Chestnut Week 29

In 8 weeks, Marcus will be full term!  Camille was born at the beginning of week 37.  So if Marcus is on the same path, we will meet the little boy in under two months.  Very exciting.  Very unprepared!

Technically, this is what's going on this week:

• Chestnut is the weight of a butternut squash - 15.2 inches and 2.54 pounds.
• Brain is busy developing billions of neurons. Milestone in baby's brain development: The brain has matured to the point where it can help regulate body temperature!
• Baby's muscles and lungs are continuing to mature.
• Baby can taste and respond to pain. 

Physical:

• Weight: 142 lb (+29)
• Belly circumference: 39.25 in (+10.75)
• I feel like the rapid growth period has slowed down dramatically.  I am not constantly famished anymore! 
• I caught a cold this week.  It started gradually ever since Tuesday and by Wednesday, I have been coughing up a lung.  I'd better not have pertussis!
• Also, because of the cough, I've been peeing myself constantly.
• I had to take another glucose tolerance test this week (routine).  I was instructed by the lab to drink the solution I was given at home and then come in an hour later to get my blood drawn.  I then called again to confirm that I could come in at 5pm (I drank the solution at 4:10pm) and they said I could come in at 4:45pm and they would draw my blood no later than that.  Yikes!  I went in anyway and they drew my blood pretty close to 5pm, but still at least 10 minutes prematurely.  Well, I got a call from the nurse the next day to inform me that my values were slightly elevated.  DUH!  That means I need to go in for a 3-hour tolerance test that involves 4 blood draws.  Awesome.

Spiritual & emotional:

• I am SO glad that Chin & Camille are feeling better this week.  It was hard to see them feel so crummy.
• We are very thankful that Chin's mom was able to take care of Camille (and us) this past week.  Still no plan for long term childcare yet...and that is scary and very frustrating.

Click here to see the comparison to my pregnancy with Camille (MacNut) at the same gestational age.

Chestnut Week 28

To recap this week:

• Chin - Hand-foot-mouth Disease
• Camille - a cold with a phlegmy cough and lots of green snot
• My MacBook screen - officially dead
• Childcare option - gone (more on this below)
• My anticipated graduation date - might be pushed back a quarter or two
• Hip pain - worsened
• Number of exams I have this week - 2

Life around the Ng household this week has been like a rotten onion.  We keep peeling and each layer is more putrid than the last.  We are still laughing it off. :)


Technically, this is what's going on this week:

• Chestnut is the weight of a Chinese cabbage - ~ 14.80 inches and 2.22 pounds (1 kg!).
• He has his own regular intervals for sleeping and being awake.
• The feet are just over 2 inches (5.5cm) long.
• The hair on the head is now clearly visible.
• The skin is wrinkled but will become less so as more subcutaneous fat, the layer of fat just under the skin, is laid down in the next few weeks.
• The milk teeth have developed under the gums.
• The eyes are starting to move in their sockets.
• Uterine growth combined with increased maternal weight gain contribute to a recurrence of fatigue similar to that during the early weeks of pregnancy.

Physical:

• Weight: 141 lb (+28)
• Belly circumference: 38.75 in (+10.25)
• Oy, it is hard to bend down to pick things up these days!  I think Camille knows this...and therefore will try to drop as many things on the ground for me to pick up as possible. 
• I was thinking that I haven't been as "fat-faced" as I was with my pregnancy with Camille.  Aaaand then this week came.  I am fat-faced!
• I thought averaging 6 hours of sleep a night a couple of weeks ago was bad.  Then 5 hours last week.  This week, I've been averaging about 4 hours a night.  I'm not sure how I am still functioning...
• Tuesday night was tough.  Chin was up late vomiting off and on.  He had a pretty bad reaction to the Vicodin given for his sore throat.  Camille also woke up a couple of times and required me to rock her back to sleep (a very rare occurrence).  Then I found out on Facebook that a 90-year-old former colleague from Macau had passed away in Scotland (we miss you, Uncle Don!).  To top things off, I had a stomach ache that started at around 3am...around the time when I'd decided that I had enough studying for the night.  The intense pain came in waves, just like contractions, and it kept going for nearly two hours.  I knew in my mind that I was not in labor, but the pattern of pain was uncanny and it did get me started to think, "What if Marcus is coming tonight?!"  He didn't, obviously.  It was just something bad I had to poop out.  And that took care of it.
• I held off on taking docusate but I finally gave in while I was at the store this week and started taking it in the middle of this week.  Wowee, what a difference!  No more plunging the toilet after every time I drop the deuce in the upstairs bathroom!

