Zachary’s Birth

Zachary Emilio Kosterman was born in the wee hours of Sunday, December 27^th, 2009, at 12:12 am. He entered the delivery room screaming and kicking and perfectly red in the face, bringing us all a joyful smile and tears. A few minutes later we learned our little 31 week 2 day old Cupcake was 4 lbs 2oz and 17 inches long when he officially transitioned to Zach. But the days leading up to his birth were anything but joyful. Instead, the 72 + hours were stressful and fraught with uncertainty and guilt.

During the day of Wednesday, December 23^rd, I felt funny, but had not really attributed my feelings to anything but 'being pregnant'. My lower back ached and I felt a weight about carrying Cupcake that was different. His movements had picked up and sometimes, I found them slightly nauseating. I wasn't feeling tightening so much as just being uncomfortable. I thought: Well we are in week 31, he is getting big, I am getting big, this must be what it feels like. I got down on my hands and knees a few times to relieve the pressure on my back. When I heard people complain of "just wanting it out", I figured this is the part they were complaining about. Little did I know that, at least for me, the lower back ache, slight nausea with baby's movement, and the feeling of added weight in my belly and being uncomfortable were the signs of pre-term labor.

Christmas Eve, Thursday December 24th

We went to bed Wednesday night like any other night, but drifting off to sleep was harder as I was uncomfortable. Around 3 am the morning of Christmas Eve, Thursday December 24th, I decided that my back ache and I might be better off on the couch. I tried sleeping again on the couch but this time, the "uncomfortable" feelings I was having transitioned to pain. I had the feelings of menstrual cramps. I had asked my doctor about having these feelings and she told me they were contractions --- she said a few contractions a day was fine. Around 6:30 am however, I had exceeded a few contractions and became very, very scared. I woke Todd up and I called my doctor's service and I was connected with Mt. Auburn hospital. They did an over the phone evaluation and asked me to drink three glasses of water and to put my legs up and see if we could break the pattern. I was asked to call back in 30 minutes with an update. Before 30 minutes was up, Todd and I were considering getting in the car and heading to the hospital. When I called to give my update, the nurse did not bother getting my feedback and told me to just come in for an in-person evaluation immediately, regardless of how the last 30 minutes had gone. We packed small bags, just a change of clothes in case the evaluation left us at the hospital for the day.

We arrived around 9 am and got brought to an evaluation room. I was given a speculum exam to look at my cervix and take a sample for fetal fibronectin (fFN) testing, a marker of pre-term labor. I was also given a manual internal exam and was told that I was 1 cm dilated. Given this finding, the doctor thought it was prudent to give me a shot of beta-methasone, a corticosteroid used to develop fetal lungs over a 48 hour period, in case this was labor. I was startled, was I in LABOR?? I was told that if I WAS in labor and I was about to give birth, the best outcome would be to hold things off so that Cupcake had 48 hrs exposure to the beta-methasone.

We laid around the room waiting for the fFN results, my cramps getting stronger. The fFN test came back negative, but since I was 1 cm dilated, I was given a shot of terbutaline, a labor-slowing drug. I was observed with no change in my symptoms. I was given a second shot and observed again. No change. By now, my "cramps" were full-on, distinct contractions and I was dilated to 3cm. The doctor left the room to consult with someone else, I found out later this was the doctor who eventually admitted me at Beth Israel. When she returned, she told me that she would like to transfer me to Beth Israel just in case labor continued to progress as Mt. Auburn only had a Level II NICU, insufficient for a baby of only 31 weeks gestation. I was given the next medication in the arsenal, an oral dose of nifedipine in advance of this transfer. She told me that an ambulance had been ordered and Beth Israel was preparing for our arrival. As we were asking questions for the next few minutes about what was going on with my body and why the labor wasn't slowing, a knock on the door from the ambulance peeps, Scott and AJ, at around 2:30 pm signaled that our journey was about to take a twist.

In the ambulance from Mt.Auburn to Beth Israel, we monitored my strengthening contractions. They were regularly spaced apart and getting closer. Todd followed in Ruby, minutes behind. We arrived at Beth Israel and, of course, had to stop at the front desk with the ambulance peeps to REGISTER. Yes, full-on labor, and I had to provide all kinds of info from the gurney in between contractions before we could pass those double doors. Luckily, my transfer papers had a good deal of info so the ambulance driver pretty much registered me with me chiming in between contractions. Once registered, at abut 3pm or so, I was brought into a room, which I later found out was a delivery room. I got hooked up to a uterine contraction monitor and a baby heartrate monitor and they started an IV for a 2 g/L magnesium sulfate drip, the final labor slowing drug I received. I was given an exam and was told I was at 4 cm.

