A little respect goes a long way.

If you are wanting an uplifting or positive post don't continue reading.

Originally, I had an appointment scheduled for my regular MFM (maternal fetal medicine) doctor on Wednesday. It was cancelled due to weather and rescheduled for today.  Unfortunately, he was out of the office and so I saw someone else.  I had my reservations about seeing someone different.  I very much like to maintain continuity of care as much as possible and I didn't want to deal with an alarmist doctor. I made several attempts to change the appointment.  But between the craziness of our house and no one answering the phone, I went against my gut and had the appointment anyway.

After the regular US the doctor and resident entered the room.  I have never been in a situation where I was not first informed that a resident was present and then asked if it was ok if they sat in on the appointment.  This was not the case.  They never told me the resident's name.  Aside from the doctor introducing himself to me, he didn't say a word to me the next several minutes...he just made small talk with the US tech and the resident.  The resident asked questions about the possibility of my individual membranes rupturing.  Hello, I'm in the room.  Please save these questions for later, especially if I never even brought up membrane rupture.  The doc proceeded to put gel on my stomach, i don't even know why because he didn't really take the time to look at anything.  He just moved the damn US thing around very unintentionally, or so it seemed.  I wanted to say, "My babies already had a rather lengthy ultrasound, unless what you are doing is beneficial get the damn thing off me."  I didn't.  I really wish that I had.  I lost my voice.  I knew the sizes of the babies, A: 1lb8oz, B: 1lb2oz, and C: 1lb7oz.  All great weights.  The fluid was normal. The bladders were normal.  Everything was stable.  The doctor even said everything is stable.  So then why did he feel the need to say "Hopefully Baby B can hang on."  Are you frickin kidding me.  What during that US, especially the part when you were just screwing around, indicated anything other than healthy babies?  I knew going into this appointment to have very low expectations.  But I didn't actually think he would make such an unnecessary and unwarranted comment.  All the joy and excitement that I had from seeing my three girls, knowing they were healthy, and growing beautifully went out the window/  Now I just wanted him out of there as quickly as possible.

I scheduled my next appointment and asked for my usual MFM.  He will be out of the office all that week.  Two were, available, Mr Jerk-face and a different doctor.  Initially, I was thinking to stay with Jerk-face to have some consistency.  Now that I've had the drive home to think about it, I don't want to see him again.  I will take another doctor or try to stretch my next visit a few extra days to see my normal MFM provider.

Needless to say, I'm going to complain.

Triplet Birth Plan: Draft

Lately I have been in a "birth plan state of mind."  So while my three girls were napping I decided there was no time like the present to put my thoughts on paper.  I have been hesitant to write anything down for a few reasons 1) compared to my other births 20w feels so early to do a birth plan, particularly with a provider who has "proved" himself in my previous births.  2) I don't want to appear naive or even flippant to the uniqueness of my pregnancy and my birth.  3) I have only experienced "normal," low risk births and an unnecessary cesarean.  So I wasn't sure I knew what was "allowed" in a triplet birth.  Then I began to think about my VBACs.  I did everything I could and  asked all the questions I could imagine so if it came down to my birth plan taking a major detour I could feel confident that I took care of things on my end.  I knew that I wouldn't have lingering feelings of doubt.  So then why should this birth be any different? Why shouldn't I be able to ask for the moon and work from there?

 So I drafted this birth plan in a similar way to my singleton births.  Without asking for things I can't have a dialogue with my care providers.  Having a dialogue with a care provider throughout the pregnancy, especially one in which things can change from visit to visit, allows the mother and provider to establish a greater degree of trust, allows the provider to better understand the desires of the mother and the mother can understand the skill set and comfort of the provider.  In this type of birth, and with most other births, I believe it is important for a mother to maintain a certain degree of flexibility.  But along the way it is paramount that the dialogue remain open and honest.  The provider must present the facts, not over dramatizing nor down-playing them, and always discussing how they would handle situations as they arise in the birth.  It is equally important for the mother to express her concerns and wishes as the pregnancy progresses as well.

So as I said, this birth plan is a draft and will likely undergo changes based on developments with the babies and conversations with the provider.  I hope to be able to provide in future posts conversations that my providers and I have had about various components of the birth plan.

