Redemption

On the occasion of my sweet son's SIXTH (!!!) birthday, I wanted to post the story of his birth-- and mine. I warn you: it is LONG! Interestingly enough, since it's been 6 years, the dates correspond to this year's calendar. 


This is the story of the birth (yes, BIRTH!) of Rowan, my third child, the first baby to whom I gave birth. It's the story of my long-fought-for and dearly wanted VBAC, my UBA2C. In a way, it's my own birth story-- because I felt that I died on the operating table when my second baby was extracted from my body after a failed induction, but I was born as Rowan emerged from my strong, resilient uterus.

I'm taking some of this straight from my journal-- I've long since succumbed to some mommy amnesia. Some of my labor and birth are already fuzzy... some parts, like the feel ofRowan's head as he was crowning, I will never forget. Never.

Sunday, 4 September 2005

My physical state is fine. No sign of impending labor. Let it be. [This Beatles song gave me my pregnancy and birth mantra.]

Emotionally... sigh. Bored, discouraged, depressed. Wish it'd just get going so I could stop worrying about it. DON'T want to go back to work on Tuesday, but no choice if no labor-- I can't afford to lose paid time off hours. BLECK!!

Monday, 5 September 2005 -- Labor Day. Ha!

Physical: fine, a few more ctx [contractions], some fairly intense.

Emotional: hate the world, wish everyone in it would bugger off and leave me alone! 

Tuesday, 6 Sept 2005

41 weeks, on the dot.

WHY AM I NOT IN LABOR???!?!?!

Am I really broken?

No. Can't be. Surely not.

It'll happen. Won't it?

Tami G. emailed me and said something profound: in a month, I'll be holding my baby. Hang onto that.

ICAN VBAC!!!!!!!

Wednesday, 7 September 2005  ~5 pm

Stopped to get gas-- reached down to pop the gas tank door-- felt another distinct POP! Water broke-- gushing, but clear. Baby obviously not engaged. Got back in the car and drove home-- lots more fluid with each ctx. Niagara Falls effect stopped when I got home and got upright for awhile-- Rowan's head settled deeper in pelvis?

Few light ctx, not regular. Trying to stay up, moving, etc, but leaking is a problem. Stood at computer and emailed ICAN, IM'd Lisa-Marie. Hard to concentrate.

6:30 pm-- kneeling on bed, rocking hips-- feels good. Ctx still seem light.

7 pm-- up and around a bit, lots of show. Loose stool. Light ctx every 2-3 minutes (trying to avoid the clock). Bored. Lying on side uncomfortable-- up to shower again.

9 pm-- ctx spaced out. Not timing. Can only focus on one thing at once during ctx. RELAX. More gushing-- not like earlier, though. Sleep soon?

10 pm-- KIDS ARE DRIVING ME INSANE!!!!!!!!!!!!!!!  Whining, fighting, carrying on-- wish I had someone to take them AWAY! Definite downside to DIY. Ctx more intense. More show. Going to sleep soon-- assuming kids will stay in bed! [NB: Rhiannon, my daughter, was 5 at this time; Gareth, my first son, whose story I posted on his birthday, was 3. They slept through everything.]

11 pm-- no sleep for me, can't lie down comfortably. Shower WONDERFUL!

_____

This is where my journal entries end-- I couldn't write anymore. The kids did stay in bed, and I sent their dad, John, to bed too. I told him to get some rest, and I'd call him when I needed him. I figured I had hours ahead of me, and he would need the sleep. Then, labor hit like a freight train!

I had been in the shower for maybe ten minutes when I got out to tell him that I needed the pool NOW. And I promptly went and got into it!

The pool was set up in my living room, and was about a quarter filled. John had started working on it as soon as I came home and informed him that my waters had released-- we never did get a hose or an attachment for the faucet, so he was filling it one bucket at a time. Luckily, we have a wonderful hot water heater-- it never failed me. And John, who was a trooper through the whole labor, boiled pot after pot of water (how stereotypical can you get?) to "hot up" my pool even more.

When the pool was about 2/3 full of blissfully hot water, John set up camp in the living room. He dragged in the mattress from Gareth's (unused) toddler bed, covered it with sheets and a comforter, then got in and tried to go back to sleep, while I labored in the pool.

It was about midnight-- I'd made John turn the clock away from me, because I didn't want to watch it all night. I knew I had a long slog ahead, and I didn't want to get discouraged. I'd seen that the contractions were coming roughly every 2 minutes, and I didn't want to know anymore.

The contractions... I'm not sure what to say about them. In the shower, I handled them best by letting the water spray on my back, down low (where I kept my fists jammed most of the night, the result being that my shoulders were killing me the next day) while I rocked my hips back and forth. I was chanting the Goddess Chant through each surge-- two versions, mine and 
Starhawk's. Sometimes I got them mixed up, but I doubt the Bright Lady cared!

