Friday, September 09, 2016

Birth Thoughts 2: B's Birth- A Closer Look at Birth after Cesarean

I’d served women during VBAC before; H’s birth had been a beautiful victory despite a posterior baby and extended pushing. I’d read all the literature and carefully researched risks and benefits of VBAC, and was staunch in my support of it. Even ACOG (American College of Gynecologists) had recently adjusted their position to be more broadly supportive of the practice. So when B & her husband interviewed me as their doula, I was thrilled. Her first baby had been an unexpected but scheduled c-section: her doctor had told her he suggested a big baby 5 days after her due date, and baby had been born by cesarean that evening. She and her husband desired a larger family and her research led her to believe VBAC was a safer option for mama and baby as well as future babies and future pregnancies. I remember her husband, W, asking me “what are the risks of a VBAC?” and I answered, “well, there are the usual risks of any birth, but the main concern in addition to those is a uterine rupture, where the uterus breaks open along the site of the previous incision.” He asked me “how would we know if that happened?” I answered “well, signs are usually pretty obvious: mom usually KNOWS something is wrong, pain is great, there is usually a lot of bleeding. These are all reasons to let the body labor on its own as much as possible, and to avoid interventions that might inhibit mom knowing what’s going on in her body. It’s also a reason to have a care provider who is familiar with and supportive of VBAC, which you all have.”

 Rather than narrate B’s birth story, which is quite the tale, I will jump to the end and say that B suffered a uterine rupture. She and her baby were fine in the end, but it was terrifying for a while there. I had to re-evaluate everything I ever knew or thought I knew about VBAC and C-section, and needed a lot of support from my local birth community to work through the emotions of the experience.

So, having now seen and experienced a uterine rupture during a VBAC, I want to summarize what I learned by asking two questions: 
 1. What does a uterine rupture look like? (What are the signs it has happened and how does this affect how we treat laboring women hoping to VBAC?) 
 2. Is VBAC really worth the risk? 

Ok—what does uterine rupture look like? This was definitely not a textbook manifestation, but looking back in hindsight it DID have several classic markers.

  •  First off, there was NO bleeding. B’s water never broke. This ended up being life-saving for Baby M, who continued kicking, snuggled safely in the bubble of her amniotic sac even as her head and shoulders edged out of the womb and into her mother’s abdominal cavity. But because B's water never broke we never had any bright red blood flow signaling a big problem. There also was hardly any blood flow internally, since the scar itself was not vascular (full of blood vessels) and surrounding tissue had only begun to tear and bleed when the c-section took place.
  • Second, there was a lot of pain. B handled contractions very well for all of one night and most of another day. Though there was a definitely frustrating stop-and-start quality to the contractions, she labored with grace and courage. She took joy in working with her body and was encouraged that her body was doing exactly what it was created to be able to do. We did find that one position (leaning back) was much more painful than any other, but she found hands & knees, swaying, slow dancing with her husband, and sitting on a birth ball all bearable. We even had been able to get her comfortable enough to snatch a nap in an exaggerated sims position (using lots of pillows). We worked through emotions from frustrations & fear both past and present. It wasn’t until dinner time that B felt she could not handle any more. In a rather abrupt change of demeanor she wanted to go to the hospital. I had left to get some dinner and nurse my own baby, and when I met her at the hospital I was struck by how this pain was much less like active labor and seemed like “transition,” which comes immediately before pushing. In hindsight, the rupture probably occurred around 6 pm, right when B felt that she needed to go to the hospital and that the pain became unmanageable. This reassures me so much—moms know. More on this later. Meanwhile, even as nurses wondered about admission because her contractions didn’t seem strong enough, I could tell B’s suffering was great. Something was wrong. Her pain was disproportionate to "where she seemed" in labor. The words she used- “unrelenting,” “just doesn’t let up,” “so bad,” - all indicated something more than normal labor. I went to the doctor and the nurses and told them something was wrong, that B was asking for c-section, because of this symptom. **Listening to moms planning a VBAC as they listen to their own bodies is crucial.** 
  • Third, the missing cervix. When B arrived at the hospital and we met in triage, she seemed to me to be in the final stages of dilation, yet the nurse could not even reach her cervix. This mystified everyone and caused B no small amount of pain as two nurses, her doctor and then another doctor all tried to check her dilation and could not find any cervix. We now know that as her uterus ruptured along the incision, the cervix was pushed further back. The baby’s head was palpable but was covered by a membrane that wasn’t an amniotic sac—it was because the baby’s head was descending outside the birth canal. The doctor brought in a portable ultrasound machine and still couldn’t see any sign of the cervix or even what was really going on. It was at this point that the doctor decided firmly on a quicker c-section under general anesthesia v a slower one in which B could have been awake and W could have accompanied her. 
  • Fourth, maternal intuition. B looked at me during one contraction in triage and told me “I just keep visualizing my scar. I just keep thinking of it. What does that mean?” In hindsight I’m sure it meant that her body knew EXACTLY what was going on. She had an urgency about her, urging her doctor to go ahead and do a section without delay—she knew, even though she didn’t know she knew. 