Spiritual & emotional:

• I get very little breaks while being in school full time and taking care of Camille the rest of the time.  After Camille goes to bed (9:30ish) is when I have time to myself...to study.  So sometimes, it completely pisses me off that after putting Camille down, Chin gets to play computer games, stays up until 2am reading baseball blogs, and complains the next day that he's tired.  That is the end of my rant.  Really.
• I'm thinking more about how to shift things around in our house so that we can accommodate the two kids.  Childcare is something that we still have not figured out yet.  If Chin's mom comes up to help for an extended period of time, this may change how we arrange our furniture.  Nonetheless, I'm having a good time looking up ideas on Pinterest...and not studying for the exams that I should be doing. :P
• Wednesday night at 10pm, I received a call from Camille's daycare lady saying that she has taken a full time job outside the home and would like to terminate our childcare contract starting immediately.  I know many of you may think she is so rude for not giving us a heads up.  But we've been seeing this day coming.  In the context of her family situation (and the Vietnamese culture), it isn't outside the realm of reason.  Her husband recently had knee surgery and cannot work for the next 5+ months.  She is the only income earner for their family of six.  We have been so grateful to her for taking on the task of taking care of Camille while juggling her family responsibilities, too (she cooks 3 meals a day, does all the house work, goes to PTA meetings, and checks her kids' homework every night!).  She has a lot going on.  I only wish her the best with this new job.
• I am so thankful for Chin's mom in coming up to help us on such short notice after our daycare option fell apart. 
• With everything that has been happening, I can't help but sense that there are deep spiritual implications for this mess.  We are in prayer, trying to discern what it is that God is trying to tell us.  I hope He tells us soon. I am ready for this week to be over!

Finally, a couple of pictures from earlier this week.

*twinkle*

Our family

Click here to see the comparison to my pregnancy with Camille (MacNut) at the same gestational age.

Perinatal choices: Where to birthe

Thanks for sticking around to read the second installment in our "Perinatal Choices" series.  This time, I'm writing about choosing a birth setting that is right for your family.

I've been trying to look for the source of a pithy quote I heard a while ago comparing the environment for labor and sex, but I haven't been able to find it...so I'm going to quit searching for it and just paraphrase.  It goes something like...

A good labor requires the same kind of setting as is necessary for a good intimate experience:

love,

safety,

and privacy.

A beautiful sentiment that I think is so true.  Choosing a setting for birth that aligns with these ideals is something specific for a laboring woman and her family.  For many, it is a simple decision.  For others, it requires delicately balancing the three elements that makes a beautiful birth.

Popular practice
To quote the 2008 Milbank Report on Evidence-based Maternity Care:

Childbearing is a major life passage for over 4.3 million mothers, newborns, and families annually in the United States. Within the U.S. health care system, childbirth is the leading reason for hospitalization. About 23 percent of all individuals discharged from hospitals are mothers or newborns. The current style of maternity care is procedure-intensive, and six of the fifteen most commonly performed hospital procedures in the entire population are associated with childbirth. Cesarean section is the most common operating room procedure in the country. Only three reasons for outpatient visits involve more visits annually than maternity care (prenatal and postpartum visits combined): general medical examination, progress visit, and cough.

Evidently, birth is a big deal...but it could be simpler than the complicated mess we've made it out to be.  So let's find you a place that works out best for your family.

So, what are our options?  Hospital, birth center, or home.  Let's look at these options individually:

Hospital

As mentioned in the last post and evidenced by the above quote from the Milbank report, this is by far the most popular option in the U.S.  For women whose pregnancy and impending births are considered to be "high risk" (e.g., pre-eclampsia, baby has a congenital heart problem, severe oligohydramnios, etc.) it is most likely that they are recommended a hospital birth.  That makes good sense.

There are other cases where a woman, under the care of midwives, was planning to give birth at home or at a birth center but she and/or the newborn is determined to need higher level care, she would also go into the hospital.  That also makes good sense.

But normal birth hasn't always taken place in the hospital.  When did this change happen?  In 1900, less than 5% of American women gave birth in hospitals.  At the turn of the century was when a whole slew of events took place to sway more families into giving birth in the hospital setting.  These events included:

• better roads, which made the trek to the hospital easier
• employee medical programs were established, incentivizing the use of licensed medical professionals and hospital facilities
• the "twilight sleep" birthing trend became popular and women [who could afford it] thought, "If I could do this without pain, heck, what's stopping me?!"
• poor public hygiene due to overcrowding made the home a less favorable environment for birth and this caused the rate of infant and maternal mortality to rise
• the American Medical Association grew in size and power in the political arena

...just to name a few.

With upper class women heading the movement of hospital births, their less financially fortunate counterparts see the trend as being a positive thing. The same kind of thinking applies to the trend shifts for breastfeeding (i.e., the use of wet nurses and the eventual use of formula). Furthermore, these trends are not only contained in the West, but are also perpetuated through colonialism. Even though the imperialism era is considered "over," we continue to see some of these practices (e.g., hospital births, routine episiotomies, lithotomy positions, routine cleaning of the uterine cavity during a Cesarean section, etc.) in areas affected by colonialism long after colonists have moved out of the area.

As an aside, I have heard that labor and delivery units in hospitals receive the most funding to "make things pretty and pleasant" because studies have found that moms are usually responsible for making decisions regarding health and where to go for care.  So if moms have a good experience during birth at a certain hospital, they are more likely to choose that facility as a care place for their whole family.  Interesting, huh?  Lots o' money to be made, m'friends!

Anyhow, to summarize, we can look at some of the pros & cons of hospital births:

Pros:

• "If something goes wrong, the most advanced help is readily available."
  
• Staff ready for normal and complicated/high-risk births.
  
• More options for pain management
  
• Insurance more likely to cover hospital births than births in other settings.
  

Cons:

• "If something goes wrong, it was probably the hospital-based interventions that caused it."
• Higher likelihood of continuous monitoring and interventions (e.g., augmentation of labor by pitocin, forceps, etc.)
  