Birth Plan for Hannah Birchman and Triplet Birchman Girls:

Due to the nature of my triplet pregnancy I am aware that there are many variables at play.  I have informed myself of the risks and benefits of a vaginal birth, breech extraction, and cesarean (planned and emergent).  I am aware that things can change quickly.  Therefore, I have prepared my birth preferences for several different birth outcomes.
 I have carefully selected my health care providers and believe they will act in the best interest of myself and my babies.  However, every decision regarding my care and that of my babies should not be made without my direct consent, or that of my husband if I am physically unable to consent.  It is within my rights to change my decisions at any point during the birth.

During the various stages of the birth, please limit those attending to necessary personnel only.

Vaginal Birth:

Stage One:

*Do not ask me to asses my pain.

*Use of various comfort measures: ball, stool, toilet, shower, and freedom to move around.

*Intermittent fetal monitoring.

*Cervical checks by the OB only or upon my request.

*No stripping of the membranes without my consent.

*No breaking my bags of water without my consent.

*Please do not offer an epidural, unless I use my code word/phrase “Give me a c-section.”  However, due to the nature of my birth…  Please allow either my husband or doula to be present if an epidural must be administered.

*Ability to eat and drink through the course of labor. 

*No Hep-lock

*No artificial augmentation of labor.

Stage Two:

*Freedom to push in any position that will allow my pelvis to open completely.  Should an epidural be used please help me get into the most optimal position for pushing.

*Use of an ultrasound after each baby is born to determine their positions.  Should any of the babies present breach I am comfortable with a vaginal birth.

*If Baby B or C is presenting breach but appears to be responding positively to contractions and is progressing please allow the baby to be birthed with little to no interventions.

*Mother-directed pushing.  No counting.

*Use of a mirror to see the birth. 

*Please allow me to grab each baby as she is birthed.

*Massage of the perenium and use of lidocaine.  Please do not cut an episiotomy.

*Delayed cord clamping.

Stage Three

*Provided there are not emergent situations with the babies I would like Immediate skin to skin until it is time to birth the next baby.  Then allow my husband to hold the baby.

*Allow my husband the opportunity to cut the cord.

*Natural birth of the placenta.  No Pitocin, unless it is apparent that it is medically necessary.

Baby Care:

*We do not want to bathe the babies and want to keep as much of the vernix on the babies as possible.

*We do not want the Vitamin K drops, Hep B shot, or the PKU test.

*I plan to breastfeed and so please do not give formula or sugar water unless direct consent has been provided.

Birth Plan for a Cesarean:

*Please do not put any IVs in my right (dominant arm).

*Freedom to move my arms.

*Drop the curtain and have a mirror so I am able to view the birth.

*Please be respectful that while this may be a routine procedure it is a major procedure for me and so please be mindful of your conversations.  I would like to be informed of what is going on during the surgery.

*Immediate skin to skin with me or my husband.  I would like to give the babies the opportunity to nurse as soon as possible.

*I would like either my husband or myself to remain with the babies when at all possible.

 

What does it look like to prepare for the birth of triplets?

So, what does it look like to prepare for the birth of triplets?  In the mere 19w I have been pregnant I have learned that I have to be very flexible.  Things change from week to week, and not just size of the baby, but potentially life threatening changes.  It looks like getting in the zone for a vaginal birth one day and then having to research a pregnancy reduction the next day.  It is all over the map.

The latest update on my triplet pregnancy is that each baby is in its own sac, so no Mo/Mo, and we are still within the range of normal with regard to fluids to TTTS has not been diagnosed.  So, I'm just a regular high risk triplet pregnancy without added risk.  What a relief.  But now that I am not trying to educate myself regarding Mo/Mo or TTTS I feel like I have to do something.  For whatever reason I can't just BE pregnant.  The fewer the complications the greater the likelihood for a vaginal birth.  And so in the past few days I have allowed myself to finally read the few triplet vaginal birth stories that are out there.  They are all amazing, but I am most amazed by the VBAC moms who have had a successful triplet birth, and not just VBAC, but VBA2C.

