Birth Story

I woke up around 4 AM with abdominal discomfort.  Contractions or gas?  Hm.  Gas.  Totally gas.  Definitely gas.  But I wasn't falling back to sleep, and gas might have been a coincident red herring.  I played with my iPad in bed until Ben and Andy woke up.  By this point I was fairly sure I was feeling contractions, but they were still mild. 

It was July 31, a Sunday, the day before my due date.  Ben had come a week early, so I was pretty impatient by this point, as I'd been 100% sure that the next one could only come sooner.  Ben's birth was also quick (contractions started mid-morning, hospital by 4, born at 7) and labor progressed steadily, so I was expecting the same or faster.  So when I was still having pretty mild, on-and-off contractions by mid-afternoon, I started to worry.  We'd just been puttering around the house all day, and now we were all kind of bored and cabin-fevery, and instead of a steady progression from mild to intense, from long intervals to short, this labor was kind of all over the place.  It would seem to be intensifying, and I'd have one or two whizz-bang contractions, and then nothing for half an hour.

At 3:53, I sent this email to C.:

Argh. Contractions pick up and then taper back off just when it looks like it might be getting interesting. I was worried she'd come even faster than Ben, but this is much worse. At it for 12 hours now, bored to death, not feeling like I'm making much progress, and worried about how tired I'll be if this drags on a lot longer.

And it worked like magic: suddenly the contractions were coming stronger and faster.  We called my mom to come be with Ben.  We called my OB/midwifery practice's service to give them the heads-up.  By the time the on-call midwife got back to us, we were ready to head to the hospital.  Luckily Midwife Jaime lives close, and so do we.

We got to the hospital around 5:00.  They offered me a wheelchair at check-in, but the idea of sitting didn't appeal at all.  I draped myself over the front desk while Andy answered questions and filled out paperwork.  I walked to the elevator and to the L&D room.

I got a room with a tub this time, which I was happy about -- I'd wanted one for Ben's birth, but the hospital was crammed and there wasn't one available.  But they had to put me on the monitor for a while to get a baseline before letting me into the tub.  Fine.  Jaime was there, and so was Emily the L&D nurse.  I remember much more coming and going with Ben's birth (a different OB practice, an OB attending rather than a midwife), and I liked very much the coziness and intimacy of having just Jaime and Emily and Andy and me in the room throughout.

During my labor with Ben, I was concentrating so intently on my breathing and relaxing that I think I put myself into some kind of deeply meditative state.  Which was nice, because I really was relaxed, and though it was certainly a painful experience, it was almost as if I wasn't entirely there for it -- some part of me was deep inside myself and insulated from the discomfort.  When the time came to push, they told me to put my knees up to my ears, and I literally had no idea what they were talking about -- Andy had to translate for me because I was able to hear him in a way that I couldn't hear the doctor and nurses.

This labor was different.  I was breathing and relaxing, but I was much more present.  Andy was making small talk with Jaime and Emily, and I was able, when not actually in the middle of a contraction, to participate.  My eyes were open.  I was there.  I was decrying the experience with colorful language.

I got into the tub, and Emily asked if I wanted to keep my bra on, and I laughed.  As if that would preserve that one last shred of my dignity!  The tub was nice.  I don't know if it actually helped ease the pain, but it certainly was distracting and comfortable.  Jaime said a couple of times that she had a feeling I wouldn't be in there long, that she had better keep a close eye on me because I was going to need to come out fast.  Which is what happened, of course.  I was feeling like I needed to poop, which I failed to mention because -- well, partly because I was kind of busy panting through contractions -- but also because even though I knew that was a sign of needing to push, it didn't feel like it felt with Ben, and it just didn't seem all that relevant at the moment!

When I finally did mention it, Jaime started saying stuff about a water birth being just fine, and I was all NO WATER BIRTH GET ME OUT, so during the next interval, Andy took one arm and Jaime took the other, and they more or less hauled me, sopping naked, over to the bed.  Where it was suggested to me that I could push on my back or on all fours, and while neither sounded appealing (what sounds appealing at that stage?  unconsciousness!), knees seemed less horrible, as leaning over had offered some relief throughout labor.

So there I was on the bed on all fours, with Andy up by my head and Jaime and Emily poised to catch.  There was a fair amount of screaming and yelling.  My water never broke, so Jaime did it.  I can't remember how many times I pushed, but I couldn't have been there for more than five minutes.

And then there she was!  A tiny little person, passed up under my belly into my arms, and they helped me turn over and sit down while they cleaned me up.  She latched immediately and nursed like a champ, thus no doubt tipping the scales on her birth weight, which wasn't recorded for a good while.

We looked at our list of names, still very much undecided.  The final short list was Joanna, Jane, and Margaret.  I told Andy to rank them and did the same myself, and our number ones were the same.

Jane W. L., born 6:11 PM.  8 lbs even, 20.5 inches.

Pot's Right

Potty training isn't quite the third rail that vaccines or circumcision are, but it's definitely one of those parenting issues that people tend to feel strongly about and other choices get interpreted as criticism.  And it's another parenting issue on which I don't have a strong opinion affiliated with any particular school of parenting, and on which, therefore, I tend to think it pays to be flexible and open to various ideas because what works for one kid may not work for another, etc.

A big part of our potty training technique was informed by laziness and a deep ambivalence about starting the whole process, which I was pretty sure was going to be awful.  I mean, if it was going to feature, in any way, poop ending up where poop was not intended to be, my feeling was that this was worse than diapers and (not should, clearly, but) would be put off as long as possible.  The thing is, I got pregnant, and while the notion of two kids in diapers at once was unpleasant, it wasn't the gun at my temple that the looming prospect of pre-school was, and the the notion of having to train Ben while wrangling a newborn.

Luckily, it wasn't like we'd done absolutely nothing up to that point (that point being a couple of weeks ago).  We started putting him on the potty at diaper changes when he was around 16 or 18 months.  This was the result of what I thought was smart advice: that even if you have no expectations whatsoever of moving past the occasional potty-sitting, it's a good idea to get the baby used to the potty long before they reach the more oppositional phase around two and a half.  And I'd tried a few times since he turned two to take it a step further.  I put him in underpants and covered the sofa with towels, and he was enthusiastic about the M&M bribes and game for the Lightning McQueen underpants, but the experiment was always a FAIL, and we went cheerfully back into diapers.  The last thing in the world I wanted was to stress either one of us out by forcing the issue before he was ready to be successful.

I think we'd tried maybe three times, each "time" consisting of a few mornings in a row, by the time his third birthday rolled around and I started getting freaked out about pre-school.  And it had been a while since the last attempt, because lately, in the last six months, he'd become quite opposed to the very notion of underpants, and I didn't want to force a confrontation.

But the weather had turned warm, and if he refused underpants, he would at least agree to a couple of hours in the morning with no pants on at all.  Which was the key in the end, I think, because the feeling of underpants was too close to the feeling of a diaper, but total bottom-half nudity made him pay attention much more closely to his body's signals, and he didn't have a single accident over the couple of weeks we tried this out for an hour or more every day.

But still he refused underpants.  And then I realized I had one powerful tool yet unused, just lying there!  Bribery.  M&Ms worked great for the short-attention-span toddler years, but they weren't compelling enough for my three-year-old.  But the promise of a toy was.

I told him if he could go one whole day in underpants, no diaper, from the time he woke up until bedtime, he could pick out any toy he liked (within reason, void where prohibited, no live monkeys).  This was a Sunday, and I figured amid the failures, we'd go to the toy store sometime during the next week and choose the desired object, which would then be dangled in front of him in some cruel but motivating way for as long as it took to get through a whole day.  What happened was that he barely left me alone about the toy -- which he decided early on would be an excavator, which I hoped existed -- to the extent that it was clear the toy did not have to be in the house for effective dangling.  And miraculously, he stayed dry in underpants that entire next day.  And we went to the toy store on the Tuesday, and lo and behold, they had a Playmobil Excavator, worth every penny of the sixty bucks it cost.

And that was that.  Potty trained.

But of course that's not how it works, is it?  Potty training is a continuum, and we had achieved only the first stage.  Which is a big deal, don't get me wrong, but it's definitely one of those things with which parenthood is rife: the thing that looks like one simple step from one side and turns out to be a whole staircase from the other.

Because it's not like you move right from diapers to the kid climbing cheerfully up onto public toilets and wiping his own tuchus.  I drive around now with a Frog Potty in the way-back of my Outback, a technique I heartily recommend to anyone at this stage of training.  (Empty pee into shrubbery or anywhere you wouldn't feel rotten about a dog peeing, which is pretty much anywhere, at least if you're me; wipe out potty with wipes.  Poop goes in trash bag and right into any trash receptacle you wouldn't feel rotten about dumping dog poop under similar circumstances -- which may mean you drive around with it in the car for a while, so have plenty of extra bags.)  The kid can pull down his own underpants, but he balks at doing the same thing for pants, and he simply isn't coordinated enough to put any of his clothes back on.  He's in diapers at night, largely because we still have a big box of them, but he wakes up dry more often than not.  And he'll sit on a proper toilet without too much fuss, but still prefers the frog potty.

