I Am Mad and I Am Sad

I just spoke to a mom who is with a practice of midwives and doctors who practice out of the large hospital on the north side of town. And she is with a large insurance company which is a global pay system. She is being told by her practice that they do not allow doulas. She will get either a doc or a midwife- you rotate through both and it is whoever is on call.

And her hospital childbirth educator- was great about teaching her “to stay up and moving- using the birth ball, etc” but told the students who lived a short distance away (5 to 10 minutes) to arrive when the contractions were ten minutes apart but since she lived almost an hour away- she needs to go to the hospital at 15 minutes apart. I reminded her that that was only four contractions an hour and would be very, very, very early labor! She called me to find out about doulas because the hospital tour person and hospital educator and her friends have all said use a doula, even labor nurses she goes to church with recommend she use one. But she is unsure if she is “allowed” to do so with this practice and wondered if I knew if they would allow us to be there! (more…)

Cesareans Can Be A Gentle Experience

There are two hospitals in the metro area that offer a “Family Centered Cesarean.” One is done at AMC with Intown Midwifery and at Dekalb Medical with Brad Bootstaylor with patients of See Baby Midwifery and with the doctors backing up Intown Midwifery. They do that type of cesarean for any non emergency- keep in mind you hear “emergency cesarean” used often for “non planned cesarean.” A true emergency is very different from a non planned surgical birth. So he provides it for any real non emergency situation and tries to offer it then if possible. One other group provides a family centered surgical birth but only does so for planned cesareans. That is the physicians who back up the ARMC midwives in Athens.

This approach is shown to “enhancing bonding, initiating breastfeeding and reduces postpartum depression”- isn’t that what we all want?

Here are some video links to this new approach as well as the traditional approach.

A Local Atlanta Family Centered Cesarean Family Centered Cesarean

This is a modified skin to skin after the birth cesarean- not really a full experience but better than most:

Modified skin to skin cesarean

A unique natural expulsion technique:

Natural Expulsion

Malpositioned baby was born via cesarean:

Malpositioned Cesarean

And for comparison sake- here is a “normal” cesarean:

“Normal” Cesarean

A local cesarean including some of the pre surgery prep:

Kennestone Cesarean Birth

You may be asking yourself, why is this not available elsewhere and why does ARMC require it to be a planned event. ARMC says it takes more staff when Dr Bootstaylor says that it does not take more staff when he does it. Elsewhere I think women are not demanding the opportunity for this type of experience. If you demand it, often the powers within the medical center will listen. Change comes from creating the voice within many. Ask your hospital why they can not follow suit and help women have a good birth experience no matter if it is vaginal or cesarean!

What Does Dancing Have To Do With Birth?

Everything! Think about dance for a moment.

DANCE: to move one’s feet or body, or both, rhythmically in a pattern of steps, especially to the accompaniment of music.

Movement is so essential to birth! It is often said that if we need to move the baby, move the mom! So having a mom who has learned ways to move her body in her pregnancy in ways to enhance the optimal positioning for the baby, is going to only help her labor to be smoother and even shorter!

Being grounded and upright- on your feet, is another thing that helps labor! Being strong and fearless is part of what our classes teach. They move you out of your comfort zone a bit so that you have new found confidence in labor! Moving your body without regard to what others think- but instead what your body is telling you to do. Yep, that is what I said- what your body tells you to do! Did you know that your body already knows how to birth? We just need to get out of the way and let our bodies guide us!

Labor and birth have a rhythm! We don’t find our rhythm laying on our back in a bed! We find our rhythm by moving! We find our rhythm by learning to listen to how our body is directing us! I have seen women move just the way their bodies were guiding them and have easy births!

When we develop a pattern of exercise in our pregnancies, that pattern is instinctive in labor. We have learned how to move our bodies in ways that open our pelvises. We use a rebozo to show you how to facilitate movement that is powerful for opening your pelvis! We teach you how to facilitate the use of a birth ball to help you in your pregnancy and birth.

We teach you some techniques to help those who will accompany you in your labors too! So you will leave class with ideas to share! Dance frees you up to begin to prepare your body in a fun way! And your partner can dance with you!

Music and the different emotions, rhythms and movement it evokes is fun! We explore different types of music and increase your awareness of some music you may not have considered for birth before!

