An Empowered CBAC
It seems that in birth circles everyone is excited about a good VBAC story. In case you don’t know, VBAC stands for a Vaginal Birth After Cesarean. This is not one of those wonderful VBAC stories. In fact, some might call it a failed VBAC story. However, I am going to call it another term known around birth circles as CBAC, or Cesarean Birth after Cesarean, and even maybe an empowered CBAC at that. I hesitate to put this out there, for surely I will meet criticism at every turn. Some people may arm chair quarterback my experience, thinking that I should have done this or that, and perhaps things would have turned out differently. I have done that many times myself. Others may accuse me of putting my birth experience above the safety or health of my baby. This is something I find particularly hurtful, as all the decisions made were with the health of the baby (and myself) in mind. Surely I can’t be faulted for wanting to be a healthy mother to care for my baby?
The beginning of every VBAC or CBAC story must start with the original cesarean. After all, you can’t have a VBAC or a CBAC without having had a cesarean in the first place. I was pregnant with my first child in south Florida in 2005. I was planning a natural birth in the hospital. I had wanted to do a homebirth but my husband objected, so I chose a Certified Nurse Midwife in the hospital, took Hypnobirthing® classes, and hired my Hypnobirthing® instructor as my doula. I had had a viability U/S at around 12 weeks in the pregnancy (when the midwife couldn’t find the fetal heartbeat with a Doppler) and they had moved my due date up by about 10 days. I didn’t think much about it, although I had been charting and knew the time of ovulation, give or take a day or two. Surely my child was just advanced, and would be coming out early. Well, that due date came and went. My midwife, who had been saying all along how big the baby was (once again, I didn’t think much about it, only that I was going to have a healthy sized baby) sent me off for an ultrasound to “see if there was enough fluid.” Well, that ultrasound showed that there was too much fluid, and estimated the baby to be 9lb10oz. I blamed myself for eating too much ice cream and not exercising enough. Through a phone call the next day our midwife told us that I had to have a cesarean because I grew my baby too big. I was horribly upset, as was my husband. They claimed that they had missed Gestational Diabetes even though my glucose tolerance test was a 67. Through additional pressure from the OB the midwife worked with and our families we agreed to have the cesarean. My daughter was 9lb8.5oz at birth. Breastfeeding was difficult, not only because the first few times we nursed I was still numb from my chest down, but also because she was tongue tied. When I got the breastfeeding worked out six weeks later I was still having problems. I sought out a counselor and was diagnosed with PPD and PTSD. I found ICAN. I learned that the ACOG does not recommend cesareans for “big baby”. http://www.aafp.org/afp/2001/0701/p169.html I vowed to do things differently next time.
When we finally decided to try again we did not have success with pregnancy right away. I got pregnant immediately, but had a miscarriage at 6 weeks. Then we tried again a few months later and got pregnant quickly again, only to have an ectopic pregnancy that ruptured my fallopian tube. After that there were 17 months with no pregnancy at all. We were about to give up and move on as a family of three when I found myself pregnant again, this time with a healthy pregnancy due almost exactly two years after my miscarriage had been due.
This time I vowed to do everything right. I walked on an almost daily basis. I did prenatal yoga starting in the first trimester. I saw a chiropractor on a regular basis. I chose the care of homebirth midwives. In Florida, a woman with a prior cesarean can have a homebirth if she goes through a consult with a physician who has OB/GYN privileges in the hospital and can inform her of her risks. http://www.doh.state.fl.us/mqa/midwifery/info_2010laws.pdf
I was working so hard at taking good care of myself and my baby. From eating healthy and exercising I had gained only 12 pounds by 32 weeks gestation. Surely I was growing a smaller baby this time. We drove three hours away for our consult with the doctor. Part of the consult involved an ultrasound that estimated fetal weight. The baby appeared to be weighing in at a whopping 5lb14oz and there was again too much fluid. I cried. Despite all my best efforts I was growing a bigger baby this time. At this rate he would be around ten pounds on his due date. We talked to the doctor. He told me to cut out all carbs. Once again I had passed my GD test with flying colors (a GTT of 108) but there must be some sort of sugar issue going on. He said that if I could keep the baby under 4200g (or around 9 pounds) and went into labor on my own I would have a good shot at a VBAC. So I did. I cut out all carbs. I ate meat and vegetables and sometimes plain oatmeal or a small serving of brown rice. I lost all the weight I had gained and dipped below my pre-pregnancy weight by a pound or two. Surely this baby would have slowed down his growth rate. I went for an ultrasound at 38 weeks. The tech did all the measurements carefully. She then told me that there was too much fluid and they were estimating his