“A Tale of Two Births with IUGR” – with Chaya Kanarfogel

Chaya Kanarfogel tells the stories of both of her pregnancies and births. While both of her babies were born very small, her experiences delivering each of them were very different. Hear more about her first, short labor and her second C-section delivery.

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Dr. Fox: Welcome to “High Risk Birth Stories” brought to you by the creators of the “Healthful Woman Podcast”. I’m your host, Dr. Nathan Fox. “High Risk Birth Stories” is a podcast designed to give you, the listener, a window into lifechanging experiences of pregnancy, fertility and childbirth.

All right. I’m joined by Chaya Kanarfogel who was gracious enough to volunteer to come on the podcast today. Hi, Chaya. How you doing?

Chaya: I’m doing great. I feel honored to be able to share my story and to be part of this podcast that I’m such a huge fan of.

Dr. Fox: The backstory is Chaya was in our office. It must’ve been just, like, a few weeks ago, right?

Chaya: Yeah, I think two weeks ago.

Dr. Fox: Yeah. And you’re walking by and, you know, we had met earlier. We’ll talk about that. And we’re saying hello and you saw the…sort of my…I don’t wanna call it a studio because it’s just an office with, like, a microphone in it. And you were saying how you listen to the podcast and, you know, you were being very nice about it. I said, “Well, why don’t you come on?” And what was your response?

Chaya: I needed to pinch myself. I was just so excited. I tell all of my friends about this podcast. I told them I was gonna be on it. They all have to listen. You’re gonna start getting, like, a few followers.

Dr. Fox: Well, and it’s good. We can increase our number exponentially with all of your…with your many friends which is amazing.

Chaya: Yeah. Happy to contribute to this amazing podcast. It’s fantastic.

Dr. Fox: Thank you. So, we’re gonna be talking about both of your births. Your first, your daughter in 2018. So, she’s about three and a half. And then your son who is now I guess just about four months and change. Right?

Chaya: Three months and change, yeah.

Dr. Fox: Three months and change. Yes, correct. He was born in March. Okay. Excellent.

Chaya: We’ll get to the…he was a month early but we’ll get to that also.

Dr. Fox: Take us back to before your first pregnancy. So, she was born in 2018 so I’m assuming we’re talking about somewhere either 2016, 2017. Where are you in life? Where are you living? Who are you married to? What are you doing for work? What’s your story before the pregnancy?

Chaya: My husband and I were married in 2014. We were very young. We were 21, both 21 years old and we were entering our last year of college. So, you know, we were married for a few years and, you know, we decided we felt ready to have kids. I was actually in graduate school when I got pregnant and my husband was in rabbinic school. Fast forward a little bit, we actually now both teach Judaic studies in a high school nearby. We pretty much have the same job now but back then, we were both students. You know, we were working part-time but I was looking forward to this experience, this kind of bizarre experience of having a baby while being, you know, in school and my schedule was so flexible. So, I was looking forward to having this really nice kind of maternity leave that I was gonna have. We worked a lot with kids in different educational settings and we were excited to finally have a kid of our own. We felt really ready and prepared and we were just really excited.

Dr. Fox: So, he’s in rabbinical school and you’re getting a master’s in what?

Chaya: In Talmud. I was planning on becoming a Talmud teacher. I always loved teaching and I always loved learning Talmud so we were both in school. I do wanna say that it was kinda funny when I found out I was pregnant. Since we were both in school and we had the summers off, we both worked in a sleepaway camp, in a Jewish sleepaway camp and I was doing a really busy job. I was, you know, like, running around. I was logging, like, 15,000 steps a day, like, easy. And I was just running around all the time and it was actually when we were in sleepaway camp that I found that I was pregnant which was a really fun experience. I could not walk into the dining hall without feeling immediately nauseous because there was just a stench all over.

Dr. Fox: Some people have that when they’re not pregnant at summer camp.

Chaya: Yeah. It was a real challenge to eat while pregnant and feeling nauseous and not having control over, you know, what my meals were. I remember eating a lot of crackers and drinking a lot of ginger ale. Those were my main sources of nourishment.

Dr. Fox: You can get by an entire pregnancy on crackers and ginger ale pretty much. So that’s good. Tell us about your decision to do a master’s in Talmud and to teach Talmud which is somewhat, I would say, rare or unusual for Orthodox Jewish women to learn and teach Talmud. More common now than before but this is definitely not something that you see a lot of people doing.

Chaya: Yeah. You know, it’s interesting because my father is a rabbi and he’s not just a rabbi. He’s also, like, an academic scholar in Jewish history, in medieval Jewish history. So, we grew up with a lot of Torah learning around the house and my father has this set of really massive Talmuds, this whole set in our living room. And I always just kind of saw it there and, you know, in school…I went to an elementary school where it was a Jewish elementary school and the boys and girls were separated for our studies and the boys got, like, you know, really deep into Talmudic text and the girls…we were given, like, a photocopy of the page of Talmud and then, like, the principal taught the class and would just read it off to us. And I remember one time I just, you know, walked by the Talmuds in our house and I asked my dad. I was like, “Hey, can you…do you wanna learn this with me? It kinda seems like a real essential text to Judaism and I’m a religious Jew and I’m curious.” We learned one page at the very beginning of Talmud, Tractate Berakhot, and I was kinda hooked. I just was so intrigued by it. And after that, I really just pursued different schools that would really give me the most out of that.

I find myself…you know, my nature as a learner is that I’m very analytical and I really love discussion and Talmud just really lends itself to that. It’s very logic based and very nuanced. And I always loved education. I was always really involved in formal education, in camp. You know, teaching Talmud just seemed like a really good marriage of these two things that I was really passionate about.

Dr. Fox: Coming back to your pregnancy. So, you’re puking all over the summer camp…

Chaya: I literally did. I literally one time puked on the side of a bunk. I went for the chicken at dinner and that was a mistake and then…no kids noticed [inaudible 00:06:24]

Dr. Fox: I guess when you found out you were pregnant in camp, you didn’t have any major issues conceiving. And did you have any concerns going into pregnancy, either, you know, physically or in terms of, you know, anything else?

Chaya: I felt okay with it. Like, I had some concerns just, you know, about actually giving birth but no major concerns. You know, no history in my family of difficulty conceiving or miscarriage related. I was just really [inaudible 00:06:52]

Dr. Fox: Oh, hello. Good morning.