Starhawk: Isis Astarte Diane Hecate Demeter Kali Inanna

Mine: Isis Athena Rhiannon Cerridwen Brighid Anath Arianrhod

Soon it changed to "Open" over and over, longer and more drawn out with each surge: "Oooooooopennnn. Oooooooooooooppppppennnnnnn." Four or five of those got me through a contraction.

In the pool, early on, I spent time on my knees, still rocking my pelvis. When a contraction came, I had to submerge-- get under it, literally. I went to my hands and knees, then into a push-up position. I hung onto the side of the pool, chanting "open" again and again-- my old trick of counting through each contraction, which I used throughout my labor with Gareth during that idiotic seventeen-hour induction, failed me this time. Nor was I able to escape the sensations and go elsewhere, the way I had last time. This was much faster, much more intense. 

I found I was better able to handle the contraction on my feet, so I stood up much of the time, knee-deep in warm water, fists thrust into the hollow of my back, toning. "Open" was now just "Ohhhhhh... ohhhhhhh" low and loud-- I couldn't control it, though I didn't want to wake John up. I stood there in the semi-darkness-- the living room lights were out, but the bathroom light shone through-- singing my birth song and trying to work with, rather than against, the expansions of my uterus.

Does anyone remember the study that said that even a "virtual doula" helps a woman get through labor-- that someone in her head, an imaginary doula to encourage her, is beneficial? Well, I can say that for me, at least, it was true. The real-life doula I had during my attempt at hospital VBAC was kind but ineffectual. The one in my head this time-- Kmom!-- was brilliant! She said everything I needed to hear: you're doing great. Keep breathing. don't forget to pee. You're doing this, you really are!

And so I labored. As before,  I had no concept of time. John tells me it was about 1 am when my vocalizing changed and he woke up fully (he'd only been dozing anyway). About 1:30 he remarked casually, "They're less than a minute apart now. You ARE progressing. They're lasting about 20 seconds."

Twenty seconds--?? I was crushed. I kept thinking, "longer, stronger, closer together." If these were only 20 seconds-- !!!

"I don't want to know that," I groaned. "Don't tell me that."

After a few minutes, Kmom told me to go to the bathroom again, so I did. I emptied my bladder-- John had placed a large mug of water and a huge plastic cup of crushed ice on a milk crate beside the pool, and I had been drinking and crunching plenty-- then got back into the shower. It wasn't as comforting as it had been, so I went back to my pool and asked John to add some more water. He tried to hold me, offering to do a supported squat, but I couldn't bear to be touched during a contraction. So he bailed some water out of the pool and replaced it with hot.

He was so supportive, even though he felt he didn't do enough, that he was "too hands-off." But that's exactly what I needed. He held the space and he kept my water hot. He sat quietly and watched me, but didn't interfere; he helped me focus when I really needed it. He was perfect, and for that, I will always be grateful.

A small piece of my mind wondered where I was, dilation-wise. I didn't want to psych myself into thinking it would be done soon, even though it felt VERY fast and intense to me. I was trying to prepare myself, physically and mentally, for another whole day of this-- longer, if necessary! Think of Eugenie, I told myself-- Eugenie, brave woman, who labored for 80-plus hours to birth her son. Yes, I argued with myself, but think...

There were clues, and I couldn't help but notice them: the way I was toning through contractions, the lowing, birthsong quality to them. Shorter, more intense contractions could mean I was in or near transition. I was starting to feel nauseated at the end of each surge. I never did throw up, but I told John repeatedly that I felt I might. I started dozing or "zoning out" between contractions, drifting into a strange, incoherent laborland. I could only endure contractions by standing and rocking my hips, then getting underwater and floating once I'd passed the peak.

I realized I was feeling very foggy. Random thoughts crossed my mind-- bizarre, dreamlike notions that seemed to make sense at the time, even though a part of me knew they didn't. The only one I remember was odd-- and please, don't anyone take this as offensive, it's just what wandered through my head: "I wonder why it is that white women named Irene often shorten their name to Reni, while non-white women just use 'Irene'?" [I have no idea if this is true, but I doubt it. Weird labor thoughts!] "And why is it 'Ear-ray-na" in England, but 'Eye-reen' here?" Transition, anyone? ;)

Then, abruptly, the fog lifted. Suddenly I was thinking clearly again-- the world came back into focus. And to my astonishment and chagrin, I realized that I was pushing at the end of each contraction!

This can't be right, I thought wildly. Something's wrong-- it's too soon--

But it didn't feel wrong; it felt right. Not good, but RIGHT. So I pushed.

I remember thinking, I want this over! I want it over and done. How much can a person be expected to take? This is silly! I did not have to do this!

