fetal sex, First Baby, Gender reveal, Home Birth, hospital birth, Midwife, Nurse, OB

Finding out the Fetal Sex, Or Not, and Why I Hope We Can All Just Relax

(The phrase “gender reveal” has become a popular way of saying, “to find out whether your baby is a boy or a girl.” However, a baby’s genitalia at birth is actually its assigned “sex,” with “gender” being a social construct that the baby may or may not identify with later in life. It is also important to remember that genitalia sometimes presents at birth as neither specifically male nor female. I have done my best to use medically correct terminology, except in certain contexts.

In addition, I generally try to use gender-neutral pronouns when referring to pregnant or birthing parents and their partners, except when I am referring to a particular individual who specifically identifies as male or female.)

In April 2017, an Arizona man started a nearly 47,000 acre wildfire, and was consequently charged with a misdemeanor, given five years probation, and ordered to pay more than 8 million dollars in restitution. The fire resulted from a gender-reveal stunt in which the expectant father fired a gun towards a target that was labeled, “Girl” and “Boy”. Anyone with half a brain could have seen that it was a high fire-risk day. The video is devastating.

It made big news and sparked (ha!) a lot of discussion about sex vs gender, our attachment to binary gender roles and identities, and some of the social implications of gender reveal parties, a trend which has spread, well, like wildfire.

While it may seem uniquely extreme for a father to have taken such a risk in order to reveal whether his kid has a penis or a vagina, I have also seen my own clients get probably more enthusiastic and attached to the fetal sex – and knowing or not knowing the fetal sex – than is healthy or practical.

The advent of non-invasive prenatal testing (NIPT) has enabled pregnant families the ability to find out the sex of the baby as early as 9-10 weeks of pregnancy. The test pulls fetal or placental DNA out of the pregnant individuals’s blood and looks at a few specific chromosomes, including X and Y. It is 98%-99% accurate for fetal sex.

The original, intended purpose of the test is to seek out evidence that a baby may have Down Syndrome, a number of sex-linked disorders, and a few other – often severe – chromosomal problems. But the fact remains, many people run it because they want to find out if their baby is a boy or a girl before their first trimester is complete.

Back in the day, it was the ultrasonographer’s job to announce or withhold the sex of the baby, at around 20 weeks. Now, with most clients choosing NIPT at their first routine prenatal visit, the boy vs. girl vs. “we’re not finding out” ball is very much in my court. More mishaps and inconveniences have resulted from the NIPT than I can count.

An NIPT result once predicted my clients’ baby would be a boy with Klinefelter’s syndrome. After a visit to the genetic counselor (where they learned that the NIPT is between 45%-55% accurate for Klinefelter’s – a fact which the original OB either didn’t know or didn’t take the time to counsel them on before the test), and after being harassed by their MFM to have an amniocentesis, they ultimately chose to take no action. Based on their understanding of the nature of Klinefelter’s, they saw no reason to go to such invasive lengths such as an amnio to find out with more accuracy what was going on. They were going to birth and love their son with a possible Klinefelter’s situation no matter what. A few months later their healthy baby was born with normal female genitalia.

YEP.

There’ve been multiple issues with the handling of the results themselves. Since I have a paperless practice, the results are uploaded to the client’s medical portal, where the sex can potentially be seen by the client if they want to view their records. When I draw an NIPT, I ask the client up-front whether they want to know the fetal sex, so that I may withhold or reveal the information appropriately.

The many and varied answers to, “Do you want to know your baby’s sex?”:

  1. Yes. (Easy…you would think.)
  2. No. (As long as the baby is negative for sex-linked disorders, my lab will withhold, upon my request, the fetal sex from the test results so that I don’t even know the sex, which is ideal. This way I can’t slip up and accidentally use a gender-specific pronoun during a visit (it’s happened). However, not all labs have always offered this service, so it has often been up to me to redact information and keep it a secret.)
  3. I don’t want to know, but my partner does. (This requires communication outside the client-midwife relationship. I usually text the partner, but still have to redact the sex result from the report so that the birthing parent does not see.)
  4. I want to know, but my partner does not. (Easy, but I still redact the sex just to be safe, because sometimes partners are allowed access to the chart by the pregnant person.)
  5. We don’t want to know now, but we may want to know later. (This means that I must find out the fetal sex and withhold the information until a later time at which point I may reveal it when requested – and try not to slip up in the meantime. Sometimes parents like the info in a sealed envelope, but sometimes they don’t trust themselves not to take a peak before their desired reveal, so I remain on standby.)

The variety of plans creates a minefield of opportunities for me or the lab or my technology to screw up, and a number of opportunities for an astoundingly upset client. Now that I am in private practice, it’s not too difficult to keep everyone’s preferences straight, but when I worked for a much busier birth center with multiple midwives, students, and administrative staff, communication about revealing or not revealing the fetal sex was a nightmare.

A couple had come to us for their first baby, and wished to have the fetal sex results withheld. At the time, our lab did not offer the option to withhold the fetal sex before they sent us the results, so somebody on our staff was going to see the sex no matter what. Our system at the time was that our admin assistant would print out the PDF that came in on the online fax account, scribble the sex out with a sharpie, then scan the document back in. She would notify me that the task was complete; I would make it available to the client in the chart and notify the client that their results were normal with the baby’s sex withheld.

Upon uploading the results with the sex scribbled out, I received an irate call from the father who was livid because we knew the fetal sex and he was afraid I was going to slip up and reveal it. I attempted to explain to him that it was the admin assistant who had seen and redacted the sex, not me, and that the X and Y chromosomes aren’t just for sex reveal but are also indicative of some serious disorders, so it was our business to know the baby’s sex chromosomes. I think he just needed somebody to yell at that day.

