Kathryn’s story

Executive summary: Kathryn is strong and healthy.  Cassia is doing extremely well also.  Their journey together is chronicled below.  We make no apologies for its length.

Preface

Recently we learned that three other babies were born this weekend to mothers in our ward.  One of those children was delivered 12 weeks early because of serious concerns for her and her mother’s health.  She weighed 2 lbs. 9 oz. at birth, and may very likely have to remain in the hospital NICU until the middle of December.  Another baby ingested his own meconium while in utero and may have to stay in the NICU for several additional days.

Comparatively speaking then, our story seems like pretty small potatoes.  We have been so fortunate to have had healthy and active children from all three of Cassia’s pregnancies.  We have never had to deal with infertility, miscarriages, physical or cognitive disabilities, or even infant death.  Several of our friends have, however, and we have grieved with them while privately expressing renewed gratitude for our own blessings, undeserved as they are.

All of this goes to say that we can only speak from our own experiences.  Others have certainly suffered more or been the beneficiaries of greater blessings.  But these things are no less a miracle to us.

Prelude to a miracle

Cassia is Rh-negative, and I am Rh-positive.  What this essentially means is if you took a small sample of blood from me and injected it in her, her body would develop antibodies against my red blood cells and eventually kill them.  This immune response is called Rh-sensitization.  Because I am Rh-positive, there’s a high likelihood our children will also be Rh-positive.  Therefore, if some of the baby’s blood should enter Cassia’s system, her body would also develop antibodies against it.  These antibodies cross the placental link into the baby’s body.  Given a sufficiently high concentration of antibodies, infant anemia, hydrops, or stillbirth can result.

With Rh-negative mothers who have not yet been sensitized by Rh-positive blood, regular injections of RhoGAM are necessary to prevent sensitization.  These injections typically begin at 28 weeks gestation since, second only to delivery, the third trimester is the most likely opportunity for admixture of the blood.  Once sensitization has occurred, however, RhoGAM is ineffective.  At that point, the most you can do is watch and pray that the antibody levels stay low.  These levels are measured in terms of titers, expressed in ratios like 1:1, 1:2, 1:4, 1:8, and so on, increasing by powers of two.  The second number refers to the concentration of antibodies, with higher numbers representing higher concentrations.  Most doctors consider titers of less than “8” to be of negligible concern.  Beyond that, however, there is much more to be worried about.

At his birth Jonathan’s blood type was A-positive, just like his father.  Cassia was accordingly given RhoGAM.  We were confidently assured that the rest of our children would likewise be Rh-positive, so RhoGAM would henceforth be a permanent part of our lives.  (I took a genetic test a few years later which confirmed the presence of two Rh-positive alleles in my blood.  Regardless of how many children we have, then, at least two things are certain: (1) they will never have blue eyes, and (2) they will be Rh-positive.)

Fast-forward a few years to Cassia’s pregnancy with Emma.  At 28 weeks she went in for her gestational diabetes test and a blood draw for the expected RhoGAM shot.  (This is necessary to screen for pre-existing sensitization.)  Three days later she called the lab to receive the results and schedule an appointment to receive the injection.  The technician replied, “Actually, the lab says you don’t need the shot.  I can’t tell you anything more.  You’ll have to talk with your doctor.”

Cassia later wrote:

I know the blood drained from my face.  I knew what that meant.  I had graduated in Microbiology two years before and understood the basics of the Rh issue and RhoGAM (though I now know A LOT more).  If I didn’t need the shot, that could only mean one thing.  I called the doctor’s office and had to leave a message.  It took them a couple hours to get back to me — what felt like an eternity.  I had no idea how bad it was.  I started to do some research online, and it scared me — at least the first bits.  I called my very sweet husband home for emotional support, as I was an emotional mess (and very mad at the doctor’s office for taking their time to get back to me!).  The more I researched, though (and prayed — I was doing A LOT of that!), the more calm I felt.  For me, having an idea of what to expect, even if it was the worst, helped me feel a lot more in control than just not knowing.  Plus, over time, I started to find information that wasn’t all bad — that sometimes the sensitization is low enough that it doesn’t hurt the baby.