I remind myself constantly, as does my OB and my MFM, that there are so many variables in a triplet pregnancy.  It would be foolish to sign-off on a vaginal birth now at 19w because things can literally change from week to week.  This does not mean my care providers are not supportive of a vaginal birth, should that be the best option and my decision.  In all honesty, in this pregnancy I am setting very small goals.  Goals that really I have very little control over attaining, but I set them none-the-less.  Every Sunday when I make it 1 more week that is cause for celebration and thankfulness.  Every ultra sound, which is now happening weekly, that indicates babies are growing, bladders are functioning, amniotic fluid is within the range of normal, my cervix is still holding up(and apparently it's beautiful and boxy and indicating no cause for concern), and my 1 placenta for all 3 hasn't crapped out that is cause for celebration and thankfulness.  Beyond weekly goals, my next major milestone is 24w, viability week.  Ok, so those are my goals about them living one week longer.

Then other factors that I'm at increased risk for due to the multiple gestation is pre-eclampsia and gestational diabetes.  At my 24w visit we will test for GD.  This is earlier than if I were your average woman pregnant with a singleton. And in the past, I have declined the test and I have that choice again and the "ok" from my OB should that be the route I choose.  But I don't need to have additional stress on my placenta and if there are things I can do dietary wise that I'm not already doing, sign me up.

So I suppose there are other things occupying my mind even after TTTS and Mo/Mo were not associated with this pregnancy.  But thinking about all those things I listed above aren't much fun.  Reading stories of vaginal triplet births and connecting with moms who have accomplished this feat or who are hoping for one is fun, encouraging, and gives me hope.  But I am not naive.  This pregnancy and birth is not just about thinking positive thoughts, saying affirmations, picturing my cervix opening, and hiring just the right people to attend my birth.   And quite frankly that view extremely minimizes every other issue, hardship, and concern.  It is about making it one more week.  It's about reducing the number of days each baby will be in the NICU.  It's also about figuring out how to care for my 3 children I already have at home and caring for the new little babies joining our family.  It is not about how  strong or determine I am.  Thankfully, I have already had 2 successful VBACs so I don't doubt my body.  I know that it will do what it needs to if and when it needs to.  I also believe the outcome has been determined by God, I just need the wisdom and discernment to follow the plan He has set and be at peace with it.

I can't just show up and expect to have a vaginal birth with triplets.  So I need to put some time and effort into finding what little data and information there is.  Uterine rupture, even with two successful VBACs, is still a possibility simply because of the extra babies.  But there isn't a lot of statistical data on rupture, vbac, and triplets...go figure. Each triplet pregnancy is so different, it's hard to find consistent protocols among OBs because of the great variability, so you can imagine there isn't a lot of information on the hows/whys/etc for a vaginal triplet birth.  So I am doing my homework and making friends with like-minded moms who have as much similarity to my pregnancy as is possible given my birth history and current pregnancy "profile."  As much as I am doing my homework on vaginal, I am also watching videos and reading about cesareans, specifically family centered ones.  Like I already said, I am not naive.  I know things can change on a dime.  I've said it before, I am so thankful that I am under the care of two health care providers who respect and practice evidence based birth, respect the almost delicate nature of the pregnancy, want what is best for me even if it may not be what they would choose, and ultimately leave the decisions up to me.  God has blessed me in so many ways in this pregnancy.

Sometimes praying for God's will is not easy

What I thought was a short explanation for a prayer turned out to be a book...So, if you haven't heard all three of my girls are identical!  1 egg that split, I'm in awe.  This means all three are sharing the same placenta and this puts them at risk for twin to twin transfusion syndrome...essentially one baby is the pump and the other a receiver of blood/fluids (still educating myself).  Babies A and B are beginning to show signs of TTFS, my MFM is super worried now, but he is doing two US next week to measure fluids so he can get a better picture of things.  Weekly scans for fluid are key because things can go bad quickly, however there are treatments.  So there is another element of risk in an already risky triplet pregnancy.  I feel like I am under the care of two caring, wise, and God-fearing care providers.  The doc yesterday gave me his personal cell-phone to call him Sunday and schedule a free, after hours fluid scan with him.  He told Taylor and I there is no guarantee with anything, whether we go to 40w with 1 baby or 28w with triplets.  But what we can do is love our kids and be thankful for everyday.  We just love them.  Every week further gestationally is a blessing.  From the moment I conceived God gave us the babies just as they were meant to be and there is some comfort in that.  I'm educating myself on TTTFS to where I can understand it but shy of scaring the crap out of myself. 

I visited the NICU yesterday and I cried the moment I walked off the elevator. Even though it's a hospital I could just feel the love on the floor.  The social worker who took me on a tour was so compassionate and I just know that should any of my girls be there they will be cared for and loved.  To not think about all these possibilities would be silly and naive.  And there is no way to really prepare.  But any little thing I can do to put my mind at ease: organize the house, freeze food, make NICU kimonos, go on tours, etc I will do. 

