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Whose crazy? Me or my OB? Re: Triplet Preterm Birth

post #1 of 52
Thread Starter 
Okay, complicated situation here and I would really appreciate some advice. I am presently 32 weeks pregnant with triplets and by all signs doing okay (no high bp, cervix long and thin, babes growing well, no contractions) -- really I feel very blessed.

Here is the clincher: I have a classical / vertical uterine scar from my DD's emergency c-section (I mean EMERGENCY, like done in an emergency room); It is so big and so different from most (all?) c-section scars that doctors think I had my spleen removed or assume that my c-section was done in a 3rd world country (that's not a joke, I've gotten it several times). My OB was quite worried about the scar intentionally and tried to convince us to reduced the pregnancy to twins. The main concern with this scar is uterine rupture; the risk is somewhere between 4-7% with a singleton pregnancy and it jumps to about 10% when in labor. These are the high ends of the risk percentages (I'm trying to give my OB the benefit of the doubt). With 3 babes, obviously my uterus is strained and therefore so is the scar; My OB puts my risk of spontaneous uterine rupture (w/o labor) at somewhere near 8-9%, which is not nothing, but it is also 92% chance of not rupturing.

Okay, so I live an hour away from any major hospital that could help me if my uterus were to spontaneously burst open. It was always talked about that I would need hospitalization at some point, if not for a high risk pregnancy condition (like high bp or cervix change), than for the risk of rupture. Docs are ready to admit me now, but I talked them into admission in one more week w/ a sincere commitment to call w/ the slightest of pain (biggest sign of rupture).

That's all background; here is the dilemma. My OB would want to take the babes via c-section at 34 weeks, solely out of concern that my uterus would not be able handle the size of the 3 babes, plus their placentas. I am arguing to be able to keep the babes in until 35-36 weeks (should I be so blessed), stating that I would be in the hospital should anything go wrong (this is also assuming that I don't develop any of the other possible risk factors). He was very reluctant to agree to this; I have an MPH in maternal/ child health and was able to rattle off numerous risk factors for babes born prematurely. He then said he would want to do an amnio at 34 1/2 weeks, to check for maturity. This amnio may give him some info on how 1 babe might be doing lung-wise, but it does not speak to the other two or to how their brains are developing or to iron-deficiency, etc, etc.

So, what do you think? Who is being more crazy? Me, for being willing to stay in the hospital longer, possibly putting my uterus at risk for a longer gestation? I do have an older DD who I feel a tremendous since of responsiblitiy to; I can't go and die for these babes to have one more week in the womb; that said, my chances of dying should my uterus rupture is tremendously low if I am in the hospital. I do of course risk a major surgery, possible hysterectomy, major blood loss, etc.

Or is my OB crazier for not giving me a week to week option after 34 and 1/2 weeks? Is he underestimating the potential risks for my babes because he is so focused on my classical incision.

For what it is worth; He is the "best" high risk OB within 5 hours; I really don't have an option to switch docs at this point. While I have not agreed with everything he has said, he has listened to me and at least given me the time to argue my side of each issue. For those of you who might remember, this is the same OB who said my weight gain was "excessive" when I had gained about 42 lbs by 30 wks; I told him I wasn't worried about it and the extra weight would be needed to help nurse these 3 little babes. This last appointment, I am up to 48 lbs and he said I had excellent weight gain??????? Who understands these people???

Oh, one last thing. To give you an idea of my size, I am tall 5'8" (so apparently that helps b/c I have a bigger uterus); the babes are measuring around 4lbs a piece (if you believe those u/s machines HA!); my uterus measures about 56cm top to bottom and I am about 48" around......wow that is scary to type.

All opinions either way are very welcome. I really want to understand if I am not seeing the light here.
post #2 of 52
That is a really tough call. I think that you are doing the responsible thing by going into hospital and staying there "until". Nobody knows what will happen, but with you being in the hospital should anything go wrong, I don't see why you shouldn't go for as long as you can. You are giving your babes and you the best chance. I had a discussion with my ob as well about some test that he wanted me to do and in the end it was to cover his butt legally. (I decided against doing the invasive procedure becaue there was no real medical reason). Could it be that he is trying to cover himself in case something goes wrong? If the stats say that you are in a better situation being in hospital when this happens, why would he take them out early? You have to weigh his concerns for you with his own agenda and legal concerns for himself. I know you will make the right descision.
post #3 of 52
I agree with you. I think going into the hospital next week and carrying the babies as long as you can is the best idea.
post #4 of 52
Quote:
Originally Posted by nummies View Post
I agree with you. I think going into the hospital next week and carrying the babies as long as you can is the best idea.
I agree with this. I don't have any medical training or experience, but I can't help but wonder why he'd want to do the c-sec so early if you're in the hospital and being monitored?
post #5 of 52
Congrats on doing so well with your triplets!

