Baby #3: The Delivery

Despite the common knowledge that each case is unique, I was nonetheless lured into the innocent contemplation of something quick and similar to what occurred during Aaron’s delivery, just because the trend appeared similar.  However, things turned out differently this time.  Here’s sharing on the arrival of the youngest brother of Alvin and Aaron.

Just like the rainbow cake.  Each layer has a different colour.  Likewise the uniqueness in each case when it comes to the reality...

Removal of Cerclage at 36 Weeks and Discharged

My cerclage removal back in 2014 was painless and took only minutes.  However, the process this time was long and unexpectedly painful.  The removal was done at 36 weeks at the ward itself, not the labour room.  But looking back, the discomfort experienced this time shouldn’t be a surprise because the cerclage had been inside for quite long, around 5 months, and as a result there was swelling on the cervix. 

Post-cerclage removal, other than spotting and despite a 3 cm os, I did not have any sign and symptom of labour.  CTG showed the presence of irregular and very mild contractions, and I did not feel any pain. 

Still no progress for another 3 days down the line, I was thus allowed to discharge.  Which meant going home and waiting for “the sign”.

 I wanna go home... time to clear up my mini pantry-cum-library

When, Where and How?

What are the signs that indicate it’s time to go to the hospital?  As I’ve never truly experienced the moment before, I was paranoid each time I went to the washroom.  Or whenever I felt a mild contraction indicated by tightening of the abdomen.

During daytime, my husband works in Pandan Indah while I’m in Seri Kembangan. What if the need to go to hospital occurred at the most inconvenient time - Serdang, Columbia, HUKM? 

25 October: Admission Day

A little short of the 38^th week, on Wednesday 25 October 2017, I had my check-up appointment at the antenatal clinic of PPUKM.  I did not expect admission into the ward on that day but already kept the necessary bags in the car earlier. 

Waiting area at the O&G clinic

While a young doctor was palpating my abdomen, a few surges of contraction suddenly occurred.  The doctor then performed a VE, and I was told that the os was “a good 4 cm”.  Upon consultation with Prof Azurah, I was admitted into home-sweet-home Ward 2B that afternoon.

In the ward, I had a 20-minute CTG for fetal heart rate and contraction monitoring.  There were contractions, but very mild and asymptomatic. Due to a GBS positive diagnosis at 35 weeks (never detected with one before this), I was started with a 4-hourly IV ampicillin on the same day, i.e. administered once in every 4 hours via injection through the IV line.

26 October: A Pain Like No Other

Things remained pretty much the same on the next morning.   Contraction was more regular but very mild.  There wasn’t any pain too.  After CTG and VE before dawn, at about 8 am, the doctor performed an artificial rupture of membrane before I was brought to Labour Room 5 on the 1^st floor.

At the labour room, a nurse took my temperature and administered enema.  After a few minutes, I was directed to the toilet.  The toilet at the labour room was clean, dry and spacious.  This was the first time I received an enema before delivery although it’s a routine for most other moms.

Back to my bed at the labour room, a doctor asked me if I wanted epidural.  Between not knowing how painful a real contraction is and also not wanting to risk regretting a “no” later on, I said yes.  There’s no right or wrong as this is purely a personal choice of each individual… there’s always risk vs benefit in any procedure. 

Before the doctor from Anaethesia department arrived, I had my first taste of contraction pain in my whole life.  It came once in 10 minutes. “So this is what contraction during labour feels like… it was indeed very painful!”

The Delivery Story

I was relieved when epidural was finally on.  At least I could lie down in comfort for about an hour.  Had labour augmentation – not my decision, but the doctors’.  Two hours later, but at only 8 cm, I felt a very strong pushing urge and great pain. The magnitude of pain this time seemed 10 times greater than what I'd experienced before.

In the past, it took me seconds and minutes to deliver, because my elder babies had been small.  Alvin was born very premature at 29 weeks weighing only 1.16 kg, while Aaron was 36 weeks plus at 2.5 kg.

It took about 30 minutes of breathing-in, pushing and breathing out before Baby No. 3 finally came out.  He is more than 3 times Alvin’s birth weight. 

The delivery of Baby No. 3 had many people in attendance – doctors, nurses and medical students.  Initially, I wished my husband was there to witness, but his absence due to work was perhaps a blessing in disguise as I had a bit of complication in the labour room after that - it's not something that I want any family member to see because it might create unnecessary worry and fear.

The joy of skin-on-skin with the baby wasn’t for long before I suddenly felt a fainting spell.  I felt extremely dizzy, drowsy, and nauseous.  As much as I feared vomiting, I couldn’t resist it and ended up soiling the pillow and my hair on one side.  Fortunately I did not eat much in the morning or else it would have been more.

Fainting Spell and Deep Sleep

It turned out that I had post-partum haemorrhage (PPH), or tumpah darah in Malay.  The placenta was alright as it was delivered intact.  But for reasons unknown to me, my uterus did not contract after delivery (uterine atony).  I was given a few injections of hemabate, a second branula was inserted onto my other hand for the Hartmann’s solution.  A few other procedures took place but I was too exhausted to remember them.      

