Wednesday, May 13, 2009

Planning the Boy's Birth

I always thought it was crazy to think you could actually plan a child's birth. But I believe in knowing as much as you can about the birth, trying to figure out what you think will work best for you, listening to the doctors/midwifes/duolas/relatives/friends whose opinions you respect, and then going with the flow once the labor process starts. Most importantly, I believe it's so important to be flexible and not be set on how it has to be because babies, your body and nature are going to do what they do regardless of what you expect them to do.

I really believe that my feelings about flexibility and not mentally insisting that labor and delivery had to meet my ideal expectations helped me adjust well to the Pumpkin's labor and delivery. The labor which started with what I had thought were Braxton Hicks until my water broke at the movie theater, continued with 16 hours of labor in the hospital and ended with an unplanned C-section for her delivery. I never mourned "what should have been" or felt robbed of any particular experience. I was truly fine with the whole thing and was simply happy that I was a healthy mother of a healthy baby.

Now that I get closer and closer to my due date (June 19, 2009), I find myself constantly thinking about the boy's upcoming labor and delivery. With this child, I'm at a completely different starting point, as a woman who is pregnant after having a C-section. Right from the get-go, I (with my husband) have a choice to make towards planning my labor and delivery that actually will influence the start of labor: Do I try for a VBAC or just go with a planned C-section?

I've known (mostly online) many women who have had successful VBACs. I thought it would be no big deal, really. It would be something to try, and if I could do it great! If it ended in another C-section, fine. Been there, done that, could do it again. I also thought it was important for the baby to start the process of labor to help prepare him for the world, although I'm not sure where I got that from. So I thought we'd plan a C-section for just after the due date to give us time to go into labor and attempt the VBAC.

So since my first OB appointment with the boy, I've been telling the doctors I'd like to at least attempt a VBAC. Most of the doctors mentioned that there were risks, but it was up to me/us if we wanted to try it. My primary OB, Dr. A, said the same and didn't disparage the VBAC, but something in his demeaner gave Londo and I the impression that he was not a big fan of the VBAC. The only real words of caution he gave was that if this baby looked to be a big one, he would be highly recommending a planned C-section.

Apparently, the risks during VBACs with a larger baby are greater than VBACs when the babies aren't so large. The Pumpkin was 9 pounds, 5 ounces, and both Londo's family and my family tend to have big babies. As Londo pointed out to me, we have to assume this baby is also going to be large based on our history and family history. Londo has voiced to me that he is concerned about attempting a VBAC because of the risks in general and the heightened risk of a larger baby. I said I would look into the risks of the VBAC more and we'd discuss it with the doctors more. I will not make this decision alone because we are a team, and if he is uncomfortable with a VBAC I respect that and will not brush it off. Yes, it's my body. But I'm his wife, and this is his son. What happens to me and this baby is of great concern to him, as it should be.

So yesterday, we happened to see a different doctor at our practice, Dr. W. After the ultrasound (the boy's kidneys still look good so the doctors aren't concerned, and that was my last ultrasound!), we had our appointment with the Dr. W, who delivered the Pumpkin. (We love this guy! We love all the doctors at this practice, but this guy safely got out the Pumpkin!) I told Dr. W, "My husband would like to talk about the risks involved with a VBAC." Dr. W confirmed what Dr. A said about large babies, and he went into the risks specifically.

Apparently, there is a 1 in 100 (1%) chance that the internal scar will rupture. I knew this, but still didn't think there was much to be concerned about. But then Dr. W went on to say that the biggest problem is that they would have very little idea that there was a rupture, because the signs of a rupture? Pain and blood. What happens during labor and delivery? Pain and blood. So how can they tell?

A rupture can lead to many different issues that could affect mother and/or baby. Most of which I can't recall at the moment (I currently have the memory of a goldfish), but the two that caught my attention were possibilities of a ruptured bladder (bladder apparently lies on next to the incision scar or something like that) or need for a hysterectomy. I kind of like my bladder the way it (normally) is, and a rupture of it that they wouldn't even realize happened sounds like it would suck. And I am still hoping to keep my options open for a third child. (I totally forgot to ask what repeated C-sections mean for another pregnancy, but I will next appointment.)

Still, I did not have an easy time of it during the C-section and recovery from it. I start to tear up when I think about having to go through the recovery again: the pain of the surgery, being laid up in bed, the months it took to for the incision to heal, the year or more until the itchiness of the scar started to get better... Well, it just sucked. And that doesn't even include the worst part of my entire labor and deliver, which was being the surgery recovery area for 1.5 hours without my child or anyone except the very nice nurse who was checking on me. That was probably the worst 1.5 hours of my life, and I'm not exaggerating. Some of it was purely my circumstances, such as the nausea during the surgery leading to them not giving me anything to drink for SO LONG even though my mouth was as dry as a desert!