 Through this experience I learned that not all ruptures are obvious, but even when they aren’t, there are clear signposts, especially in a mom who is in tune with her own body. OK, so that's the "hindsight is 20-20/what I've learned" from this birth... but the question that I had to wrestle with in a newly personal way is:

Would I now say that VBAC is worth the risk?  Well, I understand and appreciate more than ever why a practitioner would choose to not support VBAC. Having been through the anxiety of a birth where no one knows what is going on, but something is certainly drastically wrong, I understand why no one would want that. The alternative, a repeat c-section, seems so safe, so controlled by comparison. The terror of wondering what will happen to a wife and mother, and especially a baby, is not something I ever care to experience again. So I understand in a very real way the fears surrounding uterine rupture.

I also appreciate more than ever the need for truly informed consent. It’s easy to read favorable statistics and say “well, yeah, bad things can happen, but, usually they don’t!” It feels different when you are on the other side of the statistics, even if they are very unlikely. That’s why it’s so important to take a good honest look at risks on both sides—so no one is blindsided if something bad happens. The truth is that birth is only as safe as the rest of life; usually safe, but sometimes very very not. No birth worker can give a guarantee of a positive outcome, whether it’s a home birth or a scheduled c-section. We have to approach every birth like we should approach every day; ultimately trusting the Lord, and knowing that He alone is Sovereign, and that He ordains everything for our good—even the very very painful. I find this summary to be helpful:
 Women are entitled to accurate, honest, and high quality data. They don’t deserve to have the risks exaggerated by an OB who wishes to coerce them into a repeat cesarean nor do they deserve to have risks sugar-coated or minimized by a midwife or birth advocate who may not understand the risk or whose zealous desire for everyone to VBAC clouds their judgement. Sometimes it can be hard to find good data on VBAC which is why I’m so thankful for the 2010 NIH VBAC Conference and all the excellent data that became available to the public as a result. There are real risks and benefits to VBAC and repeat cesarean and once women have access to good data, they can individually choose which set of risks and benefits they want. 
Even as I relive the experience and my heart races, I remember that, when I re-examined all the evidence and research, and experiences besides my own, VBAC is statistically safer than repeat C-section most of the time. Yes, it's terrifying to walk through a rupture (or any birth complication), but reacting purely emotionally isn't fair to mamas and babies.  And honestly, would a hemorrhage during a planned c-section be any better?  We have to take a step back and look at the big picture.

 The odds of uterine rupture during a VBAC (vaginal birth after 1 cesarean) in a mom with a low transverse incision (the standard c-section scar today) is a little less than 5 out of 1000, and it goes down with each subsequent VBAC. (The risk after two c-sections, or VBA2C or VBAC-2, definitely seems to go up, but it's hard to tell how much. ACOG does still recommend VBAC after two c-sections.). That means that 994 women who attempt to VBAC would not have a rupture. To put that in perspective, the odds of a cord prolapse (when the umbilical cord comes out before baby is born- a true emergency requiring immediate cesarean) are between 1.5 and 6.2 out of 1000. So, the risk of a uterine rupture during a VBAC seems comparable as the risk of a cord prolapse in an uncomplicated ("normal") birth. I've never experienced a prolapsed cord; I know it does happen, but it isn't very often. Similarly, I am unlikely to ever witness another rupture. The attending doctor himself had never encountered a rupture before, despite being supportive of VBAC.