The last thing I recalled was that a nurse told me that they’re taking the baby to the nursery of the ward. Baby, breastfeeding, child care, etc. subsequently disappeared from my mind.  I felt uncomfortable in a way that I don't know how to describe, followed by as though going into a deep sleep, away and far from the reality (hypovolemia?).  I wonder now if that’s also what death feels like.

I spent the next 2 hours asleep in the labour room with my heart rate and BP monitored by the nurses until I completed my Hartmann’s drip, finished a cup of drink and half a cracker.  I had no appetite for food until the night.  

Conclusion

Back in the ward when I finally met my baby again, my breastfeeding challenge came back to me just like three years ago.  Colostrum only began to kick in on Day 2, on the day baby and I were discharged.  Prior to that, the nurses had given baby formula top-ups (note: breast milk is first choice, but I am alright with and agreeable to mixed feeding if necessary).  

On a quiet and sunny day...

I am relieved and grateful that the whole ordeal went generally smoothly, thanks to excellent care from the dedicated doctors and nurses, as well as the kind wishes and prayers from dear friends and family.  I am thankful to Prof Azurah for promptly getting me into early treatment and close monitoring. 

I used to wonder and in awe of how it feels to be complete the third trimester and deliver a normal-sized baby at term.  But then I am not that strong after all.  A 3.49 kg baby almost made me pass out. I wonder too if that’s why a full-term pregnancy is not something that would occur naturally for me, if not with interventions in the form of cerclage, weekly proluton shots and bed rest.

Baby #3: The Final Trimester Story

Fast forward into the third trimester, a few changes had recently occurred.

The brief return and decision

While I returned to work a week after cerclage, about 4 weeks later when I saw Prof Azurah during my antenatal check-up at the Level 1 O&G Clinic at PPUKM, she had advised me to be on medical leave until delivery.  Finally, after a thorough consideration between the pros and cons of working under the current circumstances, I have decided to be out of work for the time being in order to accommodate the need to rest post-cerclage. 

Goodbye workplace...

Moments of serenity and storm

The first 2 months post-cerclage had been smooth-sailing as far as cervical length was concerned.  

Storm awaiting beneath the serenity

However, during my last appointment at the clinic on 23/8/2017 when I was close to 29 weeks, my cervical length had suddenly decreased to less than 3 cm, with funnelling.  Oh gosh, that immediately decided that I shall spend the rest of the pregnancy with bed rest in the uncomfortable Trendelenburg position at former home sweet home Ward 2B and 2 doses of Dexamethasone injections to help speed up fetal lungs maturity just in case if touch wood, preterm labour occurs.

10, 3, 2, 1.....

Right now, I feel like a time bomb ticking away to deliver anytime… even when I’m just relaxing on the bed.  The fact that the doctors would ask me about any contraction, discomfort, leaking and bleeding each time they make their rounds, hints that I am highly at risk to deliver anytime.  

Although I feel heavy-hearted to be away from Alvin and Aaron for don’t-know-how-long, it’s better that I’m in ward now just in case of any emergency.  Otherwise, I cannot imagine how soon I can get to the hospital if the baby is suddenly going to make its way out.  With a cerclage inside, it’s even 

more dangerous.

Myth and fact

So it’s a myth that with an early elective cerclage, I can be spared from same episode of events that I once went through with Aaron. Nevertheless, what I am going through now is not totally unexpected when I changed my mind and decided to try to conceive for one more time.  

There’s a sole personal reason for trying for Baby #3, anyway let’s just keep it in the heart… Actually, I don’t mind adopting a child, but in reality, the chance of finding an infant available for adoption is even more remote than finding a needle in the haystack (note: with reference to non-Muslim child adoption). 

There's no why

I used to, and still do, wonder how am I born with cervical insufficiency? I've never had any operation done on that part of me that causes cervical insufficiency.  My mom delivered me a few days short of 37 weeks as she had PPROM at 36 weeks, and my brother at 38 weeks.  Other than GDM and hyperthyroidism, my mom had no other known issue with her pregnancy and delivery (the good thing about being a former staff midwife, my mom kept her antenatal record cards very well and they’re still around).  In any event, I won’t be able to know my family medical history fully because my mom was an adopted child and I’ve never met any of her biological family members.

As humans, we can only plan.  And to embrace whatever that comes with the decisions that we’ve made.

Prof Azurah told “I’ll be happy if you manage to hold on to at least 34 weeks”, and although I look forward to go home as soon as possible, deep inside, I feel that it’s my obligation to carry Baby #3 to at least the minimum target, or 36 weeks if things turn out alright (fingers-crossed).  37 weeks will be a miracle to me. 

Be strong..... 

(Source: Classic FM)

Despite access to a few books and internet, I do feel bored in the ward.  But I must stay strong for this last baby.  Between the baby spending a long time in the NICU and me having to stay in the ward for more than 1 month, the latter is better. 

