Placenta Previa: Can I Still Have a Natural Birth? | Mama

I've been processing my son's loss since he was born at 40 weeks exactly and died shortly after this past August. Knowing it wasn't anything I did or didn't do has helped immensely with finding peace with the outcome, and I owe so much to my faith and the hope that I'll see him again one day.
Here we are, almost 6 months later, cleared to try again and I am looking into statistics around risks and I. Am. Pissed.

• I had to have an emergency C section for a number of reasons. This was far from what we had wanted, but knew it was what was best for baby
• My doctors only recommend C sections from now on
• My doctors only recommend 3-4 C sections total, to be safe. With this past C section that resulted in my son's death, I can only have 2-3 more, and this is shrinking the number of children we can have. Not the end of the world, but we had always said 2-4 and knowing 4 on this side of heaven is not doable due to factors outside of our control is frustrating
  
• My doctors warned me that C sections increase the risk of placenta previa, accreta, and placental abruption, especially when the time before another pregnancy is shortened
  
• I was initially told 24 months before I could get pregnant again, but after more autopsy results this was reduced to 6. We also want to try again soon.
  
• I looked into what else could increase risks of the above, and of course, "exposure to the death of a child" is apparently one. source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219379
  

Throughout my grieving, I've felt helpless, confused, guilty, heartbroken, but never angry. I didn't force myself to subdue my emotions or anything; I've actually been working with a counselor several times a month since my son's death. I've never felt anger before.
But suddenly seeing this most unfortunate series of events and associated risks for future deliveries has me in tears of self-pity and anger. I haven't felt anger like this in a long time. I don't know what to do.

Hey MedSchool peeps. So I've had a few MS3 and 4s message me over the past year or two after seeing posts on this subreddit. I made up a mini high yield sheet that I wish I had read before my Obgyn rotations. It's definitely not 100% comprehensive, but it is a good base. The few people who have used it said it helped them a lot, so I figured I'd share the wealth.
I can't guarantee that other well experienced obgyns won't slightly disagree here or there on a point or two below, but generally speaking you can take this as helpful info for your rotation.
1) if you can, read the ACOG practice bulletin titled "The safe prevention of the primary c-section" ... someone somewhere at your institution has access to ACOG, I promise. You might be able to just google it anyhow. This article will give an excellent basis as to wtf is going on while you’re on L&D.
The big take aways from that are we do c-sections too frequently, active labor isn't until 6 cm dilation, if a cervix keeps changing and the baby looks ok then keep going (even if it is 'protracted' labor), women should be induced at 41 weeks as it reduces the risk of a c-section. Don't induce before 39 weeks unless there is a medical indication for mom or baby.
2) Take the time to learn when we do what for our stuff for prenatal care. (see #5)
3) Non invasive prenatal testing is screening that is basically going to fall into 3 categories. You typically only get one of these and if it is abnormal you either choose option C below, OR get amniocentesis. Almost no one does chorionic villious sampling but technically a really early gestational age (like 11-13 weeks) would get it.
a) first trimester screen - checking AFP and PAPP-A (maternal serum) and do a nuchal translucency on the baby. Performed between 11-13 weeks gestational age.
b) quad screen - checking AFP , hCG , Estriol (not estradiol or estrogen!!!!), and Inhibin-A. Performed between 15-21 weeks GA
c) cell free fetal dna- it's actually a misnomer. It's placenta DNA fragments in the maternal blood which is usually, although not always, the same genome as the baby. You can get it any time after 11 weeks although in overweight women you're more likely to get a "equivocal" result if you do it early.
The quick and dirty is that all of these are mostly screening for aneuploidy (in particular 21 and 18) although as quad checks for AFP it also helps screen for spina bifida, anecephaly, and ventral wall defects (omphalocele and gastroschesis).
4) learn how we select a due date - rule of thumb (although not 100% accurate!!!): In the first trimester if the gestational age on ultrasound corresponds within 1 week of what the LMP would correspond to for a due date, then you go with the LMP to set the due date. 2nd trimester 2 week difference, 3rd trimester 3 week difference. Again this is ball park, you can look up the actual strict dating criteria for when there is a discrepancy between LMP and ultrasound if you want. Basically anyone having their due date set after they’re already 20 weeks or later is considered poor dating.
5) Other prenatal care: routine anatomy scan around 20 weeks. Check for anemia and perform glucola (gestational diabetes check) at 24-28 weeks. Tdap is given about 28 weeks. Rhogam is given to rh negative women around 27-28 weeks. Check for vertex fetal presentation and swab for GBS at 36 weeks.
6) Definition of gestational hypertension: systolic of 140 or diastolic of 90, twice, four hours apart withOUT proteinuria. Definition of mild pre-eclampsia: systolic of 140 or diastolic of 90, twice, four hours apart WITH proteinuria (typically people do urine protein to creatinine ratios. so 0.3 or greater is considered proteinuria). Definition of pre-eclampsia with severe features: systolic of 160 or diastolic of 110 twice, four hours apart WITH proteinuria OR other end organ damage such as - severe headache, scotomata, pulmonary edema, thrombocytopenia, elevated creatinine, twice normal LFTs. If they have a seizure it's eclampsia.
We treat "severe range" (160/110) blood pressures. This does not alter the course of the disease, it only reduces the risk of a stroke. We administer IV magnesium in severe preeclamptics (and some milds) to reduce the risk of a seizure. Know that mangesium toxicity can occur from too much magnesium (especially of urine output drops off). First signs are loss of deep tendon reflexes followed by respiratory depression, followed by arrhythmia, followed by death!
Severe preeclampsia diagnosed after 34 weeks is an indication for delivery. Severe pre-E diagnosed before 34 weeks you monitor inpatient until 34 weeks and then deliver... however many preeclamptics will worsen and require earlier induction - if BPs become difficult to treat or labs worsen.
7) betamethasone injection is given to women who are at risk of delivering premature. It primarily reduces neonatal respiratory distress syndrome but also reduces necrotizing enterocolitis and IVH of all grades. These are two injections, 24 hours apart. It can only be done twice (meaning 4 shots total) per pregnancy. Best effects of the shot are seen 48 hrs to 2 weeks after administration. So we don't just give it right away unless it is someone we are worried will deliver. Traditionally after 34 weeks Betamethasone (beta) isn't given however newer evidence says it can be given after 34 if it hasn't already been done. Women who get beta are people whose water broke prematurely, are at high risk of preterm labor (like coming in at 30 weeks with a short cervix and occasionally contracting), or preeclamptic women. I'd say those are the top 3 reasons ppl get beta.
8) Painless bleeding - need to rule out a placenta previa, although in all likelihood, a chronic placental abruption is way more likely to be the cause.
9) First trimester pain should raise suspicion for ectopic pregnancy. Until at least a yolk sac and/or fetal pole is seen in the uterus, it should be considered a pregnancy of unknown location (is it ectopic or not?). bHCG levels of about 1,000 - 2,000 should show a gestational sac on transvaginal ultrasound IF it is an intrauterine pregnancy. Over 48 hours, a bHCG is expected to about double in a viable intrauterine pregnancy (the actual cut off is lower, and depending on the initial value, more like ~40% increase in 48 hours, but this is a new guideline). Just because the bHCG is increasing normally doesn't mean it is in the uterus. Just because it is dropping doesn't mean it was a miscarriage or resolving. You are only certain if ultrasound definitively shows, products of conception are analyzed from a D&C or laparoscopy... if you don't know, you need to track that bHCG to zero. An ectopic can be treated with methotrexate if they have no contraindications (there is a long list for medical absolutely contraindications that typically don't apply to young healthy people). Relative contraindications are a heart beat, ectopic gestational sac > 3.5 cm, or bHCG > 5,000. Obviously if a patient is clinically unstable, they need laparoscopy. If a patient does get methotrexate, you look for a drop in their bHCG levels from day 4 to 7 of 15% or greater. If it is less they get a repeat methotrexate, or do surgery. If the tube is left in place, risk of ectopic recurrence is 15%, and increases with each repeat ectopic pregnancy.
10) Postpartum hemorrhage: by far most common cause is uterine atony. First line drug is pitocin which is given with every delivery. After that rectal misoprostol, IM methergine, or IM hemabate. Important side effects/contraindications: miso can cause a fever, methergine causes elevated BP and so is contraindicated in PreE (my mnemonic was that Meth labs explode), and hemabate will exacerbate asthma (my mnemonic was that hemabate sort of sounds like an inspiratory wheeze... lame I know). If meds don’t work then an intrauterine balloon to tamponade. If that doesn’t work you’re looking at surgical management. This ranges anywhere from tying off the uterine arteries (Oleary stitch) to cinching down the whole uterus with suture (B Lynch). Or the ultimate option, a hysterectomy.
Next most likely is retained placenta. A d&c is done for this. Sometimes it ends up being a placenta accreta and a hysterectomy is generally needed for this as it is impossible to remove all the placenta and the hemorrhage continues.
Lacerations and coagulapathy are important to consider - especially DIC.
Really interesting is that due to hemodynamic and coag changes in pregnancy, a hemorrhage from something like atony can lead to continued hemorrhage as DIC develops. A pregnant pt should always have a fibrinogen above 200, so if it gets near that (or below) DIC is high on the differential.
Peripartum hysterectomy often called a c-hyst (cesarean hysterectomy) is the last ditch effort to stop hemorrhage and has significant morbidity.
Changing topics to Gyn...
11) there are essentially only 2 types of urinary incontinence we see - stress (cough laugh sneeze) and urgency (bladder spasm). Technically neurogenic (like paralyzed) and functional (I can't walk to the bathroom so I piss myself) exist but are obviously rarer.
12) endometrial hyperplasia - pt should get a hysterectomy because they have about a 40% chance of actually having endometrial cancer. Only if pt wants fertility should she keep her uterus but then they need serial endometrial biopsies and need to be on progesterone.
13) endometrial cancer - usually stage 1 (confined to the uterus) and usually adenocarcinoma. Usually treated with hyst alone although people who are old, have deep invasion but still stage 1, or have high grade (histologically) may need brachytherapy which is radiation to the vaginal cuff. The only caveat is endometrial cancer that ISNT adenocarcinoma such as clear cell, papillary serious, etc is treated more like ovarian cancer and gets paclitaxol and carboplatin.
I Guarantee someone will ask you this. Who should have an endometrial biopsy to o hyperplasia or endometrial cancer? Women 35 and older with AUB and risk factors (obesity, PCOS, nulliparity.. there is a long list). Women 45 and older with AUB and without risk factors. You're interested in women who have heavy bleeding or continuous/nearly continuous bleeding.
I Guarantee someone will ask you this. How do you triage postmenopausal bleeding? You can do a transvaginal ultrasound. If the endometrial lining is less than 4 cm then you don't need to biopsy. HOWEVER, this only counts for someone who had one little episode. Anyone who has a lining >= 4cm or is bleeding on and off (even if they have a thin lining) needs an endometrial biopsy.
14) ovarian cancer - most common kind is epithelial - usually stage 3c (every where in the peritoneum). Pt's get primary debulking (meaning hyst, bso, nodes, omentectomy, and if needed bowel resection to remove all tumor bulk) to get all tumors that are >1 cm... or ideally all. But optimal debulking is considered when only tumor left behind is <1cm. THEN like 2 months later they get paclitaxol and carboplatin. Cure rate not so good - like a 5 year 50% recurrence rate. Caveat is that other kinds of ovarian cancer like germ cell tumors get chemo of bleomyocin cisplatin and etoposide and have a really high cure rate.
15) cervical cancer is the only cancer staged clinically! I Guarantee someone will ask you this. It means you can only stage it based on physical exam, a KUB, or a cone biopsy. This is because most cervical caner is diagnosed in the 3rd world and they don't have all the fancy shit we do. You can take findings from a CT to stage but only if it would have been apparent on a KUB (like hydroureter from tumor).
16) PID is intentionally over diagnosed. There are criteria for inpatient IV abx, but generally speaking mildly ill patients who can reliably take PO abx are treated outpatient with IM ceftriaxone followed by two weeks of doxy/flagyl (typically, although flagyl is optional). People who need IV abx first: septic, has high fever, cannot reliably take po (due to n/v or social situations like homeless), pregnancy, uncertain diagnosis, failed outpatient therapy, or who also has a tuboovarian abscess. If you want to know more about this topic, the CDC has a great article. It is very comprehensive and an excellent article on the topic that is reasonably short.
17) vaginal estrogen is great for post menopausal vaginal atrophy and has very little systemic impact
18) Systemic HRT: Rules of thumb: as little as possible for as few years as possible, don't start on someone remote from menopause (such as a woman in her 60s), if no uterus can take estrogen only, if she has a uterus she needs progesterone as well to protect her uterus from developing endometrial cancer from the estrogen. It's more expensive, but patch HRT is safer than oral due to first pass.
19) pap smears: start at age 21. If they come back abnormal then a colposcopy is performed where directed biopsies are done. Rule of thumb: Women with CIN2-3 (high grade dysplasia) should have a LEEP procedure unless they are in their early twenties. Ideally CIN1 (low grade) is watched unless it is persistent. HPV types 16 and 18 cause vast majority of abnormal paps. HPV types 6 and 11 cause the majority of the warts.
Good luck on your rotation. Never mind the haters. Sometimes people are really catty although my med school and my residency generally treated the med students very well. Don't let the stereotypical attitudes get in your way or make you prejudiced from the start. OB is a specialty totally to itself but honestly, its worth knowing about it even if you don't go into it.
For the guys: don't let being a guy prevent you from taking it as a serious consideration. There are lots of great programs and it's actually easier to match as a guy. And you can sub-specialize if you want to do more of one thing over another.
Edit: typos
Edit 2: thanks for the gold!
Edit 3: added some sections