The two scans coming up next week (Sunday or Monday and then again on Friday) are likely very critical.  It's hard not to pray that the numbers change for the positive or to pray we make it to 35w...because really what I want is God's will.  Jeremiah 29:11- "For I know the plans that I have for you" declared the Lord."  And I have to say that's really hard to say I want God's will.  His will may look very different than what is in my mind, but He proves himself time and time again.  He is faithful.  Psalm 139 came to me while I was writing this.  Of course, I had to google "God has our days numbered" to actually know the reference. 
             Psalm 139:16- Your eyes saw my unformed body;

all the days ordainedd for me were written in your book

before one of them came to be.

I began at the beginning of Psalm 139 and felt that it was written just for me in this specific moment in my life.  And then the worship song that we sing so often on Sunday's began playing in my mind.  He knows me, but more importantly He knows my three little precious girls.  Their days are numbered and He holds their hand.  They were knit together in my womb.

I know how much I love these girls already and I do know that God loves them more than I could ever imagine and He cares for them in a way that is unfathomable.  But, to pray "Lord your will," is still hard.

Blessed

This morning the pastor at our church, The Vineyard, spoke about peace.  Not peace on earth, but peace in our lives.  He shared a story about a new widow who essentially shut people out of her life.  And then one day she got on the phone with her friends asking for help.  Without hesitation they came to her need.  They all gathered at her house for dinner on Christmas Day.  The care and support of her community brought her peace that she hadn't experienced in a while.  I instantly thought about the community Taylor and I have spent the last 6 years or so building .  I began to cry out of gratitude because of the immense  peace I have experienced during this triplet pregnancy.

 Our community of friends has embraced our family, particularly the triplets.  I know that among my closest friends in Baton Rouge as soon as they learned the news they developed a sense of urgency on my behalf.  Weekly they ask what I need.  My friend, who is in her 3^rd trimester with her 3^rd baby, has come 2 evenings to build shelves in a closet and organize my bathroom.  One morning a crew of friends and their kids came for a morning of cleaning and setting up the family closet.  They all willingly pitched in to cover the cost of a babysitter.  They have offered to take my girls for my really long OB appointments. 

Not only have my closest friends rallied behind me but so have countless other friends, some of whom are friends just through Facebook that I’ve yet to have the opportunity to meet.  A stranger donated a second fridge and a new friend’s husband picked it up and delivered it.  A group has pulled together resources to pay for a professional organizer to help with our house.  Although, in turns out the organizer wants to help us for free.  One friend has donated her photography services for the birth and even follow-up pictures through the year.  A friend in New Orleans has offered to organize the volunteers so as to not burden me with that tremendous responsibility.  Countless friends have already committed to providing my family with meals three times week beginning in February!  February and March are already filled.  Wow!  Friends have offered to run errands, fold laundry, hold babies and, take kids for playdates.  Breastmilk donations have already begun.  Someone dropped off high protein cookies earlier this week.  Another friend brought me delicious raw milk.  This afternoon a mom in my local ICAN chapter, whom I’ve really just developed a relationship with via Facebook, threw me a baby shower, she herself is 38w pregnant.  Some of the attendees drove an hour to be in attendance.  Blessed.

 I am daily reminded by God’s love, faithfulness, and His kindness.  He has blessed me with an unbelievable network of support.  He provides.  This pregnancy will get more difficult and bringing triplets into our family will be challenging.  But for the most part I have had a great sense of peace because I know that my friends and God will not let my family drown.  If you are unsure about whether God provides talk to the nearly 200 individuals in the Baton Rouge area who in some way want to offer help to my family.  All I can say is God is Good!  

A mother's concern

As much as I fought for my previous VBACs and believe that there are far too many routine cesareans performed I have basically come to a place where I am "ok" with a cesarean.  This does not mean that I have scheduled a section date.  What it does mean is if after I do everything within my power to give myself the best chance at a vaginal birth but it appears not to be the best option then I am ok with a cesarean.  And honestly, the thought of vaginally birthing 3 babies is a little daunting, but not completely out the question.  My main concern for a cesarean is the post partum experience and physically being able to care for 6 kids.  Talk about daunting. But nothing has been decided, there is still lots of time for things to change, and then change some more.  My OB and I have agreed to continue to have a dialogue and assess the pregnancy/birth along the way.