The risks of VBAC are complex, and each mother will need to take into account her own factors (ex. what led to the first c-section, or the second, etc.), but we have to remember that the alternative is a planned pre-labor c-section, and the risks to that are equally complex, and many of the most serious risks aren't seen until much much later.

C-sections carry all the risks of a major surgery when it comes to the mother: risk of infection, risk of hemorrhage (uncontrolled bleeding), risk of accidental damage to other organs (nicking the colon or bladder are the most common, at 1- 2 out of 100 women), risk of poor reaction to drugs, including an allergic reaction to anesthesia, risk of blood clots post-op, and a potentially slow & painful recovery. A mother loses twice the amount of blood in a c-section that she would in an uncomplicated vaginal birth. Maternal death is higher after c-section as opposed to vaginal birth. (It might surprise you to read how common these side-effects are!) There also are risks to the baby: risks of being nicked or cut during incision (1-2 out of 100); risks of respiratory distress in the first few days after birth and even life-long respiratory difficulties like asthma; and risks inherent to the use of antibiotics at a time when babies need to be colonized by healthy bacteria. Breastfeeding also is more difficult after a surgical birth, as is bonding. (None of these are insurmountable, and much can be done to improve surgical birth if & when it is truly necessary!)

Despite all this, I would say the most serious risks that need to be taken into account are the risks to future pregnancies-- and these are seldom mentioned to mothers deciding whether to plan a VBAC or a repeat section. These also increase with every C-section. One risk is scar tissue (“adhesions”) –these can form in the pelvic reason and lead to placental abruption (placenta coming off uterus before baby is born) or placenta previa (placenta forming over cervix). Because the scar on the uterus doesn’t have blood vessels in it, if a baby attaches near it, its placenta will have a hard time getting enough oxygen and food, so it will keep growing through the scar, at times sending “roots” all the way through the uterine wall. This is known as placenta accreta, and it is quite risky for both mom and baby since the placenta can’t easily detach from the uterus (causing extra bleeding). Usually such a pregnancy ends with a c-section followed by a hysterectomy. The risk of placenta accreta increases with each c-section, as does the risk of uterine rupture, even prelabor. This is worth considering especially in families who don't want to limit their family size because of birth method.

One last point I'll make is that, as I experienced first-hand, a rupture is not always an immediate crisis (though it certainly can be)-- in our case, though it occurred at home, we still had time to get to the hospital, to be seen by multiple doctors and nurses, to have an ultrasound and then be prepped for c-section, and baby and mom had a good outcome. This isn't to downplay the risk of rupture-- it definitely needs resolution as quickly as possible!-- but rather to highlight that a low-intervention birth environment can be safely maintained for the mother as she labors; we don't need to push all women planning a VBAC to labor in the O/R of a large hospital.

Many of my birth worker friends have asked me if I would ever consider taking on another VBAC client, and my answer is "yes." I will focus on educating any such clients ahead of time on what a rupture could look like, and will be proactively listening to her throughout labor. My only regret in B's labor is the length of time she had to endure the pain of a rupture as everyone tried to figure out what was going on. Hopefully this account will help other ruptures be identified more quickly! I also am more motivated than ever at seeing our initial c-section rate drop in the US. If that first c-section can be avoided, we don't have to worry about the risks of VBAC v. ERCS (elective repeat c-section). Without a first c-section, rupture is very unlikely.

So if anyone asks me if I would calculate VBAC as "worth the risks," I would say, each situation is different, but statistically, yes, because the alternative is a repeat C-section, and the risks there are weighty. It's definitely worth a try. Know how to minimize the chance of rupture, the signs of a rupture, and have care providers who are competent, supportive and able to act quickly if need be.

(Note: I have attempted to sources for my data; click the linked text in order to read the full articles.)


Karla Simpson said...

So very well written, Christina! This account made me so thankful for our Sovereign God who protected B and baby. I appreciate your level-headed display of the benefits and risks in either choice. There's so much mommy-guilt that can be found surrounding birth and your telling of this story gives so much grace to all mommies! I'm praising God today for the good gifts that He gives us when He blesses us with children! Thanks, friend!

Eowyn's Heir said...

Thank you so much for the encouragement! :)