So my recent stress mostly relates to timing of delivery. I’m having a scheduled C-section, which means I get to (within reason and provided I don’t go into labor) choose the date that Jay is born. And I’ve chosen it, setting my rainbow chain accordingly. But it doesn’t mean I don’t second guess myself… So, needless to say, this decision is weighing heavily on me to say the least.
My stress may not be reasonable. In all likelihood, three days here? One there? None of it matters. Most babies’ lungs are developed by a certain point. But what some fail to realize is that, after you’ve lost a baby in the blink of an eye, everything (every day, every decision) feels critical. So I figured I’d vomit my thought process on this issue here, in case it helps me, or someone else, as I know the stress that comes with making these types of decisions isn’t uncommon…
I’ll first emphasize that elective timing of delivery is an individual decision, and I don’t believe there are any absolute right/wrong answers, because everyone/every situation is so, incredibly unique. And also, I’m no medical professional, so those facing similar decisions should ultimately do what’s best for them in consult with their medical team.
But here are my thoughts on elective timing of delivery, by week, for pregnancy after loss based on my personality and my situation and on everything I’ve learned, coupled with all of my anxiety about wanting Jay here safely…like, yesterday.
40+ weeks – Like whaaaaa??!?! Some actually take a pregnancy after loss this far?
39 weeks – I’m aware that many hospitals enforce the infamous “39-week rule,” and that some even refer to it as “the law,” though my understanding is that it’s more of a guideline set by The American Congress of Obstetricians and Gynecologists (ACOG). Basically, it was established to reduce lung immaturity issues resulting in NICU stays thereby decreasing healthcare costs (this may be a gross oversimplification), and I believe it HAS actually achieved its purpose, though, there is also some speculation and research suggesting that this may be contributing to increased, or, at the very least, stagnant stillbirth rates. Suffice it to say, I think, for most babies, it is ideal to make it to 39 weeks… To me, the problem seems to be that ACOG/some hospitals have taken things to the extreme, stripping doctors of their ability to use professional judgment based on a specific patient’s situation in favor of blindly following this guideline,which prevents them from identifying at-risk babies who MUST be delivered pre-39 weeks to avoid tragic outcomes.
I’m very lucky that my doctors seem relatively unconcerned about the “39-week rule.” They realize that, after what I’ve experienced, asking me to take a pregnancy this far is completely unrealistic. Additionally, I’ve been so impressed with/appreciative of my doctor’s willingness to let me exercise my patient autonomy. In other words, my doctor is providing me with all of the information about the potential risks/benefits associated with delivering each week from 36-40 and allowing me to ultimately make the decision (of course within reason and with her buy-off).
As a side note (and delving into a subject I know less about), I’ve heard some opine that strictly enforcing a 39-week rule prevents a patient from exercising her autonomy, as, ethically, a patient should be informed of her options so she may be allowed to participate in major decisions affecting HER body (which totally makes sense!). Thus, if you feel as though a medical professional is trying to force the 39-week rule upon you against your will, I’d recommend bringing up this whole patient autonomy concept just to see what kind of response you get.
So anyway, all of this is to say that while I’m sure a 39 week delivery is ideal for most mothers and most babies, obviously, it isn’t for all. And it isn’t for me. (I’d go completely insane waiting this long.)
38 weeks – To me, this timing seems ideal, as it’s splitting the difference between 39 weeks (current ACOG definition of full-term) and 37 weeks (old definition of full-term). Also for a “wimpy white boy,” it seems slightly preferable to 37 weeks. (Yes, apparently white males are the slowest to develop surfactant, the natural substance that allows the lungs to properly function. Go figure.) But knowing that 37 weeks is the old definition of full-term and that, historically, some hospitals let patients electively deliver at 37 weeks for reasons as simple as “I’m sick of being pregnant” or “I want this year’s tax write-off,” and that the vast majority of these babies were fine, I just don’t think I could psychologically wait until 38 weeks.
