Thursday, June 30, 2011

Strawberry Mint Nettle Raspberry Leaf Tea

A long, long time ago (I may or may not have been wearing my hair in two buns) I'd posted a recipe on my old blog for strawberry basil tea a la Martha. This past weekend I re-invented the tea using my farmer's market scores. I introduce to you, a pregnant woman's delight:

Strawberry Mint Nettle Raspberry Leaf Tea
[the title needs some work]

-dried raspberry leaf
-fresh mint leaves
-fresh nettle leaves
-black tea

Bring four cups of water to a boil in a saucepan. Remove from heat source. Add black tea (I used two bags of a Hawaiian blend my in-laws had brought me) and enough raspberry leaves for two cups (I put my loose leaf tea into silver tea thingies); steep for 5 mins. Remove steeped leaves. Add mint and nettle leaves and pour over sliced strawberries. Allow to cool. Refrigerate until chilled.
Pour yourself a glass of refreshing tea (how much/little of the mint, nettle and strawberries to allow into your glass is personal preference. For myself, I just poured all into my glass and used a spoon to eat what I couldn't drink (the mint and nettle leaves were poached and very tasty! And of course strawberries are delicious).

I like making tea! I'm thinking that next I may try homemade chai.

Monday, June 27, 2011

35 Weeks and Happy!

We're coming right along here at Camp Propson. Baby is busy growing and kicking me in the ribs and Mama is finally in a good mental place after a month of fret and worry about providers and the diagnosis of gestational diabetes.

If you've followed my FB status you're aware that last week I was actually posting about feeling happy (which was a change from my sour and disappointed posts of previous weeks). For one really really exciting 48-hour period I thought I had found a midwife willing to attend an HBAC, but even after it was determined that wouldn't work for us I nevertheless felt great.  Discussing my health with a provider who  was willing to consider my whole being, beyond the 3 points on my GTT, allowed me to finally relax. My mind feels well-rested. My resolve reinvigorated.

I now know for certain which path I would be choosing for the remainder of my prenatal care:  I am confident that to refuse the interventions being unneccessarily required of me (in my current state of health) at my current clinic is the right move. Yes, it likely means being attended by OBs instead of my family practitioner. (I was surprised to hear today, however, that it doesn't automatically mean this. I still may have my family doc!) Yes, it means continuing to refuse the tests for the next month. Yes, it may mean I will have to advocate more fiercely for myself when I arrive at the hospital late in labor and decline the interventions the hospital will want.

But I now feel sure enough of myself to move forward, knowing that this truly is the best choice for me. The best chance I have for a VBAC. The best chance for a healthy, term infant.

And I am happy.

Sunday, June 26, 2011

GDM Research Quotes

I had requested copies of the references my doctor's clinic was using for the gestational diabetes care they were mandating (the high alert, the concern about birth weight, the ultrasounds and the weekly non-stress tests).  I am very pleased that my doctor was able to send three papers.

Interesting reading. I feel more settled than ever that my medical situation doesn't warrant the interventions the clinic has required. I thought I'd share some quotes.

from ACOG Practice Bulletin / Gestational Diabetes

"[G]uidelines [within this bulletin] should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient and resources..."  (Thomasin's Note:  The ACOG's guidelines have been provided to me as absolutes, not as variable based on my needs as an individual.)


"Patients should be instructed to follow an unrestricted diet, consuming at least 150 g of carbohydrate per day for at least 3 days prior to the [Glucose Tolerance] test. This should avoid carbohydrate depletion, which could cause spuriously high values on the GTT."  (Thomasin's Note:  I was not instructed to eat at least 150g of carbs/day in the days prior to my test. So I guess the clinic does adjust its procedure from ACOG's guidelines sometimes... [And unfortunately I don't have a food log of what I ate that week, so I am uncertain whether I met that 150g/day or not.])


