The next waiting game II - moving through

Exercise is like nutrition:  everyone has a vague notion that it’s good for them, but not enough of us take it seriously.  Add to that in pregnancy, most women don’t feel like doing anything that takes them off the couch.  Then add the fact that for the months or years you’ve been trying to get pregnant, you’ve treated your body with kid gloves, fearing after every embryo transfer the slightest wrong move would dislodge the little guy whom you’re begging to cling to your uterine wall for dear life!

I started the topic of exercise as a suggestion for dealing with anxiety.  THe medical literature is filled with studies showing how exercise improves general mood, and can even improve clinical depression and anxiety.  

However, the benefits of exercise in pregnancy go way beyond.  A recent review of the data^⁠1 regarding this stated, “Maternal benefits from exercise during pregnancy include improved cardiovascular function, a lower risk for gestational diabetes, improved strength and lean muscle mass, improved sense of well-being,  as well as reduction in bone density loss and physical discomfort”  Stretching exercises like yoga have been found to decrease the incidence of gestational hypertension, and increase antioxidant markers.  There is also evidence that mothers who exercise in pregnancy have longer gestational ages (it seems like a minus, but better for the baby), and infants with lower birth-weights.  There are ongoing studies which may show some neurodevelopmental benefits to babies as well.  

These statistics are not meant to add the the overload of information you are already inundated with, make you feel guilty, or make you go out and run a marathon.  I just want to reassure those of you who want to exercise that it is safe in most pregnancies, and encourage the rest of you to try some form of activity. If you are not already in the habit, try just going for a walk at lunchtime.  There are tons of videos now with 10 − 15 minute workouts, which is much easier to fit into your day.  Most cable systems have exercise videos on demand, or you can look into you-tube or your local library to try something without spending money.  Any exercise you did before you can adapt to pregnancy, which we will discuss.  My personal favorite is Zumba, or some kind of dance exercise.  I think these classes are great in pregnancy for several reasons.  First, it’s a great way to get a core workout without doing crunches, which you don’t want to later in pregnancy.  I love the latin steps with the hip and pelvic action - its a great way of loosening up that part of the body to prepare for labor, and I think pregnancy is a great time to get in touch with your femininity and sexuality.  Most women have some body issues in pregnancy, and after years of timed intercourse, or conceiving through un-intercourse, I think this applies even more.  

There are some precautions to be aware of.  First, you should not be working out at the same level you were before.  If you are on one of those fancy machines with a heart rate monitor, you want to be in the fat burn rather than the cardio zone.  If you are not monitoring your heart rate, just remember you should feel able to hold a conversation easily and if you feel too out of breath, then slow down.  One of the other changes in pregnancy is that all your joints are more relaxed, which means it’s easier to over extend or pull something.  Use good form and body mechanics, avoid twisting or stretching too much.  It may be intuitive, but avoid activities that are likely to cause injury;  the laxity in your joints also make it more likely you may loose your balance.  Lastly, avoid exertion flat on your back after you start showing (usually around 20 weeks).

Most of you are probably told in the first trimester not to do any vigorous exercise.  Unless you are on strict bed-rest, most of you can still do some gentle exercise like yoga or tai chi.  I think everyone should try yoga in pregnancy, because it is wonderful for dealing with some of the physical discomforts, and it is a great way to start practicing some relaxation.  Again, there are a lot of resources for trying yoga at home, and many places have classes.  If you are not ready to try something specifically for pregnancy, any gentle yoga should be fine as is or can be adapted.  I found tons of videos on you-tube, you can try http://www.youtube.com/watch?v=0bDo6ezueOI as an example.  If you are put on bed-rest later in the pregnancy, most women can still do some of the stretches done seated and on all fours.  

As with anything, these are general guidelines, please consult your health care provider for advice about your pregnancy, and any additional restrictions you may have.  

¹ Prather, et. al, “Benefits of Exercise During Pregnancy”, PM&R, 4-845, 2012

A Brief Distraction

There will be no midwife’s advice this week.  Pail Bloggers asked for bloggers to submit answers to the following 20 questions, and I couldn’t resist.  So if you will allow me to be self-indulgent, there will be more useful information next post. 