Although the survival rate of preterm babies at 28 weeks and above nowadays is more than 90%, they nonetheless face higher risks for a list of health issues.  This explains why very preterm babies are required to attend multiple follow-up appointments at various departments after they’re discharged from hospital – to make sure that everything is fine, and to be referred for treatment or therapy if problem(s) are detected. 

Conclusion

Looking from a brighter side, I’d better take this opportunity now to rest and relax whenever I can before the baby comes out.  But at the same time, to take care not to stay upright for too long, even by sitting down and writing too much.  

I’m supposed to lie down as much as possible, something which wasn’t possible while I was on medical leave at home earlier, which is probably why I suddenly have funneling as the fetal weight increased.

From Arabin to Elective Cerclage: The 2nd experience

Here's an update on what transpired lately, from what's planned to what really occurred later on...

Part 1: The Arabin

As the Arabin insertion is non-surgical, it's therefore done in a procedure room instead of OT.  A pre-insertion TVS was performed to check the cervical length and to make sure there isn't any opening. A post-insertion TVS was done to ensure that the Arabin is properly in place.

As initially feared, and despite a repeated attempt, the Arabin pessary did not fit despite using one size smaller (the smallest available in stock at PPUKM).  Hence, the only option left was to have an elective cervical cerclage.

As for the Arabin which I'd purchased, it's been donated to the hospital instead of being brought home as souvenir since the latter will not serve any purpose.  Hopefully it will benefit someone in need and save a baby from being delivered too soon.

While waiting for Arabin insertion by Dr Rahana outside one of the rooms of Ward 1C

The Arabin pessary

Part 2: Elective cerclage

A day before the cerclage procedure at about 15 weeks ++, for once again, I had to check into Ward 2B.  The usual pre-op procedures such as branula insertion (received a green one… argh, painful), blood count, and review by doctor from the anaesthesia and intensive care department were all completed by the noon.

For unknown reasons, the caterer had missed out my lunch.  It was oh so frustrating as hunger and mood swing simply don’t get along.  At the same time, I did not fancy troubling the husband who had gone to work after sending and accompanying me to the ward earlier.  Domino’s Pizza delivery hence came into picture.  As normal appetite had slowly resumed, a pizza for just once in a blue moon should be alright.

Pizza for the Birthday Girl

D-Day

As the cervical cerclage would be done under spinal anaesthesia (i.e. half-body anaesthesia), I was required to fast for a certain number of hours before the procedure.  No food from 2 am onwards on 23/5, and no drinks from 6 am onwards.

Morning fasting

There wasn’t emergency cases at the OT that morning, so my cerclage this time – by Prof Azurah was done at about 10 am as scheduled.  Doing it on an elective basis this time, it was fast compared to previously when it was done on an emergency basis when Aaron almost followed Alvin’s path in arriving much too soon.

I felt alright throughout the procedure, except for a moment when I felt nauseous and as if passing out as my pulse rate suddenly dropped.  Dr Nabilah who administered my anaesthesia gave me an injection via the IV line, and I gradually felt normal again.

At the observation bay, I felt extremely sleepy under the cold blast of air-conditioner and probably slept for half an hour before I was taken back to the ward on bed, where I continued to sleep for a few more hours, with thick blanket covering my legs well into the hot afternoon.  Spinal anaesthesia could make me fall asleep very easily, although I was alert when called and could respond when people talked to me.

As this is the first time I was allowed to do things on my own upon gaining my sensation after the spinal anaesthesia (compared to previously when I remained on bed for the next 24 hours and hence wasn't really aware of what's going on because everything's taken care by the nurses), it's thus a new knowledge to me that there would be some spotting immediately after a cerclage.  The doctor who came and saw me assured me it's normal and should disappear within a few days.  I was discharged on the next day, following a Proluton (hydroxyprogesterone caproate) injection.  I was advised to rest and be sedentary at home, and advised to have a medical leave of 10 days. 

What's next

According to the plan, a Proluton injection of 250 mg shall be taken on a weekly basis until 34 weeks, that's if my body permits Baby No. 3 to remain inside for long enough - fingers-crossed. 

A weekly kiss

Apart from a weekly sting on the butt - oh gosh the Proluton suspension is quite thick, my antenatal check-up is expected to be at least every fortnightly for monitoring of cervical length, on top of the normal routine.  More than halfway through the journey now, there shall be no looking back, but to embrace everything that will come along the path, which includes taking that least expected path.  

The Beginning of Second Trimester and Ward 2B, PPUKM

Don't ask me why, for the sky is so high... After more than 3 years, I'm back in former home-sweet-home of 2 months i.e. Ward 2B of PPUKM once more.  The sight of mothers in labour, mothers with newborns, and the oh-so-familiar sounds of CTG machines everywhere are close enough to touch my heart and put my eyes to tears, although I'm still far from all these right now.

The surrounding compound 

A bit of here and there along the way
The second trimester had just begun and a few things had so-called "progressed" recently.

