Monthly Archives: October 2009

Moving during labor

Amy at Lamaze’s Science and Sensibility is hosting the second Healthy Birth Blog Carnival. This one is about Lamaze’s Second Healthy Birth Practice: Walk, move around, and change positions throughout labor.

Amy did a great job explaining how natural birth advocates are constantly asked to prove that what is physiologically normal, like being free to move during labor, is better than an intervention, when it should be the other way around. Here’s a great quote from her anticipatory pre-carnival post:

Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice. While many of us believe that encouraging a laboring woman to move when and how she wants to is healthier and safer than making her stay in bed, waiting for evidence that it produces better health outcomes is putting a burden of proof on normal birth that has never been applied to routine intervention. Besides, lack of evidence of harm, less pain, and maternal satisfaction are valid and important outcomes in and of themselves, and provide the justification we need to reject routine policies and practices that restrict maternal movement.

I had a similar argument with a commenter on this post. Many elective cesarean advocates seem to want to present vaginal birth and cesarean birth as two equal options, not a physiologically normal event and an intervention.

So, since Amy already handled this angle well, I am going to talk about my own experience, and give a little advice at the end.

When I had my first child, I thought I was well informed. Hell, I had read every page in What to Expect When You’re Expecting. I read Mothering and Parenting magazines (both sides!), hired a midwife, took a childbirthing class, and thought I would have a “natural birth” as long as there wasn’t any unexpected emergencies.

Well, soon after I arrived at the hospital, I was told they didn’t have a birthing tub (I never thought to ask ahead of time, dangit) but I was told I could labor in the shower. After the shower, which was probably 20 minutes at the most, I was told I needed an IV with Pitocin. I had no idea what that was, but since my midwife recommended it, and everyone knows midwives always favor natural births over interventions, I didn’t even think of refusing. Well, I was told as soon as the Pitocin was started that I needed to be on continuous external fetal monitoring. Huh? Then, my midwife told me I had to stay in my bed(!!!), since the baby was showing signs of distress. I was not told before being administered the Pitocin that it would require being tethered to the machine, and I wasn’t told it may cause fetal distress, even after my fetus was apparently diagnosed with fetal distress. I wasn’t even told it may not be necessary, considering I had only been in active labor for about an hour when it was administered.

Fast forward several hours and I was flat on my back, pushing too soon, leading to a swollen cervix. No, no alternate positions were encouraged for my three hours of pushing, either.

So, my advice? Ask your practitioner(s), ahead of time, what their positions are on intermittent monitoring and movement in labor. Don’t just assume that what seems basic and normal will be encouraged or allowed.


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More on fat bias and pregnancy

Jill at The Unnecessarean linked to this frustrating but great birth story at My Best Birth. “A Curvy Gal’s fight for a Natural Childbirth” is full of head exploding details, such as baseless threats from her midwife, recommendations for risky procedures with a lack of adequate informed consent, and suggestions of medical approaches that would actually increase the risk of adverse outcomes, not decrease them.

Here is a choice quote:

After some research, I called my midwife to say that I did not want a Miso induction, and that I wanted to wait and go into labor spontaneously. She said, “Well, in my experience, women with BMIs higher that 26 tend to have cervixes that won’t dilate without chemical induction.” Okay—first I was being pressured into induction because of the increased risks of a long gestation to m y baby and NOW she’s saying that because I am a curvier gal, my body is somehow clueless about giving birth (by the way, I had NO other risk factors in this pregnancy—no gestational diabetes, no elevated blood pressure, etc) I have since searched high and low for ANY medical study that supports her belief and have come up with nothing. I argued with her that I’d like to give my body the chance to go into labor on its own—at least through the weekend (agreeing to the postponed induction with the foly (sic) catheter instead). She was condescending and doubtful, but ultimately said it was up to me.


The good news is that she did her research, refused the inductions, and ended up going into labor spontaneously and having a quick and easy birth.


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Sick and leaning on the mute button

So, I am sick. Sick sick sick sick. I hurt everywhere. I have a fever and I am lightheaded. Runny nose, cough…the works. Blegh.

I am planted in front of the computer and the TV. I watched these Bill Nye videos about genetically modified foods. I just happened to get a link for them by being a fan of Slow Food USA on Facebook. It was interesting timing (not ironic, huh CableGirl?), since I just got in an annoying argument with commenters on on Dispatches from the Culture Wars. First of all, I am no fan of people who use snotty insults when they’re arguing on a site. Not necessary. Sarcasm is fine. But, if you’re going to go there, you better be right. I also don’t think blindly accepting technological advances is any more reasonable or educated than being blanketly afraid of all technology.

So, while I was tooling around on the internet, I had the Travel Channel on mute. Anthony Bourdain was visiting Ted Nugent. I could never listen to that much douchebaggy conversation, but I left it on in case there were any exciting gun accidents. Not that I wish that on anyone, but still, it’s exciting.

