Monday, December 20, 2010

Twin c-section followed by a VBAC story

I am from Ireland, and we had our first pregnancy there- boy/ girl twins conceived after 3 years of ttcing and 3 rounds of fertility treatment. The pregnancy went well and I planned a vaginal birth, but always knew with twins there was a chance of c-section (my hospital had a 40% c-section rate for twins, 13% overall c-section rate). I carried to 39 weeks- which is considered past term for twins-, when the twins showed some signs of distress on NSTs, and their growth arrested and placenta started breaking down. They needed to come out. I was unfavourable for induction (-2 station on Twin A, no dilation or effacement), but we tried anyway, in the hope of a vaginal birth.  It did nothing, not a single contraction. So after 2 days, it was decided a c-section was needed. I healed well and the overall experience was good, but that doesn't mean I want to repeat it! In Ireland, VBAC is the norm and so while we didn't think we could have more kids, I always thought I'd have a VBAC if I did get pregnant again- to be honest, the thought of an RCS didn't even cross my mind.

...then we moved to NW Arkansas, where my husband is from. I found myself pregnant with a very happy surprise baby, and upon doing some reading, realised VBACs were banned here! At first I was disappointed, but thought I might be ok with an RCS. I decided to stay with our family doctor for maternity care, as he also does OB stuff. I knew from friends that he did a lot of VBACs before the ban, so at my first appointment, when he explained that he tries to schedule RCS as close to the due date as possible, I mentioned I didn't really want one. He said that was ok, that I had plenty of time to decide. By my next (12 week) appointment, I had done my research and made up my mind that I really wanted a VBAC. I had considered how to achieve that- the nearest hospital and birthing center which allowed them was 2.5+ hours away on a good day, which I didn't want to risk considering I had no experience of how my labor would go. Home birth was an option I was toying with, but wasn't sure I was comfortable with, and my husband was completely against. So, my chosen option was one many warn against: VBAC in a VBAC ban hospital. I discussed this with my doctor, who went through the risks of both RCS and VBAC with me- giving equal time to both. He seemed supportive, but did say there could be issues if I was in hospital a long time, so best to come in dilated well already. So he kept “forgetting” to schedule the RCS.

Pregnancy went well until 30 weeks, when my blood pressure started to creep up (no other signs of pre-eclampsia). At first, the doctor just asked me to keep an eye on it at home, but after a while he got concerned. He requested an ultrasound at 36 weeks to check on baby and placenta, and frankly I was worried he'd use it to pull the big baby card, especially when the u/s tech estimated baby at 8.1 pounds already! But the doctor was fine with that- he said he was looking for info on the placenta and baby's health, not size, which can be off 1+ pounds at that gestation. I started having weekly NSTs which were ok, but got some swelling. Based on that, at my 40 week appointment (actually 39+4), and with baby still -2, 2cm dilated and somewhat soft ( asked about stripping membranes, he said he would if he could but I was too high still, he could not reach), the doctor said we should look at RCS if baby doesn't come out soon, and that if I was an RCS patient, he'd have taken baby the week before. We discussed dates and decided that unless things got worse, he'd do the RCS at 41+2. I felt a bit sad, but also realised that'd give me another two weeks, and tried to make my peace with that.

At 39+4, I went to bed and shortly after I went to sleep at 10pm, woke to a “popping” sound. A gush followed and I was pretty sure my waters had broken. Went to the bathroom and there was some more clear liquid. I started having contractions pretty much right away, but they started off light, so I let my husband and doula know what was happening and went back to bed. I had an appointment for another u/s the next morning anyway, so the idea was to just keep that, hoping I was in active labor by then. Believe it or not, I never discussed what to do when waters broke before labor with my doctor, I didn't think it would happen! Contractions picked up petty soon to a strong menstrual pain type, and moved closer together (6 minutes apart for several hours), but slowed down again once I got up. I rang the doctor when the office opened and he told me to go to the hospital.