It seems to me staying in the hospital is a reasonable precaution. And I can respect your OB's caution. But I'm a believer that every extra day you have those babies in is good for everyone, babies, momma, DD1 and DH. You'll have more developed, bigger newborns. If you are as careful as you can be, and are willing to take the small risk of letting them come in their own time, more power to you! And if waiting is the plan, there's NO need for amnio. Why add another risk. Either the babes come on their own sooner, or they have more time to practice breathing.

Forgive me for having strong opinions when I'm not fully informed. I don't really know the risk with a classical incision, and don't know much about triplets.

Hope you can work this out with your OB without it becoming a fight. Tell him you understand the risks, and are willing to sign whatever waiver he'd feel comfortable with, but that you want to give your three every extra day you can!
post #6 of 52
I also think being in the hospital is the correct choice "just in case" but if I were there I'd probably push for every single day I could get. I'd probably try to get myself to 36 weeks, honestly, for all the reasons you stated. You're already bigger than I was at 39 weeks with my twins though, so I can't even imagine the strain your body is under!

I'm wondering if you had a double layer suture on your incision? I would think probably so since you had such a scary cut, but do you know for sure? According to what I understand it's much more durable and decreases your risks of future rupture. If I had a double layer I'd be a lot more comfortable going longer, kwim?

Congratulations on getting to 32 weeks Mama! I'm praying for you guys. 4 more uncomplicated weeks for you and your babies!
post #7 of 52


Good job growing the babies!

And then, I would ask yourself what you *really believe*, intuitively (or from God), regarding the risk of uterine rupture; I'd base decisions re: hospital admission and birthing date on that sort of 'knowing', as well. Our bodies are so much more than just physical vessels.

I'd also refuse an amnio for the practicality issue that you stated.

It sounds like you are doing an excellent job in partnership with the OB. Try to continue using your heart and brain till the end! If you don't agree with the OB, state your reasons and offer to sign whatever waiver he feels he needs for liability release. In the end, they are your babies, not his. You will have to breastfeed them (much easier with term babies than 34 weekers!), not he.

We're here for you. Keep us updated.
post #8 of 52
If it was me, I wouldn't let them pull before 36 weeks unless they could show me some sign that the babies were at risk. As to being admitted, if it get the doc off my back and let the pregnancy go longer, I'd be admitted.

I personally am against C-sections unless it's an emergency. But given your particular situation, you are a pretty risky vbac. They probably will try to induce you and knowing them they'd botch it and cause you to rupture. I might consider the c-section but only when you were ready for them to be born, not on the doc's timetable.
post #9 of 52
I am leading towards agreeing with you. I would be concerned about your uterus but I don't think I would let them take the babies at 34 weeks b/c of it. At that gestation, a lot can still go wrong, kwim? Since he is wanting you in the hospital, how about you guys meet in the middle? Go into the hospital next week until the babies are born and whenever you start labor, I would just let it go. If that is next week or 4 weeks from now. It's a tough call but you have to go with your gut on this one. Also I would not do the amino, but that's just me.

