Jesse and Max's birth story (Part 6)

This is just the birth story of my twins.  It can be read alone or you can use the links below for the full story in 6 parts.

Jesse and Max's story really begins at the start of my motherhood journey.  I became a mother with the birth of my only daughter Lily in 2008.  It was during this birth my eyes were opened to the abuses within the medical community.  Her birth sparked a passion in me that is still burning 5 years later.  My son Ehren was born with a midwife at home.

When Ehren was around 17 months old my husband and I decided that two children would be enough for us and that possibly have two more 5+ years down the road if our finances supported it.  Then I found out I was pregnant again.  I was so busy and tired that I lost weight and my belly grew like it was in fast forward!  My midwife asked me to consider an ultrasound.

Twin Diagnosis

After finding out we were having identical twins at 18 weeks we were relieved that it wasn't anything more serious.  I knew that with identical twins there was a risk of twin to twin transfusion syndrome. I thought that it was a black and white issue and that if you didn't have it your twins would have similar risks to singletons.  I figured we would be fine and be able to have a vaginal birth at home and if I had to, I would travel to Dallas to find a midwife who would attend me there.

We began seeing a Maternal Fetal Medicine group shortly after the diagnosis for ultrasound every 2 weeks. One baby was always measuring large and the other measured smaller.  I usually had high fluid levels as well.  But up until 24 weeks everything appeared to progress okay. We were constantly measuring the blood flow to the smaller twin and noting some abnormality in the umbilical  blood flow.  During the rest phases between heartbeats he would have no pressure and even a bit of back flow.  In a singleton baby this would be a cause for great concern but with identical twins it is common.  This is when I began to realize that this pregnancy was not a variation of normal.  There were serious issues going on here. 

High Risk Scare

Around 24 weeks we were diagnosed with stage 1 TTTS and sent to Houston to see Dr. Kenneth Moise who had handled over 400 TTTS cases.  After consulting with him he believed it wasn't classical TTTS but there was definitely a risk at any time it could turn into that and progress to dangerous levels within a matter of days.  For now, the smaller twin had adequate fluid and was measuring average size. He wanted to keep a close eye on me and told us that we should prepare for a cesarean early or even laser ablation surgery to sever the connecting vessels in the placenta.

We went in for weekly appointments with Dr. Moise until 27 weeks when it was decided that we were past the window for surgery and that we would squeak by if the boys continued to hold steady with their growth. We stayed in town for all future appointments. At each scan the boys continued to look good. Sometimes it would seem that we needed to worry about Max's heart enlargement and other weeks we would worry about Jesse's back flow through his umbilical artery. We would also be concerned that my high fluid levels would lead to preterm labor, but nothing got bad enough to merit intervention.

Intervention Time

At 30 weeks, Jesse started to show signs of growth restriction. He started falling in percentiles and by 33 weeks his abdominal circumference was equal to that of a 16 week baby. We knew that delivery at 34 weeks would give Jesse the best possible shot because at that age with growth restriction, babies do better out than in. It was determined that it would be via cesarean as the risk of acute TTTS (sudden blood flow to recipient twin due to stress of labor) was low, but would be potentially catastrophic to Max. I was nervous to be back in a hospital again and nervous for the babies.

34 weeks. My last belly shot.

The Big Day!

January 8th at 5:30am we were to report to the hospital to have vaginal bypass surgery.  We woke up bright and early and grabbed McDonalds on the way. Lucky me got to smell it but was not allowed to eat!  Brandon sure enjoyed his large coffee. True to tradition he wore his Superman tee for the birth of our final babies.

After checking in we went to preop to change clothes and get an IV. It felt cold going in and then we waited for a while the room was prepped for surgery. My doctor came by to chat with me and reassure me and find out if I had any questions. I gave her copies of my birth plan for all the nurses. Several were curious about what I was going to do with my placenta. They were surprisingly respectful when I told them I was going to encapsulate it.

