Pregnancy after stillbirth: 33 week scan and a bit after

My 33 week scan went OK.  The baby is growing and blood flow etc is fine.  I agreed to being prescribed antidepressants after the birth as I think it's a good precaution.  They'll take a couple of weeks to kick in, so won't save me from the baby blues that I have been told kick in 3 or 4 days after birth, but they should stop me from giving up after that.  I have requested paroxetine as that seems safest for the baby, if I can breastfeed.  I'm planning to try to breastfeed, but if I can't I won't beat myself up about it (hopefully).  I'll get a carton of formula in just in case.  At least I know I can express colustrum so the baby will be alright for the first few days.

The day after the scan (at 34 weeks exactly) I decided I needed more checks, to keep my anxiety down.  So I booked CTG traces for that day, and more for the following week, with the end result that I have medical appointments (community midwife, growth scan, CTGs) booked for pretty much every day between that 34 week point and when I'm booked in for induction.

My mistake was in not making appointments for the weekend directly after the 34+0 point, because I spent that weekend super anxious.  Saturdays and Sundays have bad associations for me.  So now I'm going in on the remaining two weekend between now and induction, and conveniently enough CTGs on the weekend are done on the ward where I'll be induced.

I ended up having an emergency check at Delivery Suite (it's still vile visiting there) because the baby was moving far too much - increased movements are as concerning as decreased movements.  But at least when they are moving you know they are still alive.  Anyway, the check was a ctg trace and in total I was in there for 2.5 hours, which is pretty quick.

I'm now 35 + 1 and I went to the hospital today and it was pretty horrible walking into a new hospital setting, to a bay to be checked over.  I've never stayed in a hospital bay, but my partner did have a couple week stay a few years ago as he was hit by a car, and it wasn't a pleasant time.   The midwife who did the trace did tell me that for people in our situation they try to put us in a private room, which would be preferable.  However the private rooms may be being used by families in more dire need than us.  We'll see.

Physically, the baby is dropping and jeez I can feel it.  Actually I think the drop started a few weeks ago, I remember a day when I felt really heavy,  Since then I've been getting more groin pain, lower back aches and shoulder blade aches, and it's more difficult to get my legs and hips comfortable at night.  I have woken up with pins and needles in the arm I've been lying on, and it can take a couple of hours for them to stop.  My knee is playing up again.  There's a muscle on the side where it gets swollen and is painful to bend.  I think my foot arches have fallen even more as my feet ache in a new way when I walk.  When I leave the house in the morning, to go 10 minutes to the bus stop, my calves are awfully tight and I can't walk at any speed, it's pathetic.  However I'm not getting cramps at night, thankfully.  This hot weather is a shit because my feet heat up ridiculously, but at least they aren't that swollen. I guess that's all the water I drink and the sandals I'm wearing.

I've finished work now, and that's really helped with the physical stuff and my anxiety.

I can see the baby wriggling away under my belly, it's reassuring.  Even the thumps in the groin and the shifts onto my bladder are reassuring.  I got to show a friend the movements in my belly the other day, and she got to feel the baby too.  I'm glad I could show her.

28 week and 30 week care plan

28 weeks
This was a really hard week where I felt really, really low, and was concerned about my mental state.  Or about as concerned as I could be, given that I didn't care.  I mean, I can recognise when I'm not well and I can tell people that I'm not well.

So the scan was fine and the baby was fine.  The baby measures about the 20th percentile, which is in stark contrast to my bump, which measures the 90th or 100th centile (ish) but I am assured that  all is fine.  the sonographer wasn't going to do a doppler scan, but I said the consultant said I should have one.  So he did one, and the blood flow is right in the middle of the healthy range.

I didn't meet with my consultant, instead it was a senior registrar, but she was the right person for me to see at that time, as she was warm and friendly.  She suggested I take anti depressants either now or after I've given birth, as a preventative measure against post natal depression.  I was at risk of PND even before we lost C, so now I figure i'm doubly at risk.  She recommended fluoxetine (brand name prozac) or Citalopram as safe to take in pregnancy.  She also offered me a referral to the mental health team and psychiatrist but said all they'd do is prescribe me anti depressants and give me a number to call if I felt at crisis point.  My midwife can also refer me to the mental health team.