Abstract
Introduction: Frequency of lower segment caesarean section (LSCS) is increasing today. All anaesthetic techniques used for LSCS may have certain advantages & disadvantages that affect short and long term neonatal outcome. This study aimed to compare effect of spinal, epidural and general anaesthesia on neonatal outcome in terms of Apgar score and umbilical arterial (UA) blood gas parameters.
Method: Total 90 parturients belonging to age group of 20-30 yrs of ASA grade I and II who were scheduled to undergo elective LSCS were randomly allocated by chit method into three groups (n=30). Group SA received spinal anaesthesia, Group EA received epidural anaesthesia and Group GA received general anaesthesia. Duration between induction to skin incision (I-SI), skin incision to delivery (SI-D) and uterine incision to delivery (UI-D) were noted. Intraoperative vitals like HR, SBP, DBP, RR, SPO2 and ETCO2 at various time intervals were recorded. Neonatal UA blood gas parameters (pH, PO2, PCO2, HCO3, BE) and Apgar score (at 1 and 5 minutes) were assessed after delivery of baby.
Result: Demographic profiles of parturients were comparable. Intraoperative episode of hypotension found more in group SA than group EA and GA. Mean Apgar score at 1 min, mean UA blood pH and PO2 were significantly low and mean UA blood PCO2 was significantly high in group SA and GA as compared to group EA (p<0.05) but difference in Apgar score at 1 min, mean UA blood pH, PO2 and PCO2 were statistically insignificant between Group SA and GA. (p>0.05) Mean Apgar score at 5 min, mean UA HCO3 and BE values were statistically insignificant and comparable among groups. (p>0.05).
Conclusion: All three anaesthetic techniques were safe for neonates in elective LSCS, but epidural anaesthesia was associated with better short term neonatal outcome as compared to spinal and general anaesthesia for elective LSCS.
Keywords: Spinal; Epidural; General anaesthesia; Apgar score; UA blood gas analysis
Abbreviations: LSCS: Lower Segment Caesarean Section; UA: Umbilical Arterial; I-SI: Induction to Skin Incision; SI-D: Skin Incision to Delivery; UI-D: Uterine Incision to Delivery

Introduction

Lower segment caesarean section (LSCS) is a life-saving procedure for the parturient and her baby. The frequency of caesarean section continues to rise steadily worldwide [1]. Today, caesarean delivery accounts for more than 30% of all births [2]. In India the incidence of LSCS is increased from 3% to10% between 1992-93 and 2005-06 [3]. Anaesthesia to a parturient affects both mother and fetus, so anaesthesiologist has to look over both individuals. The type of anaesthesia administered for LSCS is an important determinant of the short term and long term maternal and neonatal outcome. Each anaesthesia method for elective LSCS has their own advantages and disadvantages to both mother and neonate. Anaesthesiologist must choose the type of anaesthesia that is safe for mother, have least depressant effect on neonate and provides optimal working conditions for the obstetricians [4]. The spinal anaesthesia is commonly used method for LSCS, because of simple and quick technique, requires low volume of drugs for induction, less or no systemic effects to the baby, low risk of maternal pulmonary aspiration and an awake mother at the time of delivery but associated with high risks of an extensive block, fixed duration of anaesthesia, post-dural puncture headache and high incidence of maternal hypotension followed by decrease uterine blood flow in placenta, thus impair fetal acid base status even in an existence of a normal placental store [5-8].
Epidural block for LSCS has increased in popularity due to its benefits like low incidence of maternal hypotension and neonatal respiratory depression, less or no postoperative pain and discomfort to mother. Though general anaesthesia is associated with good control of airway and ventilation, better maintenance of cardiovascular stability, but the drugs required for general anaesthesia are multiple and may produce systemic effects in the baby like low Apgar score and sedation, directly by placental transfer and indirectly by maternal physiological and biochemical changes. General anaesthesia is also associated with maternal risks of difficult intubation, pulmonary aspiration, delayed recovery, nausea and vomiting [9]. The incidence of maternal mortality may reach up to 10% under general anaesthesia [10]. Apgar score and umbilical artery pH known to provide best measures of neonatal outcome after LSCS under all three types of anaesthesia and both can be affected by alterations in the cord blood flow with the delivery process and different anaesthesia techniques [11]. Due to benefits and risks of the different anaesthetic techniques, it is important to choose safest anaesthesia for good maternal and neonatal outcomes irrespective of indications of caesarean section.
No ideal anaesthetic method for minimizing adverse neonatal outcome has yet been described in literatures. Uniform data available regarding comparative effects of types of anaesthesia on cord blood gases of neonates in healthy maternal population are limited. So the aim of present study was to determine the effect of spinal, epidural and general anaesthesia on neonatal outcome in terms of Apgar score and umbilical cord blood gas values in elective LSCS. So that we can standardize the anaesthesia technique for elective caesarean section that have least effect on neonatal outcome.

