Scary.

So on Wednesday, at work, I get this random call. It's the referral office on base, and she says, "Mrs. N, I want you to know that your referral has been approved for specialist ob care. Please call Dr. T to schedule your appointment." I'm like, what referral? What are you talking about? She won't tell me ANYTHING.

Of course, I immediately google this doctor, and he's an ultrasound specialist in Pensacola, at the high-risk pregnancy clinic there. So I'm like, WTF?

Then I call the appointment line to leave a message with my midwife (yes, military policy, I can't actually call her directly). She immediately calls me back, and says, "I'm sorry, but there's an abnormality with your ultrasound. I don't want to discuss it over the phone. I'll wait here if you can come over now."

Again, WTF. My ultrasound was Monday, and although the tech technically can't say anything diagnostic in nature, everything looked great, measured currently for dates, etc. So I'm driving to the medical office and am pretty much hysterical at this point.

Then I get to the clinic, and am *escorted* to her office. I'm thinking, wow, this must be really bad. I'm crying.

Then my midwife sits me down and tells me that the "abnormality" is that there is "shadowing"/"calcification" in some of the baby's heart tissue. The heart is formed correctly, but there's this white area. There are no other abnormalities. She said that, "We're seeing a lot of these lately. Ultrasounds have gotten really good, and we're not sure if this is a true issue or just a phase of development we're just starting to identify." And apparently I'm going to have a Level 2 ultrasound with the specialist, and have it monitored, and hopefully it will go away.

I went home, extremely relieved, yet furious I went through all that for something that was later deemed "minor" and "probably wouldn't affect my desire to have a home birth." Way to give me a heart attack, lady. I was totally thinking fatal defect, trisomy, etc.

Anyway, I've done my research, and, like my midwife said, the echogenic intracardiac focus (EIF) that the ultrasound picked up is very common- occurring in 5-10% of all pregnancies, and usually disappears on its own. Yes, it can be a soft marker for several Trisomies, including Down's, but in those cases is usually found in conjunction with other markers, of which my baby has none. Because we choose not to have genetic testing done, it's impossible to say whether my risk is comparatively higher than most, but I'm confident that, given my age and the absence of any other markers, the baby will be fine.

And really, in the grand scheme of things, if the most likely (of the unlikely) scenarios is Down's, then really, there's nothing I can do about it. Like the saying says, "Worry is like rocking in a rocking chair. It gives you something to do, but doesn't get you anywhere."

The deuce!

At approx. 20 weeks, 4 days, the deuce weighs 13 oz. Measured right on for dates, and we got some great ultrasound shots :-) And yes, we're still going to be surprised regarding the deuce's sex.

My response to the denial of my home birth referral.

26 July 2010

Sir,

This letter represents my formal request for reconsideration of my referral for home-based obstetrical care, specifically childbirth at home under the supervision of a licensed Certified Nurse-Midwife (CNM). My referral was denied on the basis of, “OB care available at Eglin.” However, the type of obstetrical care I am requesting is not available at Eglin, as none of the Ob-Gyns or CNMs on staff attend home births.

It is my desire to deliver my baby as safely and naturally as possible, utilizing medical intervention only in true necessity. When I gave birth to my daughter last year at Houston County Medical Center in Warner Robins, GA, I was fortunate to have an extremely supportive medical staff that respected my birth plan and allowed me to both labor and deliver according to my personal needs, free from the direction of a standard operating protocol. I was not required to submit to electronic fetal monitoring, iv/heplock, etc. However, having already discussed my birth plan (please see attachment) with care providers at Eglin, I have been made aware that interventions such as these are standard, and that I will not be permitted to refuse several of them.

Therefore, in order to receive the type of obstetrical care I require to deliver intervention-free, a home birth is the most prudent choice. Numerous studies attest that for women with low-risk pregnancies and no complications, homebirths result in equally good or better outcomes for both mother and baby than hospital births. In one example, Janssen et. al. (2009, p. 377; attached) found that “Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.” Specifically, women who experienced home births as opposed to hospital births were significantly less likely than those who had hospital births to undergo electronic fetal monitoring, assisted vaginal delivery, third- or fourth- perineal tear, and postpartum hemorrhage. Further, newborns in the home-birth group were less likely to require resuscitation at birth or oxygen therapy past 24 hours, and had lower incidence of meconium aspiration.

