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Friday
Mar122010

CBAC Processing

I had a meeting with a mama recently, a 6-week postpartum mama who was one of my monitrice clients. She hired me to help her have a VBAC and, in the end, she had a repeat cesarean. Controlled, empowered and with full consent and understanding; all the things she didn’t have the first time. She needed to talk; I needed to listen. We needed to spend some time together, our first without her in crisis, in pain and without others in the room (except for her lovely daughter, of course). 

I chronicled her pregnancy and birth in FB as it was happening, her borderline pre-eclampsia, her several day powerful labor without progress, her choice to go into the hospital, the walk towards pitocin and an epidural, the continued lack of progress (where was that cervix anyway?) and, after 24 hours in the hospital, the being wheeled into the OR for a repeat cesarean. 

With the last baby, mom, alone, tried to find peace with the birth that had many indications for a surgical birth, struggled through the pain and confusion, vowing to have a VBAC with the next birth. The initial healing was complicated by, what seems to have been, postpartum pre-eclampsia. Her doctor told her to lie on her left side even though her symptoms were a cracking headache, an ocean in her ears and an inability to see clearly. I told her it’s a miracle she didn’t have a stroke or a seizure with that flippant attitude of the OB. 

When she got pregnant, she did everything she could to set herself up for success, including hiring me as her monitrice. We worked on mental blocks, working through fears and talked about all the physical ways to ensure a great “trial of labor” that could end in her triumphant VBAC.

Yet, repeating complications, blood pressure creeping up and up, edema getting deeper and higher, even a breech baby for a time, all slowly immobilized her. Eventually, she was on bedrest for three weeks, better than the six weeks last time, but complicated by a four-year old this time around. Both mom and dad are acupuncturists, well-versed in the alternative methods to balance the body, yet she continued having her body’s betrayal of all she wished for. When the blood pressure got high enough, she began serial Biophysical Profiles (BPPs), every three days, in for the ultrasound and if her BPs were too high, she schlepped off to be admitted to the hospital where they kept her on her left side, monitoring her (including blood tests) and the baby, for several hours at a time. By the time the baby was born, she’d had quite a number of scans and three admissions to the hospital – all before labor even began. Quite different from the easy-going birth plan she’d hoped for after the first traumatic birth.

Throughout, we discussed options, which dwindled as time passed and once she was having regular, strong contractions, it was hard for her to do much of anything without sending her BP to 140s over 100s. Having a really deep tub, she regularly soaked in it with Epsom Salt and that time in there was practically the only time she was upright.

Okay, moving on.

So, she labored hard for a couple of days. My vaginal exam found her to be 2cm, but that cervix so high I could barely reach it even with her hips on her fists. Trying to feel the position of the head was impossible; the head was at a -3/-4. Watching her labor, she looked to be 5-7cm, so we’d go to the hospital – something to help her sleep? That I might be totally wrong on my assessment? They’d check and send her home again. I was confused, but the reality of what was probably going on began to set in. All that lying on her left side settled the baby into a cock-eyed position. Way later, after the cesarean, that exact reason was validated, the baby having a bruise on the right side of the skull, she having tipped downward, trying to rotate, but getting caught by (the ischial spines? the pelvic brim?) bones that didn’t allow for continuing rotation.

The early postpartum period was infinitely easier than last time. She didn’t have any of the pp pre-eclampsia symptoms, the baby slept more than her first and, after she had the tight frenum snipped, she didn’t even have anymore nipple pain. Instead of having to focus on sheer survival, her mind was able to think about the birth and how it’d gone. She felt pretty good about it, knowing she really did everything she could under the odd circumstances.

She felt good about it until a woman at her son’s school, a recent homebirth convert, sent a shower of doubt on what she’d thought was a nice experience.

“Did your midwife try this? Did you stay out of bed? Did you change positions? Frequently? Did you do that? Why did you go in so early? Oh, you had an epidural. Oh, pitocin.” You could almost hear the clucking of her tongue and see the shake of her head in pity.

