Labor and Delivery, pt 1

Though my mind was spinning with possibilities and I was pretty uncomfortable, I feel like I did a good job walking into the Labor and Delivery department looking calm and under control. 

Once all of the paperwork was filled out, I was taken back alone to be weighed. I had gained another three pounds in the span of just a few days, all fluid from the Twin to Twin Transfer Syndrome (TTTS) affecting my babies. Ugh, it was progressing, the surgery is supposed to fix it, but now we had a complication on our hands with the spotting. 

I mentally collected myself. Lots of women have spotting and it turns out to be nothing. I had read. Right?  

They whisked me away to a room. Nick followed closely. Nurses, patient care techs, they all came in strapping things on me, taking measurements, asking questions, getting me into a gown. A flurry of activity that stole my thoughts. I wasn't thinking at that point, just giving myself over to the medical professionals and simply being. 

The doctor came in and introduced himself. He was one of the doctors in my doctor's group. I had never met him, he'd never met me. But he would later work some miracles which I feel is a big part of why my two boys have a chance.

After introducing himself, he tells me he has to look and to assume the position. All of the cramping intensified during his exam, as the nurse had promised. But his findings drove fear into my heart. "You're dilated 2-1/2 centimeters and 80 percent effaced."

What?

He looked concerned.

I got really concerned.

"The baby's head is right there," he murmured to the nurse who had been running a monitor over my belly, pushing way too hard, trying to get my babies' heart beats. I would learn to hate the monitor.

He ordered a lot of medications, some of which he promised will make me feel horrible, "but it would help to stop labor."

Labor? Excuse me? I was only 24 weeks! How could I be in labor!! I was walking around just an hour ago! No, no! I was supposed to have surgery and give birth ten or twelve weeks later to two healthy baby boys. This wasn't happening! This couldn't be happening! Why was this happening?

They started an IV and bag after bag was hung and connected to my arm. I swallowed four giant pills of the same medication, some sort of super Ibuprofen. It and magnesium would try and stop labor. 

About 30 minutes later, the general discomfort began to ease. I wasn't cramping as much but I did feel the hot flash brought on by the magnesium. Things started to settle, or so I had convinced myself.

The doctor returned, asked how I was feeling. 

"Better," I said and he gave a passive nod.

"We need to transfer you because if these kids come, they'll need a NICU with higher level care. I need to make some calls. Let me check you again."

Luckily, labor hadn't progressed and the doctor left to make his phone calls.

The doctor returned again. "I can't get you transferred to the hospital I wanted because their NICU is full. But we have a second option. I'll work on that." I still couldn't process what was happening. Were the babies going to come tonight? And at a hospital that wasn't the first choice? Why was everything suddenly going so wrong?

I can't remember why, but Nick had to run home and the nurse confirmed that he had time. A few minutes after Nick left, the doctor returned. 

"I got you in to the first hospital. The helicopter will be here in about thirty to forty five minutes."

"Helicopter," I asked. My eyes about fell out of my head. I had figured I'd go by ambulance.

"Yes. The hospital is a forty five minute drive from here and if those babies come in the ambulance, they won't survive. So you're going by air," he said. 

I text Nick:



"What about Seattle," I asked.

"You're not going to Seattle," the doctor said.

I let my head fall back against the pillow. Did I say a prayer? I don't know. I was too stunned to even cry. 

The flight crew arrived to the room just before Nick did. They asked questions, took information from the hospital staff. I was instructed to lay on my side. They wrapped a sheet around me to protect my dignity and strapped me down onto their gurney. Buckles and straps went all over me, clinking and clacking together, buckling with a snick. The crew was extremely polite and kept conversation light.

The hospital doors slid open and the cool air hit me. Lights slid across the shiny paint of the red and white helicopter as they pushed me towards it. As an EMT, I had sent a patient by helicopter, totally unaware of the impact it would have had on my patient. 

I was the patient now and as they slid me into the back, it finally began to dawn on me just how serious this was. My babies' lives were in jeopardy. I wanted Nick there with me.

As the helicopter whirred to life, my eyes filled with tears and my chest heaved. Please, baby boys. Stay put. 

But I would quickly learn that I had absolutely no control over the situation.

Wyatt and Cameron knock, knock, knocking on cervix' door

I've been told that I'm one tough cookie. As much as I'd like to believe that I'm in possession of an extreme amount of fortitude, it's more likely that I'm simply one dense cookie. Dense cookie like the first ones you ever made for a boyfriend or girlfriend. Dangerous, inedible, weapons of drywall destruction should you fling one at a wall. No bounce at all, just a heavy thud if you drop one on the floor. I wouldn't use the 5 second rule in this case. Just consider it a loss and keep the dog from eating it to avoid the 3am diarrhea they're sure to get from said dense cookie.

For a week, I'd been uncomfortable. I'd toss and turn in bed, unable to find a good way to sleep. My stretched belly felt like it should split right down the middle if I so much as twisted or bent wrong. It was like a balloon inside of me kept expanding. My ribs constantly ached and riding in a car made it seem as though my rib cage was about to pry open. My right side ribs were the greater offender and I'd press on them for a little bit of relief. I squirmed around constantly. I was 24 weeks and looked full term. But twin pregnancies are known to be uncomfortable. So I put up with it not knowing it was actually prelabor. These are the things dense cookies do. They ignore signs.