Once home, I found some info about these drugs:

http://www.drugs.com/pregnancy/fluoxetine.html

http://www.nhs.uk/medicine-guides/pa...ine=fluoxetine

http://www.nhs.uk/medicine-guides/pa...20hydrobromide

http://www.headmeds.org.uk/medicatio...and_everything

We changed my scans so I would have them at 30 weeks, 33, weeks and 35 weeks.  As I'm having them at week + 6 days this means I have one 1 week before induction.  I also booked weekly CTGs for those weeks when I'm not having scans.

She said that if the baby is breech or transverse at 35 or 36 weeks they'd give me steroids (2 injections 24 hours apart) and do a c-section just after 37 weeks.  When I go in they'll do a scan and if the baby has turned they'd give me the option for an induction.  If the pessaries for induction don't work (and we'll know if anything is happening within 48 hours)  they'll give me a c-section.  Both options I'm happy with.

I didn't go into work that afternoon.  I was too much of a mess.

Addendum - I ended up back at the hospital for an emergency CTG the following day, because I felt so awful I couldn't tell if the baby was moving properly or not.  It took me a couple of weeks to get back to feeling normal, but obviously my normal is not everyone else's normal, as I'm terrified of the baby dying overnight, so whenever I wake up I got to the toilet, drink a pint of water and lie awake till I feel enough movements to satisfy me.

30 weeks
The baby is fine and growing at the right rate.  This won't be a big baby, I don't think I can grow them big.

I saw the same registrar as before and we discussed post natal anti depressants again.  She got out the big book of drugs and looked up info for Citalopram and Paraoxteine (brand name seroxat).  More stuff seems to be known about paroxetine and it seems to be passed through to the breast milk more readily so I think I'm more keen on taking that.  She said that these drugs are considered so safe the neonatal doctors don't even want to know that the mother is taking them, as they see no side effects in the baby.  This is reassuring and means I can discount the info in the links above.

My notes from the meeting also say that we discussed induction, but I can't remember what we talked about.

Pregnancy after stillbirth: notes on CTGs and UTIs

Recently I've been thinking about CTGs and I also mentioned UTIs.   I wanted to put a few words about them on these here posts.

A UTI is a Urinary Tract Infection, like cystitis.  They are uncomfortable/painful at the best of times, causing pain (burning) when you urinate, making you want to pee more often than normal (and crucially, not having anything to piss out when you do go), and can make you feel grotty and under the weather.  In older people (pensioners) they can make you seriously unwell.  When you're pregnant an untreated UTI can cause premature labour and the infection can travel up your vagina, to the womb and infect the baby.  This can cause illness in the baby and can be fatal (to the child).

Hence why my midwife was concerned about the leukocytes and ketones as they can indicate an infection.  However, I did as she told me and the following Monday when my urine got tested again it was all clear.  So that's fine.

CTGs, or Cardiotocography traces, are used to monitor the baby's heartrate and uterine contractions.  It's done through putting two monitors on your bump, one at the top of your uterus (your fundus) and one roughly where the baby's heart is.  The machine my hospital uses gives the uterine contraction rate in a green number, and the baby's heartrate in a red number.  If you ring up your hospital concerned about movements and they ask you to come in they'll put a ctg trace on you.  At my hospital you go into delivery suite to have this emergency check done.  I've been in twice now, it's not pleasant.

Anyway, the point of this post is for me to explain about the baby's heartrate and what the ctg trace is picking up.  I asked a couple of fellow Sands ladies about this and they, along with my midwives, gave me the following information.

My midwives have all said that a normal baby's heartrate is between 110 and 160 beats per minute. When the baby moves, it is expected that the heartrate will go up to to 180 beats per minute (just as yours and mine heartrate would go up if we exerted ourselves by going up stairs, for example).  On a ctg trace, which records the heartrate on paper, a la the top line on this image:

You will expect to see at least two spikes occurring at the same time as movement.  The mother is given a beeper thing to press when she feels movement and this is also recorded on the trace.  These increases are called accelerations.