Finally the room was ready and I walked in there and sat on the edge of the bed. My doctor introduced me to her husband who was assisting and the rest of the team. The anesthesiologist must have been in training because an older guy was watching and telling her what to do. She told me to curl into myself and I would feel a sting like an ant bite. Not exactly much room to curl when you have a belly full of twins. My doctor stood in front of me and held me and coached me through it. Yes I felt the "ant bite" sting and then the spinal needle! Not numb at all guys! It felt exactly like what it was... A big giant needle in my spine. I must have tensed up quite a bit and the anesthesiologist said she had to do it again because I was too tense. Yeah... It's my fault you aren't good at the whole numbing step. She proceeded to "numb" me again and once again it didn't numb at all before she was jamming the needle in my back again. I kept telling them I felt it and they must not have believed me and asked me which side. I told them the right side and they acknowledged that I was correct and must be feeling it.  Thankfully she got it this time around and I quickly became numb.

From there they quickly laid me down and Brandon came back in. They put comfy warm blankets over my chest and a little cap over my hair. The drapes were not on the side where Brandon was so he got to see everything!  Everyone seemed to be in a good mood and the husband/wife doctor team talked through what was going on as I had requested. Not long after little Jesse was lifted out and he screamed and cried loudly. I got to see him and then he was taken away to be checked out by the pediatrician. Then Max was lifted out one minute later and proceeded to pee all over Dr. David Damian. Everyone laughed because when both babies were screaming and crying they sounded like cats fighting! They all assured us that was a good thing. The pediatricians checked them out and they were blanketed and hatted and given to Brandon to hold. He showed me them one at a time and posed for pictures. I forgave the anesthesiologist for poking me twice because she took all the awesome pictures of the birth. 

Jesse

Max

Dad and the babies

Me and Max

As soon as the cutting started I started feeling like I was being stabbed in the shoulder. I told the anesthesiologist and she said it was called referred pain and could only give me morphine which she did giving me the maximum dose. It turned into a dull ache but I still felt it for hours afterwards. I had no idea that could happen. It was very strange. 

Brandon then went with the boys to the NICU and I was sewed back up. They were impressed with the size of my uterus and said my insides looked beautiful which I found charming and a little gross.  Once I was all sewed back up Brandon came back. One nurse made sure my placenta got bagged and given to Brandon to put in the cooler to take home.  I only got to see a glimpse of it but was told that it was large and looked good.

We then were wheeled into recovery. We asked about the boys and were told they were well and given their stats. Max was 6 lb 5 oz, 19.25 in long and Jesse was 4 lb 15 oz, 18.5 in long. 

Jesse in the NICU.  Note how tiny his body is in comparison to his head.

Max in the NICU.  See how much bigger his body is compared to Jesse?

Brandon went with the boys while I was stitched up and watched as the boys were set up in the NICU. They were breathing fine but were given tubes in their mouths to help evaporate the fluid from their lungs, temperature monitors, heart rate monitors, blood pressure cuffs, and oxygen saturation monitors. He briefly visited with some family and friends that had come, grabbed a coffee and came back to me.

After we spent some time in recovery I was wheeled to the NICU to see the boys on my way back to the room. I couldn't see them very well and don't remember very much about it.  We were then taken to the largest and fanciest room (perks of twin births). I was instructed to relax and get some rest.

That's pretty much what happened!  It wasn't my dream home waterbirth but I was treated with dignity and respect.  My boys were given the care they needed and they did well.  Could we have had a vaginal birth?  In all likelyhood yes.  Could I have had the support to accomplish this and was I comfortable with the risks?  No.  I think I made the right decisions for me and the babies given our resources and I'm satisfied with how it all turned out.

Max was getting a whole lot more nutrients!

Umbilical cords.  Note the difference in thickness!

2 weeks old.  See the difference IUGR can make!