Regardless of the documented safety of home birth, midwives are required to equip themselves to handle common events surrounding childbirth; by Florida statute (Chapter 64B24-7 Midwifery Practice, 7.006 Preparation for Home Delivery; attached), they must possess, amongst other items, sterile obstetrical packs and oxygen. Additionally, risk assessments must be routinely and consistently conducted; if any of the complications indicated in Chapter 64B24-7 Midwifery Practice, 7.004 Risk Assessment (attached) are identified, immediate hospital transfer must occur. For these reasons, arrangements for hospital transfer would be in place prior to the birth of my child. Further, if at any point my candidacy for a safe home birth was threatened by any of the pregnancy complications outlined in 7.004, I acknowledge that I would immediately request referral back to the MTF for prenatal care.

Finally, Tricare routinely reimburses home birth-related costs for its Basic beneficiaries, as well as for Prime members who are either not assigned to or are able to secure a referral from an MTF. To me, this signifies Tricare’s recognition of home birth as a safe choice, as well as a distinct type of obstetrical care not provided by an MTF.

For these reasons, I respectfully request that you reconsider my referral for home-based obstetrical care.

Respectfully,

Emily I. Nolan

Attachments:
1. Birth plan
2. “Outcomes of planned home birth with registered midwife,” Janssen et. al., 2009.
3. Florida Statute Chapter 64B24-7 Midwifery Practice

Wordless Wednesday.

She has a cuter pedicure than I do.

Rough week (or, pride comes before a *fall*)

So last week I wrote a blog post about my irritation with parents who place their infant bucket seats on top of grocery carts. "What are they thinking?" I wondered, "how could they possibly think that is safe- what would happen if the baby fell?"

Flash forward.

Lucy is teething right now- getting her 4 top teeth in all at once. She's in rare form: not sleeping well, irritable, not wanting to eat. On Wednesday night she woke up around 10 pm- she goes to bed normally between 6:30-7:00. It's really unusual for her to "wake up," she might stir a bit, want to nurse, etc, but she rarely actually sits up in bed and wants attention.

Anyway, it was time for me to go to bed, so I thought, I'll just nurse her back to sleep and we'll go to sleep together. I should also add at this point that Lucy is a very quiet, still sleeper- she never rolls around or otherwise moves in bed at night. That's part of the reason why bed-sharing with her is such a dream. So I climb into bed, nurse her back to sleep, and we drift off to sleep- or so I thought. I was out like a light when I heard it:

THUD.

I immediately woke up. My heart stopped as I heard my poor baby begin SCREAMING like I've never heard her scream before. I KNEW what had just happened- Lucy had fallen out of bed onto the floor. I jumped out of bed, grabbed her off the floor (she was laying on her back) and had her in my arms before Brett even made it into our room from the living room. I have never been so scared in my life.

Thank God she was okay. I was initially all for taking her to the ER, but after I calmed down some and we looked her over, we ended up staying home. She had not a bump, not a bruise, no swelling. No signs of dizziness or disorientation. She could move all her limbs, didn't seem to be in pain when I moved her. Lucy's pupils responded to light, and just a minute later she went from crying to playing happily again. We monitored her for any signs of vomiting or diarrhea, but ultimately, she is fine.

As for me? Oh, the guilt! I had been bugging Brett for a couple weeks about taking our mattress off the frame and putting it on the floor- when it's on the frame, the top of the mattress is at the top of my hip- probably three feet up from our hardwood floors. I felt extremely guilty about not convincing Brett to lower the bed earlier; he wanted to move her straight to her crib, but I wasn't ready for it. After all, she almost exclusively nurses at night now. Also, I felt terrible that she fell WHILE I WAS THERE. Whenever it's just me, as in Brett isn't in bed yet, I stack pillows around her other side, but clearly Lucy was able to climb over them.

