My first birth C-section and disrespect.
I never doubted my body’s ability to give birth. I guess that is why I didn’t think I needed to research my birth options. My mother gave birth vaginally, her mother, my other grandmother had 10 children vaginally, all the way back to my great great grandmother who had six sets of twins vaginally on a Cherokee reservation. My first pregnancy was stressful but I had a great doctor who assured me all would be ok.
Unfortunately, circumstances beyond our control, we had to a move 5 hours away at 32 weeks. That’s where any “birth plan” I had went out the window. The only doctor I found who would see me obviously had no faith in me. I honestly believe when I walked in the door he saw a very petite woman and thought C-SECTION! The day before my 40 week appointment I had an ultrasound done and everything looked great.
However at my appointment the next day my doctor started scaring me by saying my placenta was depleting and becoming less safe for my baby and I needed to be induced the next day. My cervix was still hard and I wasn’t dilated. I asked if we could wait at least a week and was made to feel like I had just asked the stupidest question on earth “but your placenta is DEPLETING!” I reluctantly agreed after he assured me that if the cervadil didn’t soften me enough we’d wait or try another round.
I went to the hospital that night and they started the cervadil.
6 am the next morning the Doctor came in to check me and said that I was “a little softer, but only dilated to a one”. He then proceeded to BREAK MY WATER. Pitocin was started at some point I can’t quite remember if that happened before or right after my water was broken. The next few hours were hell. The doctor had the largest hands I’ve ever seen on any human and he HURT me so bad every time he came in to “check me” I asked tearfully several times to let the nurses do it. After several hours of the pitocin being increased and increased I asked for some pain meds and eventually an epidural.
When I requested these I was again made to feel stupid and incompetent as my doctor asked “why did you wait? You just wanted to know what pain feels like?” The epidural was terrible. I couldn’t move from the chest down and started having panic attacks. I was also almost given phenergan twice, which I am severely allergic to. I am so lucky my husband was so vigilant and asked what they were giving me every time they came in to give me anything.
Almost twelve hours in my doctor came in and started pushing for a c-section. I said I didn’t want one and that’s when he pulled out all the stops telling me “your baby will go into distress”, “fine don’t do one now but I’ll just be back in an hour or so rushing you in for an emergency c-section” and the real kicker “I have been doing this a long time and I know when a woman isn’t meant to give birth, you’re just too small”.
Feeling beat down and like my body was betraying me I agreed. Strapped down and feeling broken I welcomed my beautiful daughter into the world. They brought her over to see me for a brief second and my husband was able to hold her and go with her to the nursery. Laying there being stitched up I cried. Not the beautiful happy cry it should have been. I felt terrible. My child was beautiful but I didn’t get to hold her and bond. I was not happy like I should be I was angry. I felt like a failure.
In the recovery room it only got worse. My nurse said something along the lines of, “I hope you didn’t want a big family” I asked what she meant and she said “well they will only allow you to have one or two more c-sections”. I told her I would attempt a VBAC next time and she said, “not in this city you won’t”. Again I felt like a failure.
When I finally got to hold my baby several hours later I felt horrible because although she was the most beautiful thing I’d ever seen I didn’t feel any bond. She immediately wanted to breastfeed and was a total champ at it although my milk wasn’t completely in. Thankfully the bond came quickly over the next week and I thank breastfeeding and plenty of skin to skin time for that.
My beautiful birth center VBAC and hospital stay
Within months of my first daughter’s birth I started doing my research on VBACs and birth choices. I knew what happened to me was wrong, but I wasn’t prepared for how common it was. I was told to check out “The Business of Being Born” and was shocked! How could the state of birth be so awful in OUR country? It was then that I decided my next birth would be with a midwife.
When we found out we were expecting our second baby we started the search for a midwife. One of my husband’s co-worker’s wife had recently had a VBAC with a midwife named, Joi, and only had wonderful things to say about her. When we met with Joi, I instantly knew she was the one for us. She shared our faith, spoke confidently, and put any fears we had at ease. I told her my birth story and she was as mad as I was and even got teary eyed with me. Immediately I had a sense of comfort and a new found confidence in myself.
Over the next few months I had my share of doubters and was even called selfish for wanting a better birth experience. I had to come to realize that those who were negative and rude, just didn’t know what I knew and so I started trying to educate others on the risks and benefits of each birth option. My confidence grew over these few months as well. I was more educated than ever and had wonderful support.
Thanks to a wonderful friend I was even able to attend the Birth Without Fear conference where I was encouraged and my spirit was strengthened. My team at the birth center was amazing as well. Joi and her backup midwife were wonderful as well as the student midwife Meghan who was the person I felt most comfortable texting with random questions. I had no doubt that my team was there for me and believed in me.
We had everything planned out so well. My husband was going to get a bonus at just the right time to help us pay off the midwife, my best friend who does photography was going to come and photograph the birth, and my mom was going to be there to watch my daughter. However in the last few weeks of my pregnancy everything seemed to fall apart. Three weeks before my due date (and six weeks before Christmas) my husband not only didn’t get his bonus, but also had to take a 30% salary cut. My best friend wouldn’t be able to make it and my mother had to go out of town. I was very upset and stressed out, but Joi held my hand and assured me that it was in God’s hands and that whoever was meant to be at my birth would be there.
At 40 weeks 6 days I started having regular contractions. They would start out ten minutes apart and get closer to 3-5 minutes apart, but then they would stop for several hours. This went on for two days before I asked Joi if I could come in and be checked. I went in Thursday afternoon December 12th and I was dilated to a 3 and about 80% effaced. After my first birth experience I was so overcome with emotion when I found out how beautifully my body had progressed on it’s own.
I felt confident in my body, but I asked to have my membranes stripped at this point. It was an “intervention” I felt confident in having as it was my choice on my terms. My husband and I must’ve walked five miles that afternoon stopping every five minutes to breath through a contraction. The contractions continued to get closer together and stronger. Around 9:30 I called Meghan and told her that I thought this was it and was ready to come in. We agreed to meet at the birth center in an hour.
When we got to the birth center I was checked, and I was somewhere between a 4 and 5 and still 80% effaced. I had the option of going home to labor a little longer but decided to stay and get in the tub for a little while. My contractions were strong and I did low moans through them. As I labored it was just my husband Ryan and I.
I couldn’t have asked for a better support than my husband was. I didn’t want to be touched or coddled I just wanted him to hold my hand through the contractions. It was such an intimate experience and I was glad that it was just us, no cameras, no nurses, just us. About 1:30am I was checked again this time I was 5cm and 90% effaced. I decided to get in the bed and try to rest some. Joi told me to try just breathing through the contractions and not moaning. My husband got in the bed with me and held my hand with each wave.
After a while of being in the bed I could feel a change during the contractions. The only way I can describe it is it felt like my water was trying to break. I kept saying to myself “these contractions are not stronger than me because they ARE me.” I decided to get on the birthing ball for a little while. The contractions were more intense now and I had lots of pressure on my lower back. Joi came in and showed Ryan how to apply counter pressure. I kept thinking this hurts but not too bad, but it’s going to get worse.
About 30 minutes after I got on the birth ball Joi came in to check me again. She looked at me after a minute and said, “sweetie I think you’re complete.” I thought she meant completely effaced and my thought was “ok big deal,” but then I looked at Meghan’s face and she was smiling and excited. I looked at her puzzled and said, “wait, completely what?” “Completely DILATED,” she said excited. I realized that sensation I was feeling during contractions was the urge to push. With the next strong contraction I started pushing.
A few pushes in I moved from the bed to a birthing stool which made pushing so much easier and more productive. Having both Joi and Meghan there pushing me and encouraging me was amazing. My husband sat behind me and gave me strength by just holding me. My water finally broke but there wasn’t the huge gush of fluid I had expected. Shortly after my water broke, Joi told me to reach down and feel my baby’s head. It suddenly became so real, I’m DOING this. I am pushing a baby out! I felt a rush of strength and with the next two pushes my baby was born at 4:38 am, Friday December 13, and immediately placed on my chest.
All the pain and anger from my oldest daughter’s birth was forgotten and healed in an instant. I couldn’t believe how smoothly it went, I never had a moment where I felt it was too much or I couldn’t do it. I was on cloud nine. I did it! At some point I looked up and said something to the effect of, “suck on that, Dr. O.” I can’t describe how amazing I felt in those moments after she was born. I proved to my doubters, and more importantly to myself, that I could do it. Joi cried tears of joy with me and Ryan. She thanked ME for letting her be a part of my birth. That amazed me. What a difference in care. What a blessing.
Unfortunately a few days later I got very ill. I went to the ER with 103.5 temperature, and when I got there my heart rate was 150. We eventually found out I had a rare blood infection group a strep. There was no way of knowing how or when I got it and I was told I most likely was a carrier of it on my skin and it entered through an open wound during delivery. I could write a book on my terrifying hospital stay, but what is important is my husband and I were informed.
We asked questions. We made the doctors take their time to explain things and refused unnecessary procedures. They tried to tell us to send my baby home, but when pressed for why we should they couldn’t give us an answer so she stayed. They tried to tell me I should never give birth outside the hospital again, but when asked if they could have prevented this or caught it earlier they said no. They tried to tell me I put myself at a “great risk” for uterine rupture by having a VBAC, but backed down when I threw actual statistics their way. I stood up for myself and I believe I showed my strength.
“This is the story of my Home VBAC Water Birth after a traumatic cesarean birth and a miscarriage. My story really begins with the birth of my first son. It is fairly lengthy, so I didn’t want to repeat the whole thing here. Some of what I will share will make more sense if you do read it. It was written over a year after my son’s birth, and while I might not write it exactly the same today, it is very much how I felt at the time and a part of my journey. My son is now 3 1/2 and this birth was just as much for him as it was for me and our new baby!” – Melissa
I separated my cesarean birth experience from my son from the moment I met him. I knew I had to in order to be a mom to him. Those few days had torn my heart and made me question everything. I couldn’t have this beautiful new little being attached to such horrific event. He was here, he looked like my husband so he must be mine, and I was going to do everything I could to succeed at what was left for me to do – be a mom.
For months I didn’t dare think about what happened, I was holding on to my faith by a thread. When I did start to think about it I struggled with making sense of it. The only conclusions I could come to were either A – God wanted this to happen, in which case I was incredibly pissed at Him and didn’t want to talk to Him, or B – This was a test, as I had felt it had been, and I had failed in which case I was ashamed and didn’t want to talk to God. So I stopped. I wasn’t until our son was about 2 years old that I started to make any sense of the spiritual aspect of the events. I often get flack for saying this but it doesn’t change what I know. My first experience was a test, God tests His children with trials, and I failed. He asked me to trust Him and I didn’t. It’s taken a long time, but I have come to terms with that. The key is “His Children”, even though I failed, I am still His child and I have learned from my failure.