• Requires travel from home
  
• Because of the high number of healthcare staff present (OBs, L&D nurses, baby nurses, students, etc.), family's wishes may not be honored because of convoluted communication.
• If you give birth in a teaching hospital, you'd better believe your vajayjay is going to be poked and prodded by lots and lots of strangers.
  

Birth center

If you want to give birth in a peaceful, home-like environment but don't want to wash the placenta remnants out of your bedsheets, a birth center might be a good option for you.  All birth centers come equipped with IV fluids, isolettes with a warming mechanism for newborns, resuscitation equipment, and most will have glorious, glorious bath tubs for your labor.  (You can read more here about the Washington State requirements for the equipment and supplies that a birthing center must have.)

Birth certificate data on nearly 2.3 million singleton births in 2008 in the United States showed that about 10,700 women, or less than 1 percent (0.47 percent), delivered in a birthing center, usually a standalone facility staffed by a midwife and in close proximity to a hospital in case of emergency. The number of birth center births and home births in the U.S. in recent years are pretty comparable. 

A growing trend these days is birth centers that exist within a hospital.  Do you know what these birth centers were called before?  Uh, maternity wards.  That's right.  But because of more evidence/marketing data showing that women feel better with a big ol' laboring tub and less interventions, hospitals are shifting the way their maternity wards operate.  Some of the things that qualify a labor & delivery department in a hospital to be called a "birthing center" could include queen-size beds, jacuzzi tubs, maybe some sort of separation from the rest of the sick part of the hospital, and a large midwifery practice.

Onto the pros and cons of birth centers:

Pros:

• Without health insurance, costs less than hospital birth.
  
• Less interventions than hospital setting and more freedom in moving around during labor and even birth.
• You can choose who attends the birth (including children).
  
• No need to do the laundry. :)
• So, did I already mention awesome bathtubs?
  

Cons:

• Requires travel from home. And after you have given birth, you can only typically stay for 4-6 hours (which is usually not a problem with most families).
• In case of an emergency, delays caused by the transport might prove to be costly.
  
• Less options for pain management.  Your midwife can offer IV pain killers but no epidural.
• Insurance may not cover it.

Home

The same 2008 study with singleton births as cited above in the birth center section found 12,400 women (0.54 percent) gave birth at home intentionally.  This number has been rising by nearly 30 percent in recent years.  Nonetheless, home births in the U.S. is still a very controversial topic.  Listen to these discussions between Ricki Lake and the cast of The Doctors.

 Part 1

Part 2

*shudder*

[I know many of my friends watch this show.  But my humble opinion is that The Doctors sucks on many, many levels...beginning with evidence-based practice vs. opulence-inspired health.  Anyway...]

More controversial yet is the movement of unassisted home births.  Unassisted home birth is exactly as it sounds: birth at home without the assistance of any trained professionals. This topic is controversial because birth without assistance not only puts mom at risk but also the fetus/newborn.  If complications arise, a lay person who's in that chaotic birthing time may not have the capacity to get help in time.

But just the idea of home birth is squeamish to many Americans.  We allow Hollywood to educate us on the practice of home birth and birth in general...like in this recent movie, The Backup Plan, for instance.  I wonder if the movie was funded by ACOG.

Anyhow, pros & cons of home birth:

Pros:

• No need to leave home and risk shifting the flow of labor. And once you're done, you're already home!
  
• Without health insurance, home births cost the least out of the three options.
  
• Least amount of intervention.
  
• There is a lot of freedom in moving around in labor (no continuous monitoring), you can eat and drink freely, and you can choose who attends the birth (including children).
• Most home birth midwives are cool with water births.  If giving birth in a hospital setting (or even some birthing centers), water births are often not allowed due to the pediatric team's discomfort with the idea of baby being born into water.
• If your home is decently clean, chances are you have a much lower risk of infection giving birth there as compared to at a hospital environment.  The hospital is where sick people go!
  

Cons:

• Requires a decently clean environment...and you'd have to do the laundry. Doh!
  
• In case of an emergency, delays caused by the transport might prove to be costly.
• You have a smaller team of care providers with you (one midwife, possibly two, and hopefully a doula).  It is crucial that they know what the heck they're doing in the case of an emergency.  If the main midwife in charge is clueless, you are not in an environment where there could be a quick turnaround in getting other experienced staff involved.
• Even less options for pain management.
• Not all insurance plans will cover home births.

The evidence
A 2003 study of nearly 3,000 birth center births versus hospital births found that not only did both places resulted in equally safe outcomes for both mothers and babies, but the women who gave birth in birth centers wound up with fewer epidurals and cesareans (each having varying high rates of associated complications).

A more recent study found that babies born at home have a higher risk of complications, including lower Apgar scores, unless the birth was attended by a Certified Nurse Midwife.  Being trained as both a nurse and a midwife, these professionals have a well-rounded knowledge of medicine as well as the science of birth to equip them for dealing with emergent situations.  This study also found that birth outcomes were similar for babies born at the hospital as compared to birthing centers.

In general, however, I have found that it is difficult to track down an honestly good research study to fairly compare birth in these three settings.  Data is often convoluted with home births that were not intentional, those that were unassisted, c-section rates that do not appropriately attribute emergent home/birthing center transfers, etc.

The documentary Business of Being Born was when I first heard the phrase "cascade of intervention." Take a look:

Changing into the hospital gown
Putting on the hospital gown shifts the balance of power from woman to hospital.  Her perception of herself shifts, and she sees herself as a patient, in the care of “experts,” rather than as a woman confident in her ability to birth on her own terms. This simple act may also make the woman feel less comfortable, feel cold or she may be concerned about modesty as well, which increases stress and makes relaxation harder.

