Gestational Hypertension & Jamison's Birth Story
Having high blood pressure in pregnancy isn’t new for me personally. Toward’s the tail end of my first pregnancy my blood pressure started to creep up, but nothing serious. My 2nd pregnancy we induced at 37 weeks for elevated blood pressure, but luckily didn’t need any medication or interventions other than an earlier induction. My third pregnancy you can read more about here, but it was a 32 week induction for pre-eclampsia. After that delivery we thought long and hard on whether or not it was medically safe for my body to endure another pregnancy. My OB said, mentally plan on this happening again because your blood pressure has gotten worse with each pregnancy, and there’s a possibility you will deliver a baby sooner than 32 weeks, but we will do everything we can to keep you pregnant for as long as possible.
Preparing your body for a high risk pregnancy
Knowing that pregnancy was something we wanted, I spent the year before getting pregnant working on my own health. I focused on exercise, gaining muscle, nutrition, healing my gut and making sure mentally I was in a place where I could handle another high risk pregnancy. For the first 10 weeks of my pregnancy I continued to do CrossFit a few times a week, and then slowly transitioned that into lower impact lifting and walking. I wanted my body to be strong to be able to endure whatever was about to come. For more ideas on how to prep your body see this blog post.
High Blood Pressure
One thing I didn’t realize (despite being a labor and delivery nurse) is in your 2nd trimester your blood pressure actually lowers! I started off in my 10 week appt with a mildly elevated blood pressure, but the sequential appointments my blood pressure lowered just as my OB anticipated they would. Until about week 20… then they started to creep up and creep up quickly. From week 12 through delivery I was instructed to take a baby aspirin. This helps with placenta development and can postpone the onset of pre-eclampsia.
From about week 24 – until delivery I was prescribed labetalol which is a beta blocker blood pressure medication. We started on a lower dose, and by the end of pregnancy I was on almost the MAX dose (600mg 3 times a day). With each Labetalol increase the side effects became worse and worse. The most frustrating side effect was extreme fatigue, lowered heart rate, and tiredness. For almost 2 months I was in bed 80% of the day because I physically didn’t have the energy to do anything else. When I would be up and about cooking a meal or tidying up the lowered heart rate would make me feel like I was going to pass out. My endurance was almost nonexistent. I was lucky to get up and make myself an easy 5 minute meal before crawling back in bed to eat it and fall back asleep. Some days I would sleep until 1 O’clock in the afternoon (14+ hours in a row) only to wake up for 2 hours and be back asleep for a 3-4 hour nap. Thankfully my kiddos were in school all day and I didn’t have much required of me until after they were home.
In terms of monitoring, I had a home blood pressure cuff that I used to check my blood pressure 4 times throughout the day. Once when I woke up, around lunch, 3pm, and then before bed. The most important thing when taking your blood pressure is to sit still for 5+ minutes before taking it and to be in the same position (sitting in a dining room chair or sitting up in bed) so that the readings aren’t skewed by your position. Be sure to not have your legs crossed and remember pain, anxiety, exercise can alter the readings. Anything that is >140/90 (either number doesn’t have to be both) is considered high in pregnancy. Any reading that is >160/110 (either number doesn’t have to be both) is considered severe. If you have 2 severe readings you should be evaluated immediately.
The week before
At 32 weeks gestation I started taking my blood pressure before bed (the same time I take my medication) and it was very high. I continued for the next 2 hours checking my blood pressure every 15 minutes knowing that my medication should kick in within 1 hour and the reading should start to go down. However, it didn’t. I had several severe range >160/110 blood pressures, my last reading before I left my house at midnight was 180/120.
I checked myself into Labor and Delivery that night and they drew labs and continued to monitor my blood pressure. Although my labs were normal, they wanted to keep me for observation because along side the blood pressures I was experiencing shortness of breath and epigastric pain (pain right under the middle of my ribs) where I felt like an elephant was sitting on my chest.
I was in patient for 36 hours where we DOUBLED my blood pressure medication to get it within a normal range, as well as repeatedly drew labs to make sure I didn’t develop pre-eclampsia. During this inpatient time we also administered Betamethasone (steroids to mature his lungs). The window for these steroids is delivery 24 hours after the last dose up to 7 days is the “ideal” time frame where they work the best. They are still helpful up to 14 days after they’ve been administered.
Babies older than 34 weeks typically won’t get Betamethasone, if it’s been a month since they were administered and your still pregnant and under 34 weeks they will consider giving you a 2nd round of steroids.
With normal labs, a stable blood pressure, and 2 doses of Betamethasone I was discharged from the antepartum unit to go home and continue monitoring myself.
