Tuesday, July 21, 2015

No dignity here

We've had a few new developments since Friday. My followup check at Maternal Fetal Medicine on Monday didn't go so well. My cervix had gone back to tunneling pretty severely, leaving only 3mm closed. Just for reference anything under 25mm is considered not good, and when you start considering a cerclage. On Friday I had 24mm at my second check, so really borderline. 3mm, not so good.
A "be cautious and see" approach is no longer safe or reasonable at that point and we decided it's absolutely necessary to go ahead and do he cerclage, that the risks are indeed high, and the success rates this late aren't nearly as impressive as we wish they were, but it's the only thing we could do at this point and the alternative was looking more and more like Max isn't going to stay put on his own until the magical week 24- widely accepted as when a baby is viable outside the womb. So, cerclage it is.
My appointment was made for this morning. I was not allowed to eat or drink anything after midnight which sounds like no big deal but at about 12:17am I was pretty convinced I was going to starve or dehydrate to death, or both. Funny how that works considering I don't usually eat that late anyway. Until someone tells me I can't, apparently.
My mom watched Chase for me, and Jon took most of the day off of work to come be at the hospital. I got checked in and taken off to prep for the procedure. I have zero fear of surgery under general anesthesia. Man, knock me the heck out and do whatever needs to be done, nooooo problem. Doesn't stress me out one bit. Being awake for surgery? Oh. Hell. No. I was, admittedly, quite nervous.... not only for the possibility of something going wrong, but just the procedure itself.
Once wheeled into the OR they prepped me for an epidural- which is really the only option for total numbing, as general was not an option for Max's sake. The nurses were all incredibly friendly and really did their best to make me as comfortable as possible. They mentioned several times it really was unfair I had to be aware and alert for all this and validated the fact though I was keeping my cool and refusing to break down, I was so nervous my legs were trembling. They warned me that the first shot would burn- and they weren't lying, but I knew that's what was supposed to stand between me feeling the giant needle headed towards my spine in a few moments, soooooo I will take a little burning. Except it didn't work the way it was supposed to. I felt the weird pressure of the epidural needle and then was caught completely off guard by what I can only explain as an overwhelming searing pain that shot up my spine to my neck, and radiated through my hips. I yelped fairly loudly, having been caught off guard. "You can feel that?!" Um, yes, I felt that. It knocked the breath out of me. They gave me another numbing shot, ow, and went for it again. Same thing. By this time my body was shaking uncontrollably from the searing pain and they couldn't proceed for several moments until I was able to relax. They poked around my lower back asking me if I could feel it, and gave me a third numbing shot- which I didn't feel nearly as much as the first two. Epidural successful, finally! I felt my feet and legs start to feel heavy and numb about the time my OB's partner- who is just a little more experienced in this procedure- came in to assist. He introduced himself to me though we've met once before (he was brought in Friday when the group of specialists were trying to figure out my case) and said he was just there to be an extra set of hands and direct/ assist. I said "Great, I love extra sets of hands on my cervix!" The room of nurses laughed and I was relieved they weren't too uptight to appreciate some comical relief unlike to folks in Provo Friday who seemed offended that I would even make jokes.
Having a  cerclage put in place is a procedure that strips you of any last shred of dignity that you may have woken up with that morning. Skip this paragraph if you'd prefer not to have the description. While awake and aware (but numb) of everything going on, my feet were placed in stirrups set far above me and wide apart. Unlike a normal pelvic exam where you can kind of close your knees in on each other while they aren't actively doing anything, this left no room to have any bit of decency. Then a device is used to hold the vaginal canal open and give the OB access to the cervix, and the bed is tilted to an angle to use gravity to encourage baby and membranes to move away from the cervix. A single long stitch, weaving in and out of the cervix in a circle is put in place, and then pulled shut. Imagine the drawstring on a bag that can be cinched closed. Well, that's how it was SUPPOSED to go. Except, to the surprise of everyone, I was already dilated to 2-3cm. A cerclage is considered much higher risk, and much less effective when the cervix has already began dilating and though that amount is not very much, it's a lot for being 21weeks along, and it's a lot of space to force closed. I was asked to give permission for photos and video to be taken to send to the specialist in provo to see if it was in our best interest to even proceed. After a mortifying 10 minutes of just hanging out in ALLLL my glory, it was explained to me that the risk of pROM, infection, preterm labor, fetal distress, and bleeding were much higher, and that the effectiveness of the procedure were much lower, BUT still our best and really only option to keep Max baking. If we do nothing, he was on his way. It was in my favor that my cervix had not thinned, they were confident they could perform a good stitch, and it is in my favor that I am not experiencing any contractions. (If I were, they couldn't do it) I was overwhelmed with emotions, and didn't know what to think or feel. I started crying, and not just kind of misty-eyed crying.... I'm talking full on, platypus lipped, ugly face, snot nosed crying. (Mind you, I'm still hanging at a solid 45 degree angle completely exposed. I'm sure I was super, super attractive.) We decided to proceed. The alternative was a whole lot scarier, and I am not ready to throw in the towel.
They had to tilt the bed nearly a full 90degrees to get the membranes to fall back into place, as they had hourglassed outside of the now-open cervix, and use a balloon catheter to push and hold them out of the funnel they were stitching closed. Once they got started it didn't take long.
In recovery, I was feeling quite a bit of cramping, which is normal. However, my back pain was intense, when it should have been mild. It was intense enough I had a hard time talking through it. They kept me for a while to make sure it wasn't the onset of labor and determined it was likely from the rough epidural. I had NO contractions while waiting.
I'm on very strict bed rest. The next three weeks are fragile. But all that can be done is done, and now.... we wait. And hopefully we wait for a long time. 