It was such an agonizing thing to know that my body was attacking and could seriously harm or kill my baby, and I could do NOTHING about it.  I found myself racking my brain for when [the sensitization] could have happened, but there was nothing that stood out in my mind.

The nurse finally called me back a few hours later and reported that my titer levels were extremely low—less than one.  She really couldn’t tell me much more than that, but they did set up an appointment for me with Maternal Fetal Medicine.

The rest of the pregnancy was a rollercoaster.  At my next appointment with the midwife, she said she’d never seen anyone with a titer report like that, and she wondered if it was just a testing mistake.  Unfortunately, MFM shot this little hope down by saying that though the level was low, the binding capacity was very high — in other words, there weren’t many, but they were really “good” antibodies — at least good at what antibodies do.  They did an ultrasound at the MFM appointment and verified that Emma was still OK — no signs of extreme distress, no signs of anemia or hydrops.  In the consult, I was told that this baby should be fine because the titers were so low (this was about 30-32 weeks) and she showed no signs of distress, but that if we decided to get pregnant again after this it would get worse (and there was no way to know how much worse or how many pregnancies may be viable).  And there was no guarantee, actually, that all would be fine in this one — they really can’t predict what a mother’s body will do.  Luckily, I was far enough along that even if there was a turn for the worse, my little girl should be able to survive (maybe be premature, maybe need blood transfusion(s), but at least survive).  In the end, they wrote out a plan to have my titers checked every four weeks, more frequently if they started to rise—but as long as they stayed under 16, no further action should be needed.

I did a lot of praying at this time.  I prayed for understanding and comfort and peace, and it really helped me pull through to realize that none of this was a surprise to God.  He knew this would happen before it ever did, so His plans weren’t spoiled by it.  I just needed to trust.

At first, after learning that the antibody titer was almost not there, I started to feel a bit complacent.  My second blood draw had the same results—less than 1, so I felt more confident that all would be well—not just for my little one now, but for the future, too.  But then the next blood draw, I believe, revealed it had increased to 1.  Not a big increase, but a bit of a concern.  Then the next one it was at a 2.  I started to feel a little scared again (and definitely hating my body for attacking my baby!).  By this time, I was having draws every two weeks.  The next one was at a 4.  I was crushed—although I was sensitized before, I was now “officially” sensitized.

I felt caught—wanting my little girl to get all the time she needed in the womb, yet wanting her to get out sooner rather than later so she wouldn’t be harmed and my titer level would stop rising.  I was so relieved to go into labor on my own at 38-1/2 weeks (definitely an answer to prayers!).  Emma was fine, though a blood test did reveal some antibody attacks in her blood — but not enough to harm her.  She did have a bit of jaundice, which is normally a sign that the titers got too high — but in this case I think it was due to her having an abnormally high amount of red blood cells (whole, unharmed ones) at birth that had to be filtered out.

After delivering Emma, Cassia had her titer levels checked again.  Now they were at 8.  We consulted with the specialists at MFM again, wondering if these antibody levels would ever go down over time.  No, they responded, prior research had demonstrated that antibody levels don’t just “go away.”  Like the antibodies the body develops after exposure to invaders like measles, mumps, and chicken pox, anti-D antibodies are also a lifelong presence, and tend to only increase over time.

We were heartbroken by this news.  We both felt that at least one more child was intended for our family, but decided together that we would wait to have another one until we were both emotionally prepared to deal with whatever may happen to him or her, even if the worst were to occur.

There was, of course, the possibility that the doctors were wrong, that Cassia’s antibody titers would go down.  One year after Emma’s birth and shortly before we moved to Georgia, Cassia had her blood tested again.  They were still at an 8, which wasn’t a surprise to us.  But we had hoped for more encouraging news.

A few months later though, we felt the time was right.  Cassia became pregnant in January, and at 5 weeks gestation had her blood tested.  The lab reported that her levels had gone down to 1!  We were taken aback by the results.  Was it a lab error, or a miracle?  We both felt strongly that it was the latter.  Nevertheless, we proceeded with caution, praying that our great fortune would continue.