3 days later I came back to labor and delivery with a 24 hour stomach bug that my girls and I all caught at the same time. My labs checked out normal and I felt better after some IV fluid and IV nausea medication and went back home to recover.
Thursday, March 2nd I went in for my routinely scheduled Non-stress test. This is just a monitoring of the babies heart rate with a blood pressure check. That morning I was having a mild headache, and a little blurry vision, but I thought it was all related to my blood pressure medication. We put baby on the monitor and after 10 minutes his heart rate was in a normal range, but he wasn’t getting excited (having an acceleration), it was just… steady. That morning I had had a good breakfast so there was plenty of nutrition and sugar for him. We tried having me drink cold water to see if that would perk him up. When that didn’t work we used the acoustic stimulator (a little buzzer) next to my belly. We tried that twice and he didn’t react (a normal baby would have a spike in their heart rate from this stimulator). We monitored for 40 minutes and he never had a big acceleration in his heart rate which meant he “failed” his non-stress test and would require more monitoring.
The nurse wheeled me down to labor and delivery where we hooked my belly back up to all the monitors and drew labs again. While my labs came back normal, meaning my kidneys and liver were still functioning and not impacted by pre-eclampsia, my blood pressure was elevated, and my neurological symptoms (headache and dizziness) + the failed non-stress test meant it was time for delivery. I was 33 weeks and 2 days along. Because Jamison was head down and this would be my 4th baby we would induce and try for a regular vaginal delivery.
Starting the Induction
Thankfully all my Braxton hicks contractions over the last few months had started to dilate my cervix that it was open enough to do a cook catheter. This is a catheter with two big balloons on it. One balloon sits above your cervix, the other sits in your vagina and both balloons are filled up with saline (water) applying pressure on your cervix from both directions. This form of manual dilation is sometimes good for an induction because it isn’t a medication and if there are issues it can quickly be removed.
Instead of using cytotec (which is a common cervical ripening medication) we went straight to Pitocin (synthetic oxytocin) because it can be turned off if overstimulation happens.
At 1pm my OB placed the cook catheter and we started Pitocin. Within the first 20 minutes the pressure from the cook catheter plus the contractions from the Pitocin were already uncomfortable, so I requested my epidural. From 1:20-1:50 I had the Anesthesiologists in the room placing my epidural. At 1:45 I had the resident in the room already asking for me to sign a consent for a c-section because for the last 45 minutes Jamison was having late decelerations (which meant he was stressed in-utero). Everything felt like it was happening all at once and unfortunately my experience as a former labor and delivery nurse I had been part of many 4th or 5th babies which resulted in a mom’s very first c-section.
While I knew we were going to try everything we could to get a vaginal delivery, I also understood that we needed to get strong enough contractions to make that happen, which meant a fine balancing act trying to not stress baby out too much with these contractions.
From 1pm-3:30 pm my nurse remained at the bedside holding the heart rate monitors in place because every time I would have a contraction the monitors couldn’t read what his heart rate was doing. Finally at 3:30pm my OB came into the room and removed the cook catheter. To all of our surprise I had dilated from 1cm to 6+ cm 70% effaced in just two hours!
This quick dilation meant that we could break my water, and place internal monitors so we would for sure know exactly what his heart rate was doing and how strong the contractions were. It also meant that my body’s natural oxytocin would kick in and create my own contractions which would hopefully speed things up.
Part of the problem of a mechanical dilation (the cook catheter) is it got me to a 6+ but it’s very common to get stuck and stop dilating for awhile which is exactly what happened. I remained the same dilation when we rechecked at 5:30 and again st 6:30pm. The lack of progress in combination with his heart rate having variables (quick dips during contractions with his heart rate down to the 80’s) meant we still weren’t out of the woods in terms of needing a c-section.
At 6:30pm we decided to start an amnioinfusion which meant adding saline back into the uterus to give the umbilical cord some more fluid to freely float in. Sometimes this amnioinfusion helps stop the quick dips (variables) from happening. We repositioned side to side a dozen times and finally at 7:30pm tried sitting up to see if that would stop the variables.
The OB on call walked in to check progress, and if there wasn’t any progress I was sure we were going to proceed with a c-section shortly. By some miracle I was completely dilated and he was very low, almost crowning. We quickly got Lance dressed (as he tripped over his outfit and shoes got stuck) and raced my delivery bed through the hallway and into the operating room. All hands on deck at this point.
Thankfully by the time we got to the operating room his heart rate was stable, we weren’t in an emergency rush to get him out, but still moving quickly because he was.. well, coming out on his own!
Once everything was set up I pushed to 1 count of 10, and his head was out, another count to 4 and he was delivered at 7:49pm.