"Ultrasonography has been used to estimate fetal weight, especially to predict macrosomia prior to delivery. However the reliability of these measures has not been established...In addition, the use of ultrasound-derived measure of fetal weight have not been shown to be superior to clinical measures." (Thomasin's Note:  Yet the use of ultrasound and its fetal weight estimation would be a determining factor in deciding upon whether labor would be induced or not...)

from The New England Journal of Medicine / Hyperglycemia and Adverse Pregnancy Outcomes

"Caregiver bias (i.e. an expectation of adverse outcomes due to gestational diabetes mellitus) may increase the likelihood of disorders or problems due to increased intervention." (Thomasin's Note:  I've bolded this because I find it extremely significant. When someone who assumes there may be a problem goes looking for the problem they're likely to find it, truly there or no. One of the primary reasons I will not be agreeing to the ultrasounds and non-stress tests at this time.)


"Our study had some limitations. The nutritional status and gestational weight gain of the participants could affect fetal growth and other perinatal outcomes; we do not have data on these variables... [Thus,] we cannot conclude that maternal glycemia is causally related to the adverse outcomes observed; however such a relationship is plausible." (Thomasin's Note:  Could this be why my daily nutrition has never been examined this pregnancy? Because they wouldn't know what to do with that information in relation to a GDM diagnosis? Seems weird, right? Also, plausibility isn't strong enough--for me, with my diet being what I know it is, my test results as close as they were, and my excellent daily blood sugar readings--to jump through each and every hoop they are tossing at me.)

from American Family Physician / Diagnosis and Management of Gestational Diabetes Mellitus

"A recent observational study confirmed the association between increased maternal blood glucose and increased birth weight. Further studies are needed to unequivocally support the benefit of universal screening, although most obstetric practices employ this strategy."  (Thomasin's Note: Though they cannot absolutely recommend the universal screening, I--due to my age--fall into the recommended category anyway. But readers should be aware that this GDM screening isn't required during prenatal care, not for me and definitely not for others, especially those younger than I am.)


"Although earlier delivery reduced the risk of macrosomia, it did not reduce rates of brachial plexus injuries, hypoglycemia, or clavicle fractures." (Thomasin's Note:  Emphasis mine. So, inducing labor early = smaller babies [no kidding! You're expelling them from the womb before they were finished growing!] but it hasn't been shown to reduce the adverse affects that everyone worries about. Sounds like induction for the sake of a smaller baby isn't really all that good of an idea, especially since it's understood to increase the risk of cesarean...)

(1) Coustan DR, Gestational Diabetes. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynolgologists 2001; 30:1-14
(2) Metzger BE, et al, for the HAPO STudy Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008; 358 (19): 1991-2002. 
(3) Serlin DC, Lash RW. Diagnosis and Management of Gestational Diabetes Mellitus. American Family Physician 2009; 80(1):57-62

Saturday, June 25, 2011

Guest Post: In Response to "Anonymous"

The comment published as a post below came from my recent blog post about gestational diabetes and is so detailed (and says what I would like to say better than I can say it myself) that I decided it deserves full guest post status. It's in response to an anonymous commenter who'd had this to say:

I understand that you have a birth plan and that everything in your mind should go that way. From your first birth I think you should understand that it doesn't always go that way. However, at the end of the day you have to respect that the hospital is just doing their job to make sure your baby and you stay healthy. 

And here's the rebuttal:

I have to disagree with what "Anonymous" said. The actions of doctors and the hospital aren't to keep Thomasin and her child "healthy".  The Hippocratic oath may say to "first do no harm" but policies are in place to reduce risk of fatality and abide by AMA guidelines.  Risk that ultimately could mean malpractice claims.  If patient health was truly the primary concern, then much of the research on medical practices from other countries would be applied in this country but that is not the case.

The word "Health" is greatly misunderstood in our society.  Many people say that if they aren't coughing, sneezing or running a fever, that they are healthy.  This, however, is not the medical definition of "Health". The World Health Organization defines health as "A dynamic state of complete physical, mental, spiritual and social wellbeing and not merely the absence of disease or infirmity."  MD's in our society are not following this definition and if they are trying to provide care that lives up to this definition, they fall very short.  MD's in our society do very little to help prevent illness.  Sure they suggest annual physicals for screenings of various things but that is not prevention.  That is "watchful waiting" and the battery of screening procedures only screen for disease or infirmity (something that is less than half of the definition of health), not COMPLETE physical, mental, spiritual and social wellbeing (the majority of the definition of health).  How many people have sat down with their primary care physician on several successive occasions when you don't have any symptoms to discuss your mental, spiritual and social well-being?