In March 2012, I found out I was pregnant again. We were both so happy! We wanted more children and hadn’t expected to take as long as it did to conceive again. I was in the middle of planning the first Bellies to Bambinos Expo. I knew I would have a lot of work to do to prepare for a VBAC but I was busy with the expo and figured I would have plenty of time after it was over. I did, however, come to the conclusion that there was a good chance that I could have another cesarean and that I needed to be at peace with that. My husband thought I was giving up on a VBAC like I had given up on my first birth. But I explained that I just needed to be able to be at peace with either outcome so that I wouldn’t be in fear the whole time. I knew that even if I had another cesarean there was no way that it would be like the first. One major reason for that is that I was educated this time and I was going to trust God. If I had another cesarean, it wouldn’t be because an inpatient OB bullied me into it, it would be because there was not other choice and it was truly needed. This was a bit of a revelation for me.
April 8, 2012 around 1am, I was up with my son, who had been woken up by our new noisy neighbours again, and I had a cramp and got dizzy. I thought it was odd and was a little worried but I as 10 weeks, I went back to bed. I woke up with bleeding. I called for Dave, in tears, and asked him to pray. Even thought it wouldn’t end up being over for 8 days, I knew in my heart that our baby was gone. I had cramping and bleeding all that Easter Sunday that peaked that night in about 6 hours of, what I can now say was transition like, labour but without the pressure. I had taken another shower as it had helped before, but it was too hot and I started to pass out. I had no intention of going to the hospital and I was fine by the time my husband was on the phone to 911, but I went anyway. They confirmed in what I knew in my heart. I was so sad, and scared, but I was trusting God. They had offered me a pill to speed things up, but even though I thought they were right, I knew they could be wrong and there was no way I could take control of this. I left it in God’s hands and our little “Sprout” came to us on April 16, just after I had attended a birth. It is still incredibly sad, but I am at peace with it. God loves me and knows best and this is what He chose.
The end of October 2012 and I was pregnant again! I was excited, but both me and my husband were a little hesitant to be too excited. He will admit that he had issues bonding with the baby even up to the birth. He had been hurt by the miscarriage and was afraid to get attached and lose another child. I knew either way, this was going to be hard. I was either going to face another miscarriage or have to fight for the VBAC I knew I wanted. With the planning of another Expo in the works, I went to some counseling with a doula friend of mine who is also a Christian. She asked some hard questions about my faith, as I had come to terms with my failure at my first birth but hadn’t really known how to move forward from there. How do I see myself? How does God see me? Who did He make me to be? In light of this, how should I live? Questions we should all ask. I didn’t get time to finish all the sessions before the birth, but even just having someone listen to me and not throw out the standard “Thank goodness for Drs, God made them too and they obviously saved you from yourself” and “you should be happy you have a healthy baby” was a load off of my shoulders.
I remained cautiously excited and did what I could to stay healthy and give myself the best shot I could at a successful VBAC. This included having midwives and choosing a home birth. I also wanted as close to an unassisted birth as I could get and still have the midwives there. I wanted to know that this was happening on my turf and I was calling the shots. My midwives were so supportive and respectful of my decisions all the way through pregnancy and the labour.
I had gained about 70lbs with my son, I believe mostly because I was allergic to wheat, diary and corn and didn’t know. This time I gained about 25lbs and attended belly dancing classes, to which I attribute the amazing core strength I had through out my pregnancy. I also took a few different vitamins and supplements, saw a naturopath and had a few acupuncture treatments. While for months I would jump at any little twinge or gush, in fear of another miscarriage, but the pregnancy was without any major complications. I was, and remained a good candidate for Home Birth and a VBAC.
I didn’t know it was possible, but I started having Braxton Hicks contractions from about 6 weeks pregnant, I had never had any the first time. The baby also dropped in to my pelvis and was quite low very early on. Everyone, even the midwives, speculated that I might go early! Since being post dates was the major instigator of everything that happened the first time, I really hoped they were right!
Week 40 came and went, I was now 40+5 and creeping closer and closer to the 41+4 that my son was taken from me at. I was still in good spirits but the worry was always there, quietly in the background and saying that the clock was ticking and I would have to fight. I had a plan, I would be 41+1 on Canada day and I have a fairly severe allergy to milk. My plan was to go to Dairy Queen and get a Blizzard if labour was no where in site! A BIG one! I knew that it would have about the same effects as castor oil on me and would taste far better. The midwives thought the plan was hilarious and even said they hoped it would work so they could write “induction via Blizzard”. My husband didn’t mind the idea either as he hadn’t had a Bilzzard in as many years as I had.
My midwives appointments were every Friday now. Thursday afternoon I lost my mucus plug! I was excited as I knew that meant change, but cautious as it was no guarantee anything was going to happen soon. My Braxton Hicks came back again, as they had stopped for a couple of weeks, but were different. I didn’t know for sure what it meant – early labour? Nothing? I was excited about both at my appointment and really didn’t have any desire to discuss induction at our Friday meeting. I really thought the baby might be here by Canada Day. My Midwife was optimistic, but was talking about what day the hospital did inductions. I think I started to tune out at this point. I am sure she knew I wasn’t going to agree to one, even if it meant being 42 weeks and having to deliver in the hospital, but it was on the check list for the appointment. I left still in good spirits but anxious to move things along.
I had been doing and taking everything I could over the last couple of days to get labour going, homeopathics, essential oils, sex, evening primrose oil, acupressure and letting my son nurse as much as he wanted (which was the only thing that seemed to do anything). Each evening feeling hopeful I would wake up to labour. When my husband got home that evening, we went out and got some groceries and went to the bank. At the bank I saw my naturopath and asked if she would be able to do a treatment on me, she said “Yes!” and came to our house later that evening. She put in about 25 needles, ALL the way. I think that was about my third or fourth treatment ever and I really wasn’t expecting the needles to disappear into me! My husband thought it was hilarious and just had to take a picture to commemorate the moment. I thought for sure I would wake up in labour this time!
Sunday morning came, and once again I had slept the whole night. My husband went and did the setup and sound and took our son with him as he usually did. I slept in and made sure I went into church late. I didn’t want to talk to anyone, especially when most knew that I was due or post dates. I didn’t want the questions, the looks, the “You’re still here??” stare. I came in and sat at the back, with my husband at the sound table and avoided eye contact with everyone. Much to my pleasant surprise, one of the other moms came in a bit after me and walked right over and said “You look like you are going to have that baby any day!” It almost brought me to tears. I had carried very high and trim the whole pregnancy and most couldn’t believe I was full term because I looked to small this time. This instigated a lot of “You don’t look like you are having a baby any time soon” type comments, even when I was 40+ weeks. This was the first time anyone had said I looked ready. I needed that. One concerned friend came over with an almost frantic look on his face after church and said “Where is your baby??” His wife had been a part of the Blessing Way group and my Mom had told them on Friday that I was in early labour, I guess some had assumed that I would have had the baby by now. I relied pointing at my belly “In urtero.”
I came home from church tired and exhausted. I was getting scared, worried, frustrated and just plain fed up. I felt like I had done everything I could and my body was just saying “NO.” I didn’t feel like it would ever say “Yes.” My husband went took our boy outside with him and worked on the shed that we had been building, he had hoped to finish it before the baby got here so he was taking the opportunity while he had it. This left me some time to think. I often do my best thinking when I am journaling, something I haven’t done a whole lot of lately but I felt I needed to get it out. I wrote/prayed to God and wrote to my baby. I begged God, pleaded with Him to make me go into labour NOW! As I thought this I realized that this wasn’t His way. While I am all for doing things to prepare your body as best you can for labour, I had been attempting to take things from His hands, once again I wasn’t listening to Him or asking Him or trusting Him. The chief end of man is to glorify God and enjoy Him forever. If I “made” myself go into labour, who would be glorified? God doesn’t like to share His glory, and He clearly told me He wasn’t going to. I could either trust Him, or fend for myself. Well, I know how well that worked out for me last time. I chose to trust Him. I also wrote to my baby, I told it that I was sorry I was so sad and that it was safe to come out now, but if it waited to much longer, it might not be. Mostly I was scared to fail, scared to fail by baby and my son, who wanted to be at the birth so much. After my praying and journaling I felt more at peace, I had let go.
Once I had let go, I decided I needed to do something to keep busy and keep my mind off of things. Cleaning the bathroom has been my husband’s job for a long time. It started with the toilet when we got married. I said the two things I do not do are garbage and the toilet – that is a boy’s job. Since he was already there he kind of just took over the rest of the bathroom and it’s been that way for years. However, every woman knows that most men’s version of clean isn’t quite the same as ours and I would need to do a really through clean every once in a while to satisfy myself that it really was clean. I had found out I was pregnant right after moving into our house and had never had the energy to bother with a good scrubbing the whole time we had lived here. In the back of my mind I had known for weeks that the bathroom was going to get cleaned by me before the baby would come. Now was the time! I scrubbed my heart out and cleaned every inch. My husband came in at one point and tried to take over, being sweet and not wanting me to have to do it. I quickly bit his head off, tired of waiting for labour, and said “Just leave me alone! I have to do SOMETHING!” I just as quickly apologized and he left me to clean.
About 8pm Sunday I started to feel the surges again, but stronger. My heart was elated, I knew this was it! I kept it a secret as I wasn’t having to breath through them yet and didn’t want my husband to be too excited to sleep. I had a bath in our soaker tub with a small glass of wine and some cheese. I floated and swayed in the water, reveling in every surge and delighting in secret that only myself and my baby knew – we would soon meet. I went to bed but I didn’t feel I would wake in the morning.
About 4am Monday I had been awake for a bit off and on, the contractions were becoming stronger and I couldn’t sleep through them any longer. The birds were singing outside our window as they always were at this time. The sun was just beginning to make it assent into the sky. I had to get up and move. I put on my robe and paced and swayed. They were strong enough that I couldn’t ignore them but I didn’t have to breath through them yet. I hummed and sang to my baby, standing and swaying in the front door watching the sun rise. I sang the song from church the day before that’s lyrics were “Grace to you and peace, from God the Father and the Lord Jesus Christ.” It was new but words and the melody had been playing in my head since I had heard it. I enjoyed our time together, some of our last hours so close. I am in tears remembering the beauty of it as I write.
About 6am my husband and son woke up. He had known that things were happening but had tried to get some more sleep. He got us breakfast then proceeded into a flurry of action that lasted the rest of the day. He was excited and nervous and I think he felt like completing tasks was the best way to “fix” the situation. Some of the things needed to be done, he went to the grocery store and got some food for everyone and kept our son busy and fed. But all I really wanted was for him to hold me, sit with me and for us to spend some time together as a family. The contractions had gotten stronger and I was having to breath through them by mid morning, but they were still irregular and anywhere from 5 to 10 minutes apart. I waiting until I thought everyone would be up on a holiday Monday and let them know what was happening. I called my doula, my midwife, my photographer and my Mom. I had at least 2 or 3 contractions when I was on the phone with each of them and always felt like a creep doing all that heaving breathing on the phone. I had a good laugh with each of them about it too. They all appreciated that I had waited until morning to call and were on standby if anything changed. Nothing really changed.
When my doula and midwife arrived to stay, I felt like things were finally really happening! I was vocalizing through contractions and coping well. Up to this point I had been labouring on my own. My husband had been home for the most part, as well as our son, but mostly I was going doing my own thing without any support through the contractions. It was good to know I wasn’t alone and I didn’t have to troubleshoot things myself anymore. I could just let my mind go and let things happen.