I don't think I said any of this aloud (and Kmom chastised me, albeit gently, in my head!). I know I did whine, "I can't do this!" once or twice, and John came and looked me straight in the eyes, saying, "Yes, you can, you are, you're doing great." I reminded myself that I'd known what I was getting into, I'd made my choices and I had to accept them, and whinging about it wasn't going to help anything. I may as well be there, since I had to be-- it was like that old kids' game, "Going on a Bear Hunt" : "Can't go over it. Can't go under it. Have to go THROUGH it." At times I hated it-- my friend Gretchen is right, pushing SUCKS-- but I kept going through.

The urge to push was subtle. It wasn't "I GOTTA PUSH," the way it was when I was laboring with Gareth. It was like something had taken over my body and was pushing whether I liked it or not! I began to roar with each push, getting louder and stronger.

"You're progressing," John said with satisfaction.

"I think I'm pushing," I told him.

"Don't wear yourself out. Take it easy."

Easy to say, but the effort was impossible to resist. I was worried-- it still seemed too early (as far as I can make out, it was only about 2 am) to be pushing. I hadn't been laboring long enough. I was afraid that I was only 5 cm with a badly malpositioned baby, that I was making it worse with every surge, swelling my cervix and sealing my doom. I didn't know what to do, and I said so. Then, in a fit of desperation and doubt, I asked John to check me-- the first vaginal exam I'd had since I was 9 weeks along and worried about a possible miscarriage.

He went and scrubbed up-- offered to use bleach (!!!) but I convinced him that soap and water was sufficient, as long as he scrubbed for at least 20 seconds. (I think he did 2 solid minutes. ;) He came back, and we waited through another contraction. Then I tried to lay back and let him fumble around for a moment or two, as long as I could endure. He reported, "No, nothing."

I wanted to cry. In fact, I think I did cry, a little it. How much more could I bear? What should I do?

Another surge, like a terrier shaking a rat. Lots of show, some gushing fluid, intense pressure in my rectum. Something was moving through me-- there was no escaping it. "It feels like it's right there," I kept saying. "It" was hard to describe, but it felt foreign-- not me. It seemed to move opposite to me-- if I swung my hips left, it rotated right, or else I rotated around it while it stayed still. It didn't hurt, but it was very, very uncomfortable. There was no getting away from it. It was... inexorable.

I pushed and roared and pushed, giving up my brain's worries to let my body, my primitive self, take over. "I surrender," I told the Universe. "Whatever happens..."

It went on, and on, and on. I had no clue what time it was, or how long I'd been there. I pushed standing up in my pool until my knees shook and threatened to buckle, then I went back to kneeling. I tried to push while lying on my side-- first right, then left-- but while floating on my side and back between contractions felt good, pushing in those position did NOT!

Standing was best-- kneeling was tolerable, but only just. Sitting, lying, even floating in the push-up pose I'd used earlier-- these were all completely untenable.

"Bathroom," Kmom commanded in my head, and I managed to drag myself out. I sat on the toilet and pushed there through a few surges-- that felt pretty good, but not as effective as I'd hoped, so I went back to the pool. Surge-- push-- howl like a wolf. Repeat.

After awhile, John, who was getting more excited and nervous, asked me, "Should I check you again?"

"If you want..."

More groping, then, "It feels like it's getting harder."

"The head?"

"I don't know... but I can tell you, you're really open."

Push. Roar! Breathe. Again. And again. Have I ever worked so hard in my life?

Push. Push with all my might-- I was worried that I was doing the "purple pushing" encouraged in hospitals. Shouldn't I be trying to breathe the baby out instead?

Screw it! I thought grimly. I don't care if I tear six ways from Sunday. I want this kid OUT!

Push. ROAR! Breathe.

Over and over, more than body and soul can bear. I can't do it. I can't. Not anymore. I can't.

"Yes, you can," John insisted. "You've come this far. You're not giving up now. You've told me a hundred thousand times you can do it, and I believe you. You CAN."

I reached down, trying to see if I could feel-- something, anything. "If it helps," John was saying, "your belly [meaning the bump that was Rowan] is lower." With my last push, I had felt a stinging sensation, and the phrase "ring of fire" had danced through my mind, but I had quickly dismissed it. Still-- maybe my perineum was at least bulging a bit--

And there "it" was, just under my fingers, barely inside me: a squishy soft mound, damp and warm. I froze. O my dear good Goddess--

"There's a head there," I said, shocked.

John lit up. "Yay! You're almost there!"

Another push-- the head slipped back, but only a little, and there was a definite burn now. I didn't care-- it wasn't bad, and anyway, there was a head there! Set me on fire, I don't mind, I'm BIRTHING!

