My heart is with you, Dr. Poppy! And may your words be the voice of experience for others.
It is long, but a very worthwhile read.
As I type, I look over at my one-week old baby zonked out in his cradle swing and am in awe at how awesome his arrival was. Instead of having my third c-section as scheduled, I went into labor on my own (first time in 5 tries) and delivered him (precipitously in fact), one hour before I was to arrive at the hospital for my surgery. I find this wonderful and quite ironic in light of the recent NIH VBAC conference in Bethesda, MD; I had just downloaded the consensus statement and was digesting it while awaiting my baby’s arrival (more on that later).
In order to tell the story of how I ended up with a surprise VBAC, I have to start at the beginning of my long and adventurous reproductive journey. My first pregnancy ended in the first trimester with a miscarriage and heavy bleeding requiring a D&C to stop it. I was a OB/Gyn resident at the time and was surrounded by high risk OB patients every day. I trained in downtown Philadelphia where an addicted mom with no prenatal care could deliver on one end of the hall, while a high risk IVFer from the Main Line might be delivering on the other end. Although we worked side by side with midwives, we only became involved if their patients developed complications or needed a C-section. Needless to say, like most OB residents, my experience with normal, low-risk physiological birth was minimal. Being pregnant in this environment and then losing the baby certainly colored my perspective. Like any mom who loses a first baby, I was troubled with the worry that I wouldn’t be able to have another baby, so that when I did become pregnant again, I embraced the “we have to be very careful and be supervised very closely with this one” approach. I worked up until term, 36 hr shifts, 100 hr work-weeks, having to turn sideways at the operating table at the end, and then it was decided that I should be induced at 39 weeks due to gestational hypertension. There were no signs of pre-eclampsia and the pressures were not sky-high, but at the time, I fell into the “you’re term, what’s the need to take a chance” mentality and was scheduled for an induction. I went in at night for prostaglandin gel due to an unripe cervix (should have known better) followed by Pitocin the next morning. I labored all day, getting the obligatory epidural that a Pitocin induction necessitates, finally getting to complete around 8 pm. I pushed for 2 1/2 hrs, I used the bar, the sheet, everything the hospital approach has to offer…but the baby was OP and would not rotate with “all” of our maneuvers and so I received a C-section for “arrest of descent.” Happy as I was with my new son, everyone who has labored and then had surgery, knows the pain that you are in for. I wasn’t disappointed in the C-section because at that time, I was still fully entrenched in the “at least I have a healthy baby” mindset.
Despite that experience, I always wanted to have a vaginal birth and since most university hospitals were still doing them regularly (’03), I chose a new doctor whose obstetrical/surgical skills I trusted who would support by desire for VBAC. My pressures started acting up again so I was slated for induction, although this time my cervix was riper and I went right in for Pitocin. They did one of the most inhumane things which was to artifically rupture my membranes on Pitocin in the active phase of labor. Needless to say, an epidural was imperative but I almost couldn’t sit for it due to the pain. This time I pushed for 3 hours, hard pushing, hands and knees at one point (I must have learned something from the midwives), and ended up with a vacuum extraction and a fractured coccyx, from a 7#14oz baby. He had jaundice and a cephalohematoma but hey, I got my VBAC. He today is honored to say, “I broke mom’s butt when I was born.”
Baby number 3 was an easier pregnancy although this time I added on gestational diabetes so that plus the usual spike in blood pressures brought us back to induction. Although he was my smallest baby, 7#, he still was delivered by vacuum although my butt remained intact. With baby number 4, I figured another VBAC was practically guaranteed so I didn’t resist the induction assuming the last birth meant smoother sailing now. This time they decided to start the Pitocin the night before, but instead of staying at a low dose overnight, the nurse kept coming in and increasing the dosage. I knew I wasn’t progressing because I was not in active labor, so I questioned her about the dose, reminding her that I did have a scarred uterus. She responded that everything looked fine but she would stop until morning. Morning arrived with the usual course of epidural, AROM and increasing Pitocin. When it came time to push, within 20 minutes, I knew something was wrong. Despite the epidural, I could tell he wasn’t coming down with my pushing and by the frazzled looks of everyone in the room, I knew the heart tones were dropping. I looked at my husband and told him we needed to stop. By the time they got down to the uterus in the OR, it became clear that if we wouldn’t have stopped, I would have had a uterine rupture. As it was, I had what is called a uterine window, they were able to see the baby’s hair through a very thin lower uterine segment.