Chaya: See, now you got to hear the baby. Baby Itai. [inaudible 00:07:00]

Dr. Fox: Baby Itai. Well, he’s on the podcast too. He’s a guest on the podcast. Excellent. So, we’ll have the two of you. No problem. How did the pregnancy go?

Chaya: It was really a very normal pregnancy throughout. I was very nauseous as I said the first trimester but I figured, you know, I was in camp, not in my own bed. Once I would get home, I’d feel better and I did. And after the first trimester I felt a lot better. Things were really normal until…I think it was week 37, the beginning, very beginning of week 37. They had noticed, you know, on my ultrasound that the baby was looking small and they kept saying, “Oh, the baby’s small but healthy and everything looks fine.” Until it got to a point where, you know, my doctor thought, “The baby’s looking really small. I want you to go to get an ultrasound at the hospital.”

Dr. Fox: Right.

Chaya: You know, just a higher-grade machine and we could check, you know, the measurements they got in the office against the measurements at the hospital. And that was when I started feeling a little nervous. And it was a combination of feeling nervous and also just, I don’t know, kind of, like, annoyed that I had such a sweet pregnancy and I was so close to the end and now all of a sudden, I was being told that I was gonna have to come in for all these ultrasounds and have really close monitoring because the baby was looking really small. And also, that uncertainty of, you know…ultrasounds are not always super accurate so, you know, is this all really just being very cautious or is this really necessary. So, some frustration I guess too.

Dr. Fox: Right. The analytical Chaya is coming out.

Chaya: There you go. You’ll see a lot of that throughout.

Dr. Fox: The Talmudic dispute between is which way does the growth go? Is it good, is it bad, is it wrong, is it right? Okay. Were you…what was the messaging you were getting? Were you getting the messaging, like, there’s a problem or, “Hey, we’re just looking at this and we’re just gonna be cautious.”

Chaya: Yeah. It was more of the latter that my doctor just wanted to be cautious and even the fact that the baby was looking small wasn’t necessarily any indication of there being anything wrong. You know, both…and certainly not with the baby and potentially not even with me. You know, it could’ve just been that I was meant to have a small baby, that this baby in particular was supposed to be a small baby always and not…you know, this was just the size of my baby and some babies are extra big and some babies are extra small. I wasn’t being given any reason to be concerned. I do remember that after I found out that the baby, you know, was in…you know, below the tenth percentile, I called my mom and she always liked to remind us that my brother-in-law who, you know, is certainly an average size person…you know, a little bit tall I would even say, that he was 2 pounds when he was born and he…look, he turned out fine.

So, you know, like, I felt a little reassured by that and I knew it would pass but I was just kind of…I was a little thrown off because my whole pregnancy had really been so…just everything was really without a hitch and I felt really lucky and I was just kinda like, “Hey, this wasn’t how my pregnancy was going this whole time and I’m so close to the end.”

Dr. Fox: And did they recommend inducing?

Chaya: They had mentioned inducing maybe, like, around 38 weeks. They said they would come back to it and it would be based off of what they saw in the ultrasound because at that point I had only had one ultrasound at the hospital. They were telling me, the doctors were telling me, you know, come in twice a week, you know, for the rest of your pregnancy until we induce you or until you go into labor. You know, whichever one we think would be more appropriate.

Dr. Fox: Right. And what ends up happening? So, you did not get induced. I guess you went into labor.

Chaya: I actually did get induced at 37 and a half weeks. It was a Friday night and I started feeling contractions that were pretty consistent. I remember telling my husband…and this is our first kid so my husband was freaking out. And I said, “You know what? It’s okay. I’m just gonna [inaudible 00:10:38] a little bit and I’ll see.” And I called my doctor and the doctor said, you know, “When the contractions are every four minutes or five minutes or whatever it was, you know, then you call me,” because it’s still so early and I wasn’t in, like, pain or anything.

Dr. Fox: Right.

Chaya: I was just feeling the contractions. So, it was Friday night and we’re Sabbath observers so we couldn’t just, like, sit down and watch TV to get our mind off of it. We had to actually think of things to do to just not think about it and just get on with things. So, my husband and I love playing board games. We’re very competitive about it. And I beat my husband harder than I ever beat him in any game we’ve ever played that night because he was just freaked out.

Dr. Fox: What game did you play? Do you remember?

Chaya: It was a really random game. I think we still have it. It might’ve been Settlers of Catan. It was something like that. It was…

Dr. Fox: Oh, all right. That’s a Fox kid special, Settlers of Catan. Yeah.

Chaya: Oh, boy. Oh, boy.

Dr. Fox: Yeah.

Chaya: Yeah. We were, like, even, like, [inaudible 00:11:31] tracks with these board games like…oh, no. Now I remember. It’s called Seven Wonders. See how you haven’t even heard of that? No. Because we’re…that’s how much we were into our board games before…obviously, before we had kids.

Dr. Fox: Yeah. When you had time to have board games. Okay.

Chaya: Yeah. So eventually we went in. It was, like, very early in the morning when we finally went into the hospital and they checked us in and then we tried to sleep and I was still feeling the contractions and then by the morning…I would say, like, around 10:00, 11:00 a.m. my doctor came in to check on me and she said, “You know, listen. It looks like you’re in very early labor and your contractions have actually kind of petered out. But, you know, if you want, because your baby was looking so small and because we were planning on potentially inducing you anyway, I can just induce you today.” So, I had to make that decision. I remember I really wasn’t sure what I wanted to do. And I didn’t mention this before but I did have a doula who I was using for that birth. She wasn’t at the hospital yet but she was actually on her way at that point. I ended up not even calling the doula to ask for what she thought about this decision. I just kind of asked the doctor and I asked one of the labor and delivery nurses there. And this is at Englewood hospital and I remember the nurse said…so I said, “What do you think I should do?” And the nurse said, “Listen, this is Englewood hospital. If you were in the city, your doctor would’ve already sent you home. Nobody has time for that. But you’re in Englewood so…”

Dr. Fox: This is…we’ve got plenty of time here. It’s all good.

Chaya: We’re…everyone’s here. We’re all just hanging out. So why not go through it?

Dr. Fox: Where were you living at the time?