The surge ended. "Want to feel?" I asked John, and he reached into the water-- I must have been kneeling at this point. I can't describe the expression on his face. "Yeah," he whispered. "Yeah..."

PUSH! I bore down hard, remembering the old saw, "Giving birth is like passing a watermelon through a hole the size of a lemon." I pressed my fingers hard into the skin around my vagina, trying to stretch the tissues. That one stung-- but in the next moment, I had a small (!) firm head in my hand! John was holding it too-- Rowan was out to his ears, maybe, and I was screaming. It HURT-- the only part of the whole labor I could truthfully call, well, excruciating.

"What now?" John wanted to know. He was stunned.

"Wait," I gasped, "for the next contraction..."

"Come on..."

It felt like forever. I tried to push without the contraction, but the baby didn't budge. For the first time all night I was praying-- pleading-- BEGGING for another contraction!

Finally it came-- and I PUSHED--

The head came out; the shoulders and body quickly followed. (So much for my fears about shoulder dystocia!) Before my brain could register was had happened, I was holding a slippery new baby in my arms!

I sat back-- the pool, which up till now had stayed remarkably clear, was now murky with fluid, blood, mucus, and fecal material-- but mine; there was no meconium. I didn't care what I was sitting in. I had done it! I BIRTHED MY BABY!!!!

I VBAC'd!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

"Hello," I crooned to my new little bug. "Oh, hello!"

He was perfect-- well, I didn't know he was a "he" yet-- snuggled up to my shoulder. He was dusky, but his face and chest were pink. He hadn't made a sound. I rubbed him, talked to him-- he opened his eyes and looked at me, but he still didn't make a peep.

"Hi, sweetie," I said. "Oh, you're so beautiful. Look at you-- oh, hello, Rowan!" 

He finally whimpered a little when I gave into John's increasingly anxious requests and turned him over to check the sex. I laughed in surprise: "Oh my God, it's Rowan Riley!"

Rowan would have been Rowan whether he was a boy or a girl, but with different middle names depending on gender. We had been expecting a girl all along, but Rowan fooled us. We laughed and Rowan finally cried, and I held him close while John got a towel to cover us.

I couldn't stop thinking, I did it! I DID it!! I DID IT!!!!!

"What time...?" I managed.

"Congratulations!!!" John shouted. "You did it-- 4:33 am!"

4:33 am?? That's ALL??! I was in complete shock-- my water broke at 5 pm, I'd only really labored since 11 pm. Five and half hours, and most of it pushing...? Early in the evening I had joked, "Wouldn't it be great if the kids could wake up and find their new sibling? And I could call my mom and tell her to stop by on her way to work?" I never thought it would happen...

John helped me out of the pool and we headed for the bedroom, marveling over our new baby boy. I found a tape measure and tried to get some stats-- I came up with 14 1/2" head circumference (molded) and 21 1/2" body length, but Rowan wasn't very cooperative, so they were largely gross estimates. He seemed smaller than his siblings-- smaller than Gareth, certainly, who had been 10 lbs 5 oz; maybe littler than Rhiannon, who'd weighed a pound less. But who cared? I had birthed him!

I put him to the breast, and he latched on and nursed for quite some time-- twenty, thirty minutes? Can't recall. I was still have irregular, intense contractions, and around 5:15, they started gearing back up, getting stronger and closer together. I told John to get the big plastic bowl I'd bought, and I got up to deliver the placenta. Push-- but only a small, palm-size piece came out. A clot? No, definitely part of the placenta. It was followed by another, larger chunk, and in a few minutes, the largest piece-- but still only a quarter to a third of the whole. This one included the cord, which was perfectly, beautifully attached, just as it should have been-- a proper, three-vessel cord with textbook insertion.

I knew that a placenta that delivers in pieces is a bad thing, and if I had been thinking straighter I would have called for transport then. But I was high on my birth, I was exhausted, and I just wanted it to be over so I could bask in the afterglow and snuggle with my little guy. In retrospect, of course, it was a bad call.

John went and called my mom and said, as I'd instructed, "Stop by the house on your way to work-- there's someone you'll want to meet." Then he came back and took the baby, and I got up and took a shower! Such a small thing, but when one's previous "birth" experiences entailed major surgery and a long period of convalescence, the ability to step into one's own shower, unassisted, is nothing short of a miracle-- and underscores yet again (as if I needed reminding!) the vast difference between a vaginal birth and cesarean surgery. The latter is most definitely NOT "just another way to have a baby"!!

At 6:30 we woke the kids up to get ready for school. John told Rhiannon, "Come in here and see-- baby Rowan came." Rhi tore into my room, saw Rowan, and stopped short, staring in awe. Then she cooed, "Oh, he's soooo cute!" Gareth came just after, amazed to find that "the baby came out of Mama's tummy!" They were just precious, both of them.

