An Update, a Correction, and the Aftermath

I lied. Zach's birth story was not my last post.

First, the correction:
I later discovered that my due date was off by several days. Zach was not born at 36 wks, 3 days like we thought. Instead, he was born at 33 wks, 5 days. Which means everything I blogged was off, too. Sorry. I have since gone back and tried to adjust the dates, but some of it will still be off. We didn't know this until I went for my postpartum check-up.

The Update:
Zach is now 3 months old--13 weeks chronologically, 8 weeks old with the adjustment for his prematurity. And he is absolutely perfect. Our angel. The easiest baby ever! He ended up having a few issues from his prematurity, such as an abnormal newborn thyroid screen. He also had a few feeding issues where he would mix up the suck-swallow-breathe routine and sputter and choke while eating. And difficulties latching on. We are continuing to work through all of it. Developmentally speaking, he is just a couple of weeks behind on his milestones, but that is to be expected.

He lights up our world with his beautiful smiles, loves to be "worn", and is the apple of his big brother's eye. We cannot even remember what life was like before he came into our lives.

The Aftermath:
It turns out that my relief I felt at the end of the pregnancy would be false. Instead, I find myself having difficulties with coping with the pregnancy. I feel like I am a failure as a woman as a result of the whole experience and have a bitterness I did not expect to feel once I held my baby in my arms. This is not something that has interfered with my ability to mother my children or carry on with my life, but rather serves as a sort of hang-up. Not really postpartum depression and not a simple case of the baby blues, it has no label. About the closest thing I can find is "Traumatic Birth Experience", in that the pregnancy and birth served as a sort of emotional trauma. I find myself resentful toward other pregnant women who get to have a positive experience, which in turn makes me feel guilty for feeling the way I do. And I simply have not been able to let it go. And despite all of the pain I felt in the last months leading to Zach's birth, I wish I could go back and do it all over again. Only this second time, things would go as they are supposed to. I would get to leisurely shop for the baby, not be in the hospital over and over. Maybe even have a baby shower. I would be able to spend more quality time with E before Zach's arrival instead of having such physical limitations or being submerged in the fuzziness of painkillers to get me through. I would be able to bond with my baby through a more natural childbirth instead of the cold and calculated world that is a scheduled c-section. And it would all be perfect.
As for the mathematical aftermath: My pregnancy cost my insurance company over $484,000. Thank God for Humana. My family's share? $15,000. By the time I delivered, I had exhausted every resource I had to compensate me for maternity leave. My FMLA job protection had long-since run out, and the only reason I had a job to which to return was because my supervisor likes me. I ended up returning to work at 5 weeks postpartum, just 3 days after my due date, simply because I was worried for my job and also because I needed the financial compensation of my full salary. We were scraping the bottom of the barrel. That in itself was a source of emotional difficulty: I simply was not ready to leave my baby yet. We still needed each other.

I have been back to work about 2 months now. I still run into people in the halls of the hospital who ask me where I have been. I was off of work for 21 weeks, from start to finish, and when I tell people this, they always reply the same way: "That must've been nice!" And then I want to scream. No. There was nothing nice about it. Not the needles, the pain, the hospitalizations, the tests, the bills, the fear, the tears. I honestly cannot think of one positive thing other than the gift I was given when Zach was finally born on May 13th. Not one thing. I don't tell these people the details. They don't want to know. The details are my burden to carry. Instead, I just smile the fakest smile in the world, and hope that they never have to endure what I did.

35 Wks, 2 Days: Hoping for Lots of Bubbles

This is so bizarre: the very career-oriented respiratory therapist waiting on a test to determine lung maturity. My amnio is at 1:30 this afternoon, and I, as usual, cannot sleep. This is essentially where the rubber meets the road- what I have been gearing towards since January 29th, when I was first hospitalized for preterm labor at 20 weeks.

I have been talkng incessantly about it, but then realized that the layperson may not realize what all of the fuss is about. We all know that the lungs are the last to mature in a fetus. Lung development actually takes place in 2 stages. First, Baby Zachary had to produce all of his tiny little alveoli and his bronchiole tree. All of the exchange of carbon dioxide and oxygen occurs through a very thin membrane called the alveolar-capillary membrane. A single alveolus is very small-not much surface area for this exchange to happen. In its beauty of organization, his body has grown a ton of these little grape-like clusters of alveoli. More of them means more surface area for the all-important exchange vital for life outside of the womb, when my body will no longer be taking this role over for him. But that simply is not enough.