Chaya: We were living in Riverdale so, you know, 20 minutes over the ridge, yeah. The way that my doctor proposed it to me was that she thought I would likely go into labor naturally in the next few days. She kind of seemed to be in favor of inducing me in the way she presented it. You know, she said like, “Listen, you can sit around and wait the next couple of days and just, like, kinda wait for things to happen or you could just get it over all with. Like, and you’re already here and…” I don’t know. So, it didn’t seem like there were any concerns on her part for the health of the baby. And yeah, and especially because the baby was so small that, you know, it seemed like the baby might be better on the outside than the inside so why not.

Dr. Fox: Right, because you could’ve made a decision theoretically to induce two days earlier, I mean, just for the growth. There’s a lot of leeway with these decisions. Were you planning on an epidural in labor? Were you planning on not having an epidural and that’s why you had the doula coming?

Chaya: So, I was planning on getting the epidural. I wanted a doula mainly just to help alleviate my own anxiety around birth and to feel like I understood everything that was happening around me and that there was someone whose job it was solely to just attend to me and help me understand what was happening because I know that, you know, doctors and nurses…you know, as helpful as they can be, they have a lot of patients and there can be a lot of things happening potentially, you know, when you’re giving birth. So, we met with her beforehand and she kind of gave us, like, a lot of birthing education and based off of her recommendation, I wanted to get an epidural and I knew I wanted that but I wanted to try as much as I could to push off the epidural for as long as I could. Kind of, like, straddle that tricky balance between waiting to get the epidural and not being able to get it at all. You know, I kinda wanted the best of both worlds. I didn’t want the pain of birth but, you know, based on what the doula had talked to us about, it seemed like there are instances in which she had seen that epidurals could push…you know, could elongate the labor and elongating labor could lead to further issues.

And, you know, it’s funny because my main, you know, goal that I wanted to avoid was I wanted to avoid a C-section. That’s what I wanted to avoid at all cost if I could. That was what I felt comfortable with. I wanted an epidural, didn’t want a C-section. So, I wanted to kind of see how far I could get along in the labor, an active labor without the epidural until I was ready.

Dr. Fox: Did anyone else know you were in the hospital besides you guys, your doula and your doctors, your doctor?

Chaya: Yeah, so it’s funny because, you know, throughout my both birthing experiences, my religious observance completely played a role in it and in this instance, I was actually really happy that because my husband and I are both Sabbath observant, we weren’t using our phones. So, no one knew that we were there and it was just the two of us. There was no one calling asking like, “What’s happening?” So, it was actually really, really nice, yeah.

Dr. Fox: Was it weird to drive to the hospital?

Chaya: We actually got an Uber. It was, you know what, it was weird to use my phone and the doula also is Sabbath observant so when I called her the first time, I was like, “I think this is okay. I’m pretty sure.” And it happens to be my husband and I are both pretty well versed in one of these…in Sabbath, Sabbath law because of our [crosstalk 00:16:13]

Dr. Fox: Yeah, but, you know, when the pressure’s on, it’s different. It’s different when someone asks you and you sit and you contemplate and you, you know, pontificate and give an answer versus, you know, when you’re up at the plate and they’re throwing 100 miles at you, it’s different, you know. You could freeze.

Chaya: Yeah, that’s fair.

Dr. Fox: What do I do? What religion am I? Oh, my God.

Chaya: Actually, I think we had also…because we had anticipated the possibility, we kind of did our homework beforehand of, you know, it happens to be that Jewish law actually is extremely lenient when it comes to breaking Sabbath laws for pregnant women.

Dr. Fox: Sure.

Chaya: Talmud actually talks about that anything that someone can do to help alleviate any pain related with labor…not even life-threatening pain, just, like, pain or discomfort even…

Dr. Fox: Yeah, yeah. Lighting a candle or, you know, all that stuff. It’s…yeah, it’s amazing. It’s great. That’s why doulas are, you know…that’s when observant doulas…game on. She’s in, you know.

Chaya: Totally, totally, yeah.

Dr. Fox: All right. So, you’re there and you’re in labor. Are there…you know, they’re augmenting or inducing your labor. And how did that go?

Chaya: Right. So, the doctor broke my water. Then it was, like, around 11:00 a.m. I remember. And then gave me Pitocin right away.

Dr. Fox: Sure.

Chaya: And as soon as I got the Pitocin in, I felt this contraction that was pretty intense. And for about an hour I was just doing what I could to get through those intense labor pains on my own without, you know, without the epidural. Again, I wanted to see how far I could get without it to, you know, keep that labor as short as possible. And then it was, like, you know, the angel comes in. At the end of that first hour, my doula came. And I always say I only got through that second hour of active labor because of my doula. You know, she gave me the birthing ball, she showed me different positions and she had some music, like ska music and then she asked me what kind of scent I wanted in the diffuser and I said lavender. It was amazing. At that point, you know, we…I wanted to see how far dilated I was and I wanted to be checked. The nurses were very hesitant and very, you know, opposed to checking just because my water had broken. But, you know, my doula really helped me to, like, you know, advocate for myself, to ask, “Please, can you check me? Please, can you check me?”

Dr. Fox: And the baby’s small so you could be a lot more dilated than they would’ve thought.

Chaya: Two hours active labor, they did not check me. They wouldn’t check me. They refused.

Dr. Fox: So, so much for you advocating for yourself. Okay.

Chaya: So, no. I really tried. I really tried. I know. In my mind, I was like, “I won.” No, they refused. So, then I said, “Okay, you know what? I’m gonna go for the epidural.” And then I guess just check…so they gave me the epidural and then right after the epidural they checked me and they said, “Oh, we’re ready to push.”

Dr. Fox: Oh, wow.

Chaya: Yeah. So, it was two hours of active labor and I was ready to push. I remember there were about, like, 15, 20 minutes between when I first got the epidural and when I started to push that my husband and I just had this really relaxed, you know, few minutes. My husband was getting all emotional and I was like, “Why are you crying? I’m the one in labor.” But it was all good.

Dr. Fox: Oh, that’s so sweet. He’s crying because he got killed in the board game. So, let’s go. Monopoly, right here.

Chaya: For sure, for sure, yeah. And then I pushed for about 20 minutes and my daughter was born and she was 4 pounds, 15 ounces so, so small.

Dr. Fox: There are some upsides to a small baby. Geometrically, it’s better.

Chaya: Well, right after I pushed her out, I turned to my husband and I said, “My sister-in-law did that two times in a row with twins so how did I…how was that so hard for me with just one?” But even under 5 pounds…

Dr. Fox: So she was small. What was the estimated weight, you know, based on what they think she would be?

