The stories from the labor and delivery ward at UW Medical Center in Seattle are often told breathlessly.
A nurse tells of a pregnant woman who arrived at the hospital brain dead after being airlifted from Eastern Washington. She was kept alive as nurses pumped her breasts to feed her baby, who had been delivered by cesarean section.
A doctor mentions his oldest patient, who, at 62, was among his healthiest.
And a young mom shares that she has a rare muscular disorder, defied all odds to become a teacher and later discovered that – surprise! – she was pregnant with twins.
About half the women who deliver at the UW hospital have complications, which partly explains the hospital’s high C-section rate. For first-time moms whose babies are on time and head down, the rate is 35.8 percent. The state average is roughly 25 percent.
Other factors contribute to that high rate. Group Health sends its extremely obese moms – those with a body mass index over 40 – to UW. Unsuccessful homebirths account for 10 percent of the hospital’s total deliveries. Between 50 and 60 percent of those moms end up getting C-sections.
“There are older and more medically complicated women having babies now than there used to,” says Dr. Tom Benedetti, a high-risk obstetrician who has worked at UW for 36 years. “C-section, besides being related to age, is directly related to a mother’s weight. Everybody in the world knows what is happening to the weight of the population, both men and women, and as a consequence, we are also a bariatric center.”
Big Fish: Kidney Transplant
Many of the most vulnerable patients see Dr. Tom Easterling, a fast-talking, crisply dressed obstetrician who oversees the care of some of the highest risk patients in the western United States – moms who have had cancer, organ transplants and preeclampsia.
Easterling thumbs through papers at a narrow desk at the maternal medicine clinic at UW.
“Sometimes I feel like I spend as much time doing paperwork as I do seeing the patient,” he says, squinting at rows of tiny letters and numbers. He wears an ironed, button-up shirt and around his neck is a badge that reads, PROFESSOR. It’s fitting, as he was once a fifth- and sixth-grade teacher in Dallas and still views himself as an educator.
His next patient is Tessa Axelson, 36, a high-level administrator of a federal agency in Alaska. Five years ago, she had a kidney transplant. Three years ago, she had a kid. Now she’s back, 11 weeks pregnant.
It wasn’t long ago that women like Axelson couldn’t have children. But now, thanks to modern medicine and high-risk obstetricians who specialize in the care of medically fragile pregnant women, they can expect relatively normal pregnancies.
“How’s Ketchikan?” Easterling asks Axelson as he walks in the room.
“Sunny,” Axelson says. “We just went on a girls' fishing trip.”
She pulls out her iPhone and shows Easterling a photo of 30-pound silvers. Axelson is stylishly dressed. Her nails are painted neon yellow, and she is tan and fit.
“The best part is that these men from North Carolina were there, and they didn’t get anything,” she says. “We local girls were like, ‘Yeaaaaah.’”
Easterling rattles off questions.
“Your appendix has come out?”
“None, zero,” she says. She adds, somewhat tersely, “And no, I haven’t taken up drugs, drinking or smoking since I last saw you.”
“Bring your phone back up,” he says. He pulls out his own and takes a photo of the fish she caught.
Axelson asks, "What's the difference now that I'm over 35?"
Easterling shakes his head. "Your age risk pales in comparison to your kidney transplant," he says.
Also, she won’t get the test recommended for moms who are 35 or older. A new test that analyzes cell-free fetal DNA has been touted because it requires only a blood draw from the mother. From that sample, genetic problems can be detected in the child.
It likely wouldn’t work for her, though, Easterling says. Another kidney transplant patient was tested using cell-free fetal DNA and was told she was having a boy.
Then, at 20 weeks pregnant, that patient went in for an ultrasound and learned she was having a girl.
“The test picked up her kidney donor’s blood,” Easterling said. "He was a man."
Easterling wraps up the visit asking about Axelson’s son, Elliott, 3, named for Elliott Bay.
No Mas: Hypertension
Back at his tiny desk, Easterling nods toward two women in lab coats walking through the clinic. “The hand gel police are here,” he says.