2 g/L MgSO4 was not working. Contractions got more distinct, painful, and regular. The dose was increased to 3 g/L. My contractions were still powerful. Not expecting my labor to slow, we began to meet the doctors of the team who would eventually deliver and care for our Cupcake. In between contractions, we were given a chance to meet the doctors, all of whom fully expected for us to deliver imminently. However, everyone was hoping for us that the MgSO4 slowed labor down enough to give the steroids the 48 hrs they needed to work. We were told stories that the MgSO4 slowed labor for days, sometimes weeks. We didn't know what to expect for me.

As day turned into night, I labored on with powerful contractions. I was not given any pain medication so as to leave certain options open --- narcotics could not be given if delivery was less than 4 hrs away, and the epidural was reserved for when the doctors decided that labor could not be stopped.

At around 9 pm, I was examined again. I was still 4 cm dilated. Pleased that dilation hadn't continued despite the contractions, they finally allowed me to have Nubain, a narcotic analgesic. The narcotic was magic, I was finally able to relax. And the MgSO4 also began to work better, spacing the contractions apart from 2 minutes to 10 minutes. I remember telling Todd, "I'll lay here and do this for 3 weeks if I have to, I CAN DO THIS!!". Anything to keep him in the warmth of my womb until 34 weeks, the magic number for fetal development. I was desperate.

As the MgSO4 began to work on the contractions, it also worked on the rest of me too. I became unable to get out of bed, dizzy, tired. A few hours later, one of my vital signs checks revealed that my lungs were crackling. I was moved out of the labor and delivery room and downstairs to an ante-partum room just before midnight for observation as my magnesium drip got slowed back to 2 g/ml to preserve my lung function.

Also, because I never got the Group B Strep test that all pregnant women get in the months before delivery, they prophylactically started me on an IV antibiotic drip.

Christmas Day, Friday December 25^th

Not enough can be said about the staff at BIDMC. I was always made to feel that Cupcake and I were VIPs, no question was too small, no concern too silly, no request too big. All through the night, they continued to check on me and monitor labor. Thankfully, contractions were still coming about an hour apart and their intensity had slowed dramatically. 24 hours had passed!! We'd given him 24 hours with the steroids!! Critically, at 9 am, I received a second shot of beta-methasone in preparation for the next 24 hours of his lung's development. We were all determined that he would absolutely have another 24 hours, I was hoping for much longer.

I spent the day on the 25^th monitoring myself and having Todd keep track as our family members arrived. We had an impending move that we had planned to spend the Christmas holiday preparing for. We were going to pack for 4 days straight over the holidays – we hadn't even closed on the house yet, closing was scheduled for Monday, December 28^th and we'd move that same day. Our families jumped in, with Todd's parents doing the lion's share of the packing, supported by Todd's brother Doug and my sister Mari. It was so amazing having them all there taking the pressure off of Todd so that he could focus on being in the hospital. Numerous times throughout the day, I became overwhelmed. I remember little of the day, being blurred by magnesium sulfate, but importantly, labor was still slow enough that Cupcake stayed put.

Boxing Day, Saturday, December 26^th

Over night, labor picked up. As a contraction would hit, I'd get awoken from the pain. At some point in the middle of the night, maybe 3 or 4 am, I was put back on a contraction monitor. Things slowed down during the monitoring, but picked up almost immediately afterwards. I was single-minded, get to 9 am, get to 9 am, give him his 48 hours, give him his 48 hours. As 9 am rolled around, I was contracting 3 times an hour. But the mood was palpable. I was in tears as I celebrated a milestone – we'd given our little Cupcake 48 hours on the beta-methasone, hopefully enough time to take his 31 week fetal lungs and get them developed. Every minute that passed by now was icing on the Cupcake.

Through all this -- terbutaline, nifedipine, antibiotics, magnesium sulfate, Nubain, epidural – our little Cupcake's heart rate was strong. His movements had slowed down considerably when I was on the magnesium sulfate, but now that the drip was off, his movements picked back up – setting off a contraction whenever he gave me a good firm kick.

Todd's parents and my sister came to visit around 10:30 am and watched as I continued to have contractions. By 11 am, I was being wheeled up to the delivery room. I had hoped to go longer, but the magnesium sulfate was wearing off and labor could be held back no longer.

Upstairs in L & D, we were situated and started fetal heart rate monitoring and contraction monitoring again. Contractions got closer and closer together and more powerful. We labored on, passing time in the L & D room making phone calls to family and monitoring my contractions and dilation. By 4:30 pm, contractions had picked back up to the frequency and intensity of contractions from Christmas Eve, 2 days earlier. I asked for a painkiller, and since delivery could be imminent, we opted to go ahead and get an epidural.

Getting the epidural was not fun…not only was it somewhat painful and scary, but I was contracting the entire time it was getting implanted. Minutes later, the pain of getting the epidural was all worth it as for the first time in three days, I could no longer feel the contractions. Now, I was being told by Todd and Mari when the contractions were happening. Hours passed like this as the contractions got more frequent.