My mom and sister arrived at 7:15 with a baker's dozen of Krispy Kreme doughnuts. They stayed with me and admired the baby while John took Rhi to school. My sister was especially amazed-- she had fully expected me to have to be taken to the hospital in a flight-for-life helicopter for emergency surgery. She'd had nightmares that Rowan and I would die-- the main reason I hadn't told her or my mom that I'd been in labor.

"I can't believe it," my sister kept saying. "You look great. I remember after Gareth was born-- even after Rhi. You looked so sick-- grey and little and sick. Now you're just... glowing!"

If pride and excitement were visible, I'd be lighting up the entire city. I've never felt so alive, so empowered, in my life. I could move mountains!

My mom went on to work, and my sister took Gareth. John and I rested, then got up and took Rowan to our pediatrician, when he was 6 hours old. The office staff was aghast and amazed when we told them about our unassisted homebirth. But the doctor pronounced Rowan "perfect!" and gave us the official stats: 21 1/2" long, 14 1/2" head, 10 lbs 8 oz!!!! Bigger-- just a little, but he had had a wet and dirty diaper since his birth-- than Gareth!!!

I was stunned-- I'd really thought Rowan was smaller, since I didn't get as big as I had with his brother, and he just seemed little. I'll admit I was slightly disappointed, thinking, Well, maybe I couldn't deliver a ten-pounder, but at least I can deliver an eight-pounder.... But the scale confirmed it: TEN-POINT-FIVE POUNDS, definitely a "big baby" by modern medical standards. That ten-pound stigma had caused my medwife to dump me last time-- she was terrified of Gareth's size. But I birthed the same size baby on my own with no problems-- no sticky shoulders, not a tear, not a skidmark, nothing! HA!!!!!!!!!! Take THAT, sOBs and Evil Medwives of the world!!!

Birth happens. I know it does. It happened right there in a blow-up pool in my living room. Birth happens as God/dess intended, without drugs or knives or sterile fields. Birth happens.

It wasn't perfect-- I still had the retained placenta to deal with. (I'll write a separate epilogue for that-- I've gone on long enough!) But in the end, it was all so beautifully simple. I went into labor. I dilated to complete, without anyone having to reach gloved fingers into my body to verify it. When it was time to push, my body did what it was supposed to (although I'm a little bitter that I didn't get my "rest and be thankful" moment!). I acted instinctively to assume the positions that were best to facilitate Rowan's descent. I supported my own perineum, and I did not tear. Rowan was born-- and so was I.

How to Have a Hospital VBAMC

It's difficult-- nearly impossible, in some parts of the country-- to find an obstetrician who will agree to "let" a mother attempt to use her vagina for its biologically mandated purpose once she has had a cesarean. As access to hospital VBAC gets more and more rare, many moms opt to stay home, choosing to labor and birth with a midwife or on their own. Others, though, still want to have their babies in the hospital, but refuse to submit to a repeat cesarean. These mothers may plan to stay home as long as possible in labor, waiting until the last moment to notify their OB and go to Labor & Delivery. Sometimes this works-- "showing up pushing" can mean that even a VBAC-wary doctor won't have time to object, when they walk into the room and the baby is already crowning. Other times, though, the ploy fails: there are many horrible stories (see Jennifer Block's Pushed for details) of mothers arriving in the emergency room in hard labor, and being forced instead to undergo a stat section. One dear friend experienced just that: as she neared the end of a perfectly normal labor, she was wheeled into the OR, screaming, "I do not consent!" No one listened; she was cut against her wishes. Another brave mom I know had her crowning baby shoved back up the birth canal and then removed surgically-- again, without my friend's consent.

If having a hospital VBAC is difficult, finding someone to attend a VBAMC (vaginal birth after multiple cesareans) is that much harder. Even though ACOG itself admits that two c-sections are not an absolute contraindication to VBAC, it's a rare OB who will agree to attend a trial of labor for a VBA2C, and only then if the mother has had a previous vaginal birth (not necessarily a VBAC). Higher-order VBACs(those occurring after three, four, and even more cesareans, as documented here) by Kmom in hospitals are nearly unheard of; the majority of OBs, and even many midwives, consider the risks unacceptable. In fact, there are few studies that look at VBAMC, and a recent study even suggests that VBA3C moms face risks comparable to any other VBAC mother. Of those risks, the most loudly trumpeted is uterine rupture-- something a mom who wants to labor after multiple cesareans is likely to be told is nearly inevitable in her case, even though this assertion is not supported by the evidence. Faced with this fearmongering tactic (referred to by birth advocates as the "dead baby card"), most would-be VBAMC mamas back down, defer to the "expert" obstetrician, and schedule a repeat cesarean-- which will be coded as "elective"-- and honestly, who can blame them? Aren't doctors supposed to know best-- aren't they there to protect our interests as patients, to keep us safe? To do no harm?