The reason MD's don't focus on the other aspects of health is that, in many cases, it can't be easily quantified and analyzed.  So, MD's focus on disease and infirmity, not health.  Our society has sick care, not health care.  When you're sick, you go to the doctor, the doctor orders a test and gives you a pill, after the fact.  This approach is clearly emphasized in Thomasin's prenatal care.  A discussion of proper diet and exercise, to help prevent an unhealthy pregnancy including GD, was never once mentioned.  It wasn't mentioned until after the GD diagnosis was made and at that point, the only advice given was to avoid high glycemic index foods. That's it.  No more.  End of story.

Also, MD's tend to rely heavily on quantitative analysis. They test your blood, urine, hair and skin to look for chemical alterations.  This can be good.  It provides a great deal of information on the patient's present condition.  However, the problem arises when only these test results are used to create a clinical picture of a patient.  Every patient comes from a different place and has different contributing factors.  I am not saying that a doctor should try to find a normal value for the physiology of every patient (But be aware that people do in fact have minute discrepancies in their normal values for these medical tests and that is why normal values fall in a normal range and are not absolute values and normal values can fall outside the normal range.  The normal range is based on one standard deviation unit from the mean value).  If MD's truly wanted to create a complete clinical picture, more information has to be considered before making a diagnosis off of a single test.  Also more information needs to be considered before prescribing treatment.  If you have an ulcer, you have alterations in your levels of stomach acid.  So, prescribe a drug to falsely alter the chemical composition of your stomach contents, right?  But what of your ulcer is due to stress?  Shouldn't your stress, the true cause of the problem, be fixed before the more invasive treatment of altering your physiology? Unfortunately, that is more complicated than prescribing a pill.

Thomasin had a thyroidectomy but there has been no study on the normal blood sugars of pregnant women who underwent thyroidectomies so she is lumped in with normal subjects who can regulate metabolism on their own.  Thomasin, however, is now dependent on the MD's to dictate to her what her metabolic rate should be and is dependent on them to make adjustments.  Her input on how she feels and functions under those prescribed levels is not considered, even though the normal range is actually rather large.

For those who don't know, the thyroid produces hormones that impact other organs which produce other hormones that play a direct role in blood sugar levels.  When concern was expressed to Thomasin's doctor that this might not have been taken into account prior to labeling her with a diagnosis, the doctor admitted that yes, a thyroidectomy would impact blood sugar and her medically regulated levels of thyroxin could have been less than optimum at the time of the glucose testing and that fact alone could have made the difference in her diagnosis but there is currently no study on that subject so it will be completely neglected.  

So here is Thomasin, nothing more than the sum of her parts as far as the allopaths are concerned… let me rephrase that, nothing more than the sum of the parts that allopaths can measure.  If we were merely the sum of our parts then we would be able to take bits and pieces from here and there and assemble them into a living thing, just like Dr Frankenstein did.  However, this is not the case, every living thing is far more than the sum of its parts.  It's silly that I should have to make that statement but the allopathic approach is just that.  The test results say your low on this chemical, here is a pill that makes those levels normal.  Oh, that pill we gave you has a side effect of causing this other chemical to be too high but don't worry, we have a pill for that too.

The problem here is that what is best for most people was put in front of what is best for Thomasin.  The bureaucratic approach of  procedural correctness at the expense of people's needs… the "do the best you can for most patients instead of the best you can for each patient" has left Thomasin as an unfortunate outlier.  Choosing to look out for her own best interests, which the MD's are not doing, does not mean that she should still have respect for their approach to her care.  In fact, the doctor stated very clearly that this situation "sucked" as she put it and she would actually like to use a less invasive approach moving forward but if she doesn't follow policy, she would lose her hospital privileges and could lose her job.  Now, while it is understandable that someone might not risk their livelihood for a patient, it does not warrant respect.  That admission by the doctor stated, in very plain and simple terms, that policy took precedence over the appropriate approach to Thomasin's condition and pre-natal care.  Someone who would risk their livelihood for the well-being of a patient and to provide the most appropriate care to a patient, does warrant respect.  There are still doctor's in the world that believe in the oath they took with all their heart soul.  It's too bad there aren't more of them out there who are willing to stand up for what is best for their patient.

