Elective Cesarean

My Journey to VBAC

Posted on November 19, 2009. Filed under: Cesarean, Elective Cesarean, Face First/Mentum Presentation, inverted t incision, vbac, VBAC after inverted t incision | Tags: , , , , , , , , |

I had a c section with Graham because he was left mentum transverse. This means he put his face into my pelvis first, sideways, with his chin on my left hip and his forehead on the right hip. This is considered a vaginally impossible delivery. I can pretty much attest to that as I had 52 hours of contractions without pain medication of any kind. I was upright and active the entire labor. I didn’t even go to the hospital until my water broke with particulate and thick meonium and even then I was 7cm. Because of all of this, it as very difficult to deliver him once the docs were inside so my uterus was cut a second time. The first cut was the standard bikini incision on the lower segment of the uterus and the second cut was perpendicular to that. It was a vertical cut extended into the contractile portion of the uterus. The result is an inverted T incision style scar on my uterus. This type of cut is reserved for emergency or very difficult deliveries. Only about .4% of c section end in this type cut.

American OBs quote the rate of rupture during a trial of labor in a subsequent pregnancy as 10%, 15% or even higher. It was originally recommended that any future babies were delivered by c section at 36 weeks after an amniocentesis to check for lung maturity. This was very disturbing to me on so many levels. First, I would be purposefully delivering a preterm baby. Graham gestated until 41 weeks and 1 day. By that reasoning, he would have been 5 weeks  early.  It was also concerning because if the rate of rupture was truly that high then was it even  sensible to carry another baby at all?

I started digging around and what I found was the most alarming thing of all. The true rupture rate found by the biggest study ever done on VBACs found a rupture rate of only 1.9%. How could it really be that low? How could I be told something so different previously? Where did the doctors that told me 10 and 15% get their info? I have no clue, I have never been able to find any reference  or study reporting that high of a rupture rate. It kind of made me mad and when I get mad I get determined.  I started reading everything I could find on this type of scar, why the cut is used, what doctors recommend and then I found that women did VBAC with this scar and they did it under the supervision of doctors and midwives that actually supported the idea.  I knew I had to find out all of my options before I could consider getting pregnant again.

I learned through ICAN of Atlanta that there is a doctor in Atlanta that would be VBAC supportive after an inverted t incision. He also support VBAC after multiple cesareans, VBAC after classical incisions, twin VBAC, and does breech vaginal.  His name is Dr. Tate.  I emailed him and talked to him months ago and he was on board when the time came. He was willing to take me as a patient, meet me at the hospital at the onset of labor, only require a saline lock and fetal monitoring and he would stay as long as it took with no pressure how long it took. He was willing to let my body work and do it’s thing without interference. He, like me, believes that the body is capable of birthing without intervention and time constraints and in a higher risk VBAC it is safer to be as hands off as possible.  The level of commitment that he was making touched me and motivated me and  I knew that was the answer. I could go back to the States in my third trimester and live at Ft. Benning and go to Dr. Tate in Atlanta. I finally had some peace of mind.

Then I found out I was pregnant on November 4th.

Yep, that’s right for  all of you that have been guessing, I am pregnant! Due July 15th. It is still very early, I am only 6 weeks along and I didn’t imagine announcing it so soon but I decided that I wanted to blog this experience and I was anxious to get started in case anyone else was going through something similar. So there it is 🙂

Once I found out I was pregnant my brain went in overdrive. I was already planning the move to Georgia in my mind and thinking of all the logistical aspects. I was bummed to have to separate my family for such a long period of time but willing to do it. I had decided that I would pretty much do whatever it took to make this trial of labor, my chance to VBAC happen. For me it is that important. I want my next baby to have a gentle peaceful birth. I want my body to experience labor and delivery the way it was meant to. I want to labor. I want to feel my contractions and my body work and my baby work in sync with it. I know it can do it. I am not afraid of labor, I had a very long labor with Graham,  I know that I can labor. I am not afraid to birth. I am surrounded by birth, I attend births, I know that my body can birth. I want that moment of realization that I birthed my baby myself. I want to hold my baby the instant it’s born, preferable pulling it out myself. I have had 19 months to process Graham’s birth but I will always hurt that he didn’t get to be with me for the first three hours of his life. How terrifying and confusing it must have been for him to go to the arms of strangers and bright lights and to be force fed formula rather than nurse. I want to give this baby a  more gentle entrance, it deserves that. I deserve that.