We will be offering morning classes in Atlanta off of Shallowford Road and we will offer evening classes in Lawrenceville off of 316 near 85. Which class are you interested in joining? Oh and guess what? These classes are also wonderful postnatal fitness classes- bring your baby and your favorite baby carrier and come join us to get back in shape quickly while having fun!

Are Doulas Anti-Epidural?

NO! We support women in the choices they make. But… we do hope women are making informed decisions. This week one of my doulas had a mom with a long induction and the mom received an epidural after many long hours of labor. The midwife told her when the baby was born that she was pleased that the doula had stayed for the birth. The doula was shocked by the comment and inquired as to why that was shocking. She then went on to say that most often doulas did not stay once the mom received her epidural. We stay with the mom throughout her labor and birth irregardless if she chooses to be medicated.

We had a mom recently told that she was pre-pre-eclamptic- meaning that he felt she was going to end up with an induction due to her having one symptom of possibly having a future of pre-eclampsia. It is difficult to have moms have a care provider who seems to diagnose this six weeks before she is due and with only one symptom. But she was considering not having a doula since she felt an induction would mean she would need to have an epidural. This is not always true- in fact we have several moms who are induced every year and are still able to have an epidural free birth.

But speaking of informed decisions- Leigh William just sent me a document that is worth reposting so you can make sure you understand the risks of an epidural. There is a time and a place for epidurals. You may have your reasons for getting one that we do not understand or know- that is okay- it is your choice. But don’t make it uninformed or due to your friends or family telling you to get it- or feeling you will need it before you go into labor- give yourself an opportunity to labor before you make that decision.

Common Side Effects of Epidurals: Minimizing the Risks

Side Effect / Who affected	Incidence: What percentage of moms or babies experience this	What medical staff does to prevent this.	What you can do which may help prevent this.	What other interventions this side effect could lead to.
Limited Mobility / Mom	100% Some studies indicate that women may have more muscle mobility than they realize, but required monitoring equipment tends to make movement difficult.	Can’t prevent it once you have an epidural. Can give a lower dose of medicine to minimize.	You may choose to delay epidural so you can move around a lot in early labor to help prevent problems due to immobility	Could lead to a posterior baby or other malpositioning, or could lead to failure to progress at any stage in labor, which may lead to cesarean.
Low Blood Pressure / Mom	0 – 50% † Relative risk (RR) 74.2 *	Give extra IV fluids before epidural is given.	Rather than lying flat on your back, prop one hip up on a pillow.	More fluids, oxygen, or medication. If mom’s BP drops too much, baby’s heart rate can decrease, oxygen supply to baby can decrease.
Fever / Mom	4 – 24% ** RR 5.6 * The longer mom has epidural in place, the higher the fever risk.	Monitor mom’s temp.	Keep cool: eat ice chips, use cool cloths under arms or between legs, on forehead and back of neck. Fan.	May lead to elevated heart rate for baby, which may indicate fetal distress, which may lead to c-section. Mom may be given antibiotics for possible infection.
Urinary retention in labor / Mom	0 – 68% †	Bladder catheter	Wait as long as possible for epidural. Urinate (pee) just before getting epidural. Try using a bed pan if you can…	A full bladder can prevent cervical dilation and fetal descent. Increased risk of infection, postpartum urinary problems.
Postpartum urinary incontinence / Mom	Immediate postpartum: 27% with epidural, 13% without	Keeping bladder drained during labor.	See above. Kegel exercises before & after labor. Biofeedback can be used to treat.	May last for weeks. (At 3 months, was 16% for women who had used epidural, 4% for those who had not.)
Shivering / Nausea / Vomiting / Itching	Shivering 33% (Thorp) Nausea 0 – 30% † Vomiting 0 – 13% † Itching 8 – 100% †	“Harmless”. No need to prevent.	Blankets, massage for shivering. Support.	Can give medication for nausea and itching. May make mom very sleepy.
Backache after birth / mom	Immediately after birth: 53% with epidural, 43% without	Proper placement of catheter.	Try to avoid awkward positions and muscular strain during labor	Postpartum pain medications.
Incomplete Pain Relief / Mom	5 – 10%	Proper placement of catheter. Adequate levels of pain meds.	Tell caregivers if relief is incomplete, or if you have painful spots. Change positions.	May be more stressful than no pain relief at all. Epidural can be re-positioned; medication can be increased.
Slower first stage / labor	Most studies show this effect. -.4 – 4.8 hours longer. ** Average is 26 minutes longer.*	Pitocin (artificial oxytocin through IV). 3 times more common with epidural	Wait as long as possible to have epidural	If first stage stalls, you may require a c-section for failure to progress. Also, Pitocin can cause longer, stronger contractions. May lead to fetal distress, which may lead to c-section.
Longer second stage (pushing) / Labor	All studies show this effect. 0 to 55 minutes longer.** Average is 15 minutes longer.*	Pitocin and/or Second stage interventions	Ask for a “light-weight” epidural, so you still have some mobility. Change positions. Turn down epidural for 2nd stage. Delay pushing till baby’s head crowns.	22 out of 24 studies indicate a higher risk of instrumental delivery (forceps, vacuum) With IV narcotic pain medication, chance was 3-7%. With epidural, chance was 15-53%.
Fever / Baby	30%	Monitor mom’s temp.	Try to keep mom’s temperature down.	May cause elevated heart rate. If baby has fever, may be assumed to have an infection: can lead to observation or isolation, blood tests, antibiotics.
Fetal distress due to Pitocin, mom’s low BP, maternal fever, or other causes/ baby	10 – 15% of babies	Monitor baby, attempt to avoid maternal conditions which may lead to fetal distress.	Stay off your back, change positions frequently. Breathe.	Oxygen for mom. Treat maternal conditions. Decrease pitocin, which may lead to failure to progress. May lead to cesarean section.
Baby in posterior position, other malpresentation / Baby	One study showed 20 – 26%. Another showed that all but 4% of babies rotate without epidural. With epi. 19% will stay posterior.		Change positions frequently in early labor, especially using positions that bring weight of baby forward. Wait until baby is engaged in pelvis (0 station or +1) before getting epidural.	Greater chance of c-section or instrumental delivery.
Cesarean Birth / Effects mom and Baby	Studies consistently show that c-section is 2-3 times more likely with epidural. One study showed that risk was 26% if epidural at 4 cm, 33% at 3 cm, 50% if epidural given at 2 cm dilation.	Pitocin to aid dilation. Forceps or vacuum extractor to aid delivery.	Delay the epidural as long as possible in labor. Follow all other recommendations given above.	Risks of c-section for mom include: risks of infection, increased bleeding, longer postpartum stay, possible anesthesia effects, more postoperative pain, and possible impact on future pregnancies. Effects on baby may include respiratory distress syndrome and other impacts of surgical birth.