Chaya: It was within that range. It was under 5 pounds.

Dr. Fox: Got it.

Chaya: You know, high four or something like that, yeah.

Dr. Fox: And when she was born, were you worried at the time that there would be…you know, that she would be healthier, she’d have to go to the NICU or something because she was small or were you pretty confident like, “Everything’s going okay. It’ll be fine.”

Chaya: Yeah. I hadn’t really thought about the NICU and I was concerned that she was small but I don’t know. I just…I guess I didn’t know what I didn’t know and I just had a feeling she would be okay and I, you know, was focused on giving birth and…so I wasn’t really so concerned. And it turned out that she actually…she had a really high Apgar score because apparently little babies can do that because they’re just, you know…and she was 37 and a half weeks so, you know, she was, like, really…she was really moving and screaming and she was great. She had a little bit of jaundice when we were in the hospital and I remember they put her under those phototherapy lights.

Dr. Fox: Yeah. The suntan.

Chaya: Yeah. And it was toward the end of our stay in the hospital so I remember my husband and I, we…there was a moment where we were a little concerned are we not gonna leave the hospital with her. And we were…you know, we were sad she had to go under the phototherapy lights and we were so emotional about it. And then it turned out, you know, I think we stayed an hour extra so she could be under the lights and then she was fine and she was, you know, released from the hospital with us.

Dr. Fox: And this was on Monday I assume. Right? If you delivered Saturday, so you went home on Monday.

Chaya: Yes. Sure, yeah.

Dr. Fox: And so, if she was born early afternoon, I’m just doing the math, it was February. Shabbats probably ended around 5:00 to 6:00. So, there were several hours where it was just the three of you before anyone knew.

Chaya: Yes, yeah. It was this blissful experience. I mean, I say in general about [inaudible 00:21:24] Sabbath that, you know, turning off my technology…I would be a seven day a week tech addict if I didn’t have Sabbath but it was just…it was amazing. It was so nice to just, you know, be a new family, having those moments together, nobody’s visiting, nobody’s, you know, even knocking on the door aside from the nurse to come check me. It was beautiful.

Dr. Fox: And what did you name her?

Chaya: We named her Avigaea. She was named after my husband’s grandfather and the theme of Avigaea was always that, you know, she’s small but healthy. She’s just small, you know. She’s just a little girl. We were just so, so happy. And, you know, it felt like I had gotten really everything I have wanted out of my birthing experience. I had gotten epidural but I had also had a really short labor. And the baby was totally healthy and, you know, it was like…everything worked out amazingly.

Dr. Fox: Yeah. It was…listen, it’s a great story. It’s a big win. So, let’s jump to your second pregnancy. Right, so the one that you just delivered baby Itai. So going into the second pregnancy, were you concerned about getting pregnant again or were you like, “Oh, first one was amazing. Let’s do it.”

Chaya: You mean, like, in terms of getting pregnant or having a second kid?

Dr. Fox: All of the above. You can answer that any way you want.

Chaya: Yeah. I was totally confident. And, you know, in the back of my mind, I was thinking…you know, the doctors had always said, “Well, we don’t know why Avigaea was so small. You know, maybe she was just meant to be a small baby.” And, you know, I saw her. I was like, “Okay. She’s, like, little, petite, you know, kiddo.” You know, she’s average size now and she turned out totally fine and I have no reason to believe why, you know, things wouldn’t, you know, be the same or…I was kind of even expecting that, you know, this baby would be bigger. I just had a sense. I was like, “Oh, you know what? Everything’s gonna be totally fine. Nothing to worry about. This is not a big deal.”

Dr. Fox: Right. And this was the pregnancy where we met, basically?

Chaya: Yes. From the get-go, though, it was certainly a different type of pregnancy just because I had had that conversation with Avigaea being so small that my doctors really wanted to monitor me from the beginning and send me in for ultrasounds more regularly and keep an eye on the birth of the baby from much earlier on.

Dr. Fox: Right.

Chaya: By the time I met you…and I think I said this to you even. You were the one who told me, “You know, you’re gonna start coming in now for ultrasounds twice a week.” And I don’t remember how early that was on in my pregnancy but it was daunting. I think I even said this to you on the spot. I was like, “Whoa. Like, this is a fulltime job.” I mean…

Dr. Fox: That wasn’t prophylactic. That was once he was already measuring very small, you know. Because he was measuring, I mean, pretty small. So that was, you know…and again, like you said with the other one, looked healthy, everything looked fine. Again, most likely nothing’s going on. Just a small baby. But because it was, like, early enough and sort of profound enough, we like to check pretty closely just to make sure everything’s okay. And yes, it is at least a part-time job to come in twice a week but, you know…plus, you’ve got a kid at home and you do have a fulltime job. So, it’s a lot, absolutely. And there’s also the holidays were going on.

Chaya: Yeah, yeah. And…

Dr. Fox: There was a little bit of COVID I think still happening here and there, you know.

Chaya: Yeah, yeah. Towards the end of my pregnancy, it actually ended up being three times a week [inaudible 00:24:38] because I was also seeing my OB for just those regular check-ins. So, it felt like a lot but again, you know, the baby was measuring small and then I think at a certain point, you know, it seemed like, “Okay, the baby’s just on the cusp of being too small so we’re in the clear.” And then again it was like, “No. Baby is really, really small.” It’s funny because I remember with Avigaea that…I don’t remember exactly how much weight I had gained but I remember feeling pretty big by the end of the pregnancy and thinking, “Where did all that weight go to? This baby’s tiny.” So, this time I, you know, was kind of a little bit more mindful. I almost feel like I need to gain that much weight. And people would always comment to me like, “Whoa, you’re this far along. You look so tiny.” I was like, “The baby’s actually really small.”

Dr. Fox: By the way, there’s nothing that can be gained by telling a pregnant woman how she looks, right. You say, “You look really big.” It’s awful. You look really small. It’s awful. Like, just all you should say is, “You look great. Everything looks perfect.”

Chaya: Yes, yes. You’re glowing. You look amazing, yeah.

Dr. Fox: Glowing, you’re…I mean, because people think it’s, like, a compliment to say, “The baby’s looking small.” And frequently it’s like, “Oh, that’s so nice you didn’t gain weight.” And you’re like, “My baby is small.” You have to come three times a week because of that.

Chaya: Yes, my baby is small and I have a lot of issues and you’re [inaudible 00:25:50] thank you so much. Thank you for reminding me.