All that said, I am no fool. I know that I may have to have another c section. If the safety of my baby or my life is compromised, I get that. I have a lot of perspective and knowledge going into this next birth and I know that if we have another c section it is because it was truly necessary and I can live with that.

As all of this was coming out, my friend Karen, suggested that I talk to Dr. Chung. He is a Korean OB that has a solo practice and as the Korean’s say it he has gone the “natural way.” Women seek him out specifically for natural birth. Korea has a 45-50% c section rate and a 90%+ epidural rate for vaginal births. The “natural way” is small population in Korea. Dr. Chung also attends homebirths and has even attended homebirths on post at Yongsan Army Base. This is how Karen and I knew of him. It never occurred to me to ask him but I wasn’t aware that he attended VBACs. Once Karen told me this, I immediately emailed him. He got back in a couple days and said to come see him as soon as possible that he thought he could  help me.

OH MY GOODNESS!!! I couldn’t believe it. I may have the option to stay in Korea and do this! I had a question list a mile long. Everything had to be on my terms and my way. I want to do this but  it has to be as  safely as possible.  Here is the list of questions I used…

  • Approximately how many VBACs have you attended?
  • Of those patients in your practice who wanted a VBAC, how many were successful?
  • What do you think my chances are of a VBAC success, given my childbirth history?
  • What is your rate of cesarean sections and under what circumstances do you usually advise them?
  • Who is your back-up? Is he/she VBAC friendly? Would he/she support my birth plan?
  • What hospital(s) do you have privileges at? (Which would you recommend for a VBAC?) (Natural birth?)
  • What prenatal tests/procedures do you usually require? Recommend?
  • What do you think of Birth Plans/ Preferences?
  • How do you usually manage a postdate pregnancy? Or a suspected Cephalopelvic Disproportion (CPD)?
  • Do you have a vacation scheduled near my estimated due date?Labor & Delivery
  • What’s a reasonable length of time for a VBAC labor if I’m healthy and my baby appears to be healthy?
  • Do you know any kind of restriction I should expect from the hospital on a VBAC? (Who do I need to have policy exceptions approved through?)
  • How many people can I have with me during the labor and birth?
  • How do you feel about doulas?
  • What is your usual recommendation for IVs? Pitocin? Confinement to bed?
  • What’s your approach if the bag of waters has broken at full term but the mothers feels no contractions?
  • In what percentage of your patients do you induce labor?
  • Approximately how many of your patients have un-medicated births?
  • If my baby is breech will you still consider me for a VBAC? ECV?
  • At what point do you arrive at the hospital during labor/delivery?
  • What labor positions do you recommend to your patients? Do you encourage movement during labor?
  • I do not intend to push on my back. I may stand, kneel, squat or get on my hands and knees. How do you feel about this?
  • I would like to push spontaneously and without coaching or counting. I would like help breathing my baby out to reduce tears. Will you do this?
  • Do you require continual fetal monitoring for VBAC?
  • Do you allow light eating/ drinking during labor?
  • Are you OK with No IV – but a Saline Lock?
  • I would like a for my labor room to be quiet and undisturbed unless medically necessary. How do you feel about this and can you advocate for me to the hospital staff?
  • In the event that I need a c section and there is time, will I be able to have spinal anesthesia rather than general?