By Janelle Durham, 2004.

* Leighton, B.L., and S.H. Halpern. 2002. The effects of epidural anesthesia on labor, maternal, and neonatal outcomes: A systematic review. American Journal of Obstetrics and Gynecology 186: S69-77.

** Lieberman, E., and C. O’Donoghue. 2002. Unintended effects of epidural anesthesia during labor: A systematic review. American Journal of Obstetrics and Gynecology 186: S31-68.

† Mayberry, L.J., D. Clemmens, and A De. 2002. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. American Journal of Obstetrics and Gynecology 186: S81-93.

Additional Sources: “Epidural Anesthesia in Labor: An Evaluation of the Risks and Benefits” by Thorp and Breedlove, Birth, June 1996. This was a literature review article, which summarized the results of numerous studies involving thousands of births. Other information from: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (2001 edition). Maternity & Women’s Health Care by Lowdermilk, Perry, and Bobak (6th Edition, 1997). Family-Centered Maternity and Newborn Care by Celeste R. Phillips (Fourth edition, 1996). “Epidural Epidemic” by Dozer and Baruth, Mothering, July-August 1999. “What no one tells you about Epidurals” by Penny Simkin; “The Cascade of Interventions” by Pam England; and Epidural’s Effects on Babies” by Beverley Lawrence Beech, in Mothering, March-April 2000. “Epidural Express” by Nancy Griffin, Mothering, Spring 1997; “So you Want an Epidural” website by Kim James.

Additional data from the most recent studies can be found on the childbirth educator resources page.