1.  What is the last thing you threw in the garbage?  The bad ends of the vegetables I just cooked for dinner.  

2.  What is the #1 most played song on your Ipod?  I don’t have one, but I have a broadway playlist that I shuffle constantly. 

3.  What is your favorite quote?  From the Dalai Lama, “Religion and logic should never contradict.”

4.  What chore do you absolutely hate doing?  Washing dishes - because no matter how much time I spend, they never seem to be done.  Ever.  

5.  What is your favorite form of exercise?  I love Zumba - I now do it on my Wii and pretend I’m on Dancing With the Stars. 

6.  What is your favorite time of the day?  This doesn’t happen every day, but waking up at 5am on an overnight call shift and realizing I’ve been asleep most of the night. 

7.  What is on your bedside table?  Alarm, lotion, and an eye mask for napping during the day after a busy night call (see #6). 

8.  What is your favorite body part?  My kids’ little round bottoms!

9.  Would you use the power of invisibility for good or evil?  I would use any power for good.  Evil is only fun for a few minutes, good attracts good people, which stays fun. 

10.  If you could choose to stay a certain age forever, what age would it be?  Always my current age, because I seem to learn something every year.  (Although I would choose my 21 year old body).

11.  What is the first thing you would do if you won the lottery?  Start planning my next trip.

12.  What is your biggest pet peeve?  Abnormal hair configurations on men’s faces, (ie  the soul patch).  I have a fantasy of Apolo Anton Ohno where we make love all night, then I shave that stupid thing off him in his sleep. 

13.  If you could know the answer to any question, what would it be?  I doesn’t matter, because as soon as I find the answer to something, it just opens up 10 more questions. 

14.  At what age did you become an adult?  39, the year I became a mom.  I played grown-up alot before then. 

15.  Recommend a book, movie, or television show in three sentences or less.  Call the Midwife:  it gives voice to women of a little known profession, who give voice to women who have none. 

16.  What did you do growing up that got you into trouble?  Always mouthing off!

17.  What is the first album you bought with your own money?  Queen, “Play the Game” (on vinyl!).  It’s still one of my favorites. 

18.  If someone wrote a book about you, what would be the title?  “I’m not Loud, I’m Italian”.

19.  What story do you wish your family would stop telling about you?  My mother tells everyone she’s ever met about me having a big mouth when I was a kid. (See #16)

20:  True of false:  The unicorn is the greatest mythical creature.  State your case.  False.  Am I missing something, or is it just a horse with a horn?

The Next Waiting Game

How long have you been waiting?  1 year?  5?  Then there are all the little waits in between.  Waiting until the next cycle.  Waiting until the pregnancy test.  Waiting until the next quant.  You may have thought pregnancy was the finish line, when really it’s just another drawn out wait.

Maybe you’ve gotten really good at waiting by now, and you have a repertoire of things you can do to relieve your stress and take your mind off your current/next cycle.  Sometimes in pregnancy, it’s a whole new ballgame.  And worse, now you’re worried the stress will be harmful to the baby, which has the opposite effect than helping you relax!

This post contains no new information to most of you, just a reminder, and some encouragement.  Pregnancy is a great time to learn how to take time for yourself.  Think of it like a smoker who quits and uses the money he saves to buy something he’s always wanted.  Use all that time you were spending on calculating your med doses and going for ultrasounds to do something that brings you joy.  As a matter of fact, I’m writing this post while watching the Oscars on DVR, (yes, the chick Super Bowl, but I can’t resist).  You can google and get lots of suggestions for stress relief techniques, but ultimately, whatever works for you is what you should give yourself permission to take time for.