So we talked to Dr. W about planning the C-section and the recovery from it. A main difference from a planned one to an unplanned one is that I wouldn't be exhausted from hours and hours of labor. That is actually a HUGE difference and I think would make the recovery (short term and long term) go so much smoother. Also, they would give me something for the possibility of nausea before I started feeling nauseous. In addition, my mother can be in the surgery recovery area with me, AND Dr. W said that they now do some of the newborn checkup stuff right there where I'd be recovering! I'm pretty sure he meant where I'm recovering from surgery, but we are going on a hospital tour soon where I will find out for sure.

We are giving birth at the same hospital, but now they have Mother/Baby suites where Londo could stay the night while MIL stays with the Pumpkin at our house. No sharing rooms! No waiting on the verge of tears for Londo to walk through the door in the morning! No worrying about how others feel when I have the baby room-in with me! No strangers glancing into my curtain while I try to breastfeed my infant!

Finally, a planned C-section means that we will (most likely) know the date of the boy's birth and make sure everything is in place (this is huge for my hubby who is a total planner). We can set up our support system, make sure that my mom is available to be in that recovery room with me, and ensure that my MIL is at our house (5+ hours from hers) to stay with the Pumpkin. We will (probably) not have to sit around wondering when labor will begin and worry about gushing water somewhere inconvient.

The idea of going through labor again doesn't scare me. I like the thought of possibly delivering vaginally. But the more I look into the risks, the more I look into the benefits, the more I think about our history and the likelihood that my labor will most likely end in a C-section anyway... Well, let's just say that we are heavily leaning towards a planned C-section. My biggest concerns with going through another C-section really seem to be mitigated by the circumstances of planning and the changes at the hospital.

I'm open to any stories, thoughts, ideas, facts, statistics or whatever you guys have on VBACs versus planned C-sections. I will listen to it all. Londo and I need to figure out what is right for us, but as I said in the first paragraph I believe in learning all I can before figuring what is going to work for us. And even then, nature might have something else in store for us!

10 comments:

Anonymous said...

I didn't have a C-section, so I don't have an experience to share with you. (although I do have a good friend who had a VBAC and felt like it was the most amazing experience of her life - months later she was still gushing about it.) I just wanted to encourage you to ask your doctor about the dangers of repeat C-sections. I'm always surprised by how generally unsupportive OBs are about VBACs, yet they act like repeat C-sections are the safest things in the world. But don't get me wrong - the statistical probability that anything would go wrong should you choose C-section is most likely quite low. I'd just be curious to know about that stat lines up against the relatively low risk of a rupture. I'm also wondering if the book Moxie recommends (The Big Book of Birth) might have unbiased information about repeat Cs vs VBACs (since this is a subject that can make people pretty extreme). I sure whichever you choose everything will go beautifully!

AmyinMotown said...

Caramama, I wrote about this exact question awhile ago when I was getting ready to have Will. I'll dredge up the post if you'd like. For me, and this is me only so take this as you will, I had the repeat C and I wish I'd at least tried the VBAC. Many reasons, one being that he is likely my last kid and so I'll never have the chance again. Another is that it was a lot harder to recover from a c-section with an active three year old. And I had my husband home with me for the first two weeks. And I was surprised how scared I was going into surgery. And I had never been away from Maggie that long and it was SO HARD. Our hospital was very family friendly so she was there a lot, and it was still just really hard.

Also, the anti-nausea thing? Not so much. I hurled in front of Maggie.

Of course, hindsight is 20-20 and I could not know how a VBAC would go. And one of the things that drove my decision is that if things went south like they did with Maggie I would NOT have been able to handle it!

Either way, it's remarkable and wonderful to welcome your new baby into the world, and that is not diminished by how he gets here. In many ways the immediate postpartum period was so much happier because I wasn't dealing with the trauma of an unexpected c-section (so there's that, too). Again, this is just my experience, and I am not trying to sway you one way or another.

Cloud said...

I don't have any C-section stories, since my Pumpkin ended up coming out vaginally. I will say that while you're thinking about scars, my scar took almost a year to heal to the point that I don't feel it anymore during sex. It was REALLY uncomfortable at first. I did not have a episiotomy, I just tore (which is supposed to heal faster). So maybe the scar thing is a bit of a wash?

Its a hard decision. I suspect OBs prefer C-sections because it feels a bit more controlled to them. I'll ask my sister (who is in public health and used to specialize in mother-child health) whether she knows of any good impartial sources about the risks either way. If she knows of anything, I'll come back and post another comment. It might take a little while- she's currently super busy tracking swine flu cases.

Mamanesq said...

My DD was a planned C- 9 lbs, 14 oz and breach. Knowing ahead of time, I took zantac to avoid nausea, and never got sick. in my hospital, she would have been with me the whole time if she hadn't been taken off for liver tests right away with my husband. I was walking normally within 3 days, and my scar healed fine within 6 weeks (June baby). I'm planning to repeat my C whenever #2 decides to come along.

Parisienne Mais Presque said...

I have no wisdom, just a big hug. It's hard figuring all this stuff out, making the best choices about the part you can plan for, preparing yourself mentally for the part you can't.

I wish you a beautiful birth experience, whatever you decide.

Ruta said...