During my client’s pregnancy, this Natural Birth Prosthelytizer bragged about watching baby shows on tv and being able to pick which ones were going to end in a cesarean within minutes of the show beginning. She had an infinite number of “suggestions” for my client, many of which were contraindicated because of her circumstances.

So my mama, now filled with doubts, needed to talk about what happened. Did she try everything? Was there anything she could have done differently? Why did her body fail her twice? She’d been scouring the Internet looking for any clues she might have missed. She asked her husband, over and over, “why this, why that, how come…?” Her husband told her it was over, move on already. Why did she have to obsess about each birth like this? Couldn’t she be happy with the baby and that be good enough? I let her know that maaaaannnnnyyyy partners said those exact words to healing women, that she wasn’t alone. She said he finally told her to “Call Barbara!” and that’s when she called.

When I sat down with her, I explained that if she hadn’t had the pre-pre-eclampsia, if her BP hadn’t been so high, if she hadn’t been on bedrest, then it was possible the baby wouldn’t have imbedded herself into her pelvis and there might have been a vaginal birth. Of course, I had to qualify that with the truth that some women who are upright throughout, who hula, wiggle, dance, walk up and down the stairs sideways, lift the baby out of the belly with a rebozo and are as evolved as Ghandi, also have acynclitic babies that need to be born via cesareans. I explained that because of her BP, I was limited in the suggestions for re-positioning the baby. She couldn’t tromp the stairs, she couldn’t tump upside down to start the baby’s descent all over again, I couldn’t use a rebozo because she was a VBAC, they were already doing acupuncture, soaking, meditating –and remaining calm on her left side. She wanted to know why I hadn’t said those other possibilities when she was in labor and I said, “What would be the point of saying, ‘Gee, if you didn’t have pre-eclampsia I could do A, B, C, D and E. Too bad you do, eh?’” Wouldn’t that have made her feel worse? She said it would have. It is important to remember, too, that she wasn’t my midwifery client, I was her monitrice. While I did discuss informed consent issues with her, knowing her, there were simply things that would have dragged her down instead of keeping her as positive as she could be. Not that she would have, but even if she said she wanted to put her head on the floor and her torso up on the bed, I would have had a serious issue with that. If she had a stroke because of something I suggested, it wouldn’t have gone over well… with the family or the doctor.

As we talked, she understood that her options were limited because of her individual circumstances and thought she had more information to tell the Natural Birth Prosthelytizer (NBP). I told her she owed that woman NO excuse/explanation at all. She’s an acquaintance who will learn humility one day, realizing her arrogant attitude towards others’ births and the belief she can predict all outcomes isn’t really true. I suggested that she could tell the woman, “I appreciate your interest in my birth, but I’m uncomfortable with your judgment of it without having all the information.” Or “Please don’t judge my birth. You don’t know all the information about my case.” I told my client I wanted to write the BP a nastygram, but she would blow it off that I was just one of those medwives who didn’t have a real appreciation for the perfection of birth – if left alone. I made my client laugh.

The conversation shifted to the Is My Body Broken part of the healing. It’s hard to say no when the same woman has had pre-eclampsia twice, had to live on bedrest for weeks at a time and who had a cesarean because the baby couldn’t find his/her way out. But, I shared that, from what I knew, the pre-eclampsia possibility is laid down when the placenta is born in the first few weeks of pregnancy. I said there seems to be a chain of events, a bumping of chemicals into each other, triggering one more step towards pre-eclampsia. That the dance is so intricate, no one really knows what causes it; if they did, she wouldn’t have had it. I told her there are some things we know for sure: high glucoses cause gestational diabetes, anemia causes fatigue. But, there are other illnesses or complications that have no easy answers. Preeclampsia is one of those. I told her it was very hard not being able to say, “If this, then that.” But, much of life is ambiguous; pregnancy is no different.

In a near whisper, she asked if being a sexual abuse survivor might have subconsciously influenced her body’s imperfection. She said she’d worked for so many years in therapy, but maybe there were still threads she didn’t know about that got in the way of the vaginal birth. I shook my head and said that was very unlikely. That there was a much better explanation – the increased BPs and the baby’s odd position were the obvious reasons. I reminded her that she was very easy-going with vaginal exams and that it isn’t uncommon for women with a sexual abuse history to struggle with them. She said again that she thought she’d worked through things and felt better that it probably wasn’t that.

