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.

The 3rd and Last: A 1st Trimester Overview

Instinct is illogical, but true - as what a few experiences in the past had taught me.  This time around, the so-called logic side of me still wonders if I have stepped into the right path or otherwise, although the decision between "yes" and "no" was made more than half a year ago.

More than halfway through the 1st trimester now, here's sharing the experiences so far.....

Appetite
I tend to eat more properly in the morning, but for lunch and dinner, I can only take half the amount of what I used to consume.  I have a dislike for rice right now, so other sources of carbs seem more palatable.

Night sickness and run down
Sicknesses in the form of nauseousness if I consumed the wrong food, or sometimes for no reason tend to occur between evening to night.  Got to trust my intuition when eating, and refrain from what causes discomfort or gives rise to a cold throat sensation e.g. rice, too much meat, soft fruits, carbonated drinks and slimy food like yogurt and half boiled eggs, and got to brush my teeth very quickly... it's a compromise on oral hygiene, but what to do?  And by 9 pm, I'll be completely run down.

Sensitivity and that weird metallic taste
Highly likely due to rapid hormonal changes, my digestion is much slower nowadays, and my stomach feels gassy quite easily either with the consumption of food that I can't tolerate right now, or if I am too hungry.

I feel a weird metallic taste in my mouth during certain times of the day.  The bitterness is worst after I eat anything sweet.  I also find that plain water tastes bitter, unless it's lukewarm and so, I only drink warm water nowadays.  Or if it's room temperature or colder, it has got to be lime or lemon juice - I'll try to make it very dilute to minimise harm to the teeth.

Scent oh scents....
Slightly different from the past experiences, this time, I have repugnance towards certain smells, e.g. flowery scents from perfumes, body washes and detergents (so I refrain from going into a bathroom immediate after anyone takes a bath), the smell of cooking especially garlic and spices, and most notably, the smells of various ointments such as minyak angin, Yu Yee oil, Tiger Balm, Vicks, and generally any menthol-smelling stuff.

I feel bad at work where there's this lady janitor who is very nice, but unfortunately I felt immediate discomfort when she comes near with the flowery-fragrant spray which she carries around.  It's like having to avoid a person whom I have nothing against.  In order to mitigate the obviousness, when she comes near, I'll walk somewhere else, e.g. to the washroom or pantry, or on the pretext of ensuring that I do not block her space in performing her duty.

Dislike for what I used to like
No fresh milk, no meat especially fish, meat-based soups, no spicy food, no butter, and no rice.  I only feel like eating steamed vegetables, vegetable soups, fried egg and tofu. My former savior mandarin peel also tastes weird to me this time. Gosh, apart from daily folic acid supplement, how to avoid becoming anemic?

Food crave for the first time
In the past, I did not have craves for any particular food.  But for this time, I crave chee cheong fun and would have it a few times in a week.  As the signature mushroom gravy that's popular in dear hometown Ipoh is not available here, the best alternative would be curry gravy - without additional chili paste because the stomach can't tolerate hot stuff at the moment. Prior to this, I am not a fan of chee cheong fun and used to take its abundance for granted when I used to live in Ipoh with my parents.

Got to feel it to understand it
My pregnancy with Alvin was emotionally alright, although I was missing my mother dearly for she had just departed 6 months before Alvin's conception.  But I suppose it's normal for anyone to feel that way regardless of physical state... and further, who isn't keen to share a happy news with a loved one?  With Aaron, my state of mind was alright despite having to stay in ward for a long time, I felt occasionally bored, but upon knowing my ward-mates better, I gradually felt more at home.

I used to wonder whether emotional roller-coaster during pregnancy is a truth or myth.  Although I've frequently heard of it and think that it may be true, I had no experience.  So when one hits me this time, I really have no words to describe it.

Teary spells and thin ice
A short video or advertisement featuring a cute baby, or even a cute puppy could turn on my tear mode.  On one fine morning when I saw two ambulances near Hospital Serdang while on my way to work, I was almost moved to tears as I was suddenly reminded of my mom.  But strangely, I did not shed any tear with my mom's sudden demise 6 years ago (it was unexpected as she appeared energetic and healthy right before that), and was able to take it positively despite missing her deeply.

I have no idea how long this will last, but the current phenomena makes me feel like walking on thin ice when I easily get snapped by common remarks by close folks around me for trivia things. Hopefully baby no. 3 will no absorb this vibe somehow or else baby will turn up as cry baby.

Conclusion
Not wanting any disappointment later on, I shall not over-expect things around me.  And never underestimate the influence of hormones upon the body and mind.

I'm glad that so far, I've been going around without spotting (or threatened abortion), unlike the past 2 experiences - fingers-crossed.  The pregnancy symptoms started very early this time - good appetite at week 4, but started to feel the opposite from week 5 onwards, and a mixture of feelings until now.

I am quite afraid to think of the risks of various stuff, but it's a fact that all pregnancies come with risks.  If everything works alright, I'll go for an elective cerclage later.

Let's take one thing at a time and see how it works.  If the baby can sit in safely until early term, then I shall be more than thankful.  Boy or girl, I shall not care much since it's already determined once conceived.  I don't know where I want to deliver this one, which will depend on convenience as well as fate.  God please let everything be smooth and safe this time, no long medical leaves like previously, and most importantly everyone at home is prepared to embrace a new person, if this new person safely arrives into the world.