As contemplated, the plan itself is isn't complicated, but sometimes, involves a small degree of red tape.

PPUKM, or formerly called HUKM, is the nearest hospital with the necessary facilities and expertise from where I live when it comes to cases of high risk pregnancies, which include cervical insufficiency.

Obtaining a referral to the O&G clinic of PPUKM is straightforward, likewise obtaining an appointment.  However, when it comes to decision on further management, it depends on how soon the case gets elevated to a specialist.  For instance:

Flow of event
I have taken action very early this time.   At 5 weeks when things were still highly uncertain, I made an appointment with one of the Profs at UKMSC, whom I've met during my stay at Ward 2B in 2014. The waiting list is long, so the fastest appointment I could get is when I'm already 14 weeks.  There's been some changes in the list of doctors, e.g. Prof Jamil whom I used to see during Aaron’s time had retired while Dr Suraya who did my emergency cerclage back in 2014 is currently practising elsewhere.

At the same time, immediately upon confirmation that the baby is inside the uterus at 7 weeks, I went to my nearest ob-gyn Dr. Norshida for referral to the O&G clinic at PPUKM - public wing.  It was done, and I was given an appointment within a reasonable period.  Let's keep both options on and see which one works.

My first antenatal visit at the O&G clinic PPUKM was given on 26/4, which was close to 12 weeks. Routine tests such as BP and weight measurements, urine test for protein and glucose, and USG were done.  There was a 15-minutes session on breastfeeding by student-nurses that day.  Apart from HVS taken that day, but contrary to my expectation that some sort of decision may be available regarding what's next, I was told to return in 2 weeks' time for cervical TVS.

2 weeks later, I had my first check-up with Prof Azurah at UKMSC - the private wing as per my appointment.  Prof Azurah immediately remembered me when I told her about my previously dislodged Arabin, because apparently, at PPUKM, among the many success stories, I'm the tiny minority with an opposite outcome.

Prof Azurah expressed her surprise that I was not referred to her while at the public wing for check-up on 26/4.  Had my routine check-up, with an additional scan to measure the cervical length, which thank God was still within normal parameter for 14 weeks.

Arabin insertion at PPUKM: My history and now
Prof Azurah suggested that I should go for the Arabin pessary early this time, but I will have to be referred to the public ward.  Arabin and I, at first I felt great suspense, in view of how it failed in just 24 hours back in 2014, resulting in an emergency cerclage and prolonged bed rest in the ward until delivery!

(Note: The Arabin pessary is a device used for those with incompetent cervix for the prevention of preterm delivery - an alternative to cervical cerclage.  At PPUKM, depending on the case, it's the first in line treatment for cervical competence.  In Malaysia, the use of the Arabin is limited, mainly available at teaching hospitals)

I was asked to be admitted to the good old Ward 2B on Monday (today) for Arabin insertion by Dr. Rahana was Prof Azurah will be out of town the following week for examination.

Day 1 and precious Monday
Other than the familiarity which is the only comforting factor, it's pretty devastating to be informed in the late afternoon that the Arabin insertion will only be done on the next day.

The present scene

The reality: A mixed bag of good and bad
Other than praying that this time will be better than previously, trying to avoid as many physical activity as possible, and to stick to whatever diet or medication I'm supposed to take, there's nothing else that I can do to make sure that I deliver full-term for another time - for one last time.

Ahh..... many things are running across me right now.  I had an instinct that I should try for one last child for only one obvious reason, and I finally did.  But when I think again, I wonder why am I putting myself through so many challenges once more - have I forgotten about how the 2014 long medical leave crept into my work that I felt really blur when I finally returned to work?

Where I wish I am right now, besides home

The waiting time, the risk of yet another prolonged leave for bed rest if the Arabin fails once more, the risk of premature delivery is everything else fails, and the emotional toll for all these mess.............  Although people always tell that beneath all the hard work and pain, you'll finally see the blessing, keeping motivated isn't as easy as how I wish it is.

Three years down the line: Ward 2B of PPUKM in 2017
On a more positive side, it's pleasant to note that Ward 2B is still generally comfortable, and the 2 meals that I've had so far were better than back in 2014.  It's a different caterer now, the utensils used are different and feels more at home this time, the chicken rendang served during lunch was tastier compared to previously although the menu looked the same.

A layout that suddenly reminds me of Hospital Ampang when Alvin's still very tiny 

Tea at 3 pm

Conclusion
The ward is quiet today, and I hope it will remain throughout my stay.  I don't know whether the Arabin will work or not this time, I don't know when, where and how will Baby No. 3 come out, and right now, I am most concerned if I can safely carry the baby at least until early term.  How I wish I can be like those who are able to continue going to work even in the third trimester so that conscience remains intact.  Regardless of the outcome of this time, this shall be my last pregnancy, because this is my maximum threshold, after various rocky paths.

Year of the Goat. Happy New Year.

Today is the last day of the Chinese New Year celebration, popularly known as chap goh meh which stands for 15th night in Hokkien.  Happy New Year of the Goat...