The very next day, we took our bed off the frame. Further, we placed Lucy's crib mattress on the floor, between our bed and the wall. Add in a baby gate at the end of her mattress and you have what we call "the baby cave." This is my compromise with Brett- Lucy gets her own "sleep surface" so we can gradually move her into her crib, and I get to keep sleeping with her nearby.

The "baby cave"

It's really an ideal set-up. I nurse her to sleep, move her to her mattress. If she wakes up, I can reach over and pull her into our bed to nurse (and we often just fall back to sleep together in our bed). She is also able to pull herself to standing and reach me to wake me up.

We're working towards ultimately having Lucy sleep in her own bed, because I don't believe bed-sharing with a newborn and a toddler to be safe, and I don't think I could manage night-nursing two children at once. I definitely need to work on my own anxiety, though- I can't bear the thought of having her in the other room all night. I worry a lot: that she'll somehow become trapped in her crib, that she'll throw herself out and hit her head, that she'll be hurt in some kind of freak accident that would have been avoided had be still been bed-sharing.

I have no clue how some mamas are able to put their newborns in cribs in their own nurseries from the start. Please don't misunderstand me- I'm not judging here. I just trust my own instincts, and I worry about things like SIDS. The other day I was reading a magazine and saw a print ad for a device that alerts you when your baby doesn't move for a given amount of time. To my way of thinking, if I was worried enough about SIDS to consider buying such a device, I would prefer to bed-share instead. When Lucy was an infant, she never needed to cry at night when she was hungry, because I always woke up when she started to stir and her breathing changed. I trust my mama instinct over a monitor any day.

Wordless Wednesday.

Lucy signing "dog" to Savannah and Charleston.

It’s a CARseat, not a CARTseat.

(I’m stealing this quote from a friend, who posted it on my FB account after I related my frustration with this topic. Love it!)

I am becoming increasingly frustrated lately with the number of people I see in the grocery store pushing their children in the cart, whether they’re sitting in the basket or perched on top. I personally choose to wear Lucy in some sort of carrier when I shop rather than placing her in the designated “child sitting area;” however, at least children placed there are, generally, restrained. (I do want to point out, however, that even children sitting here are at risk. According to the AAP, roughly 25,000 children in the US are injured every year in shopping cart-related falls and accidents. 93% of them are under the age of 5.)

What REALLY gets my goat is seeing an infant car seat perched precariously on top of a cart. I know you’ve seen it- the baby likely falls asleep in the car, and mom or dad is hesitant to wake him or her up. So what happens? The parent carries the seat in, baby and all, and plops in onto the cart. Mind you, the vast majority of infant seats have no means of being secured to a cart- the “latch” mechanism many parents think is holding it on is actually where the seat attaches to the base. It wasn’t designed to, and will not prevent the seat from falling from the cart. I’ve read and heard countless stories of a cart being accidentally bumped into (whether by another shopper or even another child in the same family) and the child falling from the cart. Brain bleeding and damage are possible, and not uncommon, injuries in these types of scenarios.

What’s the solution? LEAVE THE CARSEAT IN THE CAR! Buy a wrap or sling- a Moby-style wrap is great for a newborn, and my daughter has spent countless hours napping while I’ve shopped. Wraps/slings/carriers add the extra benefit of keeping baby extra close and away from the curious, germy hands of strangers. Rarely does someone attempt to touch Lucy once while she is in her carrier- yet I frequently see strangers walk up to babies in carts to say hi. It’s all about establishing your personal space and keeping baby within it.

Further, I’m starting to think that many parents regard infant bucket seats as ideal (and convenient) baby habitat. I understand the allure of the bucket- heck, we have one, and I’ll confess that, on occasion, if Lucy fell asleep on the way home, I’d remove the bucket from the car and let her finish her nap. However, those occasions were few and far between. I understand that leaving an infant in a bucket seat for hours at a time is dangerous both physically and mentally. According to recent reports, incidents of “flat head” are at all-time highs, partly because of the “back-to-sleep” campaign, but also because some parents leave their infants in their seats for hours at a time.

