How was your night?

Okay at best.  Ginger was taken off the nifedipine (which obviously didn't stop her contractions; she was on it at 10:00 this morning when it all started) and was put instead on magnesium sulfate in an IV push.  Ideally, magnesium sulfate was supposed to slow the contractions (I suppose we'll never know whether it did) but it is also supposed to have some side effects (it did).  For one thing, you can't get out of bed when you're on it because it is a strong muscle relaxant.  For another, it can cause the build up of fluids in the body.  And boy, did it.  Ginger's lungs filled up with fluid and she began having even more copious nosebleeds.

Coughing and contracting, bleeding and contracting.  That pretty much sums up the night.  You?

How was Ginger doing through all of this?

Of the frequently asked questions that form the titles of these posts, this is the one that is most important to me.  The fact is, she was amazing.  If there is such a thing as "the right amount of courage," she had it.  Of course, anyone who has delivered a baby before 32 weeks will look with disdain on all of this.  "Thirty-two weeks?  Pikers."  When it comes to fetal development, not all preterm infants are created equal.  A 32 week baby is actually going to stand a very good chance of "a positive outcome," as the doctors euphemistically say.  But it means time in the NICU.  There is no question about this.  It's not as if some babies with a gestational age of 32 weeks are somehow capable of doing the things a 35 week old or full term baby can do.  So it meant no birth whatsoever in Burlingame, no "rooming in," and no happy time of going home as a family after a two-day recovery period.  These things were decided by a gestational age of 32 weeks.

But some things weren't yet decided.  Could we still have the birth we wanted?  Was it going to be an emergency c-section?  Were there going to be other medical problems for our kids?  These were unknown.

The things that helped us get through this have names:  Christa and Jen.  At some point in the early afternoon, I sent out a text message to a bunch of folks asking for their prayers.  Christa and Jen answered it by coming to CPMC that afternoon.  And staying until 10.  And coming back at 7:30 the next day.  And staying again until 10.  If Ginger and I had the option of stepping outside and going home, we would have taken it.  Christa and Jen had that option, and they stayed anyway.  And that's what helped Ginger get through all of this.

So why was it so important to make it until morning?

Okay, you've forced me to confess a narrative trick.  We'd met the perinatologist once before, on Tuesday.  He had been asked to consult on our case because we were showing two signs of preterm labor -- fetal fibronectin (a protein that can appear on the cervix as a harbinger of labor) and the cervical thinning that had been showing up on ultrasounds for about a month.  He met with us at Peninsula and told us that we were showing risk factors, but it might be possible to get it under control.

And he did another thing:  He prescribed betamethasone.  Betamethasone is a steroid that boosts lung maturity in fetuses that are at risk of preterm birth.  It is administered in two intramuscular injections to the mother, placed 24 hours apart.  But it only has beneficial effects if delivery occurs more than 48 hours after the administration of the first dose, in order to give the steroid time to effect a change in the lungs.  He administered the first dose when he met with us on Tuesday morning at 10:00 a.m.  The second was administered at 10 a.m. on Wednesday morning -- just before the contractions started.

All of a sudden, our primary goal became to keep the babies in utero until 10 a.m. on Thursday -- i.e., 48 hours after the administration of the first dose of betamethasone.  Doing so would mean the babies, if delivered, would have a chance a sufficient lung maturity.  Delivery any earlier than 10 a.m. on Thursday might mean the steroids would not complete their task.

Okay, give Ginger a goal, and she will meet it.  Right?

Perinatologist?

Good question.  A perinatologist is an obstetrical subspecialist concerned with the care of mother and fetus at a higher-than-normal risk of complications.  In other words, they're like an oncologist -- you wouldn't wish one on your worst enemy, and yet they're a godsend when you need one.

We were out of the realm of the midwife, where we'd started this and all of our other pregnancies.  We'd even outstripped the OB.  Now we were in the Land of Perinatology.

What did you think of CPMC?

You mean aside from not wanting to be there?  My first impression was that it's a slightly run-down facility that it staffed with some really top notch people.  The first half of that impression was developed instantly.  The second half also didn't take much time.

I arrived in Room 206 at 2:06 or so.  Mom called to say that Ginger was just being put into the ambulance now.  Wha?!?  Well, apparently these things take time to accomplish.  Wish I'd known that; I spent the entire drive from San Mateo thinking that I was going to be passed on the freeway by a barreling ambulance with its lights flashing.  When that didn't happen, I expected I would be passed on 19th Avenue by two kids entering the world in a sudden moving rush of blood and amniotic fluid.  I also learned that the "90% effaced" estimate was being modified to 75%.  That gave me hope that we could see this through and get the contractions to stop.  Maybe Ginger would spend a day or two, promise to be a good girl about bedrest, and we could go home.

I paced the hall for forty minutes.  Ginger was wheeled in at 2:45.  Not exactly the fastest ambulance ride in history.  But the important thing was that Ginger was not crying, and neither was anyone else at that point.

They got her set up in the bed and hooked up to the all-too-familiar monitors.  As usual, the fetal heart rates were perfect -- 125 to 140, always in the sweet spot, never in stress.  The contractions were still regular.  The perinatologist told us that with her contractions and dilation, the best we could hope for was getting through to morning, but that it was very important that we make it to morning.

Where is CPMC?

