The choice

So… The consultants have asked me to make a choice, and as the 4 weeks since my last appointment come to an end, decision day is getting closer and closer.

The choice is whether I want to stay on my current dose of medication or halve the dose.

If I leave it as it is, then my risk of thrombosis is lower but I would have to wait 24 hours from my last injection before I could have an epidural or a local anaesthetic into my spine in case of an emergency c-section. And if still within the 24 hour window when it is determined that I need the emergency c-section, then it will have to be under general anaesthetic.

And if I halve the dose? Greater risk of thrombosis, but a 12 hour window before spinal intervention would be allowed.

And the choice is mine!

Sometimes I reckon you can have too much choice… I am sure Amartya Sen would agree – in fact one of my enduring (perhaps only) memories from university lectures is he propounding that more choice is not always better, since faced with a fruit bowl at a dinner party (where someone foolishly decides to serve fruit rather than profiteroles) that includes two apples and a pear, the first person to choose will feel obligated to choose an apple in order to politely leave more choice for the second person. So do I choose to maintain my dose and potentially deny my future self the choice of an epidural or the opportunity to be awake for an emergency c-section, or do I keep those options open and let the spectre of clots hang over me?

The trouble is there is no obvious or easy choice. I have been amazed by how little scientific research there is into pregnancy and from looking into it, I think that is because medical research into pregnancy is so constrained by the ethics of it all: is it ethical to know you are giving someone a placebo and hence putting an unborn child at risk? So there’s generally not a lot of data to go around and what there is is tempered by the extremes, hence the hyper-conservative pregnancy diet when you imagine that even if those restrictions were lifted the majority of babies would still be fine. But in pregnancy, all risks must be reduced to increase the likelihood of a healthy baby entering the world.

So what are the risks?

Risk of thrombosis… Difficult to say – they don’t know what is causing my condition so there’s no research full stop on what the risk levels are. I’ve had 10 years since the last incident without any medication, and my Dad had almost 30 years between his second and third thromboses, so it’s possible that even without medication I might have been perfectly fine through pregnancy. Or I might not have. There is no way of knowing…

Risk of needing a c-section… Based on this amazing set of NHS data and if my maths is right then of planned vaginal births, 15% end up having a c-section.

Risk of needing a c-section within 24 hours of my last dose of medication… Well apparently the average first labour is between 12 and 18 hours and although I know labour is unlikely to suddenly start the minute I jab myself one morning, 24 hours seems a long time in the context of 12-18 hours.

Risks associated with having a c-section under general anaesthetic… There are four different ways to receive anaesthesia for a c-section (spinal, epidural, a combination of those or general) and general anaesthetic is the least desired of the four under normal circumstances. The risks associated with it, according to Healthline, are to the mother (risk of breathing difficulties and aspiration which could cause pneumonia) and the baby (respiratory depression that could lead to the need for resuscitation).

Risk of needing an epidural… Using my favourite set of data again, it looks like 16% of women who have vaginal births have an epidural, but that figure is swayed quite a lot by a much higher proportion (42%) when the birth ends up being instrumental e.g. via forceps or ventouse (seemingly a vacuum cleaner that sucks the baby out!) – the trouble is I guess you can’t know in advance if that is going to happen to you (instrumental births making up 13% of the total births). There are risks associated with having an epidural too, including low blood pressure (resulting in reduced oxygen to the baby), slower labour and greater likelihood of the need for oxytocin to speed it up again, and an increased probability of needing forcep intervention in the birth.

Interestingly, when I asked my consultant about epidurals he said that the majority of women went into labour saying they didn’t want an epidural, but in that hospital, the majority ended up having one. There was an anaesthesiologist from Bath visiting and I asked her what the rate was there – she said it was low, but that was probably because most births happened in the birthing centre where there wasn’t easy access to an epidural.

I am seeing the anaesthetist so will get their perspective on it all. But in the meantime, I am tending towards halving my meds. I really don’t want a general anaesthetic given the risks involved and because I think it would be weird not to be conscious for the birth, and to miss out on the precious moments after the birth holding your new baby. To wake up to it just makes me worry that I would feel detached from it all, and I’d miss out on Fred holding the baby for the first time because that will have already happened before I woke up.

Whatever will be will be, but if there is one thing about the birth plan I do care about, it’s that I don’t want to miss a thing…

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