But he's trained enough that I don't have to hoist him up onto the changing table or get down on the floor to change his diaper, which is a mercy at nine months pregnant.  And he's trained enough for pre-school, where I'm relying on a little old-fashioned peer pressure to carry him the rest of the way.

Chatter

I was talking to a father at one of Ben's activity groups this week about his daughter who at 18 months has just a few words.  He was worried.  As it happened, I had just reread this blog post, so my attitude about the same stage with Ben was fresh in my mind.  I told him that we, too, were told we ought to work at being a little less attentive, to pretend we didn't understand what he wanted so as to elicit words, and that I didn't like that kind of deception and didn't do it.  (Instead I prompted him for the word before giving in to whatever it was I already knew he wanted.)

I have no idea if any of what we did or didn't do hurried or delayed his talking schedule.  He had around 50 words at at his 24-month check-up, which I know because we made a list, and it's a pretty entertaining little artifact.  His pediatrician said to give her a call if the summer passed (his birthday is the end of May) without a substantial language explosion, and I remember being a bit concerned even into July, and I don't remember ever thinking, "Oh, here it is: the language explosion!" but I also don't remember reaching the end of the summer and even considering calling the pediatrician.

And now here we are at nearly three, and it's not unusual for people to comment on how articulate and chatty he is.  He's very chatty.  He likes to bust into whatever conversation is happening between me and the check-out clerk or me and the server or me and the FIOS installer to announce apparent non-sequiturs like, "But I have a semt mixoo [cement mixer]!" or once, memorably, to respond to the age question from an enthusiastic waitress, "Two half.  But I have gun!"  (A wooden one Andy made so that Ben would stop stealing his carpenter's square.)

I was never really worried about his language development.  I knew the range of normal was wide, and it was clear from very early that his receptive vocabulary was huge.  But it was one of those things, lurking just beyond the horizon, ready to burst into star-spangled worry at any moment.  Until it wasn't.

Knock Wood

I've been superstitiously avoiding my blog, but it's time to get a grip.  The last few times I posted about feeling better, I immediately felt worse, and while that might happen again, I miss writing it, and several readers have been so kind as to say they miss reading it, so there it is.

What's happened since I last posted is a lot of ups and downs in terms of how I've been feeling.  Finally in September I had a full-blown panic attack over absolutely nothing, and that sent me back to my doctors willing to try the SSRI I'd pooh-poohed earlier in the summer.  And wow, let me just say again how very glad I am to be living now rather than, say, in the mid-nineteenth century.  Zoloft is much, much better than a few weeks in the country for an attack of the nerves.  So I was on it for a couple of months, and now I'm weaning off it (with doctor's supervision) because I want to get pregnant and my GP and I agree that there was something of a perfect storm this summer that created this anxiety, and I'm unlikely to need medication forever -- so this seems a good time to try getting off it.  And just the notion that I can go back to it later if I want to is a great comfort.

It's still shocking to me how many purely physical symptoms could be chalked up to the anxiety.  When I went on the Zoloft, I was experiencing spikes of anxiety (often unrelated to any events or trains of thought -- just out of the blue), but also periods of extreme nausea and dizziness.  I expected the Zoloft to take care of the anxiety and allow me to analyse the other symptoms without freaking out over them.  Instead, they all went away.  Though, to be fair, my GP discovered I had a B-12 deficiency and I started taking B-12 at the same time, so it's not altogether clear which issues were solved by the SSRI and which by the vitamin.

Anyway, even on the Zoloft -- and I was on what could be considered a half dose, just 25 mg -- I still had occasional spikes of anxiety, which I was able to treat effectively with Valium.  And as time went on, I was able to wait longer and longer before taking the Valium to see if the anxiety went away, since I knew from experience that I'd be able to zap it if I needed to.  And what I found was that mostly I could breathe through it, do a few yoga poses, or distract myself, and it would go away rather than building.  Which makes me feel more confident about coming off the Zoloft and getting pregnant, when I won't have the safety net of the Valium.  And can I just say how cruel and awful it is that there's nothing perfectly safe to take for anxiety during pregnancy?  What kind of nasty trick is that? 

So.  Back to parenting, I hope, and not so much about my health in this here blog.  And thanks again to all of you who reached out while I was feeling wretched or told me that you missed the blog -- you're peaches, every one of you.

Update

The short version: I had some further medical drama, but I'm feeling much better now, and apart from the cyst thing, I think I'm past it.

The long version:

I was feeling better after that week or so of drama, and then a few weeks later, I went to the OB for a follow-up, expecting to talk about whether or not it was wise to start trying to conceive again, given this weird possibly-migrainey stuff that was going on.  Instead I found out that the ovarian cyst I wasn't worried about hadn't gone away on its own as was hoped, and might in fact need surgery.  If I didn't want to get pregnant, said the OB, he'd want to leave it alone and keep an eye on it, but he didn't want me getting pregnant and then having the cyst do something wacky and need removing while I was pregnant, making the surgery risky to the fetus.  Here's the fun part: if I have the surgery, it's likely I'll lose the ovary, reducing my fertility by about a third.  Great.  We agreed to give it eight weeks to resolve on its own, still a distinct possibility, and re-assess after another ultrasound. 

I found this extremely dispiriting. 

Then I had another week of weirdness, this time bouts of extreme nausea with anxiety and what I would call general low mood.  In retrospect, I'm pretty sure this was a dire case of PMS, but at the time, it felt like more strange and very unpleasant symptoms of something that none of my doctors could identify let alone fix. 

I canceled a road trip I was supposed to take with Ben because I was afraid of getting dizzy or heaven-knows-what-else while on the road a hundred miles from home, alone in the car with my toddler.  As it turned out, I felt fine that week, but I was happy with my decision: much better, I thought, to be thwarted by feeling fine at home than by feeling like hell far away from home.

I saw my GP again, and she thought the whole thing at this point might just be anxiety born of so much medical drama.  She told me to stop taking notes on all my symptoms, and advised I start an SSRI.  I didn't like the SSRI plan, so we met in the middle with a low dose of Valium.  I also thought the anxiety diagnosis was wrong and more than a tidge dismissive, but at that point I was open to trying almost anything, so I took the Valium and put away my notes and hoped for the best.

I felt better once my period started.  Which supported my growing notion that everything had to do with hormones.  I took C.'s advice and went to an acupuncturist.  I took my own advice and started yoga, thinking that every step I could take to make myself all-around more healthy would help whatever this nonsense was, too.  I stopped taking the Valium after a day or two: I wasn't feeling so anxious, and the Valium just made me tired and depressed.

I went to another OB for a second opinion.  He agreed with me that apart from the crazy brain stuff at first, the second round of weirdness sounded very much like extreme PMS, and that that was not abnormal for the few cycles after a pregnancy, even a short-term one.  He was also much more optimistic about keeping my ovary if we had to operate on the cyst, and more optimistic about the cyst generally.  (I liked him a lot, and his practice is also about twenty-five minutes nearer to me than my current OB's -- and he shares his practice with three midwives, which I like, too.  So I'm thinking I'm going to change practices.)

So here I am.  I've had a few sessions of acupuncture and have been taking Chinese herbs as prescribed.  I've been getting out and walking as well as doing yoga once a week.  Who knows whether any of that made a difference, or whether time was the thing, but I just sailed through PMS last week with nothing worse than some lower back pain.  Pain -- so uncomplicated! so easy to treat!  And now that my period has started and the pain has let up considerably, I'm not even afraid that the pain is a symptom of some other dire whatnot.

The cyst is still there, of course.  (Unless it's not -- I won't know until the ultrasound at the end of this month.)  But now that the mystery symptoms seem to have tapered off and been proven out to my satisfaction anyway as hormonal aberrations of post-pregnancy, I feel equipped to handle the cyst, even if it means surgery.  My native unflappability has returned, for the most part.

There's still the "slightly abnormal" EEG, too.  I saw my GP again last week, and she and I agreed that it made sense to wait a while, until I'm more sure of feeling normal otherwise, before going back to the neuro for the follow-up he wanted, which is another EEG, only with my brain stressed by a night of not sleeping.  I'm choosing not to worry about it.  For one thing, he said they treat symptoms, not tests, so as long as I continue to feel fine, they consider me fine.  I feel fine.  But I'm not eager to learn anything more about how not-fine I might be under the surface.  So I'm happy to put that testing off until after the cyst thing is resolved.  One category of bad news at a time, please.

I downloaded a bunch of video from a tape onto my computer this weekend, and a couple minutes were from February.  The video is of Ben, of course, but I'm in the background, wearing woolly slippers and a sweater.  Just turned 37.  Pregnant.  Blissfully unaware of all the crazy to come.

