Wednesday, December 8, 2004

A Tale of Two Births

A Tale of Two Births
Kathleen Lopez

It was the best of births; it was the worst of births.

No, scratch that. It was two births, and they were simply different—on opposite ends of the Western medical spectrum, if you will. With my first, my son, who is now two and a half, I was able to follow my crunchy heart and soul to a midwife for care and delivery. I was very excited to do the same with my twin girls, now five months, but the Universe had other plans in store for us.

I had an absolutely glorious first pregnancy, and loved just about everything about it. I felt round, sexy, and amazing, and loved learning all about pregnancy and development. It was over all too soon, as I went into labor two days early according to my calculations, and about eleven days early according to the midwife and the ultrasound. I woke up early one morning and needed to go get doughnuts for breakfast after dropping my husband off at the ferry. We had both worked in downtown Manhattan, but I had been laid off on 9/11 because of the extensive damage to my building, and my husband returned to work full-time back in his own building in December of 2001.

At the grocery store, the doughnut craving passed and I went home with two turkey TV dinners for breakfast instead. By lunchtime, I had ordered mozzarella sticks, chicken fingers, garlic bread, and cheesecake to be delivered by a nearby deli. I sat surrounded by greasy food and piles of napkins and called Carlos at work to let him know I thought things were in motion – that we would have the baby by the weekend. It was Tuesday.

By 6:00pm or 7:00pm, I was having strong contractions. By 8:00pm, we had called the midwife, who was swamped with two other births and wanted us to measure progress and call back in an hour. At 9:00pm, she said the same thing. The nurse we spoke with wasn't aware that I had been 3cm and 90% for almost a month, and we called back at 9:20pm and said we were on our way in. The car ride was torturous, and when we arrived at the birth center, I couldn't focus beyond getting on all fours on the floor and putting my head on the cool tile.

They let me wander and pace and do whatever I needed to do. We tried a few different positions, but I felt best using the low birth stool. Melanie at one point gently let me know that all my yelling was taking my focus away from pushing, and that it seemed as though I was backing away from my contractions rather than using them to my advantage. When we had arrived at the birth center I was about 9cm, and had still been thinking that I wasn't "allowed" to push yet, and truly had been backing off. I told her that I was afraid, and when asked of what, I crested an enormous contraction and yelled, "Of breaking in half!"

The next contraction and push had me thinking in my head that I simply couldn't handle any more and that I was going to ask as soon as that one was over that I needed to be transferred and screw this because I was done and I didn't care what kinds of drugs they pumped into me or my spine or whether they cut me from neck to belly or what or how. With that, I felt Alejandro swoosh quickly between my legs and into Melanie’s arms. As I opened my eyes, startled by the feeling of the umbilical cord still hanging from inside of me, she said, "Hold your baby!" And there was a wriggly, slimy little BABY in my arms, and it was the most amazing thing in the world. I felt as though I had given birth a million times before, and could easily do it a million more.

With the twins, we were pretty much aware that I'd conceived the moment it happened. My husband said, "Gee, I bet that wasn't good timing, was it?" I went outside and looked at the moon, thought, and thought, "No, probably not." Nineteen or so days later, three or four tests showed those ominous lines. We had just bought a house a few months prior, and my husband had taken an enormous pay cut in moving to South Jersey. We had hoped that we would be able to have me working part-time in the evenings for a year before trying to have a sibling for Alejandro. But what is what is, and there it was.

At six weeks, my belly popped out, and there was no hiding my pregnancy. I thought to myself that even though I knew second babies showed sooner, either I’d calculated funny and was an extra month pregnant, or that I really had weaker abs than I thought! The midwife I was seeing, though part of a fourteen-person practice, was fairly new to midwifery and was staffing the New Jersey office all by her lonesome. She said that I was measuring large for my dates, but perhaps I was off, and she scheduled me for an u/s to check things out.

The Friday prior to my Monday ultrasound appointment, I had some cramping and bleeding, heavier than I would have expected, and I thought that perhaps I was having a miscarriage. I didn't call - I just figured I’d wait until my appointment on Monday. I was very frank with the u/s tech, and told her my suspicion, and she promptly showed me a heartbeat and said not to worry. She did all her measurements - and then did them all again - and I couldn't help thinking how thorough she was. She asked me a couple of benign questions about how I was feeling before she dropped the “T Bomb,” which she did simply by asking if twins run in my family. I was shocked to somewhere between laughing and crying, and couldn't get in touch with Carlos for over an hour to let him know.

What I hadn't understood during the appointment was that the tech was unable to find a membrane dividing the babies. I simply thought that meant they were identical; I didn't understand the complications at that point of them sharing an amniotic sac. A week or two later, the head midwife at Penn Hospital called to let me know that based on my ultrasound, they wouldn't be able to continue my care, and would have to refer me to a high risk practice. I was livid - THIS is midwifery? Simply because I was having identical twins, I was being passed off to someone who would want to intervene as much as possible and schedule a c-section at the earliest possible to avoid going past 37 weeks?