My husband filled the birth tub in our living room while our son was still sleeping. I was in different positions and tried the tub. I was still eating, drinking, peeing and pooping – oh the pooping! I don’t think I have ever pooped so much in my life! The student midwife arrived and at 6am I was 3cm and 90% effaced. I didn’t want to hear that, I was tired and already felt like I had been in labour forever. It was progress, but it wasn’t as much as I had hoped. The midwife called this the start of active labour. I knew I wasn’t going to give up but I was discouraged that I had made what seemed like so little progress. I also knew that things could change quickly as my cervix had almost completely thinned. We called my friend, fellow doula and volunteer birth photographer to come when she was ready. I continued in and out of the tub and different positions, vocalizing eating, drinking – pooping! Around 10am they checked me again.
I was 6cm, once again it was progress but labour was getting really hard and it seemed like it should be happening faster. I was in the thick of active labour and it hurt like hell. Nothing seemed to help. I was getting frustrated that nothing seemed to even be taking the edge off. At every birth I had attended there was always something that helped. I couldn’t understand it and I was starting to feel like no one was helping me. They were all there and supporting me but I didn’t feel like they were. I think everyone could tell I was hitting a wall and suggested I go out side for awhile, it was humid but a nice day. I really didn’t want to, but did it anyway.
As soon as I stepped out the door I had to drop to my preferred hands and knees position as this was how I had been labouring, that, and howling like a banshee! When it was over I made it about another 20 feet and was down again. I stayed down when it was over. My husband was with me and I could tell he was worried. I really wanted to say “I can’t do this” but I knew I couldn’t, I wouldn’t. I did say “I don’t know if I can do this” but that is because I didn’t know. It was so hard, nothing had prepared me for that. Not the books I had read or even the births I had attended. My husband was strong for me when I couldn’t be, he told me I could do it and that I there was no way I was going to give up.
I made it back in side and sat on the birth ball. My midwife could see that I was still having a hard time, she talked to me about my head space. She suggested that maybe I was trying to have three labours at once – my first son’s, my miscarriage and this one. She later said I gave her a look of death and that is why she had backed off after, but it was just that I hadn’t had a conversation with anyone in a while and just wasn’t in the head space to think quickly. I took a few minutes and really thought about what she said. I came to the conclusion that I didn’t think that was the issue, or at least the biggest one, but I did realize that I was thinking too much about the future. I needed to deal with what was happening right then and there. I needed to take it one contraction at a time and the truth of the matter was that I WAS doing it and had been doing it already much longer then I ever thought I could have! That was the moment I dug deep and fully committed. This was happening, it was what I had wanted so desperately and I was going to see it through. I wasn’t alone, God was with me, friends and family where praying for me and I was joining every other woman throughout history that had every given birth.
Less then an hour later I was on the toilet, again, and started feeling a little “pushy.” My contractions actually stopped for a little while too, and my whole demeanor changed. I “woke up” and looked around, I was smiling at people and greeting them, as I didn’t remember doing it when they came in. It crossed the back of my mind that this could be my “rest and be thankful” stage before pushing! I asked to be checked. About 1:30pm I was 8cm with a thick lip at the front, they told me not to push. Once again I was feeling somewhat defeated, happy that I had made progress but really expecting to be closer to fully dilated. Now I was in transition, wanting to push, feeling like my pelvis was going to break into a million pieces and I couldn’t do the one thing that had brought me any relief – push. I got into some forward leaning positions to try and put pressure on the the front of my cervix, it was so hard, but there was only one way out – quite literally! And that was for things to progress. At some point my husband had started breathing with me as I had totally lost control of my breath at the peak of the contractions, he said “Breathe innnn and ouuuut.” This became my ritual, my breaths were me saying/yelling “IIINNNNN – OOOOWWWWTTTT!” And, yes, “Out” just so happens to start with “Ow!”
Just after 2pm I was into the tub again and that is where I stayed! I was actually sleeping in between contractions and my body was starting to push all on it’s own! About an hour later they checked me again and I still had a cervical lip at the front, so they said not to add anything to the pushing my body was doing. My body might push through the lip but they didn’t want me to cause anything to swell. The student had checked me and she also said that I could likely reach the head if I wanted to feel – did I ever! It was the most amazing thing to feel my baby’s head while it was still inside me. I could also feel what my body was doing and boy was it doing something! I had moved into a squatting position in the tub and thought I might as well try and do a bit of pushing with a contraction to try and get the feel for it.
I had my finger on my baby’s head and it moved a little when I pushed, but right after I stopped, my contraction peaked and my body pushed – it moved about a 1/4″! WAY more effective than anything I was doing. My contractions spaced out a bit at this point, likely to catch up to the movement of my baby down the birth canal, and I slept in between them. I felt my baby through every one, I even let my husband feel too.
The second midwife was there and keeping our son occupied as official “Pooper Scooper” and got him involved in checking the tub temperature too. It wasn’t too many contractions before I started to feel a bit of the “ring of fire” and everyone said they were starting in be able to see hair! I hadn’t been freaked out or worried up until then. This was the part that I had been a little worried about – crowning – I didn’t want to tear and I heard it burned like hell. I had to take my hand away for a bit so I could gather myself. I put my hand back and my baby’s head was right there! It was slipping back a bit in between contractions so I did a little bearing down in between so that I wouldn’t loose any progress. A couple more contractions and it’s head was out! They knew I wanted to be the one to pick the baby up so all they did was check for a cord around it’s neck. It had a tight one they couldn’t get off, so I pushed out the shoulders. My baby was born! I picked it up and brought it into my arms. As a family, my husband, my son and myself – we welcomed our new son!
At 5:49pm on July 2, 2013. Our family was reborn. As a family we welcomed our new son and brother, Levi, into this world, into our home, without drugs, without interventions, without fear and in God’s own timing. Levi means “joined together” or “joined with him”. That day our family was joined together and so was my heart, it was healed.
- Photos © 2013 Nicole Marozzo & Melissa Van Dam
Surita Carstens from South Africa described her first baby’s birth as, “…one of the most traumatic experiences in our lives.” We published that story in 2012 and it moved many of us to tears with its senseless cruelty. At the end of it she wrote, “I hope that one day I can have a VBAC to empower me and feel like the woman I was born to be.”
Almost a year ago, Surita’s daughter Sandra Maria was born. This is the story of her birth.
“It all started with the birth of my son, Nicolaas Mertiens Carstens. His birth was a traumatic experience, filled with a lot of unnecessary interventions. It started with my water breaking, a rush to the hospital, a lonely night bound to a hospital bed with no contractions, a forced induction and after five hours of labour, being scared shitless, an emergency C-section at almost five centimeters due to “failure to progress”. That day I made a choice: never again would I get a C-section unless it was really necessary, and I would be informed enough to know when it was necessary.
Before my son’s birth I never knew about VBACs. But when I started talking to people I heard differently. Then on a Facebook forum I met a lady, now my friend, who had three natural births after a C-section. And then I learned about water births, home births, midwife births and so much more! Things that we thought were “old aged” but that were coming back.
My dreams were focussed on home birth after reading several home birth stories and because I was so scared of another medicalised birth in a hospital environment. So we started searching for a home birthing midwife. However, soon we found that in the small town we lived NO doctor would support us for a home birth, no midwife would help us unless we had a doctor’s support, and also, there were no midwives in our town.
I emailed many, talked to doctors (and I wasn’t even pregnant yet). Finally we found one midwife who would help us. We met with her and liked her, and then we got her price rates. Shocker! We could NOT afford her and as she didn’t use medical aid, there was no way for us to pay her at all. We started searching once more. After months of searches our General Doctor told us he would help us, so we settled on him. We trusted him and thought he would be a great choice, the birth happening at his offices one block from our home.
When our son was 21 months old, I told my husband Jp that I really wanted to get pregnant. It was a Saturday evening, I knew I had the perfect cycle and was ovulating the Monday, so we started trying. When I tested 10 days later we had a BFP. We were pregnant! On our way to having our next baby!
When we talked to our GP again he told us that, since he wasn’t getting any clients for births anymore, he had cancelled his birth insurance the previous year. He couldn’t help us anymore.
The search started all over again.
Finally at eight weeks pregnant we found a gynaecologist in another city who was reputed for doing natural births. His secretary told me he would allow a VBAC, so I made an appointment. He could only see me for the first time at 15 weeks, but I was OK with that, having learned from my research that I preferred not to have a lot of scans early in pregnancy.
The doctor asked how my son was born; I said it was an emergency C-section and his reaction was, “Oh, OK, so we will do a C-section again.” When I told him that I wanted a VBAC he got upset and started talking about how ‘dangerous’ it is. I told him I had the facts, and got out my research and handed it to him. His reaction was, “We’ll talk about it later.” Next up, he wanted to do an internal exam, which I also refused. Another fight, because according to him he needed to do internal scans with every visit to ensure baby was healthy. I said NO!
So we did a normal scan, but according to him he couldn’t a) say what sex it was without an internal, b) look for any birth defects without doing an internal and c) he only gave us the approximate weight at that stage, didn’t check lengths of the femur, head circumference or anything else. After the scan I brought up the VBAC again. His answer was, “I will do an internal check at 36 weeks and then I will decide IF I will MAYBE allow you to do a VBAC, else you will have a C-section between 37 and 38 weeks.” I told him I refused to have a C-section early, and wanted to go into labour naturally. Again he refused, and told me to come back in three weeks so he could do an internal scan to look for defects.
I walked out super sad and feeling beaten. After two years of waiting, everything was falling apart. Another two weeks of phone calls started, calling every and any doctor that I could find, fighting with the medical aid in emails and on the phone and searching, searching, searching.
And then my miracle happened!
Jp and I drew a bank statement of our savings, which to our surprise, were over R7000! And when talking on a Facebook group, a midwife mentioned that if I could come to the city my parents lived in she could help me with a birth and a payment plan over six months. Wow! We started making sums, but I couldn’t finalise anything until end of November when I got my bonus. When it came it was much smaller than expected but we decided to go for it anyway. I also really wanted a doula as well and had met one in October, but finances would just not allow it. Then a Facebook friend heard of my problem. Being a doula herself she said she would help me for free. I was way past happy!
However, there were a few glitches. Number one, the midwife was over two hours’ drive away so I would only be able to see her maybe once a month; I would need someone closer to home for more visits. Two, if an emergency arose I had to have a doctor near our home who could help. Three, because of our financial situation, a home birth at my parents’ place was out of the question – we needed the medical aid to pay for the birth. So another round of fights started about the hospital I should birth in, some of the operators stating the medical aid would pay and others stating it would only pay a certain amount and even more stating that it wouldn’t pay at all. I got the promises to pay in writing via emails.
We planned, we budgeted, and we planned some more. What was clear was that I had to birth at a hospital or else they wouldn’t pay at all, and we found out that my medical history with Myasthenia Gravis and epilepsy meant I had to have a paediatrician on standby in case my baby had breathing or heart difficulties. We never even knew this with my son.