Now I am watching Birth Day. I wish I had the mute on here, too. I have heard “vertex position is NECESSARY” for a vaginal delivery. Also, I heard about a woman who had been in a long labor, and when her nurse introduced the next shift nurse, she said “And Amy has been with us forever.” Nice. She ended up with a fever after several hours of an epidural, and of course they discussed ZOMG infected baby!! but didn’t mention the link between epidurals an fever. The baby was born by “abdominal rescue” (wha??) and then was immediately taken to the well child nursery. Wait, I guess they don’t think there is a big risk this baby is infected. Then they talked about how it’s just great that she had a healthy baby.

I did get to see a successful external version (I cheered!) but I was surprised to see she got a neck down epidural for it, and then they induced labor immediately. I don’t know that much about external versions, however. The baby has distress now. They think it’s from the version. But, can it be from the Pit?

There is a woman who is one day past her due date (the horror) and was told her baby is “big” and she needs a cesarean. Oh, but she’s a hemophiliac. How does this sound safer? Her bleeding time test did not look good from my amateur eye. Why cut her without good indications?


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White fat, black art

A Canadian friend recommended the show White Coat, Black Art from CBC Radio. I have enjoyed several of the shows. There’s one on burnout, which is supposedly worst in ob/gyn. She wanted me to listen to the show on obesity. (Link to mp3 of “Fat Doctors”.)

I was kind of napping while I listened, but I played it twice and I think I got most of it. I think they thought they were showing “both sides of the issues” by having advocates for bariatric surgery, and someone who lost weight through diet and exercise. But, it was a very judgmental show. No one argued that not all obese people need to be fixed, either with surgery (which they started the show with) or diet and exercise, which the other two segments suggested.

I was struck by some of the people in the support group. Like, the one who was talking about how you could never tell a heroin addict to just take it 3 times a day in small amounts, but we expect people with food issues to self regulate food consumption. I am happy the doctor at the bariatric center emphasized that no one chooses to be morbidly obese, and no one gets morbidly obese by making poor choices.

I also kind of related to the doctor at the end who talks about being overweight and struggling with weight loss and her self image, which I am sorry to say. I feel a lot of self hate and guilt (and I have gained even more weight. I am afraid to weigh myself.)

I loved it when she said she secretly thinks “I would hate to live like that” when people give her weight loss advice and discuss strict, boring diets. I admit, people tell me about getting their “butts kicked” by their spinning instructor, and it makes me wonder if sedentary life isn’t worth it. But, I felt better about myself when I was in better shape. I like many types of exercise. It doesn’t hurt to fit in my clothes, either.

I guess it made me feel a lot of self hate, but I didn’t realize it at the time, because I am surrounded by that attitude constantly. I was just reading a maternal mortality review (pdf) today, and they were analyzing trends of BMI and maternal complications. But, I know this is a multi faceted issue. Obese women get more unnecessary interventions, including more inductions and more cesarean sections. And, the maternal mortality rate is much higher for African American women, who are more likely to be obese when of childbearing age.

I am afraid I may get passed over for a residency spot because I am obese. Spots are competitive, and are based on interviews and personal interactions with people on the team at the site. I know some people don’t think obese people make good doctors, some people think a person who is forty and obese may not be a good investment for four years, since I may succumb to some sort of fat complication, die young, and be a waste of their training. And even more people have unconscious negative reactions to fat people. We do worse in interviews, period.

Anyway, thanks for the recommendation. It was definitely worth the listen and gave me a lot to think about.


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Newest, bestest KALI questionnaire, annotated

Here is the annotated survey, with an attempt at dividing the questions into domains and scaling them. So, the domains so far are K=Knowledge, A=Attitude, B= Barrier, P=Practice pattern, and Y=Autonomy of the patient. If a question says “Reversed” after it, then it is phrased in the reverse or negative compared to the evidence cited.

Sorry about the messed up formatting; I swear it looks OK in Word. I will try to edit it later today when I have more time.

The KALI Project Survey

Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.

First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.

