About My Friend Mr T.

There's a little boy who thinks of me as his friend from back in the days when he was in his mum's tummy.

Let's call him Mr T. 

Mr T is four years old, he was born in February of 2019 and I proved myself as his friend in the lead up to his birth when I supported his parents through some rocky times. 

I met Mr T's mum and dad when his mum's belly was beautiful and round at the end of her pregnancy. I met them because I was one of the sisters in charge of the midwife led unit they wished to have their baby in and their care plan was coming 'out of guideline'. Mr T's mum had been imagining an intervention free birth in our unit and that bubble was about to burst given that her blood pressure had been outside of the normal range at her last appointment. 

Blood pressure can do this at the end of pregnancy and that is worth paying attention to because a raised blood pressure can cause major problems. Perspective is everything though! A one off blood pressure outside of normal range in a mum who has her toddler in tow and has just come through the door isn't something I would have dwelled on. I probably wouldn't have mentioned it to her initially. I would have taken the BP cuff off and had a chat with her whilst checking in with baby and then I would just have rechecked it at the end and it would probably have been okay. But this is not what happened here. The high blood pressure became an issue right away and the midwife at the midwives' clinic wanted the consultant obstetrician to review this mum. The prospect of not being 'allowed' to give birth in the MLU was mentioned right away, so of course the blood pressure didn't settle when it was rechecked. The consultant obstetrician was to review this mama and decide 'if she could give birth in the MLU'.

The most important potential medical issue to be aware of in the context of high blood pressure is pre-eclampsia. Raised blood pressure after 20 weeks of pregnancy is one of the symptoms but slightly raised blood pressure on its own does not mean you have pre-eclampsia. The diagnosis of pre-eclampsia is made when you also have signs of deteriorating kidney and liver health in your blood work. With pre-eclampsia you can develop an inability to clot your blood, so your clotting factors and your platelet count also get tested. You may have symptoms like headaches and visual disturbances and those occur because the high blood pressure can cause a strain on your brain and central nervous system. In severe cases you can even have seizures. As you can see, pre-eclampsia is not to be taken lightly and it can endanger the life of mums and babies if it goes unnoticed and the pregnancy continues. The only 'cure' for pre-eclampsia is for the baby to be born, so an induction of labour or a caesarean section become valuable interventions when true pre-eclampsia is present. 

The other potential complication to be aware of with high blood pressure even without pre-eclampsia is that the increased pressure against the placenta can cause the placenta to detach before the baby is born. This is called a placental abruption and you can imagine that this is also an emergency situation that could potentially result in tragedy for baby and for mum. Mr T's mum didn't have any symptoms of pre-eclampsia in her blood tests, neither was her blood pressure always raised. There was no emergency here!

The consultant obstetrician had a conversation with the parents and took on board their own evaluation of the potential risks and benefits of interfering versus those of waiting. Given that the blood pressure was not significantly higher than the mum's baseline blood pressure taken at the initial early pregnancy appointment, a birth at the midwife led unit was on the cards again. A plan was made to sit tight and keep an eye on the blood pressure. If it was rising significantly or was consistently elevated, then the consultant would recommend considering an induction of labour at the obstetric unit. Given that Mr T's mum had felt quite upset at the initial midwife's attitude, we decided that a familiar face at each visit would be helpful. I was fully on board with the plan and we arranged an appointment in a few days' time to check in on blood pressure and touch base. 

When we met again I made sure that there was time for Mr T's mum to settle and take a moment to breathe deeply before checking the blood pressure. We did this every time we met and we found that her blood pressure was normal every time even when new challenges came up. The days went on and on until Mr T was now running 'late' by all accounts (except for his mum and dad's or mine).

Being 'late' to your own birth is frowned upon in the NHS. It comes with all kinds of issues none of which are actual intrinsic problems. Overstaying your allocated time in your mother's womb is considered a major hazard by NHS practitioners and many of them think that it must not be tolerated. The issues you will be facing include that advocating for having an out of hospital birth after the acceptable timeline will be difficult. You'll be having lots of conversations about when your induction of labour should happen and if you wish to continue to decline it you'll need a lion's heart. There's an exact second when things shift from being absolutely fine to being outright dangerous. Back in 2019 that exact second was midnight on your 14th day past 'due' (now, in 2023, it's midnight on the 7th day). The days continued to tick on with no sign of labour. As the magical line in the sand approached, Mr T's mum and dad really had to dig deep, mainly because of the focus on 'risk' during their consultant reviews. Whilst the consultant 'agreed' to an MLU birth up to midnight on day 14, the overarching message to parents in this type of situation is that they are taking unnecessary risks by declining to 'get the baby born'. 

This is a complex topic because the perception that 'doing nothing' represents only risk whilst interfering represents only safety is the prevalent attitude from NHS midwives and doctors. In reality this is much more fluid. By shifting risk away from one outcome you inadvertently shift it towards another. There is inherent risk in being pregnant. For a woman it is riskier to be pregnant than not to be pregnant. Living life is risky! If we were to apply the same risk focused approach to our daily lives as we do to pregnancy and birth we would never be carefree! Sadly I see that healthy perspective in maternity services is being replaced by fear and coercion. One of my clients last week told me that in her last pregnancy, when she asked for more time after her waters had released, a doctor told her that she was 'risking her baby's life' if she waited any longer. This statement is coercive and it misrepresents the facts. A baby could also die from complications purely related to induction of labour. Whether this mum waited or had the induction of labour the doctor was pushing on her, the most likely outcome by far was that the baby would be fine. I have spoken about this in my other blogs. The possibility of a baby dying before you get to hold them in your arms is always there. Ultimately you are 'risking your baby's life' by conceiving them. This type of coercion is unethical and I wish practitioners would stop using it. One way of finding perspective as a midwife or doctor is by reviewing absolute risk data before speaking to parents about their choices. Informed consent does not mean 'we inform and you consent'. Please stop paying lip service and instead act in line with the values NHS representatives are advertising. 