The conversation went even further than this list of questions.  I spent well over an hour with Dr. Chung yesterday. I was very pleased to learn that he would be willing to show up at the hospital with me at the onset of labor and stay until about two hours after the birth. NO MATTER HOW LONG IT TAKES. There will be no time restrictions. He said that he envisioned his job in my labor and birth as a back up. He said that he felt like he should be there with  me and if I need him he will be there. I will be laboring unmedicated so that I can feel any changes to my scar if there are any, and he can respond quickly because he will be in the room with me. He said that he understood the need to labor undisturbed and peacefully so he would be sure to keep staff out of the room unless medically necessary and that he would be an unobtrusive and quiet observer unless medically necessary. He has attended Hypnobirthing training and could certify as a Hypnobirthing practitioner if he wanted and that really got me excited. I am going to be using Hypnobabies and while the programs are different they are similar enough in that the laboring women requires peace and quiet and he totally gets that and is on board. He also said that his job was to let the staff know that my case is a special situation and while we do want little interruption that everyone should be on guard to respond to an emergency at any time. I will be doing this at a very large university hospital in Seoul that is also the most natural birth friendly hospital in the city. There will be pediatrics, NICU, anesthesiology, adequate nursing staff and a back up OB in case I get into trouble.  I am also A+ which is great because that blood type is abundant in Korea.

I cannot think of a more perfect scenario given my circumstances.

I would normally be very wary of going to the hospital at the onset of labor and laboring with my doctor present the entire labor but I truly believe that Dr. Chung is going to give me adequate  space and time. I don’t believe that his presence will pressure me. I think it will reassure me. Because I know that he isn’t going to put time restraints on me and he will not augment labor in any way, that I can relax. For me, because I have never had a vaginal birth, I need that security of immediate response and there are not many doctors in the world that commit to a patient the way he is committing to me.  I know that if I have another c section it will be because it was necessary. I know that he believes that my body can do this and that my body can birth but that if there is trouble he is prepared to repsond accordingly. With that kind of support, I know that I can labor quietly and peacefully and without worry.

So, like my friend Karen said yesterday, I have all the pieces in place, now it is time to switch gears to “I CAN birth my baby” and leave behind the “what if something happens.” She is right. I am ready. I can trust that I am in good hands and in the best case scenario possible for a trial of labor.

For me and my family, this is the best decision and one that I have been working on for a long time.  After Dr. Chung and I finished talking yesterday he did an ultrasound and I saw the little tadpole. It finally hit me that I was rally pregnant and not just planning any more 🙂

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Do You Know What You are Signing? Elective Cesarean

Posted on July 5, 2009. Filed under: Birth, Cesarean, Elective Cesarean, vbac | Tags: , , , , , , , , |

Below is a copy and pasted version of a real elective cesarean consent form provided by an L&D nurse on her blog. Often times women sign these when they schedule their cesarean but they sign them without reading it or if they do read it they do not understand exactly what they are reading. Yes, they may see the words on the page but they do not realize that the risks outlined on that page are so very real. I have made some additional notes within the content of the form. My notes are in italics.

Consent for Elective Cesarean Section

A cesarean section (c-section) is the surgical delivery of a baby through an incision in the abdomen and uterus. An incision is made on the abdomen just above the pubic area. The second incision is made in the wall of the uterus. The physician can then open the amniotic sac and remove the baby. The patient may feel tugging, pulling, and pressure. The physician detaches and removes the placenta; incisions in the uterus and abdomen are then closed.

I authorize and direct _______________________________, M.D. with associates or assistants of his/her choice, to perform an elective cesarean section on _______________________________.

(Print Patient Name)

Patient’s Initials

_____ I have informed the doctor of all my known allergies.

_____ The details of the procedure have been explained to me in terms I understand.

_____ Alternative methods and their benefits and disadvantages have been explained to me. How many times are the benefits of VBAC explained? Does the patient understand that with a successful VBAC the risk of uterine rupture (which is initially 0.05%) decreases and that the risk of rupture (before labor and during) increases with each cesarean?

_____ I understand and accept the possible risks and complications of a cesarean section, which include but are not limited to:

* Pain or discomfort

* Wound infection; and/or infection of the bladder or uterus. Bladder infections are very common after cesareans because of the catheter. It is not uncommon to be re-catheterized after cesarean because of the inability to urinate independently. This increases the risk of bladder infection immensely. Obviously the uterus is at risk for infection as it has been cut open.