Additionally, constantly toting an infant in a seat deprives him or her of interaction. A baby in a bucket is limited in what he or she can see, and parents tend to interact less with him or her. Contrast that with a baby being worn- he or she gets a whole new vantage point. You’re getting skin-to-skin contact. Baby is learning. I probably look like an idiot doing it, but ever since Lucy was 4 months old or so, I’ve picked up items in the grocery store and showed them to her. Spoken about them. Let her see and touch them (i.e. this is a red apple. Doesn’t it look yummy?) Mothering published a great article about this recently.

Of course, I still get plenty of “check out the crazy lady” looks. When Lucy was still in the Moby, people would come up to me and ask “is that a real baby?” Even better, there are plenty of times when I’d have Lucy in the Maya ring sling, nursing away, and people would ask, “can I see your baby?” They’d turn all kinds of red when I’d answer, “I’m sorry, she’s nursing right now.”

I think my favorite incident happened when I ran into a coworker at the grocery store when Lucy was 2 or 3 months old. She was in the Maya, nursing happily, when HE (yes, this was a MALE coworker) walked over unannounced and before I could say a word, pulled back the sling, cooed “hey, baby!” and patted her little head. HE NEVER EVEN NOTICED SHE WAS BREASTFEEDING.

Resources:

http://www.mothering.com/green-living/car-seats-are-for-cars

http://www.aap.org/family/shopcartPP.pdf

http://www.drmomma.org/2010/02/aap-car-seats-lower-oxygen-levels-of.html

I'm cautiously optimistic.

I got a call from the MTF on Thursday, and guess what?

THEY PUT IN MY REFERRAL FOR MY HOMEBIRTH!

Very, very big deal. This means that I am, in a way, "approved," that this is being recommended by the med group. So, I cannot, in theory, be charged with "seeking unauthorized care," even if Tricare refuses to pay and I decide to pay out of pocket. Also, according to the MTF, I'm the first active-duty woman to get a referral for a homebirth from them.

Still, I'm not shouting from the rooftops yet. Over the phone, Tricare acknowledged that as long as I secured a referral, and that it was for a CNM (an RN who specializes in midwifery), they would cover it, because it is considered "healthcare services not able to be provided by the MTF."

My only concern is the crazy Tricare lady at the base. When I first started this journey, I started with her. She basically refused to even consider what I was suggesting, pretty much blew me off, and referred me to the process where you can get approved by your commander for care, but have to pay completely out-of-pocket (this is the same process you use to get plastic surgery, btw.) I'm not exactly sure how this process works, but if it involves her, you can bet it will be denied.

Once you get past the underlings, though, Tricare acknowledges that they cover homebirth. I'm just hoping my referral makes it to the desk of someone who, excuse my French, knows her shit.

Regardless, it's a lot easier to fight Tricare than fight Med Group, because I'll be talking to a civilian organization rather than a military one. So cheers to that!

All the prayer you can muster is very much appreciated. I should know next week whether I'll be approved by Tricare or not.

Almost 19-weeks.

18-week appointment. FAIL.

Was supposed to meet my new midwife today.

She was in a car accident on the way to work.

Met with crazy CNM lady (I'm NOT going to call her a midwife) instead.

Answer to all my questions? "Because, according to ACOG...."

FAIL.

My home birth request is now at the legal office. They're determining whether the Base Commander can refuse it, regardless of whether I live on base or not (I don't, and according to current regs, he isn't supposed to be able to.)

Some other gems?

"You can have intermittent monitoring until it's time to push, then it has to be continuous. I have seen babies DIE, and you haven't. ACOG says...."

"I don't mind your belly ring, but you can bet the hospital will."

"I can be as midwife-y as the rest of them."

"Why don't you just stay home and have your baby in the bathtub?" (insert sarcasm here)

"Now that you bring it up, maybe I will." (me being totally serious)

"Just make sure you bring in the placenta so you can prove it."

"Promise you'll give it back?" (again, me being totally serious)

(Insert disgusted look here)

W is for Watermelon.

(and for Wordless Wednesday, but I forgot to post this week! Better late than never....)