Method

This study was conducted in the Department of Anaesthesiology and Critical care, Pt. J.N.M. Medical College & Dr. B.R.A.M. Hospital Raipur, C.G, after approval from the institutional ethics committee. This prospective, randomized, open label observational study was done in total 90 parturient belonging to the age group of 20-30 yrs, ASA grade I & II, who were scheduled to undergo LSCS under spinal, epidural and general anaesthesia. The Parturients were randomly divided by chit method into three groups of 30 parturients in each group (n=30), Group SA received spinal anaesthesia; Group EA received epidural anaesthesia and Group GA received general anaesthesia. Before the study, a power of study was calculated by using software G Power 3.0.10, taking mean values from the study of Petropoulos G et al [12] and considering a probability level of 0.05 (α-error) and power of 0.80 (1-ß) yielded a sample size of 30 parturients for each group. Parturients complicated with following conditions were excluded from the study: Anaemia (<10gm/dl), severe PIH, placenta previa, abruptio placenta, oligohydramnios, gestational diabetes mellitus, morbidly obese (BMI > 40 kg/ m2), major cardiac abnormalities, congenital malformations, intrauterine growth retardation and fetal distress. Induction to delivery time >10 minutes, skin incision to delivery time >8 minutes and uterine incision to delivery time >3 minute were also excluded from the study.
Pre-anaesthetic evaluation was carried out and written informed consent was obtained either from the parturient or from her relatives to carry out the procedure and enrolled her in this study after explanation. In operation theatre multipara monitor (Philips MP 30) was applied to monitor non-invasive blood pressure, ECG, SPO2 and ETCO2. Intravenous line was maintained by inserting 18 G i.v. cannula in vein of dorsum of hand. Premedication was given with inj. Ranitidine 50 mg i.v. and inj. metoclopramide 10 mg i.v. 30 min before induction to all the parturient. Parturients were induced with particular anaesthesia according to groups assigned. In group SA, with all aseptic precautions subarachnoid space was approached at L3- L4 or L4-L5 interspace with 26 G Quincke spinal needle in sitting position. Inj. Bupivacaine 0.5% (heavy) 2 ml was injected and parturient was placed in supine position immediately. A tilt of 10-15 degree was given to achieve appropriate block height. Block height was checked by spirit swab for temperature sensation. Parturients in group EA were placed in sitting position and with all aseptic precautions epidural space was approached and identified by loss of resistance method at L3-L4 or L4-L5 interspace, epidural catheter was inserted, left in situ and fixed. Inj. After injection of test dose of Lignocaine with adrenaline 2%, 3ml, Inj. Bupivacaine 0.5%, 12 ml were given. Block height was checked by spirit swab for temperature sensation. In group GA, parturients were induced with i.v. Thiopentone sodium 5-7 mg/ kg after 3 min preoxygenation with 100% O2. Inj. Succinylcholine 1.5 mg/kg i.v. was given to facilitate tracheal intubation. Trachea was intubated with 7-7.5 mm cuffed endotracheal tube. After checking bilateral air entry, tube was fixed.
Depth of anaesthesia was maintained with O2:N2O 50%:50%, isoflurane and muscle relaxant i.v. Atracurium 0.5 mg/kg bolus followed by maintenance dose 0.1 mg/kg. At the end of surgery, when parturient resumed some breathing effort, residual effects was reversed with i.v. Neostigmine 0.05 mg/ kg and i.v. Glycopyrrolate 0.01 mg/kg. When the patients were fully awake then the endotracheal tube was removed with oral suction. Hypotension defined as fall in baseline SBP >20% was corrected with intravenous crystalloid fluid, if persist then i.v. Mephentermine 6 mg incremental dose was given. Bradycardia (HR <60) was corrected with i.v. Atropine 0.6 mg. ECG, Heart rate, Systolic blood pressure, Diastolic blood pressure, Mean blood pressure, Respiratory rate, Oxygen saturation and End tidal CO2 were recorded throughout the procedure and note at the time of induction and at every 2 minute after induction till delivery of baby. Induction to skin incision, skin incision to delivery and uterine incision to delivery time were also noted. Umbilical artery blood sample was taken from a double clamped segment of umbilical cord and umblical arterial blood gas analysis was immediately done using COBAS 121 ABG machine. Apgar score of neonate at 01 and 05 minutes after delivery of the neonate were assessed. Statistical analysis was done using Graph pad prism 7 software. Data were analyzed by One way ANOVA test and Tukey’s multiple comparison test. Tukey’s multiple comparison tests was used for multiple pair wise group comparison. The results were analyzed by various statistical techniques like percentage, mean and standard deviation. p- Value <0.05 considered significant finding.

Results

The maternal and neonatal demographic profiles, induction to skin incision time, skin incision to delivery time and uterine incision to delivery time were statistically comparable among three groups (p>0.05) (Table 1). Highly significant fall in maternal HR from baseline was seen just after induction, at 2 min, 4 min and 6 min in group SA and group EA than group GA (p<0.001) but bradycardia was not seen in any parturients and none of the parturient required atropine ([Figure 1](https://juniperpublishers.com/jaicm/images/JAICM.MS.ID.555585.G001.png)). Highly significant fall in SBP and DBP from baseline was seen at 4 min and 6 min in group SA than group EA and group GA. (p<0.0001) The difference in mean SBP and DBP was statistically insignificant between group EA and group GA. (p>0.05) (Figures 2&3) 3 patients in group SA had episode of hypotension that was not severe and did not require vasopressure. None of the patient in group EA and group GA had experienced episode of hypotension. Respiratory parameters RR, SPO2 and ETCO2 were comparable in all three groups. Mean Apgar score of neonates at 1 minute was significantly low in both group SA and group GA as compared to group EA. This difference was statistically highly significant between group GA and EA but only significant between group SA and EA. Difference in mean Apgar score at 1 min between groups SA & GA was insignificant. (p>0.05) Mean Apgar score at 5 minute was statistically insignificant among groups. (p>0.05) Mean UA pH and pO2 were significantly low while mean UA pCO2 was significantly high in group SA and GA as compared to group EA. (p<0.05) Difference in UA pH, pO2 and pCO2 values were statistically insignificant between SA & GA groups. (p>0.05) The difference in mean UA HCO3 and BE was statistically insignificant among groups (p>0.05) (Table 2).
Discussion
As with increasing incidence of LSCS in India, the role of anaesthesiologist is also increased. Since beginning spinal anaesthesia has been used for LSCS but it is associated with maternal hypotension which impairs uteroplacental flow. In our study heart rate was decreased from baseline in both spinal and epidural anaesthesia group but bradycardia (HR <60 per min) was not seen in any parturients. Heart rate was significantly raising in general anaesthesia group after induction which was due to sympathetic stimulation during laryngoscopy. Abdallah MW et al [13] also observed tachycardia after induction in general anaesthesia group. Incidence of hypotension was 10% (3 of 30 parturients) in spinal anaesthesia group in our study, but none of them required vasopressure. We observed no episode of hypotension in epidural and general anaesthesia groups. Similar result was observed by Tonni G et al, Mekonnen S et al and Saygi A et al [14-16]. Frequency of hypotension observed in studies of Kolatat T et al [17] (56.8% in spinal anaesthesia & 51.3 % in epidural anaesthesia) and Sener EB et al [18] (51% in epidural anaesthesia) were more as compared to our study.
This could be due to drugs used by them i.e. Kolatat T et al [17] used 1.2 ml 5% Lignocaine for spinal block and 20 ml of 2% Lignocaine with Adrenaline for epidural block and Sener E B et al [18] used 20 ml of 0.325% Bupivacaine, were different from our study. In our study 1 min Apgar scores were low in spinal and general anaesthesia as compared to epidural anaesthesia, but 5 min Apgar scores were statistically comparable among groups. Gori F et al, Rasooli S et al and Saygi A et al [1,19,16] also found similar results in their studies. Hypotension in spinal anaesthesia and depressant effect of drugs used for induction of general anaesthesia might be responsible for low 1 min Apgar score. But these effects are short term and do not affect 5 min Apgar score. Mean UA pH was significantly low in spinal and general anaesthesia as compared to epidural anaesthesia but UA pH<7.15 (acidemia) was not observed in our study. We also found no significant difference in mean UA pH between spinal and general anaesthesia. Similar findings were observed by Kolatat T et al, Sener EB et al, Tonni G et al, Strouch ZY et al and Rasooli S et al [14,17-20]. In our study UA PO2 was significantly low and PCO2 was significantly high in spinal and general anaesthesia as compared to epidural anaesthesia, while no significant difference was found in UA HCO3 and BE values among groups and all these parameters were within normal limits.
Kolatat T et al, Petropoulos G et al, Tonni G et al, Abdallah MW et al and Rasooli S et al [17,12,13,14,19] observed similar findings regarding UA PCO2, HCO3 and BE. Kolatat T et al [17], Petropoulos G et al [12] and Tonni G et al [14] found high UA PO2 in general anaesthesia group and their results were different from our study. They explained it, that high maternal inspired O2 concentration in general anaesthesia result to high UA PO2 in neonates. Long intervals including induction to delivery time >10 minutes, skin incision to delivery time >8 minutes and uterine incision to delivery time >3 minutes adversely affects neonatal outcome by decreasing uteroplacental blood flow, but these intervals are within normal limits in our study. Limitation of our study was small sample size and also we have not done maternal arterial blood gas analysis which might be the reason for the neonatal acid base imbalance. Further study with large sample size including both maternal and neonatal arterial blood gas analysis should be done to evaluate the effects of anaesthesia techniques on neonatal outcome.

