It took a comment from my last post to remind me to check on Tina Cassidy's blog. I am sure this is old news to everyone but she had her VBAC at home in January! Check out her blog to read the story. Congrats Tina!
And while we are on the subject of VBACs, Amy at Hospital to Home had hers too!
I find it interesting that moms who attempt VBAC (vaginal birth after cesarean) in our area seem to be treated the same whether or not they have had a prior vaginal delivery. Once upon a time, I am told, VBACers with a prior vaginal delivery were "allowed" to deliver at a birth center, but that was several years ago. I am hoping recent research will encourage doctors to be more supportive of moms who have had prior vaginal deliveries and would like to have a VBAC. A new study, Labor Outcomes with Increasing Number of Prior Vaginal Births After Cesarean Delivery, had these results:1
Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P<.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.
To repeat, after one prior VBAC, your chance of success jumps from 63.3%-87.6%! That is no small increase. I can't help but suspect your chances for VBAC success might be greater with an HBAC (home birth after cesarean), assuming you feel safe at home. Many women who VBAC in hospitals require continuous fetal monitoring and are subject to staff who are nervous about VBACers, not exactly the best environment in which to let go, trust your body, and open up. I know the VBAC success rate of my midwife's VBACing clients is greater then 63.3% and she has attended quite a few VBACers in her day.
1 Brian M. Mercer, MD, "Labor Outcomes with Increasing Number of Prior Vaginal Births After Cesarean Delivery," Obstetrics and Gynecology 111 (2008):285-291.
Thanks to Tami for sharing the beautiful story of her HBAC (Home Birth After Cearean)!
Emma, yesterday for the first time in your life you stood up without any assistance and walked to me. You had a gigantic grin on your face, showing me all six of your teeth, and you laughed as you took each step, so proud of yourself. It amazes me that it's been a whole year, and that a year ago today you were engaged in the first great journey of your life.
Your daddy and I had found out around Mother's Day that we were expecting another baby and we were so excited! I immediately started searching for a midwife who would help me have my baby safely at home. After several interviews I chose Peggy Franklin and I felt very comfortable and peaceful about the idea of having my baby at home. Your brothers' births each presented their own challenges because of the hospitals and doctors, and I wanted to have a peaceful birth experience this time, and to give you the best chance of having a gentle birth. We expected that you would be born around January 20th. As that day came and went, I grew a little discouraged. Finally we decided that we would wait until Valentine's Day if we needed to (as if we had much of a choice in the matter).
The morning of February 1, I woke up at 4:30 and went to the bathroom. I felt fine, nothing unusual. I sat down at the computer to check my email and do some work before the rest of the family got up. Within a few minutes I started feeling contractions. I stayed at the computer for nearly an hour while the contractions got stronger and more frequent. By 5:30 I knew it was time to call the midwife and wake up your daddy. Daddy got to work getting the pool ready--he had a hose that he had planned to use to fill the pool, but it was frozen, so he drove to Home Depot to get a new one. I called Peggy, who had just left another birth, and we decided she should come right away. I set out towels and a washcloth for her so she could take a shower when she arrived at my house (since she had been at another birth all night). My instructions from Peggy had been to make up the bed for birth as soon as I knew I was in labor, and since I still wasn't completely decided about whether to actually have the baby in the pool or in the bed, I got to work on making up the bed. It took me about 45 minutes to make the bed! I would get a sheet on one corner, have a contraction, start to walk to the next corner of the bed, have to stop about halfway down the bed for another contraction, then get to the corner and have another contraction... I think I set a world record for the longest time to make a bed. Once the bed was made I put on my "birth clothes," a bathing suit top and sweatpants, and went downstairs to the living room and sat on my birth ball. Your daddy was home by then and turned on a HypnoBabies CD for me to listen to. My favorite blanket was a soft fuzzy blue blanket, so I wrapped that around my shoulders and just rocked on the birth ball. I threw up once or twice.
At about 6:30 Peggy arrived. She said I was making good sounds and went up to the bedroom to organize all the supplies that we had piled in a box. I continued to rock on the birth ball and threw up a couple more times. Peggy came downstairs and rubbed my back through a few contractions, then she offered to check to see if these contractions were causing any progress. I figured she would tell me I was at 2-3 centimeters, since it had only been a couple of hours. I was shocked to hear her say I was at almost 10 and the bag of waters was bulging. She suggested that I get in the pool if I wanted to labor in the pool at all.