Continuous Electronic Fetal Monitoring (EFM)
The major effect  of continuous EFM is that it keeps the mother immobile in bed. The use of EFM is not evidence-based, and has had no effect in improving outcomes for babies.  Evidence shows that Intermittent EFM with a handheld Doppler is just as effective as continuous EFM at identifying babies in distress.  The only effect continuous EFM has had is that it has increased the cesarean section rate.

Getting the IV
IV’s restrict a woman’s mobility and make it easier to administer fluids and medications that interfere with natural birth.  Women need to be free to move their bodies throughout labor, and should be encouraged to change positions frequently.  Having an IV can hinder that. The IV is also simply uncomfortable, annoying and may interfere with her focus on relaxing with contractions as well and make holding hands with her support person more uncomfortable or impossible. Even a hep lock can be bothersome in the same ways. The perception that having an IV readily available is helpful in an emergency is not evidence based. Many times this IV port is not working well enough to handle an emergency and must be restarted.

Labor augmentation with Pitocin®
The use of synthetic oxytocin (Pitocin®) makes labor more painful for the mother, and more difficult for the baby to tolerate. There are studies that show pitocin may interfer with the body's natural ocytocin hormone production which may hinder the mother's natural efforts in the pushing stage, may contribute to postpartum hemorrhage and may interupt her bonding with her baby, contributing to postpartum depression. http://www.birthresourcenetwork.org/resources/54-pitocin-the-whole-story-

Pain relief
Because the contractions are so intense with Pitocin®, the mother frequently will choose to receive an epidural for pain relief.

Restriction of movement
An epidural keeps a woman confined to bed for the duration of the labor and birth.  Being unable to move restricts the woman’s ability to help her baby get into a good position for birth. It may also hinder the baby's ability to move, too.

Contractions slow down
Epidurals can slow labor progress, which results in increasing dosages of Pitocin® to increase contraction intensity and frequency, which can lead to an even greater need for pain relief and greater risk of fetal distress.

Progress slows or stops
Assuming the woman reaches full dilation, the epidural can interfere with the woman’s ability to push effectively.

Fetal distress
Hard contractions, combined with reduced blood pressure and the lack of blood flow to the baby, cause the baby to go into distress.

Cesarean section
After having exhausted all of the tools at the obstetrician’s disposal, this one option remains.

(from novabirthcenter.com)

From my experience in the labor & delivery departments of several area hospitals, I have seen this cascade far too many times.  It doesn't always end up in a C-section, but interventions are almost guaranteed in a hospital setting and when things go South, the phrase, "We need to do what is best for your baby" gets tossed around a lot...

As a final note, I want to point our attention to this number: 41.  That is the position the U.S. is in with the maternal mortality ranking.  This means that if you are giving birth in the top 40 countries, you have a better chance of surviving childbirth.  The CDC further states that many of the maternal deaths in the U.S. are completely preventable.
Does that make any sense?  How do we spend the most money and get such sh*tty outcomes?!

Our experience
We chose to have both Penelope and Camille (and eventually Marcus) at the Family Beginnings "Birthing Center" at Group Health Central in Seattle. In an effort to piss off a large number of people in one single shot, I have been heard comparing the choice of birthing at a birth center to buying a townhouse, using a hybrid cloth diaper, or driving a hybrid car.  And, ha!  I've bought a townhouse-ish condo, used hybrid cloth diapers, and recently bought a hybrid vehicle!  So, really, joke's on me. What I meant with the comment above is that birth centers serve as a safe compromise between hospital and home birth.  My criticism here is that sometimes these middle-ground compromises are neither satisfying nor are they the best option for you and your family.  Nonetheless, you need to make the decision that is best for your family.  And oftentimes that involves a lot of compromising.

For me, I would like to have a home birth.  As much as I like to go out, I am not a fan of traveling when I am in pain.  I like to be in a comfortable home environment where I know that nobody has C.diff or that a colostomy bag had busted just down the hall.  A friend of mine (who is now a Certified Nurse Midwife) once said that she would like to have a home birth because that is where she knows she has no option for an epidural, which she is well aware is associated with many complications.  Another reason for a home birth is that after I gave birth to Camille in the hospital, I was given a UTI by a not-so-careful nurse who failed to catheterized me in a sterile manner.  This wouldn't have happened at home...where I think I would feel more naturally in my element and in control of the situation so that I could refuse unnecessary procedures.

Chin is less keen with the idea of a home birth because of the "just in case sh*t happens" scenario.  

I get that.  I'm pretty cautious, too.

"What if something unforeseen happens?  Like baby needs a lot more extra help."  We opted not to do any prenatal screening for genetic abnormalities (despite of, or perhaps because of, what happened with Penelope).  So what if baby has some strange complication that we weren't aware of?  What if I run a high fever and need an immediate administration of an IV antibiotic?  I don't want to be transferred!  Not all of these concerns are rational, but they are feelings...which are not always based on logic but are valid all the same.