I believe that the lower line on the above image measures baseline uterine activity, i.e. contractions, and is normal.

The ctg tracking the heartrate will pick up when decelerations, i.e. when the heartrate dips below 110.  If more than two of these happen in a 20/30 minute period for more than 15 seconds at a time your midwife/consultant should be concerned and further monitoring is needed.

You have to meet set criteria for the midwife and doctor to be happy with the traces.  A normal CTG needs 4 features - baseline rate to be between 110 and 160bpm, variability has to be 5bpm or more, at least 2 accelerations in a 20 minute period and no decelerations.

For a non-reassuring trace, you need to meet just one of  the following criteria: baseline heartrate below 109bpm or above 160 bpm, variability less than 5bpm per 40 minutes or more than 5bpm for 90 minutes, unprovoked decelerations, decelerations related to uterine tightenings when not in labour.

A baby's heartrate is expected to vary from second to second, like humans out of the womb but there will be a baseline, which is not the same as a deceleration.  I have been told that decelerations are very obvious on ctgs, and that experienced midwives can hear a deceleration without having to have it checked by technology.  This applies when you have your heartbeat checks at regular antenatal midwife appointments and even the parents attending the appointment can hear it.  Having now heard this baby's heartrate weekly since 16 weeks, I would agree that it is obvious what a normal heartrate of around 140 to 150 beats per minute sounds like.

Note: fellow Sands women who are also midwives have told me that a normal heartrate is between 110-160 beats per minute and they expect accelerations with movements to go up to 180 beats per minute.  They have said a deceleration is classified as being at least 15 beats below the baseline for at least 15 seconds.  Which to me says it comes back to being what it normal for your baby.  One off decelerations can be fine, but the baby should always be monitored with a ctg and/or scan if one is suspected.

Another Sands mother says that when she had hours of CTG in the last 5 weeks of her pregnancy, her son only had decelerations in the day before being delivered, and that they were really really obvious on the CTG feed.  She says that movements led to a raise in heartrate, which then came back down, sometimes with a little valley below the average heart rate.  The deceleration was "massively and very distinctly different, with a marked downwards tench with no movement before it".  I'll add that although the mother might not feel every movement, on a ctg trace and a regular heartbeat check, you can hear movement as the baby pushes or shifts against the uterus.

I also asked Sands women about what they can pick up at scans regarding heartrate.  Most scans don't take 20 minutes.  They might take just ten or less.  I have been told that during a scan the sonologist looks for normal movement patterns and they can see if the heartrate is slow - they check it by eye.  if you have a doppler scan they can record the blood flow through the umbilical cord - the print out looks a bit like the ctg trace.

That's a rather long post, but I feel better for getting it out there.  I'm a huge believer in the more information available to parents the better.

Pregnancy after stillbirth: 24 weeks scan and consultant appointment

We had the 24 week scan last week.  Here are the notes from it.

Our post scan meeting with the consultant went as follows:

Can I have extra scans at 30 and 34 weeks? They will review at the 28 week scan.  The consultant would prefer me to have them 3 weekly from 28 weeks as they have pressure on resources, but if I feel I need them every 2 weeks then he will agree to that.

We agreed an induction date that is bang on 37 weeks, which I am incredibly relieved about. It's a weight off my mind to know that I won't have to argue with them.

I asked again about my muff itching, the change in discharge colour and smell. He examined me and said everything looks normal and is putting changes down to normal pregnancy changes.

I came out of this appointment feeling so much better,

Pregnancy after stillbirth: 20 week scan and consultant appointment

We had our 20 week anomaly scan.  I think writing it up here would be good, so others can see what these appointments are like.  And it will help me get my head clear.  I'm finding these meetings quite traumatic and I tend to not think about them much after we've left,

The scan itself was fine, all is normal and developing as expected.  The meeting was with a registrar, not our appointed consultant.  I shall henceforth refer to her as the underling.