Anyone who would say that the medical community in our society has the health and best interests of patients in mind should probably look a little more closely at some of the policies in place in the medical community and then step back and look at the big picture of the global medical community and not take so much on faith alone (that is dangerous).

If MD's really care about a patient's health first and foremost then why do we have the highest rate of cesarean deliveries (especially elective cesareans) of any country? A method of delivery that carries the most prevalent and severe side effects of any birthing method.  Why do we have the highest rate of circumcision of any country? A procedure where risk (albeit relatively minimal) outweighs any health benefits (which are zero).  This contradiction goes beyond obstetrics alone.  If a patient's health was truly the primary goal over risk of injury, there would be no cosmetic surgery to improve self image.  Rather, there would be more emphasis on trying to help that patient be happy with who they are and help them work to better their self image naturally.  There would be no prescription of drugs that caused side effects.  Instead, there would be more emphasis on wellness programs (diet and exercise) than on medicating an illness.

As someone who holds a doctorate in health care, who has spent countless hours reading medical texts and research from both here and abroad, I can say that just doing your job doesn't warrant respect because just doing your job means just that… following company policy and fulfilling your job description.

Adhering to the oath you took and pushing back on the medical establishment in the best interests of your patients in spite of company policy, is something that deserves respect.  Because at the end of the day, the patients are the doctor's patients, not the establishment's patients.  If something goes wrong, the establishment isn't held responsible, the doctor who treated the patient is.  It is the responsibility of each and every doctor to provide the best care for their patient.

Perhaps the Hippocratic oath in this country should be rephrased to "first follow procedure, then do the lesser of two evils…"

Saturday, June 18, 2011

Gestational Diabetes

Three points. Three points between what seems to be an otherwise healthy and uneventful pregnancy and the mess I'm facing now.

I'm beyond frustrated. Several weeks ago I was diagnosed with Gestational Diabetes. But I think it's bunk (or as my doctor told the diabetes nurse at my clinic who then told me:  I'm "having difficulty coming to terms with my diagnosis").

First, I was just surprised I found myself in such a rare category. According to the American Diabetes Association, GD affects just 4% of all pregnant women.  And according to the Mayo Clinic white women, "for reasons that aren't clear," [kind of a sketchy quote, I realize] are less likely to develop GD than African American, Latina, Asian, or Native American women.

So, it's a relatively uncommon condition (96% of pregnant women won't have GD). And, if I'm doing my math right (no guarantees), a woman with a Scandinavian heritage such as myself could consider herself as having less than a 4% chance of developing GD.

There are other "risk factors," of course. Obesity is one (I'm a bit plump, but not obese), having high blood pressure (nope, mine's great), being older than 25 (okay, I'll cop to this one), and having high blood sugar (again, nope) all tend to be factors.

Essentially, this came out of left field for me and my mind is still swirling with it all.

And truthfully and sincerely, I'm not certain the diagnosis itself was appropriate. Here's why:

The basic [very general] idea behind GD is that you've begun to have difficulty processing/maintaining healthy levels of glucose/sugar in your blood; these high glucose levels end up making their way to your baby. On this diet of extra sugar, a baby may grow larger than your body was meant to birth (which varies by each and every woman, of course. Many women deliver 11+ lbs fine and dandy). A "too big" baby is at heightened risk of becoming malpositioned during birth (and thus possibly of getting stuck).

But here are my initial issues with my diagnosis:

First~ my blood sugar levels (which I've now been checking 6x daily for going on a month) are all excellent. Every day. Excellent.

Second~  my hemoglobin A1C test (which shows my average sugar levels over the past 6-12 weeks) was fantastic (it was 4.9).

Third~ the reason I've been diagnosed is due to just 3 little points.