“But, what about the surgery (colposcopy) I had on my cervix?” I told her I didn’t feel any adhesions when I did the exams and if I had, I would have asked permission to snap them. She seemed relieved to hear that, too.

As we addressed each concern, I reminded her that we were sitting on the couch with a newborn on her breast. That looking back, it was easy to say, “Well, maybe it would have been okay to tip upside down. I could have walked up and down the stairs” because you are healthy and alive. If we had done those things and you stroked out, it would be a totally different discussion. Birth is trial and error, risks and benefits and using the available information to map out the path ahead.  It isn’t perfect, but it’s the best we have.

Feeling more at peace, I got ready to leave. Sweetly, she said, “I know you’re busy, but would it be okay to call you again?” I gave her and the baby a giant hug and told her, looking her in the eyes, that I am always her midwife. Forever. She could call anytime and I am there. If she wants to discuss things again, I am there. I told her it takes time to assimilate it all and to be patient with the process. She promised she would.

That women bring me into their worlds this way is an incredible honor. That women let me share their world with you all is an even greater gift.

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Reader Comments (19)

I love this post! Thanks for sharing and thanks for all the important work that you do!!

March 12, 2010 | Unregistered CommenterEmily CNM

Thank you for sharing this (and to the mama for giving permission!). Many hugs and much love to her as she processes. It can be so hard to process when so very many interventions went into it, when you don't want to blame your body and there are so darn many variables and they all could have been the one that broke the camels back, or none of them, and oy how is one to move on when there are no ANSWERS?! I'm so happy she has you to talk to. Lord knows talking to you, and La Shel and Jamin, and my ICAN sisters has helped me in so many ways. We really underestimate the power of being able to talk, in person, to someone that will allow you to safely feel your feelings and express your doubts and fears and pain without being told to "just move on". (And no offense intended, my husband said this too and while he has learned to not do so, and why, he would probably still roll his eyes and heave a sigh of frustration if I still brought it up as frequently as I once did.)

While online posting can definitely help, and I'm not at all one of those "you can't have real friends on the internets" types, I have to say there is just a totally different power to sharing and discussing in person. We joke about cloning Dr Biter and Dr Fischbein but we need more of you too, Barb!

March 12, 2010 | Unregistered CommenterStassja

Thank you. That means a lot.

March 12, 2010 | Registered CommenterNavelgazing Midwife

Just curious you mentioned not doing rebozo for a VBAC...huh? Is there some concern w/ the incision?

March 13, 2010 | Unregistered Commentercyan77

Amen!

(Happy baby, she knows it went the way it should have).

March 13, 2010 | Unregistered CommenterEthel

Every time I think I've processed my c-section and moved on, I encounter one more natural birth enthusiast who makes me question it all over again. I did everything "right" throughout my pregnancy and labor, and my cervix just would not open past 6 cm, no matter what we tried. The c-section, while disappointing because it wasn't what I expected, was not that bad. The doctors and nurses were respectful and kind, and my midwife stayed with me all the way. I labored for two days at home and 22 hours in the hospital before they started talking surgery.

I still firmly believe that natural birth can work most of the time, but I'm tired of self-righteous so-called birth advocates telling me what I did wrong. And to be honest, I'm kind of embarrassed about the way that I talked about my upcoming "natural" birth when I was pregnant. I didn't know everything that I thought I knew.

Thanks for posting this story, and please tell your client that hearing her story and all the similarities to mine, is very helpful.

March 13, 2010 | Unregistered CommenterKaty

I know that sometime. somewhere that BP will have something not work out for her, have her body betray her. Until then it isn't worth talking to her about this. I smile everytime I tell someone about my low milk supply and they tell me the herb or homeopathic remedy that woulda fixed it. Right.

March 13, 2010 | Unregistered CommenterLaura

@Cyan - I would not do a rebozo because it can stress the uterus and if the scar happened to be a thin one, I wouldn't want to aggravate/damage it with a stressful activity.

