inverted t incision

The Birth of Stella Rose: Home Water Birth After Inverted T Cesarean

Posted on July 25, 2010. Filed under: Anterior placenta, AROM, home birth, inverted t incision, vbac, VBAC inverted t incision, water birth | Tags: , , , , , , , , |

My baby girl Stella was born just over 24 hours ago and I have to get the story down now. I’m high on it and the details are running through my head and it needs to come out now! Stella’s birth story begins with her big brother Graham’s birth story. This is Stella’s story though so HERE is the link to Graham’s story.

After having a c/s with an inverted t cut, I was nervous to get pregnant again. I knew that I didn’t want another c/s but finding a doctor to attend me would be really hard. I did find the perfect team right here in Korea, which saved me from having to split up my family and going back to the States. My birth team was so much more than convenience though, each person was there for a specific reason and each person was there in their own perfect capacity. I truly did have the best birth team possible in Korea and most likely Stateside as well. I am very sure of this.

Graham and I were already in Seoul at my friend/doula’s apartment, where I planned to birth. We live two hours from Seoul and the nearest hospital is about 45 minutes away and my OB and I agreed that was too far away in the event of transfer since I was planning to have a(n) HBAC (home birth after cesarean). We came into the city on the 15th, my estimated due date to await baby Fuller’s arrival. My husband was out in the field for an exercise and waiting to get the call to join us. He was 2.5 hours away minimum which made me nervous. In hindsight that is really really funny.

On Thursday, July 22nd I began having prodromal labor: start and go labor, regular then irregular contractions, no contractions, ‘false’ labor, etc. I also began losing my mucous plug. I called Josh to let him know and he decided to go ahead and make the trip to Seoul. Even though we weren’t sure when labor would really kick in, we knew it would be soon, especially since I was 41+ weeks at that point. He got in that evening and Josh, Graham and I checked into the hotel on post to get some private time as our last few days of a family of three. The next two days were spent hanging out, playing with Graham and doing lots of walking. I continued to have the prodromal labor until Friday night.

Friday night at 1am, I was woken up by a contraction that was not like the prodromal ones. It was ‘real.’ I layed there thinking I should ignore it and go back to sleep. Three and a half minutes later, I had another one. Then another one the same interval. I went to the bathroom and realized they weren’t stopping. Graham and Josh were both sleeping so I got on Facebook and started what would end up being a live feed of the birth until the end. I never planned on doing that but it helped me cope for many hours of the labor and once I couldn’t do it anymore, my husband and Karen (friend/doula) took over.

For the next 2.5 hours, I had contractions 3.5 minutes apart. I started to get the shakes and decided to text Karen and let her know I was thinking about coming back to her apartment. I also woke Josh up. It took about an hour and a half to get ourselves back to Karen’s and thankfully, Graham went back to sleep for a few more hours. I continued to labor all morning. I also had bloody show and knew it was the real deal.

Around lunch time or so my labor seems to space out. The contractions went down to 7-8 minutes apart and I was mildly annoyed. I knew it was because the baby was trying to get into a better position and just went with it. I made sure to eat and drink and I took a nap between the contractions. After that, Karen did a maneuver on me called a hip lift that we learned from the Pink Kit and I had immediate results. When she did it, I felt my pelvis open and there was an obvious shift in the baby’s position. Karen felt the movement too and she was only touching bony pelvis. As soon as I stood up, my contractions kicked back in stronger than ever. They were very intense compared to my labor with Graham. I had no back or hip pain but had intense cervical and lower uterine pressure, so much so that it caught me off guard and I found it overwhelming at times. I listened to my Hypnobabies tracks the entire time and it really helped me focus if I began to struggle at all. A few hours later I was able to nap between contractions some more and it really helped since I had only had four hours of sleep the night before.

Karen and I had discussed when to call Dr. C and I just felt like that even though I was definitely in active labor, it wasn’t very progressive and I didn’t want to have the pressure of a bunch of people there just yet. Little did I know that my med team (Dr. C and MW1 and MW2) would be the least pressure I’d encounter! We did call them around 7pm to let them know we were ready for them but that they didn’t have to be in a hurry. They arrived around 9pm. They checked the baby with a portable contraction/fetal heart tone monitor for about a half and hour and she was doing perfectly. My vitals were great as well. Everyone retreated to the kitchen and living room and gave me my space to continue to labor. Karen and Josh alternated helping me and keeping me company. At some point before the med team arrived, Karen and Rachel (another doula friend of ours that came by to help out evening #1) got the pool filled and I got in. I love it.

Around midnight I decided that I wanted a vaginal exam. I am not a fan of routine exams and my team knew that if I wanted one that I’d ask so no one ever offered. Rosa (MW1) checked me and said I was complete, 10cm and 100% effaced. I was floored that I was complete and excited too because I just knew that I’d be pushing soon and would be done! Then Rosa said that the baby was still a -2 station which is high in the pelvis still.

