Beau Choix

So Very Tiny

by 1 Comment

This is a reflective paper I’m writing for my certifications with Childbirth International. It is the postpartum experience I had after the birth of our 3rd child who was born SGA (small for gestational age). While she was not a preemie, we experienced many of the same experiences as preemie families. November 17th is World Prematurity Awareness Day.

Our third child in born 2009. I was an American living in Germany. Our baby was due 18 October, but was born on 6 October after a prostaglandin gel induction beginning on 5 October. I consented to an early induction because she was diagnosed as being Small for Gestational Age and there was concern that my placenta wasn’t working effectively.  The labor and delivery were rather easy and unremarkable with the exception that our daughter was born weighing only 2160 grams.

In the many weeks leading up to the birth there was not discussion about what would happen after the birth. My biggest goal at the time was to do everything I could to make sure she was growing & getting the nutrients she needed to thrive before her birth. When she was born I thought I would just breastfeed her until she was nice & plump like my first 2 babies. The ultrasound scans did not indicate any physical issues other than her size, and all my prenatal testing came back negative. There were no expectations for an impaired baby.

There is no nursery in the hospital where I gave birth.  My OB came in to check on me after the birth and said he didn’t think the baby would need to go to the Kinderklinik (NICU).  I was sure I would be taking our tiny baby home the next day. A short time later the pediatrician came in & said our baby would be transferred right away to the “well-baby” NICU and I could follow later after being discharged.  They could not guarantee that there would be a bed available for me to stay with her.  I called our military patient liaison to come for help and guidance. She was of no assistance.  I asked that no one feed my baby any glucose water or formula, that she would be breastfed by me when I arrived.

By the time I had arrived a few hours later she had already been fed glucose water.  Communication with the nurses on duty at the time was minimal because few of them spoke English. I had to wait for someone who could translate better. I was allowed to sleep in her room.  The baby was subjected to constant monitoring of her temperature, oxygen and heart rate as well as a battery of tests while we stayed. In addition she was having latching problems. The doctors’ solution to this was for me to pump and feed & supplement with formula. I had to document every gram going in and coming out. I asked for someone to help me fix her latch, but was denied as there was no one trained at this hospital. There wasn’t an internet connections to search out a private IBCLC nor would the staff search for one so I sent my husband a list of books to bring me from home. I was determined to fix it myself. It wasn’t worth transferring to another hospital because it was over an hour away and our baby wasn’t sick. She just needed to gain weight. And I needed to be close to my family so that when they were able to come see us it wasn’t additional stress on everyone to come to the hospital.

Once she began gaining weight they had no reason to keep her any longer. We had been in the NICU almost a week. None of their tests showed a single anomaly. Upon their determination of her ability to self regulate her body temperature she was given a final battery of normal newborn testing, pronounced ‘perfect but tiny’ by the resident assigned to her, and we were released to go home.

—

 After the birth I was elated because the release of all the worry in the culmination of this pregnancy with an induction that worked the way it was intended to, a relatively easy birth, and a baby who was wee but healthy.

This quickly turned to frustration and anger. I was told her transfer was policy because her weight too low, was unavoidable and couldn’t wait. She wasn’t sick, acute or in grave danger, yet they wouldn’t wait until I was discharged, they wouldn’t let me go with her during transfer nor would they let me drive her to the NICU myself. I pulled one of the nurses aside and tried to tell her this was happening too fast and I needed someone to talk to. She was empathetic, but couldn’t help me or fully understand what I was saying despite my tries at some decent German. Few people on duty that morning spoke English. My efforts were futile. When I called the patient liaison for help, I was told I should listen to the doctor & I was frustrated she wasn’t listening to what I was asking. She should have been the person to help me iron the transfer questions out. I felt like no one was listening to me.

Upon arrival at the NICU I was so upset to find our baby crying, in a room alone. I went from upset to infuriated when she vomited glucose water. She wasn’t supposed to be supplemented. Again I felt like no one was listening to me.

Through our entire stay I felt like I was fighting to be listened to. About day 2 or 3 the doctor came in with his entourage and told me to take my baby home to die because I didn’t just want to pump & supplement with formula. I wanted to breastfeed her but no one wanted to help me breastfeed her.  At that point I was like a Momma Bull in a China Shop. I was being treated with such disrespect & wasn’t being listened to. I can only think of one other time in my life that I was so angry, disappointed, disrespected & completely let down by everyone around me. It was bad enough that I was the lone American on the floor completely segregated from everyone else, but they treated me like I was a nuisance. That I wasn’t worth their time because I asked questions and challenged their standard treatment.

