Fool Me Once...

Almost every woman loves to tell her birth story. Whether her labor began during American Idol and ended before the evening news or lasted for days on end, it is a story worth telling. The end result--a precious, hopefully healthy, baby--makes it instant family lore and a tale that will be repeated as long as women gather and share their experiences. So having a birth that was a bummer, is, well, a bummer.

Before I get reprimanded, let me emphasize that I know the point of pregnancy and birth is a HEALTHY CHILD and god strike me down if I fail to be grateful for the soft, glorious, human that is Violet. I would have squeezed her out of my nostril if that was what was asked of me and would sleep in a box of live mice every night if it would keep her out of harm's way. She is my blood, my life, my sweet child, and she is far more of a blessing than I have ever earned.

That being said...

Violet's birth was, in hindsight, far from my ideal. My labor was induced at 40 weeks even and ended in a cesarean section. If I had had any idea what kind of parent I'd become prior to V's arrival, I might have done a little more planning, a little more reading, really brushed up on what kind of care and medical advice is being doled out in OBs offices and delivery rooms in the US these days. Had I known that my blind trust, my desire to meet my baby NOW, would have left a permanent mark on my body as well as severely limited my available choices for the rest of my childbearing years, perhaps I'd have thought more seriously about my decision.

And maybe that is why I feel cheated. It is not that I had some grand plan for natural childbirth when I went into this and maybe that is where I went wrong. I wanted an epidural if the pain became overwhelming. I got one long before the pain was too much; the nurse anethstitist must have been a GM dealer in a past life because he convinced me if I didn't have the epidural NOWNOWNOW he may be tied up with other patients and THEN WHAT?? It should have tipped me off when I got the feeling that the hospital was trying to sell me something. That's not why they're there, is it??? If I'd had that plan, if I'd researched my options independently, if I had felt that I'd given Violet's impending birth the study it deserved, maybe ending up with a C-section wouldn't have been such a kick in the ass.

The induction--yep--I wanted that, too. I was over 200 pounds, constipated, weepy, scared, eager, had hemorrhoids, couldn't breath, couldn't sleep, and had no realistic concept of time. The possibility of going 3, 7, 10 days beyond my "due" date was inconceivable. So when my OB offered to bring me in on May 12, the day that had been circled in red on the Pierce calendar for 40 weeks, I agreed and thanked her. And when she ducked out of the exam room leaving Shawn and I to schedule the induction for Monday morning, she even implored us, "If anyone tries to tell you anything bad about being induced, call me. It is perfectly safe."

And I trusted. And we induced. And I lay on my back or side for 15 hours, wearing a fetal monitor (external til noon, internal after doc broke my water), hooked to an IV releasing Pitocin into my bloodstream causing my uterus to contract, not that my cervix ever took note. So after a long day of fake labor, and a measly 3 cm of dilation, my Doc called the game on account of darkness, and wheeled me into the surgical delivery room, where I had the most miraculous experience of my life. Or at least Shawn did.

So, that's my story...and if it ended with that story, maybe it wouldn't be such a sore spot. But Violet's birth story is, I have every reason to believe, going to be only the beginning of my Cesarean saga. Since her birth, (I sure wish this sentence began "Before her birth"), I have read oodles more literature about birth in this country and seen how Violet and I were a part of that machine. ( I'll add some links to some of my favorite sites at the end of this post for those of you who are riveted.) I've realized that the medicalization of a wholly natural human process is taking us further away from our parenting instincts instead of empowering mothers to trust their bodies and listen to their babies. Since Violet was born I have realized how often I act on my instincts and her cues as I mother her and how that rhythm was disrupted when she was born. I've seen how far removed from natural human behavior so many of us are when it comes to our babies; whether it is the mother who lets her tiny baby "cry it out" despite her heart that aches at doing so; or the mother who had every intention of breast feeding her child but convinced herself that her body wasn't making enough milk because the babe wanted to nurse more frequently than the every 3 hours her pediatrician told her to expect.

I am so thankful that we do not live during a time when death was a common result of childbirth and I cannot say enough positive things about all the medical advances that have saved lives, both of mother and baby. But I do think that there is truth in getting too much of a good thing and that, while miraculous when necessary, medical intervention in the birthing process is detrimental when overused. And it is being overused.

Long story longer, I have been corresponding with my OBGYN (actually with her office manager), about the potential for a VBAC (vaginal birth after cesarean) when and if Shawn and I are lucky enough to get pregnant again. My OB is a young, hip, lovely, fashion forward, woman so, despite what I'd heard about most obstetrician's aversion to VBAC, somehow I thought she would be on board. Turns out, not so much. Below is her response to my inquiries:

Dear Jillian,

Office Manager passed your email on to me and I thought it would be easier to communicate directly with you about your desire to VBAC.

