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 , 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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Why I Want To VBAC

Posted on January 24, 2010. Filed under: VBAC after inverted t incision | Tags: , , , , , |

My friend Desiree inspired me to do this one. I have talked about how I am going to VBAC and all the logistics and preparation and details involved but I haven’t talked about why I want to. I think for a lot of women it is easier to schedule an elective repeat cesarean section (ERCS).  Many OB’s do not support VBAC or hospitals have VBAC bans or people have misinformation that does not make VBAC seem like a safe and healthy option.

I know I am certainly one of those women that it would be easier for. It would probably be easier to go ahead and schedule my ERCS now. I was told after Graham was born that due to the inverted t incision scar on my uterus that there was an up to 15% chance of uterine rupture and that it would be best to schedule an ERCS at 36 weeks to avoid any labor. At first, even though I was devastated, it didn’t sound too bad. I didn’t have Graham until 41 weeks 1 day. Having my next baby at 36 weeks kind of sounded great compared to going past 41 weeks. Plus, we had a really hard long labor, 52 hours total, so the thought of skipping all that and just having the baby sounded pretty tempting. That’s how I rationalized it all in my head, to make myself feel better about having had the first c section and about having to have the inverted t incision. I thought, ‘well, at least I don’t have to be pregnant forever and I don’t have to labor just to end up with another c section and I can plan everything.’ But it never really set in and it never really felt right to me. So I started researching.

I already knew that VBAC was a safe and healthy option for moms with bikini cut scars so I didn’t really start out researching VBAC safety as a whole. I started with the inverted t incision because that put me in a whole different category of risk according to the doctors. I looked for the studies that backed up the 15% claim of rate of uterine rupture in a subsequent trial of labor (TOL) and couldn’t find anything. I did find the most commonly quoted rates of 4-9%. So I started thinking that at least that meant there was a 91-96% chance that no rupture would occur. That was motivating. The I found my friend Jessica, another inverted t incision mom. She had started a Yahoo group, Life After Inv T, on her own webiste, Jessica’s Haven, she shared her birth story of a VBAC after inverted t incision. It was the first I had ever heard of this and I was so excited. I didn’t even know it was possible then I realized, she had two other moms stories on her site too. This gave me confidence to start really looking at VBAC as a viable option for me.

One reference that Jessica made as far as determining the safety of VBAC after an inverted t incision was the Landon Study 2004. The Landon Study found a rupture rate of 1.9% for inverted t incision type scars. I was floored. This was the largest VBAC study ever done and the rate was more than half to almost four times less than the smallest rate quotes I had found previously. At this point I got angry. I got angry at all the information I was given after my first c section. I was angry at the suggestion that I purposely deliver a preterm baby when I have always known that it is better for babies to initiate labor, letting us know they are ready to be born. I was angry at the thought of having to endure another c section, not just for my own sake but my baby’s sake.  I realized that ERCS tend to be easier on both mom and baby but what if I want a third child? A fourth? Each c section a woman has increases risks of complications. And what about the issues that area associated with babies that are born by c section? They weren’t risk free either were they? My brain was racing and I was again on a quest to learn more.

I have read the Landon Study many many times. I gave my Korean OB a copy of it the first time I met him, in case he had never heard of it. I highlighted all the parts that pertained to me and any other information I thought should be discussed. He was very welcoming of that information and asked me to be sure to bring him anything else I come across that my help me have a better birth or for him to be a better doctor. I really appreciated that support.  I found a post on a message board the other day that kind of breaks the Landon Study down a little bit. I am including that information here because there are several points that I want to touch on that really define why I want to VBAC. I am going to bold these points and I am going to italicize any of my own commentary.

The 2004 Landon study in the NEJM (12/2004) is a very good source for UR information. It included nearly 18,000 that had a TOL (trial of labor which may or may not lead to a successful VBAC). The overall rate of UR was 0.7% which translates into 124 uterine ruptures in that group of nearly 18,000. Only 2 of the babies died following a uterine rupture. Keep in mind, the group included women having a TOL after 1, 2, 3 and 4 c-sections. It also included women who classical, invert T and J incision as well as the low tranverse incision (which is most common and considered the safest for a TOL). About 25% of the women in the TOL group had their labors induced (with prostoglandins or pitocin) and/or augmented with pitocin which also increases risk of uterine rupture. About 25% of the women in the TOL group were less than 2 years from their previous c-section. Clearly, there were many other potential risk factors that could come into play here with the risk of UR.