There are tons of data on the benefit of specific relaxation methods like meditation and yoga.  Even if sitting in lotus position saying “Om” is that last thing you ever imagine yourself doing, I encourage you to experiment with some type of relaxation.  There are tons of CDs, MP3s and even apps now you can use.  There are a lot geared specifically for pregnancy, but if thinking about your pregnancy still makes you nervous, find something more general.  Some are 5 or 10 minutes long.  Set your alarm like you used to when it was time to give yourself your injection and take 10 minutes for yourself.  If you are further along and looking at childbirth classes, I highly recommend hypnobirthing.  (See http://www.hypnobirthing.com) The class is geared toward women planning natural childbirth, but it teaches general relaxation, which is useful at any stage in pregnancy or life.

There are other important methods for stress relief that all deserve posts of their own, namely exercise, nutrition, and social support.  So until next time, in the words of Quentin Tarantino, Peace Out! (Yes, still watching the Oscars.)

All it takes is Faith and Trust, Part 2.

I had a patient I was taking care of early on in my own journey.  I had many infertility patients before.  We, in obstetrics, know what to expect when we take care of patients who have had infertility.  We call it anxiety, but knowing what I know now, that’s not exactly the right word.  This patient did not seem anxious the whole time I knew her.  She had a history of infertility, and got pregnant with her second IUI, which I thought wasn’t too bad on the infertility spectrum.  She always came for her appointments, never asked a lot of questions, and never called in between her appointments.  When she was around 7 months, I had a conversation I typically have from time to time, asking her had she had a baby shower, and how was she decorating the nursery, etc.  She said, “I haven’t bought anything”.  I was still allowing myself to look at baby furniture and think about how I would decorate.  I thought then, that as soon as I knew I was pregnant, I would buy out the baby store.  I hadn’t gotten to that stage yet where you avoid the baby section of any store at all costs.  When I continued talking to this patient, she said “I’ll believe there’s a baby when I see one”.  

As I comb the medical literature for psychological issues in women having ART pregnancies, the results are all over the place.  Some showed women were more anxious during pregnancy compared to women having spontaneous pregnancies, some less.  Some showed women were more likely to have problems with depression, some less.  There were several theories about why the research results were so varied:  the studies were done in different countries; they used different methods for measuring emotional states.  I think there is a fatal flaw in research like this in general, which is that we in the medical field try to take an experience and “medicalize” it, or pigeon hole it into our diagnoses.  I believe that having been through infertility affects the experience of pregnancy.  Every woman will express that experience differently, some through symptoms of depression or anxiety, and some may look no different at all to the outside observer, like the woman I just mentioned.  Some may actually make the trek to Babies-R-Us, have a baby shower, and decorate the room.  But for most, there’s a small gut feeling that doesn’t quite believe that after so many false starts, you’re actually going to cross the finish line. 

So what’s wrong with that little feeling?  Absolutely nothing, which if you get nothing else out of this blog, I hope you hear this.  If you want to buy a million baby booties the minute after the positive pregnancy test, be my guest.  If the worst happens, it’s going to feel horrible, it doesn’t matter how much you bought or planned.  If you don’t want to see one diaper enter your house until the baby is born, that’s fine too.  Despite what the baby registry brochure tells you, you really don’t need much right away.  The big problem with that little feeling, is that for many women it feels “wrong," which in turn causes more distress.  It’s kind of like the snowball effect that happens with postpartum depression:

1. I should be happy
2. I don’t feel happy
3. There’s something wrong with me — which in turn makes you worried and less happy.

There’s another factor that can cause you to feel distressed — in general, everyone else.  Pregnancy, like most of life, does not happen in a bubble.  There are grandparents and aunts and uncles who have also been waiting for this baby.  Everyone else is celebrating, and you’re still waiting for the other shoe to drop.  You may get told, like I did, to “think positive” if you’re not ready to join in the party.  As someone who truly believes in the power of positive thinking, comments like this hurt.  Let me reassure you:  you do not have a negative attitude if you don’t feel ready to prepare for a baby.  You will feel connected to your baby in your own time.  For some women, its after the first ultrasound, after the first trimester, after the second trimester ultrasound, and for some, it’s literally after the baby is born.  So how do you deal with the rest of the crowd?  Well, you’ve had experience dealing with friends and family during your infertility journey.  There are some to whom you can explain how you feel, there are some you will smile at and avoid.  I often say to my patients who are having physically difficult pregnancies that the best thing about pregnancy is that it always ends!  Unlike infertility, there is a finite amount of time you have to negotiate that voice in the back of your head.  