I had decided (against my better judgement) to take the 1-hr glucose test when offered (well, not so much offered as told to take it. Because it's routine. And I thought, hey, if it makes them happy, okay). This test doesn't, by itself, diagnose gestational diabetes;  instead, it quickly helps identify who may require a second look/test. The morning of the test I took my thyroid meds, waited 30 mins, ate an egg scrambled in whole milk, waited 45 mins, drank the nasty glucose (50 g), and then an hour later had blood drawn. The providers would have considered the results as normal if they were between 70-140. I tested 147.

I wasn't concerned with the test results. I knew I'd fudged a bit with the breakfast thing (I was supposed to wait 60 mins after eating to take the glucose, but was running out of time that AM. And I didn't eat a well balanced meal.) But my doctor was concerned. When I refused to take a 1/2 day of work to do the 3-hr follow-up diagnostic test she "called in some favors" to schedule me with a weekend clinic. A clinic, I should add, for which testing would be out of pocket for me. ::sigh:: I checked on the cost of the test. It'd cost less than taking 1/2 day off of work, so I decided to just do it and hopefully calm my doctor's fears.

The morning of the 3-hr test I was careful to show up having totally fasted since the night before. Hungry and thirsty, they started the poking. Eventually they found a vein. (Over the course of the morning I was poked 8 times for the 4 required draws. Super nice.) With my fasting blood drawn, I drank a higher concentrate of glucose than I'd ever eat in corresponding food stuffs in real life (100g) and then sat around and waited. Had my blood drawn, waited, had my blood drawn, waited, etc. 

The results:

     Fasting--79 (normal)
     1 hour--170 (normal)
     2 hour--157 (abnormal. They wanted between 70-154)
     3 hour--147 (abnormal. They wanted between 70-140).

For a diagnosis of GD the 3-hour test requires two abnormal/high readings. One abnormal reading is considered within normal parameters. So let's toss that final draw out (why the last one? Because why not.). Now let's take a peek at the other abnormal number, taken two hours after I'd ingested that ungodly high amount of glucose. My body took care of it except for 3 points. 3 points too high.

Three points. Not all that alarming. Why isn't it alarming? Because your body processes glucose at different rates throughout the day depending on what the heck it is you're doing. If you're walking or exercising or stretching it draws more glucose from the blood to feed your muscles than if you're sitting around on your rump reading. And what was I doing in the waiting room at the lab? I was waiting. On my rump. Reading. I wasn't even stretching my arms or walking to the bathroom. Just sitting. Statuesque. After the results came back I asked the doctor whether that third draw could have been lower by three points or more if I'd only walked around the lobby a little bit. She admitted that it very well may have been lower if I'd stretched my legs, yes. But then she said that that was irrelevant. Because I hadn't stretched my legs. And thus the test shows what it shows and that's that. Per her clinic's practice I have GD. End of discussion.

Except that it's not the end. Suddenly there's so much more to talk about and decide!

What does a diagnosis like this mean? First off, it means that I've been asked to "manage" my blood sugar levels. A woman with GD is supposed to keep her fasting numbers between late 70s-early 80s and her post-meal numbers are supposed to be <120 two hours after a meal. That's compared to the <140 that non-diabetic mothers should maintain as their normal. Why the difference between normal population and a woman with GD? My doctor said that it's because the normal population are trying to stay healthy for 20 years in the future. That's vs. a woman with GD who is growing a baby right now, and thus any higher blood sugar could directly impact the fetus today.

Okay. Fine. Stricter rules for a mother with GD. Except... what if I hadn't been diagnosed with GD? If that second glucose test's third draw had been 3 points lower because I'd dropped my book on the floor and had had to bend down and pick it up? Well then, in that case, the normal non-diabetic numbers would be just find and dandy for me during my pregnancy. A blood sugar level up to 140 after two hours of a meal wouldn't hurt the baby at all if only I hadn't been diagnosed with GD.


But whatever. So I'm supposed to keep my blood sugar super low. Lower than normal. Okay. So I start to use the glucose meter 6x a day (fasting/pre-breakfast, post-breakfast, pre-lunch, post-lunch, pre-dinner, post-dinner). And what do my numbers show? Fasting and pre-meal numbers in the 70s and low 80s. 2 hour post-meal numbers <120. Interesting... So there's nothing to worry about, right? My numbers are sublime?