More Medical Drama

It's been a while since I posted.  Here's why.

The Very Short Version

I had some mysterious medical issues, at first very scary, now largely resolved, which for several weeks meant that if I looked at my computer, I felt sick.  After extensive medical testing, everyone's best guess seems to be atypical migraines brought on by anemia.

The Long Version

On Thursday, April 29th, just before bedtime, after I'd been at my computer for several hours straight, I started experiencing a visual anomaly: basically, I had a big splotch in my field of vision that looked like the kind of bright semi-blindness you get after a camera flash.  I had it in both eyes.  It freaked me out, but it went away after five or ten minutes.  When I got in bed and tried to read a book, I couldn't.  I could read each individual word, but when I tried to string them together to make some kind of sense, I couldn't.  Which really freaked me out.  I felt perfectly fine otherwise, and I thought maybe I'd just given myself such a scare with the vision thing that I had, I don't know, made myself temporarily unable to concentrate.  Or something.  I put the book aside and went to sleep, figuring I'd deal with it in the morning if whatever it was was still happening.  And it wasn't: in the morning, I was fine, and I chalked it up to eye strain and freaking myself out, and went about my business.

Nine days later, Saturday, May 8th, it happened again.  This time it was around 9:00 PM, and I'd been playing a computer game for about an hour, and I got another camera-flash blob.  I left the computer and went into the living room and turned on the TV.  Again, the blob went away within five or ten minutes, and what followed was some kind of disorientation.  I was watching Lost (on the TiVo), and though I could understand everything that happened, I couldn't follow the thread of the plot from scene to scene, and nothing seemed to have context.

I thought I was having a stroke.

We hauled the kid out of bed and went to the ER, for the second time in a month.  They took my blood and pronounced me extremely anemic (from the blood loss from the miscarriage) as well as dehydrated.  They did a CT Scan which showed nothing.  They said it was probably atypical migraine or atypical seizure, and I should see my doctor as soon as possible.

The next few days are kind of a blur.  I felt like hell, in retrospect partly because I kept looking at my computer, which it took me some time to realize was provoking a lot of the rotten feeling, but also because I was terrified.  My doctor wanted me to get an MRI to rule out some very scary shit including brain cancer, and it was a couple of days before those results came back totally clear.  I didn't have any more visual anomalies or periods of disorientation.  What I had was a lot of nausea, dizziness, and general feeling like hammered crap.  I also had a full work-up by a neurologist, including an EEG to rule out seizures, the results of which I'm still waiting for: I have the follow-up appointment this week.

Once I figured out that the computer, particularly reading anything on the computer, made me feel terrible, I turned it off and stopped looking at it entirely.  Books and magazines were the same, but less intense: I could read non-electronic text for a a few minutes before it started making me feel weird, and my ability to read non-e text without adverse effect returned within a week or so.  Oddly, I could read my iPhone comfortably.

By Friday, six days after the episode that sent me to the ER, I was feeling considerably more like myself.  Feeling normal again made me realize just how wrong I'd been feeling all along.  That wasn't the end of the episodes, but it was the end of feeling shitty all the time.  From that point on, I felt mostly normal and fine, with isolated incidents of not-OK.

I went back to my GP, and she said that based on all the data she had by that point, her best guess was that I was having clusters of migraines, the first few "with aura" (that's what the camera-flash blob was), and that it probably had everything to do with my extreme anemia (which I have been beating back with massive doses of iron since my first GP visit after the ER) and the stresses on my body caused by the miscarriage and hemorrhage, and that she doubted it meant I'd become a migraineur.  The neuro said basically the same thing, but wanted to rule out seizures, which I'll find out about later this week.

It's common, apparently, for women (most migraineurs are women) to begin getting migraines during some big hormonal change: pregnancy, menarche, menopause, etc.  And the migraines often stop at some other hormonal event.  Some women have them during pregnancy and never have them again.  Many female migraineurs tend to have them at particular points in their menstrual cycle.  Anyway, it makes some kind of sense that the the anemia along with the hormonal upheaval of my system resetting after the miscarriage would have provoked either a one-time cluster of migraines or the beginning of some migraine phase of my life.  Of course, I'm very much hoping it's the former, but I can live with the latter.  Better nauseous and disorienting migraines than the kind with blinding pain, after all (presuming, if I continue to get them, they will be like the ones I've already had) or any of the far-more-terrifying possibilities ruled out by the MRI.

Did you know they have TV in MRIs now?  I couldn't actually see the Today Show because I had to take my glasses off, but the sound was pleasantly distracting.  So was the Valium.  The neurological evaluation was nifty, too.  It was all a bunch of follow-my-finger, walk-in-a-line-heel-to-toe, tell-me-where-I'm-sticking-you-(gently)-with-this-pin type stuff, all of which made me want to grill the dude about neurology.  I'd have even warmer and fuzzier feelings about all of it if all the tests and hospital visits and the fact that Andy's employer hosed us this year on medical insurance didn't mean that we had to cancel our modest September beach vacation.

Anyway.  I had my last arguably migrainey spell on the 23rd after having a short night's sleep and being a bit hungover.  And really, for the past few weeks, it's been tough to tell what's migrainey from what's just a bit queasy and wifty.  I started back at the computer five or ten minutes at a time last week with no adverse effects, and now I'm spending upwards of an hour here (hello!) without even having little panic attacks about it.  My guess about why the computer and to a lesser extent other reading provoked the spells is something to do with eye strain and maybe needing bifocals (I've been myopic since I was 8).  So I'm hitting the opthalmalogist this week, too.

I talked to my pal the midwife at my OB's office a couple of weeks ago, and she said she didn't think it was a good idea to start trying to conceive until the anemia was gone.  She said "a couple of months," but I can't see it taking that long.  My hemoglobin had gone from around 8 to over 10 the first week after the ER visit, when I was taking three iron pills a day.  That's already nearly normal, and I've been taking two a day since, so I'll be very surprised if my blood test next week doesn't show perfectly respectable levels.  I've already had a normal (I suppose) period, which means I'm (probably) ovulating again, so now that I feel normal and am no longer freaked out about this whole thing, I'd just as soon get back on the horse ASAP.  Especially since this entirely-without-fun roller coaster ride started when I got pregnant in February and it is now June, and I am in no way getting younger.

I'm off to the OB for a follow-up ultrasound and sit-down with one of the full-metal OBs this afternoon, so I'm going to talk to him about it.  And I'll see my GP next week after getting the EEG results and also the results of a blood draw, so I'll be talking to her about it, too.  And then I'd really like not to see the inside of another medical establishment until I'm safely and successfully and without incident knocked up.  Cross your fingers!

Miscarriage, Act III: There Will be Blood

Tuesday evening, three weeks to the day after the disappointing ultrasound, the miscarriage began in earnest.  And when I say "earnest," try to picture that scene in The Shining with the elevator doors.  In retrospect, now that I'm home from the hospital, I know that what was happening was not just surprisingly heavy flow, but a hemorrhage.

I called my OB's office and got juggled by incompetents at their answering service for a while, finally got a call back from the on-call doctor, who wasn't a member of the practice.  He prescribed Methergine, a hormone, to slow the bleeding.  Andy went and got it, and I took the first dose at 9:30 PM.

It was a scary night, and one of the worst things was having to make the judgment call myself.  The standard is soaking through a pad an hour; more than that, and you're supposed to go the ER.  But that's an extra-tough call to make when going to the ER involves waking your sleeping toddler and hauling him off with you.  After the Methergine kicked in, the bleeding slowed, but I was still soaking more than a pad an hour, and I was passing some pretty horrifying clots.  Tissue (normal) or clots (if large, worrisome)?  How was I supposed to know?  The trend was positive -- I was definitely bleeding less.  So I stuck it out, and after the second dose of the hormone, around 2:00 AM, the bleeding slowed significantly, and I was able to sleep until 6:30.

In the morning, everything seemed fine.  Bleeding like a normal period.  I called the OB's office, and they said I should come in and get checked, which I did at 11:30.  Andy took the day off work.  I saw the midwife, she did a pelvic exam, and everything looked normal.  In her opinion, I'd just had an all-at-once miscarriage, and though she could still see some blood and clots, she expected that I wouldn't bleed heavily again, and probably not for long.  So, good!  Hurray for that.  Such relief.

We got home around 1:00, and the heavy bleeding started again.  I called the office, and by the time the midwife called me back, I was beginning to feel light-headed.  I should have mentioned it, but it didn't seem significant, especially since I'd hardly eaten all day, and I'm prone to feeling light-headed when underfed.  She told me to take the Methergine again, but if I was still soaking a pad an hour after four hours to go to the ER.  I took the Methergine at 2:30 and went upstairs to try to nap.  I slept some, but mostly I just lay in bed and bled and worried.  When I got up at around 5:00, I had to sit down at the bottom of the stairs because I felt like I was about to black out. 