Monday's ultrasound has thrown a bit of a wrench into the situation.

The report from Monday's ultrasound indicated that the twins are Mo/Mo or monochorionic and monoamniotic.  They share a sac and a placenta.  The photos were not great and so my OB could not definitively one way or the other, but he is pretty certain that they are Mo/Mo.  This means that the babies are skin to skin and their cords can very easily become entangled.  It also essentially means that a cesarean is the only option for a birth. 

Like I said, I am not opposed to a cesarean.  What makes me nervous is the postpartum experience.  I brought this up at our monthly ICAN meeting tonight.  I began to cry as I talked about recovering from major surgery and possibly having my babies in the NICU and the rest of my family at home.  What will I physically be able to do?  Will I have to rely on someone else anytime I want to go to the NICU and if so, for how long?  After Evelyn it was weeks before I could sneeze, laugh, cough, and cry without pain.  Taylor changed every single one of Evelyn's diapers within the first 2-3 weeks that she was born.  There was no hopping out of bed to do anything.  I distinctly remember one time I was trying to get out of bed and I didn't have the strength and I fell, leaving half my body on the bed and half on the floor.  I had to yell for Taylor to help me up.  I laughed because it was so absurd and cried simultaneously because it hurt.  I was fortunate that I did not have issues with the scar; no infections, no reopening of the wound.  There isn't a guarantee with a repeat cesarean. 

I have heard people say the repeat cesarean recovery isn't as bad.  For some women was it better because they actually had a say in their care and so psychologically they were better off which in turn helped with their physical recovery?  Or is there something scientific about the recovery of subsequent cesareans?

I do believe these babies are a blessing from God.  I know that He is faithful.  I know that He loves me and each of my children.  Yet, it doesn't really change a mother's worry and concern, or at least not this mother's.

In the meantime, I need to keep eating my liver, protein rich diet, and all the calcium to keep those babies growing for as long as possible!

What does evidence say about multiples and vaginal birth?

Disclaimer: I am not a medical professional.  I am merely a mom doing some basic research.

This post won't be anything you will write home about saying it changed your life, ha!  It is meant to simply be informative.  It is not at all exhaustive of the research that is out there regarding multiples and birth.

I think there is a belief that a multiples pregnancy must always result in a cesarean.  This is just not true and frankly not completely supported by evidence.  This doesn't mean that a mom can't choose to have a cesarean.  In general, a vaginal birth should still be on the table.  Now I understand that with each additional baby other factors must be taken into consideration.  And from the limited research I've done thus far there is more data on twins than triplets.

I think it's often wise to see what ACOG says about a particular birth option.  The ACOG bulletinon multiple gestation states the following:

“The route of delivery for twins should be determined by the position of the fetuses, the ease of fetal heart rate monitoring and the maternal and fetal status.”6

So, if baby A is position right and is looking good that should determine the birth route not the fact that it is a multiple.

According to an article in Reviews in OB/GYN if your first birth was a cesarean and you find yourself pregnant with twins a VBAC is not contraindicated.  The data indicates that a mom attempting a twin VBAC is at no greater risk for uterine rupture than a singleton VBAC.  

Ok, now for some triplet specific articles:
Preliminary experience with a prospective protocol for planned vaginal delivery of triplet gestations.:  In selected cases vaginal delivery of triplet gestations can be accomplished without increased maternal or neonatal morbidity and mortality and may significantly decrease maternal hospital stay and postoperative morbidity.

Neonatal outcomes in triplet gestations after a trial of labor:  Our experience suggests that offering vaginal delivery is an acceptable management plan for triplet gestations.

Birth in triplet pregnancies. Vaginal delivery--how often is it possible?:  In terms of fetal outcome cesarean section in triplets is not superior to a policy of vaginal delivery. Vaginal delivery may be suggested when there are no obvious obstetrical contraindications.

I will leave it at that for tonight, this mama is exhausted.  As you can see from this very small pool of evidence that a vaginal birth is not contraindicated.  For what it's worth, I didn't have to go on a great expedition to find this data, nor did I skip over articles that didn't agree with my point.  I merely read the first few articles that appeared in my search.  I would say that's rather encouraging.  What is also encouraging is that my OB has asked me to share articles that I find!