As kind of an aside, one thing to consider if you are giving birth in the hospital is what kind of care is available should your newborn require special medical attention.  There are three types of nurseries available:

• Level 1 nursery - This is the nursery you see in the olden days where nurses will swoop in to save the pooped-out parents by taking the healthy newborn away for a number of hours during the postpartum period.  The overwhelming evidence for better outcomes in rooming-in has more or less made these simple type of nurseries obsolete.
• Level 2 nursery - aka progressive or special care nursery (PCN/SCN).  Instead of having a full-on neonatal intensive care unit (NICU), some hospitals only have a Level 2 nursery where they can take care of mildly complicated cases.  Here, babies can be given supplementary oxygen, be tube-fed, and receive some IV therapy.
• Level 3 nursery - aka a NICU. A NICU is equipped to take care of basically all your little baby problems from needing sugar water to being on a ventilator.
  

If you know before hand that your baby will require special attention after birth, you will most likely need to give birth in a setting that has an adjoining NICU.  If you just like to be super safe or tend to freak out in general, you will probably want to give birth in a setting that has an adjoining NICU.  So, check with your hospital.

Anyway...

Weighing our pros and cons, we decided to give birth at the Group Health Central birth center because:

• Our insurance will fully cover it. (Since Marcus will be born in 2012, our insurance will still cover everything at 100% and does not require a co-pay.  After 2012, all bets are off.)
• Our families would flip if they hear that their grandchild was born somewhere outside of a hospital.  And the headache that would cause is not worth it for us.
• We are working with a fantastic team of midwives who we trust and who we believe will honor our wishes.
• We are educated individuals and we are [mostly] aware of our rights, options, and the evidence behind perinatal practices.  Should something come up in the hospital setting where we felt like we are strong-armed, we fully know we are the health care consumers and we are the ones ultimately making the decision.  (Easier imagined in theory, I think.)
  

Thrilled

My opinion is that when we choose the care provider or setting for birth, too many women and families operate out of fear instead of rationally thinking through the evidence.  We are already irrational beings to begin with.  Throw in birth hormones and family pressure and pain...and we are a mess!  It's a very vulnerable time, really.  Which is not surprising that when the sacred bubble of this birthing experience is breached, some women refer to it as "birth rape."

My best advice to those who are trying to choose a birth setting: choose a provider/group of providers that you trust.  I think it is paramount that in this vulnerable scenario, women are surrounded by people who (1) know their stuff and (2) are truly supportive of her and her family.  From there, consider your options and, with the help of those you trust, make an informed decision about the birth setting that is the most ideal for your family.

I wish you the best birth!

Acknowledgements & Resources 

• Read more about the Milbank Report on Evidence-based Maternity Care here.
• A good guide to choosing a birth setting that is appropriate for your family plus the evidence behind the different birth setting options.  Another nice one here. One more here. And there is yet another one coming soon.
• An interesting article on the importance of privacy in labor and how a good labor support system could help build this privacy for a laboring woman, even in a hospital setting.
• Great website on revealing the medicalization of birth with tangible recommendations of how to reduce your chances of getting into these situations.
• Take a survey and/or look up survey results from real people who reviewed providers (ObGyns and midwives) and birth settings (hospitals, birth centers, and home birth services).
• An extensive timeline of birth in America and its criticism. 
• Some resources for each setting:
• Hospital:
• Here are the C-section rates for Washington hospitals and here are rates for Oregon hospitals (click here to see rates for hospitals in other states).
• An article written by my good friend Vina on how to increase your chance of giving birth naturally in a hospital setting.
• Birth center:
• Birth centers in Washington state
• Home:
• A blog on the safety of home births
• A blog on home birth horror stories and a critique of the pro-home birth evidence.
• A few short videos worth your time here, here and here.  But you can find a lot more on YouTube, including footage of home births!
• I think this is a great article on the topic of "If I were home, I/my baby would have died." Not just an opinion piece, but an article that critically examines the evidence behind what people consider emergent situations and the causes of these disasters.
• The pictures are from here, here, here, and here.

Amusing moments with Camille

Camille has been growing so fast.  What happened to this little baby?!

One month old

There have been so many funny and heart-warming Camille moments lately.  I feel that if I don't write them down somewhere, I'll forget.

Swiper from Dora the Explorer

Her language skills are amazing (to us, anyway).  She can count to 10 and knows 10 colors (black, white, brown, yellow, red, blue, green, purple, pink, and orange).  She is putting together sentences...and they're all to communicate something that she wants us to do for her (e.g., "I can't open it!" or "I eat gummy bears!" or "Nes ehsode!"...meaning "Next episode [of Dora the Explorer]" as a spoken command for the Xbox).

She is so enamored with Dora the Explorer.  While reading a story out of a Bible story book the other week, she pointed to the fox on the page (picture below) and said, "Swiper!" She then extended her short little arm and said, "Swiper, no swiping.  Swiper, no swiping.  Swiper, NO swiping!  Oh man!!!"

Fox from Bible story book

***

At pediatrician's office...  Pediatrician had just finished with checking her for a resolving cold and said, "Well, Miss Camille, how about we go get you some stickers?"

Camille was super excited and started going batsh*t crazy over the idea of stickers.  I tried to put her clothes back on (which was no easy task) and gather all of our stuff.

"Mommy!  Mommy!  Stickers!  Dora stickers!" she exclaimed.

I kept working on putting her shoes on.

"Mommy!  Mommy!!  MOM!"

I put on the other shoe.

"Bao!  Bao!  Bao Ng!"