Dr. Fox: Yeah, this is a good lesson for our listeners. You look great. That’s it. That’s all you gotta say. Don’t comment on the size. Oh, my God.

Chaya: You seem so happy and excited to have a baby. I’m so happy for you. Yeah.

Dr. Fox: How did it play out in terms of, you know, labor and delivery?

Chaya: So, with Itai, I was going in, like I said, many, many times, it felt like, getting these ultrasounds. And around 35 weeks the doctor had noticed that the fluid was looking a little bit low. It wasn’t too low yet. It was just that the fluid was dipping, starting to dip. And two, I don’t remember which doctor once said at Englewood hospital but one of the doctors said to her credit, as much as I ended up being taken by surprise a little bit, she did warn me. She said, “You know, any time you come in, we might say the fluid is too low, you need to be induced, you know, today.”

Dr. Fox: Right. Pack your bags.

Chaya: Yes. So, I should’ve heeded the advice about specifically…she should’ve told me actually, specifically, “Pack your bags,” because I did not pack a bag but in my mind, I always had the awareness that every time I go in, you know, the news they could deliver to me at the end is, “You’re having this baby today.” So, when I went in for my 36-week ultrasound, it was in the middle of the Passover holiday and I remember that morning I told my mom, “Yeah, every time I went in, they’re like okay, the fluid’s looking low it’s normal.” So, I was like, “Okay. It’s gonna be like that this time too.” And I came in and I remember we were staying with my parents and I told my mom that morning, “You know, could you watch my daughter Avigaea. I’ll be back in, like, half hour or 45 minutes tops.”

Dr. Fox: Tops.

Chaya: And…tops, tops. Little did I know then that I would be home I think five days later. So just a little bit longer than 45 minutes. I didn’t even say goodbye to Avigaea. I kinda just, like, went right out. You know, I didn’t want her…I just, you know, snuck out. I didn’t want her to notice. My husband actually went to the DMV because we’re…since we both teach in a Jewish school, we were both off from work that day and he had to take care of something at the DMV. So, I went to the ultrasound and…

Dr. Fox: I just figured it was sort of in solidarity. If you might have to go into labor, he’ll do the DMV because that’s the only thing that’s painful as labor. He should’ve gotten a doula for the DMV to help him. The ball and the lavender would’ve been great.

Chaya: It actually was. It was a very stressful experience but it was…they were being very unhelpful in particular that day. So, it was already, you know, a rocky start for both of us. So, I went in and the doctor says like, “Listen, you know, the fluid has gotten, you know, below what we’re okay with and you’re gonna have to be induced today.” So, I took a deep breath and, you know, I felt like, “Okay. I was kind of expecting this, you know. Somewhat, I knew that this was a possibility. And, you know, the doctor said, “Okay, you’re gonna go to your OB’s office and your doctor’s gonna check you and then give you more instructions. You’ll probably come back later tonight to get induced.” I said, “Okay.” And I, you know, started driving to the OB who…the office was, like, you know, a 10-minute drive in New Jersey. And as I’m driving, I get a phone call and it looks like Englewood hospital is calling me. And so, I answer the phone and it’s the doctor I had just seen and she says, “I’m so sorry. There’s been a miscommunication. You need to go to labor and delivery right now.” Like, I was in the middle of driving. I was like, “Okay.”

Dr. Fox: Meaning, we didn’t need to send you to a doctor’s office. You should just go into labor floor because they’re definitely inducing you either way. Why make the extra trip?

Chaya: I guess so and that was, like…it was just, like, the immediacy of it.

Dr. Fox: Yeah.

Chaya: Stop what you’re doing, turn your car around, get back to the hospital.

Dr. Fox: Do not pass go. Do not collect $200 as you may say. Okay.

Chaya: So, at this point, I was starting to get a little nervous because I was like, “Okay, like…” You know, I thought my dad was now gonna be, “Okay, I’m gonna go to my doctor. We’re gonna make a plan of what’s gonna happen tonight. I’ll go back home. I’ll pack that bag. I’ll just come back.” And instead, I’m just being told…I’m by myself right now. I’m being told to go to the hospital to deliver my baby. Like, what’s happening? And I called my husband right after and I said, “Honey. Yeah, leave the DMV. Stop what you’re doing. You gotta come here.”

And then I also called my doula and I was really so grateful that I had a doula in this experience even though as you’ll find out my experience with the doula was…the rule that my doula had this time was very different but the doula said, “You know, tell your husband to stop off at home, pack your bag, take his time. We don’t know when the doctor’s gonna get there.” You know, in my mind, I’m thinking like, “This is an emergency. They’re telling me my baby is in such danger that I have to be in the hospital right now in the labor and delivery room.”

Dr. Fox: Sometimes it’s logistics. Sometimes it’s like there’s a room open and if you don’t get it now, you’re gonna be waiting, like, 12 hours in a chair. So sometimes…it’s not always a medical thing. It’s sometimes just like, “Let’s do this. I have a spot.” Like, you know, it frequently happens that way.

Chaya: So, I felt a lot calmer after speaking with the doula. Like I said, it was also…it was Passover so I was immediately thinking about the food. I was like, “We can only have matzo and kosher for Passover things. And I gotta send my husband to the grocery store.” You know, so I told my husband. I was like, “Go to the grocery store and just buy us a bunch of food because I don’t know what we’re gonna eat in the hospital and I’m hungry.” So, my husband took his time which I wanted him to. He packs the bag and food. And eventually he came. When I got to the hospital, I was feeling a little bit better. I called my doula again and we just, like, kind of talked things out. She really just helped me calm down a lot which was amazing. I ended up sitting in the hospital for a couple of hours by myself. I watched “Shtisel” which, if anyone hasn’t seen that, it’s an amazing show on Netflix about an ultra-orthodox Jewish family in Israel and [crosstalk 00:31:40]…

Dr. Fox: What season did you watch?

Chaya: Oh, the new one. You gotta watch the new one, yeah.

Dr. Fox: I just finished it last week. It’s awesome.

Chaya: It’s amazing. And I had been saving it for, you know, when I was gonna be in the hospital. I knocked out the whole season in, like, one day, just [inaudible 00:31:54]. So I was in that hospital. I had, like, one of the first appointments of the day at the ultrasound. So, I was in the hospital at 9:00 a.m., left for a couple of minutes to drive and then turn around and then I was waiting in the hospital. My doctor came at…I think it was 7:00 or 8:00 p.m.