The second stage is the production of surfactant. What in the hell is that? Well, it is a slick, soap-like substance that lines and lubricates these alveoli. We all make it via these cells called Type II Alveolar cells. We see pathophysiology in adults, even, when the surfactant in their lungs is depleted. Without it, we can compare breathing to inflating balloons. No regular balloons either. Think of those teensy, tiny balloons you use to make fill with water for a water-balloon fight. And you blow and blow into the balloon, about to pop a blood vessel in your forehead trying to inflate them. That is essentially what it is like to try to breathe and inflate all of these little tiny alveoli without surfactant. So the surfactant acts to reduce surface tension, making this job easier. Once they are inflated, the body also does something else to make it easier--the functional residual capacity of the lungs. Basically, with each breath we take, a small amount of air remains in the alveoli after exhalation. Just like it is easier to inflate the tiny balloon once there is a small amount of air in it, it is also easier to breathe with the FRC.

A newborn's first breath is vital, and is also the most difficult, stressful event of his birth. Because after this development takes place, he "breathes" amniotic fluid to practice. This is how they are able to determine lung maturity from a sample of amniotic fluid. There will literally be traces of what is in his lungs in the actual fluid they withdraw from my belly via a very large needle poked through all of the layers of my belly, my uterus, and into the amniotic sac. If adequate surfactant is present, agitating the sample will produce bubbles like soap will, and we know that the cells in his lungs are working. (It's actually a little more complicated, as they actually send the sample to be chemically analyzed.) So when a baby is born vaginally, the process of childbirth actually squeezes this fluid out. Obviously, with a c-section, this doesn't occur, and often the baby will require invasive suctioning. Then his work begins. It takes an astounding amount of pressure to take that first breath. Even with the help of surfactant, his little body still has to generate enough negative pressure to pull in that first breath, overcoming the remaining fluid in his lungs and the collapsed alveoli. Once accomplished, the air literally pushes out the remaining traces of fluid in the alveoli, through the alveolar-capillary membrane, and ultimately into the his lymphatic system to be carried away.

In the meantime, a fetus's circulatory sytem is still geared to life in the womb. Our bodies, as adults, are designed to do all of the work for us. We filter our own blood. It goes in and out through different circuits, because it has to first go through the pulmonry circuit to be oxygenated by the lungs and rid itself of carbon dioxide before it can go through the remainder of the body to oxygenate the rest of the body tissues. For months and months, a fetus has had this role performed for him by Mom. In a portrait of efficiency, as a result, the fetus's body has these shunts in place. There are several--the Foramen Ovale, the Ductus Areteriosus, the Ductus Venosus--all designed to bypass the organs in his body that are not yet needed while in the womb.

Ever read about or talked to someone with a preemie who had a "PDA"? That is a Patent Ductus Arteriosus. Basically, birth is what we in healthcare call a "hypoxic event".The baby isn't breathing while he makes his transition to life outside of the womb in those first seconds. Without breathing and exchanging gases, the concentration of oxygen in his blood drops and the concentration of carbon dioxide increases. This shift in concentration causes changes in the pressures in his blood vessels, which triggers all of those shunts to close so his circulatory system can switch to that of an adult. In a PDA, this fails to occur.

So there you have it--a primer on what took years of college for me to learn, summed up in one little blog post, off the top of my head. Of course it has also been years since I have studied perinatal pulmonary development. But this is what we are waiting for so anxiously. This is why the biggest problem with a premature baby is usually respiratory in nature. Without proper time to "cook", the baby's lungs just aren't ready to do this on his own, which usually means intubation and machines doing it for him while his lungs finish developing. Then failure of the lungs to do this work results in a failure on the part of circulation to close all of the shunts. A steep, slippery slope.

Of course we have the tecnology to do a lot of this. We even have artificial surfactant we give. The biggest brand name is Survanta. We simply administer it through the endotracheal tube once the baby has been successfully intubated. Then we literally tip and tilt the baby around to make sure it gets to as many of those alveoli as possible. Picture greasing a cake pan. You pour a bit of oil into the pan, then tip and tap it around until it has covered the entire surface. We literally do the same thing with these tiny babies. But no matter what we can do artificially, nothing is as good as the Real Thing, like Mother Nature intended. Being on a ventilator opens the baby up for a host of complications. As with anything invasive,there is the risk of infection. There is the risk of damaging the tiny, fragile lungs with too much pressure or volume. There is a risk of pneumonia.

Knowing all of this has been my greatest strength and my greatest weakness throughout this horrendous pregnancy. I know exactly what can go wrong, making it even scarier for me. But I also know what we can do for the preemie outside of the womb, making it all the more harder to endure to give Zachary more time. When one has been a part of the successful resuscitation of a preemie so many times, and you see these babies go home with their families, it gets hard to picture any other result for your own child, and each painful contraction gets harder to endure.