Finally at 22 weeks I went to visit another GP in our town who did do births (mostly C-sections and he refuses all VBACS) for another scan and at 23 weeks we saw our midwife for the very first time.
I loved Heather from the very first minute. She had this way of just making you feel confident in yourself and in her. But she also had a softness and kindness that made me feel at home. Most of all I loved the way they did the examinations. It was so much softer, kinder and more intimate than at the doctor’s. Instead of feeling like just another number I felt accepted and for the first time I wasn’t scared of going for a check-up! And thus it was settled, we would use Heather and any of the other midwives who work with her and we would pay financially as we could, when we could.
I couldn’t see her in January, but saw her again the first Friday of February, March and April. My due date according to ovulation was 15 April, but last menstrual period said the 18th, so we met her three times in April, the last on the 15th.
The baby was still not engaged. She was very low already, but I showed no other signs of imminent birth. I didn’t want any interventions, preferably not stretch and sweep and most definitely no breaking of water or induction, so we decided to wait two weeks before doing anything. My doula, Anina, suggested that I start looking into using pressure points for induction and gave me a site to visit for help. That evening hubby started using them. We also started with evening primrose oil and several other non-invasive natural induction methods, including sex, bouncing on a birth ball etc. The days passed without anything happening. Every morning I would get Braxton Hicks contractions and every evening I would have prodromal labour, contractions 10-12mins apart and lasting 30seconds from 6pm till around 9pm, but as soon as I hit the bed they would stop. We waited.
My other birth companion was to be my best friend, Erika. On 17 April she came to visit so we could chat one last time before the birth and she would know what I expected from her. Three times during the day she and Jp did some pressure points and that evening I ate some pineapple, joking with my mum that I hoped it would induce my labour. Then Jp dropped off Erika at her home and I put our son to bed. The prodromal labour was worse than before and my mum was getting worried, she kept saying I was going to go into labour. I didn’t want to get my hopes up. After days of prodromal labour I was just not hoping anymore and thinking my body was failing me. So I went to bed and Jp stayed up watching a movie. I was sad.
Our son woke me just after 3am to go to the loo. I wasn’t feeling well but didn’t want to wake hubby for “not feeling well”. At 4:15am I woke up again, my tummy was hurting and I thought it might need to go as it had woke me the two previous nights; so I went to the loo – nothing – got back into bed and it started hurting again. Went to the loo again, still nothing and back to bed. When it hurt for the third time I looked how late it was (4:35am) and started timing. Every seven minutes, lasting 30-40seconds and I was…resting? This was different.
At 5:30am I woke hubby telling him I thought I was in labour. I stayed in bed until 6:10, as the contractions moved to five minutes apart, lasting for 30-40 seconds. I went to tell my parents and called Heather. My mum got stressed, wanting me to go to the hospital, saying her contractions were like that with my brother and he was born shortly after. Heather, however, said to wait until they were regular at four to five minutes and lasting over one minute long. So I helped my mum to leave for work and then crawled back into bed trying to sleep. The contractions weren’t really sore, just uncomfy. We all dozed until just after 8am when I got up and started breakfast and washing some clothes. I wanted my son to be sorted with clothes while I was in hospital.
Hubby decided to take a shower while he still had the chance. While he was away I was hit by a contraction and while breathing through it my son decided he wanted to drink some of my mum’s cleaning agents. When I opened my eyes I saw what he had done and rushed to him, smelling the cleaning agent in his breath. The ultimate stress! A friend phoned just at that moment, said she would help and get back to me. During these moments my contractions came every two to three minutes! One hour later we had finally learned that it wasn’t terribly poisonous but to watch him for vomiting and nausea. I was relieved but the episode had stalled my labour and my contractions were back to being seven minutes apart. My mum, a crèche teacher, decided to pick our son up and take him with her to work. Hubby and I went for a walk, hoping it would help get things back on track. But my contractions went to every 10-12 minutes and almost non-existent in length. Just great.
Told hubby labour was gone and I wanted to take a nap. It was 10:30am and I was feeling unsure. So hubby went to watch a movie and I rested. I woke at 11:15am to a hard contraction! We were back on track, every five minutes and lasting 30-40 seconds once more. I got up and went to join him, bouncing on my birth ball, breathing slowly through the contractions, enjoying the new sensation of it. They still didn’t really hurt and I was in heaven knowing my body was working to birth my baby. My doula sent me a message asking how I was and suggested I take a bath. At just past 12pm I got into the tub. Immediately my contractions increased, and by the time I got out they were two to three minutes apart and lasting up to one minute. Hubby got a little worried so I decided to get out and eat something. I ate some wonderful leftover carrot soup, but the labour slowed down again. The contractions still didn’t really hurt, I used hubby to breathe through them and I was just enjoying it, so when Anina phoned I told her I’d let her know when I needed her.
By 2pm my contractions were four minutes apart and lasting just under a minute. I phoned Heather who suggested waiting another hour before we decided what to do. I wasn’t worried yet, was just enjoying the ride and was sure it would be some time still. Then suddenly I felt a change. I couldn’t sit still during a contraction anymore. I had this peculiar urge to kneel and sway my body during the contractions and they felt stronger, harder than before. I had three very close together like this and at 2:45pm told hubby I think it’s time to leave, something had changed. We phoned Heather and Anina and got into the car to leave. Heather told me that she was in another city and it would be some time until she could get to the hospital but she would get a colleague to meet us. The car drive hurt, a LOT. Sitting still in one place was sore, I couldn’t kneel and sway, couldn’t bounce or anything except breathe through the contractions and they were coming over and over on top of one another.
At 3:15pm we stopped at the hospital. While getting out of the car I had another contraction and the security guard rushed to my aid while Erika supported me. She immediately wanted to fetch a wheelchair but I said it wasn’t necessary. Inside I booked in with the hospital and another security guard got super upset that I didn’t want a wheelchair, telling me that if I fell I would get hurt. (Erm, you’re SUPPOSED to walk during labour.) Erika just brushed them off and we went to the midwives’ labour and delivery suite.
When I arrived I was met by Christelle, the other midwife, and within moments Anina also arrived. While hubby fetched the bags Anina supported me during contractions and Erika took photos. First I sat on the birthing ball bouncing while we all chatted and Christelle put up the monitor to see what the contractions were doing and how they affected bubs. My labour had stalled after the car drive. After a while of bouncing we went for a walk through the parking lot, stopping every once in a while for the contractions where I would hold onto hubby and breath through them. Anina encouraged me to sway my hips and would put pressure on different parts of my back to help with pain. I can’t say that it was hurting at all – though I did have to concentrate and breathe through them. I was envisioning circles in a water pond, opening up growing bigger and bigger.
After a nice long walk and some chats and laughs we went back inside. Anina suggested listening to some music and that hubby and I dance to get some oxytocin flowing. Hubby put up Celine Dion’s CD which immediately got me into tears and we were swaying together, holding onto each other. We have been through so much lately and it just was too much for me. Again it was Anina who made the suggestion that I relax a little in a warm bath. Heather arrived and asked to do a doppler check first. The baby’s heartbeat was doing great so I undressed and got into the bath where I just relaxed and chatted while holding onto hubby during my contractions. Still it didn’t really feel like I was in labour.
After the bath Heather suggested some stretches to help with bringing baby down into the birth canal and we went for a walk. Every time the contractions hit I would sway and bend my legs pushing down, breathing through them, concentrating on baby coming down and in between contractions I would do the stretches. I was surprised to find it was dark outside; I had lost all sense of time.
When I re-entered the birthing rooms I was tired, so tired, I just wanted to sleep. Anina helped me down onto the birthing ball. I wasn’t resting very long when Heather asked if she could do an internal exam. It was almost 7pm and she felt it was necessary to know how far I was as I was so relaxed. This was the one part I had been dreading – after my son’s birth I was scared of internals and I was scared of what it would tell us! I was scared I wasn’t dilating enough and would have to go in for a C-section. Heather knew this and she was so kind and helped me to relax and breathe. Hubby helped me down onto the bed and to lie back, another contraction hit and Heather waited it out with me. When it was over she did my internal.
I was at 8cm, almost 9cms!
WOAAA!!! This was really happening! I burst into tears. After the hard long road, I was birthing my baby. What a feeling!
When I got off the bed I felt something shift and change again: the contractions were suddenly so much longer, more painful, more intense and I was feeling different. It was as if I was there, but also not there at the same time. Heather went to get a hot water bottle and poured my bath and Anina helped by applying pressure on my hips. Heather returned and stood behind me, hubby sitting on the bed in front of me. I was bending, swaying and doing things without thought, and I was moaning. Heather applied pressure with her hands on my rectum pushing upwards and at the same time pressing on my back down, both definitely helping, and next thing I knew I felt this bursting sensation. My waters had finally burst. I remember thinking, “Oh no, I just messed myself as well!” But I hadn’t.
Everyone was excited, but I felt this rush of tiredness. It was as if all my energy had drained away and I could barely breathe.
Anina asked if I wanted to get into the bath, but I was so exhausted, tired, I couldn’t even answer. After she asked for the third time hubby made the decision to get me into the bath. Between him, Anina and Heather they almost carried me to the tub a few meters away. The relief of the pain was immediate.
At first I sat hunkered forward on my knees. But this caused a problem. My baby’s head was pressing down so hard that I immediately felt the urge to push and push HARD, but I wasn’t fully dilated yet and was hurting myself. Hubby and Heather both kept asking me to try and stop pushing, which I just couldn’t do! My contractions weren’t even one minute apart and they hurt a LOT.
After a while Heather suggested that I turn around and sit leaning against the bathtub. I didn’t have the energy between the contractions to do it myself, so they had to lift me up and do it for me. But it brought immediate relief. The urge to push was gone and the contractions didn’t hurt as much. I was so grateful to have a little breather.
After a few minutes, Heather announced that baby’s head was moving down the birth canal and that I should start pushing when I felt the urge. I followed her instructions and I was LOUD, making lots of noise, sometimes almost screaming with the pushing. Everyone was encouraging me to push harder, push more and in between Heather asked me to not scream as loudly as it interfered with my pushing. Suddenly Heather realised I couldn’t concentrate through all the noise and asked everyone to just keep quiet and told hubby that he was to tell me when to push and how to push. He sat, holding my hands, lifting me up when the contractions hit and talked to me into my ear, encouraging me. In between contractions everything was quiet. Sometime, someone had put up Josh Groban’s music and I heard him singing. It gave me the courage to go on.
Baby started crowning, and damn that hurt. It felt like my clitoris was on fire and I instinctively wanted to close my legs and shut out the pain, but then I couldn’t push. Hubby leaned over me and held my legs open while I pushed. Heather encouraged me to feel her head crowning and took my hand and guided it to feel her. It felt soft and I could feel a little bit of hair. But every time, just when she crowned her head would pull back in. It felt like ages passed and I just had to keep pushing. Heather suggested that I continue to push just a little between contractions to keep her head crowning. Again she guided my hand down. I could feel our baby’s entire head now and could feel my perineum stretched over it. I pushed, but it didn’t want to come out. I really didn’t want to tear or be cut, so I started praying, asking God to help me, and in between I talked to our baby, encouraging her to come out.