Saturday, July 18, 2015

A scare

Pregnancy after a preemie is a different experience, especially when we're just not really sure why Chase was early in the first place, it just kind of happened. As much as I love the idea of a natural home birth, our gut instincts told us it wasn't the right path this time, either, and I have been under the care of a competent OB since my first trimester, and a few high risk fetal specialists for equally long. My prenatal appointments are frequent, mostly impersonal, and not enjoyable like they were with my midwife the first time around. But, I still feel like it's what needs to be done to get Max here as safely as possible so it's what we do.
Part of my specialist care has been having cervical length checked every other week. Let me tell you what a boatload of fun THAT process is. The appointments are the same every time. Go in. Pee in a cup. Strip from the waist down, including every last shred of dignity that I have, and hop on the table, feet in the stirrups where I proceed to have an awkward small talk chat with a nurse I've probably never met before about if we know gender or have started thinking about names yet as she probes my crotch. BOATLOADS of fun, guys. Boatloads. Then I get a lovely, burning shot of progesterone in my hip, wait for the actual doctor to come in and tell me everything looks fine. Then I get dressed and go home, to repeat the process in a week or two.
Except this week was a little different. I knew looking at the screen something was off. I've had enough of these checks by now I'm halfway decent at knowing what I'm looking at and it's not all just a mass of black and gray on the screen anymore. I knew my cervix looked way, way off. And when the nurse went silent it was confirmed. This wasn't going to be like every appointment the weeks before. She proceeded to do a couple of checks and measurements on Max- something we don't always do at these appointments- and assured me HE looked great, and the doctor would be in to talk about me.
I like my doctor. He's quiet, humble, kind, and listens to my concerns. He seems to be pretty understanding of the anxieties I (and Jon, too!) has surrounding all of this based on our experience with Chase. He isn't pushy and actually talks to us like we are educated human beings, which is honestly more than I can say about a lot of the specialists we have dealt with.
He pulled out the images from the ultrasound and started going on about dilation and "funneling" and using words like cerclage, preterm labor, viability,  and miscarriage. His deep concern was obvious and I was nervous. I kept asking what all of this mean for Max, and he explained that a cerclage (stitching the cervix closed) may help keep him in longer- at least until viability- but that if I was in preterm labor or contracting that it would be too dangerous to do, and we would lose him. He explained my cervix was funneling, which means in side side was opening but the end closest to the outside of my body was closed- for now- and we needed to know how gradual this was happening.
There I was, alone, (Jon usually goes to be supportive but we decided together that he wouldn't this time because it was juuuuuuuuust like all the other appointments nothing ever happens at and he was better off staying home so Chase could get a much needed nap.) It was about 4:30 on Friday afternoon and my doctor said it couldn't wait until Monday, and he wanted me to leave there and go straight to Provo for the night, to be monitored for 12 hours and make sure it was safe to have a cerclage done first thing in the morning. If I contracted even somewhat regularly they would not be able to perform the procedure.
Not one, two or three but FOUR cervical exams later, another ultrasound, two hours of monitoring, and a team of five doctors later we came to a few very interesting conclusions.
First, we all know what the initial ultrasound showed and there's no mistaking it. But when I had another just a few short hours later, while it was not perfectly normal there was NO funneling to be seen. It is short, it is softer than it should be, and I am slightly dilated. None of these are good things, but none of them are as dire and scary as what the image that sat before us, showing extreme funneling was showing. The specialist herself even said it was one of the "probably the scariest 20 week cervixes she's seen, and she sees a lot of cervixes." We watched, for 5 minutes. Nothing changed. Medically, it makes no sense. She explained how angles, pressure, etc. can change or skew measurements and images slightly, but was baffled, ABSOLUTELY baffled at the difference. Baffled enough to have several other doctors brought in on the case. (yayyyyyy more exams!)
The cerclage is less effective the later it is performed and they stop performing them near 24 weeks. I comes with a lot of risks, and is done as an absolute last resort.
This entire team of doctors, and myself and Jon, decided that because we have things to worry about but the situation has shifted to not AS intense as before, to not have the cerclage done just yet. I am on very, very strict bed rest this weekend and will go back first thing Monday morning again. ANY changes in an unfavorable direction and we will be performing the procedure immediately, and hospital bed rest may be a reality until viability. That is to be determined then.
They recommended we stay the weekend but said it wasn't unreasonable to go home with the commitment to honor the bed rest bit. It's not that we don't take it seriously, we do, but I much preferred to be at home with Chase for now. Expecially as the liklihood of another go in NICU seems to grow day by day, I want to soak my little buddy up as much as I can now.

I am immensely thankful for the medical interventions that help keep these babies baking. I've had a few well-meaning comments about how glad people are we aren't attempting "the whole home birth thing" again, and I do want to make a few things clear:
I am NOT planning a home birth this time for one very simple reason: I'm not a good candidate. I still aaaaaaaaaaabsolutely believe it is a WONDERFUL, dare I say superior, option for low-risk, healthy women without a history of these complications. For reasons I may never know or understand, my body doesn't do this gracefully. But I know this is the EXCEPTION, not the RULE and that birth is USUALLY beautiful, safe, and not complicated. Things can change, and when I went into labor early with Chase, I was not filling up the bath tub and starting the hypnobabies tracks while Jon lit candles and started the tea. No, we went to the hospital. Where early labor belongs. I have so much gratitude for the knowledge of all of the doctors who are on our team. I also have so much respect for the reproductive process, and what it means to me. I'm thankful for the knowledge *I* have so I can make choices for myself and Max with confidence, and not be blindly following doctor's advice.
So we press on. 21 weeks tomorrow. I think I will get to know Netflix a bit better.