It is well to keep in mind that physicians are human, and humans, no matter their ideals or sense of altruism, are ultimately most concerned with their own best interests-- precisely why every pregnant woman, regardless of circumstance or desired birthplace, must educate herself and become her own number-one advocate. ACOG is, first and foremost, a trade union, and it does what such organizations do best: it protects its members. Obstetricians, because they deal intimately with such a life-changing (life-beginning!) process, are targets of litigation- because in our society, if something goes wrong with a delivery, if a family is presented with a so-called "bad baby," they naturally look for someone to blame. It's common wisdom among OBs that "the only c-section you get sued for is the one you don't do"-- in other words, if a baby sustains injury or lasting damage during a vaginal birth, the first question a lawyer seeking reparations will ask the OB is, "Why didn't you do a c-section?" (Or, in this day and age, even "Why didn't you do a c-section sooner?")

Fear of litigation drives medical care in this country, especially where mothers and babies are concerned. Obstetricians pay some of the highest malpractice insurance premiums in the business. So perhaps it's understandable that they panic in the fact of what they see-- what they are conditioned to see-- as unacceptable risk, such as VBAMC.

Dr Wells (note: all names and a few details have been changed, in compliance with HIPAA laws) must have experienced a chill when he got the call from the medical exchange Wednesday night: his 25-year-old patient, Anne, was in labor. Anne has three older children: five, three, and eighteen months. Anne has had three c-sections.

At just 37 weeks' gestation, Anne hadn't expected to go into labor. Her (arbitrarily and probably unwisely) scheduled fourth c-section was still a week away. When she realized that she was having regular contractions only a minute or so apart, it dawned on her that she might behaving this baby sooner than later. She went to the nearest emergency room-- at a small local hospital with no L&D and no maternity services. She was triaged, and the ER nurse quickly determined that she was definitely in labor: Anne was completely dilated, with a bulging amniotic sac. Dr Wells was paged and implored to come, stat!

Dr Wells hit the road running. As soon as he arrived at the emergency department and checked Anne, he called for her to be taken to the nearest OR at once. The staff balked; they did not have the necessary equipment on hand for a cesarean, much less to care for a late preterm infant. Dr Wells-- who, it must be said, is well known for his colorful vocabulary-- cursed and called the nearest large hospital with a level III neonatal intensive care unit, demanding that they send a team at once. The NICU staff demurred, stating-- quite reasonably-- that they would be unable to provide a comprehensive neonatal resuscitation team, with all the requisite personnel and equipment, in time. The physician argued, insisting that a nurse and respiratory therapist must jump into an ambulance at once and drive at full speed to attend a stat section fifteen miles away. Again, the NICU declined, at which point the nurse manager was treated to an unexpurgated rant by the OB.

And Anne? She was still in labor, and within twenty minutes of the irate doctor's arrival, she delivered a healthy seven-pound baby girl-- vaginally, without complications of any kind, right there in the ER. Mother and daughter were transported to the larger hospital, to our mother-baby floor, where I was privileged to care for them until they went home yesterday. When I asked her how her recovery was going, she laughed and said, "It's a world away from a c-section!"

When her OB rounded, he spent less than a minute in his patient's room-- and nearly half an hour with her chart. Dr Wells's main concern, it seemed to me, was to fully document the incident-- concerned, as always, that a lawsuit of some kind might be in the offing. He wasn't interested in the implications: Anne had escaped major surgery-- a surgery he had mandated-- and had instead had an uncomplicated VBAC. She and her baby were happy and healthy-- isn't that all that matters?

Not to this obstetrician. He had lost control of the situation. Instead of a calm, routine cesarean, he was forced to race across town in a mad dash to catch a baby in a hurry. Apparently, non-bankers'-hours obstetrics are not his cup of tea. Will he encourage VBACs for future patients? I doubt it. Will he permit Anne to labor again, if she becomes pregnant in another year or so? Unlikely... he will probably scare her to death with what-if tales of horror, and insist that she submit to a cesarean at 36 weeks. What's one more preemie, if he can continue to circumvent birth?

I'm at a bit of loss, myself, as far as how to feel about this story. I'm thrilled for Anne, who had a quiet everyday miracle of her own in a rural emergency department. But I'm honestly not sure she understands what she accomplished-- or how she did it. I don't know for certain that she's ever even heard the term VBAC-- I'm positive, given that Dr Wells has delivered all her children, that she has never been offered the opportunity to even go into labor, much less have a vaginal birth. If she gets pregnant again, will she go back to Dr Wells, knowing what she does now? Will she demand a VBAC, or will she schedule another section?