Wrong. Worry! Worry!

I've been instructed that I must now have weekly (weekly!) "non-stress" tests at the hospital to ensure the baby is doing well. I'm also supposed to go in for several ultrasounds to try and gage the baby's weight (though, as the doctor admits, ultrasounds can be off by 1 lb or more...) and if I'm found to be growing a baby over the 75th percentile in weight (anticipated to be about 8 lbs at term) I will be pressured to induce labor early. If I require medication to maintain my blood sugar levels they'd induce at 38 weeks but if I'm able to maintain without medication they'll "allow" me to go till 40 weeks. And, at the shocked look on my face, my doctor said that she'd even consider allowing me to go to 41 weeks.

Non-stress tests. Ultrasounds. Scheduled induction. If I refuse the interventions, refuse even one of them?  Then I'll be transferred to High Risk OB/perinatology at the hospital and be required to have the remainder of my prenatal care and my delivery with them.

I don't want a surgeon at my birth. I don't want to spend my time and money (and lose my earned time off at work, which is perilously low as it is) to go in for weekly "non-stress" tests (not stressful for the baby, perhaps! But what about the mama?!) in addition to my normal prenatal appointments. I don't want to give ultrasounds (which are perhaps their best imaging tool but nevertheless sorely lacking when it comes to deciding whether a baby is "too big" for a woman to birth) the power between "allowing" me to continue to nurture my baby in the womb or being "required" to evict it early.

I am not a happy camper. And I have some decisions to make. Quickly.

Tuesday, June 14, 2011

Chaos and Despair

(Warning. This is a whiny post full of self-pity. Just so you know up front.)

I live in chaos. Or at least I feel like I do.

I'm overwhelmed and cannot begin to stand up under this weight. Haven't been able to in four years.

Here, you decide if this is chaos:
My bedroom

For the most part I try and ignore it because I don't feel like I can do anything about it and there's nothing worse than feeling like you can't fix the problems you're staring at. The dog hair. The bazillions of plastic cups. The toys from McDonald's Happy Meals. The textbooks. The craft supplies. The pieces of paper that hold information I'd meant to blog about but can't ever find time/energy to actually craft into a post. The poisonous bug sprays I want to throw out. The candles. The twine. Even my clothes---they're just... everywhere. Out in the open. Without belonging or fitting anywhere.

Also my bedroom

Yes, I have a vacuum. You'd think the dog hair problem wouldn't be insurmountable. But the vacuum gets plugged and runs out of batteries. The biggest problem, though, is that in order to vacuum you need to have the floor picked up. And in order to pick-up you should put stuff away (not just shove it into tubs/closets/bags randomly). And in order to know where things should belong you should know what you actually have so you can label a specific space for them. But in order to know what you have, you need to pull everything out and down and look it over. And you need to be prepared to toss out the stuff that you don't need (the broken stuff. the stupid stuff. the old, unused stuff. the stuff you hate) and only keep what you actually want and will use.

My daughter's bedroom

And if you don't feel like you can make those decisions at the moment (to rearrange or toss stuff)? Well, you do what I do. You ignore the space in which you live. Pretend it 's not there. That all is well. That nothing's wrong. You ignore your surroundings until awareness comes streaking at you through momentarily unveiled eyes. And then the naked ugly truth makes you despair. And you cry. And then, because you can't spend your life crying, you bottle it up, push it all back, and keep on going. You pretend that it doesn't bother you to live amidst chaos.  And that works for a few days and then you despair and cry again and then bottle it back up once more. Rinse and repeat.

And sometimes you write blathering blog posts about how you cannot seem to find the gumption to organize your own damn house. Because it doesn't really feel like your house, your stuff. (I suppose because you are constantly trying to ignore that it exists?)

Please tell me that Clean House or some other such reality TV show from TLC will come rescue me? I'd even settle for a really thorough burglary (just please take the Happy Meal toys too, Mr. Burglar!).


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