I learned about Rh incompatibility when I was pregnant with my first son: I have A negative blood, which means I lack the Rh protein in my blood cells, while my husband is B positive, which means he has the protein.
The incompatibility exists because, in essence, the immune systems of Rh-negative individuals, like me, view the Rh protein as a threat. When Rh-positive blood gets mixed with Rh-negative—like during childbirth ifan Rh-positive baby is born to an Rh-negative mom—the mother’s immune system goes on alert to eliminate the threat. In the process, it forms antibodies against Rh-positive blood to protect against future “assaults.”
Our first son was born in a smooth, beautiful home birth. And while the Rh incompatibility wasn’t an issue then, I knew it had the potential to turn into Rh sensitization, which could be disastrous if we were going to have any more kids. During my pregnancy, my midwife had advised receiving a shot of RhoGAM, the medicine that prevents sensitization, after giving birth to prevent that particular complication in the future, as blood mixing can happen even in the gentlest of births. A few days after my son was born, I went to receive my dose, and I thought that was that.
RhoGAM is supposed to provide purified antibodies that eliminate the Rh-positive blood cells before your own body can mount an immune response. Prior to its invention, women in an Rh-incompatible situation would have one baby, maybe two, before the next was born anemic and sick. Once a woman’s body has anti-Rh antibodies, they never go away. Antibodies will cross the placenta and go after the blood of unborn babies. And the immune response gets stronger with each subsequent pregnancy.
I hadn’t realized that my body had already built up defenses against my babies, despite the RhoGAM. My husband and I decided to try for another child when our first was about two years old. I miscarried a few months in, and it was then that I learned that the medicine hadn’t been effective for me. My Rh sensitization was a casual diagnosis, thrown out between pacifying comments about how I could get pregnant again right away and (incorrect) advice to get RhoGAM again to keep my sensitization from worsening. Sensitization hadn’t caused my miscarriage, but it would play a huge role in my reproductive future.
My last pregnancy was a struggle, as I sought to understand Rh-sensitization, dealt with the medical procedures it entails, and worried about the effect this seemingly harmless protein would have on my baby.
Rh disease can cause anemia and jaundice. It can cause birth defects. It can cause stillbirth.
Nowadays, thanks to awareness and the aggressive use of RhoGAM, Rh sensitization is rare. It’s given during pregnancy and after birth; after abortions and miscarriages; and after amniocentesis and any prenatal procedure that has even the slightest chance of causing blood mixing.
In recent years, there’s been some pushback against RhoGAM within the natural birth community. There are many myths about sensitization. Some people swear that delayed cord clamping will prevent it. Others worry that there are dangerous ingredients in the shot. Still others maintain that sensitization is exceedingly unusual, and the medication simply isn’t necessary in most cases. All of this is false. The use of RhoGAM has enabled countless women with Rh-negative blood to go on to have healthy second and subsequent babies.
In my case, the RhoGAM hadn’t worked, though I’m not sure why. Rh sensitization was my new normal. So when I got pregnant again, I had to deal with the aftereffects.
The beginning of my pregnancy was straightforward. My perinatologist was impressed with my knowledge of my condition yet always made time after appointments to answer my questions. Early monitoring of Rh sensitization is primarily via bloodwork: titer tests to determine how many anti-Rh antibodies I had. If antibody levels were low, the baby was safe. Once antibody levels started to rise, it indicated a problem.
Next came regular ultrasounds, checking for four “soft” markers for fetal anemia—one of the major risks of Rh sensitization. First was the rate of blood flow in the medial cerebral artery (MCA) in my baby’s brain; faster blood could be anemic blood. Second was the presence of extra fluid around certain organs (lungs, stomach, or heart) or just under the skin. Third was swelling of either the liver or spleen. Fourth was excess amniotic fluid.
The presence of any two of these would mean closer monitoring and more testing. But most important was the MCA. When, at around 28 weeks, my baby’s blood flow in the MCA shot up, I was immediately scheduled for cordocentesis, in which a sample of the baby’s blood is taken from the umbilical cord to check complete blood count (CBC). My baby wasn’t actually anemic at the time of this first procedure, but knowing the CBC helped us develop a timeline for the coming weeks.
Two weeks later, I arrived at the hospital for a second cordocentesis, knowing it would likely be followed by an intrauterine blood transfusion. I checked in early, fully aware of all risks; the procedures could possibly trigger premature labor or otherwise necessitate immediate surgical delivery. I was given an IV and a hospital gown and left to wait.
Early afternoon. The operating room was cold; socks weren’t allowed. My stomach was numbed with a local anesthetic before ultrasound was used to guide a large needle through my abdomen and into my child’s umbilical cord. First, a blood sample was taken and CBC determined; then, blood was transfused.
After each procedure, I remained in recovery for hours, fetal monitors keeping an eye on the baby’s health and ensuring I wasn’t beginning labor. On one occasion, the wiggly baby required anesthesia before a transfusion; that time, I was monitored until I felt fetal movement again.
All in all, my baby received three transfusions and two separate bouts of cordocentesis during my third trimester.
I knew all along that I was looking at medical induction, possibly as early as 34 weeks, although our plan was 37 weeks. At my 36-week appointment, however, things changed. MCA blood flow was high again, and my baby was too big for another transfusion to be safe.
I opted for a membrane sweep and scheduled an induction for the following weekend. Thankfully, the sweep nudged things along, and my little one was born the following evening. The birth was so different from my peaceful home birth but perfect in its own way.
I wish I could say that birth was the end of my second son’s troubles, but my antibodies remained in his blood. He endured 11 days in the NICU under constant phototherapy for Rh-related jaundice, nearly requiring more transfusions. Even after he came home, he still had to be monitored for a month for his fading Rh disease.
Overall, we were lucky. My son is healthy and sustained no lasting damage.
I, on the other hand, am still mildly traumatized and have since sought sterilization because I simply cannot do it again. I had my blood drawn 25 times over the course of pregnancy and received 18 ultrasounds. I spent 25 hours under fetal monitoring when I wasn’t actually in labor. If I didn’t have solid health insurance, I’d be mired deep in debt.
I have long felt that being informed is the biggest key to a satisfying birth experience. I am very thankful that I took the time to learn about my condition before becoming pregnant again. Books, websites, and an interview with a specialist all helped me understand the risks I was facing; I can’t imagine how scary such a pregnancy would have been if I hadn’t been expecting any of the monitoring or procedures!
Because I was informed, my doctors were better able to involve me in making decisions for my care. I walked into every procedure with a plan, and I was able to write a flexible birth plan that covered all possible outcomes. This gave me peace of mind, which meant my hospital birth was every bit as beautiful and empowering as my home birth.