weight to be 11lb3oz with an error margin of a pound or two. At 38 weeks. At first I just couldn’t believe it, but on the way back to the office I cried again. How was this possible? I did everything I possibly could do to grow a smaller baby. At this point I risked out of homebirth midwifery care per the Florida rule due to the polyhydramnios and the fetal macrosomia. I tried to transfer to an OB practice in town that was supportive of VBACs. They had CNMs on staff. Shortly after my records were transferred over I received a call from one of their midwives. She told me that they refused to take me unless I scheduled a c-section at 39 weeks. This was also a practice that was responsible for taking women who drop in to the hospital in labor. She told me that I better not show up in labor trying to have a VBAC or it would be a “bad scene.” I called everyone I could think of for help. Luckily in the past five years I had made a lot of contacts. I called the Farm, but they were full. Florida midwives were unable to help me because of the midwifery rule. There was a midwife across the border in Georgia, but my husband did not feel comfortable using a midwife up there due to the difference in legal status. I went to my family practitioner (who I had seen for the first trimester of the pregnancy due to my history of ectopic pregnancy) and pleaded my case. He told me that I could go into labor, but he expected me to come in for an immediate cesarean, and would only accept me back into his care with this agreement. If I showed up pushing and trying to have a VBAC it would be an “antagonistic situation.” My local hospital is known for court ordered cesareans, so I really believed that the situation would be bad if I tried to have a VBAC there now. http://en.wikipedia.org/wiki/Pemberton_v._Tallahassee_Memorial_Regional_Center I asked my FP what I should do. He suggested that I return to the doctor that did my sign off. I did return (traveling three hours away) on my due date. They did another ultrasound with an estimate of 11lb3oz. He told me that he would recommend a cesarean, but if I showed up in labor at the hospital and told them that I was his patient, well, he would still tell me to have a cesarean but he recognized my right to say no.
On Monday the 28th of March I was 41 weeks pregnant. I was sick of being around people and their stupid comments (any day now, right?) and people were texting me every day. Even the well meaning people were driving me nuts. That day I felt really restless. At some point I just felt really unprepared for anything. I wasn’t ready to labor, I wasn’t ready to have a cesarean, I wasn’t ready to parent a newborn again. I went to bed and tried to sleep and had a few Braxton Hick’s, no big deal, I had been having those for weeks. Around midnight I got up because I couldn’t sleep. My husband was out in the living room, he is a night owl. He asked if I was ok, and I told him I couldn’t sleep. I sat with him and ate an orange. Then I felt/heard a pop. I jumped up with surprise and said “My water just broke!” I “ran” to the bathroom (holding my legs together, leaking some fluid onto the carpet) and sat on the toilet. Fluid was everywhere. I freaked out. What was I going to do? I knew that because of the amount of fluid I was at higher risk for prolapsed cord. I stuck my fingers up in there to see what I could feel, I couldn’t get them far up enough to feel my cervix. My husband was asking me what we should do, where were we going to go? It was either go into the local hospital for a c-section, or drive three hours away to hope for a trial of labor. I told him to call our friends who were going to watch our daughter and get them to come over. I put on a depends (thank goodness I had prepared for a homebirth) and called my local doula. I told her that I didn’t know yet what I was going to do. I got on facebook and saw that my former midwife was on. I messaged her that my water had broke. She suggested I call a homebirth midwife friend of mine that lived nearby. At first my midwife friend was confused, but as soon as she figured out I was not the client she was expecting to call, she came over. She told me that the fluid was clear, there was no prolapsed cord hanging out, the fetal heart rate was 140 (which is what it had been in pregnancy), and I was 3cm dilated and a -2 station. With this information we decided to make the trip for our trial of labor. Our friends were there to take care of our daughter. I thought they were going to spend the night, but they needed to take her to their house. It was a very exciting moment and I treasure the memory of the look on her face (and I also treasure hearing her tell strangers about that moment for weeks afterward). She was already partially packed, I stuck her big sister t-shirts in her bag and off she went with our friends. Then my husband was packing up our van and getting it ready for me. I was doing random things around the house and having some crampy contractions. Then he yelled at me to get going, he was getting nervous. We hugged, got one last belly shot, and headed to Pensacola.
I labored in the back of the van while my husband drove. Contractions were varying from 7 to 12 minutes. I ate a granola bar and drank water. I labored on my side, on hands and knees, sitting up. I had him put in my Earth Mama Angel Baby VBAC CD for me and I listened to it. I did have some back labor.