At the same time I was worried about my family at home. They couldn’t come up because my oldest was sick so I didn’t have the full support of my family at the hospital. We couldn’t all just be together and work it out. And I couldn’t take care of my older daughter. I felt like I wasn’t there for her. My husband wasn’t able to be at the hospital & help be my back up for the majority of the time we were there. I really felt alone. He had just returned days earlier from out of the country for the previous 3 months and hadn’t had time to even reintegrate back to regular family life let alone deal with this situation our daughter’s birth brought. I wanted him to be there for me, but I also didn’t want to overwhelm him. I know he was feeling lost not being able to help but I felt even more abandoned not having him there to help me.

I was afraid to leave her alone at the hospital at all because even when I went down the hall to pump after breastfeeding her, at night especially, if she woke up & cried, by the time I got back to the room there would be a pacifier in her mouth with an empty syringe of gas drops or something beside her. Everywhere I turned there was something else that was interfering with her breastfeeding.

It was at that point that made the switch in my head that I couldn’t feel sorry for myself. I had to work to get her weight up so we could go home. So I felt comfortable taking this tiny baby home. I took my anger and made it productive.

—

I was so focused on the pregnancy itself I didn’t think to ask about what happens after. I knew there wasn’t a NICU at the hospital I chose, but I didn’t ask my doctor what might happen to the baby after the birth. After the induction I thought we were in the clear. She was tiny, but perfectly healthy. I could have asked to transferred to the American hospital at Landstuhl an hour away at the end of my pregnancy. They have an in-house special care unit and an IBCLC on staff. It would have been further from my family, but I see now I may have had a better chance at the care I wished we’d both had.

When the baby was transferred I could have been less passive in allowing it to happen & found a way to go together to the Kinderklinik. I didn’t ask enough questions of the patient liaison so she would also ask questions. Her every answer was, “It’s their policy”.  I didn’t keep asking why. When I felt she didn’t have an answer to my issues my focus turned to getting discharged so I could go be with our baby. I just wanted her to go so I could make the rest of the calls to leave.

When the doctor ripped me down & told me to take my baby home to die I should have stood up for myself in the moment. I was tired, hormonal, worried, but I could have stood my ground instead of breaking down. No doctor should speak to a parent that way. My baby was not in grave danger. Yes she was still losing weight, but simply saying do it my way or go isn’t proper care. I didn’t ask for his supervisor, I didn’t ask for another doctor to take my case, I didn’t complain later through our military channels. I should have and I kick myself for taking that kind of abuse. Although he never came back to my room again, not even to do the final assessment. One of his interns did the final exam. Again, I could have asked for a transfer to Landstuhl, but I felt that she wasn’t sick so why make that long trip to have to start at square one again. I only wanted to get our baby home.

When I was denied an IBCLC at the Kinderklink  it didn’t occur to me to ask for a telephone consult with the Landstuhl IBCLC for more suggestions to get the baby to my breast or for suggestions to create an SNS system with what was on hand at the hospital where we stayed. I would not have had an in person consult, but because I did have a professional report with her I may have gotten extra telephone time if she was available. This may have sped up the baby’s weight gain & latch issues & we might have gone home sooner.

I was focused on getting the baby back on the monitors after every feed because the nurses said to. Instead I could have worked out a schedule with them for intermittent sessions & just taken the baby with me to pump so she wouldn’t cry and they wouldn’t feel like the needed to do something to her to make her stop. I could have had much more skin to skin time if I hadn’t allowed her to be put on the monitors constantly. This might have helped her breastfeeding issues too.

Instead of involving my husband more, I tried to take everything on myself since he had to be home so he wouldn’t have double the stress. I buried some of my feelings which came out later after I came home. It wasn’t the fix I hoped that would be, it added to stress later.

—

At the time I thought I was being proactive in my actions, but I see now that I could have done more. I was asking questions but they were not enough or the right kind of questioning. I let the policy guideline be the end of the road. I allowed the cultural and language barrier create a bigger wall to scale than it needed to be. My anger allowed the staff to take power away from my choices and kept me from seeing that I had more choices. I know some of the emotions came from the intense hormonal shift, lack of sleep and being in an uncomfortable environment, but I could have kept pushing. I need to let go of the anger because I made a choice &I didn’t change it then & I can’t change it now. I can only make decisions in the now and move on.

I needed to involve my husband more in the process instead of shielding him from it. Some of this wasn’t possible because he couldn’t be there, but I could have had him working behind the scenes making phone calls to our American clinic in town trying to find some better answers. I didn’t have to try do it all myself. He would have coped better knowing he was doing something to help me beyond caring for our older children.