Conclusion

We concluded that spinal anaesthesia, epidural anaesthesia and general anaesthesia are safe for both mother and neonates as maternal blood pressure, Apgar score and umbilical arterial blood gas values are not significantly affected. However among three anaesthetic techniques, epidural anaesthesia was associated with better short term neonatal outcome and could be a preferred anaesthetic choice for elective lower segment caesarean section.
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Here's a breakdown of my expenses so far at 17 weeks. For reference, I live in Cleveland, Ohio, I have SummaCare insurance, and I'm using the University Hospitals health system.
I was caught off guard by a huge bill yesterday. Apparently, none of my ultrasounds fall under the "prenatal care" umbrella and I have to pay 20% of the total cost, subject to my deductible.
My ultrasounds seem really expensive. For example, the facility fee-the price I pay for the privilege of using the machine-for my 15-minute NT scan was almost $1,500. On top of that, the doctor charged me for two procedures- a basic ob ultrasound and an NT scan. According to the hospital's billing department, I should expect at least two more bills from the radiology department in the next week or so. When it's all said and done, I'll have to pay around $500 out of pocket for just one ultrasound!
I have a short cervix and placenta previa so I know I'll have at least 3 more scans like this if everything goes well, but that number will continue to rise if I'm still having complications. Now I'm seriously considering skipping the anatomy scan and cervical checks because I can't afford them.
I started this process assuming all of my prenatal care would be covered at 100%, so I definitely wasn't planning to spend ~$5,000 before any labor and delivery expenses.
Do most insurance policies cover ultrasounds as part of prenatal care? Does everyone spend this much on prenatal care?

I found out I was pregnant on October 17, just before the 4-week mark (due June 29). I was absolutely devastated. I wasn’t ready for a baby, just started my junior year, I was preparing to write my medical school applications, my wedding was set for November 4, my husband (Marco) and I had just bought a trailer to go camping on weekends and travel the country over the summer, I am also a type 1 diabetic, I lost a baby almost exactly 2 years ago due to its complications. I immediately told my best friend since middle school, she was in a similar situation a few years ago, had her first when she was 17, but her and her boyfriend (who also happens to be my husband’s cousin) have become very successful and have had a second baby too. My husband was away for work and vacation until November 1, and I didn’t want to tell him on the phone, and I knew he’d be over the moon, so I put together a little surprise. I ordered a jersey from his favorite soccer team (Chivas Guadalajara), the number was “88” (his birth year) and the name on the top said “Daddy”. I also bought a baby size one with “18” and “Baby”. I put them in a box, and underneath them I put the pregnancy test. When Marco got back to New York, I gave him the gift, I put his shirt on top so he wouldn’t think much at first. He started crying and hugging me, he was so damn happy. As soon as I saw his face, that’s when I became just as excited, I was finally happy about having this baby!
I experienced morning sickness in the beginning, I was able to prevent vomiting by making sure I don’t get hungry, which meant I had to eat the second I woke up. Otherwise I had a pretty mild first trimester. I had to go to weekly appointments from 6 weeks, which meant I went to an OB twice during my honeymoon, but it also meant I got weekly ultrasound pictures which is so awesome to look back on baby’s development. I got my diabetes fully under control during the pregnancy, I started using new technology which helped with management so much. My blood sugars basically became that of a non-diabetic (most recent HbA1c was 5.0%).
We had our wedding day as planned, it was absolutely magical. Nobody but that best friend and Marco knew anything. We planned an amusement park honeymoon in Queensland, Australia, so I couldn’t enjoy as much as Marco did. We also spent a few days in Townsville which was very relaxing, but also a little boring as we like to be busy. We got home just before Thanksgiving, managed to keep it quiet there too. On Christmas we announced the pregnancy to family, we put a framed photo of my latest ultrasound in with Marco’s parent’s gift. There was a bunch of screaming and crying and hugging and jumping. We told our friend’s over the next week or so.
The second trimester was great physically, but my mental health suffered a lot. I almost rejected being pregnant for over a month, I just wasn’t ready to have a baby, and I didn’t want to give up the life I had planned. I didn’t neglect my health or anything, I just didn’t want the baby anymore. Because of my belly, I didn’t want to be close with my husband anymore, even just hugging him felt strange, so I wasn’t as close to him as I wanted to be, and it caused some issues. By mid-February I was excited about baby again and felt ready (thanks to therapy). At 22 weeks we moved to Utah to be with my husband’s family. I wasn’t happy about moving to Utah, I always pictured living in the suburbs above NYC, but my husband planned his whole life to stay in Utah to raise his family. I absolutely fell in love with Utah once we settled in though, apart from the guy at the DMV who tried to convert me lol (we’re both Catholic).
Over Easter weekend (27 weeks) we went to Mexico to visit Marco’s extended family, it was the first time I felt really fatigued from pregnancy, I spent most of the day in the pool as the resort we were staying at, and it was amazing. Swimming always made me feel better from day one. At 28 weeks we went to Wyoming for a week for a “Babymoon”, there we sorted out all the issues we’d been having the last couple months and we became closer than ever. After Wyoming, I had to start going to three-time weekly appointments, Monday and Wednesday appointments were only 15 or so minutes, and Fridays were the big ones where they did ultrasounds and stuff. Everything continued to be completely healthy, better than we could’ve expected. At the same time, we started slowly buying baby stuff, I didn’t want to go too fast because I was worried that having a baby room set up for months before baby comes would only torture me (I’ll never make that mistake again).
On Saturday, May 19, at nearly midnight, I started getting some cramping. It was similar to period pains, but it was lower (above my pubic bone) and sharper. Marco texted his dad, who’s a pediatrician, and said that it’s probably nothing to worry about, especially because I wasn’t experiencing any other symptoms, and my belly was still super high. We went to sleep, and when I woke up I decided that today was the day that I’d buy all the hospital necessities, a car seat, and a stroller (I didn’t realize at the time but I think it was a part of my subconscious instinct). We spent the day going from store to store, bought everything we’d need for hospital.
That night (Sunday, May 20), at about 7pm, we were eating dinner on the couch and watching the news, I needed to go to the bathroom, when I was walking there I felt something happen “down there”, I completely ignored it, didn’t process it until I saw the dime-sized blood clot on my pantyliner. When I wiped it was absolutely covered in blood, it was pure blood, I’d almost never seen so much blood come out of me. I put on a maternity pad, got up and the toilet was full of blood too, I almost didn’t look diluted by the toilet water. I called to Marco, he starts freaking out, I’m repeating “we’re going to the hospital”. We get in the car, he calls his parents, I call the maternity ward, they told me to go to emergency as they’re busy and it may not me labor. When we were driving I realized I had been getting painless contractions all day long, I don’t believe they were regular, but they happened once or twice an hour.
We arrive at the ER in about 30 minutes (thanks to evening traffic), they admit us straight away as maternity called them to expect us. They do all the normal ER stuff, like vitals. My heartrate was a little high, my blood pressure was 160/110, my blood sugar was over 300. The BP and sugar probably caused the bleeding. They did an ultrasound and confirmed no tears or previa, and an internal exam confirmed I was 2cm dilated and 80% effaced. The maternity pad only seemed to have residual blood on it, so the bleeding only lasted a couple minutes, and they never found the cause of the bleeding. We’re gonna do more investigating soon so it doesn’t happen again.
After a few hours in the ER there was a spot for me in labor and delivery, I went to sleep pretty soon after, and woke up at 8am with painful contractions. I labored all day long, going up a centimeter every few hours, medication-free, alternated between walking the halls, sitting on the ball, and sitting in the birthing pool all day. At 9cm my water broke, and just after 9pm I was 10cm and started pushing in the pool. I pushed for 50 minutes and my baby was born!
Isaiah Morales Cruz 05.21.2018 - 10:07 PM 4lbs 2oz - 16 1/4 inches
He was born screaming and bright red, coughed up everything he needed to, seemed very strong. I got out of the tub almost immediately, I never felt so energized and healthy. They laid me on the bed while they checked his vitals, and his oxygen and heart rate started going down, and his blood sugar was 44. They took him to the NICU, they didn’t let Marco go with at first. I delivered the placenta, and it was all healthy and intact. My blood sugar also started going down. They stopped my insulin but I kept dropping, I got to about 20 an hour later and had a seizure. They gave me glucagon which made me sick, but I went up after that, and they took me to the ICU. They didn’t let Marco come with me either, but at that point Isaiah was stabilized and he was able to be with him. They gave him a CPAP machine, feeding tube, IV, and all the wires and cords to monitor his vitals, as well as hourly blood glucose tests, more if they felt they needed to. He was in a little pod so Marco couldn’t hold him. His blood sugar kept dropping despite the basal dextrose he was receiving, so they kept blousing him every time he went under 50. At 2am he had a seizure from a low of 18, administered glucagon, and upped his dextrose basal.
I was in the ICU for 24 hours, so I wasn’t allowed to see Isaiah, Marco spent the day moving between the two of us. They had to give him another bolus of dextrose at 7am that morning but didn’t need one for the rest of the day. On Wednesday I got moved back to maternity but spent most of the day in NICU with Isaiah, I was able to breastfeed (which he did so well at), change diapers, sponge bath. He also graduated from CPAP to nasal cannula which means he can breathe on his own, his dextrose basal got moved back down to where it was originally (he needed a bolus 7 hours later). His heart rate was fine as long as his oxygen was, and he developed jaundice that evening too, so he has spent some time under the lights. On Thursday afternoon they lowered his dextrose basal even more, to the lowest whole dose, and he tolerated it perfectly. They were also lowering his oxygen when he stayed over 98% for 6 hours. On Thursday night they let him in our room for a few hours, we took photos, watched TV, and had such a good time, it’s when I really bonded with him and fell in love, but we had to take him back when we were going to sleep.
On Friday I got the news that I’m being released, but Isaiah has to stay. He has to meet these certain requirements that I wasn’t totally aware of for some reason: 35 weeks gestation age, birth weight, graduation to crib (temperature regulation), 7 days of consistent, steady breathing and heartrate (on or off oxygen), 48 hours of blood sugar over 70, parent skills, and a “room-in” (Marco and I will stay for 24 hours with Isaiah and they will test how we all go). He reached the 35 weeks that day, parent skills were assessed, but he was still losing weight, at the time 8 ounces so far, a big drop of 5oz between Wednesday and Thursday. We left in the evening, and we decided it’d be a great time to finish his room, I was so devastated when I found out I was in labor because his room wasn’t finished, so that was an upside to getting out before him. We bought preemie clothes and diapers, toys, blankets, sheets, changing table, baby monitor. We had a really good time, it was a good distraction. We stayed up until 3am working on his room and pretty much finished, we just needed to tidy up. We were back at the hospital at 9am, along with Marco’s parents where they met him for the first time (they had no idea what was going on for over a day because everything was so hectic, nobody even knew we had him until Wednesday).
He graduated to a crib on Saturday, managed to get off oxygen and dextrose on Sunday, and on the next Tuesday he reached his birthweight. Tuesday night and Wednesday, we did the room-in, and it went amazingly, it felt so good and right. On Wednesday evening he was discharged with a clean bill of health. I’ve checked his blood sugar a couple times since, and we have a foot brace that monitors his heartrate and oxygen, and we haven’t had a single issue. It’s now Friday night and everything is perfect. He’s sleeping when we want him to be awake and vice versa, but it’s still so fun.
When they were talking about the risks when I was in labor, nobody expected it to go like this. His lungs were just a little too young compared to the rest of him, and my diabetes made his blood sugars suffer. He’s breastfeeding and doing it so well, I never wanted to breastfeed until I tried it in the NICU. So glad he’s out now, I couldn’t be more in love with him. I never thought it’d be possible to love someone as much as I love Marco, but it happened and it makes me want to explode. Sorry this was so long, but it was a long process and I was excited to share because I love reading y’alls birth stories!