Amazing Model of Care

Yesterday I received a call from a third time repeat doula client. She felt something different was happening from her normal braxton hicks contractions. She has FAST labors and is 40 minutes from the hospital of choice, so watching and being mindful is imperative for her with two little ones to settle first. She chose to go into the office for a labor check first. So, the exam was inconclusive. She was dilated to 4 cm and was 40% effaced and definitely contracting, but could it be early labor or prodromal labor, who can tell. Oh I forgot to tell you, her usual behavior in labor is to contract without any real pain until transition- then she speedily gives birth. She is a no mess around, get her done kinda birther. So the fact that she is not moaning, not swaying but contacting every 2 to 3 minutes with a firm belly is her normal labor. So she decided to wait around the area of the hospital for another hour and sure enough the pattern became stronger and closer together, so she decided to check into the hospital. Her dad and mother in law were called to come help with the kids and she enlisted me to come meet her and her husband.

I took more than an hour to get there due to the rain and nearing after work traffic but found her the way she is in the middle part of her labor. She would stop and breathe heavy ever so few contractions and then begin to talk and chat about wishing she had eaten more since she was now hungry but feeling a bit nauseous at the same time. She would sway, stand by the bed, sit in the bed, eventually eat a sandwich and chat. She began to be frustrated with the lack of progress and eventually at the recommendation of the midwife on call, decided to try to sleep. And exam 12 hours after the first one- with another offered somewhere in the middle- showed no further dilation. We had kept hoping that something would break loose and she would be having a baby quickly like the previous times. (more…)

It Is Just One Day… Right?

Last night we were reading through the script for the play Birth, rehearsing. And one character in the play does little preparation for her birth, saying it is” just one day” in her life. I had a conversation with Guina today about how sad it is that often women really do not realize that birth is so much more than one day in their life. Consider the events that we as women prepare for…. the college to attend, the man to marry, the job to have, the kind of car to drive, the house and neighborhood to live, the dress to wear when married, the kind of cake at the rehearsal, the wedding day in general, the color of the nursery, the type of bedding to select for the master bedroom, etc… and yet one of the, if not the most important day of our lives- the day we turn from women to mothers- the day we experience a life being born from our bodies. It should not be a day we just swallow deeply and hope it all goes well….

I wish that women would allow themselves to dream of their birth of their babies…. dream about how they want it to happen….dream about the events surrounding that experience- their care provider, their birth options,the location for the birth, and do the preparation they need to do emotionally, mentally, spiritually and physically. I wish they understood this is a day that creates the story they will retell for the rest of their lives. It is important. It will shape the way they see themselves forevermore. It will shape the way they view themselves as women and mothers and even daughters.

I wish instead of fleeing from their fears, hoping they will not show up in labor, they would allow themselves to release and just let their bodies birth gently having done the preparation to allow that to happen. And realizing if their birth unfolds in such a way that is not like they planned, it will be okay since they did the best they could, fully prepared. I wish women would realize that this day is not just a day- it can be a wonderful life changing day that will forever transform them.

So, give some real thought to what kind of birth you desire…. realize you have options that you may not have explored…. but most of all prepare for this day- it is a day- one day- but it is a day that will forever change you either in a negative way or a positive one…. the decisions you make may determine that outcome.

Consider This Timeline… Choose Your Ending Story

actually happened:

mom has taken Birthing in Awareness childbirth preparation with her first child
has fast, gentle birth of first child on the day her child chose
mom has history of hypertension which is only exasperated with pregnancy each time
mom is pregnant again
prepares with the FEAR to FREEDOM class and a review of the Birthing in Awareness class they took the first time
mom has continued issues that cause her doctors to consider her high risk: age is one issue, weight is another and her BP is the third
hospitalized for tests and passes with flying colors
threats of induction only to be dismissed by her perinatologist each time
finally the hypertension and fear of placental abruption after all of the physicans now show concern, causes her to enter hospital for induction nine days before her official due date
cervidil placed in the evening
cervidil removed in the morning with little change
baby is high, still bloatable- perhaps as high as -4, so midwife does not want to break her water yet, but pitocin started
although told it would be slow management, the midwife says the doctor has ordered active management of pitocin