According to this study :

The absolute risk of neontal death is 0.08% with a TOL vs 0.05% in an ERCS; stated otherwise, the risk of neonatal death is 1 in 1250 babies with a TOL vs 1 in 2000 with an ERCS . Babies can die in both a TOL and an ERCS. The difference between the two is very very small as you can see. TOL and ERCS both have risks. There are risks associated with vaginal birth in an unscarred uterus. There are risks associated with getting in a car and driving to work and leaving your house with the oven on and with pretty much everything else we choose to do in life. At least these are calculated risks with firm data to give us an idea of what we are dealing with.

The absolute risk of the mother’s death was 0.04% with an ERCS cs 0.02% with a TOL; stated otherwise, 1 in 2500 mothers will die due to an ERCS vs 1 in 5000 mothers will die with a TOL)   Again, very small increase in risks here. Even though the risk of maternal death doubles for an ERCS, it is still under a half of a percent. Compared to the risk of fetal death, the mother’s risk is lower so one could say that VBAC is safer for the mom than it is for the baby but I am not sure that is very accurate since again, all of these numbers are under 1% total. And even if I sound cold or strange, I think for me I have to consider Graham, the child that I already have living here now. While the baby growing in my belly is very important to me, I could not imagine dying and leaving Graham to grow up without a mother. If I were basing my decision on the risk of fetal death vs maternal death, I would choose to lower the risk of maternal death. I have not based my decision to VBAC on comparing these two risks, however, and again, since all the risks are so very low, it’s not really important that I compare them that way. Some people may, but I’m not.

This study also separated out the number of women and the number of UR based on incision type:
– Low transverse incision (n=14,483): 105 ruptures (0.7%)
– Low vertical incision (n=102): 2 ruptures (2.0%)
– Unknown type of incision (n=3206): 15 ruptures (0.5%)
Classical, inverted T or J incision (n=105): 2 ruptures (1.9%) I can’t really say anything. It’s right there to see. It’s not 15% or 4-9%, it’s 1.9% and I believe this.
– Unclassified (n=2)

It also separated out the number of women based on rates/types of induction:
– Spontaneous labor (n=6682): 24 ruptures (0.4%)
– Augmented labor (n=6009): 52 ruptures (0.9%)
– Induced labor (n=4708): 48 ruptures (1.0%)
– With any prostaglandins, with or without oxytocin (n=926): 13 ruptures (1.4%)
– With prostaglandins alone (n=227): 0 ruptures
– With no prostaglandins (n=1691): 15 ruptures (0.9%)
– With oxytocin alone (n=1864): 20 ruptures (1.1%)
– Not classified (n=496): 0 ruptures

Augmenting and inducing does raise UR (uterine rupture) rates. The numbers are still very small but in the absence of a valid medical reason to augment or induce, I would not do it. I feel that way about unscarred uteri though. Elective induction causes problems whether it’s for a first timer, a VBACer or anyone else.

A Breakdown of the number of previous cesareans (obtained from a subsequent study by Landon in Obstetrics and Gynecology 7/2006) (the women who had more than 1 c-section were grouped together and had a UR risk of 0.9% while the women who had 1 VBAC had a risk of 0.7%):
• 16,915 (94.5%) had 1 prior cesarean
• 871 (4.9%) had 2 cesareans
• 84 (0.5) had 3 cesareans
• 20 (0.1%) with 4 cesareans
8 women had an unknown prior # of c-sections

Risks of choosing a a TOL (trial of labor) vs an ERCS (elective repeat c-section):
•More likely to suffer a uterine rupture – the rupture rate in the TOL group was 0.7%; there were no ruptures in the ERCS group, however, women who presented in early labor and did not have a documented intention to labor were excluded so it is possible that women went into labor before their scheduled c-section and ruptured but were excluded from this study’s data
•1.4 times more like to have a uterine dehisence (typically a benign, thin area in the uterus)
•1.7 times more likely to need a tranfusion
•1.6 times more likely to develop endometriosis
•1.3 times more like to have another adverse event such as (broad ligament hematoma, cystotomy, bowel injury, ureteral injury)
•1.6 times more likely for the baby to die (doesn’t sound like that big of a difference right? Remember that babies only die in about 2-10% of uterine ruptures according to many studies AND babies do die after c-sections.