While I’m always apprehensive that I might mess up and say what the baby is when I shouldn’t, I more often forgot the sex of people’s babies when I was doing office visits for 30-50 active patients, . Many parents still strongly value gender-specific pronouns when referring to their baby, so if I can be accurate when referring to a baby during the visit, I’ll do my best.

We used a charting system that required several clicks of the mouse to get to the section where the sex was either noted or redacted. Some days, I admit I was just in a hurry, or the pages were loading too slowly with our crappy wifi. Sometimes I genuinely chose personal connection over burying my face in my laptop. Thus, it was not unusual for me to turn to a client I’d met with several times already and ask, “Remind me if this baby is a boy or a girl? Or is it a surprise?!”

Most folks didn’t really have an issue with my forgetfulness. They’d remind me over and over again and were super sweet about it. But one day a couple came for a routine appointment, and I asked my routine question: “Remind me if this baby is a boy or a girl?”

The mom looked like I had slapped her, and the rest of the visit felt awkward and overly quiet. Predictably, I received a phone call from the father several days later; they were offended that I did not remember the sex of their baby. I replied that frankly their baby’s genitalia doesn’t matter to me too much. Their baby’s health is what mattered. Each of my clients has a unique plan of care, and I care deeply that each person’s plan of care is delivered. However, I cannot memorize everyone’s plan of care, so I need reminders. Perhaps a midwife in smaller practice would serve them better? A week later, they switched to a solo-practice home birth midwife.

These days, I use a charting system where I can display in large red letters at the top of every page: “BABY IS A GIRL!” or “DO NOT REVEAL FETAL SEX!” So the sex status is in front of my face at all times. It shaves off so much time and uncertainty. Thank you so much ClientCare!

Technology doesn’t always work like you think it will. When our administrative assistant moved away, there was a time where I was uploading and processing my labs by myself. Instead of printing out NIPT reports to redact the sex with a sharpie, I used some basic PDF modification software that came on my laptop to block out the fetal sex. I’d save the new, redacted PDF, and upload it to the chart.

One morning I woke up to one of the most strongly worded emails I have ever received. It was from a first-time father who claimed he found out his baby was a girl even though the couple specifically asked the fetal sex to be withheld. Among other things, he stated that I had “ruined the pregnancy.” Hyperventilating, I logged into the chart to find that the results were still safely redacted, just as I had edited them the day before.

Baffled and weeping, I called my boss. She was kind enough to moderate a group phone call between herself, myself and the parents. It turns out that the parents had opened the chart on one of their phones, and because the phone did not possess the same software as my laptop did, THE redaction did not show up in their version of the test result. I DID NOT EVEN KNOW THIS WAS POSSIBLE FOR A PDF! I THOUGHT A SAVED PDF WAS A SAVED PDF!

The family and I got through this challenge and they went on to have another baby with me. We are friends now and I adore them.

It occurs to me that so many occasions in which a client gets upset about the fetal sex-related mishaps, it’s the dad who takes issue. (A dad once become angry at a birth because out of the six multi-colored, multi-patterned receiving blankets we routinely put on the baby tray during pushing, a couple of them happened to be pink or floral, and the baby was slated to be a boy.)

I’ve rarely had a mom be so emotional about it. There was a sad occasion where a hurried admin assistant told me that she had redacted the sex, but she hadn’t. I didn’t think to check the assistant’s work, and notified the client that the results were in. I received a polite but disappointed email from the mom the next day…”I can never unsee this information.” I felt like garbage; she forgave us.

I’m not certain if this difference in degrees of reaction has to do with the patriarchy poisoning dads’ minds, or if it’s pure biological love that allows the birthing parent to be more neutral, but it sure is an interesting pattern.

When NIPT was very new and insurance companies weren’t covering the service, yet, I had a couple for whom money was no object. They paid over $3000.00 out-of-pocket for the NIPT (the mother had a lot of anxiety about Down Syndrome) but asked that the sex be withheld. They were a Jewish couple in a very Christian community, and I had never before been called upon to research resources for Mohels. Since they did not know their baby’s sex, but knew they wanted a bris if it was a boy, I spent several weeks gathering leads for home-visit Mohels even though I knew all along their baby was a girl.

Laboratories can screw up, too: We had a couple who were getting married and wanted to announce the pregnancy and sex of the baby at their wedding. The lab lost the results – for weeks! – and in a race against time, my boss teamed up with the lab rep and finally got the fetal sex results about 20 minutes before the wedding dinner. I’m so grateful that situation was taken off my hands. I simply would have lost my mind.

Other medical offices can mess up – or maybe they don’t even try. It’s not unheard of for a client transferring late into my care to pick up her records from her old provider, with the sex results glaringly visible.

Recently a client asked me to redact the fetal sex from an NIPT, so I asked the lab to withhold it. The lab screwed up and sent me the fetal sex with the results. Not the end of the world; I simply redacted it on my own, and sent an email to my lab rep to let her know about the mistake.

However, when the client went for her anatomy scan, the perinatologist put the fetal sex in the ultrasound report EVEN THOUGH SHE SPECIFICALLY ASKED THEM NOT TO. Again, I just redacted it on my own, but now I have to erase her baby’s sex from my mind – forgetting is harder when it’s such an issue. I cannot deal with any more angry dads or wildfires!

I grow more and more appreciative of one of my heavily pregnant teachers in school, who, when asked if her baby was a boy or a girl, would simply reply, “Yes.”

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