posted 15th Jul '12
Here's an inspiring story... sorry if there's typos at all- I retyped it online!
Laying the Bugaboo of Uterine Rupture to Rest:
VBAC After Four Cesareans
Mary Jo Camillus
The Birth of Sheila
Mary Jo: My husband and I attended "natural childbirth" classes during our first pregnancy and felt that we had prepared ourselves as well as possible for the birth. The class consisted of factual information, relaxation, and breathing, but there was certainly no attempt at educating us for cesarean prevention. Because I was in fine health and the pregnancy was completely uncomplicated, we hardly gave that possibility a second thought.
Our baby's due date was December 15, 1972. When I went into labor, it was December 28. My contractions were about 5 minutes apart when we set out for the hospital, 35 minutes or so away. By the time i arrived at the hospital, the contractions slowed down. When the doctor did an internal exam and discovered that I had not begun to dialate, they immediately ordered pitocin and broke my waters. I was on my back with an external fetal monitor.
Suddenly I had a sustained and very powerful contraction, unlike any other I had had. The fetal monitor showed a sudden drop in the baby's heart rate. The doctor decided the placenta must be in the process of detaching, and he immediately ordered the nurse to "prep" me for a cesarean, to "save the baby."
Comments: Although it may appear that the doctor was a hero because he did a cesarean to save the baby, the very emergency which threatened the baby's life may have been caused by the doctor's mismanagement of labor.
Artificial rupture of membranes -waters (ruptured intentionally by the practitioner) can cause fetal distress because the baby is no longer protected from the force of contractions. Imagine yourself squeezing a water balloon as hard as you can with an egg inside of it. The egg is protected from the force by the water balloon, and is very difficult to break. Now, imagine breaking the water balloon, and exerting the same amount of force directly on the egg. The egg would shatter. Clearly, then, the longer the membranes remain intact, the less stressful labor will be for the baby, and should be used to stimulated labor only after all other less risky methods have been attempted first.
The supine position (lying flat on your back) increases risk of fetal distress because the weight of the pregnant uterus presses on the vena cava, thus preventing adequate blood flow return, and causing poor oxygenation to the fetus.
It has been known since the 1940's that the dangers of Pitocin include abruption (the placenta tearing away from the wall of the uterus before the baby is born), fetal distress, and even uterine rupture. It is precisely for these reasons that the monitor is used routinely with a pitocin stimulation of labor.
However, practitioners rarely discuss these risks with mothers. In some states in the country, it is now required by law that physicians and hospitals enumerate the risks (as well as benefits) of any medication of procedure they plan to use for a woman in labor. If a woman has had a pitocin induction without being informed of the potential risks, she may be in a position to bring suit against the prectitioner and the hospital. If more women would have the courage to bring suit for an unnecessary cesarean (especially when unninformed consent is an issue), then practitioners would become influenced not only by fear of malpractice suits for not doing a cesarean, but fear of suts for performing unnecessary cesareans as well!
Mary Jo: My husband, who had planned on being with my throughout the birth, was whisked away. He told me that they were working quickly, not only to save teh baby, but to prevent me from rupturing and being in danger. So, while my fears were focused on the baby's well-being, he was left out "in the dark" with mortal fears for both me and the baby.
I was offered the "reassurance" that I would have a spinal, rather than general anesthesia, and would thus be awake to "see the whole thing".
Comments: Usually if a cesarean is a "true emergency" (the life of the mother or the baby is at risk now) spinal anesthesia is contraindicated. Spinal anesthesia almost always lowers the blood pressure to some degree. If the blood pressure is already low because of blood loss, the spinal could create dangerously low blood pressure, thus possibly causing a maternal death.
It seems doubtful to me that the "emergency" that the doctor depicted to Mary Jo was indeed so emergent. Had it been a "true emergency" I feel quite certain Mary Jo would have received general, not spinal, anesthesia.