I asked about what vitamins I need to take - folic acid is no longer needed as the baby is fully formed.  I am also taking zinc and vitamin D and I can keep taking those.  Bloods will be taken at 28 weeks to assess my iron levels and confirm if I need any tablets.

I asked about having CTG scanning in the last week of pregnancy, this was agreed to although it wasn't formally booked in. It will be booked in once we have decided on a delivery date.

When can I be induced? - I said I wanted to be induced bang on 37 weeks. If I can't be induced then I want to be admitted.  The underling said they would normally induce between 37-38 weeks and we would decide this at the 32 or 35 week scan. This makes me feel uneasy but I'll accept it and keep pushing for a 37 week + 0 date at future meetings.

What do I do if I decide inbetween appointments that I want more regular scans? The underling said that I could ring the consultant’s secretary but they are unlikely to see me more often than my current plan suggests, as they won’t be able to tell much so it’s not a good use of time/money.  However I can come in for emergency checks whenever I want.

Note - this is at odds with what was discussed at the 12 week appointment as we were told by the other underling there that the maximum amount of regular scans offered could be every 2 weeks, as any more often than that don’t show enough growth to come to any conclusions. So I'll bring this up again at the next appointment.

I've been having a fitting feeling in my belly, at a guess it lasts between 20 seconds to a minute. It just feels like really high intensity movement, more definite than just vibrations. There is no hardening of my uterus and it's not hiccups. The underling suggested this is down to intestinal/bowel gas. It's not gas, I know what gas feels like. My midwife suggested it was the baby moving really really fast. I'm not convinced by that either, but these two separate opinions show me that it's probably not a problem.

I've been getting pain across a small part of my abdomen. It's a tightness, and a pain, and lasts for up to twenty minutes before it eases. The underling said this is nothing to worry about and is just normal pregnancy pains. I'm guessing it could be ligaments. I think I had this with C, but back then I wasn't worried.

I next asked about delivery options if there are problems after 24 weeks. The underling said if the baby is measuring small but there is enough amniotic fluid and the placenta is doing it’s job they would induce me.  If the baby is small but fluid is low and blood flow looks bad, they would do a c-section.  I am still happy to be induced but I was assured that they would be quicker to give me a c-section (when compared to other women) if there were any problems, given my history.

I asked about my discharge as it's changed colour, it;s kinda gone creamy. She said don’t worry about the colour, only worry if it is itching, smelly or causing pain when I pee. I had a swab done pre-12 weeks and that came back clear so there is nothing to worry about. I disagree with this as infections can turn up at any time.

I also asked about taking antihistamines as I have a dust mite allergy and take piriton near daily. The underling went and checked with the pharmacist.  Piriton is prescribed up to 34/35 weeks so is perfectly safe.  After that they advise loratidine.  Both are sedating antihistamines so can cause drowsiness and tremors, but if the baby comes out pre-34 weeks it will have bigger problems for them to deal with.

Pregnancy after stillbirth: 13 weeks 0 days - the care plan

We had our 12 week dating scan and our first meeting with the consultant (this pregnancy), so I wanted to write up how the meeting went in the hope that it will help some others.  Reading other people's accounts would certainly have helped me.

Remember that we had no known cause for C's death and our care plan reflects this.  If you lost your baby to a genetic disorder (inherited or random), or if you had an infection, or placental problems, or an incompetent cervix, your care plan will likely be very different.  Also remember that I was 34 when I fell this time and I had a vaginal delivery with C.  If I were older, or younger, or had a cesarean, this care plan would look different.

We had the dating scan first, the sonologist was lovely, warm and friendly. I actually thought she was a nurse at first, because she had that smiling manner that I don't associate with doctors.

She let us see the screen from the start, pointed out the heartbeat, facial bones, arms, legs, etc. She measured the nuchal fold, it's in normal parameters. She confirmed it has a stomach. She let us watch it for a while. She said everything was absolutely fine, as normal.