(1) What lies ahead for the festive season
Prior to the long break as CNY fell on a Thursday and Friday this year, among the FAQs received were "When will you be on leave?", "Only 2 days, such a short break, is that enough?", "Where's your hometown and when are you going back?", etc.

(a) Flashback to a year ago...
As any other ordinary person, I can only plan.  But what ultimately transpires is sometimes beyond contemplation.  Last year for instance, it was totally outside my imagination that I was to spend most of the CNY "celebration" at HUKM.  Ended up spending my entire third trimester at ward 2B for 2 months, which felt a lot like living in a dormitory, with shared bathrooms, makan ramai-ramai, the purple uniform, and a fixed daily routine.

Anyway, despite the dread and boredom at first, it was overall a pleasant experience after getting to know some new friends.   Lots of time to rest and sleep, but couldn't help missing the little guy at home.  While others enjoy yee sang and an array of festive dishes out there, I was only confined to bland hospital food.

It was the 9th day of CNY when threatened preterm labour occured (also at 29 weeks) and I was transferred to the HDU for tocolysis before undergoing the emergency cerclage.  Thankfully everything turned out well and Ken-ken did not come out during the CNY period.  "Be patient baby... the angpows can wait until next year..." I thought. 

(b) Cuti-cuti New Year
I only took a day off on CNY eve and another a day off post-CNY weekend.  After skipping Ipoh last year, we went there on the 3rd day this year to the home of my cousins+aunts in Bercham.

Scene along the PLUS highway.  

(This is an old picture taken a few years earlier... not during the recent trip)

Alvin was in a rebellious mood.  The rebellion was probably further aggravated by a previously-unknown fact that he's car sick, as he had never puked in car prior to this.  Puking can be traumatising to a young child, and worse when it occurs in a strange place.

Speaking of Alvin and some of his behavorial/sensory issues...  It's NOT TRUE that Alvin's rebellion is due to seldom going out, as what a few concerned relatives said to my parents-in-laws.  He was seldom exposed to crowds before he turned one due to low immunity as a very preterm baby... but after that, he started going out, unless he's having flu or something like that.  I swear that he had been to more places than me at the age of 1+ compared to when I was 5 (i.e. visits to local attractions, not overseas). But then this is my fear... how to bring him to people's house without his  resistence?  Tak bawak kang unfair to him...

Maybe this is related to prematurity as very preterm babies are born with immature brains.  Or maybe it's not.  If by God's will, things works out successfully, I shall try to share them here for the benefit of those under the same shoe.   Issues may not end upon discharge from the NICU, no matter how positive things appear to be at first.  The longer your baby stays inside your womb, the better it is... even by a week.  I don't know whether to be happy or otherwise, but I have probably been chosen to walk a path that differs from the majority... and parenting an ex-prem baby may or may not be the same as for other children.

Despite being a brief, simple and impromptu one, the one-day trip to Ipoh was memorable indeed.  From meeting up with family members whom I've not seen for a long time to passing through places that was once a part of me, I cherished them a lot despite already not feeling well a few days earlier... oh my sorethroat!

(2) The voiceless CNY
On 1st day of CNY, swallowing felt painful to me.  Body temperature was up at 38 deg C by evening.  All clinics around my place, including non-Chinese doctors, were closed for public holiday.  The only safe home remedy available?  PCM and Difflam lozenges.  Tahanlah dulu....

The same thing persisted on the following few days, coupled with cough later on.  I lost my voice completely on Sunday (Day 4), a day after the visit to Ipoh.

On Day 5, when the panel clinic resumed operation, I went to see my regular dr.  I had no voice at all, thus wrote everything on a piece of paper and showed it to the dr.  Fever was still on after so many days... although just very mild.  A medical leave of 2 days after the CNY break was a lil against conscience, as if taking advantage to sambung cuti.  But, commit no fault and hence fear nothing...

Remaining silent, especially when in front of the kids was very odd esp when they are too young to understand why you're suddenly all-quiet with them.  Then they'd frown in front of you, as if wondering why, when they hear your strange voice.

(3) Conclusion
Today, on the 15th day of CNY, my voice still has not fully-recovered although improvement is starting to be more visible now.   :p

Fortunately the voice came back early this week or else I might have to miss the sponsored CNY luncheon again at my workplace.   It's very thoughtful of the management to organise such an event for its (minority) Chinese employees, so how could I have the heart to skip it... unless I genuinely couldn't be present, as in last year?

Part 3: Hello Brother of Alvin

Introduction
Due to constrain of time, this post is almost half a year overdue by now.  Instead of discussing on my 2-months experience as a patient of ward 2B, today I would like to jump into Part 3 first - my delivery experience at HUKM, the arrival of Alvin's brother:

Removal of cerclage
For first-timers who wonder how does the removal of cerclage feels like, it is painless, done without having to go to OT, and takes only a few minutes (note: speaking of cerclage done via the " v ", not abdominal cerclage). 