* Blood clots in my legs or lungs You are four times more likely to develop a clot after a cesarean than a vaginal birth. This may not seem like a big deal to most people but as a person with a hereditary blood clotting disorder and a mother with chronic DVT, and a sister who had a hysterectomy at 23 years old because of a blood clot in her ovary, I can tell you first hand that this is real and it is serious.

* Injury to the baby Babies born by c section 50% more likely to have lower APGAR scores than those born vaginally. About 2% of babies born via cesarean are cut by the scalpel. After my own cesarean my OB told me about a friend that she went to school with that cut a baby on her face so badly that she required plastic surgery. What a nice welcome to the world.

* Decreased bowel function (ileus)

* Injury to the urinary tract of GI tract I have ready many stories of the bladder being cut by the scalpel. If you are not aware, the bladder sits on the uterus and is connected by a layer of tissue that must be separated so that the bladder can be moved out of the way and the uterine incision made.

* Increased blood loss (2x that of a vaginal delivery)

* Risk of additional surgeries

* Post surgical adhesions causing pain/complications with future surgeries Adhesions make subsequent cesareans more difficult and longer to perform. They do not interfere with vaginal deliveries.

* Increased risk of temporary breathing problems with the baby that could result in prolonged hospitalization We were in the hospital six days total as a result of this very thing.

_____ I understand and accept the less common complications, including the risk of death or serious disability that exists with any surgical procedure.

_____ I understand in a future pregnancy that I have an increased risk of complications including, but not limited to: These aspects of cesarean are so very important and so often omitted from the discussion. Risks are increased with every cesarean.

* Placenta previa, where the placenta covers the cervix.

* Placenta accreta, where the placenta grows into the muscle of the uterus.

* This may lead to a hysterectomy and excessive blood loss at the time of the cesarean section.

* An increased risk of uterine rupture (with or without labor) and that this risk increases with each subsequent cesarean section. Uterine rupture can lead to the death of the baby or myself.

_____ I have been informed of what to expect post-operatively, including but not limited to:

* Estimated recovery time, anticipated activity level, and the possibility of additional procedures.

_____ The doctor has answered all of my questions regarding this procedure.

_____ I am aware and accept that no guarantees about the results of the procedure have been made.

I certify that I have read and understand the above and that all blanks were filled in prior to my signature.

________________________________ Patient Signature/Date

________________________________ Witness Signature/Date

I certify that I have explained the nature, purpose, benefits, and alternatives to the proposed treatment and the risks and consequences of not proceeding, have offered to answer any questions and have fully answered all such questions. I believe that the patient fully understands what I have explained.

________________________________

Physician Signature/Date

________copy given to patient ________copy placed in office chart

(Initial) (Initial)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

What is not included on the consent form is the psychological effects on both mom and baby when a cesarean is done. The interference with the normal hormonal processes that both the mom and baby go through do have an affect on bonding and breastfeeding. I have talked to some people who say that they had no bonding issues at all and that breastfeeding was easily established after a c section and that is wonderful. However, MANY times this is not the case. Many mothers and babies do have problems. The rate of postpartum depression is higher as well.

Because the c section rate in the US is so high (31% for 2008) many people just assume that it’s routine and simple and safe. So many women are not taking time to fully understand the consequences of a c section. There are medical reasons for them but that is the small minority. Most c sections are unnecessary. Most primary c sections should have never happened to begin with. The data is there, these are not my opinions. I believe that if women were truly informed and educated on the risks and benefits involved in current obstetrical practices that they would take a more active role in their births. For this to happen, we have to start questioning procedures and asking the questions. We have to have a level of awareness and believe in our bodies abilities to birth.

ICAN’s (International Cesarean Awareness Network) Patient Choice Cesarean Position Statement says:

“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.

All physicians take an oath to “Do no harm”. This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.”

Food for thought…

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