So we went to the ER.

The admitting doctor was a putz.  He asked me how long my OB would "let me" continue bleeding.  I told him what the midwife had said about four hours post-Methergine, and he started arguing with me in way I didn't entirely understand.  I explained that I expected -- and I assumed my OB practice expected -- that going to the ER meant I would get a D&C at the hospital.  The doctor said no, the ER would refer me back to the OB.  That seemed crazy, but I wasn't about to argue with him, since I figured either another doctor would be less stupid or someone would call my OB.

They wheeled me into the inner section of the ER, and Ben became blessedly absorbed by Cars and Trucks and Things That Go.  Eventually another doctor came in, who began by asking me how I knew I was pregnant, which flummoxed me completely.  Uh, because I know how to pee on a stick?  So he got the whole history and concluded that I needed an ultrasound before they could determine any course of treatment, which seemed entirely sensible to me.  By the time they wheeled me out for the ultrasound, the bleeding had mostly stopped.  That was around 7:30.

Another doctor joined in the fun.  He said based on the ultrasound, which showed a small amount of tissue remaining, and the fact that the bleeding had stopped, we had two options: send me home with the caveat that if heavy bleeding started again, I was to come right back, and if not, go to the OB in the morning; or transfer me to Bellevue (the sister hospital a couple of miles away that handles all the OB/Gyn stuff for the hospital system) where they could keep a closer eye on me and possibly give me the D&C as soon as that night.  They wanted to take my vital signs again and consult with someone from my OB practice before making the call.  The vitals were what clinched it: they took them lying down, sitting up, and standing, and my heart rate was somewhere in the realm of crazy-cuckoo when I stood up, so no going home for me.  Which was fine.  The last thing in the world I wanted was to go home and start bleeding and have to haul the poor toddler out of bed and start this whole nonsense over again, but at some charming hour like 2:00 AM.

So Ben and Andy went home.  And let me take a moment here to sing the praises of my mellow and largely unflappable toddler, who sat quite happily in a chair looking at books and crashing toy cars together and watching Seinfeld and eating crackers and charming nurses until nearly three hours after his bedtime.  And Andy, for whom patience and calm do not come easily, who smoothly distracted Ben out of every possible turn into crabbiness and held my hand and didn't freak out even a little.  At around 9:30, they went home, and I waited for the ambulance.

The next few hours were kind of hard.  From the time we got to the ER, I felt enormously relieved that, whatever happened from that point, at least I wouldn't be the one making judgment calls, and if the crazy bleeding kept up or started up again, someone would know what to do.  But when Andy left, I felt alone, and sad to be alone.  I have lovely friends here who I'm sure would have jumped in the car if I'd called, but it didn't seem a dire enough emergency, my desire for further company and hand-holding, to get other mothers of babies and toddlers out of their beds at 10:30.  I'd have called my mom if she weren't three hours away.  I'd have called older friends with whom I have deeper credit, if they lived nearby.  Maybe.  It's hard to ask for help, even when you want it.

When the EMTs wheeled me into my room at Bellevue, I could hear a newborn crying.  The room was just down the hall from where I'd stayed when Ben was born.  I've never felt, throughout the loss of this pregnancy, that I was mourning a lost baby -- but ending this journey in that place was hard.  The doctor on call couldn't come talk to me because he was delivering babies.  I asked, when I woke up the following morning, how many babies they'd delivered that night.  The nurse said five, and I'm not even sure why I asked, because of course it made me cry.

No one knew whether I'd be getting a D&C that night, or in the morning, or not at all.  Which was fine, but it meant that I wasn't allowed to eat or drink, which sucked.  I was substantially dehydrated from all the blood loss, and I'd been getting IV fluids since arriving at the ER, but it didn't make me less thirsty.  They let me have a sip of water to take the Ambien which it was someone's excellent idea to give me around midnight, and handing that cup back demanded the kind of willpower I don't generally admit I'm capable of.  I wasn't hungry until morning, and then I had to start changing channels when food ads came on.

In the morning, I had another ultrasound and another blood draw.  The doctor (this time someone from my own OB practice) came in around 11:00, 12 hours since I'd been admitted and the first time I'd spoken to an actual MD, and said if I hadn't already lost so much blood, he'd be tempted to send me home to let the rest of the tissue pass normally, but he didn't want to run the risk that I'd start bleeding again, so he wanted to give me a D&C.  Which, duh.  I mean, I think I'd have burst into tears if he'd tried to send me home again.

They put me under for the surgery, bless them.  Not on-a-ventilator under, just knocked out and with a local.  So the surgery, so far as I'm concerned, was a total breeze.  I came to, dozed for a while in recovery, then got wheeled back to my room.  Most of my focus was on when could I eat something and might there be crackers and I have crackers in my bag if there aren't crackers here and can I eat crackers yet?  The nurse brought me saltines and ginger ale, and never have such things tasted so good.

Andy and Ben had come for a visit in the morning between breakfast (theirs, of course) and nap time, and I'd requested -- for my sake and Ben's, not so much Andy's -- that they not come back until I was about ready to be released, since I preferred to rest and watch something on TV other than Dora or Dinosaur Train.  After I gorged myself on crackers and further demonstrated my ability to function extra-hospitally by peeing, the nurse said it was just a matter of some paperwork (translation: maybe two hours) before I'd be free to go.  That was around 3:30.  I called Andy, and he and Ben came back.  I was home by 5:00.

The bleeding started Tuesday night.  I spent Tuesday night bleeding and freaking out, Wednesday night in two hospitals, and Thursday night sleeping soundly in my own bed.  Today is Friday.

In terms of the surgery itself, I feel absolutely fine.  I had some very mild cramping last night, wholly solved with ibuprofen.  No pain whatsoever today.  But I'm still feeling weak from the blood loss.  The doctor told me to take iron supplements, and I should have thought to buy some on the way home, but I didn't, and I don't think I should drive, so Andy's going to stop by the pharmacy on his way home from work.  Not feeling 100% up to kid-wrangling this morning with Andy back at work, I called in the cavalry, and two marvelous friends turned up to take Ben to the playground and wear him out. 

No sex for four weeks.  No attempting to conceive until after my next period, which will probably be in four to seven weeks.  If I'd had the D&C three weeks ago, of course, I'd be three weeks ahead of this schedule.  I think it's the timing I find most frustrating.  We would have started trying to get pregnant this past fall, but I needed several dental procedures that were best done before conceiving, and what with scheduling and waiting for pre-approval from insurance, that ran us into January.  I got pregnant in February, the first cycle trying, but it turned into a bit of a catastrophe, and now we can't even start trying again until the end of May at the latest, and probably more like the middle of June.  I'm 37.  The clock is ticking.

In the short term, right now, I'm feeling kind of traumatized.  My bathrooms freak me out.  Having always enjoyed rude good health, having my only experience of pregnancy before this an entirely by-the-book gestation and delivery, I'm finding myself pretty shaken, especially given my age, by the idea of the next pregnancy and all the things that can go wrong.  A miscarriage, even one that goes as badly as this one, is really the least of my worries.  It's like, once the possibility of this bad outcome was made manifest, the floodgates opened, and now all the bad outcomes seem far more plausible, far more threatening, far more real.

Fifteen Days

Two weeks ago yesterday was the ultrasound.  That was a bad day, but the days since have been fine.

Like I said in my first post about the miscarriage, the fact that this pregnancy never made an embryo was significant to me, and has really meant that I haven't mourned the loss the way I would have had a proto-person ever developed.  And I certainly don't mean to minimize the grief experienced by other women in the same situation.  I feel pretty strongly that you don't get to choose how you feel about something, and there's a big range of valid reactions to any experience, and it's just the luck of the draw that I don't happen to have been made very sad by this one.

It has been a bit of a roller-coaster, though.  When I still wasn't bleeding after a week, the NP became concerned that my hCG levels weren't dropping the way she'd expect, so I had to go for more bloodwork and schedule another ultrasound.  It was possible that I was still pregnant, but my dates were way off, or I might have had an ectopic pregnancy.  The former possibility seemed so remote to me that I honestly didn't really even consider it.  My cycles have never been irregular.  I tested positive the day before my period was due, and then again about a week later, and the likelihood of two false positives is so close to zero that it might as well be zero.  The latter possibility, though, was pretty terrifying.  I drew some comfort from the fact that it seemed implausible that I'd have gotten to nine weeks with an ectopic pregnancy without feeling any pain.  In any case, when the results of the second blood draw showed that my hormone levels had dropped significantly, I was relieved -- way, way, way more relieved than disappointed.  I canceled the ultrasound and turned down another shot at a D&C.