Risks of choosing an ERCS over a TOL:
•1.5 times more likely to need a hysterectomy I could have lost my uterus the first time, it was T’d secondary to difficult delivery of the head and once removed for cleaning and stitching it was found to be extremely large. So large in fact that they couldn’t get it back in. And it wouldn’t contract. I remember the slight panic in the room in those minutes. Luckily with a few shots of pitocin straight into my shoulder, it contracted and they got it back in. I’d kinda like to avoid that drama this time around. I’d like to have another baby, maybe two after this one.
•2.5 times more likely to have a thromboembolic disease (deep venous thrombosis or pulmonary embolism) I have a blood clotting disorder, prothrombin gene mutation. I am already higher risk for developing a DVT or PE. I do not know the stats but factored in with the risks of developing these issues just by having an ERCS, it is very motivating for me to stay off the operating table. PE  is the number one cause of death in pregnant women. So while the data shows a higher rate of death for the ERCS group at 0.04%, mine risk is going to be higher than that, even though I don’t know what the numbers are. It would be pretty hard to find information on risk of death by PE during an ERCS for a woman with PGM. That’s a mouthful.

•2 times more likely for mother to die
Risks of a successful VBAC delivery (remember that TOL can end in repeat c-sections) vs an ERCS:
1.2 times more likely to need a transfusion My doc said I could be a little higher risk on this one as my placenta is anterior and if I have any detachment issues after the birth. I am A+ which is an extremely common blood type in Korea and I am delivering at a University hospital in Seoul with plenty of blood in the bank. I feel ok with this.

Risks of an ERCS vs a succcessful VBAC:
•3 times more likely for mother to need a hysterectomy   See above. The above stats were for ERCS vs TOL (VBAC attempt whether successful or not). This stat here is for ERCS vs successful VBAC.
•5 times more likely to have a thromboembolic disease (deep venous thrombosis or pulmonary embolism)
See above. The above stats were for ERCS vs TOL (VBAC attempt whether successful or not). This stat here is for ERCS vs successful VBAC.
•1.5 times more likely to develop endometriosis
•4 times more likely for mother to die

2 things this study does not address regarding newborns is the incidence of respiratory distress in babies born by elective repeat cesarean which can be quite serious. It also does not address the number of babies that have brain damage as a result of a UR. I want to say the chance of brain damage is about 10-15% when you have a UR but I’d have to double check that. Obviously, UR is very rare but it does happen. When it does happen, UR rarely results in fetal death or brain damage though that too can happen. Babies are usually okay after UR. As far as the mother goes, it doesn’t address the decrease in hospitals stay, post partum surgical infection, etc.

Overall, I feel as if the medical data on the safety of VBAC, fetal death, maternal death, and other complications assure me that VBAC really is the best option. Medical reasons aside, there are emotional reasons as to why I want to VBAC. HERE is the linkt to a fantastic video of a woman and her three births. The first two were c sections and the third was an HBA2C (homebirth after 2 cesareans). Bring tissues.

I just feel like i owe it to my baby to birth it in a natural and peaceful way. I owe it to the baby to come into the world, straight my arms and not into the hands of rough strangers. I want the experience but mostly I want the baby to have the experience. Graham and I were separated the first three hours of his life, that is heartbreaking!  Part of giving my baby the peaceful birth is to also birth it without drugs as well. I don’t want the baby to be groggy and disoriented at birth or to have latch or suck issues which is very common with c/s babies, including my first baby. I want immediate skin to skin contact with my baby after it’s born, not for it to go to a warming table where it is suctioned and scrubbed and roughed up so it will cry. None of that is necessary, what’s necessary is the skin to skin contact, with me, with my body heat and my scent and my touch.

I truly believe that how we birth matters. I realize there are women who have c sections and they are happy about them and they had no bad outcomes and their babies were fine after them and emotionally they are happy they had their c sections. I also believe that a lot of women who have an unplanned c section the first time do have some emotional baggage as a result. I think that many women who go on to have ERCS rather than VBAC still think about VBAC and ‘what if’ really aren’t that happy that they had c sections and wonder if they really were necessary or not. I am not a woman who escaped my c section unscathed. II did have a lot of emotional baggage as a result. It’s already been proven that c section moms have a higher rate of postpartum depression and I can attest to that one personally. For me, ultimately, I just believe that I can birth. Even though it didn’t quite work out that way the first time, it doesn’t stop me from believing it or believing that birthing the baby myself is the best option for both me and the baby. I know that I could end up with a repeat c section and I am mentally prepared for that outcomes but it won’t be because I didn’t do the work or set myself up for the best possible scenario. It will be because it truly was necessary and that will be enough for me.

I am really looking forward to my labor. I am looking forward to the contractions and finding my rhythm with them, going off to labor land and having a pretty low intervention peaceful birth. I am looking forward to it because at one point in time I thought I’d never get to do that again but I am getting that chance and I am thankful for it. It seems so far away right now but I bet it will all be in here in no time.

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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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