A terrifying experience

On Sunday, March 2, I stayed at home to watch a couple of sick children while Cassia went to church to play the organ for sacrament meeting.  Almost immediately following the close of the meeting, as people were filing into the various rooms for Sunday School, Cassia experienced some internal cramping, followed by the release of quite a bit of blood.  She was certain she had miscarried.  Our ward Relief Society president, a former labor and delivery nurse, witnessed Cassia’s panic and urged her to go to the hospital.  There was still a chance, however slim, that they might be able to save the baby.  After arranging impromptu babysitting for Jonathan and Emma, we left for the hospital straightaway.

The seven hours we stayed at the hospital were mostly spent waiting for doctors, nurses, and lab technicians to get their act together.  We were propelled by a sense of urgency to get to the hospital quickly to save the life of our baby.  The attitude of most of the personnel we interacted with, however, was one of “eh, typical miscarriage and over-reacting parents.”  This drove Cassia nuts, and to a lesser extent me too, but I kept these feelings subdued so I could be a source of strength to her.

We received an unexpected visit from my elders quorum president and home teacher, who brought dinner and some additional hands for a priesthood blessing.  I don’t remember much about the blessing, but in her journal Cassia wrote that “it promised strength and comfort, that I would heal quickly and that the remainder of the pregnancy would go well, and that this child would be able to fulfill its mission in life.”

At length we were finally allowed an ultrasound to see how the baby was doing — or even if it was still there.  This would have been the first time we were able to get a peek at our daughter.  The technician was gentle and polite, yet gave us no encouragement as she spent several minutes looking for signs of life inside Cassia’s uterus.  Then we saw it — just a tiny blob of cells nestled against the uterine wall — but with a head, four stubby appendages, and a tiny little four-chambered heart merrily pumping away.  With tears glistening in our eyes, I told Cassia “I’ve never been so happy to see a jelly bean with a beating heart!”

From the ultrasound we learned that Cassia had experienced a subchorionic hemorrhage, a partial tearing away of the placenta from the uterus, but that it had already resolved itself in the intervening time.  At another ultrasound two days later, the technician told Cassia that she wouldn’t have known there was a subchorionic hemorrhage if she hadn’t already known to look for one.  The placenta was fully re-attached and the cervix was closed.  Even more amazingly, a blood test confirmed no change in Cassia’s antibody levels, when intermixing of the blood seemed absolutely certain.  It was another miracle.

Unexpected news

Cassia and I share the same philosophy about birth: namely, that God designed women’s bodies to deliver children without needing to cut extra holes in them for convenience’s sake.  (Of course, there are always exceptions to this philosophy, and it’s not our purpose to denigrate anyone who has experienced or prefers the Caesarean method.  Jonathan himself was a Caesarean birth, though not for reasons we anticipated.)  With Emma, Cassia sought to have a “normal” birth after Caesarean, otherwise called a VBAC.  In the 1990s VBACs were considered “no big deal” by obstetricians, but lately they’ve become a point of skittishness and controversy.  It turns out that there’s a school of thought, gaining popularity by the day (and publicized in this Time article), that “choosy moms choose Caesareans” and that it’s safest to perform C-sections on every baby delivered subsequent to the first C-section.  These people minimize the risks of this major abdominal surgery because it’s much more predictable and controllable than delivering children the usual way.  But even the most conservative research published in refereed medical journals state that VBACs entail no greater overall risk than C-sections.  Many have stated the risk is much less.

In Georgia we found a much less favorable climate to VBACs than in Utah.  Emma was a successful VBAC delivery, and we sought to repeat our success with this baby.  However, we soon learned that several practices promise VBAC “support” at the outset, only to change their tune midway through the pregnancy and put pressure on couples to go the Caesarean route.  Many hospitals in the Atlanta area are also not known for being VBAC-friendly, which made Cassia’s search for comfortable and reliable health care a difficult one.  She changed practices twice during her pregnancy as she found out about their unfavorable histories and practices after the fact.  She eventually settled on a practice that was a solid 45-50 minute drive from our house, the closest one she felt comfortable attending.  It was managed by a Dr. F., who also allowed two midwives to practice there, K. and M.  We met with both midwives during the latter half of the pregnancy, and they kept a close eye on the antibody titers.