Another week passed, still no bleeding.  I had the next weekly blood draw yesterday morning and checked in with the NP in the afternoon.  My hCG levels are now below half of what they were at the first test.  She wasn't concerned yet about the possibility of necrotic tissue causing an infection and was totally on board with my continuing to wait for things to work out on their own.  Which is still and will remain, until it seems like any kind of threat to my health, my preference.

And it kind of blows to be two weeks out and still with no end in sight, unable to move on, wearing pads when I leave the house because who knows when the bleeding will start.

Too graphic, too intimate?  I'm erring on the side of over-sharing because it seems to me that we're all a little too delicate about stuff like this, and the result is that every woman who has a miscarriage has to learn it all herself, rather than benefitting from other people's experiences well before the event.  It's too common an experience to be so shrouded in mystery.

Beating It*

I should probably leave well enough alone, but I went to bed last night still thinking about the anti-circ petition and what I'd said about it, unable to let it go, and convinced I'd become bogged down in nitpicking the text instead of making the bigger points that were really under my skin. (Ew, how did I end up with lice metaphors?)

So, allow me to beat this dead horse.

I don't think opposition to routine circumcision is wrong -- generally I find it reasonable and justified, and though I chose to circumcise my son, I consider myself an opponent of routine circumcision. But this petition obliterates any respect I might ever have had for the sense of anyone involved with it because it A) seeks to shut down debate rather than encourage it, and B) shows no respect whatsoever for science or expertise.

If you have taken a position based on a reasonable interpretation of factual evidence, you should never be afraid to hear new evidence that tests your position. If you're correct, new evidence will bear you out. If you're incorrect, why would you want to maintain your position? Similarly, you shouldn't be afraid to argue the point, especially with an expert in the field. Opposition to routine circumcision isn't an irrational position and has considerable foundation in medical science, so of all the responses available to a potential challenge, why on earth choose the one that boils down to SHUT UP SHUT UP SHUT UP LALALALALA WE CAN'T HEAR YOU?

I can't fathom what motive the authors and supporters of the petition ascribe to the CDC for doing something so unethical and counter to its mission as ignoring -- not insufficiently weighing, but ignoring -- the risks of a procedure it is considering recommending. The CDC is not some crazy bunch of penis-mutilating yahoos. It is a body of public health experts. Being human, of course, they are fallible and certainly have biases of their own. It is foolish to take their word as gospel, but it is equally foolish not to accord them the respect their expertise deserves. If we could all conduct research and draw appropriate conclusions, we wouldn't need scientists, but the fact is that we're all a little busy doing other things, and many of us plumb ain't smart enough, and few of us have the talent or training, honed over a lifetime, to conduct or interpret the kind of medical research that the CDC is reviewing before making its recommendations. Skepticism is fine -- it's admirable even -- but when it crosses the line into anti-intellectualism, into opposition to science itself, it deserves a smackdown.

Though I chose to circumcise my son, I do not support routine circumcision. But if the CDC is considering recommending it, I'm certainly interested to hear why. What research, what interpretation of the research, could support such a radical position? I look forward to the opportunity to re-evaluate my own position in light of new evidence or new argument. I look forward to hearing the opposition's response -- if it's rational, if it's based, as the CDC's certainly will be, on evidence and informed interpretation.

I definitely look forward to any chance to improve public health. If it turns out that the research demonstrates that routine circumcision actually does provide a significant protection against deadly STDs, against cancer, wouldn't that be good news?


*I'm so sorry. I'm 12, and I can't write two whole blog posts about penises without a single bad pun.

Recommendations

Mothering magazine and Intact America (a non-profit advocacy group opposing circumcision) are calling for signatures on a petition to stop the Centers for Disease Control (CDC) recommending routine infant male circumcision.

Circumcision is not a big issue for me, though of course I'm aware that it's one of those parenting third rails, like breastfeeding and vaccination. I did a lot of reading about it before Ben was born, and the most I could muster was a mild bias against, based on a general principle of avoiding all non-crucial surgery. At the time, there was some not-extraordinarily-significant research supporting circumcision as plausibly prophylactic against certain STDs, and the combination of that, Andy's more-than-mild-but-not-very-strong bias for, and the extreme discomfort and embarrassment of a family friend who had to be circumcised for medical reasons in his 70s added up to a Yes. There's also in there somewhere, in a way I can't possibly justify, a weird little family-cultural / atheist-but-CYA adherence to the covenant. Or comfort in the tradition. Or notion of tribal belonging. Or something.

Anyway, like I said, it's not something I can work up a lot of strong feelings for or against, and it's one of those things, like whether you use a baby carrier or stroller, that I have a hard time understanding why some people are excited enough about to advocate publicly rather than simply decide for themselves. But I do feel strongly about this petition, strongly enough to have broken my own very sensible rule about not picking fights on Facebook.

Here's some of what Mothering says:

Based on flawed studies that ignore the risks and ethical concerns of infant circumcision, the CDC may recommend this unnecessary surgery for our baby boys. We know that safe sexual practices and abstinence – not circumcision – prevent sexually transmitted diseases. And we know that there is NO link between infant circumcision and better health.

We will be delivering our petitions to CDC headquarters in April with the hopes of convincing them to make the right decision.

Mothering doesn't specify which studies it considers flawed and what those flaws might be. Unlike the CDC, it doesn't cite references. The CDC's fact sheet on male circumcision contains a useful paragraph, helpfully titled "Risks Associated with Male Circumcision," which includes no fewer than eight cites to studies that explicitly did not ignore the risks of the procedure. Mothering doesn't state its ethical objections, but I'm guessing they have something to do with the fact that an infant can't consent. And that's not something to dismiss out of hand, but we make decisions for our children every day, and that kind of ethical hairsplitting simply can't weigh heavily against substantive evidence (should there prove to be any) that performing the procedure would be a significant benefit to public health.

Mothering knows some stuff. Again, they don't cite references for how they know circumcision doesn't prevent transmission of STDs or how they know "there is NO link between infant circumcision and better health." And this kind of arrogant ignorance professing knowledge just honks me off. Take the claim that there's NO link between infant circumcision and "better" (as if that's even a meaningful or specific term) health: the American Medical Association says in this report, "there is little doubt that the uncircumcised infant is at higher risk for urinary tract infection." Smaller risk of UTIs = "better health"! But that's hardly the point, is it? The question isn't whether circumcision has any health benefits whatsoever (the most cursory review of current research makes it clear that it does); the question is whether the benefits are significant, whether they outweigh the risks and justify the costs. The ability to make that kind of essential distinction is only one of the reasons we trust the CDC before Mothering magazine to advise us about public health issues.

Mothering claims to want to convince the CDC to make the right decision. But to convince someone of something, you need to present an argument -- ideally with some evidence to back it up. A petition is not an argument. It's political pressure. It's a more or less polite way of ganging up. And I think we should all think very carefully about whether applying political pressure to the CDC is something we'd want to put our names to, or something we seriously think a group like the CDC should allow itself to be persuaded by.

It would be one thing if the petition advocated further specific study, if it made specific criticisms of the evidence, if it provided, in other words, an evidence-based argument to which it could then legitimately claim the CDC wasn't giving enough credence. But that's not what the petition advocates. Here's the text of the introduction:

No medical society in the world recommends male circumcision – yet newborn male circumcision is the most common surgical procedure in the U.S. This painful and risky procedure deprives more than a million boys each year of healthy, functional tissue – without their consent – while increasing medical costs by an average of $678 per baby.

The Centers for Disease Control (CDC) is developing public health recommendations for the U.S. on male circumcision that could ignore the serious risks of this non-therapeutic surgery. As the foremost expert on public health in our country, the CDC has a responsibility to share the truth about infant circumcision.

We need just a few more signatures to help us reach our 25,000 goal before the end of March. Sign our petition to the CDC below and demand a truthful statement on the risks and harms of newborn male circumcision.

So, if the CDC's recommendations don't ignore the risks of the procedure and do present a truthful assessment of said risks, but conclude that the benefits outweigh the risks, Intact America will support the recommendations?

Here's the text of the petition itself:

As the foremost expert on public health in our country, the Centers for Disease Control (CDC) has a responsibility to share the truth about public health issues that can affect millions of Americans.

Newborn male circumcision is the most common surgical procedure in the U.S. - yet this painful and unnecessary surgery carries serious risks, including hemorrhage, infection, surgical mishap, and death.

The role of circumcision in preventing sexually transmitted diseases (STDs) and other health claims has been investigated by public health researchers and remains highly debatable. Only safe sexual practices, such as the use of condoms and abstinence, can prevent STDs, including HIV/AIDS. Circumcision cannot be responsibly recommended as a way of preventing disease.

If the CDC chooses to promote newborn male circumcision, it is supporting a procedure called "non-therapeutic" by the American Medical Association - in favor of inconclusive and highly debatable research.

I ask that the CDC not recommend circumcision as a means of preventing HIV/AIDS and formally recognize the risks and harms of the procedure and the right of every child to bodily integrity.