I am almost positive Baby Zachary is ready. The combo of how long I have managed to carry him with the administation of steroids means we are most likely to see the results we want today. If we don't, however, I will have to stay pregnant longer. This would be awful for me, for obvious reasons. But if his lungs aren't mature, it means that after delivery, we can guaruntee he will need to be on a ventilator of some sort. I don't want that. No mother does. So if the results aren't favorable, I 'll have to endure whatever comes next, which will most likely be more steroid injections and more waiting. More pain and contractions. But at that point, I will know, without a doubt, that it is necessary, making the thought of it easier to handle.

31 Weeks, 1 Day: I Take It All Back

I have been a whiny baby lately, complaining about this pregnancy and how I am "done".

I lied. I'm not done. I wish it were easier, but I want him to be healthy. And be in there as close to full-term as possible.

I'm nervous. Today, I have to go back to the doctor to "check everything out". They're worried about my BP and pregnancy-induced hypertension. Not pre-eclampsia yet, as none of my lab values mesh with that. Urine, blood..everything was normal but my blood pressure. My BP has always been perfect. As a matter of fact, when pregnant with E, I was on Procardia for preterm labor and they had to stop it because it would cause my normal BP to drop, then when I would do anything that would cause it to lower more, I would randomly pass out. I had to take cold showers bcause the heat would cause me to vasodilate and John would hear a big thunk! where I would hit the floor. So when oral brethine didn't work this time, that is how I ended up on the pump. They didn't want to add nifidepine to the mix.

So yesterday, when they sent me to the hospital for PIH, I was the talk of L&D. From my stretcher in triage, I could hear the doctors and nurses at the nurses' station talking about it. "She's here for PIH and on a brethine pump!" They kept implying that it would have to be stopped, and the doctor that sent me to the hospital in the first place even said so much--that if BP became a problem, they would have to stop it.

Hmmm. Stopping the brethine pump.....

I've been fantasizing about this for weeks. What it would be like to sleep without worrying about rolling over on the tubing and occluding it. Of worrying about the syringe emptying in the middle of the night, causing me to miss a scheduled bolus and wake up contracting. To be able to take a hot bath because there is no catheter on my thigh that cannot be submerged in water. To be able to go to a doctor's appointment or anywhere else and not have to worry if I have enough batteries or meds to survive the trip without going into labor. About not having something constantly attached to my body.

And if they stop the pump,they are going to stop everything. My progesterone shots. Most likely my home monitor that works in conjunction with the pump. I'm getting scared.

The truth is that, while I have been getting really sick of this stuff, I also realize that there have been countless times where I have avoided hospitalization because of it. And as much as I hate it, I hate being in the hospital even more. And I know that, while they have spent months trying to find the delicate balance of injection frequencies and infusion rates to keep me from having breakthrough episodes of contractions, those breakthroughs would occur more frequently without the stuff. Or my contractions just won't stop, period. And my beloved son will be born too early. Or if he isn't, I will lay in misery in a hospital bed, contracting away, in pain, with my needs not being taken into consideration as I incubate him longer. Neither one is an option I can live with right now.

I'm really scared for myself. And terrified for Zachary.

Watch "Born Too Soon"

Stumbled across this link this morning. How interesting that in my last post, I was just talking about the risk of delivering a 34-weeker. This documentary gives lengthy mention to late-preterm delivery.

This is taken from KET. Some interesting information is discussed on prematurity and social ills, smoking in pregnancy, and more. On an interesting note, the hospital where I delivered E is highlighted.

(Image Credit goes to KET and their wbsite. It isn't mine.)

20 wks: What You Aren't Supposed to Say

The contractions started while I was at work. I felt them. I knew they were there,but I didn't want to be a burden to coworkers. I remember feeling fear. Fear for my unborn baby. Fear that this, combined with my history with E's pregnancy, would end my ability to work. Which spawned fear for the financial well-being of my little family. Fear.

But we, as pregnant women, are not supposed to think of anything but the baby. After coworkers convinced me to go to L&D to get checked, all I could think is "this is it: there goes my life right before my eyes". All of the overtime worked to keep on top of bills. All of the hours of study-time logged to get me closer to my goal. My job. My house. My car. My ability to provide for E. All of it. Whoosh! There it goes.

They stopped the contractions and I was able to go home after a few hours. Home to bedrest until I could see my OB in the office. But something happened to me that night. I left the hospital feeling less adequate and faulty. What was wrong with me? I was supposed to be the selfless mother, concerned only with her baby. Who thinks of work, school, or others at a time like that? The answer is ME. I do.

Because what they DON'T tell you while you are laying there, strapped to monitors that are recording your body's dysfunction is that you are only human. And that while I have an obligation to be selfless for this baby that still needs to grow, I also have obligations to others in my life. E is young, and he needs me. J needs me. My coworkers rely on me to be there when scheduled. And my family relies on me to work to provide, to get my education to provide more in the future.

But I'm not supposed to say that. There is no "self" and there is noone else when you are pregnant. The world is supposed to stop. For the baby.