Because of the work I did with the Pink Kit and and the time I had spent discussing my birth history and pelvic shape issues with Gail Tully, the midwife that runs www.spinningbabies.com , I knew that I had some things to contend with and work through. I knew the entire labor that these things were why the labor had been somewhat funky with the spacings and with the baby being high. I also knew that if I could get the baby to descend into my pelvis that there was a very strong possibility that I’d push her out. The trick to this would definitely be getting the baby to descend.

Rosa began working me in different positions to aid descension. The first was walking while doing abdominal lifting in between contractions. I did this for 30 minutes. The she had me swaying my hips between contractions for 30 minutes. Then she had my so a side lying position in the bed for an hour. This was nearly torture. The rest of the birth team slept except Karen and Josh. My contractions were at the strongest intensity that they had been the entire labor at this point and laying down in bed on my side but while also squishing the left side of my belly into the bed (to force the baby out of a left occiput transverse position) was torture. Karen and Josh had to talk me through every moment of it and the last 20 minutes made me want to scream at both of them. And I did along with many choice cuss words that would embarrass some people but I managed to do the hour because of those two and it did help the baby move so it was worth it in the long run.

That said, that hour was so incredibly difficult that I lost my control and focus. Josh went to take a nap while Karen stayed with me. I got back into the birth pool and tried to refocus and get my control but I struggled. I told Karen I was done and I ready to go to the hospital and I didn’t care about a VBAC any more. I wanted an epidural and some sleep and if that didn’t work, fine. She looked at me as if to say ‘everyone else is asleep’ and I glared back ‘then go wake them up!’ But what I said out loud was “I’m so tired and I need to sleep” and she responded with “so sleep then.” She didn’t pity me or baby me which is what I wanted. She was blunt and she wouldn’t let me jump of the ledge I was so desperately trying to escape from. It pissed me off but I do mad way better than I do upset or pity so it worked and I went to sleep. For two and a half hours I slept in the pool. My contractions had spaced a bit, maybe 6-7 minutes apart and I did wake up to work through them and then I went back to sleep. Karen slept on the bed next to the pool.

When we woke up the sun was coming up and I puked and ate, in that order. Rosa did another exam and said that the baby was still at -2 but that her head had moved to an OA (occiput anterior, optimal for birth) position so we were all encouraged that things would start moving. My water had not broken either and the bag was bulging out in front of the baby’s head. I wondered then if they would want to break it and analyzed how I felt about it. I didn’t like the idea but felt like something needed to happen. No one said anything about it.

Because of the nap and the food, I felt much better. I was still worried that I didn’t have the stamina to continue when my labor kicked back into high gear but I was beginning to believe that maybe I could do it. I had more energy, now I just had to find a rhythm. Karen and Josh rewarmed the pool and I got back to work. I labored in positions that made my pelvis feel open. Mostly I stayed on my knees while holding onto the side of the pool. Around lunch time, Dr. C told me they were going to go eat in shifts and that when they were all back that we’d discuss rupturing my bag of water. I had been at 10cm for about 12 hours that we knew of at that point and since the baby still was’t descending it seemed like something worth exploring.

They (med team) were all back by 2pm. They discussed what they though amongst themselves then Dr. C came to talk to me about it. Since the head was in a better position he thought that if he broke my water that the more intense contractions that would create would push the baby down farther into my pelvis. He was blunt and honest and said that he didn’t know if it would work but if it did hopefully I’d have the baby soon (music to my ears since I was 36 hours into it at that point) or it wouldn’t work and we would go to the hospital to explore other options. I agreed with him and gave him the go ahead.

They wanted to do a half our of monitoring first so we did and baby looked great. It was about 4pm when we were all ready to rupture the membranes. He wanted to break the water during a contraction so that the force of the contraction would bring the baby’s head down and prevent cord prolapse since the baby was still high in my pelvis. Rosa did the job and wow did i ever have some water! It just poured out. The baby’s heart rate jumped up to 180-190 for a bit so they gave me oxygen and had me lay on my left side. I had a contraction and more water poured out and then I had another contraction and my body pushed with all it’s might in the most uncontrollable way that I have no words to describe it. I looked at Dr. C and said, “I pushed!” and he said “I see that!”. They had me side lie for about 20 minutes longer and continued monitoring and the baby looked great so I was given the go ahead to get back into the pool.