I was told my placenta was (maybe?) slightly covering my cervix at my 20 week anatomy scan at the perinatal assessment center where my OB sends her patients for big scans. MFM Doctor told me there wasn't much to worry about as it would most likely move, but to refrain from sex and flying. I told her I had a flight scheduled for a week from then. She had me schedule an appointment for a week later (the day before we were supposed to go - 21 weeks) to check on it again. At that appointment she spent a long time looking. She said the "meat" of the placenta was quite far away but there was a trail of it that she determined was about 1cm away. She said still too low for a vaginal delivery but I was fine to fly.
Now I'm 23 weeks and have another flight (3 hours) in a couple of days. They had me come back again today to check on placenta. Still about where it was at 21 weeks....1-1.5cm from cervix. A different MFM Doctor examined the images this time and was very vague about what he thought. At times he made it sound like it was risky, and other times he made it seem totally fine. He said I have no reason to think I'd go into preterm labor and my cervix is really long. Just not to stress. I kept asking about what his thoughts were about flying and he never really gave an answer. Just told me what I should do if I happened to go into labor while away from home. I feel like he didn't want to give me a straight answer. I much prefer the "yes" or "no" type Doctors! I have no history of bleeding.
I called my regular OB nurse line in hope's she could take a look at the results and see what she thinks. Hoping she returns my call quickly so we can make decisions. Has anyone had this issue while pregnant? From what i've read online it seems very split: some Doctors put no restrictions on you (as long as it's not covering the cervix) while others treat it as a complete previa and you're put on bedrest. I just want a straightforward opinion (like the first Doctor!).

Trigger warning, I suppose: mentions of bleeding during sex, feelings of sadness, anxiety, and panic about preterm labor and bedrest. Baby is fine, though!
Husband and I had sex around 12:30pm yesterday. We stopped midway because I was bleeding very heavily. This is nothing new to me... especially since I did this with baby #1, too. I know this happens when the cervix gets irritated. OB nurses line has instructed me on keeping an eye on flow, cramping/contractions, baby movement. Regardless, I went through the steps as I've always been instructed. Lots of baby movement, no cramping, but the blood wasn't really tapering off. I refused to bug the nurses line about it because this is part of it, right? Well, I went to tinkle at 5pm...still bleeding, kind of like period flow...and when I wiped there was a clot the at least 2 inches long. I have NEVER had a clot of that size before...even during a period. I panicked and called the nurses line. She gave me the same spiel about what to keep an eye on, but I still felt uneasy after passing that clot and the the bleeding never tapering off. Anytime I've bled after sex, it's only lasted maybe an hour or two...never 5 hours and certainly never passing clots. We loaded up the toddler and went to L&D to be monitored. Baby is fine. I'm having super tiny contractions that I can't even feel because of the post-sex aggravation. Cervix is still completed closed (but soft because this is baby #2...normal). I was put on bedrest today until I talk with my OB tomorrow (Monday) and she instructs me further.
 
I'm still spotting some 19 hours later...still bright red. Everything else is fine, but I'm very anxious and disappointed in my body. Baby #1 we had total pelvic rest because of placenta previa (corrected by 24 weeks) but had to remain on total pelvic rest because I continued bleeding during each sex session. I was admitted to hospital at 34w with #1 for preterm labor..strict bedrest until delivery. Delivered super healthy, no nicu time preemie at 36+2. They still have no idea what caused my preterm labor...no diagnosis of irritable uterus or incompetent cervix.
This pregnancy has felt so different and less complicated so far. I've been on weekly progesterone injections to cut down preterm labor chances by 1/3, my every-two-week ultrasounds of my cervix look PERFECT, no previa, no weird aches/pains. This is the first weird thing...and it's SUPER weird to me. Of course, NONE of the women that I know have had weird pregnancies or complications...so, no one has really been comforting to me or can even begin to understand. My amazing husband has been such a champ, again, about this...but the guilt and disappointment that I feel for having complications and my body not performing the way it needs to is beyond what I want him to comfort me about. I also have so much to take care of...getting toddler ready for Meme's house tomorrow, getting our lunches prepped for the week, and finishing the laundry...all of my weekend chores. Plus, we are showing our house to three different people on Tuesday evening (we're trying to sell our home). I know that husband can carry my load, but again...the guilt I feel is AWFUL.
Bedrest with #1 wasn't so bad compared to this...wanting to run around with my toddler, needing to take care of my home before our work week begins (both work full time), and wanting make love to my husband while not being able to. I'm already grieving things that haven't even been taken away yet. I'm so sad, guilty, and disappointed y'all. I'm sorry!

Anyone out there dealt or dealing with placenta previa? 19 weeks and had some bleeding. Had an ultrasound and everything looks mostly normal but my placenta is very low lying. Dr said could be placenta previa but it was difficult to tell how much of the cervix it was covering, and problem may resolve as baby/placenta/uterus grow. If not, then I should expect more bleeding and a c section. This is my second baby, and my first pregnancy and birth were totally normal and natural, no problems at all. I'm not opposed at all to a surgical delivery if it's necessary, but it is a lot to wrap my head around. Now it's a wait and see game until the next ultrasound. Anyone have experience with this? If so, how did things go for you for the rest of your pregnancy and birth? Thanks!