1. You are:
[1] Male [2] Female

2. Age:
[1] 20 – 29 [5] 60 – 69
[2] 30 – 39 [6] 70 – 79
[3] 40 – 49 [7] 80 – 89
[4] 50 – 59 [8] 90 or older

3. Do you have children?
[1] Yes [2] No

4. Ethnicity:
[1] Hispanic or Latino
[2] Haitian
[3] Neither Hispanic nor Haitian

5. Race (choose as many as apply):
[1] White / Caucasian [4] Native Hawaiian / Pacific Islander
[2] African American / Black [5] Native American Indian /Alaskan
[3] Asian or Asian American [6] Other:_______________________

6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] Other: ____________________________

7. Year of residency completion _____________

8. Which of the following most accurately describes your practice type?
[1] Public hospital
[2] Community health center
[3] University based practice
[4] Private practice
If private –
[a] Large partnership (four or more partners)
[b] Small partnership (two or three partners)
[c] Solo practice
[5] Military / government
[6] Other:____________________________________________

9. Do you currently practice obstetrics?
[1] Yes
If yes:
[a] Average clinical time spent with prenatal clients:______________(%)
[b] Average number of deliveries per year:________________
[2] No

10. Which of the following most accurately describes your personal practice scope?
[1] General obstetrics and gynecology
[2] General gynecology only
[3] Obstetrics only
[4] Laborist
[5] Maternal Fetal Medicine
[6] Reproductive Endocrinologist
[7] Gynecologic Oncology
[8] Urogynecology
[9] Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
[1] None / I “go bare”
[2] I pay for individual malpractice insurance
[3] My practice pays my malpractice premiums
[4] I am an employee of an institution that pays my malpractice premiums
[5] I am an employee of an organization or institution that provides legal defense but
not malpractice insurance
[6] Other: __________________________________________________

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you. Please choose whether you:

[1] Strongly agree
[2] Agree
[3] Neither agree nor disagree
[4] Disagree
[5] Strongly disagree

1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.(K)1 Reversed

2. _____Elective cesarean section should not be performed on a woman desiring several children.(K)2

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.(K)3, 4

4. _____Episiotomy should be avoided if at all possible. (K, A, P)1, 5

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery. (K)6

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries. (K)7, 8 Reversed

7. _____Insurance should not reimburse use of doulas for labor and delivery.9 (A,B)Reversed

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used. (K,P,B) 3, 10 Reversed

9. _____Fear of liability claims limit the options I present to my obstetrical patients.(B,Y,P)11, 12 Reversed

10. _____Liability insurance company policies forbid me from performing VBACs. (B,P) Reversed

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes. (K)1, 13 Reversed

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy. (K)6

[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

13. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact. (A,P,K)1, 14 Reversed
14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.(Y,A,K)3 Reversed

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery. (B,P,A)15 Reversed

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.(K,A,Y)6

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.(K)2, 8

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies. (K)16, 17 Reversed
19. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.(K,Y)18

20. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.(B)6 Reversed

21. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.(K,P)1, 19Reversed

22. _____I regularly employ episiotomy to prevent pelvic floor relaxation.(K,P) 3, 5, 16, 17Reversed
23. _____Hospital policies forbid me from performing VBACs.(B)20-22Reversed

24. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.(A)7, 23, 24 Reversed
25. ¬_____I have made changes to my practice because of the risk or fear of liability claims. (B)11, 12 Reversed
26. _____Childbirth is only normal in retrospect.(A)3Reversed

27. _____Clinical guidelines are useful tools for me in daily clinical practice.(A,P)25

28. _____I regularly employ episiotomy to prevent perineal trauma.(K,P)5, 15, 17Reversed

29. _____The use of continuous EFM reduces perinatal mortality.(K)6Reversed
[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

30. _____ Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks. (K,P)18

31. _____I encourage my patients to try alternative or upright positions during the pushing stage.(A,B,P)1, 13, 26, 27

32. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care. (A,P)28 Reversed

33. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.(B,P,K)29, 30 Reversed

34. _____Women should have the right to refuse an episiotomy.(Y)12, 29, 31, 32

35. _____I recommend that most patients use a doula for their labor and delivery.(A,P,K)1, 9

36. _____I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.(A)3, 28 Reversed

37. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.(K)6

38. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.(B)33 Reversed

39. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.(Y)31, 32

40. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery. (K)1, 14

41. _____If a patient asks if she could use a doula for her delivery, I would encourage her.(Y,A)1, 4
42. _____ Time and scheduling pressures affect the way I manage labor and delivery.(B) Reversed
43. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.(K)34

44. _____Episiotomies increase the risk of third and fourth degree tears.(K)5, 16, 17

45. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.(B)25 Reversed

How often do you consult the following sources regarding obstetrical practice?

[1] Never
[2] Rarely
[3] Sometimes
[4] Often
[5] Always

1. _____ACOG Practice Bulletins
2. _____ACOG Committee Opinions
3. _____Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. _____Cochrane Database
5. _____Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. _____Books and/or textbooks
7. _____Professional conferences
8. _____Physicians in my practice
9. _____Physicians in my local community
10. _____Physicians I trained with in residency
11. _____Physicians I consider experts in the field
12. Other sources: ______________________________________________________

Have you ever been the subject of a professional liability claim or litigation?
[1] Yes
If yes – Did the liability claim involve an obstetrical claim?
[a] Yes
[b] No
[2] No

Thank you for your time and participation!