The pool made everything better. I was ready to do it. I pushed when my body said push. I was loud and I roared and grunted and made noises that I never imagined. I remember Karen saying to be a lion and thought it was funny even though I ignored her. I pushed spontaneously for about two hours before I asked Rosa to check the baby’s station. The baby was at zero which was improvement but I knew I still had a ways to go. Rosa made sure I was swaying my hips and changing pushing positions at interval. I also got very serious about pushing and began bearing down as hard as I could on top of what my body was doing. It just seemed like I should. I was exhausted and had been pushing forever and was so ready to be done with birthing! After a bit, I could feel the baby’s head just inside and that gave me a lot of strength. I was oblivious to the world around me. I knew Graham was in the room and he seemed ok with my roaring. Josh said that he said ‘ow mama’ a few times and ‘oh shit’ more than a few times as that was my cuss phrase of choice. After the three hour mark of pushing I knew the baby was really on it’s way out. I felt fierce and determined. Everyone was focused on me and I didn’t care, I was happy and loved every single person present and so grateful that each of them were there for that moment. I soon realized that the baby’s head was crowning and I yelled “OH ring of fire, that’s sucks!” and I thought about how many times I told a client that ‘you can do anything for a minute!” and it made me want to slap myself and hug myself at the same time! In the next push, Dr. Chung reach down to help slow down the baby’s head and I really felt the stretching then. The next push I bent over on hands and knees and Josh got prepared to catch the baby from behind from outside the pool (I didn’t want him to get in). Dr. C and Rosa moved to the backside with Josh and I pushed what felt like a huge rock. Dr. C told me when to push and when to breath through it and not push. He has a 70% no tear rate so I told him I would listen and do exactly as he said. In fact, when I realized the baby was crowning, I asked him if it was time to listen to him which got some laughs. The next push brought the head all the way out and that was the hardest thing I think I have ever done. I waited until the next contraction for push again and Josh said that she opened her eyes and mouth and moved her head under the water. The next push brought her shoulders out one at a time which I felt every bit of then her body just squished out which kind of felt like a reverse vomit or something equally strange. I looked over my should in that moment and saw Dr. C and Josh both with outstretched arms and the next thing I knew they were trying to pass the baby back under my legs to me. I sat back in the pool and was somewhere between “OH MY GOD I JUST HAD A VBAC” and “OH MY GOD, I’M DONE!”. The very first thing I did when they handed me the baby was lift her leg and then say “I knew you were a girl!” It was an amazing moment. Karen was crying and saying “you did it! you did it!” and Josh was tending to Graham because as soon as the baby popped out he lost it. I sat back in the pool and stared at my baby girl and just couldn’t believe what had just happened! I had a perineal tear that wasn’t bleeding so we decided not to bother with stitching and opted for resting with my legs closed for a week or so instead.

The amazing thing about my birth is that Dr. C was so incredibly comfortable and confident. He was confident but not cocky. He listened to Rosa, who is more experienced than he is but he still made the call when it came down to what he felt was best. He discussed everything with both me and my husband and Karen and I ultimately had the final say in every aspect. There were no time limits, no unwanted interventions, lots of privacy. They did monitor regularly but were not over bearing and were unintrusive. Rosa is probably one of the most experienced home birth midwives in Korea. She is a CNM who worked in a hospital for 10 years before doing home birth. She also runs a birthing center. Dr. C respects her and listened to her and she did exactly what I wanted her to do when I asked her to join the birth team which was help me deal with positioning issues. I knew going into my birth that I have pelvic shape issues that would made birth more difficult and that lended a hand in what was Graham’s c/s birth. I wanted the best and she brought it. Dr C told me later that adding her to the team was the perfect choice.

I was 10cm dilated with an intact water bag for 20 hours or so before any intervention. Dr. C told me today that he didn’t feel intuitively about doing anything earlier than what we did. There was a chance it could have cause more harm than good and by waiting we were able to increase the chance for best case scenario. I agree wholeheartedly and adore him for his patience and do not know of another care provider that would have been comfortable doing that. He said that the baby was fine and I was ok so waiting was what was needed. When we did break the water, it worked exactly as it should have. I am in awe.

After the birth, I had some heavy bleeding. It wasn’t to the point of hemorrhage but it was concerning. The placenta did not detach either. Afte two hours and still bleeding and still no placenta birth, Dr. C told me he wanted to take me to the hospital. He felt like everything was ok but he wanted me monitored over night and wanted blood work done. Josh and Karen got us together and Karen took the baby. I was weak and needed a lot of assistance getting out so Dr. C and Danica (MW2 who was also great but more of a Dr. C/Rosa support person than so much for me). We got checked in to the hospital and I ate some food that Karen packed up for me and Josh took care of baby Stella. Once settled in, i was able to sleep for about 5 hours until Stella was ready to nurse. She nursed like a champ and slept all morning on my chest. Josh go to sleep for 5-6 hours in the morning.

Once morning came, Dr. C dropped by and checked me out. The bleeding was at a normal level and my labs were fine and other than being weak I was ok. The placenta was still attached but in the absense of any indication to do so (such as infection or bleeding), Dr. C is comfortable with waiting to see if it will come out on it’s own. He doesn’t want to have to do a manual or surgical extraction. So orders are bed rest and daily check ups and blood work and infection monitoring and we will reevaluate the situation daily until either it comes out or he takes it out.