Though Intact America makes no wild claims about what they know about circumcision, they throw the word "debatable" around as if it means "worthless." But they fail to mention what standard of proof they would find conclusive, and indeed fail to cite a single reference, most notably for their claims of the associated risks. They demand that the CDC admit the truth, implying of course that the CDC has failed to do so or is likely to fail to do so, but there is no evidence presented that suggests any kind of obfuscation or dishonesty.

What I can't understand is, if they accept that the CDC is the foremost expert on public health in the US, that the CDC has a duty to present the truth to the American people, and that there is debatable evidence about whether routine circumcision is beneficial to the public health, why on earth they can't just get the hell out of the way and let the CDC examine the evidence and make its conclusions?

The evidence is debatable, so for pity's sake, let's debate it! Let's hear it, all of it, including what the CDC -- the acknowledged experts -- think we should do. Let's open our minds to the possibility that while there might not have been significant evidence to support recommending routine circumcision five years ago, or last year, perhaps there is now. And if there isn't this year, perhaps there will be five years from now. Let's keep asking the questions whose answers might save or improve lives, and let's listen to the people who can speak about those questions with informed intelligence before we start arguing with them. Let's not dig so deep into the trenches we make of our personal decisions that we can't occasionally climb out and take a look at what a new day's sun might have revealed.

Miscarriage

About a month ago, I got two lines on the pee stick. For the second time, it seemed, I got pregnant the first cycle of trying.

Yesterday I went for the dating ultrasound and discovered I had what's called a blighted ovum, which means the fetal pole (thus the embryo itself) never developed: I had a fetal sac and a yolk, but no fetus.

It's too soon to know exactly how I feel about this. I mean: I feel what I feel now, but who knows what I'll feel about it next week or next month or next year. Mostly, at this point, I'm surprised by how not surprised I am. On some level, I knew it. I had a bad feeling about this pregnancy, and some part of me is relieved to know for sure that it went wrong, to be able to move on rather than continue to worry about it. Of course, if the ultrasound had showed a squirmy little proto-human with a solid heartbeat, I probably would have shaken off the bad feeling and chalked it up to second-time-around jitters. You don't tend to know a lot about what can go wrong your first time. But then the second time, you know more mothers, and you've heard more stories.

I find myself comforted by the fact that an embryo never developed. There's something less tragic about a lost possibility than a heart that stopped beating.

It drives me crazy that there's no way to phrase it that doesn't lay the blame, at least grammatically, on me. I miscarried, or I had a miscarriage, or I lost the pregnancy. There's no the pregnancy failed, or the embryo lost itself. Even the word "miscarriage" tells you it was the carrier who fucked it up. English language FAIL.

I find myself dwelling on some really stupid details. Like: hey, now I can clean out the room where the cat boxes are so Andy doesn't have to do it. (Andy hates the cats, and I forgot to set him up with a minimally gross set-up to take over catbox tending while I was pregnant -- pregnant women aren't supposed to mess with kitty litter because of the risk of toxoplasmosis.) Like: crap, now if I get pregnant again ASAP, I'll end up delivering and racking up hospital bills on next year's deductible instead of this year's.

B., my nurse practitioner, said in terms of my health and well-being and future ability to conceive, it's about six of one, half dozen the other between letting nature take its course and having a D&C. In both cases, the risk of infection is around 7-9%. Which surprised me: that's a pretty high risk for a thing that happens so frequently. And this kind of infection can be extremely dangerous. The temptation to do the surgery is to have it all over with sooner and to skip the worst of the gore, though even with a D&C, you still have some bleeding and cramping. For now, though, I'm planning to let things just happen, with an option, of course, to go for the surgery if it's not happening fast enough or if it's too unpleasant. There's a considerable gross-out factor to the mechanics of miscarriage. B. said that because there's no fetus, for me it's likely to be more like a very heavy period. Let's hope so.

People who mean to be sympathetic and kind tend to say things about how nature gets rid of its mistakes or something, how miscarriage happens because the fetus wasn't good enough. I understand this impulse, and I certainly appreciate that it's kindly meant. But it's pretty stupid, and I wish people would think it through. Would you say that to someone mourning a person who died from a genetic disease? That it's somehow less sad because the person obviously wasn't made very well? Yes, it's true that many miscarriages are caused by genetic abnormalities. But that's not particularly comforting, especially because with current technology, some would-be mothers may actually know for a fact that that's not what caused their loss. They may have very strong, very complicated feelings about what did cause their loss, whether it's genetic abnormalities or something else. Plus, honestly, what seems comforting to one person may seem like minimizing to someone else, like: you shouldn't be so upset, because here's this information. In my opinion, the thing to say is the same thing you'd say to someone mourning any other loss: "I'm so sorry. Is there anything I can do?"

I cried on the table at the ultrasound. I cried in B.'s office. I cried in the car. I've cried a little here and there since. But mostly, so far, I'm ok. I know that I have physical discomfort and unsettling gore to look forward to, plus the hormone crash at the end. But for me, mostly, this feels like a very annoying roadblock between us and the next wonderful member of our family.

(One quick request: I'm going to link this post at Facebook, but I'd really prefer that people not comment about my miscarriage on my Facebook page. Comments here are fine, or feel free to contact me some other way.)

Enthusiast

I hear these rumors of toddlers who eke out an existence on a couple of crackers and a fish-stick per day. Not my kid. Ben is and has always been a food enthusiast.

I've been giving him portions of what we eat for dinner fairly regularly, sometimes supplemented by a cup of steamed broccoli or peas if a green vegetable isn't on the menu for the adults. I'm constantly surprised by the things he decides he loves. Like chili. I make fairly spicy chili, and it might be his favorite food. Generally he's not a big fan of meat, but if it comes in the form of chili, stand the hell back. He will yell for more so long as we're still at the table.

Mostly I'm happy with how he eats. He's open to new things, he has a lot of favorites that include mom-favorites like broccoli and veggie burgers, and he's thoroughly engaged by food, so he's pretty easy-going at restaurants. His pediatrician approves, so I'm not concerned that he's overeating. A worry pings me now and then, though, that he doesn't have an off switch. If he likes something he's eating, he wants to go on eating it well past when he must be full. He will go on clamoring for chili until physically removed from the table -- though, at that point, he is perfectly content to give up his demands and move on to the next thing.

Happy to Vaccinate

Generally I'm all about agreeing to disagree when it comes to someone else's parenting choices. After all, what you choose to do to your kid usually begins and ends inside your house, and while I might have an opinion, it doesn't directly affect me and mine. But that's not the case with vaccination, and that's part of why there's such a bitter debate about it. Anti-vax people feel oppressed by regulations and pressured, sometimes bullied and terrified, by doctors. Pro-vax people feel betrayed by members of their communities whose refusal to vaccinate reduces the herd immunity and puts everybody -- even the vaccinated -- at risk.

I should say up front that I am squarely, adamantly in the camp of the vaccinators. But I'm not without sympathy for the members of the other camp. I'm by nature a skeptic, and the healthcare industry deserves major skepticism. I am also, like many anti-vax-ers, a buyer of organic foods and eschewer of nasty chemicals. I treat colds with herb tea and bed rest. I clean with vinegar or baking soda. I don't love the idea of injecting my toddler with a passel of chemicals I can't spell -- it goes against a lot of my better instincts as a parent.

But here's the thing: there's a lot of good science on the side of vaccination, and opposing it is one flawed if not downright dirty study, a lot of anedote, and a lot of straight-up ignorance.

Most of the recent fear of vaccination comes from a study led by Andrew Wakefield and published in the British medical journal The Lancet in 1998. It purported to show a link between the MMR (measles mumps rubella) vaccine and autism. The study followed only 12 children -- a head-scratchingly small sample size -- and made only modest claims of correlation in 8 of those children. But even though 10 of the 13 co-authors of the Lancet article formally withdrew their findings, even though the study has been thoroughly discredited, and most importantly, even though considerable subsequent research has been unable to find a link between the MMR vaccine and autism spectrum disorder (ASD), people are still freaked out about vaccination.

Part of the reason is that there's a lot of anecdotal evidence of correlation between vaccines and the onset of autism. What happens is a kid gets a shot, and the next day, or maybe an hour later, or maybe a week later, he begins showing the first symptoms of ASD. Now, it's completely understandable that the adults in this child's life draw a line between the jab and the symptom, but it's not necessarily scientifically significant. Correlation is not causation. Just because two things happen in temporal proximity doesn't mean that one is the result of the other. Kids get vaccinated at almost every preventive-care visit (every three months) for the first two years, and most autism is diagnosed during that same period. When you think about how many millions of kids are getting shots, it makes sense that hundreds of them -- not a significant percentage, but a big number -- happen to develop ASD symptoms within 48 hours of a vaccination.