Things stayed under control for several months.  Even at 31 weeks, Cassia tested “less than 2” and we felt that we would sail comfortably to a normal birth on or around October 5.  A few days later, however, we received word that her titers had suddenly spiked to an 8 — the level they were at subsequent to Emma’s birth.  But then at 34 weeks they dropped down to a 4.  Again, we couldn’t explain it, and M. said it could quite possibly have been a lab error.  At 36 weeks they were tested again, and were back at 8.  Just “to be safe,” K. recommended that we schedule an appointment with our local Maternal Fetal Medicine office to make sure the baby was alright. The appointment was scheduled for the afternoon of Friday, September 19.

By this time we had already decided on a name — Kathryn — but were still vacillating between two middle names, “Ann” and “Grace.”  “Ann” is Cassia’s middle name (as well as her mother’s), and one we’d considered giving to Emma before she was born.  We held off, though, believing it was reserved for a later child.  “Kathryn Grace” was a name Cassia had in mind for well over a year, but I demurred somewhat because another couple in the ward had named their baby Grace Kathryn.  We figured we still had a few weeks to sort it out, though.  I was comfortable with either middle name at this point.

On her way to pick me up from the train station north of midtown Atlanta for her appointment with Maternal Fetal Medicine, Cassia decided to call the midwives’ office to learn the results of her most recent blood draw Tuesday morning (37 weeks gestation).  K. said that her antibody titers had now spiked to 32, and that it was best to skip the appointment and head to the hospital for an induction.

We were stunned.  Cassia hadn’t finished packing.  Our childcare arrangements weren’t finalized.  And Cassia certainly wasn’t in labor, an element which threatened to totally upend our plans for a Caesarean-less delivery.

We decided to go to our MFM appointment anyway.  Amid the emotional upheaval of the afternoon, we realized the best course to take was a thoughtful and deliberate one.  If we didn’t take control of the situation (as at Jonathan’s birth), others would gladly step in to take the reins from us.  We knew that MFM would provide us with an ultrasound view of Kathryn, so we could tell if there were any problems before heading to the hospital, where we certainly would not enjoy the same privilege.

The ultrasound revealed a perfectly healthy and normal baby, and a Doppler scan showed no trace of anemia in Kathryn’s blood.  Nevertheless, the physician’s advice was short and to the point: at full-term, it’s simply best to go have the baby.  We resolved ourselves to this action.  Kathryn was safe now, but was the desire for a naturally occuring labor worth the risk to the baby?  Knowing Cassia, I knew it was not.  She would hardly rest a moment knowing that Kathryn was in constant danger.

On the drive home, Cassia turned to me and said, “So it’s ‘Kathryn Ann’ then?”

I nodded.  “‘Pure grace,'” she said.  “That’s what it means.”  I knew it to be true, and so appropriate.

Labor

By 8:00pm, we had returned home, finished packing our things, ferried the children to a friend’s house to stay the night, and driven to the hospital.  When we walked through the Emergency entrance doors, Cassia was still not in labor.  But we knew we would not be leaving without our baby girl in our arms.

The labor and delivery nurses sent us to an observation room, where we could discuss our plans with K. and determine if an induction was still viable.  A completely closed cervix would guarantee an automatic C-section.  K. examined Cassia and said that an induction was still possible if we wanted to go that route.  A Foley bulb could be used to manually dilate her a few extra centimeters, after which they would gradually introduce pitocin (“pit”) into her system to get the contractions going.  While the process would be more drawn out than a quick C-section, it entailed the least medical and chemical intervention of all the available options.  We wanted to roll ahead with this plan, so K. left to discuss it with Dr. F.

She returned a few minutes later and informed us that Dr. F. didn’t see any reason not to begin using pitocin immediately, and to just skip the Foley ball.  “Uh, can we just go with your plan instead?” I asked.