A cerclage is normally removed from the 36th week onwards.  In typical cases where contraction is absent or when the os is otherwise still closed, these patients will be discharged... and will only return when it's time to deliver.

On Monday, 31/3/2014 at 9 am, I was sent from ward 2B to the labour room - Room No. 1 (LR) for removal of cerclage, and possibly delivery on the same day.  Prior to that, I was told not to eat after breakfast - a precaution just in case if a c-section is required... you'll never know until the time comes.  And prior to the removal, a CTG was done in the LR.

 Labour Room no. 1, 1st floor, HUKM

But I was in the middle of nowhere...
In Part 1, I had mentioned about an opening of 2 cm prior to admission into the HDU where I was tocolysed before undergoing an emergency cerclage.

Upon removal of cerclage, the os was already 4 cm.   However, there was no contraction at all. To induce, or to return to the ward and risk everyone getting "kelam-kabut" if suddenly I felt like delivering?

Epidural vs. no epidural
At HUKM, the doctor readily asked if I would like to have epidural.  Cost-wise, I did not see it being included in my bill - I wonder if it's free, or only at a very minimal charge? :)

My initial principle was to have everything as natural as possible with minimal intervention (I later betrayed that so-called principle but arguably it's for good).  The devil in me suddenly changed my mind when I heard someone screaming in pain from a neighboring room .  Thinking of it now, my fear might not be unfounded for after all, I was already distressed by the long stay in ward, and did not want to aggravate what's already there by undergoing tremendous pain... One may or may not agree with this, so it's entirely a personal and subjective decision.


"Hot soup" and epidural is not 100% pain-free
Induction of labour:  This is my first experience going through an induction.  The membrane was first artificially broken.  I felt a gush of warm fluid slowly flowing out.  It felt so much like hot soup.  From the CTG, I could see a rise in fetal heart rate, which went back to normal 15 minutes later.  Adik must have been irritated by the sudden 'disturbance'.. haha.  The pitocin drip was administered 30 minutes later.

Epidural analgesia: A little similar to spinal anaesthesia, but they are not the same.  With epidural analgesia, contraction, VE and suturing were all pain-free... but not when the baby started crowning where sakit bersalin tetap ada...  despite having it.

A brand new experience
With epidural on and half a pint of pitocin left, I was relaxing myself when I suddenly felt a very sharp pain as if something was poking my pelvic real-hard.

I'm by nature a person who does not scream easily, yet it wasn't easy restraining myself from uttering some "uhh" and "ahh" every now and then.  This was definitely nothing like what I went through with Alvin... this was a totally new experience for me.

I called the nurse, and 2 of them came in.  One of them did a VE and told me "wah, cepatnya sudah 7 cm.... awak akan bersalin ni".  The nurses had helpfully guided me until the baby came out.  The whole process didn't take long.

If I remember correctly, the baby took 5 minutes from when I began to push to be out.  The reason why it's fast is not because I'm strong, but an incompetent cervix probably makes it easy to get the baby out.

Deep breath in, hold the breath, push... then breath out.  I do not remember how many times I repeated that, but beneath the pain, I was filled with gratitude for the brand new opportunity to share similar experience as what typical mothers who carry their pregnancies up to 9 months go through.  If a baby of 2.51 kg is enough to give rise to so much pain, imagine moms of truly full-term babies whose little ones are 3 kg and above.

The first touching moment was when I heard adik's first cry...  It was very loud, very loud indeed (to me as one who delivered a near-term baby for the first time ever).
NB:  It's still fresh in my mind that I all heard of Alvin at Hospital Ampang some 22 months ago was some faint "weeeee"-sounding cry, which is expected in the case of a very preterm baby due to immature lungs.

Another moment that felt touching to me was when the nurse put adik onto my body for about 10 minutes before cleaning him up.  All these, were my first experience although I was by no means a new mother when adik came along. 

As soon as the epidural was off, I felt a little dizzy and had no appetite to eat the sandwiches served at the labour room.  Gosh, while I felt generally well with spinal anaesthesia except for urticaria on both legs, I felt sick after the epidural was off.  Fortunately I did not eat anything in between meals, or else imagine the possibility of puking... something which I fear very much. 

The 1st few days post-delivery
Due to an unforeseen reason, both adik and I did not get to go home on the next day although moms of typical SVD cases are usually discharged the next day.

Conclusion
I was advised that if I get pregnant in the future, I must come in for early booking.  An elective cerclage will be necessary, and should be done early at 16 weeks.  Which means a cerclage is a must each time I am pregnant.  And hopefully will not have to be on long stay in ward.  If God lets both Alvin and Aaron grow up smoothly, I should preferably not be pregnant anymore in view of some realities that seriously require me to stop playing with risk.

Although unplanned, I am nevertheless grateful for the arrival of Aaron despite the close age gap with Alvin. It will be an uphill task upon the family to simultaneously take care of 2 very young children at home but I believe there is a reason behind everything that occurs in life, why at this time and so on.