Then the next moment I felt her head pop out! Wow, she was there! Then with the next contraction her body just slipped out and after a few moments Heather lifted her onto my chest, covering her with a towel. I was in ecstasy, I had done it, I had gotten my VBAC! When every doctor, every person I talked to, had told me I couldn’t, not with my history. I had proven them wrong. My baby was there and I had birthed her myself. At 8:30pm, after about 30 minutes of pushing, she was born weighing a nice 3.3kgs!
No words can describe how I felt. Minutes later the placenta was born and I could join hubby and baby on the bed. I got to breastfeed her immediately and my parents and sister could see her moments later. My son, however, had fallen asleep while waiting for us.
I only had three very tiny tears on the inside of my vaginal wall, no tears on my perineum. It was the most amazing and empowering feeling ever!
I am so grateful to Heather, Anina, hubby and Erika. Every wish I had expressed in my birth plan was followed by Heather. I achieved every dream I had and I can never forget how amazing that felt. Thank you to everyone and mostly thank you to my Lord Jesus for helping me! I am a woman, I have given birth and I am a mum!”
Maternal Death – the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. (WHO)
This is a subject no one really wants to talk about. Mothers die. Mothers die in pregnancy and childbirth and just after birth. The weight of that reality is just so heavy and heart breaking. In our current birth culture, fear reigns. However, fear reigns without reason or knowledge of what really needs fear. And of course – all of us hope to Birth Without Fear. And so, I approach this subject with a heavy heart but hope as well.
Where Does It Happen?
In short, it happens everywhere. However, some areas are more prone than others. This can be due to lack of care – think of sub-Saharan Africa or rural villages in some undeveloped countries. Maternal death in those areas is an unfortunate fact of life (though organizations are striving to change this).
But apart from the “obvious” places, where do you suppose it happens? Perhaps war-stricken places, or those places without advanced medical facilities? Would it surprise you to know that the United States has one of the highest maternal mortality rates in the developed world?
Yes – you read that right. Our current maternal mortality rate is 21 deaths per 100,000 live births as of 2010 (WHO). This rate went up from 2005 (18/100,000). The 2010 “Healthy People” Goal for the United States was set at 4.3/100,000 – we grievously missed that by a large margin. The 2020 goal is 11.4/100,000, which would only be a 10% decrease from what the US considers to be its current statistic (the 12.7/100,000). I find it interesting that the government decided after they missed the 2010 goal that maybe they should try less to save mothers, since their efforts before had no effect and saw a rise in deaths.
The WHO number is adjusted from the number reported by the CDC (12.7/100,000) – this is because the United States does not have a universal system of reporting maternal deaths and the CDC admits that our numbers are drastically under reported due to this lack of uniformity in reporting (See this CDC publication, specifically page 20). Currently, only 25 states make it mandatory to state that a death was pregnancy related on the death certificate – and even this method is questionable due to lack of doctor training in filling out certificates and the great fear of litigation in the medical system. Ina May Gaskin writes about the lack of reporting here.
Other countries have much better standards of reporting. The “gold standard” is considered to the be reporting system in place in the United Kingdom. The UK ensures that not only is every death reported, but they also compile the deaths and reasons for them in a report every three years. This report is available to the public and the locations and names of the deaths remain confidential. This allows the nation and the nation’s health workers to look at the issues without fear of litigation – meaning they have no reason to hide maternal deaths.
To provide some perspective, here are the rates of some other countries:
- Australia: 7/100,000
- Brazil: 56/100,000
- Denmark: 12/100,000
- Germany: 7/100,000
- Israel: 7/100,000
- Japan: 5/100,000
- Netherlands: 6/100,000 – note that about 30% of all births here are at home.
- United Kingdom: 12/100,000
As you can see, we are rather behind many other countries – and don’t worry, I am going to come back to Brazil and why I included that statistic which is very high for an industrialized country (as is the USA’s number).
Why Are Mothers Dying?
This question is hard to answer since as mentioned above the reporting methods are varied and not always followed. We do know that some deaths are simply not preventable, this is just a fact of life. However, looking at the much lower numbers in other comparable nations we know that unpreventable deaths are not the reason for the very high numbers in the United States.
We know that it is not from lack of care in general – reports show that over 99% of all women in the United States receive prenatal care. However, we have to look at the level of care women are receiving. We have to ask, does a 5 minute rushed visit with your actual doctor count as adequate care? Does more diagnostic testing equal better care? Does spending more money equal quality care? (The numbers say no – we spend more than any other country in the world on birth).
We see a HUGE disparity in death rates in regards to ethnicity. An African-American woman is 3.3 times more likely to die in childbirth than a white woman. This is simply not acceptable in a country as advanced as ours, and one that is supposedly equal. Midwives such as Jennie Joseph are helping to implement ways to combat this disparity – her creation of The JJ Way is an example of how we can work to correct this travesty.
A big question that needs to be asked in the United States has to do with who is providing this care – care that is obviously not saving as many mothers as it should. In the United States women overwhelmingly see Obstetricians. While Obstetricians are amazing for complicated and high-risk pregnancies, they don’t have much training in plain old boring pregnancy and birth.
A majority of the time pregnancy will proceed in a normal fashion, and birth will follow in the normal fashion. When we use care providers who are trained to search for problems there tends to be a trend of finding problems whether they exist or not, or whether they are actually emergencies or not. As the saying goes, “Give a boy a hammer and he will find something which needs to be hammered.”
We can see that in countries were the majority of care is given by midwives (or that country’s equivalent care provider) the maternal mortality rate is lower (and the infant mortality rate is lower as well). The United Kingdom is a great example of this. They are comparable to us in many ways (general health and population structure), and yet consistently have better maternal outcomes. And they use the midwife model of care in which all women start with midwives and only transfer if problems arise. (Note that a woman can opt for an OB to start with, however most do not).
Now for the elephant in the room: the United States cesarean rate. Our current cesarean rate is 32.8% (CDC). Yes – basically 1/3 of all babies in the US are born through cesarean. So are 1/3 of all US women somehow “broken”? Unable to birth? Producing massive or stubborn babies? NO – of course not. If 1/3 of all women in the US were “broken” then those numbers would be reflected all over the world, and the statistics show this is not the case. In the same vein, we are not producing massive babies either – in fact the average birth weight has gone down as the cesarean rates have gone up (and is independent of that rise or that of induction).
Remember when I said I would come back to why I included Brazil? Brazil has a rather good medical system and is considered a developed country, so why the massive maternal death rate (56/100,000)? Take a look at their cesarean rate – 52.3%. Yes – over 50%. Brazil is an interesting case since most of these surgeries are elective, even for the first time mothers. The fear of childbirth is so deeply engrained in Brazilian culture that women jump at the opportunity to have a cesarean and avoid labor totally. A vaginal birth is seen, culturally, as something only poor women do because they can not afford a cesarean.
That mortality rate could be the United States’ future. We see a fear of birth in the US, and a huge cultural love of telling horror stories about labor and birth. We see more interest in elective cesareans (though elective first time cesareans are not significantly altering the rates). As VBACs are “allowed” in fewer and fewer places and malpractice issues continue to rise we see more and more women forced into surgeries they do not want or need. Our rates are heading right up to that of Brazil’s, and our maternal mortality rates will be sure to follow. A Cesarean increases the risk of death significantly in comparison to vaginal birth.
In comparison, the rate of cesarean in the UK is 25%, the Netherlands has a rate of 14%. As I stated before, the UK has 12/100,000 rate and the Netherlands 6/100,000 – rather interesting that as the rate of cesarean is almost half in the Netherlands and their rate of maternal death is also half that of the UK. While in some countries a higher cesarean rate does not correlate to a significantly higher mortality rate, those countries with very high rates of cesarean typically have higher (or rising) mortality rates.
We also cannot forget postnatal care. The postpartum period is one that needs care just as much as the prenatal time period. In the US, typically a woman is seen in the day or two after birth, at two weeks or so, and then at six weeks…and that is about it. This is simply not enough during this time of life when hormones are changing, the body is attempting to heal from creating another life, and things like retained placenta or clots can cause major issues. A much better plan of postpartum care must be put in place.
What Can We Do?
Be Educated. That is the number one thing you can do to not only help yourself have a safe pregnancy and birth, but also to help the women around you as well. When you learn, share the information. Break down the myths that pervade this culture – break down the assumption that VBACs are dangerous, or that “big babies” need surgical birth. Share the studies and articles you read.
Be Fearless. Help to eradicate fear of birth. Can birth end in tragedy? Yes. Unfortunately is does happen. But with proper and evidence-based care we give ourselves and our babies the best chance. Share the positive birth stories you hear. Share your positive birth. How does this help? It helps women to not fall into a fear based decision that increases her risks of complications – namely induction and cesarean. When a woman can start her pregnancy and birth journey from a positive place it gives her more space for growth and research. Absence of fear is not ignorance of risks – it is not being beholden to the fear of risk.
Those two things hand-in-hand – education and fearlessness – can go a long way towards helping this mortality rate go down. An educated woman is better able to avoid situations or care providers that increase her risks, and a fearless woman is better able to stand up for herself and decipher what is really in need of intervention and what is not without cultural fears clouding her view. Lets do our part to save mothers.
“My sweet man will be a year old tomorrow so I wanted to share my story and pictures. I wrote this a couple of weeks after his birth and never could have realized how much this baby would change and bless our family. We’ve come a long way in our almost 15 years of marriage. My story does leave out a major event. Due to a difference in opinion in my care, one of my closest friends and I split ways when I was almost 37 weeks. The trauma from that, really effected the last weeks and threatened my focus.” – Piper
So much happened to lead up to the conception and birth of this baby. Dealing with infertility. Re-evaluating our marriage and relationship with God. Deciding to sell our house where we’d built our family. So much had changed in our lives in the 7 years since I was pregnant with Pruitt and things had really changed since Cale’s birth in 2002. Pruitt’s birth was quite traumatic for me and we knew this birth needed to be different. It was immediately decided upon that I would VBAC (vaginal birth after cesarean) and that I would birth at home. We were confident in our decisions and not once did Chris or I question what we felt was the best for our family.
My pregnancies with Cale and Pruitt were pretty uneventful. I felt great and thoroughly enjoyed pregnancy. However my pregnancy with Callaway was NOT at all what I had expected. We found out that I was pregnant one week after moving into our new home. Surprise and shock don’t adequately describe our feelings, but we knew that this baby was a gift. You can’t argue with God! This pregnancy, I was constantly nauseous, tired, had pain from what we think was stretching/ripping of scar tissue from my c-section with Pruitt, major pubic bone pain. Then right as I started to feel great again, I was hit with rising blood pressure, protein in my urine and the threat that I may need to birth at a hospital. The entire pregnancy I did my best to not complain, to feel grateful and blessed, but the last 4 weeks of my pregnancy were some of the most difficult.