We began stimulating his back to get him to cry and he perked up quickly and I got to enjoy 1 minute with him on me before we cut the cord and passed him off to the NICU team. Apgars 8 and 9 despite being 7 weeks early and breathing all on his own.
Placenta and Cord
It’s always fascinating to me to see after the fact the reasons why the fetal heart tracing was concerning. Jamison had a very short cord. Total it was maybe 15 inches in length which meant that each time I was having a contraction and he was attempting to descend, the cord was tugging like a leash pulling him back.
My placenta was also ridiculously small. We ended up sending it to pathology and it was in the 5th percentile for size (very very small) and had 2 infarcts (non oxygenating spots) and 2 calcifications (dead spots) on it. This, of course, contributed to his small size, was impacted by my elevated blood pressure, and it was time for him to be delivered before the failing placenta caused even more serious complications for him.
Looking back, is there anything I could have done to develop a better, healthier placenta than what I was already doing? Good nutrition, daily baby aspirin, limiting stress, etc? I don’t think so. Instead of being hard on myself for not producing a good healthy placenta, I understand that that was out of my control, and am instead so extremely grateful for the beautiful perfect little boy that was formed. If you find yourself in the same situation, don’t be hard on yourself either.
Jamison Leon Gummersall
Jamison was born on Thursday, March 2nd, 2023 (3/2/23 such a cool birthdate).
He was 4 pounds even and 16.5″ at 33 weeks and 2 days.
He didn’t need any oxygen for the 6 days in the NICU and never has had any apnea events.
Daily progress in the NICU:
Friday Day 1 – IV with TPN/heparin infusions. Sucked on his binkie aggressively that morning and started tube feeds.
Saturday Day 2: On bill lights and feeds up to 50ml. He had his first time latching for a nonnutritive feed. Lance held him for the first time.
Sunday Day 3: Increased feeds to 80ml and continued to decrease IV fluid. /
Monday Day 4: Bill level back up, and put back under lights. A little more lethargic today, but perked up and was alert when I came in.
Tuesday Day 5: His IV was discontinued. Dressed in his first outfit. Taking in all of his feeds via NG tube. Off warmer and just swaddling maintaining his own temperature. Had his first nutritive feed.
Wednesday Day 6: Lowest amount of oxygen, Put him in his first outfit. Assessed by PT to start drops and a pacifier.
Thursday Day 7: You are one week old!
Friday Day 8: Evaluated by physical therapy to start bottles. Started on the ultra premie nipple. I fed him for the first time via bottle and he looked a little like he was being waterboarded and he was very fidgety.
Saturday Day 9: Eating 0-6 ml of his bottles throughout the day.
Sunday Day 10: We did skin to skin for 2 hours, fed him his 2nd bottle and he ate 9mls and seemed to do it rather quickly and with coordination. First time for me giving him a bath in the NICU!
Depression during pregnancy
Physically it’s a lot to deliver a baby, and mentally it’s a little more taxing to deliver prematurely. I’ve shared a little of my journey on IG stories, but from November – January I struggled with pregnancy depression. It felt like waves coming in and when one wave crashed I was really low for a few days and then I would come out of it and things would feel normal and fine.. until the next crash. I tried lots of alternative things to help pull me out of it. From talking to good friends, taking time to myself, decreasing my work load, baths, meditations, affirmations, gratitude journaling, etc. Some of it helped, but the waves kept rolling in and crashing. I had a few OB appts where I could have brought it up, but around the time of the appointment I would be back to my norm and thought I was through it and just fine. It wasn’t until January that I finally came into the office in tears. My ability to cope with daily things was nonexistent. Something that shouldn’t be a big deal, like a work email would send me spiraling and crying for hours on end. Finally my OB suggested I take something for the depression.
We sat in clinic for almost 40 minutes going back in forth because I was adamant that I didn’t want to take any medication and she was trying to convince me that since all the alternative methods weren’t fully working, it would be best for me and my growing baby to take even the lowest dose of an SSRI (Zoloft). It gives you a buffer of just enough serotonin to help you cope. And would help so much during the postpartum period to prevent postpartum depression.
I was worried with my history, that delivering a premie on an SSRI would further complicate his ability to breathe on his own. What a blessing that it didn’t affect him at all! He came out crying and with no oxygen need. Even within days of starting Zoloft I felt like myself, and truthfully it has helped immensely has I go through all the hormone changes after delivery. I feel safe, I feel in control of my emotions, I am able to think clearly, and from the day I started taking it, I didn’t have a single day of crying while pregnant.
I did have a moment where I felt, weak, for needing to be put on medication but as I messaged with hundreds of you in DM’s, and seeing that I wasn’t alone in my feelings and seeing how much medication helped you, it opened my eyes that this is nothing to be ashamed of and how important it is to be aware of your mental health!