Finally, I made the connection between the induction and the narrow avoidance of catastrophe. So with baby number five, I knew I did not want another induction. Interestingly, this pregnancy was also my healthiest. I had made a concentrated effort before becoming pregnant to address my diet and treat my vitamin deficiencies, so I had no blood sugar or blood pressure problems, kept my weight gain to 15 pounds and did not have any obstetric problems other than being an advanced maternal age grandmultipara with a history of 2 c-sections! Knowing that I had never gone into spontaneous labor, I felt the safest route was to do a scheduled repeat C-section at 40 weeks. I did put it into God’s hands and had been in prayer that I was open to the baby coming forth in whatever way he was supposed to…and so I went into spontaneous labor at 2 am, the morning of surgery, got to the hospital at 4:30 and was 9 cm dilated. The staff asked me what I wanted to do and I said, “I’m going to have him!” They also offered me an epidural (too late for that) and IV pain meds (I certainly didn’t want a narced up baby), so unmedicated it was, and he was born at 5:13 AM, a beautiful, alert 7#11oz baby boy who latched right on and has been peaceful ever since. Not having to recover from an extensive surgery was a gift for which I continue to be amazed and grateful.
Reflecting back over my journey, I see how much the field of obstetrics has managed to contribute and sometimes outright cause complications, all the while assuming they are just keeping everyone safer. And I see how much fear has overtaken the natural birthing process. I’ve said before that shows like Deliver Me, A Baby Story, and Birth Day should be renamed “Fear Factor” because they play on a woman’s often natural concerns about the birth by portraying the whole process as highly dramatic, with a woman strapped down and hooked up, by a doctor gowned and gloved like an alien visitor and often highlighting very anxious family members. Sure a woman has fear, fear that something is going to happen to her or the baby, fear of pain, fear of failure, that she just won’t be able to “do it.” Add in snarky, cynical nurses and doctors who ridicule anyone who seems to want to be in charge of her birth (after all we’re the experts)…limited labor support or assistance in the form of doulas or labor coaches except in certain areas…restricted mobility, food and drink…and almost endless interventions and you have potential for trouble. We have cultivated an environment that this is normal, and somehow now some women even find value in being “risky.” My mentor, Dr. Lauren Plante, a maternal-fetal medicine specialist who had two midwife-attended home births, wrote about this in anessay entitled “Mommy, what did you do in the industrial revolution?” Meditations on the rising cesarean rate: “Although the inherent literal meaning of the high-risk pregnancy is one that entails a higher risk of a poor outcome (for mother or baby), the sub-text seems to be that high-risk equals high-value…is it the Disneyfication of a primal human endeavor, longing for the synthetic and dramatized in preference to the authentic?” In other words, do we have more regard for the Main-Liner’s IVF-achieved pregnancy who has an elective c-section over the addicted mother’s unmedicated spontaneous birth?
All of the repeat C-sections and almost extinction of VBAC, have not really prevented poor outcomes as revealed by the NIH VBAC conference. Women who have a trial of labor after a previous cesarean have a lower risk of maternal mortality compared to those who have a repeat cesarean. Although there is a higher risk of uterine rupture with trial of labor, spontaneous labor versus induction has the lowest risk. And there have been no reports of maternal mortality due to uterine rupture (we were constantly told…mother and baby could die with VBAC). Repeat C-sections are also associated with an increased risk of abnormal placental position and growth in subsequent pregnancies, which also increases risk of cesarean hysterectomy. Although there is an increased risk of perinatal mortality with trial of labor, the risk is small and not that different from a laboring woman with her first pregnancy. Issues related to medical liability are a big concern for many practitioners, a fact that could be alleviated or helped by tort reform and hospitals assuming some malpractice costs up front. In our local hospital, although the hospital allows VBACs, there is at least one doctor who simply doesn’t want to take any risk and personally won’t do VBACs. This approach is unfortunate since the overall finding of the NIH conference is that trial of labor is a safe option for many women and that women should be fully informed so that they may make the best decision for them. ACOG certainly needs to revise its mandate that anesthesia and c-section should be available immediately so that more rural hospitals can still offer VBAC to their patients without feeling they are not within standard of care. Can you imagine if I had been in a VBAC-banned hospital and been forced to have surgery at 9 cm dilated? Can you imagine how that would have increased my potential for morbidity and even mortality? Should everyone have a VBAC? No, but every woman should still have the opportunity to discuss her personal issues and whether it could be an option for her, and she should be not be forced to have surgery against her will due to a medically-unsubstantiated VBAC ban. We should continue to make efforts to reduce medically unnecessary inductions for mom and baby’s well-being, we should attempt to humanize cesareans for moms who need to have them, we should properly evaluate and assess each VBAC individually to decrease risk, and we should place natural labor and birth back into the realm of the norm, with the interventions and surgeries reserved for the truly high-risk.