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Entries in Uterine Rupture (2)

Monday
Jun112012

HBACs

After some long and deep thinking about this topic over the last couple of years, I’ve come to the conclusion that Vaginal Birth After Cesareans (VBACs) should be permitted to birth at home (a Home Birth After Cesarean – HBAC). I’ve been vocal about my belief that homebirth midwives need more education and skills training and have intimated that breeches and twins should not be born at home, but this is the first time I’ve spoken clearly about my feelings about HBACs.

As I considered this, I re-read the entire National Institutes of Health VBAC Summit’s recommendations a couple of times, read statistics in a variety of journals and then read both pro and anti sites regarding both VBAC (at all) and HBACs. I also tapped into my own cesarean and VBAC experiences as a doula and homebirth midwife, but tried to take the hard data at least as valuable, if not more so, than mine. In my ponderings, I’ve also put myself in the place of a birthing woman; what would I do if I were considering a VBAC/HBAC? Also, I’ve taken my own daughter’s situation… a primary cesarean, wanting a VBAC… and wondered how I would counsel her. I honestly feel I am infinitely more conservative with her life than I ever was with my own.

While I acknowledge there is risk in VBAC and surely more risk in HBAC, I feel that weighing the risks between a possible rupture versus the risks that can and do occur during and after a cesarean can lead a woman to, with true Informed Consent, to choose to VBAC/HBAC. And in some ways, having an HBAC can be even safer (safer being relative) than a VBAC in the hospital because women are able to be mobile and not be induced or augmented. Of course, women having an HBAC do not have continuous fetal monitoring so there is the argument that early signs of rupture can be missed in a homebirth. I’ll accept that and women choosing HBAC will have to, too. Women at home, however, are able to feel the rupture when an epidural’d woman would not. Not that all ruptures can be felt.

The great majority of ruptures are slow, not the catastrophic ones usually thought of when discussing this topic. While time is of the essence, there can be enough time to transfer to the hospital if a non-catastrophic rupture begins. (Catastrophic meaning sudden and imminently life-threatening… not that a uterine rupture isn’t a horrible event all on its own.)

In my opinion, the ideal HBAC client looks like this:

  • has had a previous vaginal birth
  • has had only one previous cesarean
  • has had at least two years between pregnancies (not births)
  • does not have insulin resistance issues or gestational diabetes mellitus
  • has not had a previous baby over 9 pounds
  • is not expected to deliver a baby over 9 pounds
  • does not go over 41 weeks 3 days (Seems arbitrary, I know, but will explain below.)
  • has a midwife who is highly educated and amply skilled
  • is within 15 minutes of a hospital, 15 minutes car driving, not ambulance driving (ambulances coming to the home and then getting to the hospital can take 15 minutes or more)

But, ideal is probably pretty rare.

I’ve written that the safest place for birth is in the hospital. Ample staff, access to technology, an operating room and blood products are in hospitals, not at home. So, if one is wanting the safest (with regards to the mother’s and baby’s lives) place for any birth, the hospital wins, hands down. But, there are trade-offs and they do not always have anything to do with “the experience.” At home, technology isn’t foisted on women and babies, technology that can hinder labors and cause more problems than they solve (induction and augmentation as one huge example). Women are also treated as human beings and while this might seem “experience-y,” civility can help women relax and allow their labors unfold as well as trust the provider more and, therefore, be more inclined to share worries or concerns about what is happening in the labor.

Regarding delivering before 41 weeks 3 days as the ideal time frame, if a woman is wanting a VBAC, this timeline allows hospital interactions if the birth doesn't happen before then. That labor might begin after that and an HBAC happening, that's certainly true, but I am inclined to want to offer the mom every opportunity for a VBAC and, to me, that includes the hospital "interventions." Again, it does seem awful arbitrary, but just how I feel.

This is, in no way, meant as The End of the VBAC/HBAC discussion, but a beginning. Women must play out every scenario, discuss every concern with their partners and providers (ideally, a medical and midwifery provider in order to get a balanced perspective) and ultimately decide, for themselves, if the (extremely) minimal risk of a catastrophic rupture is worth staying at home. Remembering that uterine ruptures also happen before labor even begins can help them consider the risks.

In this discussion on my Navelgazing Midwife Facebook Page, women have shared their stories of uterine rupture and fetal death, so acknowledging that possible reality is crucial. Weighing each location’s pluses and minuses is vital. The only two uterine ruptures I've had with clients have been with women having their first babies and the women were induced/augmented with pitocin. I've known of other ruptures, but have no experience with any catastrophic ruptures. But, even so, I absolutely understand the risks. (I have seen a maternal death, so totally get risks in birth.)

For me, I would, with the above ideal situations, attempt an HBAC. Even though my daughter hasn’t had a previous vaginal birth or a baby under 9 pounds, I believe that, with care, she could attempt an HBAC next time. That, above everything else I’ve said, speaks volumes. (Not that she would want or try to HBAC; she isn’t pregnant, so moot at the moment.)

I look forward to thoughts and concerns, though I did try to address most of them.  

Tuesday
May012012

Cesarean Scar: Cj's Story

I absolutely love this site.  I wish when I was younger there had been something available such as this. I had my first two babies before we ever had the internet. It's nice to see other women go through the same thing.  And also nice to be able to share with others.
 