mom does not agree to active – fast pitocin and it is agreed to do it slowly
pitocin on all day with no real change
doctor comes in and wants to break her water- although baby is still high- mom declines
midwife comes in to talk about options, doctor returns to offer his suggestion- still wanting to break the water although baby is high
mom and dad discuss things and decline option of breaking the baby or water
doctor sends word via midwife he thinks this is a big baby who does not want to enter the pelvis and suggests a cesarean
mom and dad decline the idea and instead go with the option of turning everything off and resting for the night
by morning although the cervix remains the same, the baby is much lower, now at -1 rather than-3
midwife pin pricks the amniotic sac and water leaks slowly out
pitocin started back slowly
baby is born within two hours of active labor starting, only four hours after pitocin started that morning
no pain medications needed- although offered by the midwife about an hour before the birth- mom declined
mom and dad ecstatic that their second baby is born without any pain medication- mom says one of the most empowering things she ever has done!

now let’s look at how this normally happens in our area without an educated consumer and perhaps without a doula:

mom takes a one day, six hour childbirth class with her first child, probably taught by the hospital which could be how to be a good patient class
mom has hypertension and agrees to an induction of her first child
gets an epidural due to it being an option that drops her blood pressure and since she is not allowed out of bed due to her BP
mom’s history of hypertension is only exasperated with pregnancy each time
mom is pregnant again
does not further preparation since her first class she found to be of little help
mom has continued issues that cause her doctors to consider her high risk- age is one issue, weight is another and her BP is the thrdi
hospitalized for tests and falls prey to the fear that her doctor shares and decides to have an induction almost three weeks early
cervidil placed in the evening
cervidil removed in the morning with little change
baby is high but doctor suggests pin prick to break the bag slowly although he does say it could risk breaking abruptly
parents do not fully understand the risk of prolapsed cord

here is where things could have drastically changed:

cord prolapsed when bag broken since baby was at -3 station and the gush of water carried the cord out
immediate cesarean under general anesthesia without her husband by her side

or this could have happened:

water trickles out and baby moved down
pitocin started and brings about cervical change but with increased discomfort
mom receives pain medication
mom goes on to give birth without incidence but not feeling as empowered as she would have if unmedicated
baby born early and needs to go to nursery for observation
baby does not nurse well since born 3 weeks prior to due date- officially premature since he did not complete his full 37th week of gestation

or this could have happened:

water trickles out
pitocin started and brings little or slow change
doctor discouraged at the progress the mom is making suggests cesarean
mom and dad go to the OR to have their baby

I share this to say, being full informed, knowing what your options are, knowing the questions to ask, having a doula by your side, understanding risks and dangers and knowing that a doctor can not truly predict size or outcome can really make a difference. The baby that the ultrasound had suggested was probably close to nine pounds was only 8#5ounces, only 7 ounces larger than her first! Patience, asking the right questions, being strong in her desires, having a great support team and the preparation she and her partner did made a huge difference!

Ellen Shares Her Journey and Regrets

My pregnancy was easy with no complications. I obsessed over natural birth information, took classes, read books, did yoga, and planned on an unmedicated birth. A doula friend said her 2nd choice for natural birth was the midwife practice right up the road. The practice had 2 midwives and an OB, and delivered at our local hospital, with the wonderful reputation for supporting natural birth. I LOVED the midwives until I went into labor. I didn’t think I needed to have a doula, because I felt so confident and relaxed about the process. I trusted my midwives and the hospital. I also fully trusted that my body would know what to do when it was time. I didn’t realize how much I would need someone to advocate for me. I was naïve.

My due date was Thursday August 11; it came and went. Wednesday night the 17th – I was up all night with contractions and bloody show. By morning things had slowed down, so my husband and I went to my scheduled 41 week appointment that morning.

I saw one of the midwives, M, and she said everything looked great. She said my fluid felt great, baby was in a great position, and she did not see me needing to be induced. Said we’d probably have our baby by the weekend. She stripped my membranes, which got me to about 4 cm dilated, and told me to keep doing what I was doing and just wait. Then she realized we were supposed to have had an ultrasound before we saw her. So she sent me across the hall so that they could do an assessment of the following 4 areas: fluid; movement; heartbeat; and placenta. This is where things started to go downhill. The baby would not move. She moved all morning, and don’t you know, she moved as soon as we left that office, but when it counted, my girl wouldn’t budge. They also couldn’t measure an “acceptable” amount of amniotic fluid, despite the fact that my experienced midwife could tell by feel that my fluid levels were fine. They must be able to measure a pocket of a certain size. They couldn’t. So we failed 2 parts of this test, and scored 4 out of 8 points. The midwife informed us that they needed to induce. I started crying. She said it was not an emergency, and that nothing was wrong. She told us to go home, eat, do what we needed to do, and then go to the hospital. She repeatedly said it was not an emergency and that we did not need to rush. (more…)