Mary Jo: A classical incision was made to my uterus, and our daughter was born very quickly. She was--thank God--alive, and so perfectly beautiful. Everyone seemed so busy that I had to ask at least 3 times, with mounting insistence, that someone go out and tell my husband. I remember assuring myself that not only did the baby seem fine, she must be, or the doctors wouldn't be talking about football scores as they stitched me up!
Although my husband and I both saw our baby in the corridor, neither of us were permitted to hold our daughter. I assumed Sheila would be brought to me at the regular nursery feeding hours. But she was not. I was desperate! Finally, seven tearful hours later, I held and nursed my baby.
The cesarean was certainly a major disappointment-- especially because I was told to expect that all future births would also have to be sections.
The Birth of Johnney
When I became pregnant for the second time, I was still with the same doctor. I had no notion that I could question his assumption that the delivery would have to be by cesarean. My main concern was to have the baby with my much sooner after birth. I contacted the pediatrician in advance at the hospital and got a promise that he waive the 24-hour observation in the special care nursery that was still routine for cesarean babies. Unless there was some specific contraindication, I could have the baby with me as soon as the usual nursery rituals (eyedrops, weighing and measuring, etc.) were complete.
The baby's due date had been September 30, 1975, so the cesarean was scheduled for one week before that date. However, early in the morning of September 16, my waters broke, and the doctor delivered our Johnney a few hours later.
Emotionally, this birth experience was easier than the first, because it didn't have the "emergency" character and aura of fear around it. Besides, I did get to have Johnney with me within a few hours. Physically, however, my recovery period was the hardest of my four cesarean experiences. It was hot in the hospital; I was feverish when my milk came in; I had the usual stomach-gas problems after surgery. I missed Sheila terribly. We had some teary phone calls. I didn't see her from Tuesday (when John was born) until Saturday, when --against hospital policy-- my husband Joe smuggled her in to see me. By the next day, I had convinced the doctor to let me go home.
My mother was able to come from out of town to help me this time. Her presence, from the day after John's birth until almost three weeks later, was a tremendous blessing in terms of my recovery.
The Birth Of Tina:
By the time of our third pregnancy, two years later, my husband and I had read a newspaper article about the new cesarean support group, C/SEC, and we went to one of its meetings.
With C/SEC's help, we were able to find a hospital in Boston where my husband could be present for a cesarean birth, where the baby could be with us in the recovery room, and where the older children could visit daily. We also found a doctor on its staff who would permit my husband to give the baby a Leboyer bath right in the OR. This doctor was recommended to us by C/SEC as one of the more likely doctors to consider vaginal delivery, because by this time we had heard of some exceptions to the "once a cesarean, always..." rule. On inquiry, he said he would have considered it after one cesarean, but that he knew of no one, himself included, who would allow it after two. At my request, he did agree to deliver the baby only after I went into labor instead of scheduling the birth. This request was made, not so much out of any great respect for mother nature's sense of timing, as out of my husband's and my flicker of hope that if labor progressed fast enough, we might finagle our way into a natural birth after all.
On the morning of September 21, 1977, when this baby was already a few days overdue, I began having occasional contractions. We stayed home until shortly after midnight, when the contractions were coming at about 5-minute intervals. When we got to the hospital, the doctor arrived shortly, ready to operate. When I asked for an internal exam, he did one, but dashed our hopes with the announcement that I was less that 1 cm dialated and we would certainly have to go ahead with the cesarean.
Having Joe there for the birth made so much difference-- the miracle of watching together as that new life emerges! I still had the screen between me and the surgery, but he stood up and looked around it, giving me the "play by play account" as our little Christina was taken out of my uterus. I really can't say who enjoyed the Leboyer bath more-- father or daughter! It was just bliss for both! We had Tina with us for well over an hour in the recovery room and I was able to nurse her for most of that time.
After the first two births, i had remained catheterized for a day or two and on IVs for even longer. This time, the doctor removed the catheter before leaving the OR and allowed me to drink liquids in the recovery room. By the next mealtime I was eating real food! What a morale booster that was!