4 Months old - Jesse is catching up!

Links to the detailed story:

Ultrasound reveals all (Part 1)
High risk here we come (Part 2)
Houston Perinatal Consultants (Part 3)
Texas Fetal Center (Part 4)
The Final Stretch (Part 5)
Jesse and Max's Birth Story (Part 6)

The Final Stretch (Part5)

At 27 weeks we stopped driving to Houston for ultrasounds and started staying in town. We would see one of four doctors each week for our scans. We were also seeing an OB once a week. Because of the delay in sending her the results of the ultrasounds she would often ask me how things went and I would explain it as best I could. The delay was caused because the four doctors in the group would meet each week to discuss each patients results. I liked to observe each doctors methods at the ultrasounds and ask them the same questions to see if they would give the same answer.

One thing Dr. Moise told me in Houston was that he didn't expect I would make it full term and to prepare for a cesarean.  After two vaginal births I was devastated. I researched and asked and consulted but always came up with the same issue.  There was a risk in both kinds of birth, but the risks were different. What I could not justify in pushing for a vaginal birth was the relatively low risk of acute TTTS happening while baby A was born and B was in the womb. It was a small risk percentage, but it could be fatal to baby B or cause neurological damage.  With a cesarean there was more control because baby A and B could be born and cords clamped immediately to stop the blood sharing between them. Every doctor I saw (all 7 MFMs) were unanimous that a cesarean section would be best  as well.  Try finding a doctor in town who will go against the recommendations of 7 MFMs!

I made peace with the inevitability of a surgical birth but wanted to carry them as long as I could. I was huge because of too much amniotic fluid (polyhydramnios) but at each ultrasound they measured my cervical length via ultrasound and it was great. No signs of preterm labor. The doctors said it was good that my last baby had been large and "taught" my body to handle a larger than normal uterus.

Two times after my ultrasounds and once after an OB appointment I was sent to the hospital for a nonstress test. A nonstress test measures the babies movements for one hour to ensure their heart rates go up in response to their movements and basically measures their level of health. Every time the boys did well and I was released soon after. One nurse thought I should get a vaginal exam and when I told her I didn't need one she called my doctor. My doc told her the exact same thing. I knew they tell you nothing and might send you into preterm labor and introduce infection and I would have refused all the same but it was a bit annoying to have her try to go over my head.

As the weeks went by the babies continued to grow and look fine although my fluid levels continued to creep close to the levels at which it would be enough to drain. Thankfully we never needed that.

At 30 weeks we began to notice that Jesse was slowing down in his growth while Max continued to top the charts in size for his age. The blood flow through Jesse's umbilical artery was also not looking very good. Normally you have a bit of blood flowing even between heartbeats but Jesse had no blood flow between beats and even some back flow sometimes due to force of the pull of Max's heart. 

Even this compromised blood flow situation had been working enough to allow Jesse to grow up until now but his body started showing signs of IUGR. IUGR is a big deal because if the placenta is not functioning well enough to provide adequate nutrition, the body will use up its fat stores. The first thing to be cannibalized is the fat around the organs (visceral fat) so abdominal circumference is the first indication of IUGR.  The last fat to be taken is in the brain and from there you have neurological impairment and stillbirth. I watched Jesse's abdominal size shrink dramatically from one week to the next and my heart sank. I knew we would have to have the babies early to keep poor little Jesse from starving to death. 

I had read a study that twins delivered at 37 weeks do better and actually have higher birth weights than twins who are born later and couldn't understand why that would be possible until I understood more about IUGR and how important its effects are. 

So it was decided that at 34 weeks we would have our twins via cesarean. The cesarean was to give Max the best chance (non presenting twin B) and 34 weeks was to give Jesse the best chance.  I felt like we had been walking a tightrope between the two boys needs and now I was relieved that it was almost over. 

I had done the best I could to keep them inside and eaten as much as I could to help them grow and now it was time to finally meet the little babies who showed me the scary world of high risk pregnancy.

22 weeks

24 weeks

26 weeks

28 weeks

30 weeks

33 weeks

34 weeks

Links to the detailed story:

Ultrasound reveals all (Part 1)
High risk here we come (Part 2)
Houston Perinatal Consultants (Part 3)
Texas Fetal Center (Part 4)
The Final Stretch (Part 5)
Jesse and Max's Birth Story (Part 6)

Texas Fetal Center (Part4)

After hearing we had stage 1 TTTS and being referred to a new MFM in Houston we were scared and nervous but still hopeful. We were already 24 weeks and the babies were viable at this stage and we had hundreds of prayers being sent up for our boys.