Next post - more concrete suggestions for stress relief in pregnancy.

All it takes if Faith and Trust...(part 1)

OK.  So I couldn't resist the chance to borrow a line from my favorite movie as a kid.  Sorry, but no pixie dust in this story. 

There are a lot of issues that make a pregnancy after the journey we have been through unique, but I think this is the most central.  At some point during my infertility process, I was at a conference, and I came across a sticker that said “Trust Birth”.  I’ve seen it many times before; it’s a common slogan for midwife and doula groups, representing a belief in the fact that pregnancy and birth are natural processes.  I’ve always believed it, and still do, but I remember thinking at that time, “Trust birth?  I can’t even trust conception!”  We don’t always think of infertility treatment as a loss, but there are several losses along the way, and the most important is faith or trust.  It may be a spiritual faith that the universe or God will take care of you, or trust that your body will not let you down in what seems like the most basic of functions.  Faith is something that may vary from day to day, depending on your situation, and it may be somewhat restored with that positive pregnancy test, or first ultrasound.  For most women, however, it will never be exactly where it was when you were still assuming a baby would come with a simple night of intimacy. 

There was a commercial running on television, during the time I was going through IVF, that used to make me cry.  It had nothing to do with pregnancy or babies (although those “having a baby changes everything” ads used to get me too).  There was a Weight Watchers ad with a line that said, “For every woman who has tried and failed more times than she can count”.  That was me.  Intellectually I knew I had a medical condition, that infertility was not a personal failure.  It didn’t feel like that at all.  

I had two miscarriages before my first term pregnancy.  It was uncanny, but around the time I was going through both of them, I had clusters of patients with miscarriages.  I found myself saying over and over to these women what I tell all my patients who have the misfortune of experiencing miscarriage:  you didn’t do anything to cause this, you couldn’t have done anything to prevent it.  And yet I’d still go home at night and think “maybe if I hadn’t eaten this, or done that”.  It didn’t matter what I “knew”, what my gut told me is that I was a failure and I couldn’t have a baby.  

As a new blogger, I'm trying to stick to the rule of short posts, so to be continued next week...

A little introduction.

Congratulations!  You are pregnant and you are officially infertile no more, right?  That’s what I used to think.  As a midwife, I took care of women who conceived assisted by various means, and I knew only that they were a little more nervous and anxious.  Then I joined the legions of women on the roller coaster of ovulation predictor kits, clomid, IUI, and IVF.  At some point along the way, we had a meeting with someone from one of the local maternity boutiques to talk about what classes and services they offered.  She mentioned there was talk about doing a childbirth class for women who had experienced infertility.  I had yet to make it to that phase of my journey, but the idea resonated immediately.  I remember thinking, “yeah, I bet this doesn’t all just go away”.  I began to ask different questions to my infertility patients, and really listen.  I discovered not that there was anything necessarily wrong or abnormal about them, but that this was a unique experience.  I tried to do research, to find some solid information in the medical literature, or resources my clients could access.  I found very little.  I looked into doing a support group, or group prenatal care for women who have had infertility.  However, in the current climate and endless bureaucracy of health care, adding any service that may cost an extra dime was too big a mountain as I was willing to climb at this stage of my life.  I spoke to some women at my local Resolve who were thinking about putting a group together about parenting after infertility.  I didn’t feel like an expert in that.  The most I know about parenting is my personal experience with my now 6 year old son and 4 year old daughter, and most days, I feel like a complete novice!  I have little knowledge of how my experience is different from someone else’s.  However, after 7 years as a labor and delivery nurse, 14 years as a midwife, and 3 years of infertility, I have a unique perspective I feel the need to share. I hope to be a source of information, support, and comfort for those who have taken the time to read my few words.