GL and congrats on making it to 32 weeks w/o any complications! My friend is 23 weeks pregnant with triplets (b/b/b)and not having good run right now. She was admitted to the hospital 2 days ago with a thinning cervix and mild contractions. They did an emergency clerage on her and she is staying in there until her babies are born.
post #10 of 52
I think you are reasonable.
To be fair to him, each day they stay in increases HIS risk. Right now, getting them OUT of you ENDS his job in the matter. He is an OBGYN. He's not a PED, which means that frankly, the babies aren't his concern. (I'm not saying he dosn't care at all about them, he might be a very caring man for all i know) But right now, each day they stay in you in another day something might go wrong ON HIS WATCH. By getting them OUT of you, he is done. His risk, his worry, his stress is over and done with. So, from his POV, to him, getting them out is all pro and no con. Leaving them in you is much pro but also a little con. If something were to happen, rupture, or abruption, eclampsia, heck, fricken heart attack, it's his failure, his fault, his blemish on his record.
So...when making your decisiosn, just know that while YOU have both of your sides to consider, your health AND your babies, he really only has the one...by 34 weeks, your kids would live, and probably be mostly fine, even completely fine, and for HIM, that's good enough. But you are obviously their mother, and probably want more than "goog enough" for them, you want what is better, even what is BEST. And that probably means trying to keep them in a little longer.
It's a hard decision though. Each day they stay in gains them something in development, but increases your risk or rupture or worse. Getting them out erduces your risk drastically, but also puts them at higher risk of having devlopmental issues.
Use your heart, use your mind, use your soul.
Honestly, the fact you are at 32 weeks with no problems is amazing. One way or another, chances are very good that in 2-4 weeks, you and your 3 babies will be happy and cuddling with each other. Good luck.
post #11 of 52
Quote:
Originally Posted by bobandjess99 View Post
I think you are reasonable.
To be fair to him, each day they stay in increases HIS risk. Right now, getting them OUT of you ENDS his job in the matter. He is an OBGYN. He's not a PED, which means that frankly, the babies aren't his concern. (I'm not saying he dosn't care at all about them, he might be a very caring man for all i know) But right now, each day they stay in you in another day something might go wrong ON HIS WATCH. By getting them OUT of you, he is done. His risk, his worry, his stress is over and done with. So, from his POV, to him, getting them out is all pro and no con. Leaving them in you is much pro but also a little con. If something were to happen, rupture, or abruption, eclampsia, heck, fricken heart attack, it's his failure, his fault, his blemish on his record.
So...when making your decisiosn, just know that while YOU have both of your sides to consider, your health AND your babies, he really only has the one...by 34 weeks, your kids would live, and probably be mostly fine, even completely fine, and for HIM, that's good enough. But you are obviously their mother, and probably want more than "goog enough" for them, you want what is better, even what is BEST. And that probably means trying to keep them in a little longer.
It's a hard decision though. Each day they stay in gains them something in development, but increases your risk or rupture or worse. Getting them out erduces your risk drastically, but also puts them at higher risk of having devlopmental issues.
Use your heart, use your mind, use your soul.
Honestly, the fact you are at 32 weeks with no problems is amazing. One way or another, chances are very good that in 2-4 weeks, you and your 3 babies will be happy and cuddling with each other. Good luck.
Whoa. That's one of the best assessments of obstetrical risk management I've ever seen typed out. Kudos.
post #12 of 52
The stats on uterine rupture say 34-39 weeks is when most ruptures happen. Carrying triplets puts you at well past a 34-week size uterus. I think going into the hospital and getting steroid shots to speed lung maturity is the safest thing to do. But I'm not the one in charge of 3 little lives, and with a 4th child at home. Yes, every day in is 2 days of a NICU stay saved. And even at 35-36 weeks babies can have GI and feeding issues.
My only thought is getting them into the world safely is priority #1. And even if you are monitored, a catastrophic rupture would most likely result in fetal morbidity (brain or other organ damage) if not mortality - or maternal mortality depending on how close to the artery the uterus ruptures. Even in a planned C-section, it takes 5+ minutes from first cut to get the first baby out, and that depends on the amount of scar tissue and bleeding. And that's prepped already in the OR, with a scrubbed, awake OB. Sometimes in hospitals, OR's are full, OB's are in other deliveries/surgeries, and things happen. In my first C-section, the cauterizing machine wasn't working and I bled for 5 minutes until they got the backup working. And that was at a hospital with a Level 3 NICU.

On the other hand, there are risks with preemies. But they are known risks, and at 34 weeks the chances of severe risks are much lower (brain bleeds, intestinal issues).