I was 24 weeks and 4 days when I saw my maternal fetal medicine (MFM) specialist. He measured my cervix. It was 4.5cm or there about. Fluid levels on Cameron were above normal. Wyatt had low levels, but still normal. It was Cameron's heart that caused my MFM concern. His heart showed signs of stress in trying to deal with Twin to Twin Transfer Syndrome (TTTS). There was a little bit of thickening on one side of his heart and so my doctor diagnosed them with stage III TTTS and recommended Fetoscopic Laser Photocoagulation. The procedure would split the placenta in two and stop the TTTS. If everything went as planned, I'd carry to 36-37 weeks. The procedure comes with risks, including a 40% chance of one of them dying. However, if I did nothing, there was an 80-100% chance of both of them dying.

I would have to fly to Seattle to have the procedure done. My appointment was set up for that Monday at 8:45am. I was instructed to fast just in case they take me into surgery right away, since TTTS can worsen rapidly. If I didn't have the procedure Monday, they'd wait until Tuesday.

Things were happening so fast. I was scared to death that I could lose one. I was also a bit relieved. There was a procedure that could help. We also had a diagnosis and a plan. Even before TTTS showed up, I was worried about it to the point of researching it nearly every hour I was awake. I'd learned that increased protein could help prevent TTTS or at least help it from progressing. And so I managed to ingest 200 grams of protein daily. I felt like I had a brick in my stomach 24/7.  There are many cases where TTTS remains at stage I and all they do is closely monitor. I was not one of those cases. Left alone, mine would progress with dire consequences.

At 24 weeks, 5 days, we had our hotel and flight arrangements made to the tune of $1800. Everything was listed as medical. The airline gave us a $200 discount due to it being an emergency surgery. The surgery center we'd go to had a deal with some hotels near the hospital. We found a place to board the dogs that I was happy with. "Cage free boarding" the place was so they wouldn't be locked in a kennel for the next 5 days. Everything had worked out so smoothly.

After dropping off the dogs, we stopped by my husband, Nick's, office because I had to use the restroom for the twentieth time that day. That's when I noticed the spotting and my heart screeched to a stop.

I called my doctor who recommended I go to labor and delivery. I told Nick we had a change of plans. The amount of worry consuming me for the 45 minute drive from our location to the hospital was but a ripple in the ocean compared to what we were about to face.

Twin to Twin Transfer Syndrome

Twin to Twin Transfer Syndrome (TTTS) is a rare condition that can only happen in multiples that share a placenta. Without treatment, it's almost always fatal to both of the babies. With treatment, there's a 60% chance that both twins will make it.

In TTTS, the babies start to share blood vessels within the placenta. It's okay if they share the placenta equally. If they don't, one baby "donates" blood and fluid to the other. This stresses the babies to the point of causing things like heart failure, cerebral palsy, and other conditions. If they make it to birth, they are born very sick. If they make it to birth, they're usually premature on top of being very sick.

In our case, Wyatt was the donor and Cameron was the recipient.
First, there was a discordance in their fluid levels. Cameron had higher levels than Wyatt. Normal is greater than 2cm, less than 8cm when they measure the deepest pockets of fluid in their amniotic sacs. When I was about 22 weeks along, they noticed Cameron was flirting with the higher limit and Wyatt was close to the lower limit. Twins can have fluid discordance and be normal and healthy. Or it can be a sign of something dangerous. My doctor increased my frequency of visits from once every two weeks to every week to monitor things more closely.

To diagnose TTTS, they also look at their hearts, how blood is flowing, bladder size, and a few other things. Often the donor will be smaller than the recipient, but my doctor said that criteria isn't considered anymore. It's mostly changes in the heart, abnormal blood flow, a visible bladder, and fluid around the heart or brain (hydrops).

I was 24 weeks and 4 days along when my doctor said he could see some stiffening in Cameron's heart and considering that plus the fluid discordance which was now over 8cm for Cameron, he recommended laser surgery for TTTS.

The laser surgery for TTTS has been around since the late '80's and has good success rates. They take a laser and burn the connections between the twins basically creating two placentas. Then they watch you for a day or two to make sure you don't go into labor. The hope is that you go on to have a normal healthy pregnancy. For 90% of cases, families end up taking home a healthy baby. For 60% of cases, families take home both babies.

The closest place was 12 hours away. It was a Friday and he set up the appointment for Monday. He wanted me to fast in case they decided to take me to surgery that day. Or it would be Tuesday. On Monday I'd be 25 weeks and their cut off was 26 weeks.

I remember getting home to look up the success rates. I started to cry. It was scary considering 40% of the cases, one of the twins dies because there wasn't enough placenta for the baby to survive. I love both my boys and while there was no question that I needed to have this surgery, 40% seemed awfully high.

We quickly made plans to fly out and have the surgery. We found a place to board the dogs. My husband, Nick, worked out a flight and hotel. We were all set. I was surprised by how smooth it all went.

And then I started spotting...