I'm a maternal and child health researcher at UNC... Here is the info that I have on VBACs:

From ACOG's recommendations:

- Vaginal delivery rates for VBAC range from 60-80% (good evidence to support recommendation)

- The benefits of a trial of labor outweigh the risks (good evidence)

- In the absence of contraindications, a woman with one previous cesarean delivery with a lower transverse uterine incision is a candidate for VBAC and should be counseled and encouraged to undergo a trial of labor (good evidence)

- A previous classical uterine incision is a contraindication for VBAC (consensus recommendation)

- Suspicion of macrosomia [big baby] by itself in a nondiabetic patient should not disqualify a patient from a trial of labor (fair evidence)

- Available data are insufficient to determine the risks and benefits of VBAC for patients with multiple gestation, for patients with breech presentation, or for the use of prostaglandin gel (consensus recommendation)

There is also a systematic review that was conducted for the Agency for Healthcare Research and Quality that was published in Obstetrics and Gynecology:

Guise J-M, Berlin M, McDonagh M, Osterweil P, Chan B, Helfand M. Safety of vaginal birth after cesarean: a systematic review. Obstet Gynecol 2004;103:420-9.

I will email you the PDF.

z said...

I had a successful VBAC with #2 but it came after a very long and dramatic story. In the end what I took away from the 2 births is that I now know what my body needs when I am in labor (to relax and not be stressed). In both labors my labor stalled (for different reasons) and it was because I was under stress and in the 2nd one once the element of stress was taken away I delivered rather quickly. My first one was 8lbs 1oz and he was induced 2 weeks early. My second one was 8lbs 7oz and he came 1 week early. So while they were not as big as the pumpkin they were not small. I don't have any regrets, I think in both situations we made the best decisions at the time though we were definitely a lot more proactive in the 2nd birth. With the first birth, we both suffered from scary new parents worst-case scenarios because we had an old school doctor and he swayed us heavily. I went into VBAC with teh attitude... this would be great if it happens but with the c-section I too had a been there done that outlook and would have been okay with that.
I don't want to add to the other typical responses out there but my vaginal recovery was much quicker physically, mentally and emotionally than my c-section and I had a fairly easy recovery from my c-section and that is with 2nd degree tearing.

Jan said...

This is my story almost exactly. First baby, labor (3 1/2 hours of pushing) followed by "emergency" (unplanned is a better word, I think, but I'm sure my medical record shows emergency) c-section.

I recovered very nicely the first time around -- was off the pain meds within a week or so, drove myself to my two-week checkup.

I was up for trying VBAC. My husband really didn't want me to.

The really scary risk to me was the one you're talking about, with the uterine rupture. Not only can it sometimes go un-noticed, but once it happens (if it happen), there's a really short time-frame in which to deliver the baby safely. Like I think I recall hearing 10 or 20 minutes? Which really isn't long.

My first baby was really wedged-in-there-stuck (3 1/2 hours of pushing, right?) and they wound up having to make a bigger incision on my uterus than usual (twice the length, I was told). So that increased the risk of rupture some.

But the deciding factor for me was that the reason for the emergency c-section was my own anatomy. I have very narrow hips AND my baby came down the birth canal at a wonky angle (not a technical term :) -- she was rotated 90 degrees so instead of the shoulders trying to go through the wide way, they were trying to go through the narrow way -- poor kid was born with bruises on both shoulders). This meant the same scenario was more likely to occur.

That, combined with my husband's natural ability to catastrophize medical stuff, meant we decided to go for planned c-section with our second.

I had a much more difficult time recovering from the second surgery, but I suspect that was related to other things (December birth + SAD-ness + husband issues coming to the forefront).

For me the most difficult thing about the second c-section was that I had this adorable, yet needy, little Munchkin at home who weighed too much for me to pick her up, carry her, put her to bed. And we both really wanted me to, to ease that transition from only child to big sister.

Mamanesq said...

Jan - I hadn't thought about the last part about the toddler and picking them up. Something to muse about.

Colleen said...

Never had a c-section, but when I talked to a few friends of mine that had multiple c-sections, they said that they recovered remarkably quicker from the 2nd (and subsequent) c-section(s) because, like your doctor mentioned, they didn't go through hours of labor.

But, I do know that from delivering both my kids vaginally, that I was up and walking around (probably more than I should've been) after Cooper than after Gavin. I think because I had a better idea of what to expect during L&D that I was able to really work with my body more and not be so worried and uptight like I was the first time around. In fact, the day we came home from the hospital, less than 48 hrs after Cooper's birth, I drove myself to Target to get my pain prescriptions filled and to pick up more nursing pads. Granted, I didn't have a scar across my lower abdomen, but since I wasn't as uptight about the second birth (and I had them jack up my epidural a bit), I didn't wear myself out as much and physically recovered quicker. I also swear that not being as uptight also led to a quicker labor...Cooper took 3 less hours than Gavin...and was a little smaller. Well, his head was bigger, but he weighed less than Gavin. But I digress.

I'm sure you and Londo will make the best decision. Having the mindset that having a healthy mom and baby at the end (no matter which exit he took) is the best way to go into this and I wish you all the luck!