When talking to Mr T's parents I tried my best to give them perspective. We talked about how 'risk' behaved as the pregnancy continued given the occasional marginally high blood pressure reading. Stillbirth had been mentioned to them as a possible complication of waiting and I shared with them that whilst there was a marginal increase in this risk between 40 weeks and 42 weeks, the risk of stillbirth was actually highest before 37 weeks. I assured them that it was overall the most unlikely thing to happen regardless of what they decided. I often explore with parents the tendency of health care practitioners to judge risk by the worst possible outcome and how that translates into policy. Ultimately nobody has a crystal ball. There are no guarantees but there is huge potential in dialling down fear and tapping into our intuition. I tell parents to have the conviction to listen to their instincts. This type of trust requires commitment to self love and compassion for oneself because, of course, this does not guarantee that 'everything will be fine'. What it does allow for is a certain flow in life, an acceptance for the things we can't control whilst living true to one's values. These are the types of conversations we had and I always let them know that I was fully supportive of whatever they decided for their little baby.

When it came to quantifying the risk the elevated blood pressure might add, the consultant obstetrician didn't have any data to offer. I had done a quick literature search and came up empty for reliable data too. The fact that the blood pressure was never in a range where the doctor felt that medication was needed was reassuring. We had conversations around what contribution quantitative data would make to their decision making in the first place. What role did their inner knowing play? How did they feel their baby was doing right now? Whilst data is important to assess possible outcomes to the population as a whole, it can only offer so much to the individual making the decision. 

I like to give the example of Philippe Petit. You could say that he proved that wire walking between the Twin Towers is 100% safe. The sky scrapers in question have been gone for a while now but statistically speaking everyone who ever spanned a wire rope in between them and walked across it survived and yet, I wouldn't ever consider it. The decision of what's safe and what's too risky is personal and can be made only by us. Even though there is no scenario in pregnancy even remotely comparable to you walking on a wire rope in the sky without a safety net, your midwives' and doctors' language would make you believe that every single decision you make is just as precarious. In this type of noise there's immense power in learning to trust your intuition. Regardless of the odds, a thing either happens or it doesn't.  Philippe *knew* he could do it. He manifested it from when he was a little boy. He went with his gut feeling and crossed that wire 8 times on a cloudy August morning in 1974. Against all odds he lived to tell the magnificent tale. 

Our decisions have to fit into our big picture. They have to integrate with our beliefs, our values and our aspirations. It's easier to cope with the consequences of our decisions when they make sense in the context of our whole being. 

Trust yourself.  

Mr T's mum and dad held on tight. She gave birth on the morning of day 15 'post dates', not in the MLU. Unfortunately, despite the fact that her labour started before midnight of day 14 and it was clearly documented that that meant she 'could give birth in the MLU', the midwife on shift that night took the view that even though labour had started, his birthday would be after fourteen days overdue. She told the parents to drive past the midwife led unit to the consultant led unit.

What was the risk associated with driving your labouring wife twice the distance in the middle of the night during the month of February in Northern Ireland?

Thankfully they arrived unscathed and my young friend's birth was all that his parents had dreamed of, so it is a happy ending overall.

Most importantly Mr T. got to decide when his grand entrance would be.

It's been four years and 9 months since and occasionally in life things come full circle. Some people might call it coincidence but to me there's no such thing. The loop of this story was beginning to close in the evening of April 27th of this year. Just as I was having a wee after dinner cuppa, I received the most beautiful voicemail to my Essentially Birth Instagram account.

'Hi Nicole, I don't know if you remember me [...]' It was Mr T's mama. Her own path had brought her to a close friend of mine. They discovered that they both knew me and she felt called to reach out to me to thank me for standing by them when things got tight. She finished her beautiful voice message with this sentence: 

'Women really don't forget those women who fly the flag and hold the space for them, Nicole'

And so we got back in touch and as a result she held space for me last Sunday at the most beautiful event she facilitated. She told me that her boy, Mr T was super excited that I had booked a ticket. She told him how I helped her wait until he wanted to be born. And he said that that was very kind of me because I was listening to him when he didn't want to come out yet. 

'So was Nicole my friend before I was even born?', he asked.

His mama said: 'Yes, she was!'

Isn't it amazing that he knows that this was important? That he sees it as an act of friendship to let him decide his birthday? There are measurable benefits for the baby when we wait until they are ready (of course there are!). We now know that the final signal for labour to start comes from the baby. There are so many intricacies to the process and we don't even know the full story yet.

Mr T's mama tells me that this time and the conversations we had have impacted her parenting in a way that I will never know (although I think I do know). She credits her conviction to trust her instincts, to drown out the noise from other sources, to my advocacy for them. She got to know herself as she was waiting, she trusted her son to know what he was doing.

Listening to your inner voice is a lifeskill that has served me personally over the years, too. I love nothing more than witnessing young people becoming attuned to their inner knowing. You can find my step for step guide to mindful decision making in my R.O.A.D. To Birth program. It comes free with my pregnancy massage packages and you can read about it in my book.

I wish my friend Mr T and his parents only happiness. I am so happy that our paths got to cross again!