After Tina's birth, I had much less discomfort of any kind and gained strength much faster than after the first two. I feel my faster recovery can be attributed to the differences in procedures after the operation, and that I had a different kind of incision. Although this doctor entered through the same vertical incision externally, he did not use the classical uterine incision (an incision which runs vertically from the top of the uterus down to the cervix) that I'd had the first two times. He did a low cervical uterine incision (a transverse incision just above the cervix). I was able to walk without clutching my abdomen by the time I left the hospital! I hadn't been able to do that for weeks after the other two!
The Birth of Rebecca:
If a vaginal delivery was out of question after TWO cesareans, there was certainly no hope for it in our minds after three. So Rebecca was born March 10, 1980, in a C-section scheduled a few days before her due date. Joe was again able to be there and to give her the Leboyer bath in many ways, the details of her birth and my recovery were similar to those of Tina's birth.
The Birth of David:
How did we get from there to a VBAC for baby number five? By an odd route indeed!
Joe's mother lives in India, where cesareans are considered to be high-risk procedures, and tubal ligations are always done with the delivery of a second cesarean baby. She had already spent 18 months "on her knees" through the last two pregnancies, and the news of this one -- as delightful as it was for us -- was liable to cause her heart failure! So I pulled out an old list of C/SEC phone numbers to try to gather reasurring stastitics on the safety of cesarean births to send to her.
However, the person I happened to connect with was Nancy Cohen, who was hard at work on a book about VBAC and cesarean prevention, Silent Knife. I was apprehensive, but intrigued. We talked at length. Nancy gave me the names of four doctors whom she thought might consider doing a VBAC in my, admittedly unusual, case. Joe and I had had a lot of fear (particularly of uterine "rupture") instilled in us along the way. So a VBAC after four cesareans- particularly with a classical incision-- sounded to us like a pretty awesome undertaking. On the other hand, we hoped for more children after this one and did NOT relish the thought of more and more surgery. So, we decided to make an appoinment to talk with Dr. Richard McDowell.
We had thought about that upon hearing a history of four classical C-sections, any doctor might climb the walls at the suggestion of a vaginal delivery. But, in his own low-key way, Dr. McDowell received the request thoughtfully. In our presence, he phoned a colleague who had also had a great deal of experience with VBACs, and conferred with him about it. In the end, his conclusion was that, if all went well with the pregnancy, and if there should be no contraindications in my medical records when he received them, he would be glad to help give it a try. He would want to take certain precautions, such as having crossmatched blood available and a heparin lock in place on my wrist (to allow quick insertion of IV if necessary).
Dr. McDowell felt strongly that we should attend a VBAC class. We found it incredibly helpful. We started the class with some serious misgivings about the wisdom of a VBAC for us, and ended it fairly bursting with confidence and optimism. In the meantime, Dr. McDowell had put us in touch with a midwife, Kim Brodie, whom he recommended as a labor support person.
Comments:
The creation of the birth team-- the childbirth educator, the midwife, the doctor, the mother, and the father-- all knowing, trusting, and supporting one another is a tremendous asset in preparing for a positive birth experience. Unfortunately, many doctors feel threatened by the presence of a midwife/labor coach at the birth, and do not understand that the midwife is not there to usurp the power of the doctor. However, Dr. McDowell clearly did not harbor those fears. His recommendation to Mary Jo
to not only take classes, but specifically to take VBAC classes, and his recommendation of a midwife/ labor support person demostrated his true support of Mary Jo's VBAC. His efforts created the cohesiveness of the team. When a VBAC mother knows that she has an entire team surrounding her to support her in her efforts to give birth vaginally, she feels much more strength and faith in her own abilities to birth her baby.