March 13, 2010 | Registered CommenterNavelgazing Midwife

It's amazing how one comment can unravel a woman's confidence when two minutes before she was blissfully fine with her birth experience.

It happens all the time to new mothers, and it's always other mothers who are NBP undermining friends and family, and acquaintances alike.

Are the NBP doing this to bolster their own lack of self confidence and they only have birth to hold onto as something they accomplished.

I can't figure out the reason why NBP do this to other women.
I notice it's always women not working in the alternative birth or breastfeeding community that do this to others.

Once you work as a birth professional You don't give unsolicited nasty comments or mean spirited planting seeds of doubt to other women. Hopefully we become emphatic and kind about what women experience in birth and breastfeeding.

It's the mothers at school and playground and on sites like mothering.com who are the absolute worst towards other women's experiences.!

As a co-founder of an ICAN chapter in 1991, a Doula, and lactation consultant I learned long time ago It does not matter if the cesarean was necessary or not, it's each women's own job to figure out if it was necessary, it's not my job, and it's not anyone else's place especially some obnoxious NBP to question a Women and plant seeds of doubt when she has not asked for your opinion!

We are all entitled to be happy with the birth experience we had even when it's an unnecessary c/sec, unless the women who had the experience decides she is not happy or satisfied with her birth experience.

Barb, Your post brought tears to my eyes for this women, I'm so glad you were there to provide her with reassurance and evidence based reasons exactly why her medical situation made a c/sec necessary.

March 13, 2010 | Unregistered Commenterdewi

I just had a baby and had a great healing experience. Thank you for being out here! You know my story of the meaner nurse who was not friendly...not allowing me to go to the bathroom and putting me flat on my back...pushing 1 hour and 1/2.

I got a midwife this time but stuck with the hospital birth. Baby was born this time OP and asynclitic (spelling?). I believe because I have had 6 babies before and due to the anterior placenta, my babies may decide OP is much more fun. Also, baby was not having a great tracing...slowly coming back up after contraction decels and mec again. Still, with a midwife I was moving the whole time and up. I used the tub. I tried position changes. I coped. I got back rubs and pep talks. I had a calm midwife encourage me to push and ask me not to vocalize because we needed to get the baby out (O2 on my face by this time).

I was worried, I pushed the baby out in 10 minutes like a momma bear. She was swollen but healthy. I was fine, a small tear but no stitches. I did question myself a bit because I allowed her to break the water just before I pushed, and maybe the water would have cushioned...maybe we could have tried a few more position changes. But other than that, I trusted her, I trusted my body at a time when I could trust it. I didn't feel that saddness and abuse after birth. Two weeks out I'm very happy and recovering fine.

I know that if I needed a c-section, that midwife would have helped me handle it. I knew we were doing as much as we could to get the baby to turn and she was allowing free movement/drinking/etc. I know she was serious when she said, "I usually don't ask moms not to vocalize, but try to push without it now." With that little head turned to the right, I just couldn't have gotten her out without serious pushes and a very roomy pelvis.

I hope this mommy feels empowered at being able to try to have a vbac. Thank you for your influence and for comforting/counseling her. My midwife really said it best when she said I would have a healing birth this time. Consenting and understanding what is happening helps a lot...rather than being coerced and forced into things.

Blessings!

March 13, 2010 | Unregistered CommenterDawn

Wow - such a great post. I think I've been the NBP before. I don't think it's always mean spirited. It was when I was still learning and I only knew my oen birth experiences (which I was blessed with).

BUT the mean NBPs are out there too. My first birth was not perfect (ended with an emergent transfer and vacuum extraction due to placental abruption), and shortly after I encountered a NBP myself who had not yet given birth herself. When I told her my birth story she immediately gave me the brush off - like I was an amature.

I think we have to be so mindful of the questions we ask PP. Mammas need love and support, no matter their birth outcomes and especially when things did not go according to plan.

Thank you for the beautiful words!

