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07/09/2008

I think I will call him Dr. Iron Fist in My Velvet Glove for short

It is common for bloggers to refer to their doctors with colorful nicknames, both to maintain a modicum of privacy and to distinguish in their posts between "my doctor" — Dr. Pretty Sure He's God — and "my other doctor" — Dr. Also Pretty Sure He's God.  I haven't done that much here, although I've done so in my head; when I've written about my treatment, I haven't really required differentiation between, say, Dr. Didn't Even Laugh at My Jokes Much Less Get Me Pregnant, Dr. Head Is a Mathematically Improbable Perfect Cube, and Dr. You Know I Really Like You and Think We'd Probably Be Friends If Circumstances Were Entirely Different and I Weren't Your Patient and I Didn't Feel a Flare of Fight-or-Flight-Style Panic Every Time I Think of You.

Which is a good thing, because I don't really feel I have the knack for this nickname thing.

Anyway, I had an appointment earlier this week with a doctor who gave me my first manual cervical check of this pregnancy, which is to say my first manual cervical check of any pregnancy.  May I introduce you to Dr. Worked Me Like a Sock Puppet?

Like any good doctor, he told me what he was going to do before he did it, and I certainly understood the mechanics of the operation, but I did not know it would be done without the aid of any lubrication whatsoever, and although I thought I had a working understanding of the female reproductive tract, I guess I did not realize that my cervix is located somewhere in the vicinity of my aorta.  But reach it he eventually did, wearing me like an eighteen-button glove, and he verified that there is nothing going on, not even rural electrification, in that remote uncultivated stretch of Upper Julie.

Which is also a good thing, even if it took quite some time for him to return with the news.

He also did me the favor of checking for group B strep — inarguably a very serious matter, as Julia of I Won't Fear Love writes at Glow in the Woods.  This involves the brief intromission of one swab into the vagina and another into the rectum.  Again, he warned me what to expect, so I was prepared for the onslaught.  I was not, however, prepared for him to tear off his lab coat, shake out his mane of wheaten curls, and hit me in the delicates with that.

Gladiators

Which is yet again a good thing, because if I'd had any time to think about it, I would have felt awfully silly calling a well-respected medical practitioner Dr. I Already Know That Tan is Fake But Holy Shit What About That Package?  (In the heat of the moment I simply settled for Dr. According to Johnson and Johnson That's Not Supposed to Go Alllllll the Way into the Ear Canal You Know.)

Finally he consulted my records, including my last couple of growth scans, looked at me with a practiced eye, and said, "You know a VBAC is probably off the table, right?"

This was not the first time my OBs — from Dr. Blue Eyes Made Perpetually Watery No Doubt by My Unparalleled Radiance through Dr. Marvels at My Bruises Every Time I Lift My Shirt Like I Get It Doctor I Am on Anticoagulants For God's Sake, on down the long, long line to Dr. Puts the Fun in Fundus and the Party in Parturition — have floated the probability of a C-section.  Every time they have, I've made it clear that I am not averse to the idea, and that my first priority is the baby's well being, but that my preference is to wait as long as possible before making that call.

It is beginning to seem that the time for a decision is near — or rather that the leeway in which there's a decision to be made is dwindling.  This baby, according to every growth scan I've had, is big, 95th percentile last time we checked.  And while I am aware that ultrasound is a notoriously unreliable tool for gauging a baby's true size, especially in the third trimester, I have had enough scans to be reasonably confident that they haven't all been off by two pounds or more.  (Speaking of the plethora of scans I've had, let me offer you some advice: If you want to feel like an asshole, ask the ultrasound tech to stop showing you 3D views of your baby's face because you're running late and you really need to get out of there, and besides, if the baby had an adorable button nose last time, you're comfortable stipulating that, yep, he probably still does.  If you want to feel like an even bigger asshole, confess this jaded impatience to the entire Internet.  Here endeth the lesson.  You're welcome.)

So we're talking about a big baby.  Macrosomia.  And while that is certainly not in itself an indication for a pre-emptive C-section, macrosomia plus gestational diabetes muddies the waters a bit.  Or bloodies the show.  Or meconiums the amniotic fluid.  Or oversaturates the sugar water many GD babies are given shortly after birth to stabilize their blood sugar.  Whatever.  The point is that in babies born to diabetic mothers, it is not necessarily the size of the baby that's the problem; it's the distribution of weight.  (I was told by Dr. So Cute and Nice I Don't Know Whether I'd Rather Be Her or Date Her that this holds true even for smallish babies of diabetic mothers.)  These GD babies can be larger about the chest and shoulders than their unaffected peers, incurring a greater risk of shoulder dystocia during vaginal delivery.  The risk is not huge in the absolute sense, and the most dire effects of shoulder dystocia — permanent nerve damage, hypoxia, and death — are quite rare.  But even the less dire effects — a broken arm, a broken shoulder, maternal hemorrhage, fourth-degree lacerations — are unsettling.

And of course an argument can be made that even those risks, which again are small, are not an absolute indication for a C-section.  According to one Dr. Web Page I Googled and Cannot Currently Locate but Seemed Relatively Authoritative As These Things Go, it would take 153 C-sections of women in my circumstance to prevent even one case of shoulder dystocia.  And I am, as Dr. Laughs Throatily Every Time She Looks at My Chart Which Strangely Enough I Appreciate observed, not especially narrow in my pelvic anatomy.  And there is the niggling idea, of which I am slightly ashamed, that any doctor's aversion to risk comes from places both noble and ig-.  (I couldn't really blame my doctors if that were the case.  Would you want to defend that lawsuit?)

The trouble is that despite study after study, there appears to be no reliable way to predict who will be affected by this, except to make the generalization that as a GD baby's size increases, so does the likelihood of dystocia.  And once you know you have the problem, once the baby's shoulder is implacably lodged behind the mother's pubic bone, it's too late to back out.  And I cannot think of a single good reason for me — Julie, veteran of one C-section already, with as much investment in a good outcome for this pregnancy as any other mother-to-be, and therefore intent on forming no enduring attachment to the idea of vagina as egress — to take that kind of risk.  Pushing a baby out is not that important to me when having a baby at all is such an improbable wonder.

Given all this, the current plan is to wait for Friday's growth scan and evaluate the baby's size then.  If he is still above the 90th percentile, my OBs will stand firm in their recommendation of a C-section.  Based on my weekly Doppler scans, which have consistently revealed that the blood flow to the baby has been uncompromised — another good thing — I'm not expecting his growth to have slowed, nor would I hope it has.  So I am accustoming myself to the idea that a VBAC is, as Dr. Despite My Fear of Being Damned for My Lack of Team Spirit I Must Report That My Entire Body Might As Well Have Been One of Those Giant Foam Pointy Fingers Being Waved Around at a Junior High Hockey Game for All the Gentleness He Displayed said, probably off the table.

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