37 weeks – This timing also seems like a valid option to me… For many, many years 37 weeks was considered full-term, and, again, most babies born at 37 weeks were, in fact, fine. But there is that whole “wimpy white boy” thing that keeps entering my mind… And, honestly, some part of me fears a NICU stay. Now don’t get me wrong, a NICU stay is far preferable to a more adverse outcome (e.g. death) and is, of course, no big deal in the grand scheme of life, but I also think a NICU stay sounds more reassuring to a loss parent than it actually should, so I want to avoid this potential pitfall in my thinking. Because, to be clear, there are risks associated with being hooked up to a machine in the neonatal intensive care unit, and some of these risks include…death.
36 weeks – Though she prefer I not take her up on it, my doctor has offered to just take Jay out at any time…starting today (as I have officially passed the 36 week mark). I almost wish she wouldn’t have offered this to me, because it is so freaking tempting. Though, for most babies, 36 weeks is just fine, it does seem a bit early to me. I don’t necessarily want to invite lung immaturity issues unless there is a medical indication for delivery (in which case, yes, of course, take him out!!!). And currently, knock on wood, there are no medical indications for delivery. And I also discussed this with a couple of doctors and nurses who basically explained that week 36 is very important for producing surfactant and that any day I could keep Jay in from here on out would be equivalent to two days of development on the outside. So it seems prudent to at least attempt to buy myself a few more days.
Some other points that have come up…
Steroid shots for lung maturity – In summary, before 34 weeks the benefits of administering steroid shots outweigh the risks, hands down. After 34 weeks, it seems to be unknown (and widely debated) whether or not administering steroids shots will result in a net benefit. And, with steroid shots comes a risk of blood sugar issues (that I know nothing about but sound scary), which the NICU doctors have assured me aren’t a big deal, but the maternal fetal medicine doctors (MFMs) and Dr. Google suggest otherwise. So I’m a bit leery of steroid shots and would like to try to avoid them.
Amniocentesis to check lung maturity (amnio) – With an amnio, they’d poke my belly with a large needle to gain a concrete answer regarding whether or not Jay’s lungs are ready. From what I’ve been told, the procedure isn’t so widely used anymore. Though I think it’s a great idea! Because if the results said “ready,” they’d just take him out. But what if the results said “not ready?” Doctors couldn’t keep stabbing me to see when, exactly, his lungs might become ready, so I’d then be looking at a 7-10 day wait, and, meanwhile, my anxiety might skyrocket as a result of the small risks associated with having been punctured by a needle.
A NICU stay is better than death, so the earlier the better – YES! But this logic holds true even at 28 weeks, so it doesn’t really answer the question of when exactly to electively deliver a baby. In my opinion, the line has to be drawn somewhere (based on the specific situation, of course). And is this line 35, 36, 37, 38, 39 weeks? Jay could just come when he wants to, but if I’m left to make the decision? I just think it’s easier said than done…
Big baby – Jay is big and well-developed, it seems, which is great for lung maturity, right? Wrong. Apparently, babies affected by intrauterine growth restriction (IUGR) or babies of mothers experiencing pre-term labor are actually more likely to have mature lungs because their little bodies have been forced to prepare for the outside more quickly.
So, with all of this said, I’ve scheduled my C-section for 37 weeks and some change, with no steroids and no amnio… It feels like the best option for me and for Jay after considering all of the aforementioned and based on all of the information we have at this time. I think my anxiety can handle this timing (maybe). Though I, and everyone involved in my care, has agreed to take it day-by-day, monitor me
closely extensively, and, if anything comes up, just deliver him.
Obviously, if all goes smoothly, this will look like the best damn plan there ever was. If not, it won’t. But the hard thing about these decisions is that we don’t have all of the information, a crystal ball, or a window into the uterus. And of course, though every detail feels so important to me right now, maybe none of it matters. Some babies have mature lungs at 33 weeks, and some don’t have mature lungs at 39 weeks… So it’s all just a crapshoot and a guessing game, just like much of life is, whether in utero or on the outside.
So we just do our best. And we hope.
At the moment, I guess I’m just happy to have a medical team who continues to be flexible with me. And I guess I’m also pissed off that, right now (probably), some woman is successfully delivering her 42-week gestation twins in a pool in her backyard, never once having thought about any of these issues. (Not that I ever wanted to do this. Because I can assure you, I didn’t. But still……………I’m not much of a fan of this analysis-paralysis, which is likely inconsequential but feels SUPER high-stakes, either! Argh!!!!!!!!!!!)
Sorry for the information overload. I probably lost like 14 readers with this post!