We did many things that we believed would help achieve the homebirth I wanted. I had received chiropractic care the entire pregnancy and continued to do so right up until the day of the birth. I received personalized care from midwives. I had my BFF as my doula. I kept my plans of VBAC and homebirth to myself (which I highly recommend since both topics seem to get TONS of unsolicited information/opinions!). We spent a lot of time as a family, planning, talking, praying for a great birth. I even went for hypnosis. I visualized and prayed for a relatively quick, easy birth, with very little discomfort (these were my exact words). I told myself that my birth would be easy considering how trying the pregnancy had been. That made sense, right?! And most of all, my husband, Chris, he continued to support and encourage me. He was my rock the entire pregnancy and birth.
From the beginning of my pregnancy I told people that I was due at the end of September. I wasn’t ever really sure of my due date and knew that it didn’t mean squat. The midwives had my due date as the 23, my chart said maybe the 25, and I had given myself the date of the 28. I decided to start counting weeks on Tuesdays so when I hit the 40wk mark, I did have a mini-breakdown. I had never been that pregnant before and couldn’t believe that I was STILL pregnant. I started to question if my body knew what to do, if my body worked. I had to truly let go and come to terms with the fact that it wasn’t ME in control. I knew I needed to trust God, my body and my baby, but that’s easier said than done!
Friday, September 28
My midwife came to the house AGAIN, to check on us AGAIN. Blood pressure, urine, baby – all doing well. Told the midwife that I was sick and tired of everything. I was done with the prodromal labor. I was done with the pubic bone pain. I was done with drinking a gallon of water. I was done with counting grams of protein in each meal. I was done with the constant blood pressure and urine checks. I was done with taking all the supplements. I WAS DONE. She assured me that even though she’d told me it wouldn’t be much longer, it truly would NOT be much longer. I assured her that I was not believing anything she said anymore, but accepted that he’d come when he was ready, not when I was ready. I found out later that she told Chris that I was truly truly close since my attitude was deteriorating! After she left, I introduced my boys to Psy’s “Gangnam Style” song/dance and decided to relieve myself of “resting” and dance. Chris shook his head and the boys laughed at me attempting to “Gangnam Style” the baby down and out. Unfortunately, there are no pics and there’s no video. I do wish I had both!
Chris and I went to bed as normal. He rubbed my back as normal (yes, he’s freaking AWESOME!) and during that back rub, at 11:55pm, I felt a kick and internally heard a POP. I yelled about how much that movement from baby hurt and started having a contraction. After it was over, Chris continued and I had to have him stop again for another contraction. I explained to him that the pop I had heard is what I imagined women heard when their water broke, but how baby’s movement seriously hurt and how shocked I was. Denial much?
Saturday, September 29
I got up to go to the bathroom before going to sleep. As I hit the tile, I felt something run down my leg. I flipped on the lights and looked at my legs. I then looked at Chris, gasped and stated that I thought my water had broken. He lunged up on his elbow in the bed and said, “YOU ARE KIDDING!!!”. I started laughing and ran to the toilet. When I got up, I started laughing again and there was a big GUSH. Chris then asked me to quit peeing on the bathroom floor. I didn’t know what to do at that point and just kept laughing. When I’d talked with baby during the last weeks, I’d told him that with all the contractions I’d been having, he needed to break my water so I’d truly know that labor was indeed labor! The contractions had continued but weren’t bad at all when I was upright. I attempted to clean up what mess I had made, but kept making it worse with gushing fluid. I knew my BFF was out on the town so I decided to call her and give her a heads up. She didn’t answer! So I called her back as I sat on the toilet laughing. When she did answer, we were both way too excited. Chris then shows up in the doorway and asked what he needed to be doing. We decided he would start filling the birth pool that had been sitting in the corner of our bedroom for 3 weeks. I then decided to call the midwife to give her a heads up. I was still in disbelief but the fluid kept coming! Everyone decided to lay down and rest while we could. However, after laying down and going through more contractions, I decided that was NOT going to work. It was way more comfortable being up.
I had no concept of time at all. I kept going to the bathroom as my body had decided to cleanse itself. I then found a comfy spot in the chair in our room. At this point, Chris was nodding off and I was just breathing through the contractions. Around 1:00am I told Chris that time was flying, that I thought the contractions were coming too frequently and lasting too long to only have been “in labor” since around midnight. Chris started timing them and fell asleep again… *sigh*
My 1:44am text to Brandy: “avg 3 min apart, lasting over a minute.”. I was feeling well and doing well but really in shock that it was all happening!! I explained to Chris that this is when we usually tell doula clients to head to the hospital or call their caregiver. At 2:06am I texted Brandy again to tell her that Chris was sleeping through all the contractions! I tried to sit on the birth ball at this point and Chris made coffee. It was another attempt to rest for me and his attempt to stay awake. I asked Chris to light my labor candles from my Mother’s Blessing and he brought them in and lit them. 2:38am text to Brandy: “Ball is a no go. Too much pressure”. 2:46am text to Brandy: “Sorry. Everything is intense down low” because I wasn’t answering her texts! At 2:58am Brandy called to check in with Chris and give more ideas on how to get me comfy. I wasn’t having any of it! Around 3:10am, I decided I was getting in the birth pool. It sounded inviting and holy cow it felt great. However, as I relaxed into the pool, my doula brain told me that I was going to relax and those contractions were going to start coming more intensely.
At 3:25am Chris called Brandy for me to let her know that I thought “This is stupid. I’m not doing this.”… She said she was on her way.
After hanging up with her, Chris decided to call Margarett because of the way I was acting. He had surpassed his level of comfort with my laboring. Again, my internal thoughts were “How is this happening so quickly? Am I really overreacting? I can’t believe it’s time! There’s a birth pool in my bedroom and I’m in it!”
Here’s where my viewpoint gets hazy. Things did start to ramp up even more once I was in the water. I was still in disbelief that things were moving so quickly but couldn’t figure out why it was taking everyone so long to get to my house. The reason they weren’t there? It had only been 5 minutes since they had been called! I was having to start vocalizing through the contractions. I would say OPEN during the contractions. As the contraction started, I’d tell the baby to “come out come out come out”. Brandy showed up about 20 minutes after the call. I barely remember her showing up, but remember her hanging the labor necklace by the pool so I could see it.
Around 4:00am, 15 minutes after Brandy arrived, Margarett came in. I don’t remember much about her coming in, just some quiet talking and incredibly cold hands that felt so good! I do remember announcing to everyone, in between a contraction, that I was done – I didn’t want to do this anymore. Chris was awesome as he watched on from beside the pool. He’d remind me to breathe, to relax deeper and deeper, he held my hand, and he would place his giant hand on the side of my face which has ALWAYS triggered me to relax. I did have a thought during one contraction that I really wanted to bite him!
As I held onto the edge of the pool, I do remember shaking. Again, doula brain kicked in and I knew that shaking, deciding I didn’t want to labor anymore, the nausea I was feeling, the burping, were all signs that things were very close, but I didn’t grasp HOW it could be so close when it hadn’t been long since my water had broken! Margarett asked if I wanted her to check me and I said yes. I then looked at Chris while Brandy and Margarett were busy and told him that if I’m at a 4, we were leaving and going to the hospital. Margarett checked me and lo and behold an 8. EIGHT. Holy moly. I was an 8. I was close to finally meeting my baby!
The next two contractions I felt like I was starting to lose control. Everyone kept me calm and talked me back down but I just wanted to cry and crawl out of my skin. Then my body decided to do a test push. Margarett asked me if I was pushing because I wanted to be done or because my body was doing it. I let her know that I had NO plans on pushing because it didn’t feel good. I personally remember freaking out and screaming too. I’ve been told that I did NOT scream at the top of my lungs, just started to vocalize more. I couldn’t focus on stuff much but tried to focus on Chris and tell him that I was going to leave, that I was seriously done. He told me that he wouldn’t let me quit. That this is what I had wanted and had fought for and I could do it and that it hadn’t been taken from me. All things that I needed to hear and to be reminded of. Margarett got in my face at one point and talked me back down too. I would go back and forth from handling a contraction well to begging for help. Seriously. I’d say “Someone help me!”. They’d all agree to help but never took away my discomfort so I bounced back and forth from Chris’ side of the pool to Brandy and Margarett’s side of the pool. Brandy also had to step in and quietly reminded me that there were people that were skeptics, that didn’t believe I could do this, that didn’t believe in homebirth and that I was showing them that it can and would be done MY way! Again, exactly what I needed to hear! Then my body decided it was ready to push.
I gripped the side of the pool and let my body take over. Margarett said I had a lip of cervix left and said she was going to push it back. During a contraction, sometimes my body would push, sometimes it would just rest. I swear I pushed for a year, but was later told it was 15-20 minutes. The pushing was very controlled, I couldn’t voice that I was letting my body push when it needed to, but that’s what I felt was right and that’s what I was telling myself in my head: let your body work and push him out. I could feel him moving down and stretching things. I kept waiting for that ring of fire feeling, but it never really hurt, was mostly an intense pressure feeling. Chris reached down a time or two and felt the baby’s head.
I was in my own world. During this 15-20 minute period, I had a few thoughts: “Wow, this is TOTALLY happening!” “Remember all the love and support that women brought into the house at the Mother’s Blessing” “So many women have birthed their babies and now it’s my turn.” “I can do this.” “There’s no way out.” “This is MY body doing what it needs to do and it is NOT stronger than I am, it can’t be!”
As he crowned, his head was out to his eyes and the pressure was pushing his fat cheeks up and Margarett later told me that she had a thought about baby being able to fit. I remember ignoring most everything around me, seeing my labor necklace hanging by my head and the intensity of my body pushing by itself. During this part of pushing, I do remember biting the side of the pool.
Then I remember hearing Margarett saying that one more big push and baby’s head would be out, that I could finally see my baby. I was SO ready at that point so I pushed with everything and he literally shot out. I couldn’t believe it. The emotions hit and I felt Margarett place him on backside to get a better grip on him. I then said that I couldn’t see him! They got me flipped over and she handed him to me.
I’ll be honest, I wanted that euphoric feeling of “I DID IT!!” but I do remember thinking “OH MY GOSH! OH MY GOSH! I am so glad that’s over!”
I looked up and saw Chris’ face and told him to come see! He leaned over, kissed me, looked at his new son and said “You did it!” Pretty sure I just sighed and whispered back “I did it.” I also stated he looked just like Pruitt and then asked to have the boys woken up and brought in. They had both wanted to be present for the birth so I wanted them there as soon as possible. Brandy went and got them and I sat in the pool, holding my squishy baby and made sure that he was indeed a boy. Next thing I knew, Brandy said the boys were there. Their faces right there by the pool, as they looked at their new baby brother, an incredible feeling as a mom. And I had hoped that their presence would help me regain strength and control as I was then reminded that I still had to birth the placenta! Baby C was very calm and peaceful. He squeaked a few times but just sat and looked at me.
The feeling of the umbilical cord still attached to the both of us is still fresh in my mind. Not sure why that memory is so vivid but it is. And the shock of the 5 hour labor and the fact that I did indeed birth, unmedicated, in my bedroom is/was overwhelming. We waited for the cord to stop pulsing and the placenta detached. I’d always heard that the placenta coming out was an incredible relief and oh my heavens was it ever! We then handed baby AND placenta to daddy for some bonding while I got out of the pool and tucked in bed.