We were opposed to using pitocin right away because it had been a common factor in both of Cassia’s previous deliveries, and her experience with it hadn’t been very favorable.  While it certainly had been effective in ratcheting up the frequency and intensity of her contractions, it did almost nothing to ripen “the way out.”  (Of course, it didn’t help that Jonathan had been transverse in the womb, and Emma posterior.)  The result becomes something like slamming your fist down onto a wood plank in the hope that you can weaken it enough to break.  You might eventually punch out a hole, but your hand is in for a whole lot of hurtin’ until then.

Here again I could feel the noose tightening around our necks as others tried to wrest control of Cassia’s care away from us.  K. asked if we’d like to speak with Dr. F.  Yes, we would.  As she left the room I steeled myself to fight for what K. wanted — for what we wanted.

Dr. F. came into the room and began a very blustery spiel about our “options” in which he repeated himself several times on multiple points and did not finally arrive at the point of contention (to Foley or not to Foley) until after nearly five minutes had passed.  We told him we wanted the Foley bulb first, followed by “pit”; he replied by saying he didn’t think the Foley bulb would do us any good.  We said we still wanted it.  He said he still didn’t think it was a good idea, but that “hey, if you guys want it, we can do it, whatever, but it’s really not going to do anything for you, but hey, we can do it, that’s alright, but it’s just going to draw things out even further.”  He then pulled out the C-section card: “You know, if we take this gradual approach like both of you want, and we’re just doing a little bit of this and a little bit of that, there’s a good chance your labor could end up stalling, and we’d just have to do a C-section on you anyway.”

At this point Cassia asked him point blank: “You’ve been saying that you don’t think the Foley bulb would do any good.  Would there be any harm in trying it?”

Of course, the answer was no, other than the chance that her labor could stall and she could need a C-section.  We again reiterated our desire to pursue our original plan — this must have been the fifth or sixth time now — and he finally gave up and marched out of the room.

After he left I pulled K. aside and asked if Dr. F. would be taking over our care.  No, she responded, he wasn’t willing to do much more than talk.

Whew!  Another hurdle passed.  I told Cassia he must have thought we were the most stubborn, bone-headed people in the world, and if our plan failed would likely come into our room and do the “told you so” dance.  As it happened, however, we never dealt with him again.

Because of delays, the Foley bulb didn’t arrive until 3:00am.  When K. inserted it she inadvertently broke Cassia’s water, so at that point we knew we were in the game for real. When the ball fell out at around 8:30am, it had accomplished what we had hoped it would do.  Cassia was now dilated to between 5-6 cm., with mild contractions ensuing.  The nurses hooked her up to the “pit” and got it going.  Unfortunately, the contraction monitors they had attached to Cassia hardly picked up a thing, and in spite of continual readjustments, failed to help the nursing team understand the frequency and intensity of her contractions.  As a result, every hour or so the nurse would enter the room, casually increase the pitocin dosage, and return to the nurses’ station to see if it helped at all.  It took a personal appeal to K. to help her understand that ramping up the “pit” wasn’t helping us at this point.

Delivery

As at Emma’s birth, the intense surges were wearing away on Cassia.  Her strength was spent after more than 14 hours in the hospital, and she began to lose the motivation to continue with delivery unmedicated.  In addition, three hours of pitocin had only widened her by a few centimeters — as we predicted, unfortunately — and Kathryn refused to move from the posterior position she had occupied for most of the week.  Cassia was nearly ready for an epidural, to allow her body to rest.  I told K. how an epidural had helped Cassia get the rest of the way with Emma’s birth, and suggested that it might help us out here too.  We did not yet formally request it, though.

At 12:30pm K. and our doula-in-training, J., came up with an ingenious plan to help Cassia turn Kathryn around.  K. had Cassia assume a certain laying position on her left side, while J. had the nurses place a warm blanket on Cassia’s stomach and a bag of ice against her back.  In theory, it should cause the baby to turn away from the cold and toward the heat.  It worked!  Kathryn was now in the ideal delivery position.