We left our big kids in the care of Brandon's aunt Angie and off to Houston we went. Everybody at the office in Houston was very nice and we felt a little less apprehensive. The specialists in Houston looked at the same things we had looked for previously and then we were sat down with Dr. Moise who explained what was going on and his prognosis. 

He did not think the babies had TTTS after all. The smaller twin had lower fluid but his size and fluid were adequate for an average size baby.  The larger twin had macrosomia (big baby) and some enlargement of the heart due to pumping extra blood. His fluid levels were also high. The boys shared some deep connections in the blood vessels running through their shared placenta. Dr. Moise explained that if we could get to 34 weeks the survival rate and chance of no neurological impairment were very good. If we continued to hold steady we could continue without further intervention, but if TTTS progressed quickly enough by 26 weeks we would consider laser ablation surgery to separate the vessels connecting the boys. To complicate things, I had an anterior placenta (located in the front) so they would have a much more complicated surgery to access it. 

We were told to travel to Houston for weekly scans and continue to see HPC on Fridays in College Station until 26 weeks.

The next two weeks were a flurry of dr appointments and scans and driving just waiting for the other shoe to drop.  It was on our second trip to Houston that i told Brandon we needed to settle on their names.  I felt like they needed names so I could bond with them and talk to them. Calling them twin A and B was so impersonal so we picked names for the boys. The smaller twin was Jesse Alexander and larger twin was Max Elliot. During this second trip to Houston we also got 3D ultrasound pictures so we got to see their little faces and an echocardiogram on Max's heart. They looked ok and even a bit better than before. I had begun to eat as much as possible and increase my protein intake and focus on resting as well. 

Jesse

Max

Jesse

Max

After our third visit to Houston at 27 weeks it seemed we survived the most critical phase and the laser ablation surgery was off the table. We agreed to be closely monitored in College Station by the HPC group instead of driving to Houston.

Links to the detailed story:

Ultrasound reveals all (Part 1)
High risk here we come (Part 2)
Houston Perinatal Consultants (Part 3)
Texas Fetal Center (Part 4)
The Final Stretch (Part 5)
Jesse and Max's Birth Story (Part 6)

Meeting Houston Perinatal Consultants (Part3)

Every Friday a member of Houston Perinatal Consultants would come over to College Station to see clients in this area and they rotate each week. Thankfully this was perfect for us since getting a sitter for all day would be difficult.

The first appointment was with Dr. Reiter. Brandon couldn't come so I went by myself. He was very businesslike and had his technician start the scan right away. They determined that the boys were indeed identical and needed intensive monitoring because TTTS can progress quickly and suddenly. The cutoff date for laser ablation to separate the vessels that connect the boys can only be done before 26 weeks. After 26 weeks, the babies are instead delivered. The most important reason to get the more advanced scans was to evaluate blood flow with a Doppler. Each boy had blood flow measured in the umbilical cord, a large artery in the head, the liver, and placenta. The heart is studied closely and each boy measured to ascertain growth. The kidneys and bladder are observed as well. The amounts of fluid are also measured because the first sign of TTTS is fluid discrepancy and disappearing bladder volume in the donor twin. Each scan took between one and two hours because so many facets were being monitored. Dr. Reiter was optimistic and said the boys were looking well and we would check again in two weeks.

Two weeks later (20 weeks) both boys showed good progress but the size discrepancy was increasing. We scheduled another scan for two weeks following but the office called and cancelled so it was three weeks before I was in for another ultrasound. Meanwhile I began to see an OB every two weeks.