My thoughts after the birth besides disbelief: my body works! My body worked to get me pregnant with no medical interventions as I’d had with the other 2 boys. My body worked to birth my baby on his time, not when someone told me that he should be born and my body worked to birth my baby quickly (and with no tearing!)! There were no unwanted checks, no poking and prodding, no constant monitoring, no pitocin. I got everything that I wanted and that I’d worked so hard to achieve. I was now one of “those” moms.
Callaway, born September 29, 2012
5:13am | 9lbs 8oz | 22 ¼” | 15” head | 15 ¼” chest
VBAC – Vaginal Birth After Cesarean.
The term and action is wrought with political and emotional meaning in the birth world. Can you have a VBAC? Does your doctor or hospital “allow” a VBAC? Under what conditions can you have a VBAC? Should it be called a TOLAC (trial of labor after cesarean)? What sort of prior birth history is preferred? Once I have one successful VBAC, will I still have to jump through hoops in subsequent pregnancies?
All these questions and more come up when we start to discuss the mine field that is VBAC in today’s world. But I wanted to know what ACOG really says. I am not talking about the public statements – which you can read HERE. I want to know what ACOG is saying to the doctors, what they put out in their practice guidelines.
The document I found is HERE. I encourage you to not only look at the document for yourself, but to also follow the many links I have scattered throughout this article.
At the opening of the document, ACOG has this to say:
Trial of labor after previous cesarean delivery (TOLAC)* provides women who desire a vaginal delivery with the possibility of achieving that goal––a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decrease in the overall cesarean delivery rate (1, 2). Although TOLAC is appropriate for many women with a history of a cesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, is associated with increased maternal and perinatal morbidity (3–5). Assessment of individual risks and the likelihood of VBAC is, therefore, important in determining who are appropriate candidates for TOLAC. The purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery.
Lets start with noticing that ACOG automatically terms all VBACs as TOLACs first. If you complete the trial with a vaginal birth, then it is a VBAC. The issue with this sort of wording (and thought process) is that it sets women up with doubt and it sets the doctor on the defense against the failure of the trial. I will use the term interchangeably only because the document that I am citing uses the term so often. But moving past this unfortunate wording we do see that they know VBACs are beneficial. They state that VBACs lower the maternal morbidity rate and risk of complications in future pregnancies and that as a whole they lower the cesarean rate. They do also point out that there are certain factors that make a TOLAC less likely to succeed, and that when they do “fail” you are more likely to have morbidity (which makes sense, as a major surgery is considered a morbidity to begin with).
In the “Background” section at the start of the Practice Bulletin we see several points that seem to be denied in the general obstetric community. First they state that the cesarean rate has increased rapidly since the 1970s, from 5% to more than 31% in 2007. They blame this increase on the introduction of electronic fetal monitoring, and the decrease in breech births and forceps births. I put emphasis on the EFM use, since we are often told that it is needed for a safe birth, even though research proves that it does not lower fetal morbidity or mortality. Again and again, research also shows that it increases the chances of a cesarean, which in turn increases the risks to mother and baby. Yet, ACOG still insists on the use of EFM as standard care.
They also state in this section that after the 1970’s VBACs gained popularity. By the mid 1990’s the rates of VBAC (28.3%) were such that it was actually reversing the cesarean rates. However, this increase in VBACs seemed to come with an increase in uterine rupture – though the literature does not state what sort of uterine scars were common (since certain types are known to have more risk, such as classical), whether induction was used, or what type of rupture occurred (most ruptures are not catastrophic but are instead considered a “dehiscence”). Due to this increase in ruptures, the case for VBACs was again set back to “once a cesarean, always a cesarean” in many practices. They finish this section by stating that it is known that liability is a large part of why VBAC is not offered to many women who are actually good candidates.
Now we get into the nitty-gritty of what they say about VBAC. I am going to take questions and statements from the document to break this down. All noted pages are from the Practice Bulletin unless otherwise stated or linked.
- What are the risks and benefits associated with TOLAC? (p2)
- Neither an Elective Repeat Cesarean (ERC) or a TOLAC are without risks.
- Most maternal morbidity that occurs during TOLAC is related to a failed attempt when a cesarean becomes necessary.
- VBAC is associated with fewer complications than an ERC.
- Thus, the risk of a VBAC really comes down to whether it is achieved. If it is a “failed” TOLAC it has more risk than an ERC, but if it succeeds, it has lower risk than a ERC.
- The main risk of TOLAC/VBAC is a uterine rupture. However, as stated in the background, some studies do not give background information about what type of ruptures are occurring nor on what type of prior incision or induction methods.
- They include a chart of maternal risk in this section and it is interesting to note that maternal death risk can be almost double (0.2%-0.4%) with a ERC compared to a TOLAC after one prior cesarean (0.2%), and that TOLAC with more than one prior cesarean had no death risk within those studies. It is also noted that a ERC also comes with the risk of uterine rupture (0.4%-0.5%).
- It is noted that for families wanting several children a successful VBAC takes away the risks of multiple surgeries which includes hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as previa and accreta.
- They include a chart of neonatal risk factors when comparing ERC to TOLAC. It should be noted that there is no significant increase in neonatal death or neonatal admission (NICU admission). We see a much higher rate of respiratory distress (1%-5% vs. 0.1%-1.8%), transient tachypnea (too much fluid in the lungs which causes breathing issues) (6.2% vs. 3.5%) and hyperbillirubinemia (jaundice) (5.8% vs. 2.2%) in babies who go through an ERC.
- What is the vaginal delivery rate of women who have a TOLAC? (p3)
- Most studies show a 60-80% success rate.
- Studies show a decrease in success if the same circumstances happen again, such as stalled labor, which lead to the first cesarean (however, I will note that the definition of “stalled labor” is more likely the issue than anything else).
- The chances of success are increased if the mother has spontaneous labor with no augmentation.
- One VERY interesting note is that being “non-white ethnicity” lowers your chances of success. This speaks to the huge disparity in maternity care in ethnic groups in this country. Simply taking one look at the maternal mortality rate in non-whites gives a clear and horrible picture of this undercurrent in our maternity care system.
- Who is a candidate for VBAC? (p4)
- The best candidate is one in whom the risks and benefits balance out in a way acceptable to the client and care provider, this may be different for each woman and there is no specific “formula” to come to this answer.
- Decisions about the first VBAC should be considered with future pregnancies in mind. This is due to each subsequent cesarean increasing the risk for future pregnancies, and the inability in some areas to find care providers to attend a VBAC after multiple cesareans.
- For most women with one prior cesarean and a low transverse incision VBAC is a good option and they should be counseled and offered a TOLAC. Women with other incisions (T-incision or classical) or with prior ruptures and surgeries of other sorts to the uterus should be evaluated more.
- Individual factors should be considered in all cases (i.e. – no hard and fast decisions to ruling mothers out of VBAC), and in the case of women presenting in labor, VBAC should be strongly considered as spontaneous labor increases the success rate of a TOLAC.
- More than One Prior Cesarean:
- Studies addressing TOLAC in women with more than one prior cesarean find rupture rates ranging from o.9% to 3.7% – again, without specifying the type of prior incision or level of rupture. They also have not consistently compared these findings directly to women with only one prior cesarean.
- One large study in particular found no significant increase in rupture between VBAC and VBAMC (vaginal birth after multiple cesarean) – o.7% vs. 0.9%. A second large study only found a slight increase – 0.9% vs. 1.8%. They also found no significant increase in morbidity.
- The chances of success are similar to that of a VBAC after only one cesarean.
- Macrosomia (Big Baby):
- Some studies show a decreased chance of success with a baby larger than 4,000g, and posibily higher rupture rates. However, these studies are based on actual birth weights, and not the estimates given before birth. This is significant given the inability to accurately predict birth weight before the birth.
- Suspected macrosomia alone should not rule out TOLAC.
- Gestation of more than 40 weeks, according to the largest study done which looked at this factor, does not increase risk. There is evidence that after 40 weeks chances of success decrease but we must consider that induction of some sort may be common at that point (given current practice trends) and that lowers the chance of VBAC in general. Gestation of more than 40 weeks should not rule out TOLAC.
- Previous Low Vertical Incision:
- Studies show similar rates of success compared to low transverse incisions (the most common).
- Studies do not show increased risk of rupture or morbidity for mother or baby.
- Studies are limited, but a low vertical incision should not rule out VBAC given the current information.
- “Unknown” previous uterine incision should not rule out VBAC. The two large studies done at large tertiary hospitals show that there is no increase in rupture rates or morbidity, and success rates are similar. Unless there is a high clinical suspicion of a complicated previous uterine incision TOLAC should not be ruled out.
- Twins Gestation:
- In all studies available it is shown that in women with a previous low transverse incision there is no increase in risk to VBAC a twin gestation.
- Success rates are similar to those of singleton mothers. Twin gestation should not rule out TOLAC.
- How does management of labor differ in a VBAC? (p5)
- Induction of labor for maternal or fetal factors remains an option for TOLAC. However, the increased risk of rupture that comes with any induction and the decrease in success rates should be discussed.
- One large study of over 20,000 women found that rupture rates increased slightly with induction. Spontaneous labor had a 0.52% rupture rate, non-prostaglandins induction with a 0.77% rate, and with prostaglandins a rate of 2.24%. However, again the types of rupture were not specified and the context of the inductions are not known (unfavorable cervix, need for multiple induction methods, etc).
- Another study of over 33,000 women found a slight increase in rupture (o.4% for spontaneous labor, 0.9% for augmented labor, 1.1% for oxytocin alone, and 1.4% with the use of prostaglandins). An analysis of this same study noted an increase in rupture rates when the highest levels of pitocin were reached, however no upper level of dosing has been decided for VBACs.
- Studies done on the risks of misoprostol (cytotec) show an increase risk of rupture and should not be used for TOLAC. (Actually, it increases risk of rupture in ANY mother so it should not be used for induction, period.)
- Due to the small absolute risk found in several studies, ACOG notes that use of pitocin for labor augmentation is not ruled out for VBAC.
- Mechanical cervical ripening (such as the foley bulb) are also considered acceptable for labor augmentation/induction in VBAC.
- ECV (External Cephalic Version), such as to turn a breech baby, are not contraindicated in a woman who wishes to VBAC.
- Epidural/Analgesia use is not contraindicated and studies show it does not effect success rates. However, epidural use in general is shown to increase the chances of cesarean in all mothers. (to view that study, right click and select “copy link location” and input into google)
- Electronic Fetal Monitoring is suggested since the main sign of uterine rupture is abnormal fetal heart rate (up to 70% of cases). It is noted that internal monitoring does not help in diagnosing ruptures.
- How should future pregnancies be managed after uterine ruptures? (p7)
- If the rupture is in the lower segment of the uterus, the chance of another rupture is 6%. In the upper sections of the uterus it is around 32%.
- ACOG suggests an elective cesarean for births after a rupture.
- How should women be counseled about TOLAC/VBAC?