W....T....F?!  How do you know my full name, kid?!

***

A bite out of every piece

Before nap time, I was changing her diaper and Camille said, "Mommy, I poop."  So off to the potty we went.  She sat there and sat there and played with her toys.

"Do you need to poop?" I asked.

"No," she responded.

"Do you at least need to pee?"

"Pee?  Yellow one?" *pees* "See?  I pee.  Yellow one."

Then she gets up from the potty and starts to walk around the bathroom.  She sees her toothbrushes and asked to brush her teeth (one of her favorite things to do).

"Brushing teeth is for early in the morning and before bed time, Camille.  But if you poop, I will let you brush your teeth."

Within 4 seconds, I kid you not, I see a poopy face...and my reaction time was definitely too slow.

[imagine this in slow motion] "N...o...o...o...o...o...o...!  Get...back...on...your...potty...chair!"  I reached out to her.

It was too late.

She had already pinched off two loaves on the bathroom floor.  Two soft lumps with black kiwi seeds.

"Brush teeth?" she asked.

***

Doing PT with BaBa

While I was at the store to get Chin's prescription today, Chin got to spend some quality time with Camille.

Camille points to her tummy and said, "Tummy!  Miu tummy."

"Does BaBa have a tummy?" Chin asked.

She points to Chin's tummy.

"Does Mommy have a tummy?" Chin asked.

"Yeah," she replied.

"What's inside Mommy's tummy?" he asked.

Camille stops to think about it and then shyly said, "Baby Marcus." :)


We love this little girl

Chestnut Week 27

*pop!*

This first week of 3rd trimester has been good, despite being very busy and living through Camille's first febrile episode.  (Yes, her first time mounting a full-on immune response that resulted in a fever!  I credit my boobs.)  Here are some pictures from this week...to make up for so many of the late belly pictures.

Camille has been eating better these days.
Weighed her at my midwife appointment on Wed
and she was 21.9 lbs...with clothes on!

Loves drawing with and sometimes eating crayons

Drawing with BaBa

"Cheeeeeeeese" (Easter 2012)

All dressed up in Mariner's uniform on opening day!

Chin & I got to go to the Mariner's game on opening day
at Safeco Field.  Thanks to Kristie for the tickets & thanks
to Sherwin & Mina for watching Camille!

Technically, this is what's going on this week:

• Chestnut is as hefty as a head of cauliflower, - ~ 14.41 inches and 1.93 pounds.
• His head is over 2.5 inches in diameter.
• His hearing continues to develop.
• His eyes can blink, open and close.

Physical:

• Weight: 140 lb (+27)
• Belly circumference: 38.5 in (+10)
• Fundal height: 25.5 cm
• I had a check up with my midwife this week and found that I had gained three pounds over the past week.  I'm not exactly sure how this happened...but I guess I should not be surprised because I am hungry all the time.  I have been more intentional about cutting down on carbs and controlling my portion.  It is tough.  And I can empathize with all of you who are trying to modify your behavior in any sort of way.  I just want to eat, eat, eat!
• With Camille being sick this week and my school workload being a bit heavier, I've been averaging about 5 hours a night.  Chin captured a very typical picture of me these days: heavily gravid, sedentary, and tired.

*yaaaawn*

Spiritual & emotional:

• Despite the busy-ness of school and home life, I am doing well.  The weather has been beautiful and I have been soaking it all in!
• When I saw that I had gained 3 pounds this week, the thought of needing a c-section briefly entered my mind.  "What if Marcus is so big that I am too pooped to push him out?!"  It's a fear that may not be too unrealistic, eh?  Anyway, I know just need to calm the eff down, eat less, and exercise more.
• I think I have reached this paradoxical/ambivalent stage in pregnancy where I am conflicted with the feeling of wanting baby to come soon (because I am tired of being pregnant) and not wanting baby to come soon (because I am not quite ready).  Regardless, I know that in my mind I want Marcus to stay in for as long as necessary.  So, hang out in there for a bit longer, Little Boy!  I love you!

Click here to see the comparison to my pregnancy with Camille (MacNut) at the same gestational age.

Perinatal choices: Choosing a provider

Sheesh!  You all know that I don't like to stress out and I choose not to.  But I was almost at the point of stressing out about writing this series.  "Where do I begin? When do I find time to write? What if the topics are all out of order? How do I maintain a readable length for each entry? Do I need to cite everything?!"

Then...

I decided to take a deep breath...

With that, I'd like to welcome you to the first segment of our discussion on perinatal* choices!  I'd like to keep things casual...but I am also a little anal about being systematic.  So I'm going to keep a consistent format of going over these headings:

• Popular practice: What is an average American doing? What's common practice? What's the history behind these practices?
• The evidence: According to research, what should be put in practice?  How do we compare to other countries?  Where are we in achieving the goals for health outcomes that we have set? What's stopping us from getting there?  How do we get there on the level of personal decision-making, telling others about the evidence, and integrating this into the broader healthcare systems?  (Okay, this is where I might go off because I seriously love what I do: bridging the gap between research and patient care delivery. But I hope that I don't spend too much time in this section as I think the next section is very important.)
• Our experience: This is where I tell our story.  The best part, I think. :)
• Acknowledgments & resources: Obviously I needed help putting this all together!  This is where I cite some of the key people and resources that helped me present this information.