When we made it to the scan at 23 weeks we were quite alarmed to hear that the boys had TTTS. The big twin had some enlargement around his heart, high amniotic fluid levels and the smaller twin was showing some abnormal circulation in his umbilical artery. We were immediately referred to the maternal/fetal medicine specialist (MFM) in Houston, Dr. Kenneth Moise. Our appointment was scheduled the next business day which was Monday. We were sent an informative video about TTTS and had a stressful weekend. I think it's impossible to watch that video and not cry when the mortality rates are laid out there. I was also a bit confused that we were diagnosed as having TTTS when we did not fit the criteria of low fluid on the donor twin.

Things were not looking good.  We asked for prayers from everyone we knew.

Links to the detailed story:

Ultrasound reveals all (Part 1)
High risk here we come (Part 2)
Houston Perinatal Consultants (Part 3)
Texas Fetal Center (Part 4)
The Final Stretch (Part 5)
Jesse and Max's Birth Story (Part 6)

High risk here we come! (Part2)

My third pregnancy was turning out to be a surprise in more than one way. After finding out we were having twins we scheduled an appointment with the most advanced ultrasound machine in town and a tech with experience in twins.

We took Lily with us because she begged us to go while Ehren went ahead on to preschool. Brandon and I had been throwing around the idea of finding out the sexes. He was fine not finding out when there was only one baby but felt strongly that with twins he wanted to be prepared. I gave in and decided twins would be enough adventure and it would make naming the kids easier if we found out what they were.

At the time we were hoping for g/g or b/g combo because I really wanted another sweet little girl and felt that Lily should have a sister.

When the technician looked at the babies she was checking for chorinicity. She also was looking at anatomy. She spent a lot of time on the placenta and the membrane. She told us that the babies were sharing a placenta and outer sac and asked if we wanted to know the sex and we said yes. She waved the wand around one baby and immediately we knew we were having boys. Both babies were approximately the same size at 17 weeks but they were already different just a week later. I asked her if the difference was a concern for .... I didn't even have to say TTTS because she knew what I was asking and told us that yes, it was a concern. My heart sank. Here I was pregnant with boy babies that were going to be high risk and may not even survive.

I was strangely mad at the babies for messing up all my home waterbirth plans. Then I would feel bad about feeling negative towards the babies. Lily told me she was upset that night and cried because she wasn't going to have a sister. I sympathized so much. Brandon told me that God knew what he was doing and he gave us these babies to teach us lessons we need to learn... Namely learn how dependent we need to be and how we need to accept his plans instead do focusing so much on our plans. He thought I was a birth snob (which I probably was) and that having to go back to OB care was to knock my pride down a notch.

I wallowed in self pity for a while and then decided to spend my time making a new plan and researching instead of worrying.

I needed to make lots of decisions quickly as to what doctor I would use for my care. I asked around and tried to read reviews and research. I decided to go with a doctor that was in the same group as Dr. Rice who said on her online info that she very seldom misses a client's birth. The main concern I had was that I would work hard to establish a relationship with a doctor only to have some random person attend my birth and wind up with another traumatic birth. Another plus was that she was Catholic and had worked in Guatemala which indicated to me that she understood what women were capable and likely respected natural birth and NFP but was qualified to be more interventive if the need arose.

I set up an interview with Dr Anna Damian for the next week. I suppose interviews are not really popular because when I got there the office staff wanted me to start paying when I hadn't even made a decision yet. I had a notebook with my concerns and my birth plans all ready to discuss with her. She seemed competent and caring and listened to my concerns and told me that there was nothing to be afraid of. I think she must come across moms who are scared of birth... I was scared of doctors! Birth was not my concern at all. She seemed supportive of natural vaginal birth as long as baby A was vertex. I thought she seemed reasonable and that I could work with her. I told the office that I wanted to have her for my care and scheduled an appointment to see her in two weeks. In the meantime she referred me to a maternal fetal medicine specialist group that sent a member to College Station from Houston every Friday.

Although so much was still in the air, I started to feel better about our situation now that I could have a little bit of a plan.

Links to the detailed story:

Ultrasound reveals all (Part 1)
High risk here we come (Part 2)
Houston Perinatal Consultants (Part 3)
Texas Fetal Center (Part 4)
The Final Stretch (Part 5)
Jesse and Max's Birth Story (Part 6)