Labor and Birth Jenga

Labor and birth is a balancing act. Moms sit down with their doulas and share what their birth ideals are but often times what is shared is what she thinks her birth ideals are supposed to be. She may be thinking she wants one type of birth, but internally she is not sure she is committed to that ideal. There are a lot of factors that enter into their birth experience. What kind of birth does her partner want for her? What kind of birth does her family want for her? She may be committed to her birth ideals but as her labor and birth unfold parts of the jenga puzzle are pulled out and all of a sudden emotionally she is spent and she can not hold onto the ideals she thought she was committed to at first. Perhaps her water breaks and her labor does not begin on its own. The augmentation to her labor shakes her to her core and she no longer is able to see herself managing without pain medication. Perhaps she thought she would begin labor rested but instead it began after a long day of work and beginning labor fatigued is too much for her to be able to stay the course originally planned. Perhaps her water releases only to reveal thick meconium and the plan to labor in the tub are no longer an option. Maybe in her wildest dreams she labors for a full day but then when 24 hours of labor pass and she still has more to go, she can not move past it being longer than she had ever imagined. Maybe she thought she had her friends and family on board with the emotional support she felt she needed, only to have phone call or text messages asking why she has not already had that cesarean that seems to be inevitable anyway. There is a wall she can not climb over. (more…)

Pampering: Preparation for Birth

Sometimes when I remind a mom who is due soon that she should be using the last weeks of her pregnancy for pampering, she thinks this is frivolous behavior. Pampering is a great preparation for birth! Here are the ideas and the benefits to each of these things that I suggest!

Resting, getting more sleep! Our bodies when we are almost due becomes in more need for sleep and rest. So listen to your body! If it says to call in to work for a rest day- do it! If you need an afternoon nap- take it! And although you are feeling the need to finish all of your last minute tasks, don’t! Go to bed early! Why? Fear and fatigue are the main reasons women who did not plan to get medication end up doing so in labor! So deal with your fear- but definitely don’t go to bed late to only wake up in a few hours in full labor and not have had any sleep. So, please listen to your body- your body and baby will appreciate you doing so!

Massage. Circulation improvement, muscle tension relief, round ligaments being softened so that the baby can position themselves beautifully, mind release… need I name more reasons? Really, come on now- if you are one of those folks who does not think they enjoy a good massage, there are different types of massage. Try something different! Watsu is a gentle water massage in a warm pool and is very passive- stretching and swirling and softening tight muscles. Shari Aizenman offer this in the metro area. KMI is my favorite- and everyone knows Harry Kramer is my go to man for keeping my body albe to be at births over and over! I see him once a month! This is a deeper, stretching massage but he caters to what your body is craving. And one of our doulas, Charlotte Scott offers energy body work that is a different approach as well. She has this magnificent table that offers music and rhythm as part of the experience in a unique way. She does more lymphatic massage when working on me and it is wonderful as well.

Chiropractic. I have a few favorite chiropractors. I think you should consider regular chiropractic care during your whole pregnancy- just like regular massages. Why? A well aligned body keeps the baby well aligned. Blood flow and your organs working at peak performance can only enhance your birth body! I think you should choose your chiropractor based on where will you go most- is it close to your work or is it close to your home- or are they open in the evening- whatever it is – make sure they are well versed in good alignment for the best birth body you can go into labor with! I enjoy going to see Leyla Cheveney in Lilburn and Danielle Drobbin in Midtown. But I must confess I need to go more often! Find the chiropractor you love and go!

Acupuncture. I have to say going to my acupuncturist is one of my favorite things to do. I love the environment of his space and his energy is contagious. I always leave feeling energized and whole. So, who does not need to feel energized and whole for labor? Two of my favorites include the gals at Intown Acupuncture but I have to say my acupuncturist is Gurusahay at GRD clinic. But in order to get the most benefit from acupuncture, go early in your pregnancy- don’t wait til you are in your final months! (more…)