VBAC is becoming an increasingly difficult situation in my practice and I think for many Ob/Gyns in general. There is significant risk to the baby and the mother in the event that the uterine incision opens or ruptures during labor. Because of the poor outcomes in cases of uterine rupture, 50% mortality for mother and/or baby, many Ob/Gyn's do not do VBACs in their practice. In fact, of the seven physicians in my current call group, Dr. X and I are the only physicians who will do a VBAC in the right patient. For the other physicians, they are not willing to take on the increase risk of allowing VBACs to labor, or they have seen the dangers of uterine rupture firsthand and are apprehensive about the potential liability with such clearly documented risks. They have even refused to cover any patient that she or I believe are good candidates. While I understand the serious risks associated with VBAC, I do think that some patients are good candidates and I am willing to be available for those few patients 24 hours a day should they go into labor. Ultimately, I want to do what I feel is the best for the patient and her baby regardless of mode of delivery. I don't do C-sections out of convenience. I perform C-sections when I honestly think it is best and to do otherwise would compromise care. Furthermore, while having a C-section is not without risk, neither is a vaginal delivery (esp. VBAC). Patients who have significant pelvic floor dysfunction, injury to their infant secondary to a difficult vaginal delivery, or chronic pain following a vaginal delivery often feel that a C-section is a much better and safer option for subsequent pregnancies. Again, my focus, and I think your focus should be less on mode of delivery but what is the safest for you and your baby.

To answer your questions, induction can increase the risk of C-section in some patients remote from term or inductions done electively without a clear medical indication. I do not believe that your induction was the reason you needed a C-section. Many of my patients are induced, largely for medical reasons or postdates and the vast majority of my patients still deliver vaginally. You were induced at 40 weeks which would not have been considered elective or premature. In addition, despite adequate contractions and a significant amount of waiting for further cervical dilation your cervix stopped dilating. In my opinion, this suggests that Violet was too big for your pelvis or your pelvis was too small for her, depending on how you want to look at it. In general, subsequent babies are larger and the idea is if a patient either fails to progress in labor despite adequate contractions or is unable to push out a baby, odds are that the next baby will be larger and thus even less likely to deliver vaginally. Patients that have a C-section for breech presentation, fetal distress, placenta previa, and/or multiple gestation have not had an opportunity to labor and therefore are better VBAC candidates than a woman who had a trial of labor prior to their C-section.

Going into labor spontaneously does not guarantee a vaginal delivery, although certainly spontaneous labor in a patient without a medical indication for induction is optimal. I generally induce my patients between 40 and 41 weeks because after 41 weeks there is an increased risk of stillbirth, meconium stained fluid, large babies, and low amnionic fluid. In addition, of those patients who have not gone into labor at 41 weeks I do find that my C-section rate is higher because the increased incidence of large babies, fetal distress, and meconium fluid. I also think that if labor has not happened by 41 weeks that may also suggest that there is an underlying reason why labor did not occur spontaneously (i.e. large baby, inadequate pelvis, etc.) thus leading more often to C-section...this is based solely on my personal experience in practice.

I certainly value you as a patient and would hate to have to transfer your care with your next pregnancy. On the other hand, I do want you to have a positive experience and if that means pursuing a VBAC I respect that as well. After reviewing your labor course, I am not comfortable with the significant risk to you and your baby associated with managing you as a VBAC patient. Although I cannot say with 100% certainty that you would not deliver vaginally, as I have said before, I don't feel you are the best VBAC candidate. As such, I am uncomfortable with the associated risk of VBAC in your particular case. I am happy to discuss this further with you or meet with you in the office if you have any other questions.

Warmly,
Dr. NoChanceInHell

I forwarded this email to my mom, a fellow C-section survivor, looking for the wisdom only your mom can give. Her response?

"How does that make you feel?"

Well, Mom, it makes me feel like she is so entrenched in the medical establishment that she is blind to how birth works.

It makes me feel like a subversive for wanting to see if my body can deliver a baby.

It makes me feel scared that she may be right and I may end up with another cesarean, or worse, a death.

I feel grateful that she took the time to answer my questions herself but I feel belittled for asking: see the part where she says: "my focus, and I think your focus should be less on mode of delivery but what is the safest for you and your baby." As if I would be selfishly endangering my baby's life by attempting a normal birth. It makes me feel like a birth is a birth so what's my hang up?

It makes me feel like she believes she is on the cutting edge of medicine for attending any VBACs and there would be no way I would ever find an OB flippant enough to take me on. I worry that she may be right.

I feel that she is selective with her invocation of statistics. 50% mortality rate in the case of uterine rupture is a scary thought but what is the rate of uterine rupture during VBAC? I've read as little as 1%...Isn't that a tiny risk as far as risks go?

It makes me feel that my due date with Violet was miscalculated. Maybe only miscalculated by a week, but enough that it could have made a huge difference.

I feel that there must be a very real risk of a malpractice lawsuit for an OB who has a VBAC go wrong.

Most of all, I feel powerless. And that sucks.



Here are some of the links that I have been digging on this topic:
www.thebusinessofbeingborn.com/
www.ican-online.org/
www.theunnecesarean.com/
http://yourbirthright.info/
http://www.childbirthconnection.org/