I called my old birth center in hysterics, and they told me to keep looking around. I called everyone I could find – and prepared to take the drive to The Farm - and was met with much warmer responses. A few days later, I wandered into a bookstore to look for something to read on twins, and came home with Elizabeth Noble's book, Having Twins and More. Within the first few pages, she described different types of twins, and I began to realize, with horror, what we were up against.

I had scheduled my next ultrasound for 16 weeks - convinced that I'd find a midwifery practice that would take me. I had wanted to wait until we could find out the babies' sexes since I was sure it would be the last ultrasound of the pregnancy. At my 16 week appointment, I was met by a young, handsome high-risk doctor, who was not pleased that we'd waited so long to come in. Although we'd immediately seen a sliver-thin membrane separating the babies - almost wrapped around Baby B, hugging her - one baby was surrounded by amniotic fluid while the other almost seemed dry, and they had a size discrepancy of 29%. We were informed that the babies had Twin-to-Twin Transfusion Syndrome. Our doctor told us that we would have been almost "better off" with monoamniotic twins. He wanted to start serial amnioreduction the following week or have us enter a clinical trial at CHOP that included either the amnioreduction or a septostomy of the dividing membrane to help alleviate the fluid pressure and hopefully even things out.

I was very flustered. It went against every fiber of my being – being bossed around and told that my babies had an 80% chance of dying without any treatment. My girls, as we'd found out. I went home and did all the research I possibly could on TTTS. I contacted the TTTS Foundation and spoke with the founder. I emailed other survivors, and spoke with people who had lost their babies. I read success stories, and I read tales of grief and loss. I also, in the midst of it all, found a glimmer of hope.

It sounded as though we were close to qualifying for a laser surgery on the placenta that could only be performed by two doctors in the U.S. One was in Florida, and his nurse was an amazing resource. She requested that I have the doctor we'd seen fill out several forms - apparently TTTS is something that has several different criteria for diagnosis, and options for treatment vary depending on what you're looking at. I called our high-risk doctor on Monday, and told him what I'd found. He wasted no time in speaking down to me, belittling the doctor in Florida, and insisting that I come in to have amnioreduction. I went in the following week and tolerated another appointment with him, and once we found that there was no change in anything, he agreed to wait another week before beginning intervention.

It was an incredibly productive and emotionally draining week for me. I had been able to get my information to the doctor in Florida, and we were not yet qualified for surgery. The AFI (Amniotic Fluid Index) in the smaller, or "donor" baby has to be < 2.0, and ours was hovering just above that. Additionally, the greater sac had to contain more than 8.0, and we weren't there yet, either. Our smaller baby was also still showing signs of bladder function, which was a very good sign. I continued to research, and found a high-risk practice at another hospital that was headed by a woman - a mother of twins herself - and scheduled an appointment. The folks at this office were infinitely nicer and less needle-happy. The doctor met with us and explained that if was our desire, she was okay with a "wait-and-see" approach, as long as nobody was in any danger. We scheduled ultrasounds for two weeks out, and went home to worry. I was 18 weeks pregnant.

During this time, it came to my attention that the other doctor doing the placental surgery recommended a daily intake of 2-3 cans of Boost or Ensure to help increase protein intake. His experience in dealing with TTTS found that the mothers often had deficiencies in both iron and protein, and by taking a liquid protein in steadily throughout the day, it seemed to help. I started upon this immediately, adding a can of Boost to 8oz of soymilk for added protein, and found at my 20 week appointment that the girls' fluid levels had reversed. The larger sac had less fluid, and the smaller had more. There was still a size discrepancy as well as fluid differences, but it seemed less severe. I was ecstatic. Over the next few days, I spoke with Dr. Brewer of the Brewer Pregnancy Diet and Hotline fame, who recommended 100g of protein daily. He spoke of the tragedy, he believed, in letting twins come out any less than term. I agreed. I upped my protein - difficult as it was - and at my 22 week appointment, Baby B had lessened the gap in their sizes, and their fluid levels evened out.

For most of the rest of the pregnancy, we sailed. I choked down as much non-meat protein as I could from dawn ‘til dusk. My doctor had an accident and broke her shoulder, and I ended up seeing another doctor in the practice, who seemed much more alarmist - much more intervention prone – and I worried. She instructed strict bedrest - Go home! Not out to dinner! Get takeout! - when an u/s showed that my cervix had thinned below 3cm. Noble suggests that in a multiple pregnancy, this thinning is not to be worried about as it is in a singleton pregnancy. I agreed with her ideas that strict bedrest seems more harmful than helpful in such a situation. I managed to reduce my activity by not lifting my two-year-old as much and by leaving a lot of laundry duty to my husband. I rested more often, and kept eating protein. At 30 weeks, I felt very hopeful that at 35 weeks I could switch care over to a local midwife who was a little more of a renegade than the rest. I spoke with her and had an appointment. She was incredibly accommodating, and agreed to take me if all was still well at 35 weeks.

Except it wasn't.