So, with that, let's start talking about the first installment of the discussion on prenatal care choices: choosing a provider.  I'm going to warn you: it's a lonnnng blog post. :)

That Ryan Gosling, he really knows!

Popular practice
What are our options?  ObGyns or midwives.  Obstetricians are trained medical physicians with an "MD" after their names.  They have gone to school for many, many years and have learned to provide care for a wide range of pregnancies and birth situations including Cesarean sections.  Midwives come in a variety of different forms, but essentially they differ from ObGyns in that they typically care for uncomplicated pregnancies and assist vaginal births.

The difference between the two models of care are outlined below:

Midwifery Model of Care Focus on health, wellness,    prevention Labor/birth as normal    physiological processes Lower rates of using    interventions Mother gives birth Care is individualized

Medical Model of Care Focus on managing problems    and complications Labor/birth as dependent on    technology Higher rates of using    interventions Doctor delivers baby Care is routinized

(from The Childbirth Connection)

Okay, okay, even though they claim to not be biased, I think the table above is pretty pro-midwifery.  Reading it with a grain of salt, please realize that there are plenty of OBs who are low-intervention and I have come across quite a few "medwives" out there, too.

So, who do we choose?  Most Americans choose ObGyns for prenatal care and birth. According to the 2006 National Center for Health Statistics, midwives attended 317,168 births - 7.4 percent of all births in the U.S. Of those births, 96.7% took place in hospitals, 2% in birth centers, and 1.3% at home.

Historically, midwives have attended births for thousands of years. Birth used to be an all-woman event where a laboring woman would be surrounded by female family members and at least one person who knows what the heck she's doing.  Then, somewhere along the way (I'm too lazy to look up exact dates), medical interventions such as Cesarean sections and forceps were introduced to help out complicated cases of labor.  And then there was the introduction of hardcore pain management such as morphine and chloroform in labor.  At the same time, general practitioners who wanted to gain a larger client base thought, "Hey, if I deliver this lady's baby, their whole family will come to me from now on for all their healthcare needs."  Around that point is where more and more women turn to the medical model for the management of their pregnancy and birth.

In the 60's and 70's in the U.S., there was then a counter movement against the medicalization of birth.  A few people said, "Eff this!" and started traveling around in buses, women didn't shave their armpits, and drugs were used in all settings except for birth.  They were considered "really weird."  But they did bring back a deep appreciation for the art of midwifery.

In the Pacific Northwest these days, evidence-based hippies as we are, there are still more women who choose to give birth in a hospital setting with obstetricians than those who choose any variety of midwives. 

The evidence
Have you heard of the Cochrane Collaboration or the Cochrane Library?  It is a collaboration that started out in the UK with the aim to find good, quality research on health and healthcare practices that can be brought back to the bedside.  In 1979, Dr. Archie Cochrane published an essay to draw attention to this need for randomized controlled trials in which he designated the field of obstetrics as the least scientific medical specialty. Ouch!

Just looking at our own backyard, birthing in the U.S., compared with other industrialized countries:

• We are the most technology-oriented,
• Spend the most $ per capita,
• Largest % of birth attended by MDs,
• Smallest % of birth attended by midwives,
• Highest infant mortality rate (are you seeing this?!), and
• Maternity mortality and morbidity rates are similar, too.

Alright, that's just data schmata.  It's not really sickening to you unless you were personally [and negatively] affected by it, right?

Well, if you are pregnant and you'd like to be well-informed about your care, this is a critical junction where you need to decide on a provider whose beliefs and practices align well with yours. It's fine to go with an obstetrician for your pregnancy and birth (complicated or not).  But if you haven't considered midwives as an option, it might benefit you to know that a recent review of 21 legit studies showed that births that are attended by midwives:

• have comparable outcomes as those attended by OBs,
• result in less interventions (e.g., episiotomy, labor induction, epidural analgesics),
• have fewer incidence of perineal tearing, and
• resulted in higher rates of breastfeeding.

There you have it.  There is a lot more evidence to show that care given by a midwife in pregnancy and labor is more cost-effective and result in more "peaceful" outcomes.  If you are interested, please let me know & I will send you those articles.

I feel that I can talk until I am blue in the face about evidence...but it doesn't impact the lives of people until it is relevant.  I am hoping that by telling our story and perspective, you could see the benefits of a less medicalized birthing experience.  So, read on!

Our experience
We went with a group of midwives from Neighborcare Health starting when I was pregnant with Penelope in the Spring of 2009.  I chose to go with midwives for a number of reasons:

• I found them more personable,
• the approach of these nurse midwives are both scientific and intimate,
• I always felt that they were informing me of everything along the way,
• and I have not met many OBs that I have felt very comfortable with.

Sam, the UW midwifery student who caught Camille
(with Chin's help, of course ;P)

A typical office visit with my midwife would start out with her asking, "How are you?"  I never felt rushed or brushed off.  When we found out that Penelope had many health complications, my midwife called me right away and checked in on how we were doing.  She asked, "Do you have people around who can cook and take care of household things for you during this time?"  I could not imagine any of the OBs I know to think of asking that!