None of the after birth stuff has affected my birth though. It was exactly the birth I was supposed to have and I would do it again five times over if it meant not having to recover from another c/s. I am still in shock and awe and amazement and I can’t believe I did it! It was the hardest thing I have ever done and I’m so grateful to my team, they were perfect. I know I’ve left out important details and that this hasn’t been proofread but I had to get it out. Enjoy! I’ll edit later.

EDIT: The placenta came out a few hours after I posted this birth story. I went to the bathroom and couldn’t pee much but could tell my bladder was full. I stood up and felt a very heavy weight on my bottom and I looked in the mirror and saw the placenta bulging out. I didn’t push but when I spread my legs it plopped out onto the floor all at once. My bladder immediately released and for a second I couldn’t tell what was going on and was afraid that I was bleeding. I realized what happened and calmed myself before yelling for Josh. I told him what happened and he was super excited then I told him how bad it smelled. It was TERRIBLE and like meat that had been left out for a few days. He peaked in to look at it on the floor. I had him go wake up Karen (who of course, took a picture) and she called Dr. C. Since I wasn’t bleeding he decided to wait until our planned check up for the next morning. My bleeding has been a bit heavy but still normal, so I’m not concerned and I’m sure he won’t be either.

I feel SO much better physically. I immediately felt different when it came out. I did get weak and woozy and had hot flashed but the pain I was having in my bottom was gone. I’m still sore but i can actually move around with little assistance now. My body knew that the placenta didn’t belong in there any more but I guess it just needed time to release it. I’m so glad Dr. C was patient and didn’t force manual extraction. Again, everything about this birth was exactly as it should be and I’m so happy there was not a surgical ending to my beautiful VBAC. The placenta was born 29.5 hours after my baby was. Dr. C told Karen “Time. She needs more time. With Amy, everything takes more time.” He knows me so well!

Our baby girl’s name is Stella Rose. I didn’t know Stella meant “Star” when we chose it but it’s so appropriate because for our VBAC the stars had to align on so many levels. We chose Rose as her middle name to honor our Korean birth team. MW1’s Korean name is Kim Oak Jin (Oak Jin is her first name) and there is no English translation for that name so she chose Rosa as her English name. We thought that by choosing Rose for Stella’s middle name that we were acknowledging our medical attendants and their dedication, hard work, patience and confidence in our birth. Plus, Hwan Wook (Dr. C’s first name) didn’t flow very well with Stella!

Stella Rose
9lbs 2 oz
21.5 inches
15 inch head

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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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C Section With an Inverted T Incision and Face Presentation

Posted on July 1, 2009. Filed under: Birth, Cesarean, Face First/Mentum Presentation, inverted t incision, Pregnancy, vbac | Tags: , , , , , , , , |

I have procrastinated writing this post. It is the post that I most wanted to write from the moment I my cyber friend Pam dreamed up the idea of writing a blog. I have put it off because I needed to organize my thoughts and my statistics and references and people. Well, really not MY people but the people who are out there that are dealing with having an inverted t incision scar. I feel the pull to get it all down and typed out and saved somewhere that is easily accessible on the internet though so it’s time to stop procrastinating. I just want to make sure that if there is a woman out there googling ‘inverted t incision’ she finds the answers to some of her questions because there is not a lot of information out there. I feel that if I can at least put everything I know in one place maybe someone else will have an easier time than I did when I was trying to learn everything I could.

My quest for inverted t incision knowledge began with my own birth story. In short, we ended up with a cesarean after a very long natural labor that resulted in an inverted t incision because of my son’s face first presentation. So there is no confusion about what the face first presentation is as some people confuse it for ‘face up’ or OP (occiput posterior), I have included some pictures below.The first picture shows what a normal vertex occiput anterior baby looks like in utero. The second picture shows how the baby hyper extends it’s neck when presenting face first. The third shows the different ways the baby can present. My son was Left Mentum Transverse (LMT).

Optimal Fetal Position Occiput Anterior

Optimal Fetal Position Occiput Anterior

Example of face first in utero, shows hyperextended neck

Example of face first in utero, shows hyper extended neck

Diagram of fetal positions, my son was LMT

Diagram of fetal positions, my son was LMT

Here is an article written by a woman who delivered a face first presentation. I added it into my article because I am scared that one day the link will not work. The link is HERE. Below is the article…

Face Presentation is a relatively uncommon labor presentation (only about .4 percent of births) when the baby is head down but has its neck extended, as if looking down the birth canal, rather than with its chin tucked into it’s chest.  The chin or the nose presents first (very rarely the brow), not the top of the head.