Good luck, and I hope you have 3 healthy little ones and a smooth delivery
post #13 of 52
I just have to add that I really dislike when people act like OB's make decisions based on being sued. Does it come into their minds? Yes, I'm sure it does, for many. But these are HUMAN BEINGS. They are not callous executioners. Most are deeply affected by the loss of a baby or patient and ALL remember the exact circumstances of any baby or patient they lost. It is something they do not take lightly, as death is final. I may not *agree* with what they say, but I respect what they have seen and experienced and how it colors their decision making.
post #14 of 52
Quote:
Originally Posted by MawrtyrB View Post
If it was me, I wouldn't let them pull before 36 weeks unless they could show me some sign that the babies were at risk. As to being admitted, if it get the doc off my back and let the pregnancy go longer, I'd be admitted.

I personally am against C-sections unless it's an emergency. But given your particular situation, you are a pretty risky vbac. They probably will try to induce you and knowing them they'd botch it and cause you to rupture. I might consider the c-section but only when you were ready for them to be born, not on the doc's timetable.
Lots of valuable comments here. ITA. In reading your original post, it does not sound to me like you are being unreasonable at all!

Quote:
Originally Posted by bobandjess99 View Post
I think you are reasonable.
To be fair to him, each day they stay in increases HIS risk. Right now, getting them OUT of you ENDS his job in the matter. He is an OBGYN. He's not a PED, which means that frankly, the babies aren't his concern. (I'm not saying he dosn't care at all about them, he might be a very caring man for all i know) But right now, each day they stay in you in another day something might go wrong ON HIS WATCH.
Thank you! That was just so succinct and an excellent point. We are often on here talking about "doctors and doctors" versus patients. You've raised such an important distinction about the training and responsibilities of different kinds of doctors. Bravo!

Quote:
Originally Posted by DanAbimytwomiracle View Post
I just have to add that I really dislike when people act like OB's make decisions based on being sued. Does it come into their minds? Yes, I'm sure it does, for many. But these are HUMAN BEINGS. They are not callous executioners.
Human beings are not known for being particularly logical in the face of known risks. Obstetrics is the most highly litigious field of medicine and the USA is often cited as the most litigious country on earth. I don't think the general opinions toward OB motivations are over-stated.
post #15 of 52
I don't have anything else to add to the discussion. I just wanted to give you kudos for doing such an awesome job at growing those babies.

post #16 of 52
Thread Starter 
Thank you for your input thus far. I do appreciate the different perspectives. I don't think this is as black and white as I would like it to be. Bobandjess99, you have a good point about my OB's perspective; I think he is seeing the benefits of them being "mostly okay" vs. the small, but real risk of me or one or more of the babies "not being okay." Lung development is his major concern, and I have a more rounded view of their health, being concerned with temperature regulation and feeding also. I agree w/ Interwined, that was one awesome write up of risk assessment.

DanAbie, I agree with you. I think that OBs or medical professions in general often are unfairly demonized in some circles. I do not think my OB is carelessly pulling out a number and sticking by it. We are engaged in a continuous discussion, in which we are each trying to find a middle ground and/ or convince the other. When I was pregnant with my first, young and idealistic, I was positive I wouldn't need the medical world. We had a fantastic 30wks w/ my very crunchy midwifery group and were considering a home birth, when suddenly I was in a catastrophic situation and had to be rushed to an ER, where my c-section was done w/in 6min of arrival, in the ER; my 30wker was supported and cared for by strangers while more strangers struggled to keep me alive. It was a very humbling experience. I still strongly hold onto a woman's natural ability to carry and deliver her children in the most natural, most supported way; I just now understand that the medical world isn't after us; they just have a different perspective on health, well-being and risk and there are times, especially in emergencies that they can be extremely valuable.

Of note, I have a connection w/ the chairman of a high risk ob/gyn at a prestigous university hospital. We have been emailing back and forth throughout my pregnancy to discuss issues. He is a very reasonable man who lives a rather alternative lifestyle while maintaining a well-known high risk OB practice. I discussed this issue w/ him. He polled his staff; his most senior/experienced staff (including himself) advocate for a 36 wk c-section w/o amnio, and next level staff, advocate for 35 wk delivery, some advocating for amnio, some not; his least experienced staff advocated for 34 wk delivery if amnio determines lung development to be adequate.

He also went on to end his last email message w/ more a personal sidenote. He wants me to consider expressing my thoughts and concerns w/ my doc, but ultimately letting my doc make the decision because if something goes wrong, God forbid, I loose a baby b/c my uterus ruptures, I do not want to live with that for the rest of my life. And letting someone else make this decision sort of "frees" me of that burden. I don't agree entirely w/ this perspective, as I will have the guilt of letting my doc go ahead at 34 wks if one or more babes have some difficulties, but I have to agree I don't want to be the one who pushed for a 36 wk delivery and then ends up loosing a babe due to rupture.