The next challenge will be a test upon my skill and patience in maintaining a balance between my existing routine, caring for and teaching them what they ought to learn... oh God, please guide me to the correct path in order to carry out my responsibilities with strength, fairness and patience towards them both.  Right now I am still far from doing enough for the brothers, let alone feeling like a good parent. 

P/S:
I appreciate and would like to express my gratitude to the following persons, including those whom I saw earlier before going to HUKM:

- My first ob-gyn Dr Norshida of Columbia Asia Cheras who did my antenatal check-ups during my first and early second trimesters;
 - Prof Jamil who did all the detailed scan and very thorough check-ups during my second trimester;
 - The good doctor and nurses at KKIA SK... I've gone there a couple of times for the sake of  getting the 'buku merah';
 - Dr Aqmar Suraya for promptly referring me for admission into ward 2B and doing my difficult cerclage which in turn had saved Aaron from being born at 29 weeks;
- The soft-spoken Prof Azurah for giving me the green light to go for the emergency cerclage;
 - The registrar and all the medical officer whom I've met either at the ward or HDU ... I was under "team hijau"; 
 - All the good HO and kind nurses who had worked very hard in monitoring and providing care... am thankful to the nurses for their patience in guiding and encouraging me when breastfeeding was initially a major headache + heartache - Despite frequent latching, I had zero milk for the first 3 days (will talk about that topic one day);
 - The medical students, nonetheless. All of them were very professional and in my heart I wish them the best;
- My ward-mates cum friends.  We had great times together, and I was happy to join a recent reunion with them at Iera's home recently; and
 - My husband for coming in every evening after work, my parents-in-law and sister-in-law for coming over whenever they're free although Seri Kembangan is not very near to HUKM... cousin Vernon for texting in to ask how I was doing, and friends who either came in physically to visit or gave me words of encouragements online.... Thank you Azies and family, Paul, Moganah & husband, Lidia, Maliz, Aimi, Fahmi and Ahmad for coming over to HUKM for a visit / my home /delivering the gift to me at home.  Thank you to my dear colleagues for the cute hamper from Chomel Store.  :)      

Part 1: Eventful 3rd Trimester at HUKM

Hello to all my dear readers,

It was indeed a long hiatus, being away from updating for the past 6 months.  How time flies and we're already in the third quarter of 2014.  I was in HUKM for a total of 2 months, plus another 3 months of maternity leave.

Aaron is Alvin's brother, and he's slightly more than 3 months old now.  I personally prefer calling adik Ken-ken (it's part of his Chinese name) so that Alvin may learn to call his brother sooner because it's easier to say "ken-ken".   

Introduction
My journey this time began almost the same way as previously - antenatal check-ups at Columbia Asia Cheras during my first trimester, KKIA in the second trimester, and subsequently went on to HUKM (to UKMSC first, later referred to the public wing).  Don't know what suddenly drove me to HUKM this time instead returning to Hospital Ampang as initially planned, or to Hospital Serdang as it's the nearest to my home, but I just had a strange feeling that HUKM would be the right place.

Before it All Began.....
Prior to admission to HUKM, I had received 2 doses of IM Dexamethasone at 28 weeks.  This was how I spent the 2nd day of Chinese New Year - a journey back-and-forth HUKM once in the morning and another at night.  These steroid injections were given in view of the risk of a recurrent premature labour, to help speed up fetal lungs maturity.

Also, in view of the complaint of "heaviness" on my lower abdomen during my first pregnancy from the 25th week onwards, I also did TVS this time on top of the usual scans during my antenatal check-ups, to monitor my cervical length.  That's because such "heaviness"sounds a lot like shortening of cervix, which in the past, I didn't realise was a red flag until a year later.  

Source: NICHD

So, to all pregnant mothers, should you feel pelvic pressure / persistent heaviness on your lower abdomen when you're only in your second or early third trimester, please seek your doctor to check your cervical length because it's not normal to feel heavy so early.  Cervical incompetence is very rare, but it happens and for unknown reasons, I just happen to be among the minority. 

 Treatment room of Ward 2B

The Arabin Pessary
My cervical length appeared normal until the 28th week.  The first line of treatment offered to me was the Arabin pessary.

Source: www.dr-arabin.de

The Arabin is a "ring" that is made of silicon.  It serves to prevent further shortening of the cervix. It's painless, non-invasive, and can be inserted within minutes.

That Fateful Night when History Almost Repeated Itself
I was still in the ward for observation a day after the Arabin was in.

On history almost repeating itself...  It was all too familiar that I did not even panic, but instead I calmly finished my (super-plain) dinner before calling the nurse.

 The meals served at HUKM are very plain... mostly boiled, and it's difficult to describe what the taste is like.  I'm neither a fussy eater nor someone who likes to comment about food, but I have to say that the caterer who's awarded with the tender could have done better.  This comes from my experience of eating the food provided for 2 months and I actually lost weight there although I was supposed to gain some.