She said the movement was normal and as she'd expect,  She dated us at 12 + 6 which matches up with the dates given at the 10 week scan and puts us a few days ahead of where I thought I was.  The dating scan can never be 100% accurate, different sonologists can measure slightly differently and it depends on what position the baby is in as to how accurate the measurements are.  The dating scan is to give a baseline to work out your due date and to make sure you are not wildly differing from the date of your last monthly period.
 
Then we met the consultant.  Throughout all this we were in the regular antenatal/sonology department, and there are tons and tons of pictures of new babies on the walls, and it was horrible. On the plus side, it seemed liked most women there were getting called into see consultants so I guess it was high risk Thursday. That made me feel slightly better - that we weren't the only ones in trouble I mean.

Then we saw the consultant, he had another doctor with him, one of his team, she was OK. Good enough. The consultant briefly discussed what we agreed upon at the last meeting, e.g. more scans and I could labour or a c-section. He checked my file and said all was normal. I can't really remember the exact details of this part because he then said something about did we have any questions and I pulled out my A4 sheet and said, oh yes I have a lot of questions. So the rest of this post is my write up of what he said.

General questions:
Who do we ring at each stage if we think there is a problem? - Pre 22 weeks, ring the midwife. 22 weeks plus, ring the delivery suite.  No one can do anything to help the baby if it's under 22 weeks gestation.  So now it's just a waiting game.  I feel a bit relieved by this, like the pressure is off.

Is it worth taking aspirin? - Current research is that aspirin doesn’t do any harm, but there’s not much evidence to say it has a positive effect. For that reason he doesn’t prescribe them. I had no placental or umbilical cord problems so there is no need for me to take them.

Am I at lower risk of pre-eclampsia, placental problems and an incompetent cervix? Yes to all. Well, I didn't ask about the cervix because I felt a bit silly and was having trouble getting my words out. I'm def lower risk for placental problems and pre-eclampsia though.

Perma thrush results - Remember how a few posts ago I was whinging about my unidentifiable muff itching?  4 GP prescriptions for thrush and one swab later and it's still there. So the consultant and his doc checked the swab results and confirmed everything came back normal. The doc checked me and couldn’t see anything,  She thinks it is the scar healing (I got a second degree tear in labour). She ignored me saying it itched in my last few weeks of pregnancy and before I even got pregnant first time. So I don't think it's the scar healing, but I also think it's just something I have to put up with. So long as it's not an infection I can cope.

Can I have a test to see if I am immune to Toxoplasmosis? - This is not available on the NHS. I suspect this means our NHS trust doesn't offer it. Anyway, 50% of people who grew up with cats are immune to toxoplasmosis. If blood tests show women have the virus, this does not mean it will infect the baby, if it does infect the baby there is no way to tell what effect it will have, if any at all. So they don't offer the tests as they can unnecessarily women.  I'm happy with this, I think I'm fairly low risk and I always wash my hands after being around cats.

I was going to ask 'what does the consultant do?, 'what is he responsible for as opposed to the midwife? and 'what are the warning signs or problems in pregnancy?', but I decided not to. I know who to call if I'm having problems and I know I'll only see the consultant after scans.  I'll be thinking every little twinge is something going wrong so I'm best off just calling the midwife.

I am also going to pluck up the courage to read bits of the hated What to Expect book again.  This book is great, if your pregnancy is low risk, remains low risk and you get a live healthy baby.  If it all goes wrong without any warning it's too late to read the ENTIRELY SEPARATE section on problems in pregnancy. This section should be incorporated into the rest of the book, because how many expectant parents will anticipate they might need this section.

Scans and appointments:
What will they check for at each appointment? Heart rate, amniotic fluid levels, growth (every 2 weeks - any more often than that and it’s not reliable), blood flow through the umbilical cord at 20 weeks and from 28 weeks, organs etc at the 20 week anomaly scan. CTG monitoring will be used when I come in for emergency scans - where they measure heart rate against movement.

Will we meet the consultant after each scan? - We will meet him or one of his team. he can't guarantee to be working every time we have a scan.

Are the scans going to be doppler scans? Yes.