Around 32 weeks, the girls started to show another change in their growth. They had been staying at about 24% different or so, and it jumped to 31%. I worried. At my 33 week appointment – 4:00pm on a Friday - my cervix was 1.4cm and the babies looked to be about 43% different in size. Even with an error margin for ultrasound, it was still alarming. I was showing no other signs of pre-term labor, but in each NST (Non Stress Test) that I had been having, each baby had one major deceleration. The doctor told me she wanted me in at 6:00am on Monday for induction. She argued that at 34 weeks, the girls were probably better off out than in. I called the midwife and cried, and to her credit, she told me she was unable to give me professional advice not officially being my care provider - but she told me that I really needed to listen to the babies. Pay attention, and see what they were trying to tell me.

I went home, and re-read everything I could about TTTS. It does have a tendency to resurface at the end of pregnancy, and can be particularly dangerous at that time. Baby B was said to be at higher risk for cerebral palsy among other things. Baby A could have heart failure. Long-term problems could be caused suddenly. We agreed to induce - but not until Wednesday. This whole thing was already far enough away from the natural birth I'd envisioned.

I went in on Tuesday for a NST and got kept. They wanted to induce immediately. After reassuring us that they weren't inducing simply to satisfy someone's golf schedule, we met with the doctor on call. He was a D.O. (Doctor of Osteopathy), and had liked my favorite pair of plaid maternity pants. He seemed easygoing, and wasn't in agreement with his colleague that breaking my water straight out was the way to go. I got hooked up to the Pitocin at about 2:00pm, and it went on for two hours. At 4:00pm, he said that he didn't expect anything to happen until at least 2:00am, and that at the very earliest we might have babies by midnight.

He offered to unhook everything and let us go home, rest up, pack, get our son situated, and then start over on Wednesday morning, but I wasn't having that. We needed to finish what we'd started, and I agreed that if he broke my water at 4:30pm, it would probably help to speed things up. At about 5:30pm, my in-laws showed up, thinking we’d already have a couple of babies that they could hold. I had to grit my teeth and clench the sides of the bed through every contraction to maintain happy conversation. At about 7:00pm, I was 7cm dilated. I wasn't handling the Pitocin very well anymore and requested an epidural.

When the anesthesiologist finally showed, she was surly and annoyed, and talked at full volume about scheduling problems as she inserted the catheter. Not surprisingly, it didn't take on one side of my body, and the pain was excruciating, as I was unable to move to alleviate the pain. At this point I had an external and an internal monitor, and was no longer allowed to get up from the bed. The anesthesiologist acted as though it was my fault the drug wasn't working, and didn't seem to care that the pain continued through each contraction. I was starting to get pretty upset. The doctor came back in and commented that I had seemed like a trooper and that if I was in that much pain, something must be up. He checked me again, and I was complete and ready to push.

I could hear the frenzy to get ready as they wheeled me into the O.R. - it was a teaching hospital, and they had to assemble almost 30 people in just a few minutes, including a team of doctors for each baby. As I was wheeled in, the anesthesiologist adjusted something, and I was finally put out of my misery as numbness took over. I was prepped while my husband got dressed outside; I was really glad he wasn't there to witness them emptying my bladder and heaving my numb extremities up into position. It was supposed to be one of the epidurals that allows you to feel pushing after an initial numbness, but due to the speed with which I went from dilating to ready to push, there was no chance for that, and I was simply numb from the waist down.

Just like my worst nightmares, I was flat on my back, with my legs being held by whoever was around, and the resident was instructing me to push to the count of 10 three times in a row. It seemed awfully inefficient, and barely gave me a chance to breathe. I took to faking it, instead, scrunching up my face in effort, and breathing through my contractions as I tried to remember what it felt like, un-numbed, to push through contractions, blowing out gently like I would as I played a clarinet. They told me what a great job I was doing, and I could see the shadow of Nieves' full head of hair as she exited my body in the machinery above me. After a second, I heard her cry, and I saw the expression on Carlos' face, and I knew she was OK. Four minutes later, at 9:29pm, more than three hours ahead of "schedule," Paloma followed, shoving a fist in her mouth and howling as though she'd been wronged.

My 34 week girls were perfect. Neither needed anything at all - not even oxygen - and Nieves came home with us at 4lbs. 12 oz. after just three days in the hospital. It took Paloma seventeen excruciating NICU days to add meat and sucking strength to her 3lb 6oz frame, and once she was home it took another three weeks of day and night challenges to get her from the higher calorie formula to the breast.

Their placenta showed obvious signs of TTTS; in addition to the vascular connections gone awry, Paloma's cord was about half the diameter of Nieves', and it had an almost velamentous attachment as well. After almost five months, my girls are weighing in at 10lbs., and 13lbs, and are developmentally on course with babies born at term. They are almost rolling over, have sparkling personalities, and are eating solid food like champs. I had wanted to delay them on that issue, but they were more than ready - mooching and watching me at every meal!

Although it was more of a procedure than a birth, and I still grieve that I didn't have the experience I'd hoped for, especially since I know it's my last pregnancy, but I do have tangible results of confidence in my intuition and trust in my body. Despite the needle in my back and the netted cap on my head, I was able to pull off the most natural event in the world, and have two incredible odds-beating little girls to show for it.

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