He works quickly, scanning his patient’s chart.
Chrissy Grogg, 38. Thirty-eight weeks and one day pregnant with her sixth child.
She did fine with her first four babies, but developed severe preeclampsia with her fifth, Cheyanne, now 17 months. That's why she's being closely monitored.
Easterling says that Grogg’s grasp of medicine is impressive.
“If you met her on the street, you would be surprised by her level of sophistication,” he says.
Grogg is part of a randomized research study for heart disease. “I’m betting she’s on the drug because she’s doing really well,” Easterling says, reading her latest results on the computer.
Easterling has scheduled Grogg for a C-section shy of 39 weeks. The Washington State Hospital Association has advised doctors not to perform C-sections before a mom is 39 weeks pregnant; research has linked early delivery with learning disabilities.
But that recommendation is for mothers who request C-sections for social reasons – a mother in town, a husband about to be deployed overseas, fatigue at the end of a long pregnancy. With Grogg’s medical history, the baby must come out earlier, Easterling says.
When Easterling sits down with Grogg in the small exam room, he hands her a consent form to have her tubes tied.
“No second thoughts?” Easterling asks.
“No mas,” Grogg says with a smile. “Mom is done.”
He asks about her teeth, which have decay, and whether a dentist had taken care of her most painful ones.
“They didn’t do anything,” she says. “Not until JJ” – her unborn son – “gets here.”
Back at his desk, Easterling notes that all her teeth should be pulled. “Dental inflammation can lead to maternal problems,” he says. But, “To get her work done, we would need to put her to sleep. If she didn’t need to be put to sleep, we’d take care of it in pregnancy.”
Transplant, Then Twins
Next up. Janna Stombaugh, 33.
Kidney transplant at age 17.
Pregnant with twins.
“I was already seeing the high-risk OB, and then I find out I’m having twins,” she says laughing. She is petite with blonde hair in a half ponytail.
Easterling squeezes blue gel onto Stombaugh’s belly and listens for her babies’ heart rates.
“We can anticipate the babies will come out vaginally,” he says, “if Baby A is head down.”
They discuss how she’s feeling. Later, after Easterling has left the room, Stombaugh reflects on her situation.
“I didn’t think I’d be having my own kids,” she says.
Cancer And Diabetes
As the day progresses, Easterling shows no sign of flagging. Each patient presents a unique set of circumstances, some trickier than others, but his goal, he says, is to make each feel as normal as possible.
Like Vickie Kolios-Morris, who had cancer in 2010. As we enter the exam room where she waits with her husband, Easterling says her bout of cancer shouldn't be an issue. “The biggest risk is that she’s 40 years old.”
He asks her the usual questions:
“Baby’s moving every day?”
“Yeah,” Kolios-Morris says.
She turns to me and praises Easterling. “We’re lucky here, we have a world class doctor,” she says. “You ask anyone, one name comes up.”
“You could find a prettier room,” Easterling says.
Kolios-Morris shrugs. She doesn’t care about that, she says.
Several floors above Easterling's tiny desk is the neonatal intensive care unit, where babies that weigh just a pound are coaxed through the first months of their infancy.
There I meet Abbie Ball, 29, a special education teacher. She was born with spinal muscular atrophy and grew up using a wheelchair.
She became pregnant with twins and in her second trimester developed HELLP syndrome – a complication of preeclampsia unrelated to spinal muscular atrophy.
“There are no twins in our family,” she says, apparently still in disbelief. She cradles Tatum and holds the bottle that feeds the baby through a tube.
Abbie Ball, her husband Ben and her parents were preparing to leave the NICU after 105 days. Tatum Grace and Teagan Rhysse, their twin daughters, had plumped up. Both were born by C-section; Tatum was 2 pounds, 3 ounces, and Teagan was 1 pounds, 13 ounces.
Ball is cheerful, but she sighed a little when I ask if the preeclampsia is related to her muscular condition.
“No," she says. "I just happened to get it.”
Isolde Raftery can be reached at firstname.lastname@example.org and 206-616-2035.