And again, it's not like this perceived correlation hasn't been extensively studied. The American Academy of Pediatrics (AAP) recently published a review paper (pdf) summarizing 29 studies that failed to find a link between the MMR shot and ASD and another 10 that failed to find a link between thimerosal (a preservative containing ethyl mercury) and ASD. "Failed to find" might sound like incompetence on the part of the researchers, so it's important to understand that it's usually impossible to prove a negative, so proving a negative is not the scientific standard. You will often hear from anti-vax activists that the MMR vaccine has never been proven not to cause autism, and that is strictly true, but neither has Tylenol. Neither have M&Ms. You can't prove something is safe, but on the other hand, harmful things are generally pretty easy to prove unsafe, especially when they're being given routinely to millions of people every year.

And you know what? Even if the evidence supported a link between the MMR vaccine and autism, I still might lean towards vaccinating. Autism can be heartbreaking, and I've already blogged about being afraid of it, but it doesn't kill 3 out of 1000 people who have it like measles does. It doesn't cause deafness, cataracts, and mental disability in 8 out of 10 infants of mothers who have it in early pregnancy like rubella does. Take a look at this pamphlet (pdf), from the AAP (based on Centers for Disease Control [CDC] publications) comparing the scientifically demonstrable risks of vaccines to the diseases they prevent. Choosing not to vaccinate isn't choosing to avoid risks: it's choosing to take different risks, and across the board, greater risks of mostly much more dire outcomes.

On one side of this debate is pretty much the entire medical, medical research, and public health community. On the other are a few physicians who are not scientists and a whole lot of passionate amateurs. The evidence on the pro-vaccine side is manifold, and it is backed up by established procedures of peer review and standards of scientific proof. The evidence on the anti-vaccine side is anecdotal and backed by nothing. The internet and cable news tend to present these two sides as more or less balanced: the internet because you can certainly find as many anti-vax sites as pro-, and the vast majority of the information, if presented with a bare minimum of layout competence, looks equally trustworthy on its face; cable news because it tends to bestow a level of expertise just by virtue of putting someone in front of the camera and slapping the title of "expert" on him whether he deserves it or not. Take a look at this clip from a Fox News segment on the H1N1 vaccine:



Dr. Holtorf, billed by the Fox anchor as an expert on infectious disease, claims no expertise on his own website in anything relating to vaccination or epidemiology. He is not a scientist or an expert on public health; he is a physician specializing in hormone replacement. He claims expertise in chronic infectious disease, like lupus, which is a far cry from expertise in epidemiology. In the clip, he says that thimerosal is "highly implicated" in causing ASD though the medical literature doesn't suggest any implication at all. He says it (presumably a single dose of the vaccine, though it's unclear) has 25,000 times the amount of mercury that would be considered toxic in food or water, which is simply not true: there are 25 micrograms of mercury in an H1N1 shot and 28 in a typical tuna sandwich. He says he's seen this vaccine "devastate" patients with chronic fatigue and fibromyalgia and implies that it would be similarly dangerous to pregnant women, but he doesn't specify the symptoms his patients suffered or how he determined causation or whether their reactions were life-threatening, as H1N1 certainly is to pregnant women. But if you saw this clip and were predisposed to distrust the federal government and the medical and scientific establishment, this jackass would have confirmed all your fears with the imprimatur of an established news source. And even had Fox followed this guest with an actual expert to refute the bogus claims, it would have looked like two experts who came to different conclusions, as if there's debatable evidence on both sides.

Anti-vax activists like to frame the debate in terms of personal choice: it's up to you to choose what's right for you child. And that's true. But I think you have a much higher standard of proof to meet when you choose not to vaccinate because you're not just choosing for yourself; you're choosing for your whole community. Some people, because of weakened or suppressed immune systems or certain allergies, cannot be immunized. And vaccines are not 100% effective. Those who can't be vaccinated and those who have been but happen not to be fully protected depend on herd immunity, the notion that, depending on a disease's virulence, once a certain percentage of the population has been inoculated, the lack of hosts acts as a kind of firebreak. If you don't vaccinate, you're putting kindling into the firebreak.

And this is why I have a lot of sympathy for the physicians who "pressure" their patients into getting vaccinated. Not only is it demonstrably in the patient's own best interest, it's in the best interest of all the doctor's other patients, too. Yes, it's unpleasant to have your convictions challenged, but do you really want a doctor who won't passionately advocate for what she thinks is best for your health and the health of your community, a doctor who won't challenge what she sees as your misconceptions or ignorance? Would you really prefer a doctor who doesn't read -- or worse, doesn't believe or can't understand -- the results of scientifically rigorous medical research? And if you're so sure that vaccines are the wrong choice that you're willing to bet your kid's health and the health of everybody in your community on it, you should be able to go toe-to-toe with the biggest bully in town to defend your conviction. Right?



American Academy of Pediatrics Immunization page

Centers for Disease Control vaccines page

Autism and Vaccination (2007)
Vaccines and Autism: a Deadly Manufactroversy (2009)
at Skeptic

As Flu Vaccine Arrives for the Season, Some Questions and Answers
An H1N1 primer in The New York Times

Andrew Wakefield and MMR - The Investigation
at the site of Brian Deer, the reporter who covered the story

A Pox on You: My son has cancer. He can't go into daycare because of unvaccinated children.
In Slate.

Goodbye, Good Girl

It is with the profoundest sadness I have to report that our basset hound Lola died yesterday morning.

She'd been battling lymphoma -- and beating it back with aplomb, I might add -- since February of 2008. She relapsed this past spring and had been responding well to her second round of treatment, but something simply went wrong after her last dose on Tuesday. Yesterday I had her back at the vet, and by this morning it was clear that this was a system failure, that whether it had to do with the chemo or the timing was just a coincidence, she was, as Andy put it, scritching at the door. The last kindness we could perform for her was to let her out gracefully.

She was a stubborn, grouchy, opinionated, loving, wonderful dog. When she was a youngster and loved playing fetch, she knew all her toys by name, and would get the one you asked for out of her toy box and bring it to you. When we brought her to Andy's folks' in Wisconsin, she used to lure their dogs outside with a toy and then double back by a different door to steal their marrow bones. The people at the dog hotel she stayed in in Philadelphia were convinced she was a famous retired showdog, and a junkie outside the 7-11 at the corner of 34th and Powelton once called her a symphony.

She had long, beautiful ears and a heart-shaped spot on her right front stump. She sang with soul and gusto. She was about as lovely and graceful and dignified as a basset hound can be. She would have turned nine in August.

She was our girl, and we loved her very much.

Nurse More?

Ben was an enthusiastic on-demand nurser from the get-go, and that worked for me just fine, especially early on when he desperately needed comfort, and nursing was the most effective comfort I could give. At around nine months, though, it occurred to me that I wasn't 100% happy with on-demand nursing anymore. I'm not sure that I can give a particular reason or list of reasons that would logically outweigh whatever reasons someone else might give for continuing. I have reasons, and I will list them, but I think more than anything it just felt to me that he didn't really need it any longer, and I didn't really like it any longer, and that feeling was more of a motivation than any of the reasons I'm about to give.

So here are some of the reasons:

I'm not entirely comfortable with the conflation of eating and comfort past a certain age. I'm sure plenty of people comfort-nurse well into toddlerhood without creating bad eating habits, but there's something about it that bothers me. I didn't want a toddler who fell down and then needed to nurse to regain his composure.

I've never much liked nursing in public. I don't think I'm excessively modest, and I certainly got over my initial squeamishness about it very quickly, but Ben happens to enjoy the eat-a-little-talk-a-little method of breastfeeding, which is mildly irritating at home, but creates a lot of nipple-management issues at, say, the mall.

He's a very good eater of solids, and he's a chunky little dude. I am in no way concerned that he's getting too little good nutrition. In fact, he eats way better than I do, and I believe he gets better nutrients from his plate than at my breast.

Even so, I probably would have continued on-demand nursing if he had put up any kind of fight about moving to a schedule, let alone eliminating feedings from the schedule. He didn't. I realized that he was usually nursing before and after every sleep, plus once overnight, so the first thing I did was experiment with no nursing before naps, which he didn't even seem to notice: no trouble at all. At first he did ask to nurse occasionally (he pokes at my sternum), but didn't appear fazed at my refusing and offering some kind of redirect. So he was now nursing at an early wake-up (around 4:00 or 5:00), again when Andy left for work and handed him over to me (7:00), after each nap (around 10:00 and 2:30), and at bedtime (6:30), and that went on for a couple of months. (I wasn't a total hard-ass about it, either -- if he was sick or having a very hard time with something and wanted to nurse, I let him.)

So last week we were in Wisconsin at Andy's parents', and it occurred to me that with all the distraction and excitement, Ben might not even miss one of the post-nap nursings, so I skipped it and gave him a snack of crackers and milk instead. No problem. (It should be mentioned that this kid is a huge fan of crackers.) So no more nursing after the morning nap, check. And the day before yesterday, I did the same for the afternoon nap, and again, he didn't seem fazed in the slightest.