So we went and met him there. Still -2, 3 cm dilated. He didn't want me to go back home due to the waters, but said we could wait a few hours before we did anything, to see if things started going again naturally. He gave orders not to check me vaginally so as to minimise risks of infection, and started an external CFM (his only request to me, discussed at prenatal visits, so I was ok with that). He also said the hospital's policy was c-section for anyone whose waters broke 18+ hours ago, but that we could “work with that”. I signed a load of forms, including a RCS refusal/ VBAC consent form, but refused to sign the RCS consent form they wanted me to sign “just in case of emergency, as you cannot sign if you have had pain medication”; as I pointed out to them, in case of true emergency, my husband could sign. There was no problem with that and indeed, throughout my stay not one nurse said anything derogatory about VBAC or tried to scare me- it was also noticeable that they had all read my birth preferences before coming into my room, which was nice.

Nothing started, so I consented to a very low pitocin drip. This started contractions, and my doula was a great help dealing with them. But several hours later, I had made only 1cm dilation progress and was still high and -2 station. Doctor asked to put an internal contraction monitor on for a bit, to see if the contractions were really as strong as I felt them (we left the external heart rate monitor on, as I didn't want to have a screw in my baby's head). They were. We had reached the 18 hour after waters breaking limit now, but as my waters were still clear and baby showed no signs of distress, doctor said he'll ignore hospital policy. Dr didn't want to put the pit up higher, so we waited. Soon after that, I went into transition labor. Hurray! Both doctor and doula said it would not be long now. I had very strong contractions one on top of the other for two hours, and it was hard to deal with, but I managed. After 2 hours, they checked me. 6cm... everyone was surprised, as we thought I should be getting ready to push. I couldn't take it anymore, so after discussing it with my husband and doula, I called the doctor back in to discuss pain medication (no-one had mentioned drugs to me before, as per my birth plan). I decided on an epidural to give me a break. The anesthetist recommended a low dose so I could still feel some minor pain/ pressure (as one of the signs of uterine rupture is pain between contractions), and so I could still move on the bed, get on all fours etc. It worked perfectly, and I got a bit of a break, even a little semi-nap (during which I swatted at the doctor, thinking he was my husband, when he tried to wake me).

Several hours later- some 28 hours after waters broke and contractions started-, I was almost fully dilated (only a lip around the cervix), but still high, a 0 station We let the epi wear off and I started pushing as I had the urge, but baby would not come down. Pushing was exhausting, and I felt I could not go on. Baby's heart rate decals started to last longer after contractions finished. Doctor started to get concerned and said we would need to look at a RCS soon, but he'd like to try one more thing: ventose delivery. It would probably not work as baby was still so high, and could involve an episiostomy, but it would really be a shame not to at least try, and end up with an RCS after all this. He would not try for too long- probably only 2 contractions worth- but it was worth a try. I cried a bit, I was so exhausted and felt my VBAC slipping away. My doula and husband kept me sane, and stopped me from crying as I needed all the energy I could get for pushing. After 2 contractions, there was some hope so we kept on going, and eventually- after a severe episiostomy, baby came out, head one push, body the next, more than 30 hours after my waters broke and contractions started. It was the most amazing feeling physically and mentally, feeling that head pop out. Doctor clamped the cord (husband didn't want to), and my wonderful VBAC daughter was put on my chest, where they did all their little tests while the doctor stitched me up. The doctor finally got to go home, some 15 hours into his supposed day off 

 I started breastfeeding and Rachel has been attached to me boob pretty much permanently since- she is 10 months now!  The day after my VBAC, I had quite a few nursing students visiting with their mentors- I guess I was a bit of an “event”, and ask questions about c-section vs VBAC experience. There is really no comparison. I was sore down there for a while, but it is nothing compared to the post c-section pain. With my VBAC, I got to hold and carry my toddler twins 3 hours after birth of their little sister.  I am not saying it was easy- the doctor said that would have been a difficult and long birth even for a FTM-  but it was so worth it, for baby and me and all my family.

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