Mary Jo:
The baby was due March 30. Time crept by until just before midnight, April 12, when I felt fairly sure my water had broken while I was on the toilet. I began to have some contractions, but at wide enough intervals that we decided to go to sleep until the pace quickened. By about 6:00 A.M., they were coming at 5-6 minute intervals and we decided to head for the hospital. We arrived at the hospital at 7:30 A.M. Labor and delivery was extraordinarily busy, and Dr. McDowell was having a busy morning himself. So we were doubly glad to have Kim, our labor support person, with us the whole time.
Comments:
Though many women presume that their doctor will be with them during most of their labor, rarely is that the case. Even with a doctor like Dr. McDowell who has a reputation for giving lots of labor support, the support of a midwife or other knowledgeable professional labor support person is quite often of the utmost importance. Having a skilled support person with the mother during labor encourages relaxation and flowing with the course of the labor. The mother feels "mothered" by another mother-- woman to woman.
Mary Jo:
At times, during the intermittent checks with the external fetal monitor, the labor room nurses had difficulty picking up the baby's heartbeat. But Kim was usually able to track the heartbeat down with her stethoscope.
Comments:
Though the hospital staff usually feels dependent upon the fetal monitor for monitoring the baby's heartbeat, a skillful attendant can monitor with a fetascope of stethoscope. Since electronic equipment can fail, it is much to the laboring woman's advantage to have an attendant skilled at auscultation of fetal heart tones.
Mary Jo:
I got up to walk around a couple of times during labor, but that seemed to stop my contractions rather than to strengthen them. In the end, I seemed to labor best and most comfortably lying down on my left side.
Comments:
Walking or moving about usually enhances the power of the labor. However, sometimes the acticities of the woman's surroundings may be extremely quiet, perhaps even isolation, in order to feel able to give her labor her complete inner focus and permission to relax into her labor, to let it happen.
Mary Jo:
Early in the afternoon, the contractions were getting closer and harder. I was laboring pretty quietly, and I think the labor room nurses might not have realized how close to delivering I was if Kim had not alerted them.
At about 3 PM, the urge to push seemed to come on very suddenly. I was fully dialated. "Go ahead and push." The doctor arrived. The nurses tried unsuccessfully to pick up the baby's heartbeat. I was rushed to the delivery room. Because of the staff's concern for the baby, I was urged to push hard, even between contractions. At Dr. McDowell's request, a padded, desk-type chair was brought in and draped. I knelt on the seat of it, leaning over the back, and pushed for all I was worth. Our son David seemed to be born very quickly (at 3:36 PM) and was also quickly determined to be fine.
Comments:
Mary Jo's first and last labors were very similar. Although the first labor ended with cesarean, and the last with a vaginal birth, in both of these labors the possibility of fetal distress created an emergency aura around the birth.
Often, the blocks which "caused" a woman to have a cesarean, reappear in her VBAC labor as hurdles that must be vaulted in order to deliver vaginally. Mary Jo's hurdle was fetal distress, which she most certainly vaulted.
Mary Jo might have been so frightened by the pressure to perform--- to push even when her body was not calling her to push-- that she might not have been able to push her baby out. A cesarean would then have been necessary. However, when the pressure was on, Mary Jo pulled through for her baby. Though the birth was far from ideal, she did what she needed to do to give birth to her own baby. She had a successful VBAC.
Each birth subsequent to Mary Jo's primary cesarean was a step along the way to her VBAC. With each birth she saw to it that more and more of her needs were fulfilled. With each birth she needed to sacrifice less of her own needs in order to assure herself the safety of her baby. As she "pushed through" not only the issue of self-sacrifice in birth, but also self-sacrifice in life. We all deserve to and can get our needs fulfilled without hurting those we love. Perhaps this birth may be the key to fulfilling Mary Jo's goal of a peaceful birth with her future pregnancies.
Mary Jo:
I was in great pain while I pushed and was bleeding profusely. Although my uterus had "done fine" and the VBAC was a success, I had suffered deep tears in my vagina which required immediate, painstaking extensive suturing.