Back to the threatened premature labour, I saw blood coming out the same way as previously, but didn't feel any pain.  There was contraction, as shown by the CTG, but I did not feel anything. More dreadfully, the internal os was already 2 cm opened and the bag of membrane was visible.

The CTG... number in red is fetal heart rate while the one in green is contraction.  At the time when this is captured, contraction was only very mild.

Although I looked calm and kept quiet, I was already into "Oh no, I've caused a blunder... another one into the NICU... I'm losing the battle despite being super careful." 

That Saturday night itself, I had consumed don't-know-how-many nifedipine tablets - that oh-so-familiar pill!  I had lost count.  Note: Nifedipine is an antihypertensive drug, but is used off-label as tocolytic agent to stop uterine contraction.

Three Days in HDU
The O&G HDU of HUKM is located on the 1st floor.  Just opposite the OT.  It's blasting-cold, very quiet, and isolated.  

I was on nifedipine for a total of 5 days - 3 days pre-cerclage and 2 days post-cerlage.  BP and pulse rate were closely monitored (nifedipine may cause low BP for a non-hypertensive person). It's feels "rimas"i.e. highly-uncomfortable to be hooked on multiple wires.  I believe such discomfort is not even a fraction of what my first-born Alvin felt in the NICU and I have to salute him for his strength even though he's only so small (1.16 kg). 

As I was prohibited from standing up and walking (including no toilet visit), I was on CBD, which was highly uncomfortable each time I tossed myself. As for eating, I was only allowed to sit 45 degrees.

The Mother of all discomforts?  Bed on Trendelenburg position = legs up, head down.  The reason for such position is in order to minimise exerting pressure onto the cervix.

Buttons of "my bed"... just a finger away to adjust the bed position.   Sometimes I 'curi-curi' reduced the slant of my bed in order to gain greater comfort, but at the expense of doing myself a disfavour actually.

Compression Stocking and blood clot
A person who's bed-bound is at higher risk for blood clot.  As "simple" as it may sound, it's not something to be taken lightly.  

Compression stocking, or TED stocking is available at the pharmacy of HUKM for RM80 per pair.  It's cheaper in comparison to pharmacies outside.  The stocking is long and very tight, serves to prevent blood clot in the legs.  

The reason why a blood clot is dangerous is that the clot is capable of moving upwards.  If it goes to the lungs, then it will cause pulmonary embolism.  May be fatal if not careful.  So,this is the reason why doctors always emphasised on wearing the stocking at all times during the bed-bound period. 

The Cerclage Experience
That's right... 29 weeks. 

A cerclage (pronounced as "ser-klaj") is usually done at around the 16th week.  In simple words, it's placement of stitch onto the cervix to prevent preterm delivery.

Just like any other surgery, whether major or minor, it comes with some risks.  The outcome is normally good when it's done early.

I was initially not feeling optimistic because my pregnancy was already at an advance stage.   But for a while, I felt on top of the world when Prof Azurah told me I could go for cerclage. 

D-Day
It was February 11, 2014.  I was really hungry because I was required to fast.  The sight and smell of yummy food from neighbouring cubicles were tempting yet irritating.  Irritating because it challenged my patience even further.

 This cup is great for drinking while lying down... provided at the HDU.  In moments of hunger and thirst, I took a few sips of water when no one's looking.  I am not as obedient as people think...

The Spinal Anaesthesia Experience
The cerclage was done under spinal anaesthesia (sitting down hugging a pillow, 3x injections on the back).  I find spinal anaesthesia very "pleasant", my legs felt hot at first, followed by a loss of sensation within minutes.  I felt extremely relaxed and sleepy.  I didn't expect spinal anaes to make me as sleepy as this.  There's no nauseousness, but my legs were full of hives post-op.  The antihistamine Piriton had aggravated my sleepiness and I ended up sound asleep for 4 hours straight post-op.  This is only spinal, if it's GA, I cannot imagine how long will the sleep last.

Back to cerclage, it was 2.30 pm by the time I was taken to be OT.  Dr Suraya did mine.  This is the first time I went for an op. 

My comment about the procedure?  It's painless during as well as post-op.   I was relieved that it's finally done... Prof had initially set a "target" of 32 weeks for me, followed by 34 weeks (another round of IM Dexa b.d.), and finally 36 weeks (successful treatment, thanks to the great doctors and nurses at HUKM, yayyy!). 

After cerclage, I spent a total of another 2 months in ward where  I continued with bed rest in Trendelenburg position and weekly Proluton injections.

Coming up next... in Part 2, or Part 3:
1) Out of HDU and how I spent the remaining of my days in HUKM, meeting friends, living a life of Sleeping Beauty (what beauty is there in me?);

2) How I find it at HUKM.  The people, the food, the environment, medical students, and other stuff;

3) The day of cerclage removal;

4) The arrival of Aaron; 

5) What lies ahead should I become "p2 g3", which I pray hard that I will not need to go through.

6) Another few days in ward. I was very stressed at first, but later thought it's probably a blessing in disguise in some ways.