Presentation refers to the part of the baby first entering the pelvic structure on it’s way out the vagina.  A vertex birth (head first) happens approximately 95 percent of the time.  The options (in order of occurance) are: Vertex, Breech, Shoulder, Face, Brow

Attitude is the relationship of the baby’s extremities -arms, legs and head – to his main body.  A fully flexed baby is compact and compared to poorly flexed or extended.   A fully flexed vertex presentation makes for the smallest diameter of the baby’s head exiting at all times.  If the baby’s head is only partly flexed, a larger diamer will have to come through the birth canal, making for a longer labor and more difficult exit.  (Trust me on this!)  If the baby’s head is Fully Extended, the baby is Presenting by Face.  This sounds very scary when described, as the head is bent backwards till it is resting on the back shoulders.  It appears like the baby is going to break it’s neck coming out!

Labor: The top of the baby’s head will be resting (uncomfortably!) on the mother’s backbone.  Labor will likely be slower since the face is not an ideal canidate to dilate the cervix.  Mom is probably going to be in a bit of extra pain.    In my case, once I past transition I had no urge to push since the head was not hitting the proper nerves.  (I don’t know if this is always the case or not)   I found this very disconserting since I knew from past experience I should be wanting to push.  The diamater of the head as it presents is about the same as a vertex birth (abt 9.5 cm).  However, while the presenting parts may be equal, for the face presenting baby – the full width of the head is to follow!    When a baby is vertex, the head bones actually mold together and overlap, making the head easier to push through and out of the birth canal.   Face presentations have no such luck.

Having an angel-faced baby is akin in size to a breech birth!!  However, as long as the baby is face up – chin facing the mom’s bellybutton – there is no danger.   With a breech birth, the danger is the head getting suck in the birth canal after the body has sucussfully exited, possibly with the cord pinched.  With a face first baby, the head comes out first – so there is no danger of asphyxiation.

Please note that angel-faced baby’s are routinely C-sectioned in hospitals.  Any baby that is sunny-side up “fits the requirement for a c-section”.   Moreover, since labor will be longer and mom will appear to be ‘hung up’ at stages – some will say there is a faliure to progress.  (Again, this is simply because the nose does a poor job of dilating the cervix.)  Please give labor a try – these babies can and do fit!  It’s worth the extra effort.

The Prognosis: Since Angel babies are born sunny-side up (face and throat facing upwards toward the ceiling) the baby needs to be suctioned at once, so no amnioatic fluid is asperiated into the lungs.  Since the baby is born with his neck pushing against the mother’s pubic bone, there is sometimes a fear that the child will suffer from breathing difficulties (edema around the throat), but this rarely happens.  Although the baby is terribly bruised during the labor (imagine using YOUR nose to force through the birth canal!) the prognosis for mommy and baby (assuming they have a caring provider that allows them to birth vaginally) is fine.  The face will be swollen for a day or so.  90 percent of angel-faced baby’s deliver vaginally!!!   Mine did!  At over 9 1/2 pounds too!  With a big ole face like a dinner plate!

If the chin is facing the Mom’s tailbone:  (Posterior)  Then the prognosis is not so good.  Even midwives agree that if you have a face presenting baby with a “mentum posterior”, vaginal delivery is almost impossible.   Often the chin will get hooked on the tailbone, and the baby is wedged in the no-mans land of the birth canal.   Happily of all face presentations, only about 30 percent are posterior and many of them rotate before they get stuck.

Vaginal Delivery: Remember, 90 percent of all face presentation babiess deliver vaginally!!  The reason for this is most face babies aren’t diagonosed until very late in the labor when it is already apparent that baby is coming down that birth canal, doctor training or no!  Be aware that if a hospital rountinly uses sonograms during labor, or if your doctor is doing frequent vaginal exams, they will discover your baby is facing the heavens and may request a preemptive c-section (because of the small danger a baby may asphyxiate on it’s own amniotic fluid.)  You need to decide what you feel the risks of this are.  I had my angel baby vaginally, natrually, and at home.  And it’s a decision I feel blessed I made.

Material gathered from:  Spiritual Midwifery, by Ina May Gaskin & Gentlebirth

Also some cool midwife books that I don’t own but that my midwife brought over the day after Stealth Baby’s birth to show head position, rotation and generally talk about what happened the night before while I was in labor land.

Most face first presentations are delivered vaginally as they aren’t diagnosed until the baby is descending. In order for a baby to deliver face first, it would need to be mentum (chin) anterior. Face first labors tend to be much more painful for the mom and much slower since faces don’t dilated the cervix very well. Only 0.4% of babies will present face first. In my situation, the doctor didn’t catch that my son was face first and she even tickled his head to stimulate his heart. She must have felt his cheek or forehead. Often times doctors will realize the presentation when they check and the baby sucks their finger. Sometimes the mouth is mistaken for the anus and the baby is misdiagnosed as being breech. The causes of face first presentations can be a weak abdominal wall and the pelvic shape. Other times it’s an OP (occiput posterior) baby who just happens to stick their face in the pelvis at some point during labor.