Reference List

(1) Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
(2) ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol 2007 December;110(6):1501.
(3) Reime B, Klein MC, Kelly A et al. Do maternity care provider groups have different attitudes towards birth? BJOG 2004 December;111(12):1388-93.
(4) Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007;(3):CD003766.
(5) Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Jr., Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005 May 4;293(17):2141-8.
(6) ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstet Gynecol 9 A.D. July.
(7) Gunnervik C, Sydsjo G, Sydsjo A, Selling KE, Josefsson A. Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists. Acta Obstet Gynecol Scand 2008;87(4):438-44.
(8) NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006 March 27;23(1):1-29.
(9) Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25-8.
(10) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ 1995 September 15;153(6):769-79.
(11) Hyer R. ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates. MedScape Medical News 2009 May 9.
(12) Florida Liability Lowdown. American College of Obstetricians and Gynecologists; 2009 Aug.
(13) Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. Cochrane Database Syst Rev 2004;(1):CD002006.
(14) Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2007;(4):CD006167.
(15) Low LK, Seng JS, Murtland TL, Oakley D. Clinician-specific episiotomy rates: impact on perineal outcomes. J Midwifery Womens Health 2000 March;45(2):87-93.
(16) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006 April;107(4):957-62.
(17) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
(18) ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
(19) Wei SQ, Luo ZC, Xu H, Fraser WD. The effect of early oxytocin augmentation in labor: a meta-analysis. Obstet Gynecol 2009 September;114(3):641-9.
(20) Lyerly AD, Mitchell LM, Armstrong EM et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 2007 April;109(4):979-84.
(21) Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth 2007 December;34(4):316-22.
(22) Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. J Reprod Med 2005 April;50(4):261-6.
(23) Bettes BA, Coleman VH, Zinberg S et al. Cesarean delivery on maternal request: obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007 January;109(1):57-66.
(24) Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005 February;105(2):301-6.
(25) Vinker S, Nakar S, Rosenberg E, Bero-Aloni T, Kitai E. Attitudes of Israeli family physicians toward clinical guidelines. Arch Fam Med 2000 September;9(9):835-40.
(26) Difranco JT, Romano AM, Keen R. Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions. J Perinat Educ 2007;16(3):35-8.
(27) Gilder K, Mayberry LJ, Gennaro S, Clemmens D. Maternal positioning in labor with epidural analgesia. Results from a multi-site survey. AWHONN Lifelines 2002 February;6(1):40-5.
(28) ACOG Committee Opinion No. 395. Surgery and patient choice. Obstet Gynecol 2008 January;111(1):243-7.
(29) Fenwick J, Gamble J, Hauck Y. Reframing birth: a consequence of cesarean section. J Adv Nurs 2006 October;56(2):121-30.
(30) Goodall KE, McVittie C, Magill M. Birth choice following primary Caesarean section: mothers’ perceptions of the influence of health professionals on decision-making. Journal of Reproductive and Infant Psychology 2009 February;27(1):4-14.
(31) Simpson KR, Thorman KE. Obstetric “conveniences”: elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions. J Perinat Neonatal Nurs 2005 April;19(2):134-44.
(32) Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ 1997 March 15;156(6):811-3.
(33) Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. New York: Da Capo Press; 2007.
(34) ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004 July;104(1):203-12.


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My structures list for the anatomy review

I am exhausted, folks. An old friend got married yesterday, and my 10 year old son S was in the ceremony. We have been going nonstop since Thursday. I finally crashed after the post wedding breakfast this morning, and I am almost recovered after a nap and dinner.

This week is pretty busy, too. Wednesday night I am doing a gross anatomy review tutorial for our surgical interest group. I wasn’t thrilled with gross anatomy and wasn’t sure if I would ever go back. Well, this is my second year teaching the female pelvic cavity.

Here is my structures list:

Fornices (anterior, posterior, lateral)

Broad ligament
Round ligament /ligamentum teres
Cervix-external & internal os, endometrium, myometrium, isthmus, & fundus,
Uterine/Fallopian tubes
Infundibulum w/ fimbriae, isthmus, ampulla

Ovarian ligament
Suspensory ligament
Vesicouterine pouch
Rectouterine pouch (of douglas)
Retropubic space
Rectum, external anal sphincter, anal canal
Vaginal artery

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Fertility is unfair

I have a good friend who is getting surgery right now. A very, very wanted pregnancy that she paid dearly for, injected herself with hormones for, got eggs harvested for, got embryos transferred for and went on bed rest for, and it ended up implanting as an ectopic pregnancy. She will most likely lose a fallopian tube.

All four of my pregnancies were unplanned. All of hers have been a struggle. All of the fear and frustration I have felt trying to prevent pregnancy she has felt from the opposite side, probably multiplied by a million.

Fertility is incredibly unfair.

Please send her good thoughts.


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