- Each woman will weight the risks and benefits differently. Therefore, the options should be discussed at length and documented.
- Counseling should always consider the future plans for more children and discuss the risks of multiple uterine surgeries. Women should also consider that family plans can change or there may be unexpected pregnancies.
- After counseling the ultimate decision should be made by the client. Global mandates (aka – hospital wide) should not be made as they do not consider the individual factors and wishes of each client.
- What resources should be available at a facility where a woman will VBAC?
- The previous suggestion of ACOG was that VBAC should only be offered in facilities with “immediate” access to surgical facilities and staff. However, this severely limits the locations where women could VBAC.
- ACOG now suggests that care providers and clients consider the facilities available, their individual risk factors, and the availability of other locations where more resources are available.
- Health care providers and insurance companies should do all they can to facilitate women in achieving VBAC through transfer of care or co-management of care.
- If there is no way to transfer care, a woman’s autonomy should be respected. If a woman wishes to VBAC in a hospital without immediate access to surgical facilities steps should be taken early in care to develop a plan of action in case of rupture.
- It should be noted that coercion into a repeat cesarean is not appropriate. A policy of not allowing TOLAC at a facility should not be used to deny care or force a woman into a repeat cesarean. If appropriate, transfer of care should be arranged to a facility and care provider who is better able to support TOLAC.
Now I would like to take a moment to talk about the notion of only “allowing” VBACs in facilities with immediate access to surgical teams and facilities. Lets compare the risk of rupture, 0.7% in most studies, which is not always catastrophic, to the risk of other obstetric emergencies. Cord prolapse, a very dangerous situation in which the cord proceeds the baby down the birth canal and gets pinched, occurs in about 0.28% of births. This situation requires immediate access to a cesarean in most cases. Placental abruption, another very serious complication, occurs in about 0.7% of pregnancies. This also requires immediate access to cesarean in almost all cases. Notice that the risk of abruption and the risk of rupture are the same. The rate of shoulder dystocia, which is considered an emergency that may necessitate a cesarean (or an instrumental birth) is around 1.29% though some studies report it at higher rates in the current birth climate.
Now looking at the rates of these complications, which are on par with the risk level of rupture, we have to wonder why ALL hospitals offering birth services are not required to have immediate access to a cesarean. After all, placental abruption happens with the same frequency and can happen in any pregnancy and ACOG does not seem to be concerned that EVERY pregnant mother does not have access to immediate surgical care. At the end of the day, the risk/benefit analysis needs to be decided by the mother and what she feels comfortable with since the rate of rupture is comparable to the risks of any pregnancy and birth.
The point of this article is not to suggest any particular course of action for every mother. This is about giving you the facts to make your own decision. This is about looking at what ACOG really says about VBAC/TOLAC and not just what your doctor tells you they suggest. Arm yourself with information and consider your own personal factors and Birth Without Fear, no matter how you choose to birth.
My fourth baby, an attempted VBA2C, left me with my final scar of childbirth. After 3 premature deliveries, progesterone shots allowed me to carry to 38 weeks 6 days. Labour began on its own and after a stalled labour, forehead presentation and Bandels Ring I delivered by a calm and quiet c-section, the final chapter in my family’s growth.
I didn’t fail having a VBA2C, I tried and that’s all that I can ask for. Two emergency c-sections and one successful VBAC with premature babies were stressful. This babe was big enough to come home with us and we are breastfeeding exclusively 7 weeks in. That in my eyes is success.
Loving my body, one scar at a time. Your blog gave me hope and confidence… and for that I thank you!
The stories of my children’s births are both my worst and best day ever. My son was born February 26, 2011. I had wanted a natural childbirth, unfortunately that did not come close to what I got. I was called by my midwife on the 23rd, stating that she had concerns regarding some of my blood work and said that I would need to be induced that day. This is a moment I think of often and wish so much I could have acted differently. I was close to 42 weeks and was ready to be done, and so I said “okay”. I knew I should have asked what other options were available, but I didn’t. When we got to hospital my birth plan fell apart immediately. They let me know that my platelets were low and I would be unable to have an epidural. This wasn’t a big deal to me; I didn’t want an epidural anyway. I was dilated to a one and nothing seemed to help, my body and my baby were not ready.
The first day they tried Cervidil which did nothing. The second day they tried Cytotec which gave me some mild contractions the entire day. I was still excited at this point and couldn’t wait to meet my baby. I was not scared of birth; I couldn’t wait to take part in this amazing journey. Even though I was contracting, I wasn’t dilating. The next morning they gave my Pitocin. This is when my world fell around me. Two hours after receiving the drug I was in agony. I was unable to get through a contraction without vocalizing and I felt completely lost. I was not prepared for this. After hours of intense contractions with no relief my pain transitioned into suffering. I was begging for help, but no one could do anything. At one point I looked around the room and saw our midwife, nurse and my husband simply staring at me totally helpless. No one could help me, I was entirely alone in this room full of people. I continued this way for almost an entire day. I got to nine centimeters dilated and stayed there for hours. My hope was gone, I had done enough. I was ready. They took me in for a cesarean. Every part of me that makes me “Meghann” was gone. When I got up to go into the surgery room I didn’t say goodbye to my husband, the only thought running through my head was that the pain would be over soon. I cried knowing I would not be awake at the birth of my child because of my platelet levels, but needed help.
When I woke from surgery the full impact of what just happened hit me. I was stuck on the table and could not get up. I did not know one person in the room. Tears instantly began streaming down my face. I felt like I couldn’t breathe. All of my physical pain had turned into emotional pain. One of the nurses came over when she saw I was crying and asked what hurt. I told her I wanted my baby. “In just a few minutes.” I heard them tell me that for almost an hour while I waited to meet my son. I asked “what color eyes he had?”, “what color was his hair?”, “how much does he weigh?”. They told me, “I don’t know”. How much longer until I could meet him?! It was the worst time of my life, waiting and searching for my baby while I knew he was doing the same for me.
Finally they took me into our recovery room where my husband and my son were waiting for me. I remember them wheeling me down the hall, still lying in a bed. I could not stop crying. I saw family of other women who were likely having beautiful births waiting to meet their newest family member. They saw the look on my face and they no doubt knew that child birth did not always go that way. Once I was in the room I hurriedly looked from side to side asking where he was. My husband pointed to the bassinet in front of the bed. It was strange, but I felt like I could not have him, like he wasn’t mine, as if it would be inappropriate to ask them to give him to me. It was as if the hospital had more rights to him than I did at that moment. My husband went over and picked him up and put him in my arms. While I have read about difficulty attaching after a cesarean, this was not what happened. I felt instantly bonded to him, and did not let him go. I felt that I needed to protect him and make amends to him for what we had just experienced.
I can’t tell you how painful Jackson’s birth was. He was our first child and I missed everything. I missed his first breath, his first cry. I missed my husband meeting his son for the first time. I didn’t know if someone had bathed Jackson or not. I couldn’t answer simple questions in our baby book such as “Dad’s first words to his son”. Jackson was introduced to me by others, others who knew my son first. I should have been the first. This was never going to happen to me again.
When Jackson was 15 months old we learned I was pregnant with Audrey. A dark shadow hung over my pregnancy as I was told that my platelets would likely drop again. I went back to my midwife and she told me not to worry, that it would be different. I wouldn’t have to labor, I would come in for a scheduled cesarean. She gave me a concerned look when I said that I was going to VBAC.
My platelets were indeed dropping. I did everything I could to keep them up. Took an array of vitamins, ate huge amounts of organic fruits and vegetables. I scoured the internet for anything I could find on lifting platelet levels. I had to be awake for this birth. I knew that my success did not just depend on me, it also depended on the people I chose to support me. My husband and I chose to birth in a hospital, which meant I would need to find an OB, which was a little concerning to me. It was at this point that I realized how much women come together to help one another when needed. There was hidden in society a network of women who understood the meaning of birth and would fight to help one another succeed in achieving their desired birth. I spoke to doulas, midwives, women who had beautiful and horrific experiences. Over and over the same names came up, doctors to definitely check out and doctors to definitely avoid. I began interviewing those doctors and was feeling a bit hopeless. Then I finally found a one that I intuitively felt I could trust. He listened to me and seemed to understand in a way you would not think a man could, how much Jackson’s birth hurt. He vowed to help me. I also hired a wonderful doula that listened to Jackson’s birth story and knew my desire to witness my child’s birth. She helped me establish a birth plan for every possibility and stood beside me throughout my pregnancy and birth.
I went into labor with Audrey the night before her due date. My contractions began at just under four minutes apart, but were easily handled. After about two hours of labor I woke my husband up to let him know. He urged me to call the doctor’s office. I got the doctor on call, not my doctor. She said that I needed to come in and that I shouldn’t worry, if I’m not dilating she’ll just start me on Pitocin. I got off the phone with her and felt like I could not leave my house. Was this battle starting already? I called my doula. I felt grounded when I heard her voice. I remembered that I have the right to refuse any procedure, but that I would need to be strong.
We drove the hour drive on ice covered roads. When I got into my room the doctor came to check on me. She immediately said that she wanted to feel my stomach so she could measure the baby. She said that if the baby was too big she would know later not to use a vacuum. What? Why were we already discussing vacuums and babies that are too big? I knew I had to tell her no. I then had a contraction and it hurt. I thought to myself, if I’m strong enough to get through this contraction then I can tell a doctor no, and I did.
I asked about my platelet levels right away, they were high enough that no matter cesarean or vaginal, I was going to be awake! They told me this, but it didn’t really sink in. I could only concentrate on the contractions, nothing else. I began vocalizing like I did when Jackson was born and I was ready for relief. I opted for an epidural. Once it began to work was when my doula looked at me and said “You’re going to be awake”. Tears fell, happy tears. I had worked so hard and everything I had worked for was being realized.
My doctor came on a few hours later. His first words to me I’ll never forget, “Goal one met, you’re going to be awake”. I had been clear with him that while I desperately wanted a vaginal birth, it was more important that I was awake, it was of primary importance.
He checked me about an hour after he came in and I was fully dilated! I began to push but wasn’t making a lot of progress. He told me that my little girl was sunny side up. I worked and worked, and the pain was excruciating. Even though I had an epidural, I could feel my doctor attempting to stretch me to make room for my baby to change positions. I screamed through many of the contractions. I worked for over three hours and then consented to allow a vacuum to help her out. Looking back, this wasn’t what I planned, but I trusted my doctor and felt that he would not recommend anything that was not necessary.
An intense and indescribable pain, the hardest push I could muster, and then I heard the words, “Meghann, reach down and grab your baby”, and I did. I pulled her onto my chest. I heard her cry, saw her first breath. I was the first to hold her. I kissed her and told her I loved her. I saw my husband meet her. Nothing happened to her without my consent. She did not leave my arms unless it was to go into my husband’s.
This picture that you see is not simply me meeting my daughter; it’s a moment I knew I could miss. It’s a moment I missed with her brother. It was the most precious moment of my life. It was something that is entirely indescribable. Since her birth I still feel as though oxytocin is cursing through my body. I feel so empowered, so strong. I am capable of anything! To be a woman is truly an unbelievable gift.