HBAC, anemia, sugar spikes, GBS+, oh my....

[mama2soren]

I'm feeling discouraged.  I'm 38.5 weeks and planning an HBAC.  It seems like everything is going wrong, and I need reassurance.

My most recent hemoglobin was 9.8... pretty low.  Since then, I have been taking slow Fe, cutting back on dairy, upping vit. C, doing all the "right" things.  I had it re-drawn a couple days ago, and am still waiting to hear the results.  I hope to know today if my numbers have improved.

I also just found out that I'm GBS+.  I live in a state where getting IV antibiotics at home is not an option.  I'm reading up on other options like Hibiclens, garlic, etc.  

I declined my shadow care OB's GTT, and instead purchased a monitor around 26 weeks to monitor my sugars at home.  At first, they were all over the place... fastings always well into the 90's, 2-hours in the 140's and sometimes higher... yikes.  With strict dietary changes, I've been mostly able to keep them in a "good" range, with fastings in the 80's (with an occasional low 90's after a stressful, sleep-deprived night), and most 2-hours well below 120, with an occasional spiky one in the 130's.  I had no typical GD risks factors except that I'm over 25 (I'm 30).  I admit that I have not told my OB about the sugars.  

If it was just one of these things I don't think I would feel so concerned.  I know my risk of complications from any of these factors individually (the VBAC, the anemia, the GBS, the slightly "off" sugars) is low.  But, now that I have 4 risk factors I'm feeling unsettled.

I have been receiving full shadow care.  My normally homebirth-friendly OB does not back up HBACs, so he does not know that I have been planning one.  If I had to be in a hospital, I would feel about as comfortable as a homebirth-hopeful mom could be with this OB/midwife group and the hospital they practice in.  I would have to deal with their protocols for CFM for VBAC's, but I could also bring my birth tub for a water birth, go to 42 weeks without pressure to induce, eat freely during labor, etc.  But, of course I really want to have a homebirth.  Not to mention, it's been a huge financial sacrifice for DH and I to pay out of pocket for our homebirth care. I wanted a homebirth because I felt it would be safest for me and my baby.  Now I wonder if it still is the safest option?

Any words of advice?

[mama2soren]

already have an update...

Just called to see if my last Hb/ferritin labs came back and they had.  My Hb has increased slightly to 10.1.  This is after 2.5 weeks of taking the slow-Fe.  Somewhat encouraging, but still a little lower than I'd like (my midwife thinks about 10 is ok, but prefers above 11).

My ferritin was 4!  The nurse I talked with said the doctors/midwives haven't seen the results yet.  I do want to talk to them about the ferritin, because that seems awfully low.  I guess there's not much I can do but keep upping my iron, though.

[BeanSprout Mama]

My advice would be to share your concerns with both your homebirth mw  and your OB. Including the sugars.  Homebirth is very safe - with a low risk pregnancy. Vbac carries higher risks for you and the baby - still extremely small, but higher than a typical pregnancy. The anemia increases those risks a little more. The sugars increase the risks even more.  I would argue that all those factors one on top of the other make your pregnancy not necessarily "high risk" but certainly not perfectly low risk any more.  There is a lot to be said for listening to your intuition and you said yourself that you are feeling unsettled and concerned. That means something and it's worth talking to your OB and your midwife about. The answer might still be that a homebirth is fine, but you won't have that reassurance if you don't share all the information and your concerns with them both.

[sarah_bella1050]

To be honest I wouldn't be to concerned about these issues.  The blood sugars being the most serious are only slightly off, and if you have kept them in a healthy range with just diet then it is not likely the you have GD.  I have high risk for GD and my midwife says as long as you mantain healthy blood sugar levels even with the assistance of insulin then there isn't much of an increased risk for HB.  Your iron is rising and will rise some more before the birth.  Personally I feel that Hebicleans is more affective then iv antibiotic due to the fact that it takes 4 hours for the IV antibiotics to take affect and the hebicleanse goes straight to the course.  There are also tons of immunity boosting supplements that you can take to kick that Group B out.  To make yourself feel more comfortable you can always take supplements and use Hebicleanse for a couple of weeks and then have yourself retested.

[cinderella08]

If the most important thing to you above all is a healthy, alive baby and a healthy, alive mama - I would forgo the current plans and seek care from the OB or a CNM at birth in-hospital.  Judging by what you say about the hospital and policies - for a woman as high risk as you due to all of these issues, that sounds amazing!   You have so many 'risk factors' that make you 'high risk'.  You are a VBAC, anemic, hyperglycemia with possible GD, and you are GBS+.....  The list of what can go wrong with any one of these issues, not to mention having ALL of them, is quite a large list!  I understand the desire to birth at home, and to birth in a place you feel most comfortable, but please do not allow it to happen at the sake of the safety of you and your sweet baby!

[greenhands]

I agree with BeanSprout that it would be best for you to have a heart-to-heart with each of your care providers.  They can help you assess "risk" much better than well-meaning strangers on the internet who have their own biases and do not know you or have all the information.

Having said that, here is an interesting perspective on using non-pregnant hemoglobin levels to diagnose "anemia" in a pregnant woman:

"A Guide to Effective Care in Pregnancy & Childbirth" by Enkin, Keirse, Renfrew and Neilson reports that a hemoglobin count of 9.5 is optimal for fetal growth and maternal well-being:

The normal haematological adaptations to pregnancy are frequently misinterpreted as evidence of iron deficiency that needs correcting.  Iron supplements have been given with two objectives in view: to try to return the haematological values towards the normal non-pregnant state, a strange objective when millions of years of evolution have determined otherwise, and to improve the clinical outcome of the pregnancy and the future health of the mother.  The first objective can certainly be accomplished; the key question is whether or not achieving the "normalized" blood picture benefits the woman and her baby. 