One thing to note are that my scar changed with each baby! I have three children and have three c-sections. It could have been weight gain, obviously, but even after the first baby my scar did not look very pleasant in the presence of A LOT of stretch marks.  Now I am much heavier than I ever was and it shows in my belly but I am happier with myself that I have ever been. There came a time in my life where I came to terms with my body and my c-sections and birth stories. I stopped obsessing with not getting my vaginal birth a long time ago, so for anyone who feels cheated out of vaginal birth...you may still feel at peace with it later. I feel connected to my children, regardless. They each have their own story of how they came into this world. My stomach was crooked and more pronounced on one side after my first c-section, and it looks like my belly still has that issue! If you look closely you might be able to count three c-section scars, and a tubal reversal scar (which is smaller in width). My scars got much lighter with time.
 
I am not quite 5' tall, 4' 11" 3/4 if we want to be exact. I weighed about 138 pounds at delivery of my first baby and every stretch mark you see on that belly was created during my first pregnancy.  I guess I was stretched out enough for the other two.  My almost 18 year old daughter was born in June of 1992 at 7lbs. 10 ounces and 20 3/4" long, a week late, and I was only 18 years old myself. She was as gorgeous as she is now, with dark hair and blue eyes, and olive colored skin (not like her mama!). She was born in a military hospital, they didn't offer epidurals, and I had 18 hours of labor. Surprisingly I handled the labor pretty well! I was tired but I didn't freak out. I dilated to an 8 but didn't progress and her head was floating, she never really engaged. Thus the c-section. I wish my labor had been different. I was stuck in a cold room, in a hospital bad, catherized, no medication, and unable to move!  I think if I had been in a more natural setting it may have helped me to move around and get her moved into position, but that's just a theory.She was slightly unresponsive at birth, no loud cries, just a little squeak out of her. She was stressed out by that long labor.  Also of note here is that the hospital didnt get me out of bed for two days straight. They didn't have me move and I stayed catherized. It was terrible and I think subsequently made my uterus not heal well and created a lot of scar tissue.
 
My second pregnancy I weighed 142 pounds at delivery. I was 20 years old, going on 21. I wanted a VBAC with him and desperately tried what was within my power to have that happen. They induced my labor 2 days before he was due because I was low in amniotic fluid, very low. 12 hours of labor, an epidural, and a pain that I could never describe that even the epidural didn't seem to take care of. They kept telling me it was his head moving down but it sure didn't feel like that. I dilated to a 6. I did not handle that labor as well as my first.  There was a lot of pain and crying with my contractions. I don't know exactly what made the doctor decide to do a c-section but I know I was sad about it. My Dad called and said to me while I was in labor "Just do this c-section, this isn't a competition". Well, it ended up being a good call, actually. As my doctor was doing my c-section I had a uterine rupture. The doctor and nurses got to witness right before them the spontaneous rupture across my old scar, through a major artery, and down into my cervix. My son was delivered instantly and he was fine, thank the Lord. He had a bowl movement before he was born, and with little amniotic fluid around him it was stuck to him like tar! He came out screaming and it would be hours til I held him (but once I did, it was like I knew him my entire life). There was a lot of blood loss for me, blood transfusion, and four and half hours of surgery. The doctor was actually preparing to do a hysterectomy but my bladder had adhered to my uterus and they had to call in a urologist to come in and do bladder surgery (I had to walk around with a cathater and my "pee" bag for almost 2 weeks after), which actually saved my uterus because by the time they removed the bladder my bleeding had stopped and they didn't want to risk more hemorrhaging. The doctor begged and pleaded with me to get a tubal ligation and I refused. The doctor told me by no means should I try to carry another baby. I was devastated because I was young and wanted more children. He was born 11/1994 at 7lbs 12 ounces and 20 1/2" long.
 
The third baby was a surprise. I managed to make it 5 years without getting pregnant. I was worried about carrying her but I had several doctors tell me that it would be ok and it was. She was a planned c-section, she was born 8/2000 and was 8lbs 6 ounces and 19" long, strong and healthy, and came out screaming like an opera singer. The girld coulda busted some windows with that scream and she still can! I weighed 152 pounds at delivery with her. I had a very uneventful pregnancy and delivery. In fact when the doctor delivered her he told me how great my uterus looked considering what I had gone through and that my scarring was minimal and the uterus was not thin as it was before. I attribute it to doing a lot of moving around after my second c-section, cause this helped not to heal everything into one place and cause scar tissue! Moving around is important, but don't over do it. I made sure I moved around a lot after the third baby too. She was big, she was healthy, and the previous doctor was WRONG. I had proof.  Regardless, I went ahead and tied my tubes reluctantly.
 
June 2009 I had a tubal reversal. I have been pregnant twice, with two miscarriages since. My tubes are very short at 2cm each so I think is part of the reason why it's hard to get an baby to implant correctly. My current doctor has reassured me that I can carry another baby, it will be another c-section, but being under good medical supervision I should be fine. My youngest daughter is 9 years old now, so there is a huge age difference in my children and future child to be. I am now 36 years old. My husband is 43 years old. We will try for one more baby and then I will call it quits. I will start my first round of IVF next month.