With the Penelope's poor prognosis, the midwives suggested that we transferred our care to a group of perinatologists at a larger local hospital.  We tried them out.  Here is a quotable moment from the visit with that perinatologist:

Perinatologist [talking to Chin and ignoring me]: I think you should have a D&C.  I'm telling you right now that there is 0% chance your baby can live.  And there are many health complications that could affect your wife. If the baby dies in-utero, there are risks of infection.  She could have DIC.  She could have mirror syndrome.  Your wife could swell up like the Michelin Man!"
Me: I don't believe that mirror syndrome is very likely going to occur (I saw a case on House, MD - how prevalent could this disorder be if it was on House?!).  Sure, there are risks of complications but these are risks we are willing to take.  Please, just for the sake of our conversations going forward, assume that we do not want a D&C.
Perinatologist: Wow, you sound really smart.  Are you in the medical field?
Me: I'm just well-informed and I know what I want.
Perinatologist: Because, most patients I work with would choose to terminate.  There is NO chance of survival.
Me: Please, doctor.  I don't want to discuss this anymore.
Perinatologist: Is it a religious thing?
Chin & me: [Utterly speechless.  Does it effin' matter, you moron?!]

There were several other things from that visit that made us question this doctor's level of competence.  At the end of the day, we called up our midwives and asked to be returned to their care.

Both Penelope and Camille were born under their care and we were very happy.  After moving to the Eastside and finding out that we were pregnant with Marcus (Chestnut) we considered other local options.  But after searching for a couple of months, Chin insisted that we go back to the Neighborcare midwives.  Even if this meant that I had to commute to South Seattle for prenatal checkups and we'd have to drive across the toll bridge to get to the hospital for birth.  (Yes, my husband is prepared to pay the toll.  That's how much we love and trust these midwives!)

There is a lot more of our story to come.  It'll just unfold as we delve further into this subject.  I hope you will read on because there is much more I'd like to share with you!

Acknowledgements & Resources

• A great article on birth options, written by a smart mom 
• Different types of midwives
• Read more about your options in choosing a provider
• History of obstetrics & midwifery
• Studies on safety & effectiveness of midwife-attended births
• Some documentaries that might be of interest are:
• The Business of Being Born - with Ricki Lake (there is a 2nd one out that I haven't seen yet)
• Orgasmic Birth - this was a good one
• Pregnant in America - I didn't like this one so much, it was a little pushy
• Gentle Birth Choices - this is probably my favorite out of these...probably because of the 80's hair
• Some fantastic books on midwifery & making smart perinatal choices:
• Ina May's Guide to Childbirth 
• Spiritual Midwifery - a classic by Ina May, one that I actually read!
• The Thinking Woman's Guide to a Better Birth
• Birthing from Within
• The pictures are from here, here, and here.

* Some of you (Chin) have inquired about the meaning of "perinatal."  "Peri" means "around" and "natal" means "birth."  So, around birth.

Chestnut Week 26

Today is the last day of the 2nd trimester.  Adios, 2nd trimester!  You didn't suck as much as 1st trimester, but you definitely weren't as glorious as I had hoped.  You know, I always thought I would love being pregnant.  Some days I do love it.  Most days...not so much.

That is the truth.

Aaaaand, friends, we have a name for Chestnut: Marcus!

I had a dream back in the Spring of 2009 (while I was pregnant with Penelope) that I had a little boy.  In the dream, I went to change his diaper and he projected an arc of pee onto my face.  Then he asked, "Mommy, what's my name again?"  I replied, "Your name is Marcus."  And he said, "Oh yeah, I forgot."

Now, I don't know any Marcus.  But Chin was playing a video game called Gears of War at the time and one of the main characters was Marcus Fenix.  Could it be that's how the name got into my head?  Perhaps.

"Let's do this, Marcus!"

Technically, this is what's going on this week:

• Chestnut is as tall as an English cucumber - ~ 14.02 inches and 1.68 pounds.
• His feet are 2 inches long. Hands are very active.
• His eyes begin to open around this time.
• The fetal brain scan will show response to touch. Touching and playing with the baby is possible now, as they may respond to your touch through your belly wall.
• Baby is probably very active in the womb (very much!!), as the most active weeks are typically between weeks 24 and 28.

Physical:

• Weight: 137 lb (+24)
• Belly circumference: 38.25 in (+9.75)
• I am the exact same weight and size as last week.  How could this be, especially after a period of rapid growth?  I think it is because for the first time in four weeks, this was the first week that I hadn't gone to a buffet.  Seriously.
• I rub my belly all the time.  It's big and often in motion. :)

Spiritual & emotional:

• I started taking 50,000 IU of Vitamin D once a week starting a couple of weeks ago and I feel a lot more alive.  My mood has been better!  It could also be that the weather is getting a bit sunnier, too.
• School has been keeping me pretty busy.  For a couple of days, Camille didn't nap very well and this definitely cut into my studying time.  Very frustrating.  I had to stay up late those nights to do homework and I have been averaging 6 hours of sleep each night (no naps).  Pretty tiring.
• To make up for her skipped naps, Camille had one massive day of sleep on Monday: she fell asleep on the way home from daycare (where she'd taken a 2-hour nap) and continued to sleep from 6pm until 8:30am the next day.  Chin & I enjoyed a pleasant dinner at home and I got a lot of homework done that day. :)
• We are still in the process of looking for a long-term solution for childcare (starting now and continuing perhaps beyond my graduation).  This topic is on our mind a lot and we are just trusting that the Lord will give us wisdom in where to search for a good option.  Please pray for us.  Thank you!
  

Click here to see the comparison to my pregnancy with Camille (MacNut) at the same gestational age.