More thoughts to stir the pot. . . . .
post #17 of 52


I don't envy your position. I was almost hesitant to post because it's such a huge decision with so many factors to weigh. And really, the decision is yours alone. Your body and your babies are yours to determine but I'm very glad to hear that you feel your OB is a reasonable man. It's such a hard choice. I know you want to nurse them so getting to 36 weeks is so important, especially with trips. And yet, getting them there alive is also an important consideration! I don't know honestly. I'll be praying for wisdom and discernment in this difficult choice!
post #18 of 52
I have been thinking about this post (and update) -- and the pregnant mama and her babes -- a lot but like Intertwined have been hesitant to respond because it's SUCH a huge decision with so many more factors at stake. (It's not like someone's coming here saying "Can I breastfeed twins?" -- that's an EASY one to answer! )

But the thing that I keep coming back to is the idea of risk... and yes childbirth (of any number) can be risky but doesn't have to be, and twin childbirth can be more risky but doesn't have to be, and triplet childbirth can be riskier still but doesn't have to be... but the (real) risk does increase in each case. When that is coupled with the (real) threat of harm from the scar from the previous emergency c/s... that just ups the stakes more. I suppose everyone has a place she says "that's it, I just can't risk any more"... and I don't want to be the one to tell another woman that place. But IMO, these are *real* risks and are you wise to be considering all of your options.

Let us know what you decide... and keep us posted! I love reading about all the new multiples Good luck mama. Lots of people here are thinking of you and rooting for you!
post #19 of 52
Quote:
Originally Posted by LoisLane View Post
When that is coupled with the (real) threat of harm from the scar from the previous emergency c/s... that just ups the stakes more. I suppose everyone has a place she says "that's it, I just can't risk any more"... and I don't want to be the one to tell another woman that place. But IMO, these are *real* risks and are you wise to be considering all of your options.
This is an excellent point. I'm glad you're able to communicate with the chairman, and this may not make me popular here, but I also think he made a pretty valid point about letting your doctor make the ultimate decision - not so much for the reason of having the burden off of you, but because your OB has so much more experience with these kinds of issues. When my triplets were born at 34 weeks, I had mild pre-eclampsia and thought I could make it longer. My doctor refused, and said she'd seen one mom go blind and one almost die that day because theirs was severe, and she was not going to wait until the last second with me. I'm so grateful, because my recovery was faster and I was able to be with my babies sooner than if I'd held out.

I understand your point about guilt of consenting to a c-section at 34 weeks, but if you weigh the risks, they are just not the same. I hate to be this blunt about it but waiting too long could end in death of a baby, while going a little early may mean a couple of days of feeding/breathing assistance, and maybe some nursing issues. Believe me, I know how important it is to breastfeed your child and I am not being dismissive about those issues, but weighing risk is important here.

My triplets were born at exactly 34 weeks, all perfectly healthy, all came home together after 9 days in the NICU as feeders/growers. I was in the hospital on bedrest for 2 weeks before they were born. If it means the doctor will allow you to go a little longer, I'd let him admit you, and definitely make sure you get the steroid shots for the babies' lung development.

Good luck!
post #20 of 52
Barefoot Farmer, I was very interested to hear what your chairman/OB friend had to say until he suggested that you could absolve yourself of any potential guilt by putting the decision completely in the hands of the doctor.

I'll pick my jaw up off the floor here as soon as I can find it amongst the usual assortment of toys, books and shoes.

As you've mentioned yourself, this doesn't "save" a person from anything. If things go well following the doctor's recommendations exclusively, then you'll probably be wondering if they could have gone better. If things go poorly following the doctor's recommendations exclusively, imagine the self-induced horror of re-living your decision to be completely passive in such a base decision about the lives of yourself and your children.

I really don't think I can properly sum up in words how misguided and offensive that suggestion is.

I will be sending you lots of good vibes and healthy wishes. None of us here envy the difficulty of the decisions before you. I hope you do reach the point of feeling comforted and reassured that you have made the right choice.
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