March 15, 2010 | Unregistered CommenterAnisa

I had 4 hbac with a great midwife, and am an avid reader, advocate and outright lover of midwifes and homebirths. You are so much appreciated and needed!

I am curious about having pre-e. I had some experience with that in my forth pregnancy and sat with a few ladies who also had it. I am wondering what you think/ have had experience with the high protein (brewers diet not to the letter but in theory) diet to cure/prevent it?

I LOVE U Barb, by the way! I have been following your blog for a long time now. You are a beautiful person!

March 16, 2010 | Unregistered CommenterJennifer

I started signs of labor when I was 36 weeks along. Hard enough to have three trips to my birth center and spend many hours there before being sent home in "false labor" I got to 4 cm the first time and went back down to 1 and up to 4 and down to 2 and up to four and down to 1cm for two weeks. Eventually, I gave up counting times between contractions because they'd come 7 minutes apart for a few hours working down to two minutes apart lasting 60 seconds. After several hours of that, the contractions would just stop. I had many urges to consider induction, even from my midwives who thought they were dealing with a stalled labor. They even used different cohosh routines to try and jump start labor. The night I gave birth, I didn't admit that it was real labor for 5 hours because the contractions were exactly like the ones from the stalled labors, the midwife seemed unsure that I was even in labor, but I was already at the birth center and told her I wasn't leaving without a baby. I was told that I wasn't progressing, not in so many words, but I knew that was what was happening. One hour after being told I was at 5 cm I was a full 10 cm and fully effaced and pushed out my 7 lb 13 oz daughter in 23 minutes. After two weeks of "stalled labor" that many could have gone to a hospital for induction like I had been suggested, I choose to wait, indicating that my due date hadn't even arrived yet. My daughter was born one day before her due date after a 6 hour labor that really didn't feel much harder than the two weeks of "braxton hicks" I had before. Labor is a funny thing.

March 16, 2010 | Unregistered CommenterClarissa Jarem

Just want to shout out some empathy for the NBPs of the world- I think it is incredibly tricky to navigate to difference between being a birth activist, who wants to bring light to the medicalized model of birth in culture and its inherent risks and being sensitive to individual mamas. my heart breaks with the struggle for us all of bringing compassion and nonjudgment to our activism, which frequently has roots in our anger and frustration with injustice.

while we need to work on how to listen, on how to hold out tongues in the face of a single story. and still- we need NBPs or at least people who are passionate about going against the grain and sharing unpopular, disputed, and subversive ideas about birth- if birth is ever to be considered healthy and normal by the mainstream.

so what can we do? i like the suggestions of being direct, in the post: “I appreciate your interest in my birth, but I’m uncomfortable with your judgment of it without having all the information.”

and to those who feel inspired to, maybe add something like,"i also share your passion for natural birth, but i also am trying to keep some balance between my passion and my compassion- for myself and other people like me who really benefited from the medical care we received. if i want to hear other peoples opinions about my experience, i'll be sure to ask. right now i prefer your open-hearted listening."

okay, maybe it's wordy, but i'm hoping that in cultivating our compassion in our responses to those we'd like more compassion from, we can bring more peace and harmony within the birth community. and in doing this- bring more peace to birth itself- where ever and however it happens!

April 22, 2010 | Unregistered Commenterjaqxun

I know you wrote this post over a year ago (and I read it then), but I wanted to comment because it resonates with me so deeply now. I prepared so diligently for my first birth this past October...read every Ina May book at least twice, hired an amazing doula, and received my prenatal care from a cadre of fabulous midwives at a midwifery center IN a hospital (which boasted an impressive 15.9% c-section rate--not too shabby for an American hospital!)
Alas, after 23 hours of labor, I never dilated past 5 cm. After several hours of scary decels (into the 60's and staying there for up to 3 minutes at a time), an incredibly swollen cervix, thundering contractions that offered no breaks, and getting into every position known to man to no avail, the joint decision was made to have the section. "Occult prolapse" was the post-surgical diagnosis when loops of pale white cord popped out of the incision below my baby's head.
In the months that have followed, I have dissected the course of events at least a thousand times. Why did my cervix swell so dramatically at 3 cms? How did the cord get down THERE? Did my running during pregnancy cause it? Did my coccyx get in the way? (II suffered a mildly displaced fracture to it 10 years ago) Are my narrow hips to blame? I empathize now so viscerally with this brave mama, and your words not only reassured her, but me also, and I thank you for that. I never considered a monitrice before, but I am now for my next birth. I may ask our friendly local HB midwife if she would be willing to assume such a role.
Thanks for letting me spill my emotions for a bit, and thank you for this blog. It has been a source of education and encouragement for me through every step of my journey to motherhood and beyond.