Dr. Fox: Whoa.

Chaya: So, I was sitting at the hospital for hours and hours.

Dr. Fox: And not getting induced at that time?

Chaya: Not getting induced.

Dr. Fox: Just chilling. Got it.

Chaya: So yeah. At about…I think it was, like, around 3:00 p.m. and I asked my nurse…you know, I asked earlier, “When did the doctor say he was coming?” And she was like, “Oh, we don’t know yet. We can’t get a hold of him.” So, I…around 3:00 p.m. I called my doctor, my OB’s office and I said, “Hi, I’m sitting in labor and delivery, when is the doctor coming?” And it was really frustrating because the doctor…my OB had said, “Oh, you’re in the hospital right now?” I was like, “Yeah. Yeah. I was told to come here.” And he said, “Well, you know, I think there was a little bit of a miscommunication because, you know, it’s not, like, an urgent thing and I can’t come until this evening after I finish seeing my patients.” So, I was pretty frustrated at that point and I was already admitted. We just sat there for a few hours. My doula ended up saying, “You know, yeah. It sounds like the doctors were kind of, like, trying to pin this on the other one. You know, this one said this thing, this one said that one.” So, it just seemed like there was somewhat of a miscommunication but, you know, in retrospect, that miscommunication between the doctors, it was really significant for me actually. You know, I didn’t say goodbye to my daughter, you know, before running to the hospital. I ended up having a C-section and I was in the hospital from Tuesday until Sunday night. Yeah. So, I was in the hospital for a good five days and for that first day, you know, I was just sitting there, really just sitting there. So that was very, very frustrating.

Dr. Fox: Yeah, that is frustrating. That’s odd. Because yeah, I mean, like you said, it’s sort of…you know, the situation you’re describing did not sound…again, it depends on the exact circumstances of what they see on ultrasound and this or that but let’s assume it wasn’t, like, emergent, then yeah, you generally do have time to go home, pack your bag, do this and then come back. And I don’t know. Maybe it was that they were just trying to hold a room. I don’t know. It sounds…it’s hard to understand because that’s unusual. It’s not like anyone wants you sitting there all day. So, I don’t know what the…yeah, I don’t know. That’s odd.

Chaya: Right. Yeah, it was just hard because I felt like I was missing information that I really wanted and…

Dr. Fox: Yeah. Sounds like several people were.

Chaya: And yeah. Yeah. So, my doctor came and he administered Cervidil, [inaudible 00:34:19] right in my cervix and to see if contractions would start on their own. And I did feel some contractions a couple of hours later. I was not dilated at all, you know, when I first was admitted and then the nurses kept, like, coming into my room and at first they were saying, “You know, we need you to move positions. We keep losing the baby’s heartrate. You know, we can’t see it.” And I thought…

Dr. Fox: Yeah, there’s the troublemaker.

Chaya: Yeah, yeah. And they said, “Everyone’s watching your monitor because this baby’s giving us so much trouble.” And I thought like, “Okay, this baby’s just excited to come out. I don’t know.” I didn’t necessarily think anything was wrong per se. I just thought, “Okay. Like, you know, they keep repositioning me, I guess. Whatever.”

Dr. Fox: Yeah.

Chaya: It was at 2:00 a.m. I think maybe I got, like, an hour or two of sleep but about 2:00 a.m. they said, “Okay. We…the baby’s heartrate is just too low.” I know Itai, it’s so hard for you. The baby’s heartrate is just too low and you’re gonna need a C-section. And, you know, they brought a phone to me and they said, “You know, this is your doctor on the phone.” And he, you know, he also told me about the C-section. So, I said to him, I was like, “Is this the only option?” Like, you know, like, I had said before, in my first…when I had my daughter, my first birth, my biggest goal by far was to not have a C-section. I wanted to avoid that.

Dr. Fox: Right.

Chaya: And so, I asked him, I was like, “Is this the only option?” He was like, “Well, yeah. Your baby’s heartrate is too low and we want him to be okay. And, you know, that’s the best thing for his health so yeah.”

Dr. Fox: On the one hand, you’re sort of a setup for that because, you know, when the baby’s very small, 36 weeks and the fluid is low, it’s really suggestive that there’s an issue with the placenta, that it’s not giving the baby enough nutrients, not enough water. And in that situation, definitely you’re at increased risk in labor of the heartrate dropping. And that’s sort of like, you know…so we would say, “You know, listen. In this situation we’re gonna induce but there is an increased risk of a C-section for that reason.” But on the other hand, you already had a small baby and everything was fine, right. It did not seem to be a big issue with the placenta and your delivery was so smooth the last time that you don’t wanna, like, freak someone out and say like, “Oh, you’re gonna have an increased risk of a C-section.” So, it’s sort of a balance. It’s, like, you know, hearing how your story played out, like, it’s like connecting the dots for me. Like, it makes a lot of sense. Oh, yeah. You know, small baby, like, sort of profoundly small, fluid is low, getting induced, heartrate dropping. It’s like yes, yes, yes, yes. But, you know, I think I might’ve mentioned to you potentially saying, “Hey, you know, maybe there’s an increased risk of a C-section.” But I would’ve also guessed it’s likely gonna go perfectly fine because it happened fine the first time and so I wouldn’t make too much of it, again, before we started. So, it’s just an interesting thing that it went so differently. But yeah. This one does not sound like just a small baby. It sounds like bad placenta.

Chaya: Right. And I was just in total shock about the C-section happening. It was just never an outcome I had considered. I’m sure many of the women who have given birth listening can relate to this but that company Frida Baby, they have all these, like, really cool, awesome things for new mothers and babies and infants. And, you know, I ordered this really cool, multipack that they didn’t have when my daughter was born with all the things you need after you have the baby with the ice packs and the peri bottle and all these, like, really cool things for having a vaginal birth. And of course, I ordered it because I’m like, “Of course I’m having a vaginal birth. Like, there’s no other option.” And I called the doula also and this was at 2:00 a.m. and I said, “I’m getting a C-section.” And she said, “You sound like you’re in shock.” And I said, “I am.”

Dr. Fox: Yeah, I was gonna ask you how devastated were you with that? Was it like horrifying or was it just, like…just so surprising?