Good question.  My GPS didn't seem to know.  I called Christine, who looked it up on the Internet.  It's at 3700 California.  Which was good to know, because my GPS was going to send me to a clinic in the Castro, where I'm pretty sure the NICU is perhaps somewhat underfunded.

I pull in around 2:00 and find parking.  Beautiful neighborhood.  It's how the other .005% lives.

I'm told to go to the second floor and wait.  The nurses direct me to Labor & Delivery Room 206.  I do not like the sound of that.

What does "90% effaced" mean?

When you're not pregnant your cervix is a long and relatively hard tube.  During pregnancy it should stay that way until it begins to ripen, at which point it softens.  Very late in pregnancy -- which, I would note for the record, is not by any definition at 32 weeks -- the cervix begins to "thin out" or "efface," which means that it widens at the top and basically becomes a wide funnel instead of a tube, allowing the baby's head to drop onto it and apply pressure to it, which advances labor.  Effacement basically means the cervix has stopped being the blocking point for the fetus.  Anyway, 90% effaced means that your body thinks that labor is supposed to begin.

So I'm on 101 headed north to S.F., right by the airport when the phone rings again.  Mom.  "They're saying they might not go to CPMC."  What?!?!  "She's too far along and they're afraid she'll deliver in the ambulance."  [Other voices.]  "Okay, wait.  Don't go to CPMC."  [Other voices.]  "Okay, they're talking about it now."  [Other voices.]  "Okay, they're putting her in the ambulance.  Meet her there."

I make an unsafe lane change to get onto 380.

Did you grab the bag you had thoughtfully pre-packed for such an occasion?

Don't be difficult.  Until those text messages, we were at 32 weeks and we were pretty sure the OBs were overreacting to a smidgeon of fetal fibronectin and a change or two in cervical length.  Sure, these were twins, but we were old pros at pregnancy and natural childbirth.  Why, Ginger's older sister had once gone home from a Thanksgiving Dinner dilated at four centimeters for a daughter who was born after Christmas.  A little bit of progress was nothing to panic about.  Ginger would know when she's in labor.

How do you know when you're in labor?  When you're having contractions at regular intervals.  Which she is.  Now, all bets are off.

I got home to find Christine watching Charlie.  I tried not to look panicked, but I'm pretty sure I failed to carry that off.  I wandered the house with the Post-It on which I had scribbled the list of essentials that were supposed to carry us through a week or more of bedrest at CPMC.

And then the phone rang again.  Mom.  "The nurses are saying she's 90% effaced.  The ambulance team is already here, and they're putting her in it now.  Meet her at CPMC."  Holy Mother of God!  I shouldn't have left!  I stopped packing and zipped up whatever I happened to have in the bag already.  I threw it into the minivan and hit 101.

Why would they want to transport her to CPMC?

Because it has the best NICU (Neonatal Intensive Care Unit) on the West Coast, and is prepared to deal with preterm newborns at a very young gestational age.  Frankly, 32.5 weeks is not a terribly underdeveloped stage given today's technology, but anyone born before 35 weeks can have medical issues that outstrip the care capabilities of many hospitals.  CPMC would be the safest place to have a delivery before 35 weeks, so that's where they wanted us to go.  Anyway, don't interrupt.

When I got to Peninsula at 11:39 or so, Mom was with Ginger (she had driven her to this appointment).  The nurses were prepping her for the ambulance to CPMC, but the ambulance team was still enroute.  We were told it might be and hour and a half for them to even get there.  Okay, we can all breathe a little.  The contractions were frequent but still fairly mild, so there was a chance to get them under control -- maybe even stop them.  Ginger was already on nifedipine to inhibit the contractions, so it looked like we might be going to CPMC to get them further under control.  The fact that its NICU is so advanced was just going to be an insurance policy against the failure of Plan A.

Because we had time and it looked like we might be in for a long hospital stay for bedrest, I suggested I would drive home to gather some things.  I told Ginger I'd be back.

So how did this all start?

A calendar is unforgivably presumptuous.  We like to pretend that it will tell us how our day will go.

Today my calendar said I had a meeting with one school district at 10:00 a.m. that would go until about 11.  I would then proceed to another district office for a pre-meeting for another pretty important meeting that could last all afternoon.  Not so.  I stepped out of the 10 o'clock to have the receptionist tell me my office was on the line.  "That's odd," I thought.  So I called.  Brenda said Dad was trying to get ahold of me, and that I should call him.  Something to do with Ginger.  "I don't mean to scare you, but it's medical."  Yikes.  I called Dad.  Dad said Ginger had tried calling my cell phone and texting me, but I hadn't responded.  Nothing on my phone, I said.  Dad said she was at Peninsula for the non-stress test we'd all expected, but was having multiple contractions while on the monitors.  He said they were going to transport her to CPMC in San Francisco, and I'd better get there before the ambulance left.  I bolted for the car and began driving toward Peninsula.

I crested the hill to 280 and my phone got two backed up text messages from Ginger:  "Sorry to interrupt.  Monitoring going terribly.  8 contractions in half hour.  Dr. Shapiro coming.  Dont know whats next."  And then:  "Up to 3cm dilated.  Going to cpmc via ambulance."  There was also a voicemail, but I didn't bother to check it.  I already knew what it said, and I didn't want to hear it.