It has been said that the problem with the face first presentation isn’t really the face but what follows. In our case, my son had a 14.5 inch head that had the face engaged the pelvis would have had to pass through the pelvis unmolded. I am sure that wouldn’t have happened. I do not really believe that women can grow babies they can’t birth but in a situation where a rather large head must birth unmolded, it makes me wonder. Regardless, because his face presented transversely, he was unable to engage past a -3 station anyway. This article discusses face first presentations in more depth.

My face first presentation was diagnosed once the c section began. He was wedged in such a way that he couldn’t go forward and pulling him back out was very difficult as well. This resulted in the additional vertical cut into  the contractile portion of the uterus. Interestingly enough, as only 0.4% of babies present face first, only 0.4% of cesareans are inverted t incisions. They are typically saved as a last resort in emergency situations are extremely difficult deliveries that require more room to maneuver within the uterus.

When a cesarean delivery starts out with a horizontal bikini cut as mine did and then is given the additional vertical cut, usually the cut is small and stays in the lower segment of the uterus. These kind of scars are generally considered safe to VBAC although finding a provider may be difficult. My operative report does not indicate how long the vertical cut was, sometimes the doctor does include that information. Mine only says that it was cut into the contractile portion of the uterus. Sometimes the t extension does go into the fundus or the top of the uterus. This is more representative of  a classical incision and is considered riskier.

Because of the increased amount of scar tissue and a scar in the contractile muscles, the recommendation from ACOG is that women with inverted t incisions should not TOL (trial of labor) in future pregnancies. My doctor also told me that I should deliver at 36 weeks after an amniocentesis to check for lung maturity. While the third trimester risks of amniocentesis are low
, I have a big problem with purposefully delivering a preterm baby by elective cesarean. My son was born at 41 weeks and 1 day. He was 8lbs and 5 oz. He was healthy other than the birth trauma and breathing issues related to our cesarean. He obviously needed to gestate that long. At 36 weeks, he would have been 5 weeks and a day early. He definitely would not have been ready to be born.

This early delivery recommendation stems from the increased risk of uterine rupture. There is an increased risk but it may not be as high as some doctors make it out to be. The rupture rate for a low horizontal cut (bikini) is about .5% and I have heard doctors say there is a 15% chance of rupture for an inverted t incision (offering no info to back up that claim and not responding when I challenged it). I have read online where doctors say 4-9% but with no references or studies proving that range.

Ann Frye says “.As far as the type of incision goes, the mother who has a low transverse uterine incision is at the lowest risk for scar-related problems such as dehiscence and rupture. Those with classical or T-shaped incisions are at more risk for rupture, which tends to be more traumatic than the usually benign scar disruptions which occur in women with low transverse incisions. While some types of incisions pose more risk, the highest risk is still probably around 5% (some scars are more rare and limited data is available. From looking at the existing data, 5% seems to me a generous estimate of risk for all types of Cesarean scars, with the order of risk as follows: low transverse [0.5% Haq, 1988; to 2% Clark, 1988], low vertical [1.3% Enkin, 1989], classical and inverted T [probably about the same for both: 2.2% to 4%, depending on the study], upright T and J-incision [probably somewhat higher, but no specific data is available].). Women with an upright T, J-shaped, or classical incision or those who have experienced previous uterine rupture may want to birth in the hospital, although finding a practitioner that will assist them to have a VBAC will be more difficult. However, in these cases scar disruption is **most likely** [emphasis the author’s] to occur during pregnancy with accompanying fetal distress and possible death, or not at all. ” The references are vague here as well.

The Landon Study (2004) found that the rate of rupture for inverted t incisions is 1.9%. I tend to trust this study more than anything a doctor tells me or any other study. The reason is because it seems to be the largest one I can find. Most women with inverted t’s do have repeat cesareans so there are not many large studies. This particular study included a total of 17,898 women who had TOL after cesarean. Of these, 14,483 had a prior low transverse incision (bikini cut) and the rupture rate was 0.07%. Of the total 17,898 women who had TOL, 105 had inverted t incisions, j or classical incisions. Two of these women ruptured equaling a 1.9% rupture rate for inverted t, j and classical incisions combined. All of them either showed up late in labor or simply refused repeat cesareans. The outcomes for these two women and their babies were not included in the study.

For me personally,I am comfortable with TOL after inverted t in a supportive environment with fetal monitoring. If I have a successful VBAC, I am comfortable home birthing the next one. I have found a doctor that will TOL with me. His only requirements are venous access (hep lock but I don’t have to have the IV if I don’t want it) and continual electronic fetal monitoring. I can live with both under the circumstances. I will have no time constraints on my labor, limited staff interruption, the use of a tub and wireless portable monitoring, a doula, my Bradley Method trained husband and the comfort of knowing if my uterus blows that my doctor is there waiting in the hallway. There is a 0.095% chance of the baby dying in the event of a uterine rupture. Outcomes are greatly improved when the cesarean can be performed within 20 minutes of the suspected rupture. For me, I can VBAC comfortable knowing these percentages. I think that the option to VBAC for moms with inverted t incisions should be based on the mothers comfort level and knowledge. I hope that this post can help moms make a more educated decision. I will add new information as I learn it.