Chaya: It was so shocking. It was so shocking. I just…I had never…really never considered it and I didn’t…even, you know, as things were happening with the heartrate and things like that, like, I never had thought about it. So, you know, in my mind, my only experience with having a child was having a vaginal birth and that was something I really wanted. I’ve also never had, like, any kind of surgery before and, like, I just could never, you know…when it’s, like, an emergency and you’re being told, “The health of your child is at risk. You need to have this.” Yeah, it was very scary. It was really scary.

So, you know, I was confident that it was all gonna be okay in the end but in that moment…like, it’s 2:00 a.m. and you’re being told that you need to have a C-section. Also, the fact that things escalated so fast. You know, I had been in that hospital for 12 hours sitting there relaxing, watching my “Shtisel” and then all of a sudden, you know, a few hours later they’re, you know, running me into the operating room. You know, it was just…it was, like, a real, real quick transition. I remember, like, shaking so much when I was on the operating table, you know, probably because it’s freezing in that room but also, I was just so scared. And I think…like, it was also in the middle of the night so I…there were, like, people there. I didn’t even know what was going on. I remember at some point being introduced to someone, some kind of doctor and then I found out later it was the second, you know, OB that was in…surgeon that was in the room. When they did take out my son, you know, they brought him right next to me, like, right next to my face and I gave him a kiss and it was just so different from my other birthing experience. I was just…like, I didn’t know what to do. They took him and they said he’s very small and they have to take him to the NICU. And the NICU I actually anticipated because, you know, the last ultrasound when they measured my son, it looked…they said he was certainly under 4 pounds. And I remember, like, googling, you know, how small are babies admitted into the NICU. You know, how big would my baby need to be to avoid the NICU? I mean, you know, all the things, you know, that I read online in my random googling was that, you know, usually, if a baby’s under 4 pounds, no matter what they’re going to the NICU.

So, I had mentally prepared myself that, you know, the baby would be in the NICU. I didn’t know for how long. So, they took the baby to the NICU. And then after that, my doula came. And, you know, it sounds silly because it’s like…okay, the doula’s there after we’ve had the C-section. Like, what help is she? I had actually…I remember I had been sitting in the hospital all day long and I was starving. And by the time my husband came, I was just so, so hungry. They had brought me, like, a couple of kosher Passover snacks but, like, not really much. And so, when my husband came, I just, like, devoured whatever junk he threw at me. And I remember there was, like, these chocolates that I was just…I was scarfing them. And I think, like, I…you know, I asked [inaudible 00:40:44] to check with my doctor that it’s okay for me to eat and my doctor’s like, “Yeah, it’s fine.” And I was so nauseous after my C-section.

Dr. Fox: Yeah.

Chaya: So nauseous. So, when my doula came, she was, like, the one holding the barf bucket and, like, talking to me and giving me, like, peppermint oil to smell. And my husband was just dead tired. So, it was actually really helpful to have her there because, you know, my husband needed someone to lean on and I needed someone to just, you know, tell me I was gonna get through all this vomiting. But yeah. I was, like, vomiting up, like, chocolate vomit. It was not fun.

Dr. Fox: Yeah. Oh, God. Hey, listen. The doulas, they’re great. I mean, like, they’re there to help you for whatever you need. If it’s labor without an epidural, great. If it’s labor with an epidural, great. If it’s for the delivery itself, great. If it’s for nursing, great. Postpartum, C-section. Whatever it is, they’re there to help you. And so, there’s…I mean, there’s some people who need very little help I suppose but most people do, especially first baby or first C-section. I mean, you need help. And it’s…like you said, the nurses are helpful but they’re not there with you the entire time. They have other people to take care of also. So, wow. That’s great.

Chaya: Yeah, absolutely, yeah.

Dr. Fox: So, he ultimately weighed 3-11, right?

Chaya: Yes. He was 3 pounds, 11 ounces.

Dr. Fox: That’s little. Little baby.

Chaya: Very, very little. And they wheeled me to the NICU right after, you know, once I kind of…I recovered from all of that nausea.

Dr. Fox: Right. Stopped throwing up chocolate chunks. Right.

Chaya: Yeah. I was like, you know…I wasn’t quite done but I was not profusely vomiting anymore so I said, “Okay. I’m just gonna vomit on time. We’ll go run down to the NICU. I’m gonna go as long as I can without vomiting and when we get [inaudible 00:42:22] I’ll vomit again.” And that was what we did. And so in between vomiting I saw my son in the NICU and, you know, they introduced us to who the nurse was that night and kinda showed him to us a little bit. I mean, at that point I was just kind of totally out of it.

Dr. Fox: Right.

Chaya: I remember later one of the nurses in the NICU was like, “Oh, I was there that night when you came in.” I was like, “Great. I had no idea what was happening because I was just vomiting.”

Dr. Fox: Right.

Chaya: But yes. So, he was there. So, he ended up being in the NICU for 10 days. And, you know, again, like, I had said with the first birth, the fact that we were Sabbath observers, it was, like, a plus and it was actually really amazing. This time it was a lot…it was really complicated because it was Passover. And when I gave birth, it was, you know, in the middle of Passover when we were able to, you know, use our phones and drive and all that stuff. But at the end of my stay, it led into the end of Passover which was more like a Sabbath, a holiday. So, we had to make the decision. Since I had had a C-section, I could stay a few more extra days but staying those extra days would mean that I would be there for the holiday and I really wanted my husband to be back with my daughter because she was missing both of us and, you know, because of COVID we couldn’t, like, go back and forth and just…you know, my husband couldn’t go see her or she couldn’t come visit me. So, in the end, my husband went back home to be with my daughter for the end of Passover. For those last two days of my hospital stay, I was by myself in the hospital which was really difficult. I was very torn initially about staying because I really…I missed my daughter and I also knew that she needed me. But I also felt like, “Well, my son needs me now and I just wanna be able to see him in the NICU.” So, it was a bit of a bizarre experience staying in the mother-baby unit in a room completely by myself. My husband wasn’t there and my baby wasn’t there because he was in the NICU and it was Passover and I wasn’t on my phone. I wasn’t watching TV. You know, I had my sister-in-law bring me a book. It was like a very quiet and relatively solitary couple of days.

