Friday, February 26, 2010

VBAC Viability

Other, better commentators (Henci Goer, Marsden Wagner, Sarah Buckley, Kmom, Rixa, Laureen Hudson, Jen of, and many more) have written extensively about VBAC and why it's preferable to repeat cesareans for most mothers. Anyone who has done even the most casual reading on the subject knows that surgical deliveries carry with them a significantly increased risk of injury, infection, hemorrhage, and other complications for mothers and babies. Cesareans require longer hospital stays, more pain, more drugs, more risk of respiratory problems. NICU stays are more common; so are post-op transfusions, deep vein thromboses, and hysterectomies. Recovery is substantially longer-- those first few weeks of motherhood are challenging enough without adding the debilitation of major abdominal surgery to the mix! Babies are less likely to continue breastfeeding-- mothers who are exhausted and in pain, who can't lift their infants or even sit up straight, often give up and bottle feed. Consequently, cesarean-delivered babies are more likely to experience jaundice shortly after birth, and asthma, allergies, and obesity later in life. And while the initial cut is bad enough, each subsequent cesarean raises the risk of long-term complications for mama: placentation problems (placenta previa, abruptio placentae), secondary infertility, miscarriage, and ectopic pregnancy. Any of these are potentially devastating issues-- and yet mothers are told, time and again, "It's just a c-section."

"Just" a c-section? I've heard this phrase over and over, both as a mother and as a nurse. When completing a history and physical for a new family doctor, I checked the box that said "Prior surgeries" and wrote in "cesarean times two." The medical assistant who reviewed my chart commented, "So you've had surgery? Oh, no, I see-- you've just had c-sections." I had to bite my tongue to keep from screaming, "What part of major abdominal surgery aren't you getting? Have you been splayed open like a fish, your guts exposed to all and sundry, your abdominal muscles split and left to reapproximate in whatever slapdash fashion they choose? Have you dragged yourself up and down a flight of stairs, clutching the banister with one hand and your belly with the other, convinced that you're going to open up and spill your internal organs on your shoes? Sure-- just c-sections!"

Hollywood and the media are responsible in large part for the public perceptions of birth and cesareans. Everyone has seen the TV version of labor and delivery: mom rolling around in a hospital bed, screaming, cursing her husband's name, swearing "He'll never touch me again!" Comic sidekicks rush in and out while mom groans and shrieks and generally does her best Exorcist impersonation before delivering a bright-eyed three-month-old to the general adoration of all in attendance. Celebrity moms-- Victoria Beckham, Britney Spears, Madonna-- all those "too posh to push" mums, who get tummy tucks at delivery, who have personal trainers to get them back in shape fast and personal chefs to feed them and nannies to take care of their newborns and older children-- they make cesareans look like the easy, chic way to have babies. None of the fuss and muss of labor-- just show up at the hospital on the appointed day, coiffed and made up and manicured, pop into the operating room and get that oh-so-lovely epidural, and wait for your surgeon to hand you your clean, scrubbed, blanket-wrapped newborn.

Unfortunately, we don't get to see the all-too-common aftermath: a mom too drugged to hold her new infant; when the epidural comes out, in too much pain to put him to breast. The indignity of having a Foley catheter removed, only to have it reinserted when she can't urinate on her own. The agony of hobbling to the bathroom like an octogenarian, terrified of falling or opening her incision. The frustration of having to tell her toddler that she can't pick him up because of the ouchie on her tummy. The days and weeks of lingering pain, muscle weakness, helplessness.

In the years since my two cesareans (ten years ago and seven and a half, respectively), I've gained a bit of perspective. I don't rant much anymore; I don't brood often, or for long when I do. I take care of new mothers who actively choose their c-sections, and seem reasonably satisfied with the results; mostly I'm able to keep my feelings to myself. I slip referral cards into teaching packets with links to ICAN and When families ask "is this much pain normal?" or "what can she expect when she goes home?" I tell them the unvarnished facts: Cesareans hurt, surgery is painful, recovery takes time. Occasionally I'm asked if a mother might ever reasonably expect to birth a subsequent child vaginally; on those rare occasions I offer my (heavily edited) stories and the assurance that VBAC is possible and definitely worthwhile, but it takes work. The sad fact is that most of the women I meet aren't willing to do the work-- their doctors tell them no, it's too much hassle, it's dangerous, etc., and they accept that answer as gospel. Society supports the status quo; those of us who are willing to educate ourselves, take responsiblity for our health and our births, are regarded as hippies, zealots, weirdos. Good girls don't buck the system. Good girls do what they're told, lie down and allow themselves to be sliced open for their obstetricians' convenience. Good girls put themselves and their babies at risk by choosing repeat cesareans-- or, probably more accurate, allowing repeat cesareans to be chosen for them. True informed consent is rare: as one OB famously stated, "If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree..." (Neel, J. Medicolegal pressure, MDs' lack of patience-- cited in cesarean 'epidemic.' Ob.Gyn.)

Cesareans are forever. No matter how good one's experience, the effects remain. Scars heal, fade, but mothers ever after will experience statistically higher morbidity and mortality. I had a life-altering vaginal birth after two cesareans, but my triumph was marred by a retained placenta. Was it caused by my cesareans? I don't know for certain, but I strongly suspect so. I managed to push a baby out of my vagina, but I still had to turn to medpros for a D&C-- another uterine surgery, which in itself increases my risk of complications should I ever plan another birth-- all thanks to an OB who wanted to get home sooner than later.

I will never go into labor without that CNN-style ticker tape in my head, reminding me of the warning signs of uterine rupture; I will never welcome a baby in blissful ignorance, as so many of my patients seem to do. I envy them sometimes, the mothers who have never had a reason to question their doctors, who go to the hospital with the first twinge of labor, accept all the interventions, and still pop out their babies with very little trouble and no apparent lasting effect. Still... there is something to be said about the journey. And there's no question that my journey has been valuable-- priceless, even. That's the intangible reward of pursuing VBAC: the self-searching, the questioning, the obtaining of knowledge. I learned more about myself in the years that I struggled against depression and PTSD than I ever would have if I'd been one of the "lucky ones," the women who make it through the birth mill unharmed. I survived the inferno and emerged from the crucible, tempered and, I think, strengthened. Certainly I would not be the person I am without my fight to VBAC-- and after a good many years, I'm finally able to say that, yes, I like that person. That's worth almost as much as my children.


hbacmama from Canada said...

I love you.
Always have.

Well-Rounded Mama said...

"Cesareans are forever."

Indeed. Keep speaking the truth, hon.