About 7:30 I got in the water. It felt good, but I didn't spend much time just enjoying the water. Within a few minutes I sat straight up, leaning forwards slightly. I had my eyes closed so I lost track of time. At some point I heard the voice of Aimee, the birth assistant, and I felt relieved that she was there. Peggy and Aimee both rubbed by back through contractions. Meanwhile, the boys were waking up, and Daddy got them dressed and gave them breakfast. They came in the kitchen for a few minutes, then went to watch cartoons. We had planned for a friend to come and entertain the boys while I was in labor, but we couldn't reach her. Or the other 2 people who had offered to be backups. I heard Daddy on the phone telling my mother that Emma was on the way. I heard Peggy on her phone saying things like "how far apart are they? How strong are they?"--she had a third client in labor at the moment as well. About 8:15 I started lifting my body off the floor of the pool because I need to push! Peggy helped me move onto my knees, and then she felt like you needed more room to get out, so she helped me move one leg out of the way. I was leaning on the side of the pool and we discovered that the valve on the top ring of the pool hadn't been closed tightly, and it collapsed a little--water went all over the floor. But at that point we were all more focused on getting you out safely! I was pushing as hard as I possibly could and Peggy and Aimee were saying things like "that's right, millimeter by millimeter, do it slowly." In my head I was thinking, "that was just a millimeter?" At 8:29 the bag of waters broke and your head popped out. Suddenly I felt no more urge to push, and no more ability either. It felt like an hour but was actually only a minute, with Peggy and Aimee both telling me I had to push harder to get the rest of your body out.
Finally you were born! Somebody scooped you out of the water and I sat down to hold you. You didn't cry, you just sat in my arms breathing quietly. Since you hadn't taken a deep breath, Peggy gave you oxygen for a few minutes. You looked tired, but after a couple of minutes you woke up and were very alert. I delivered the placenta in the water and then got up to move to the couch. My back went into spasms and it was very hard for me to walk, but Daddy carried you, and Peggy and Aimee supported me, and we made it to the couch. Once we were there and I was comfortable, Peggy weighed you--10 lbs 10 oz! Daddy said "She's a perfect 10!" At 9:00 a friend showed up to take the boys for a pre-scheduled play date, which was perfect. She was the first person outside of the birth team to see you and she cried because you were so beautiful.
Eventually we went upstairs and took to the bed that had been so carefully made up earlier. I sent out an email message in the morning: "
Emma Jean Conklin was born at home this morning at 8:30 am. 12 days past her due date. 4 hours of labor, a good water birth, no problems or complications. 10 lbs 10 ounces, 21 3/8 inches long. 14 inch head circumference, 15 3/4 inch chest circumference. She's a big girl, considerably larger than her brothers! So far the hair looks red, blue eyes, a dimple in her left cheek. She's gorgeous and doing great. I'm doing pretty well too--tired and sore, but starting to feel like myself already. We had a fabulous midwife who did a wonderful job in the last few months helping us prepare for Miss Emma's arrival. We were the second in a string of back-to-back births she gets to help with today!"
And then we got down to the business of loving you and helping you grow up. It's still amazing how much you've learned and grown in 12 short months. We've had some challenges this year. Your Oompa got sick a few days after you were born and died when you were only 2 months old. But he did see you and hold you, and he loves you very much. You got to meet many of your relatives because of Oompa's illness and death, and every one of them raved about what a beautiful and sweet girl you are. Your brothers have been in love with you since the moment you were born. Sometimes it's been a challenge to keep you safe from their "love," but you're a strong girl and can handle anything that comes your way. Daddy and I love you. Happy Birthday Emma!
At almost six months pregnant, I've started to think more about this upcoming birth. Khady will be present at the birth and I feel that her presence will complete the journey of healing that I have been on since her birth. Since the birth of Fenimore, Khady's favorite roles (besides being a princess) are midwife, doctor or pregnant mom. Sometimes her babies are born in the hospital "because the babies are sick of course" but usually her babies are born at home. She is currently going to be a "nice doctor" when she grows up because we need more "doctors that will be nice to babies." When we read Richard Scarry's What People Do All Day, she asks why the baby bunny is in the nursery and not with her mom. Khady proudly announces to all interested that she is big enough to be at this baby's birth. There was never a question in my mind of whether or not Khady would be at this birth. I've thought a lot about what her presence means to me. I cannot give her a vaginal birth but I can let her be a part of the
awesome power of normal birth. I can help grow the seeds of trust in birth that were planted as she joined me for home prenatals when I was pregnant with Fenimore and watched birth videos together ("play that again" she would shout) on my bed when I was feeling too pregnant to be on my feet. It feels good to have her share in the excitement of birth as well as the anticipation of having a baby/new sibling to play with and love. And I know her presence at the birth will help me open my heart even wider while we wait for our newest family member to join us.
