: Sports teams, random politicians, brands, places I had visited, news media outlets, online shopping websites and much more.
So what did I keep?
- My church. Including the Women’s Ministry and our Church home from a previous duty station.
- Personal Blog/Charity pages of people that I actually know – like my husband’s Ruck to Remember page, and the blog created by a friend chronicling their child’s battle with HLH.
- Previous Army units that I want to stay updated on.
- Team Red, White and Blue.
- My Sorority.
- My Chiropractor – they announce specials like BOGO massages on their page ya’ll!
- The Hospital where I am to birth
- My local news channel
- Humans of New York – if you don’t already get their updates, it is an amazing page.
Now, this might seem counterintuitive, especially for a writer who is trying to get more people to “Like” my page on FB and to visit my blog. But my goal is to have an enriched life, and to enrich the lives of others, not to be distracted or be a distracter.
And as I switched my page back to my newsfeed, after purging more than 320 pages, my feed was filled with the faces and stories of my friends again! It was like a breath of fresh air! I can hardly believe that I didn’t do this sooner.
The next thing that I noticed is that it was now filled with posts to various groups that I am in – so I promptly decluttered my groups as well. I left several – “Fans of ____” pages and other random ones that frankly, I had even forgotten that I was in. And I “Unfollowed” the ones that remained so I have to make an effort to actually go into them and see the posts. As I returned to my newsfeed again – it was filled with even more amazing posts from friends and family! What a blessing!
Have you tried decluttering your Social Media connections lately? What real connections has it helped you to rediscover?
I’m 25 weeks pregnant now, well into our adventure. Over the past few weeks, I have felt more driven in making sure that I am well educated and proactive in my treatment – both for Thyroid Cancer and for Pregnancy.
As I entered the second trimester, I was looking forward to an increase in energy and a decrease in several symptoms that are generally associated with the first trimester. As the weeks continued however, they did not cease but worsened. I spoke with my Endocrinologist about increasing my medication, as I believe that the continuation of the symptoms was due to my ThyCa and a continuing rise of my TSH. She refused, I appealed to her with several articles including the Endocrine Society guidelines on the Treatment of ThyCa during Pregnancy and she was steadfast in her refusal. My labs continued to show a rising TSH week after week. So I fired her.
I don’t recall ever firing a doctor before. Usually, I would just go along with whatever recommendation that they placed in front of me because they are the experts and they are supposed to know more than me. Recently though, my intuition and my quality of life has become my priority. If a care provider isn’t willing to listen to me – the one person who knows my body best – then they aren’t the right one for me. It was actually rather anti-climactic. Upon her refusal I made an appointment with someone else, and called and canceled with her. Her receptionist asked if I wanted to reschedule and I said no. And that was that.
I found a new provider who was willing to increase my medication as I requested, and since then I have started to feel better. Increased energy, decreased hypothyroid symptoms, better healthy feelings overall. I am still exploring a long-term solution, as this new provider does not want to prescribe my preferred medication, but in the mean time I feel more at ease about being heard and understood.
I am being seen by a midwife group that practices out of a large women’s hospital in the city nearby. Up until my 20 week appointment, every midwife that I met there made me feel at home and comfortable and that my care was a priority. My 24 week appointment was the first that I felt like I had a less than stellar appointment, and the midwife that I saw that day and I just didn’t click. She was concerned about my weight gain (23 pounds at the time, an average of one pound per week – not the best but MUCH better than I was doing last pregnancy) and threatened to classify me as high risk which would jeopardize my chances for a VBAC. I was really taken aback by her attitude. But it was a great reminder to me that when you are being seen at a practice with ten different midwives, you really don’t know what you’re going to get every time you walk through those doors.
The next day, I called my Monitrice and set up a time to meet and talk over my 24 week appointment. We discussed what was going on and it really helped me to focus on what I can and cannot control about when my baby arrives. I cannot control what midwife is on duty at the time. But I’m mitigating that by having a designated labor helper, my monitrice, be there through the whole labor. What that means for me is that I can put out of my mind the uncertainty of who will be there at the hospital and I can focus on myself, my husband and my monitrice being on the same page and working together.
After that meeting, I knew even more that we made the absolute right decision in hiring a Monitrice. Only 15 more weeks until our estimated birthing time, and I am feeling so blessed to have a great support team behind me. God has really moved in our lives to make all of this possible, and I know that he wants what is best for me and my family.