We got to our destination and checked into a hotel room around 3 AM local time. My husband slept and I tried to sleep as best I could. Contractions were irregular and still between seven and twelve minutes apart. Around eight in the morning I called a midwife friend over there who had gotten me in contact with the consult doctor. She said the doctor’s office should be notified and they like people to come in about 12 hours after SROM. We called the doctor’s office. I called a doula that the midwife had recommended for me (I had talked to her for the first time the night before). Everyone was on standby.
I was also texting and messaging supportive friends at this time.
We decided to find a mall to walk around because it was a chilly day. We did laps around the mall for an hour and a half. I was not having any sort of regular contraction pattern. At noon we knew it was time to go into the hospital because my water had been broken for twelve hours. I used nipple stimulation to try to get better contractions but it didn’t seem to be working. We called the doula and headed to the hospital, she told me to let her know what happened when we got there. I really thought we were going to the hospital to be told that I was only 3 or 4 cm, labor wasn’t happening and we were going to need a c-section.
When I got there I was 6cm, 70% effaced, and baby was still floating at -2 station. Also, I was having contractions, varying though (the nurse said 2 -4 minutes at one point, and then 5-6 minutes at another). We called the doula to come. When she got there, she got me out of the bed and helped me to request a telemetry monitor. She reminded me to try various positions. I sat on the birth ball, I did lunges, I did squats, the doula did a great job of getting me to the bathroom. As a doula myself I knew these things were important, but in labor I needed someone else there to remind me to do them.
I was concerned about the baby being in a posterior position due to my back pain, but they were finding his heartbeat in the left lower corner of my belly (which would be an LOA presentation).
I don’t remember how fast time was passing, it seemed like I was in my own little world. I know that I was laboring like a rock star. I breathed through the contractions and used my Hypnobirthing® training. With every contraction I thought of all my friends around the state of Florida (and elsewhere) who were thinking of me and wishing only the best for me. It put a little smile on my face (I had my husband take a picture of one of these contractions, for posterity).
However, when they next checked me I was only 7 cm dilated, about 80% effaced and baby was still -2. He wasn’t coming down. We kept laboring. The hospital staff told me to do a fire hydrant pose (on my left side, upper leg in a stirrup) because they had seen it bring down babies that were floating high. That caused my contractions to be five minutes apart, but big huge ones with back pain requiring counter pressure. I still labored through them really well. I was in that position for an hour and a half just working through the contractions. I did get bathroom breaks and noticed that the contractions were much more tolerable when I was upright. They checked and I was approximately 8 cm, 90% and baby was still at -2. We thought for sure at this point the doctor would say c-section, I think this was at a nurse change. We were prepared for this, he told us a big baby wouldn’t come down, that was a sign. But he didn’t. So we kept at it. I did the fire hydrant on the other side for another hour, and we also labored back on the birth ball and over the back of the bed. I tried vocalizing through contractions and I tried hard to get into my animal brain. It was getting tougher to manage them. I know at some point I said to my husband and doula very calmly “Maybe I should try getting an epidural.” They laughed at me because they thought I was joking. I know I wasn’t quite serious, but I know I was thinking that everyone seems to like them so much, maybe I should do one too. I got to 8.5cm dilation, 90% effaced but baby was still -2. This was around 10 or 11 at night local time and I was coming up on 24 hours with ROM.
The doula and nurse left us alone to discuss it. We decided it was time for the c-section. I was afraid of shoulder dystocia or having an infection from my waters being broken so long. I knew that I would never forgive myself if anything happened to him after going through all this for my trial of labor, so I chose to err on the side of caution. I felt like the fact that he wasn’t coming down further was a sign. I felt like I would feel differently about this c-section because I did all that I could.
Once we made that decision the contractions were impossible to manage. The doula recommended getting out of bed, but I was tired. They got me back to surgery and I finally got the spinal. Overall, this c-section was much better than the first because I was better respected by the staff. However, it took much longer. Apparently after my ectopic I was not closed up properly. My peritoneum was never closed, and it had adhered to my internal organs, so this doctor was trying to fix it. Hunter was born at 12:06 AM on March 30th. He had a little trouble getting crying. The doctor then held him up over the blue screen and said “Here’s your toddler!” My first words to my son were “Hi there, my big boy.”
He weighed 10lb7.6oz, and was 22.5 inches long. Both his head and chest had a 14.5 inch circumference, just like his sister. The doctor didn’t think he would ever come down. I did ask about positioning and he said he was not posterior. At first I felt very peaceful. Then on the way home I got weepy and self doubtful. Did we give in too soon? Was it positioning? What if I had had the chance with his 9.5 pound sister, she could have paved the way for him.
I had an empowering CBAC, but I think that I am always going to be sad about the loss of my VBAC.
By Kristen Nelson Sella. To see pictures of baby Hunter, click here.