Through all this, closing on our house and packing / moving was not far from our minds. Obviously, I would not be able to attend the closing on our house, which would be Monday, Dec 28^th. Luckily, we have an amazing network of friends and family. Packing was in progress as was finalizing the repairs to our old apartment in time to welcome new tenants. But the closing was a big question mark. How would I sign papers if I couldn't leave the hospital? Around the same time, my sister got word that my dear friend Amanda was on her way to the hospital. What if we were to get a Power of Attorney? I wasn't allowed to see Amanda but Mari explained the situation and Amanda, bless her heart, went off and figured out how to prepare the Power of Attorney for a real estate transaction. It gave me such a sense of relief that this would be in place prior to the closing, and I'll always be thankful for that. In the end, on Monday morning, we tried desperately to get the mortgage people to accept the POA. One of our lenders accepted it but another lender would not accept a POA. We ended up missing the closing, and the attorney for the bank ended up coming to my hospital room to get my signature. This was not ideal as I could barely sit for a few minutes at a time, but I was happy to get it done.

By 8:30 pm, I was dilated to 7 cm. Mari and Todd had Chinese food in the delivery room as I snacked on ice chips. Oh yeah, did I mention that I had only had food maybe once in the last three days?

Around 10 pm, I had reached 9 cm and Dr. Aserkoff came in and announced that it was time to deliver. He proceeded to rupture the membranes around our Cupcake and release the amniotic fluid. Even with the epidural, the pain increased dramatically. I felt every contraction powerfully, breathing heavily and focusing during each one. Todd and Mari were amazing, giving me ice cold compresses, feeding me ice chips, holding my hands, giving me encouraging words. For the most part, it was just Todd, Mari, and me in the delivery room with the nurse, Kristen, keeping a very close eye on me. Occasionally, a resident or Dr. Aserkoff would pop in to check in.

Another hour passed as my "window of pain" got worse and worse. (Epidurals don't always take effect, mine left me with an excruciating window of pain over my left hip). Shortly before midnight, the doctor decided it was time to push.

Things got crazy, the bed was repositioned, equipment was rolled up to the table, I was being given instructions on delivery. Still, it was just Todd, Mari, Kristen, and me. Kristen told me that pushing was going to be a relief from all of the pain of the last two hours. She was right. With Todd holding my right leg and Kristen holding my left leg, I pushed through three or four contractions (with each "push" really being 3 instances of 10 seconds of pushing) when I began to feel Cupcake descend. Each time, a bit of Cupcake's head could be seen. On the fifth push, he was about to emerge when Kristen told me to stop and she hurriedly got the delivery doctor, Dr. Aserkoff, and the resident, Dr. Lauren Cadish, and the neonatology team, headed by Dr. Munish Gupta, paged and in the room. The teams were assembled in moments, with another contraction coming as the doctors were still gowning up. As they continued to prepare, I began to push through another contraction. After the first ten seconds of pushing, I was told to stop and take a deep breath. A second later, Zachary was born at 12:12 am on Sunday, December 27th! I saw his full head of hair as I struggled to get a peek…7 seconds later he took his first breath and CRIED!!! The most beautiful sound I have EVER heard! I looked at Todd, who had tears in his eyes, and smiling he said "He cried! He cried!".

Zachary was grabbed by Kristen and brought over to the neonatology team where he was cleaned up and administered oxygen. Dr. Gupta said "He looks great, very vigorous!" Of course, I wanted to hop off the bed and grab him, but this little 4 lb 2oz, 17 inch long baby was so eager to enter the world that the delivery doctors had repair work to do.

Once the doctors were satisfied that he was stable, Todd and I were allowed to hold our swaddled bundle of joy. His eyes were open as he looked right at us, of course only seeing light and dark…I was struck by how cute he was, with perfect little lips and a ruddy glow. Love at first sight! He was wheeled away from us and down to the NICU.

The next few hours we spent in the delivery room recovering. I tried to will away the effects of the drugs so that I would be allowed to get up and go see Zachary. Time seemed to slow down as I waited for control of my legs and bladder to return, the pre-requisite for leaving the room. Legs – check! Bladder – still no…I asked them to catheterize me so that I could get out of there. They did and we were off to the NICU at around 2:30 am!

Zachary was resting peacefully when we got there, monitors strewn about him, an IV drip of dextrose flowing and a CPAP air flow tube strapped to his face. He was receiving some supplemental oxygen but seemed to be breathing quite well on his own. Within a few hours, the CPAP would be removed and oxygen would just be flowed near his face. We were allowed to touch him briefly before we were wheeled off to my post-partum room and my sister was picked up by Todd's dad. I fell asleep happy that he was doing so well mixed with all of the emotions that a parent of a premature child goes through: sadness, guilt, anger, uncertainty. More to come…