Reasons to try a VBAC after multiple cesareans:
Serious maternal morbidity increases with multiple cesarean sections. Given increased maternal morbidity, several studies suggest taking into account the number of intended pregnancies when counseling women on their options for repeat cesarean or trial of labor. Below is a great article on one such study. In other words, if you want more than one or two children, avoid that cesarean!
http://www.greenjournal.org/cgi/content/full/107/6/1226
Uterine rupture is NOT associated with women attempting a VBAC after multiple cesarean deliveries. Check out the complete study available below:
http://www.greenjournal.org/cgi/content/abstract/108/1/12
And the BIG reason to avoid a repeat cesarean after multiple cesareans:
From an article in OBG Management, I found this rather scary suggestion in a list of precautions that should be taken after the 4th cesarean:
"Consider a tubal ligation at the time of the 4th cesarean section." (Accessed 1/24/08)
Hmm... if the docs are recommending a tubal ligation after the 4th cesarean section, they must be a tiny bit worried about the effects of multiple cesareans.
So you are planning your VBAC (vaginal birth after cesarean) but are a bit nervous about uterine rupture. Here are somethings to think about.
If you had a "rupture" in a previous birth, find out if you had a rupture or a dehiscence. They are not the same thing, a rupture is much more serious but a dehiscence is often called a rupture. With a dehiscence, the serosa, known as the perimetrium in the uterus remains intact.
There are things you can do to help prevent rupture and up your chances for a successful VBAC. Get lots of exercise (excessive weight gain is associated with decreased VBAC success and with fetal macrosomia and fetal macrosomia is potentially associated with increased uterine rupture) and have a good diet (LOTS of green leafy vegetables and red raspberry leaf tea). Midwives swear by red raspberry leaf tea as a uterine toner/ strengthener. Why the focus on diet? Because the uterus is a muscle, and like any muscle, excellent nutrition enhances performance. My brother-in-law, who is training to be in the Olympics, can attest to that. He has one of the strictest diets you can imagine! Like any muscle, excessive strain (unusually long labor, or abnormally strong contractions with a baby presenting his head at a wide diameter1) can mean complications.
You might be interested in knowing that you are more likely to have a serious fire in your home during the next year or die in an accident if you ride a bike on the street then a uterine rupture. Check out this page from one of my favorite midwifery websites for more: http://www.gentlebirth.org/archives/vbacrisk.html.
1Eggleston, Kristin. "Midwives and Uterine Rupture." Midwifery Today 83(2007)24.
The stats for VBAC (vaginal birth after cesarean) are out for Northern VA hospitals, thanks to ICAN of Northern VA and they are depressing. They range from a pathetic .08% to a high of 3.18%! Finally we have in black and white what doulas and midwives and moms seeking VBAC have sensed, it is next to impossible to have a VBAC in many hospitals. There is lots of work to be done. If you are a VBACing mom, PLEASE don't believe you will be part of that .08%! If your hospital has low VBAC rates, please find a new hospital or a care-provider with a strong VBAC record (and that means hard-core numbers, not the, "but of course I support VBACs" line that most doctors like to throw out without any real intention to back it up).
I wish I had had a VBAC blog to follow when I was on the VBAC journey. It would have felt supportive to know other moms were out there struggling with the same issues at the same time. Here are the ones I've found (or who found me!):
http://visionsofavbac.blogspot.com/
http://hospitaltohome.blogspot.com/
http://labortrials.wordpress.com/
If you know of any other good VBAC blogs, please send them my way!
Regarding better outcomes with cesarean delivery for breech birth, I would have to add, based on my studies and conversations with midwives, that to ensure successful outcomes for vaginal breech birth, you need to be experienced (your average doctor has little experience delivering breech) AND you need to know your client (and how do you get to really know your client in 10-20 minute prenatal visits). I wonder how outcomes are affected if you factor in the skill of the attending care provider and the length of prenatal visits.
Of course I had to get The Farm's take on VBACs. VBACers on The Farm will have an ultrasound to find out the location of a placenta. If the placenta is near/on the uterine scar, the midwives do not recommend a VBAC. If ultrasound is not available, you can use a doppler as placenta sounds are very different from maternal and fetal heart tones. They sound similar to the sound of the ocean as heard through a large conch shell.
Ina May Gaskin is very big on single-layer versus double layer closure. Other Farm midwives, other the other hand, feel that the health and diet of the mother is the most important to prevent rupture. To illustrate the strength of the scarred uterus, one midwife narrated the story of a Ghanian mother under OB care who had a cervical cerclage to close her uterus but the cerclage was NOT removed by 37 weeks as indicated. The mom, a VBACer, went into labor and labored at home by herself all night long (much to the doctors' horror of course). She went into the hospital in the morning and her cervic had dilated to 5 centimeters! Imagine the stress on that uterine scar!! Did she rupture? No! The midwife questioned the mom afterwards and discovered that the women was extremely healthy with an impeccable diet.
Speaking of diet, I have been amazed at the dietary needs of my third baby, now almost 13 weeks! I have cut out all caffeine and virtually all refined sugar. I crave protein and greens and vegetables and eat about five times a day. I have never paid such close attention to my body before, I am usually too busy ( I renovated my house in our last pregnancy, acting as the contractor, I handled most of the renovation details). This time I am taking it easy and listening to my needs and WOW is this baby hungry.
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