VBAC Viability

Other, better commentators (Henci Goer, Marsden Wagner, Sarah Buckley, Kmom, Rixa, Laureen Hudson, Jen of vbac.com, 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 vbacfacts.com. 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.

Blogging by Proxy

I'm being lazy, but this is the best, most concise summary of the whole cesarean situation that I've seen, thanks to the wonderful and always well-informed Kmom.

Check it out!

Brilliance That Cannot Be Improved Upon

Check it out here. There's no possible way I could add to this or make it any better. I wish every VBACing mama-- every pregnant woman-- every single person who's concerned with her rights to bodily integrity and selfhood would print this out and take it to her OB.

Giselle, I applaud you. Brilliant!!!

Decompression

I was fortunate to finish up Cesarean Awareness Month (aka April) by attending the ICAN Conference in Atlanta, Georgia. It was, in a word, incredible. The speakers, the topics, the women-- especially the women-- were amazing. I volunteered to help plan the conference this year, and while I don't especially feel that I contributed much of anything, I was privileged to see how much energy and heart the women of ICAN put into the event.

I arrived Thursday afternoon, in time to help with the set-up. I helped put the name badges together-- it was like a virtual reunion, seeing who was attending this year, made even better by the knowledge that every familiar name I came across (Bonnie! Jenny! Erica's coming? Cool!!) would soon grace the neck of an actual flesh-and-blood scar-sister, and I'd be hugging them as soon as I saw them. We organized the gift bags for attendees and speakers (darn, I didn't score one of those adorable ICAN t-shirt-wearing bears!), colated manuals, arranged display tables. Our coordinators were amazing-- it was like watching an entire crew of Martha Stewarts in action!

Chapter leader training began that evening, and as more and more of my sisters arrived, I began to feel more at home, in my element. I am not broken... when my sisters are with me.

We share so much, you see. Most of us have undergone one or more cesareans, sometimes necessary, usually unwanted. We all decry the appalling rise in the c-section rate and the lack of support for birth choices, including VBAC (vaginal birth after cesarean, a safe option for most mothers) and out-of-hospital birth. We come from all backgrounds, differing in religion, philosophy, parenting style, socioeconomic level, education, politics... you name it. We all come together, though, where our babies our concerned. We can all agree that babies deserve the safest birth possible, the best start in life, and more and more evidence supports the fact that birth is safest when it proceeds the way nature intended.

One of the high points of every conference is the informal song session, where many of us gather to express ourselves musically. This year, one of my dear sisters was holding the space for a geographically distant friend whose time of birth was drawing near, and she recorded us singing for Tudu . Nothing I could say captures the spirit of the conference better than this brief moment of communion and conviction.

Birth is as safe as life gets. Birth is life... we only want to live it.

Cesarean Awareness Month: April 2009

Once again, it's April, Cesarean Awareness Month 2009. Every year the CDC announces the latest statistics; every year for the past fifteen at least, the percentage of births via cesarean has gone up.

So, what's the big deal? What difference does it make which way a baby comes out, as long as it does? Vaginal birth, cesarean birth-- it's all the same, isn't it? After all, a healthy baby is all that matters...

More than thirty percent of pregnancies in the United States now end in surgical delivery. Estimates vary, but at least half of these operations-- probably many more than half, in truth-- are of questionable necessity, and a huge number of those are outright unnecessary. When truly indicated cesarean surgery can, of course, be a lifesaving procedure for mothers and infants; however, it is clear that the majority of cesareans today are performed for nonemergent reasons.

One simple fact that cannot be argued is this: a cesarean, no matter how we dress it up and make it palatable for general consumption, is major abdominal surgery, with all its attendant risks. A mother undergoing a cesarean is four times more likely to die as a woman who delivers vaginally. Morbidities are inarguably higher: risk of infection, significant blood loss (sometimes requiring transfusion, which introduces another level of risk in and of itself), damage to bladder and bowel, blood clots, adhesions. Post-op moms face longer recovery times, lingering pain, even long-term or permanent nerve damage. Anesthesia-- even that "harmless" epidural society embraces as the savior of laboring women-- adds another tier of risk, one that is rarely addressed by physicians.

Women are almost never informed about the risks to future pregnancies, but there are many, and they are not benign. Uterine rupture, used so often by physicians to frighten mothers into scheduling repeat sections, is a potential complication-- probably the best publicized, if not the most common. Abnormal placentation, secondary infertility, stillbirth-- all are sharply increased after surgical delivery.