I will say that because I wasn’t so occupied with other things that when I went to the NICU, one benefit of me not being able to use my phone was that I would just sit in the NICU holding Itai and I would just, like, watch and listen what was happening with the nurses. And let me tell you it was very entertaining. I would watch like a show, a reality show or just a show about NICU nurses because they were just so entertaining and so fun to be around. I got all the dynamics going on and it was just fun to kind of be a fly on the wall in that room. But that’s what I did for two days. I would…at that point, I was pumping actually and with my daughter, I breastfed her. Even when she was small…you know, she was really small but I breastfed and I breastfed her for a whole year. And my son was getting pumped milk in bottles. You know, they asked me if I wanted to try to get him to latch. I was actually really…I didn’t wanna do it because I felt like first of all, he’s so small and so fragile, but I also felt like I have this complicated thing going on where this baby is here but he’s in the NICU and I felt like I didn’t wanna get almost, like, too attached to him with nursing. So, I felt that just…you know, okay. He’ll be on the bottles for a little bit. We’ll figure out the nursing later and I’ll be okay. And luckily, you know, three months later, he’s great at nursing. He, you know, he actually only…he’s exclusively nursing at this point. He takes the bottle okay but he prefers the nursing for sure. It was a rough go and, you know, I hadn’t anticipated all of the challenges that would come with having a baby in the NICU. It was definitely really, really, really challenging. And especially because we had had the experience with my daughter the first time of walking out with our baby from the hospital, like, you know, just taking her in the car seat and going. And, you know, every time I left the hospital, you know, after I was, you know, released after the birth, it was, like, surreal to leave the hospital without my baby. And, you know, I live in an apartment building in Riverdale and people had seen me pregnant and then saw me not pregnant but also not with a baby. It was like, “What’s going on here?” I was pretty numb for the whole time that my son was in the hospital. And then when he came home it was like, “Okay. Now we could really…”

Dr. Fox: Right. It’s like everything’s on pause. Like, everything’s just a pause, yeah. I mean, he hasn’t had a bris. It’s just…you’re just sorta, like, waiting, you know. Yeah.

Chaya: Yes, definitely. Yeah.

Dr. Fox: Looking back now, you know, on both deliveries, both experiences, what is it you want people to know or what do you think is a lesson that you want people to take away from your stories?

Chaya: Just even noting the stark differences between my two birth stories…I mean, yes, they were similar in that both of my babies were very, very small but in my first birthing experience I felt like I got pretty much everything I wanted and things just worked out perfectly and I had, like…one of my doulas called, like, a unicorn birthing story where it’s, like, everything falls into place and then contrasting that with the second birthing experience which was, you know, being in shock about having a C-section and then going through the difficulty of having a baby in the NICU. What I take away from it is that, you know, as much as I felt like, “Oh, I’m so…you know, my first birth went so well because I was so prepared, I had a doula and I really did, you know, did my research on things, and I knew what to expect,” you know what, in birth you really don’t know. But I do think that even with my second birthing experience there were certainly things that I feel like after the fact I’ve been able to take control over. Even just getting answers about certain things. You know, like, why…who was that other doctor in the operating room and, you know, why was it that I needed to get the C-section? Just, you know, kind of getting clarity has certainly helped me a lot in processing what happened.

I will say also that I started listening to your podcast after I had my son. Every time I went to your office, I would see your picture on…you know, with the flyer for the podcast in the waiting room. I’m like, “Oh, okay. That’s nice. If I ever have time to listen to a podcast, sure.” It was after I had my son when I would do those late-night feedings and I would just think about the birth and just wonder all these things that I, actually, I started listening to your podcast and I felt like getting all that information. You know, I listened to the one about C-sections. Getting that information was just so, so helpful. It just really made me feel like I had some kind of control back and it really helped me process what happened. And I will say that even with all these elements that were out of my control, I do feel optimistic now that there are still things I can completely have in my control that I can change for the future. So, for example, you know, I switched my OB and my provider because I felt like, “Yeah, there were some things that I, you know, I would’ve wanted to go differently and I feel like the experience that I want to have can be…in the future can be much more attainable with a different doctor.” That day that you saw me in your office, I was, like, on cloud nine. Just from the experience of being in your office and meeting Dr. Silverstein who I saw there, it was just…it felt amazing. I felt so ecstatic not only because it was effectively a good experience but also because I finally felt like, “Okay. I had this experience three months ago where it felt like nothing was in my control and nothing was going my way but now, I’m actually doing something actively to change things for the future.” [inaudible 00:49:48] try to, you know, take control of what I can.

So, it’s a balance between admitting the things that you can’t control and…trying to take control of the things you can and taking the initiative to get that information and to actively take steps to change things.

Dr. Fox: Wow. Chaya, that’s amazing. First of all, great story, great lessons. You have a really good perspective on this. Listen, I’m just really thankful that you came on to tell your story. And it’s great. I think people who listen to this, either who went through something similar on either end…they had the perfect birth, they had sort of a more of a complicated birth so to speak. I mean, obviously, your baby’s healthy, everything’s well. But, you know, it wasn’t what you expected. Or people who are coming into pregnancy or pregnant themselves, it’s just good to hear these stories because like you said, you know, obviously we do everything we can to optimize the situation and take things under control and to try to get as much information as possible and that’s great. On the other hand, there’s some things that just happen and they’re unavoidable or, you know, you can’t prepare or prevent for them. They just happen. And there is that balance between sort of accepting what we don’t have control over and trying to take control over as much as we can to make things as pleasant and optimal as possible.

Chaya: Absolutely, yeah. And I’m really just so grateful and appreciative to be able to have the opportunity to share my story. It’s really amazing. Yeah, it’s really just cathartic and eye-opening to be able to share my story with other people and to give them that hope and that reassurance that, you know, it happened to me too and that, you know, there is always…you know, some things take control over in this kind of very uncertain environment.

Dr. Fox: Thank you for listening to “High Risk Birth Stories” brought to you by the creators of the “Healthful Woman Podcast”. If you’re interested in telling your birth story on our podcast, please go to our partner website at www.healthfulwoman.com and click the link for sharing your story. You can also email us directly at hrbs@highriskbirthstories.com. If you liked today’s podcast, please be sure to check out our “Healthful Woman Podcast” as well where I speak with the leaders in the field to help you learn more about women’s health, pregnancy and wellness. Have a great day.

The information discussed in “High Risk Birth Stories” is intended for information and entertainment only and does not replace medical care from your physician. The stories and experiences discussed in our podcast are unique to each guest and are not intended to be representative of any standard of care or expected outcomes. As always, we encourage you to speak with your own doctor about specific diagnoses and treatment options for an effective treatment plan. Guests on “High Risk Birth Stories” have given their permission for us to share their personal health information.