April 10, 2011 | Unregistered CommenterKatie

Oh, Katie... first, I do pray you are able to find a way to understand and accept that shitty things DO happen in birth. I've often said, you can be as evolved as Ghandi, but if the baby has other ideas, then we follow that leader. I am ever-thankful, as I know you are, too, that that limp cord didn't mean your baby died (and I am *not* saying, "that's the only thing that matters," either, but yes, as you read the story, I got chills thinking that was where you were going.

Question: Did your baby have any caput at all? I've sometimes found if baby's have a caput, even a little in a very few women, that can *really* shove down on the cervix and, especially if mom is prone to varicose veins, *that* can cause the swelling. Did anyone go in and visualize your cervix while it was happening? How did your cervix look during surgery? You may not ever know that answer; it isn't something usually noted in surgical notes, but something else you might think of in the future.

And just because that happened once, does *not* mean it will happen again, but, if it does, you won't be the least bit shocked, right?

And lastly, thank you so much for your kind words. It means so much that something I wrote can help someone heal. Thank you so much for letting me know.

You can always email me privately, too, if you want to talk without it being here, but know that talking here helps women just like others speaking here helped you.

Much good luck and love on that baby... and your Self... a little bit more today.

April 11, 2011 | Registered CommenterNavelgazing Midwife

One more question, Katie... did anyone suggest an epidural? That sometimes is a last resort to see if it lets some pressure off the cervix. It, of course, does not always work, but just wondering how long you had the epidural before the cesarean.

April 11, 2011 | Registered CommenterNavelgazing Midwife

Thank you so much for that response...wow, now it's MY turn to get chills. My son did indeed have a caput (albeit small) along with extensive molding, which surprised us since I never dilated past 5 cm or passed beyond zero station. I have no varicose veins (knock on wood!), but I did have hemorrhoids from hell after the labor--does that count?
My midwife suggested an epidural when my cervical edema became dramatic--it was never directly visualized, however, it was apparently so large and edematous that she had difficulty finding landmarks (or an os, for that matter). At that time I had been "stuck" at 3 cm for 5 hours. Within 15 minutes of the epidural and lying supine with my tail propped up with pillows, the cervical swelling was significantly reduced and I had opened to a stretchy 5. Unfortunately, fetal tracings, which had been sporadically non-reassuring, became downright alarming within 2 hours of the epidural, and it was then that I was wheeled in for the section.
So a bit more detail for you--I hope this helps. I am intrigued by the "caput theory"--one wonders why it would form so early in labor? Hmm...we may never know.
And thank you again for everything! Every little bit of advice is more helpful than you know!

April 14, 2011 | Unregistered CommenterKatie

Like I mentioned in the comments in a couple of other threads today :), I had to go through CBAC processing after my 2nd birth 11 years ago. Eventually I did get to "my body is broken," then to, "I am blessed to have a body that CAN get pregnant and CAN feed my babies. Too bad I need help getting un-pregnant, but thank heaven that help is available." Eventually I made peace with the fact that we live in a fallen world and mortal life is imperfect.

My question is: imperfections are all over the place in biology. Some women cannot get pregnant. Some women can't stay pregnant or carry a baby to term. Some moms don't produce enough milk, despite doing everything the lactation people say. People have all sorts of disabilities, both readily obvious and not. Heck, little kids even get cancer. WHY do NBPs (love the term, btw) insist that everyone is capable of giving birth? That nobody has a body that is "broken"?

August 10, 2011 | Unregistered CommenterSara

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