However, this event has changed how I deal with stressful situations. I have learned how to be more proactive in how I question practices in general. Its lead me to keep asking questions, not just be satisfied with a single answer whether or not I’m comfortable with that answer.

I know I need to continually work to keep working at doing all this.

There are times the system isn’t going to change for me and if I decide not to step outside of it I will have to deal with what it brings. When I stay within this system I know that I can find allies, but that their hands may be tied. It’s better to recognize it now than to try to fight it in the middle of a situation.

Knowing all this makes me continually look at how this will affect my clients as a doula, breastfeeding counselor and childbirth educator. I am always looking for additional resources that other families might not know about or prepare them to deal with a situation without having to live though it like I and others have. I try to prepare them for the unexpected without overwhelming them. When I see a resource is needed I try to bring it in, or, if I’m able, provide it myself. I know I can’t do everything for everyone, but if I can enhance the birth and parenting period in some subtle way that makes the smallest difference, then I have found my niche. I hope to be able to effectively communicate how to navigate the system that most parents are left to muddle through alone. Leaving my baggage at the door is the first step. Being as unbiased as I can is the next. Realizing there is always room for growth and learning is the key.

Half a Million Babies

by 2 Comments

The March of Dimes released this year’s Prematurity Report Card with a state by state breakdown this week. More than half a million babies in in the United States are born too soon. The United Sates as a whole rates as a C and only one, ONE state received an A rating.

How is this even possible in this day & age?

Why is this happening?

Consider the following:

  • Too many mothers are uninsured or underinsured and as a result don’t receive adequate prenatal care.
  • Fully one third of births in the United States are surgical births. The rate of cesarean births continues to rise every year.
  • The rate of early inductions is also rising.
  • Overuse of testing, especially late in pregnancy, resulting in more medically managed, earlier births.
  • There is not enough access to VBACs (Vaginal Birth After Cesarean).
  • There are not enough midwives to manage healthy women during their pregnancy & birth.
  • Anecdotal rather than evidence based information is being disseminated. One look at My OB Said What? gives you only a taste of what’s being said out there.
  • Many due dates are off and babies are being born at 36-37 weeks when the care provider thought the baby was 38-40 weeks.
  • The are more families having problems conceiving and thus are having to use a fertility specialist. These pregnancies often result in multiple births and many birth early & need time in the NICU.

The two most common reasons I hear for birthing a baby early are gestational age and size of the baby.

Despite the fact that a “term” pregnancy is considered 37-42 weeks, even waiting until 38 or especially 39 weeks to induce reduces the incidence of prematurity and allows the baby’s systems to fully mature. A week or two makes a huge difference even that late in pregnancy. Just because a woman reaches 40 weeks doesn’t mean that her time is up either & she must be induced or have a cesarean unless there is some legitimate medical reason.

A “big baby” is not a reason to birth a baby early. Ultrasound images can be up to 2 pounds off on either side of the reading. I hear so many women say their doctor said they couldn’t birth this baby because it is too big only to find the baby was a mere 6 or 7 pounds, not the 9 or 10 that it was thought to be. So the baby was born too early & can have complications solely based on a weight guess. Later many of these same women birth larger babies. And tiny women can birth 9, 10 even 11 pound babies. And no, they don’t all have traumatic births. When did our bodies change so much that we are no longer able to birth our children?

Prematurity brings with it a whole host of problems from immature lungs to problematic breastfeeding. When a baby is in the NICU can create a disconnect between the baby and it’s parents creating further issues once the baby is allowed to come home. It also causes emotional and financial hardship on the family.

So what can we do to help prevent the rate of premature births from continuing to rise?

  • Educate yourself – Know what a normal pregnancy, labor and birth look like.
  • Have faith in your body – Many women are told their bodies are not capable of birth. Big Red BS flag flying there.
  • Get a second opinion or change to a new, supportive provider even if you are in your 39th weeks of pregnancy. Yes you can.
  • Have a supportive birth team. Hire a knowledgeable doula.
  • Know your options. If a provider is suggesting you need to be induced or need a cesarean ask “Why?” And then ask, “How?”, know your options and don’t settle just for what your provider says, there may be more available that would be better for you. And then ask, “When does this decision need to be made?” Use BRAIN analysis – Benefits, Risks, Alternatives, Intuition (what does it tell you), (what if I) do Nothing
  • Same questions for testing. “Is is necessary?” “What will the results tell us?” “How will this affect my birth?” Again, use BRAIN.

Of course there is a time and a place for intervention and high risk care, but there is also a time and a place to just let a woman be to birth her baby.