I haven't posted much, but I want to post an update, since this community has been very supportive, sharing their stories when I went through craziness in my own pregnancy! Also, in my most confusing medical moments, I hunted down posts of people who went through the same thing I was going through and found it empowering, so maybe this story can help someone else some day.
I had a crazy number of issues this pregnancy -- multiples pregnancy after IVF/ICSI. Bleeding from 8 weeks on and off. Hyperemesis gravidarum which was there until I gave birth. A CVS that almost became a miscarriage (I had regular contractions and tons of bleeding a few days after, but they went away). A fibroid that grew to the size of a grapefruit. A hemorrhage event in a public place with a trip to the hospital in an ambulance. Anemia afterwards. I was diagnosed with partial placenta previa. Two hospitalizations. And finally, insufficient cervix that wasn't diagnosed until I was 6 cm dilated at 29 weeks 1 day. Of course the placenta previa had resolved by then. Wheee!
The last time I posted in detail was with the 6 cm dilation, where I was hospitalized indefinitely. I went into L&D triage for a weird eye issue which resolved. I was having regular contractions which I only felt when I was being monitored (Schrodinger's Cat contractions?), which led them to doing an internal exam, which led them to finding that I was 6 cm dilated (I gasped), and that they could see one of the baby's heads (gahhh).
Baby A was acting as a cork. There were no bulging membranes. Just a membrane with a head in it. If he wasn't being a cork, I would have had a c-section that night.
They filled me up with magnesium sulfate (awful!) and steroid shots and another medicine to stop the contractions for long enough to let the steroids take effect. I was shocked that they were not interested in stopping contractions for a longer period of time. The resident explained that their practice was that at 29w, if the contractions started again, they would assume that my body could have an infection or otherwise it needed the babies out, and that they would be better off in the NICU. And that this would happen instantaneously, since I was so far along dilated, Baby A was so small, Baby B was so large and was also breech, that a c-section was the safest course of action for the babies, even though a couple of the doctors were comfortable with doing a breech extraction for Baby B (but not with the estimated size difference).
My goal was to keep the babies in me as long as possible. I held out for a week. Near the end of that week, I was experiencing intense pressure and back pain whenever I shifted my body in certain ways. I tried to suffer through it (I didn't want another false alarm and another night on magnesium sulfate -- I had one mid-week and was so miserable, I thought I was actually dead, because the heart monitoring machine crashed, my heart line stopped, and that seemed the most logical explanation to me). These weird back pains never showed up on the NST, and I kept quiet about them since they were in the realm of normal pregnancy, well, plausible deniability. But finally, after a couple of days with it, the pain was beginning to be so bad, it made me pace around the room as if I was trying to outrun it. I called the nurse.
I expected to be placed on monitoring on my bed, but the doctors were so nervous about my case, the staff rolled in a stretcher, and I was immediately placed on it and sent up to Labor and Delivery. They hooked me up to a monitor (no contractions), but when they checked for dilation, they found I was 8 cm along and had bulging membranes! I had just eaten lunch 15 mins ago, but I was being immediately prepped for c-section. At 30 weeks 2 days.
I find it amazing how quickly things happen in Labor and Delivery -- it's almost an inspiration to me, since I have trouble feeling cool and collected under pressure. I was moved to the operating room, prepped, and in surgery very quickly. They rushed because I was dilating, so they wanted to get both babies out of me before Baby A got too low in to force a vaginal delivery for him, and a c-section for his brother. The OR ran like a well oiled machine. I am so impressed with the staff at the hospital, I almost wish I could restart my life and go into medicine.
I was totally freaked out about having a c-section too, almost had a panic attack when I couldn't feel myself breathe anymore due to the spinal, but the anesthesiologist talked me down, and suddenly I had the courage and embraced where I was -- I was going to birth some babies!
From then on, the c-section was an amazing experience, and although it was so rushed, the experience was much calmer and more spiritual than the last five minutes of "natural childbirth" of our oldest, when my spouse started to bleed, and no one could tell where the blood was coming from or get stats from the baby, and a doctor we never met materialized from nowhere and threatened her with a vacuum to PUSH THAT BABY OUT NOW!
And I heard them cry! Both babies! As they took them from me! Which is something we never heard from our oldest. And I knew they were both okay, and I was so so so deeply happy.
Nurses carried both of them to me as I was being patched together, wrapped up in blankets and on CPAPs, and it was wonderful. And they were so mad to be out, and I loved them.
At the end of the surgery when I was lying in recovery, the resident told me that by the end of the surgery, I was 9 cm dilated. I really had waited to the last possible minute.
When I recovered enough from the c-section that I could move my legs, they wheeled my gurney up to the NICU, and encouraged me to touch each foot -- I was so afraid to, but it was wonderful. The next day, I could hold them -- I had no idea they would allow me given how fragile they were, but I was so thrilled.
Baby A was born at 3 pounds 4 ounces. Baby B was 3 pounds 9 ounces. Baby B was anemic and pale (I so hope it was from delivery, not the chronic anemia I was dealing with in the second half of my pregnancy) and needed a blood transfusion that night, which went well. So far, they've only had the typical issues one might expect for 30 weeks -- jaundice, apnea, needing to bottle feed. Although they were on CPAPs, they were able to avoid a ventilator, and were breathing room air from day 1.
It's been 3 weeks since their delivery. They continue to do great. They are off of CPAPs. They no longer need jaundice lights. They did their first bottle feeding yesterday. They are becoming more interactive, and Baby B is now a full pound heavier! Although everything is going smoothly, NICU life is still stressful. They are probably a month and a half from coming home, and it is a draining experience. My paid maternity leave is likely to run out before they get home from the NICU, but because I had twins, I can take up to 16 weeks of leave, so I will get some time with them when they come home.
The punch line of it all -- they were conceived by IVF/ICSI, but we think they might be identical twins! Either time or a DNA test will tell....

I need to start weaning my LO, for medical reasons/concern on my end and it feels like it's time. She turns 1 tomorrow and we wanted to make it atleast 1 year. She started only nursing once at night but she was sick recently and started nursing roughly 5-8 times a day. Which has been completely exhausting because I am just now getting over constant morning sickness and bronchitis.
I know I am making close to nothing. Last time I pumped I made a little less than 1/2 oz total. She has started biting again and playing rather than nursing. It's starting to feel like she thinks it's a toy or a pacifier.
Also I am 16w 4d pregnant, I have PP (Placenta Previa) and I have been put on pelvic restriction. The obgyn is very supportive of my breastfeeding and would never tell me to stop unless necessary. But I have started to cramp painfully and it makes me nervous. I know I might be over worrying but we had a rough pregnancy and delivery with my daughter and it has brought some anxiety with this pregnancy.
We have met our goal for BF and while I have loved every minute of this, I think we are ready to move on.
(Also she won't drink any of my stored milk warm or cold. We just got her to drink chocolate milk, but she won't drink white milk.)

After giving birth to my second baby a week ago, I've been saying that I need to write a book about my two very different stories. This is the closest I will ever get to that, but I think you all will enjoy it (as I enjoy all your stories!).
My first was born on her EDD two years ago at home. You can read the full story here. The short version is that it was an amazing experience. My prenatal and postnatal care was given by a midwife and her apprentice, and we also had a doula. Only had one ultrasound at 20 weeks. I labored in an inflatable pool in my dining room and other random places around the house for 12 hours, and then Arya was born on our mattress in the living room. No complications. No meds. Everything was perfect from my perspective! A very happy story.
My second baby was born a week ago (at 40+2) in a hospital. Initially we planned another home birth and started the prenatal care with the same midwife (no doula this time, though - we couldn't afford it). Everything was fine until we went in for the 20 week scan. The technician detected placenta previa and a low-lying placenta. This was the turning point for this pregnancy because now we had to find an OB and go in for regular checks. I was devastated, but we did what was best. Luckily, we were able to find an amazing OB that was willing to accommodate our "hands off" wishes (unless, of course, he felt me or the baby were in danger and required intervention). So now my prenatal care was switched from the midwife to the OB, but my midwife kept with us the whole time and we planned for her to be at the birth as our doula instead. Overall, I had about 7 scans, I think. I also had one cervical check, which was a new experience because my midwife does not perform cervical checks as they aren't necessary. I declined all other checks after that first one. Throughout the visits, the previa had cleared up by itself (as most do) by 35-36 weeks. At this point, my OB said it would be ok to do a home birth, but he suggested the hospital because the placenta was still low (and could potentially result in hemorrhaging). To be safe, we decided to do the hospital just in case. Fast forward to my post-due date appointment. Baby's heart beat was still strong, she had most definitely snuggled her way into the perfect birthing position, and there was talk of induction at 42 weeks or somewhere around there. I also had another scan to check the fluid levels, which were "borderline low." Because of this last little nugget, there was talk of induction sooner than 42 weeks. I was not happy about that. I went home, a little freaked out, and did some reading about inductions for low fluid on evidencebasedbirth.com (best website for solid knowledge, in my opinion). I was calmed by the information I read and just went about the rest of my day. Went for a long walk with my daughter. When we got home, contractions began. Yay! No induction! I had been told the whole time that the second babies usually come faster, so not to wait at home for too long, but I was supposed to wait until they were regular. I tracked them for about 4 hours and they were still irregular and tolerable. I was able to move around just fine and everything. Soon after the 4 hour mark, though, we decided to go up to the hospital to get checked. I really didn't want to have the baby at home or in the car. Turns out I was 4cm dilated when I arrived at the hospital at about 8:30pm. We were moved into the delivery room around 10pm and immediately the contractions were very real and getting so much stronger. The nurse was monitoring the baby and I told her "I need to push." She was so calm and said, "Ok. Do you want us to check you?" I nodded and she called a doctor. I pushed while waiting for the doctor. Couldn't hold it. He checked me and I was at 8cm. It took 2 hours to go a whole 4 cm. Wow. That doctor left and then another contraction came and I told the nurse again, more urgently, that I need to push. She frantically called the doctor while I pushed again. The doctor arrived and just barely got her gloves on in time to catch my daughter. I pushed a total of 3 times and this little peanut was out! I was so relieved that it was a quick and relatively easy birth. It was so quick that my midwife/doula and my OB were both in transit to the hospital as she was born. I didn't even get to use the rebozo I bought. :( But, there was no hemorrhaging! AND the hospital allowed my husband to take home my placenta (which is currently in the process of making a tincture). I was expecting the hospital to say it was against policy, but they were very willing as long as it was taken out of the hospital immediately.
Another difference between my stories has to do with breastfeeding. Breastfeeding with my first was a struggle from the beginning. We ended up having to supplement at day 4 or 5 and I gave up pumping and everything with breast milk at 5 months. But so far with my second, we have been going strong and exclusive for a week now! There's no sign of stopping either.
Overall, I recommend and prefer the home birth to the hospital for one main reason, in addition to several other small reasons: the stay after giving birth. This could very well have everything to do with which hospital is used, but where we were, we were not really able to get any rest or bonding time in our room because there was a nurse or some other hospital staff in there with us literally every 30 minutes. Everyone had to poke and prod at me and the baby, usually doing the same things over and over. There was only two times where we had a 3-4 hour stretch of private time. Ridiculous. And they didn't have the discharge papers ready when we requested to leave. I was very frustrated by the end.
Thank you for reading and I hope you enjoyed it! Although, my husband and I do no plan to have any more kids, I am still going to lurk on /babybumps because I very much enjoy all of your stories!