Routine iron supplementation raises and maintains serum ferritin above 10 microgram/litre and results in a substantially lower proportion of women with a haemoglobin level below 10 or 10.5 grams per cent (below 6-6.5 mmol/litre) in late pregnancy.  Routine folate supplementation as a haematinic after the first few weeks of pregnancy substantially reduces the prevalence of low serum and red cell folate levels, and of megaloblastic haematopoiesis.  As yet, neither iron nor folate supplementation after the first trimester have shown any detected effect on the following substantive measures of maternal or fetal outcome:  proteinuric hypertension, antepartum haemorrhage, postpartum haemorrhage, maternal infection, preterm birth, low birthweight, stillbirth, or neonatal morbidity.  Women do not feel any subjective benefit from having their haemoglobin concentration raised.

A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage.  There is no evidence to support this claim.  indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a give loss of blood.

There are few data derived from communities in which nutritional anaemia from either iron or folate deficiency is prevalent.  Trials are needed in these populations to establish the most appropriate strategies for combating the deficiencies.

Whether routine iron supplementation causes any harm in well-nourished communities is still unclear, but it is clearly wasteful.  The evidence suggests that, except for genuine anaemia, the best reproductive performance is associated with levels of haemoglobin that are traditionally regarded as pathologically low.  There is cause for concern in the findings of two well-conducted trials that iron supplementation resulted in an increase in the prevalence of preterm birth and low birthweight.  Perhaps there is an adverse effect on fetal growth due to the increased viscosity of maternal blood that follows the iron-induced macrocytosis and increased haemoglobin concentration, which may impede uteroplacental blood flow.

An individual's haemoglobin concentration depends much more on the complex relation between red-cell mass and plasma volume than on deficiencies of iron or folates.  The advent of electronic blood counters has given an opportunity for more appropriate criteria to be applied to the diagnosis of anaemia.  Mean cell volume may be the most useful; it is not closely related to haemoglobin concentration and declines quite rapidly in the presence of iron deficiency.  A low haemoglobin without other evidence of iron deficiency requires no treatment.

[Kim L Mosny CPM]

Originally Posted by mama2soren 

already have an update...

Just called to see if my last Hb/ferritin labs came back and they had.  My Hb has increased slightly to 10.1.  This is after 2.5 weeks of taking the slow-Fe.  Somewhat encouraging, but still a little lower than I'd like (my midwife thinks about 10 is ok, but prefers above 11).

My ferritin was 4!  The nurse I talked with said the doctors/midwives haven't seen the results yet.  I do want to talk to them about the ferritin, because that seems awfully low.  I guess there's not much I can do but keep upping my iron, though.

This Ferritin level alone (4), at 38+ weeks, would risk you out of my HB practice. Add to it VBAC, GBS+ and possible GDM...

I would be supporting you to have a hospital birth for SURE!

You should be seeing your doctor NOW and making Hospital

Birth plans with your midwife at this point.

Your risk factors FAR out-weigh the desire for home birth, in my opinion.

Just my 2 cents.

Kim Mosny, CPM, LM

Licensed in VA

Home Birth Midwifery Service

Originally Posted by mama2soren 

I'm feeling discouraged.  I'm 38.5 weeks and planning an HBAC.  It seems like everything is going wrong, and I need reassurance.

My most recent hemoglobin was 9.8... pretty low.  Since then, I have been taking slow Fe, cutting back on dairy, upping vit. C, doing all the "right" things.  I had it re-drawn a couple days ago, and am still waiting to hear the results.  I hope to know today if my numbers have improved.

I also just found out that I'm GBS+.  I live in a state where getting IV antibiotics at home is not an option.  I'm reading up on other options like Hibiclens, garlic, etc.  

I declined my shadow care OB's GTT, and instead purchased a monitor around 26 weeks to monitor my sugars at home.  At first, they were all over the place... fastings always well into the 90's, 2-hours in the 140's and sometimes higher... yikes.  With strict dietary changes, I've been mostly able to keep them in a "good" range, with fastings in the 80's (with an occasional low 90's after a stressful, sleep-deprived night), and most 2-hours well below 120, with an occasional spiky one in the 130's.  I had no typical GD risks factors except that I'm over 25 (I'm 30).  I admit that I have not told my OB about the sugars.  

If it was just one of these things I don't think I would feel so concerned.  I know my risk of complications from any of these factors individually (the VBAC, the anemia, the GBS, the slightly "off" sugars) is low.  But, now that I have 4 risk factors I'm feeling unsettled.

I have been receiving full shadow care.  My normally homebirth-friendly OB does not back up HBACs, so he does not know that I have been planning one.  If I had to be in a hospital, I would feel about as comfortable as a homebirth-hopeful mom could be with this OB/midwife group and the hospital they practice in.  I would have to deal with their protocols for CFM for VBAC's, but I could also bring my birth tub for a water birth, go to 42 weeks without pressure to induce, eat freely during labor, etc.  But, of course I really want to have a homebirth.  Not to mention, it's been a huge financial sacrifice for DH and I to pay out of pocket for our homebirth care. I wanted a homebirth because I felt it would be safest for me and my baby.  Now I wonder if it still is the safest option?

Any words of advice?