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Optimal Fetal Positioning for a Better Birth

Posted on June 10, 2009. Filed under: Birth, breech, Face First/Mentum Presentation, inverted t incision, Pregnancy | Tags: , , , , , , , , |

Optimal Fetal Positioning‘ (OFP) is a theory developed by a midwife, Jean Sutton, and Pauline Scott, an antenatal teacher, who found that the mother’s position and movement could influence the way her baby lay in the womb in the final weeks of pregnancy. Many difficult labors result from ‘malpresentation’, where the baby’s position makes it hard for the head to move through the pelvis, so changing the way the baby lies could make birth easier for mother and child.

This is near and dear to my heart and something that I tend to go into depth with my clients on. It is SO SO SO very important and it is rarely discussed in prenatal visits with OBs. It’s not really something discussed at prenatal visits with OBs amd I’m assuming that it’s because positioning doesn’t really matter when the baby can be cut out if it’s a problem.  Midwives and my homebirth OB in Korea as well as other natural minded OBs tend to spend more time on this. Anyway, it’s near and dear to my heart because I had a difficult position with my first baby, face first. Face first and face up or occiput posterior, OP, are two different presentations. Face first is rare, one in 500 at most. It is a position that is refrequently sectioned because the labor is very slow but it is vaginally deliverable in some situations. It is very uncommon and there are reported cases of broken necks and facial paralysis but I think that is generally due to pitocin augmentation causing much stronger contractions that the face first baby can handle. I planned a natural birth and after three days of contractions, meconium and fetal distress was sectioned (for failure to progress) only to find a face first presentation that ultimately resulted in an inverted T incision (which I will discuss in depth in another post).

The first picture is a face first presentation. The second is the optimal occiput anterior presentation.

150px-Smellie_XXV

190px-Smellie_XIV

I am also including the chart below that shows the presentation view from the outlet. My son was Face First, LMT, left mentum transverse. This is considered to be a physically impossible presentation for vaginal delivery and the occurrence is extremely rare.

fetal position

I spent a TON of time talking and reading and researching what happened, what caused this and how it could have been prevented and there are many things that I did wrong. I have healed from all of this and am completely capable of talking about it as I think that everyone should know how they can affect their labor, by the way. My situation was a series of events. First, poor diet in early pregnancy led to early swelling. Pitting edema at fifteen weeks usually raises red flags and of course I was told to sit with my feet elevated above my hips as much as possible, which of course I did (I mean who doesn’t want to be lazy when pregnant???). I continued with my poor diet and now lack of exercise throughout the pregnancy and managed to gain 60lbs. Sitting in a reclined position is the worst thing you can do in pregnancy because it causes the pelvis floor to tighten and the uterus to tilt so the baby has to find a comfortable position somehow and mine settled ROT (right occiput transverse, right side of my stomach, back of the head towards my back and sideways, you would see the babes profile). This apparently is the best position for a baby to flip OP (occiput posterior, face up) during labor. Instead of doing that, mine just stuck his face in my pelvis. This causes a hyperextended neck and really, faces don’t dilate cervixes.

There are a number of things that I could have done differently but I’ll get to that in a bit. First I want to discuss what the optimal position is. Then I’ll tell you how to get there.

The ‘occiput anterior‘ position is ideal for birth – it means that the baby is lined up so as to fit through your pelvis as easily as possible. The baby is head down, facing your back, with his back on one side of the front of your tummy. In this position, the baby’s head is easily ‘flexed’, ie his chin tucked onto his chest, so that the smallest part of his head will be applied to the cervix first. The diameter of his head which has to fit through the pelvis is approximately 9.5 cm, and the circumference approximately 27.5cm. The position is usually ‘Left Occiput Anterior’ or LOA – occasionally the baby may be Right Occiput Anterior or ROA.

Gail Tully, creater of http://www.spinningbabies.com
is a midwife who is very knowledgable in OFP and who helped me understand my situation better, created this to help explain positioning:
_katie-belly-rose-wroa

SO, how to achieve optimal fetal positioning? Very simply actually. First, posture. Gail Tully and Jean Sutton say no furniture! Sit indian style in the floor, this helps open your pelvis and release your pelvic floor. Use a birth ball for better posture. “Rest Smart” Nap or sleep in positions that let your baby’s back settle in your “hammock.”

To help facilitate good positioning, pelvic tilts should be done daily and several times a day. Walking and prenatal yoga also help with positioning by moving your hips and pelvis, stretching things out and encouraging the baby to engage in an occiput anterior position. Remember though, HEAD DOWN IS NOT ENOUGH! Babies can be head down but OP (face up) or asynclitic which can cause really long hard back labors. Read here to learn more.