At this point K. did something we imagine very few other care providers would have been willing to do: she used her hands to help dilate Cassia the rest of the way, hoping to distract her from the pain by urging her to push with every contraction.  This continued for nearly half an hour, and just as Cassia reached almost total exhaustion, we saw the top of Kathryn’s head.  Then her eyes.  Then her right hand (the Superman pose!).  Then neck, shoulders, and the rest of her body in one swift motion.  She was out!

She was also blue.  She didn’t move or breathe.  “Is she alright?” Cassia asked anxiously.  K. used one hand to clear the fluid from Kathryn’s mouth and another to tap her on the back to encourage breathing.  After what seemed like forever, we heard her first faint, struggling cry.

Word had spread around the labor and delivery unit about the special circumstances of Kathryn’s delivery, and a team of specialists burst onto the scene.  While one helped dry her off and observed her APGAR metrics, another two inserted a tube into her throat and lungs to clear away whatever was hindering her breathing.  After two or more passes with the tube, we heard a good strong cry.  She was alright!

Nevertheless, the doctors remained concerned about possible anemia, and had ordered additional blood to be used for a possible transfusion.  We were told that Kathryn may need to stay in the hospital for several days of monitoring as the effect of Cassia’s antibodies in Kathryn’s system was assessed.

More than we ever thought possible

After a few pictures (posted in “Kathryn the Great”) and more than an hour of nursing, Kathryn was taken to the nursery for a bath and a few other tests.  By this time her color had changed from blue to orange-pink (a side effect of the mild jaundice that has affected all our children), and she was well out of immediate danger.  Her blood type was — surprise! — O-positive, a far cry from the A-positive blood that Jonathan, Emma, and I carry.  This was a very special child indeed.

Sunday morning (September 21) the hospital pediatrician assigned to Kathryn met with Cassia to discuss the results of the direct Coombs test performed on Kathryn to determine the severity of the antibody presence.  Emma had tested positive just after her birth, a natural consequence of Cassia’s titer level of 8.  But Kathryn tested negative.  In other words, despite Cassia’s rapidly increasing titer levels (who knew how many days she’d been at 32?), not a single antibody had crossed the placenta.  It was as if she had been born to an unsensitized mother.  The baffled doctor was unafraid to admit his ignorance: “I have no explanation for it,” he said.

So here we are.  Titer levels that inexplicably went down at or near the moment of conception.  A subchorionic hemorrhage that healed itself almost perfectly.  Finding the right care provider who did for us what almost no one else would have been willing to do — take a perfectly fine and non-laboring VBAC woman and induce her to give birth.  A mother who endured an extended induction without pain medication.  A baby born two weeks earlier than expected, but beautiful and fully-formed in every way.  And without a trace of the antibodies which could have harmed her.

I just can’t explain it.

Wherefore, we search the prophets, and we have many revelations and the spirit of prophecy; and having all these witnesses we obtain a hope, and our faith becometh unshaken, insomuch that we truly can command in the name of Jesus and the very trees obey us, or the mountains, or the waves of the sea.

Nevertheless, the Lord God showeth us our weakness that we may know that it is by his grace, and his great condescensions unto the children of men, that we have power to do these things.

Behold, great and marvelous are the works of the Lord. (Jacob 4:6–8.)

Kathryn Ann, our little miracle.

[A]nd who knoweth whether thou art come to the kingdom for such a time as this? (Esther 4:14.)

6 Responses to “Kathryn’s story”

  1. Now, if we can just get the “blue-eyes” thing to resolve, I think we can call this one well and truly a miracle………said the blue-eyed, O-POS grandfather.

  2. So sweet!
    She looks a lot like Jonathan.

  3. Thanks for sharing this amazing story. Congratulations on your new daughter! I hope we get to meet sometime.

  4. Wow, what an intense experience. You are a very brave and faithful couple! She is absolutely beautiful, and I agree that she looks a lot like Jonathan!

  5. I’ve never heard your story/ies. Amazing grace! Thanks for sharing. We know how you have followed Izzy’s story and have felt your thoughts and prayers.

  6. You both have been truly blessed. She is such a beautiful baby. I cannot believe your pregnancy and delivery story. It is amazing that our bodies can even have babies but then to have such a healthy baby under those circumstances is amazing.

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