Comments: Whenever the second stage is forceful, the possibility of severe tearing increases. With the emergency nature of Mary Jo's second stage, she pushed even between contractions. Her vagina did not have time to slowly stretch to accommodate her baby without tearing. If she had another baby with the same size head, and the second stage were taken at the pace her own body were dictating, she definitely would not experience such a severe tear as she had with David's birth. Chances are she might not tear at all.
Mary Jo:
Once I was able to go to the recovery room, I held and nursed my baby. Despite all my blood loss after the delivery, I found my recovery at home to be significantly easier than with any of the cesarean births.
Obviously, our VBAC was a mixed experience for us. We felt tremendously pleased that a vaginal birth had been possible. For us, this laid to rest bugaboo of uterine rupture once and for all. Besides, my recovery was immeasurably easier than after the cesareans, even in spite of the complications and blood loss from the vaginal tearing.
On the other hand, we certainly did not have a birth experience that would be anybody's ideal. The tears and their repair were painful and frightening, and our hopes for a calm, pleasant welcoming of the baby were side-tracked by that emergency. Even if we could have known in advance how the birth would go, I think we would still have opted for a vaginal delivery, in spite of the extraneous complications we met.
Comments:
Although Mary Jo did not have an "ideal" birth, a "pure" birth, or a "perfect" birth, she did have a VBAC. She had a VBAC which was perfect for her. Through it she faced her fears and vaulted the hurdles. She grew. Her lessons were not simply about birth, but about life.
To seek a "pure" birth may be a path through which we learn to recognize our own needs. But to require a "pure" birth is only a set-up for failure. Life is not ideal, nor is it pure. Birth is but a small moment in life. Although some births appear to be more ideal, more pure, I have rarely known women who actually had a "pure" birth-- a birth that measured up completely to their ideals. Yet, every birth is perfect. Every birth teaches us the perfect lesson, through which we become more beautiful and courageous.
The Birth of Katie
Mary Jo:
On August 21, 1985, our sixth baby, Katie, was born. Once again there were symptoms of possible fetal distress on the monitor. But our fears were allayed as the results of the scalp sample were good and did not indicate that the baby was in distress. This time Dr. McDowell did not ask me to push between contractions. I pushed only during contractions, and without the emergency aura which had been present at David's birth. Katie was born pink and healthy, and I had only a small skin tear. But most importantly, both my husband and I were fully present to welcome her into the world.
In retrospect, I wish that we could have refused all the technology. I wish that we could have trusted ourselves, our feelings that the baby would be healthy. But when I felt that the baby's life could be on the line, it wasn't something I could fool around with.
Comments:
Trusting our intuition in a technological era is profoundly difficult. Before the technology was available, we had only our skills and intuition upon which to base our decisions. We had only God and our own conscience to answer to if the outcome was less than perfect. Through spiritual growth we accepted death as part of life.
With the miracles of technology, we sought to avoid death. Although the motivation is admirable, the technology is often no more accurate than the skills and intuition of a good practitioner. However, today we are accountable not only to ourselves and God, but to a legal system which seeks "proof that everything which could have been done had been done".
Practitioners and parents often feel they are a rope in a tug-of-war between their inner-most voices and the power of technology. The struggle between the spiritual God and the god of technology is the modern dilemma which is epitomized and reflected in the way Americans are giving birth.
Those of us whose consciousnesses are becoming aware of this dilemma have the responsibility to ourselves and our children to find the balance between these forces for ourselves, and to help society to realize the need for the balance as well. If we sit idly by, soon the power will be given totally and completely to technology, and we will have lost perhaps the most vital piece of life.
Mary Jo:
We certainly ought to be a "landmark case." Our messege to VBAC "canidates" would be: "Don't let anyone frighten you into a routine repeat cesarean. If a uterus with two classical incisions and two low cervical incisions can do the job, why shouldn't yours, too?!"
---The Vaginal Birth After Cesarean Experience by Lynn Baptisti Richards & Contributors
quoteI have 2 kids & 1 angel baby & live in
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