Will the scans check for growth, heart rate and blood flow? Yes

I want scans at 20, 24, 28, 32, 34, 36 weeks. What if I want more scans later on? Scans are now arranged for 20, 24, 28, 32, 35, 37 weeks. I can ask for more if I want them later on, but there’s no point having them more frequently than fortnightly as they can’t tell much if they are more often.

Are there any risks to ultrasounds? Not as far as they know.

We decided against a 16 week scan, as the Early Pregnancy Unit sonologist confirmed they can’t pick up all problems at 16 weeks, these are picked up at 20 weeks, and if they do pick up a problem there is nothing we can do. So I don't want a 16 week scan - I'll have weekly heartbeat checks by the midwife from 14 and a half weeks and that will do me.

Third trimester:
How do steroid injections to develop the lungs work? When do I need to take them? What are the risks? Steroid injections won’t be given later than 35 weeks if I intend to labour. If I decide on a c-section they can be given up to 37 weeks.

Can I meet the midwives before delivery -The consultant will check if this is possible at the 35 week scan as the rotas will be arranged then. This has not been requested before but he doesn't see why it can't be arranged, provided the right midwives are around.

What is current movement advice? Consultants say if there’s any change ring them - they follow RCOG guidelines. I told them community midwives and delivery suite say 12 movements a day is normal and expected and if that's wrong (it is) they they need to get the community midwives to stop giving out that advice. I said if I'd known the guidance was to worry when movement changed I'd have gone in the day before, or the day before that. The consultant said he'd speak to the head midwife about changing the advice.

That was the hardest part of the meeting - telling them I think their advice is shoddy and implying that my son could have been saved if they gave out correct advice. I feel awful.  Not because I feel bad for how they'd take it, but because it brings up all sorts of awful memories and emotions for me, mostly retaining to it being my fault C died.  The fact was every. single. midwife, I saw, whether that was the community midwives at my regular antenatal appointments, the 2 that delivered the ante-natal classes, and the midwives on the delivery suite who I rang when I was concerned about movements earlier in the pregnancy said:
If you are worried about changes in movement, ring us, but we only expect you to feel 12 movements a day.
This advice was given out even when it was raised that I usually felt more 60, or 80 movements, so if it dropped to 12 wasn't that a problem.  I was told no.
I'm not holding any one midwife to account here - I adore my regular midwife, she was great.  I'm sure the full midwifery team was giving out this advice with a clear conscience and that they believed it to be right.  I'm angry at the training they are given and I am angry that the consultant team gives out different advice, because by the time you see the consultant team it's too bloody late.

Can I have test for group b strep test at 35 weeks? I think they said the blood test is not available on the NHS, again I suspect this means is not available from this NHS trust. However if I go to the GP and ask for a vaginal swab to be taken at 35 weeks because I am itching, they will test for Group B Strep and everything else as standard, as I am pregnant.

What other tests are available? None that are recommended. The diabetes test at 28 weeks is always done for women in my position.

Labour:
I want the heartrate to be monitored, can I move around while this happens? They can monitor with a battery operated thing, or use something plugged into the wall which will give me some freedom of movement.

How are they going to monitor me and the baby? The baby’s heartrate will be monitored throughout labour by the above described machines.

They want to induce me between 37 and 38 weeks. I want to be induced at bang on 37 weeks. They will use the scans to determine the health and size of the baby and work out when is best to deliver. I confirmed I want to labour, not have a c-section.

I also wanted to ask these questions but decided they would be best off being brought up closer to the time:
What are the warning signs or problems in labour?
Will I have a machine to measure both heartbeats and antibiotics to stop any infections?
When is the earliest I can deliver - I want 36 to 37 weeks. Talk me through the risks and complications.
Will the consultant be there at labour?
Who else will be there at labour, what can I expect, labour wise? I mean for duration, pain relief, tearing etc.

After care
I will also ask these questions closer to the time:
Can the consultant paediatrician to do initial checks, can I have daily home visits by the midwife for the first 10 days
What are the after birth checks?
Can I have blood cultures/swabs taken at birth to test for infections?

I'm happy with my care plan. It's as thorough as it can be.  I'm happy for people to ask questions although I will not tolerate anything rude, judgmental or abusive.