So you may need to figure out what position your baby is in to begin with. Belly Mapping can help with that. By feeling where the baby is, where you feel movement, where the heart beat is, the shape of moms tummy, we can figure out how the baby is positioned. It isn’t hard to do at all. Once you learn the postition, you can then focus on improving it or changing it completely. Sometimes we know before labor even starts that the baby is OP and can get the baby to rotate. There are also ways to get a breech baby to turn.

Every pregnant woman should know this information. It is so vital in ensuring that you have the best labor and delivery possible. Sometimes breech babies won’t turn and sometimes OP babies stay OP but by learning OFP techniques you are at least giving yourself a chance to make a difference.

If you are pregnant here’s a list to help with positioning:
Pelvic tilts 20 each 3x per day
Sit indian style
Do not recline
Use a birth ball
Take at least a 20 minute walk every day
Learn what position your baby is in now
Learn what to do to improve the position
Learn what to do to keep the baby in that position
Get help if you are unsure
Get help if the baby won’t move

Good luck!

EDIT: Here is some information sent to me by Ann Tumblin concerning OP babies and epidural use.

Epidural Analgesia Linked to Increased Risk of Occiput- Posterior Babies
Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics & Gynecology, 105 (5, Part 1), 974-982. [Abstract]
Summary: This prospective cohort study used periodic ultrasound examinations during labor to evaluate changes in fetal position and their relationship with epidural analgesia. The researchers sought to determine whether epidural analgesia is responsible for higher rates of fetal malposition (occiput-posterior (OP) or occiput transverse (OT)) or whether women experiencing labor with a malpositioned baby have more painful labors and are therefore more likely to request epidural pain relief. A total of 1562 nulliparous, low-risk pregnant women were enrolled in the study.

The researchers found that the position of the baby (occiput anterior (OA), OP or OT) at the time of enrollment (in the early part of active labor) predicted position at birth poorly. For instance, of the women with an OP baby at birth, only 31% had a baby in the OP position at the initial ultrasound scan. Similarly, sonograms done later in labor were also poor predictors of position at birth. The data demonstrated that changes in fetal position were common during labor, with 36% of participants having an OP baby at the time of at least one scan. More than one-half of the women who gave birth to a baby in the OP position never had an OP baby at any ultrasound assessment in labor. Overall, 79.8% of babies were born in the OA position, 8.1% were OT, and 12.2% were OP at birth.

Epidural analgesia was strongly associated with delivery from the OP position: 12.9% of women with epidurals gave birth to babies in the OP position versus 3.3% of women without epidurals (relative risk 4.0, 95% CI 1.5-10.5). Transverse position was not related to epidural use. In a statistical model that controlled for various medical and obstetric factors that could affect outcomes, epidural use was still associated with a 4-fold increase in the risk of OP birth.

The data suggest that the association between epidurals and OP babies is not because women in labor with an OP baby are more likely to request an epidural. Women who received epidurals were no more likely to have OP babies at prior to or at the time that the epidural was administered. Furthermore, women with OP babies in labor or at birth reported the same degree of pain as those with OA or OT babies and were no more likely to report “back labor,” which is commonly thought to be related to the OP position. Finally, women with OP or OT babies at birth were much more likely that those with babies in the OA position to give birth by cesarean section, with 6.3% of OA babies born by c-section versus 64.7% of OP and 73.8% of OT babies (p<.001).
Significance for Normal Birth: Epidural use increases the risk of instrumental (forceps or vacuum) delivery in first-time mothers. Experts have proposed various reasons for this association, including diminished urge to push and changes in the tone of the pelvic floor muscles that inhibit proper rotation of the fetal head. Letting the epidural “wear off” has been thought to increase the likelihood of unassisted vaginal birth, however, this systematic review calls into question that common practice.
In normal birth, there are complex hormonal shifts that help labor progress and facilitate delivery. The laboring woman produces natural endorphins that help her manage the pain of labor. Her ability to move freely and assume a variety of positions while pushing work in concert with these hormonal changes. Epidural analgesia numbs the sensations of birth, and the production of natural endorphins ceases as a result of the disruption of the hormonal feedback system. When the epidural is discontinued, the woman’s pain returns but her natural endorphins may remain diminished and therefore her pain may be greater than if the epidural had not been given in the first place. Furthermore, when an epidural is administered, the woman is usually confined to bed and attached to fetal monitors and an intravenous line. The woman and provider may become accustomed to laboring in the bed attached to machines. When the epidural is discontinued the restrictions! on her movement may persist. Under these conditions, it is likely that the impact of an epidural on normal birth may outlast the epidural itself.

EDIT: Ann Tumblin also sent me this regarding OP (face up) babies. It was done by Penny Simkin who is basically the mother of all doulas. It is very informative so if you have ever had an OP baby and are nervous about it a second time, I highly recommend you taking a look at it.

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