Had my 20 week anatomy scan today. I was super nervous to being with because my daughter had a few problems that popped up at the 20 week scan and ended up being diagnosed as IUGR. So for this little peanut I was totally worried that it would be bad news from the get go.
Thankfully, no signs of IUGR yet, and our little guy is measuring like he should which was very comforting. However, I found out today that I have total placenta previa. My cervix is covered, and covered pretty well at that. I have to go back in a few weeks for another scan to check if my placenta has moved at all. The only issue is that my uterus didn't make a lot of room for my daughter, which contributed to the IUGR. Your uterus has to expand for the placenta to move away from the cervix, but mine might not have anywhere to go depending on how well my uterus chooses to function this time.
I'm also really confused as to why this didn't come up previously? This was my 4th ultrasound and placenta previa was never mentioned at all until today. Maybe they thought it would move before and didn't say anything because of how early it was?
I just hate feeling helpless! I can't do anything to help or cure this problem, I just have to wait and see which is going to drive me batty. They warned me about bleeding (have not had any yet) and possible bed rest/pelvic rest requirements.
Do any of you ladies have placenta previa or had it previously? Were you able to have a natural delivery? Were you put on bed rest?

Let's see how many more exclamation points I can type!
We are having a little boy!!! I couldn't believe it!!! The scan was amazing and so neat to see. Technology kicks ass! I've seen so many US and HD pics of your beautiful babes, but seeing my own and all of his little bones, his face, and his organs was SO surreal. DH and I were immediately in tears. The tech even measured his foot for us and it was an inch long! SO COOL! He has the TINIEST bones in his little body. AMAZING. He looked great!
Doc called me today to report that our boy looked great and is developing right on track! I'm measuring only 2 days ahead and he weighs 8 ounces. However, she diagnosed me with marginal previa. The tech said it looked pretty close together and I noticed it too, but doc confirmed it. No sex (WAH!), no working out, no crazy movement. I have to take it super easy! Thank goodness I'm not on bed rest though! I hope little boy is okay in there with this diagnosis...and whether I have to have a c-section or if my placenta moves...IT WILL BE OKAY, right? I literally have no expectations of labor and delivery...except to have a healthy baby and Momma.
Any shared experiences out there?
Following the scan, my SIL and DH surprised me with a gender reveal. Totally not my thing as I am super shy, but it was SO sweet! <3 Sweet Reveal
BONUS: We decided on a name the same day too! Sawyer Randall :) I sure do love my little family.

Hi everyone! Finally not on mobile and wanted to post a little about my birth, only because it was a little out of the ordinary and something that doesn't happen all the time and I had never even heard of it and it really freaked me out while it was happening... So here goes. I was due on December 16. We have a beautiful son who is in second grade. We lost twins at 21 weeks due to incompetent cervix even though we'd had an emergency cerclage placed. So, my mfm suggested we get a cerclage placed at 15 weeks, which we did. It went well and the rest of my pregnancy went pretty well (only punctuated by a placenta previa that corrected itself). I worked on my feet the entire pregnancy and stayed very active. Dr wanted to remove the stitch on November 17 in the office, after a growth scan. I'd read quite a bit on how some people had no problem getting their cerclage removed, while others had a lot of pain and had to be admitted. I went in with the highest of hopes.... While in my Dr's office, he tried to remove it- to no avail. I had to go to labor and delivery because my cervix had grown over the stitch and had to be denuded- ack! It was pretty painful but only lasted about twenty minutes. We went home. I went back to work a few days later- everything was wonderful. Fast forward to Saturday November 26. My mom came to town and we were getting some last minute items for baby and the house. While we were out I had a few cramps, which I thought "wow, this could be early labor", but nothing was unbearable. Until it was. One of the cramps stopped me in my tracks, but lasted only a few seconds. NBD. We got home and I told my husband that I thought I was starting padromal labor so we started timing the contractions. They were anywhere from seven to four minutes apart (I learned how to operate the lap function on my phone that day). We called the midwife. She suggested I take a benadryl and get in a warm tub. I did so and the contractions eased up to a steady five minutes apart;however once I got in the shower and they immediately got worse again. I was oddly totally calm (unlike me). Midwife recommended we go to l&d just to be sure everything was ok and she'd meet us there. In the car, these things got pretty harsh. I was recalling the video of the gal birthing her child in the passenger seat of the car while her SO filmed it whilst driving. We made it to the hospital at around 6pm. Got in to triage. Midwife shows up and checks my cervix.... A few hours of what I thought were contractions and she tells me I'm one and a half, maybe two cm dilated.. She gave me the option of going home, which I totally wanted to do because I felt so ashamed for making her get to the hospital, or walking around the ward to "get things going". I finally decided to walk around L&D. My husband and I got half way around when a contraction hit me like a brick wall and I had to lean over on a couch, at which time my water broke in a spectacularly movie like fashion! On my way back to my triage room, they became so painful that I was having to stop walking and was doing a lot of panting. Within twenty minutes of the last cervical check, she told me I was now at 6.5 cm. BTW, forgot to mention I was GBS positive so they started rushing to get an iv in my hand to get antibiotics. The pain was excruciating. I kinda thought I was just being a sissy before I learned how much my body had done. They offered me fentanyl which I gladly accepted. It did nothing. I mean, I felt a tiny bit high, but the pain was still stupid bad. AND I could feel his head start to drop? My body was trying to push, but I was stuck in triage, watching Friday on a tiny tv suspended in the corner of a florescently lit, sad room. I tried so hard to make it stop. They finally got me upstairs to a proper delivery room. I pushed for maybe twenty minutes and had my beautiful son at 8:57pm. I learned there is such a thing as precipitous labor. It's anything under three hours... and it hurts. I had never read anything about this, nor heard it mentioned. So mentally, I couldn't make sense of what was happening to me. In hindsight, it was kinda like being on a little too much acid- I had no control and no matter how hard I tried, I could not get a grip on it. TL;DR- I had a precipitous labor and didn't know such a thing existed. My body did in a matter of minutes what normally takes hours and IT HURT like hell!!!!! Merry Christmas everyone!

