Editing Pregnancy (section)

== Fifth Consultation ==

Everything at this stage is performing exactly as expected. Without an ultrasound we have no notion of size progression etc. but the heartbeat and movement are what we expect.

There were two additions to the process at this stage:

* An RSV vaccine
* Antenatal monitoring

=== RSV Vaccine ===

For pregnancies that are 32 w or more of gestational age during September to January (inclusive), the RSV vaccine is apparently advised. In our case, Julie would be at 32 w 0 d on the 31st of January so we were a perfect edge-case for whether to receive the vaccine or not. If the mother does not receive the vaccine, the child is given the vaccine shortly after birth so this isn't a high-intensity event.

Julie got her's at Walgreens. They weren't particularly organized, their electronic systems wouldn't accept her details (though she had an appointment), and eventually she had to fill things in on paper before she got the shot. But she did get the shot.

=== Antenatal Monitoring ===

Since Julie has gestational hypertension, she will have antenatal monitoring appointments twice a week starting at 32 w of gestational age.

What they're looking for in these antenatal monitoring appointments is for foetal movement and heart performance. The things our nurse pointed out to us were specifically:

* foetal heart rate
* foetal accelerations: these are short increased heart-rate when the foetus moves
* maternal blood pressure

One thing of note is that insurance usually only covers one ultrasound a day, and since we were getting our 32 w ultrasound the same day an hour later she didn't do one for us.

The reason we had this monitoring is that we had the following risk factors:

* IVF
* Gestational Hypertension (GHT)
* Gestational Diabetes Mellitus (GDM)
* Geriatric Pregnancy

One of the things that is interesting is that Julie's blood pressure measured at these monitoring appointments was quite healthy, ranging from 117/63 to 129/73, which is much better that what we were measuring at home. The nurse suggested that perhaps the cuff isn't correct and that we should bring it in to trial it at the same time.

Another thing the nurse, Susan, pointed out is that babies at this stage have [https://www.sciencedirect.com/topics/medicine-and-dentistry/fetus-breathing Foetal Breathing Movements], a good sign for their progression. These are easier to see if you hide the heartbeat from yourself: they're the small body contractions and release like breathing. They were very cool to see.

At one of our 34 w appointments, Julie mentioned to the nurse that she was feeling a mild<ref name=mild-chest-pain/> chest pain. This led to a sequence of events that ended with her in OB triage and then in a room with an EKG device hooked up to her so they could check her heart. Everything came back absolutely normal but it doubled the amount of time it took and we got a lot of unnecessary scans.

Interestingly, this part of the CPMC facility had their blood oxygen meters set to alarm at below 95% and so they did repeatedly as Julie's blood oxygen went between 94 and 98% while on it.

One benefit of these (which go on until pregnancy) is that they are done at the same hospital as we have scheduled delivery. As a result, we autopilot ourselves to the hospital and the process to the same floor as where inducing and labour is done. We're quite familiar with the parking lot etc. as a result.

=== 32w Ultrasound ===
[[File:Ultrasound Baby Size Estimation - 32w.webp|thumb]]

Because we had an IVF pregnancy, we have to do a 32w ultrasound. At this point, there are a couple of effects that are occurring because of the risk factors.

# GHT causes intrauterine growth restriction
# GDM causes macrosomia

Essentially, the hypertension causes vasoconstriction of placental blood vessels causing less nutrients to be supplied, and the diabetes causes more sugar to be supplied. So they work in opposite directions.

In our case, the 32 w ultrasound revealed that our baby is at the 15th percentile for weight at 1690 g  ± 247 g. The consulting obstetrician said that this isn't significant on its own: the baby could just be small.

By the time I was born, I was actually about twice this at 3.2 kg. We'll go with the obstetrician, but the difference did seem concerning.
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