Now I'm perfectly happy to go on nursing in the morning and at bedtime for as long as he shows the slightest interest. But he threw me a bit of a curveball yesterday: suddenly his enthusiasm for his second morning nursing (the 7:00 one when Andy brings him to me in bed) seemed drastically reduced! He was way more interested in clambering around on the pillows and beating on the wall behind the headboard. I heard the slightest plaintive note in my voice when he squirmed away for the third or fourth time and I asked, "Nurse more, kiddo? Nurse more?"

The Boob: Right or Wrong

The Case Against Breast-Feeding by Hanna Rosin in this month's Atlantic.

First of all, it's a wretched title. She's not actually making a case against breastfeeding so much as she's knocking a few holes in the case for breastfeeding, and in fact she concludes the piece by telling us that she herself continues to breastfeed, and even cherishes her time doing so. I've heard that Rosin had a different title in mind, and the editors switched to this more sensational one. Phooey on that.

I haven't read the relevant medical literature, but I have no reason to disbelieve Rosin's representation, which is basically that the evidence behind our culture's current mania for breastfeeding is thin because it's difficult to control for all the other healthy choices breastfeeding mothers tend to make, and the socio-economic group to which they all belong. In other words, if you want the benefits that advocates of breastfeeding claim are the results of the boob, your best bet is to be educated and upper-middle class.

I agree with Rosin that the pressure put on mothers to breastfeed is well out of proportion to the established benefits. Formula is not dangerous, and it's outrageous that it is presented by breastfeeding advocates as tantamount to smoking while pregnant. However, I don't think that the benefits of the boob are to be dismissed simply because they are difficult to prove. And even if the balance only slightly favors nursing, that's a solid argument for giving it the old college try.

Because where I really disagree with Rosin is her notion that breastfeeding is a significant hardship, that it's keeping women down the way housekeeping did in the 50s. "Modesty, independence, career, sanity" are what one stands to lose, she says, by breastfeeding, and that's utter hogwash. Sure, I have the luxury of not working, but I know far too many women who pump on the job without bitching about it to believe that it's that big a deal. And modesty? Come on -- it takes a little practice, but anyone can learn to nurse in public without flashing a nipple, and past the first couple months, you almost never have to nurse in public if it bothers you, anyway. If you stand to lose your sanity because of breastfeeding, by all means, do please stop, but I can't imagine that this is seriously a problem for any but the tiniest and therefore most entirely irrelevant minority. And if independence is that big an issue, don't introduce into your life a tiny creature who is wholly dependent on you -- how you choose to feed it is the least of your worries.

Rosin makes a stab at arguing from the perspective of the working class, but it's not very convincing. Her argument that breastfeeding can only be considered "free" if you don't count the mother's time ignores the time spent sterilizing, mixing, and warming bottles -- which is only "free" if you're paying someone else to do it, which is not generally an option open to blue-collar moms. And, yes, pumping on the job is a lot harder "if you are, say, a waitress or bus driver." But you know what? Everything is harder if you're a waitress or a bus driver, so it's not exactly a winning argument against the boob -- though of course I'm more sympathetic to a mother who gives up pumping because it's genuinely a pain in the ass than one who just can't be bothered to give it a try.

Her only argument against breastfeeding that really resonates with me at all is her claim that it makes for an imbalance in marriage. I remember fondly the very early days of Ben's life, when I felt strongly that Andy and I were a team, were in it 100% together; and I remember the feeling of being at sea when he went back to work, when it became clear that the only way to get the baby back to sleep at night was to nurse him, when suddenly I felt like the parent and he felt like the occasional assistant, when my parenting felt required and his felt optional. That sucked. But some of that would have happened even if we'd been bottle-feeding. With one of us working and the other staying home, there was bound to be an imbalance. And now that we're night-weaning, and nursing doesn't have that kind of powerful sleep magic any longer, the little imbalance that remains doesn't feel at all unfair, and has everything to do with my spending 16 waking hours a day with Ben compared to Andy's eight.

Rosin goes on to posit that this initial inequality leads to others: "[The mother] alone fed the child, so she naturally knows better how to comfort the child, so she is the better judge to pick a school for the child and the better nurse when the child is sick and so on." Talk about hogwash. This kind of gatekeeping is a conscious choice on the parts of both parents, and if you wish to avoid it, you damned well avoid it, and it has fuck-all to do with breastfeeding.

She closes the article by bringing up a suggestion of one of the medical researchers whose studies she's read that perhaps it is not something in the breastmilk, but the physical closeness between mother and child which is responsible for whatever positive outcomes are associated with nursing. And she's right to say that if this is the case, it should be more widely publicized.

I, like many mothers in my generation, have mixed feelings about the debate. I feel for women who try to breastfeed and can't, and are made to feel just awful for their "failure." At the same time, there's still enough cultural squickiness to the idea of putting a baby to suck that without some measure of peer pressure, I think fewer women would make the effort, and I do believe it's an effort worth making. I feel strongly, right or wrong, that I'd have been missing out on a profoundly rewarding part of Ben's infancy if I hadn't nursed him -- and I feel just as strongly that if I'd been unable to, he'd have been just as healthy and every bit as smart on formula.

A quick further thought: I want to make it clear that I'm very much in favor of everybody giving breastfeeding a real go, but I am also vehemently against giving anybody for whom it doesn't work a hard time. I argued against Rosin's characterization of breastfeeding as costing "modesty, independence, career, sanity," and I stand by what I said as a generalization (as Rosin's characterization was), but I'm well aware that individuals do sometimes feel these precise costs -- and others -- and I absolutely support mothers who value their own health and happiness enough to put them squarely on the scale.

Sleepless

We had a good run of sleep there, what-was-it, last week? The week before? Anyway, there was even a night, the first-ever, in which he slept through from 10:00 until 6:00. That was glorious, un-heard-of, epic.

But now we're back to hell of every-two-hours wake-ups, which isn't quite in contravention of the Geneva Conventions, I don't think, but at nine months is quite unacceptable. I have the lingering threads of a cold, too, which I've been unable to beat wholly for nearly two weeks. Now it's a sore throat which I hope isn't strep. I'm convinced I'd beat it if I could just get some decent sleep. And even when it was fairly good -- not sleeping through good, but maybe two wake-ups per night good -- it still wasn't really all that great, frankly.

So it's back* to sleep training, heaven help us, which probably won't be so bad as I think, but won't be fun, either. This kid is fully capable of yelling on and off for an hour or more, and I know there are folks who think we must be cruel monsters to subject him (or ourselves) to that, but I can only assume that these folks have not gone without longer-than-two-hour stretches of sleep for weeks on end, or without eight full unbroken hours' sleep in almost ten months.

Walk a mile in my shoes, bitches. Or maybe you have, and you're just functionally insane, and think that this state of affairs is simply one of the challenges of parenthood. Which it isn't. Everybody needs to sleep. The crying and yelling sucks, and I wish it didn't have to happen, but the sad fact is that the only way out is through.

*I say "back" because we sleep-trained Ben around four months, wildly successfully: he went from being totally unable to put himself to sleep, having to be nursed and then nursed again when putting him down jostled him just slightly so that he woke up again, and then again, and then again, unable to nap except at the breast; to being able to be put down wide awake and fall asleep on his own pretty much every single time for naps and bedtime. And it happened in less than a week. God bless Dr. Ferber.

ASD

I think it's fair to say that everybody is freaked out about autism. Diagnoses are way up, and no one knows why (beyond that we're getting a lot better at diagnosing), and though the spectrum is wide and includes a great many highly functional people, and though early diagnosis and therefore early intervention is likely to produce significant improvement in most cases, it's a hell of a scary thing to face.

Nobody has a real diagnosis, but it's my opinion that Andy and a few of his relatives show some distinctly Aspie traits, and since I think autism spectrum disorders are probably genetic (at least, predisposition to them is), I'm more vigilant than I would otherwise be about ASD signs in Ben. So I brought it up when I had him at the pediatrician for his nine-month check-up this week.

The pediatrician said the things to look for (because the absence of them could be a warning sign) are babbling (check), maintaining eye contact (check), playing peek-a-boo (check), and clapping -- at which point, he snapped to attention and started clapping and grinning at her. It's not the clapping itself, apparently, but the interactive, social-feedback-y nature of how we encourage clapping that's relevant to ASD detection.

So the kid's in the clear for now, which is a relief, except that I know that autism can show up late and present as regression in kids who until that point showed no signs. Comforting, right? I do try not to worry about it, which isn't that hard, because I'm not really the worrying kind. And I know that we're intelligent, loving, capable people who'll do our best for him, and our best will be pretty damned good. But it's out there, hovering, like the polio of this generation, and I can't help sometimes shivering in its shadow.