It seems a bit ridiculous, but labor was probably the easiest part of the whole pregnancy.
I had been told last year that I didn’t ovulate and wouldn’t be able to get pregnant without IVF. I did get pregnant immediately after being told that (because I didn’t take any precautions – we had been trying for awhile, but I wanted to time things so that we had a baby sometime in spring / early summer), but started bleeding. I ended up miscarrying at 7 ½ weeks, after we had already seen a heartbeat. The miscarriage likely happened due to low progesterone levels, which is also why the OB thought I didn’t ovulate.
I immediately got pregnant again and started progesterone supplements, which were awful. They made me really dizzy and drowsy and I spent a lot of time just lying in bed. Somebody later told me that taking them vaginally rather than orally would have helped to alleviate those problems, but nobody told me when it mattered.
At the second trimester, I switched OBs and I’m so glad I did. My original doctor’s office was ridiculous. They had records wrong all the time (for awhile they were treating me based on the week count from my miscarried pregnancy) and were just really insensitive. New OB was kick ass and I love her.
At 20 weeks, I had some abnormal quad screen results, showing a possible neural tube defect. We visited a specialist who determined that nothing was wrong with my daughter, but it turned out that I had complete placenta previa, which put me on pelvic rest until week 36, when it resolved. I was going to be scheduled for a C-section at week 37 if it hadn’t shifted. I got weekly ultrasounds starting at week 33, just to check her health and the state of the placenta.
At 37+1, I went in for an appointment. Alexandra had been moving like crazy the whole time we were in the waiting room and then completely stopped during my ultrasound. Because of this, she failed the fetal health screen. (Of course she moved around like crazy as soon as I left the ultrasound room.) My amniotic fluid levels had dropped from 15 cm to 5 cm between appointments as well. Based on those two things, my OB said we should really induce that night.
Cue panic. We were nowhere near ready. I had planned on cooking a bunch of meals to freeze the next day, and finish painting and setting up her bedroom that weekend. We raced to Target and bought a ton of stuff, as well as frozen foods, and got to the hospital about 8pm that night. I was upset because I felt so unprepared and I didn’t want her to come that early. The next day, the day that turned out to be her birthday, was also my mom’s birthday. My mom died five years ago. I had really mixed feelings about having my mom and daughter share the same birthday, but I think I’m glad it worked out that way now.
Anyway, they started me on Cytotec, which did nothing for awhile. The cervical checks were AWFUL. They hurt so bad. I think part of it was that the nurse’s fingers were short, so she was driving her knuckles into me, too. They woke me up every few hours to check on that.
At about 4 am, I started feeling some contractions. They were on the pain level similar to what I feel on the first day of my period. The nurse gave me some fentanyl to help me sleep – kind of a weird loopy feeling. At 8 am they decided to bother me again, which annoyed me because I had been finally sleeping comfortably. They found that I was at 3cm and decided to start the Pitocin. Getting the IV was awful – I have really small, crappy veins that move, so it took three tries, two with an ultrasound, to get the IV in. She hit a nerve on one attempt and I still have some weird sensations in my left hand from that, plus a numb spot.
Originally I had planned on delaying an epidural while in labor, but the nurse pointed out that they’d be the ones controlling my contractions, not my body, so I decided to get it right away so that I’d remain comfortable. (She said Pitocin was no joke, too.)
I found the epidural to be an interesting experience. The guy who put it in was happy that I was so tall, and he described what I’d be feeling at each step, which was kind of fun. First there was a zing in my left leg, and then some sensations in my hips. I just sat on the side of the bed and leaned forward to get it in. He said I was easy to work with because of my height – more room between the vertebrae.
I was able to control how much of the epidural I wanted, so I could still move my legs around in bed, but I didn’t feel contractions. I hung around 4 cm for forever, but my contractions were regular and they didn’t up the Pitocin levels at all. I think they broke my water at around 10 or 11, but I can’t remember. Suddenly at 2 the nurse said I was at 9 cm, which was shocking. I felt so much panic – I wasn’t ready at all! I started feeling some sharp pains in my right hip and upped my epidural level a bit. My left leg went completely numb, but it took the edge off the pain.
They got the bed set up and told me it was time to push. I didn’t feel contractions at all, but they told me I was pushing and for how long I should hold it. I was really relaxed throughout the whole thing, and we were making some jokes. It really didn’t feel like I was doing anything but holding my breath. My husband held one of my legs and told me what he was seeing, which freaked me out a bit. We did 4 sets total, 3 pushes for 10 counts on each set. And then suddenly I had a very warm baby on my chest. I was shocked at how warm she was. My husband tells me I said, “holy shit!” but I can’t remember.
They left her there for a while and then a nurse removed her and cleaned her up a bit while I got stitches. My husband got to hold her for a long time and my OB had him keep her while she was stitching me up. I had a third degree tear on my perineum and a pretty severe tear on my cervix that caused me to lose about 750 ml of blood. She said the tissue in that area tends to be a site for heavy bleeding.
After I got my stitches I got to hold my daughter again. Some people from lactation helped with latching and nursing.
I stayed in the delivery room for quite a while – it took some time before I could stand without feeling really dizzy or like I was going to black out. I didn’t know how much blood I had lost until a couple days later, after they did a blood draw. (They use the CBC to measure it.) We got our own room eventually and nursing became a disaster. Latching was a nightmare and painful and the second night Alexandra was screaming constantly because she was so hungry. One of the nurses basically told us we just had to suck it up and shook her finger at me for trying to feed her while she was so upset. But there wasn’t a time when she wasn’t upset, unless she gave up and fell asleep for 15 minutes. It was a miserable night and I'm still mad at that nurse.
Lactation came by again the next day and said my latch was fine. We still had so many issues, though, and supplemented breastmilk from a bank.
We finally got someone else from lactation who acknowledged the problems we were having (I love her) and helped us with a way to supplement while Alexandra was nursing, using a small tube taped to my breast. That seemed to help, but breastfeeding still went downhill, with bad latching and Alex constantly falling asleep while nursing.
We’ve been to lactation again since then, and we think maybe the problem is that she was born a bit early and doesn’t have the stamina to really nurse. She’s also latching shallow, or switching to a shallow latch even when I get her on well, and that’s not providing her with enough food, so she’s falling asleep and remaining hungry. I decided to switch to pumping and so far I’m doing about 50/50 between breastmilk and formula at feedings. It’s really helped improve my mood – I don’t feel like I’m fighting with my daughter for an hour or so several times a day. We’re going to try latching again in about a week and a half, once everything has healed, and we’re doing tummy time and things to help strengthen her muscles in the hope that it helps her nurse more effectively.
I didn’t get that instant “in love” feeling – it took a few days. I had a really weird relationship with my pregnancy and was pretty detached from the idea that it would result in a baby. I can’t really explain it. Perhaps part of it is that I’m not really a baby person and just never really had those dreams of having one, though I’ve always liked little kids. I’m really looking forward to her growing up a bit and becoming more interactive.
Other notes: I had really awful pitting edema in my feet after labor (I didn’t have swelling until that point) and couldn’t wear shoes for a week. I left the hospital in slippers that were too tight and walking was really painful – I couldn’t bend my feet at all. I wish I had brought flip flops for the shower. I also wish I had brought Always overnight pads with me. The pads in the hospital had ridiculously small sticky squares that didn’t actually stick to anything and shifted around all the time, but the Always pads have been great. Nobody told me to bring my breast pump to the hospital and I wish I had done that so I could have started pumping effectively sooner. My husband packed a lot of snacks – that was awesome.
I’ve had some ups and downs, and there are times I don’t want to be a parent, but there are also times I laugh. I like watching her face as she sleeps – she gets the craziest expressions and sometimes smiles, which really does it for me.
Here’s a picture at 2 weeks old

Birth story! I loved reading people's birth stories and advice for both labor and postpartum life. So, here's mine.
I was due March 10 but ended up having my little guy on Thursday March 6th. tl;dr: birth didn't go exactly as planned but I ended up with a really positive birth experience.
I had placenta previa and thought most of the way through my pregnancy that I would need a c section. I was really bummed about it because I've been reading about the microbiome and that babies miss out on getting really beneficial gut bacteria if they don't come out through the birth canal. At some point I realized healthy baby is the goal, and that previa necessitates c section and made my peace with it. I thought I would need to have the c section around 37 weeks. However, at 37 weeks, I had another scan that showed the placenta had moved and I was cleared for vaginal delivery. Cue panic. I was now getting the birth I wanted all along but felt totally unprepared for, both mentally and emotionally. Terrified.
I spent 2 weeks thinking about what to do and trying to prepare for the birth, and then at 38+6 weeks (last Sunday!), hired a doula. For vaginal birth, my goal was to labor at home as long as possible to avoid any unnecessary hospital interventions. I was mostly concerned with pitocin, which I've read might be linked to autism (which runs in our fam).
On Tuesday (39+1), I was working from home. I had ordered Fresh Direct for the first time because I could no longer carry groceries. They were delivered around 5. As I squat down in front of the fridge to put them away, I felt something. I was on the phone with my husband at that point and said, I think my water just broke. Went downstairs to the bathroom and saw not water but blood. I then passed a huge (size of a small fist) blood clot. Sent pic to the doula thinking it was my bloody show and maybe normal. She calls: go to the hospital now!
I go to hospital and they hook me up to monitors; baby and I are doing fine. They are not sure what caused the blood or where the clot came from. Bleeding stops, and they decide it's ok for me to go home. Am exhausted. Go to bed.
Wake up at 6 am, bleeding again. Pass another clot. Go to hospital. They hook me up again and baby I and are doing fine. They still don't know what caused the bleeding, but now say: it's time. They think that I am at risk for an abrupted placenta. Either I can have a c section or they will try to induce me. If anything goes wrong with induction, I'll need an emergency c section. Induction includes foley balloon and then pitocin and maybe cytocic. Everything I wanted to avoid! But, I would rather all of that than the c section. I also talked to my doula who made me feel better that, like previa necessitates c section, risk of an abrupted placenta necessitates induction. So, around 11 am weds they start the induction and place the foley balloon (which hurt). They started the pitocin around 1 pm. By 5 pm, I was in serious pain, had not dilated enough to have the foley come out (so less than 3 cm). They turn down the pitocin and shortly after they take out the foley balloon because I dilated to 3 (that was one of the more painful parts of labor). After it came out, I had another blood clot, and then contractions felt much more manageable. By 11 pm, I was about 4 cm dilated and 60% effaced. The doc and nurse asked me if I wanted an epidural. I kept saying no until they explained that it wasn't just about pain: if I needed a c section, I would need an epidural or general anesthesia. If it was an emergency c, they wouldn't have time to place an epidural and I would be put under. So, I decided to was time to get the epidural. I was really super nervous about getting the epidural and the catheter but I just kept telling them and the nurse and my doula were awesome about talking me through it. The epidural rocked! I was able to sleep from midnight to 6 am and had dilated to 6 cm, 100% effaced. After a top off a 6:30, I went back to sleep til 9:30 AM and had progressed to 10 cm and the baby was at -3. Time to push!
I pushed from 10:15-11:41. Started on my left side, and then moved to a squatting position, and then on my back with legs on the squat bar. I had a mirror so I could see in the beginning. I felt SO powerful, like I was the bravest, most badass women ever. When he was crowning, I reached down and felt his head. It was so cool! When he came out, they out him right on my chest. (I had asked for skin to skin right away and for delayed cord clamping).
After delivering, they stitched me up (1st degree tear). I hardly noticed because I was holding my little guy.
Takeaways: - Epidurals rock!! It let me sleep overnight while I was still progressing. Labor pain was totally manageable and I still felt my contractions. - You can't control birth. I really wanted to avoid induction but it was medically necessary. If your birth doesn't go according to your plan, it can still be a really positive experience. - my doula was awesome even though I didn't work with her in the way I imagined. She also did one postpartum visit at home and gave me excellent advice about nursing and helping my little guy to sleep. - don't be afraid to be your own advocate - I was super nervous about some things and really pushed and pushed to make sure I understand why they were happening and what my options were. It made me feel like I was making an informed and considered decision.
Postpartum Life - you will be sore after the delivery! I have a small tear and crazy hemmorrhoids. They suck. Take your stool softener a and your pain meds, and use tucks or some other pads with witch hazel. - taking care of a newborn is hard. I'm a first time mom and didn't realize how often I needed to feed. It is really every 2-3 hours, around the clock, which means you will need wake your baby up to feed. - swaddling is hard to do right. Forget those blankets! I love the halo sleep sack swaddler (http://www.halosleep.com/halo-sleepsack-swaddle-100-cotton-pin-dot-navy/) and other Velcro swaddlers a friend gave me (not sure brand, but similar to this http://www.summerinfant.com/swaddlemeorganiccottonsmallmedium) - deep leg bends while gently gently swinging side to side are super soothing. The 5 S's are important to know (look it up if you haven't already) - there's a YouTube video for everything. We watch a lot if demos to see how to do things
That's it for now. Pics coming shortly!