Cesareans, despite what apologists would have us believe, are not without risk to babies, either. Mechanical injury-- scalpel wounds, nerve and soft tissue damage from less-than-gentle extractions-- are more common than one might think. Elective sections, touted as "mother's choice" and "humane" by proponents, are often scheduled for 37-38 weeks' gestation-- technically term, at least by the obstetrician's reckoning, but babies can't read calendars, and surgeons frequently fail to account for the diversity of women's menstrual cycles and ovulation times. The lungs are the last organs to mature; when an infant is forced from her cozy womb at 7:34 a.m. (first scheduled section of the day; after all, the OB wants to be done in the operating room by 11 so he can get back to the office for more lucrative appointments) on a Tuesday, she may simply not be physically ready to part from the umbilical cord and placenta and transition to air breather. Respiratory distress is common-- disturbingly so-- in cesarean-born babies; many suffer transient tachypnea of the newborn, often referred to as "wet lungs." For many babies this translates into several days of labored breathing that resolves with time and may eventually manifest later in life as asthma. For too many others, it means a stay in the neonatal intensive care unit with assisted ventilation, IV lines, antibiotics, ultrasounds and chest x-rays, brain scans, eye exams, and unexpected complications such as NEC (necrotizing enterocolitis)-- a disease that still claims the lives of too many babies every year. This is certainly not a situation most parents envision when consulting their schedules to choose their little ones' birthdays, but it's one that is played out all too often.

The emotional cost of cesareans cannot be underestimated either. Women in late pregnancy are primed by their hormones to react, on a subconscious, emotional, or "gut" level, a certain way to labor, birth, and the early postpartum experience. This is to insure that our primal mammalian selves will receive and nurture the newborn-- simple biology at work. Often, that chemical cascade is interrupted, throwing bonding off track and making it difficult for mothers to transition fully to their new role. Cesarean mothers may be at higher risk for postpartum depression and are less likely to breastfeed their newborns. There are many reasons for this: the post-op mom is tired, hurting, hampered by an abdominal incision. She can't get around easily-- forget jumping up at her baby's first cry. Even a tiny infant starts to weigh a ton when she's resting on a fresh surgical wound. Breastfeeding is awkward and hard to manage when mom can't change positions easily and without significant pain. Let's face it: surgery is a lousy way to begin motherhood!

If asked, the majority of mothers who choose cesarean deliveries will respond that they are most concerned with providing a safe birth for their children. They cannot be faulted for this conviction: the medical establishment and the media are responsible for convincing the public that c-sections are safe and even preferable to vaginal birth. The serious potential for permanent injury-- or even death-- during and after the surgery is rarely mentioned. The cesarean is presented as an easy, convenient, scientific, controlled alternative to the inherently messy, unpredictable way designed by nature.

Convenience is a huge driving factor in the rising cesarean rate. Obstetricians prefer cesareans for many reasons, not the least of which is their ability to exercise some control over nature by making birth conform to the physicians' schedules. It is not cost-effective to attend a woman in labor; birth happens at all times of the day and night, every day of the week, heedless of holidays, vacations, special occasions, even plain exhaustion. Cesareans, on the other hand, can be timed quite specifically without creating conflict for the OB: all he has to do us appear at the appointed hour, scrub in, and be presented with the neatly draped and sterilized belly of the pregnant mother. Forty-five minutes later, the surgeon strips off gown and gloves, pauses to dictate or jot a delivery summary in the patient's chart, and is back on his way to his office, where a waiting room full of paying customers sit patiently for their fifteen-minute time
slots for check-ups or consults.

Parents like the convenience as well. Scheduling surgery means that family can be on hand at the prescribed time, employers can be informed and leave arranged-- down to the minute!-- well in advance. Mothers need not worry about how much longer their pregnancies will last, instead focusing on the matter of preparing for their new arrivals. Dad can be certain his job will accomodate his time off; grandma can be right there to scoop up her precious new grandchild; care can be arranged for siblings without any middle-of-the-night drama or panicked phone calls. All that stress eliminated-- sounds ideal. Why not schedule a cesarean? It just makes sense.

Except...

Regardless of what ACOG, a trade union dedicated to furthering and protecting the interests of its members, and the popular media insist, cesarean surgery is simply not the optimal way for a baby to be born. Vaginal birth is infinitely more complex than purple-pushing an inert lump through one's "bottom" to produce a squalling newborn. It is a complicated, carefully calculated dance, choreographed down to one's very cells, perfected over millenia to provide human infants their very best start in life. No manmade intervention, no matter how well-intentioned (for the mother or the physician), can replicate the delicate and profound forces that combine to bring a child into the world. It is sheer arrogance for surgeons to assert that they can match, much less surpass, a process millions of years in the making.

Fortunately, there are those who recognize this folly, and are fighting to be heard above the rhetoric and misinformation. There is support for mothers trying to recover from cesareans, for mothers wanting to avoid them, for women planning a birth after a cesarean-- whether that's a vaginal birth or a more empowered surgical delivery. I want to add my voice to theirs, to speak my truth: Birth is Life, and we were designed to live it.