VBAC after preterm vertical incision, *triumphant birth!*

so for those of you who may not know, i am blessed to be a co-mod of an incredible support group for women with special scars like myself. the link is posted on the bottom right hand side of my blog if you are interested! this group of women are some of the bravest, most courageous i have ever met. they (we) trust birth, they (we) trust their bodies, and they (we) are just plain awesome! we'd have to be to attempt a vbac after nearly every doctor in the world has told us we're a walking time bomb, our uteri destined to explode at any moment! (rolls eyes)
but with what little concrete research there is out there, we arm ourselves with information, and with a bit of spit and determination, we give our bodies a chance to show us what we're made of. and the outcomes have been marvelous.
this is an amazing birth story of a mama who VBAC'd on a preterm classical incision. now for those who don't know, a classical incision is a midline vertical incision that has a higher risk of uterine rupture than the standard low transverse. most studies put it at about 2%+, compared with .4% on a low transverse. with a preterm classical, the risk is a bit higher still, bc the lower uterine segment is not developed until later in pregnancy, so it is theorized that these incisions are likely totally in the upper uterine segment and fundus of the uterus, which is said to be weaker.

here is this amazing mama's story:

the birth of Lenore Calais
February 22, 2011 12:42 pm
8 lbs 1 oz 20.5"

I'm the sort of person who recognizes patterns. I don't have to try. I simply see them. My children are slowly teaching me that it's okay to break them.

I noticed several similarities between my first two pregnancies and births. Both children were born on their due dates. In general, the pregnancies were straightforward, despite some first trimester bleeding in each case. Both labors were on the long side, 16 and 18 hours respectively, but ultimately were uncomplicated. Even the things that were opposite about them could have been patterns. My first was a boy, and my second a girl. My first was a summer baby, and my second a winter baby. My first was born under a full moon and my second a new moon. My first was a typical hospital experience that I hated, and my second I was only there long enough to push her out.

And then there was my third child. I conceived in October again, with a due date within a week of my first's birthday. There was the pattern again. This one would be a boy too. I had some first trimester bleeding again but I was expecting it this time. I did worry about an oscillating pattern, where my first birth was traumatic, and my second one a good experience. That's part of the reason I planned a home birth. I wanted to stay away from the interfering hospital. But it turns out my fears were well founded. The first trimester bleeding turned into second trimester bleeding which then turned into a placental abruption and delivery by c-section at 26 weeks. My second boy spent 3 months in the NICU before coming home near his original summer due date.

I should have learned from him that it's okay to break patterns. But some lessons need to be repeated. Despite loads of trepidation and a lot of work to find supportive care providers, I became pregnant with my fourth child, and planned a VBAC. Sticking to patterns, I had a due date within a week of my second's birthday, and I was having another girl. The due date was on a Saturday. All of my previous children had been weekend babies: two Fridays and a Sunday. Breaking past patterns, I had no bleeding at all during the pregnancy. That was a welcome break. Still, there were other expectations that needed to be let go, most notably, that I expected this baby to be born on her due date.

Friday February 18th, 39 weeks 6 days, I had a prenatal appointment with my doctor and my midwife who would act as doula. My doctor was getting anxious as I neared my due date, having not been totally on board with my VBAC plans to begin with. My vertical scar had given everyone pause to say the least. During my appointment, my blood pressure was slightly elevated. That gave my doctor the leverage he wanted to pressure me into an induction. He wanted to start by stripping my membranes. I'm proud of myself that I got out of there and never took my pants off! I told him if my blood pressure wasn't enough of a concern to send me to the hospital right away, then I wanted time to go home and prepare. But I did schedule an AROM induction for the following Thursday, the 24th, as well as a prenatal appointment for Monday. I didn't expect to need either. When I got home, I asked Kurt for a blessing, wanting this baby to come before she was forced out.

That night I woke up around 2 with strong contractions. I celebrated! It was my due date and we were rocking and rolling! Excited, I got up and began to time them. 5 minutes apart! Yay! Then they were 6 minutes...then 7...then 10... After an hour, they had all but gone away. Disappointed, I went back to bed.

Later that morning, I met with my midwife, and I allowed her to attempt to strip my membranes. Ow, ow, ow. I don't ever want to do that again. But we still hoped to see results from it. She said she didn't guarantee before midnight, but it should help things. She also told me it was kind of too bad to kick me into higher gear already. If we let things go, I would likely have a few more sessions like I had the previous night and then when labor really started, it would be quick. Well, I thought, that is too bad, because it's my due date and I'm having a baby!

The rest of the day passed peacefully. Too peacefully. I also slept fairly well that night and woke up the next morning thinking, this is officially the longest I've ever been pregnant. We went to church and I was impressed how few comments I got along the lines of "You haven't popped yet?" After church I fell asleep for an hour or so. When I woke up, I was having strong contractions again. Could it be? Might we still have a weekend baby? Probably not. They spaced out again. But I did have some bloody show this time. So surely it couldn't be too long. That night, I was up for about 6 hours with regular strong contractions. The only problem was they never seemed to get closer or stronger. They let up by about 5 and I grabbed a couple of hours of sleep.

The next day, President's Day, Kurt and I dropped off our three older kids at a friend's house. Then we headed over to my prenatal appointment. We learned that my induction date had been bumped up to Tuesday the 22nd. The doctor also wanted to strip my membranes again. Now that I had experience with it, I did not want to do it again. I didn't even want him to check dilation. I was more than a little delirious and emotional from lack of sleep and the start-and-stop labor, so I wasn't in the mood to be cooperative. I felt the induction was a huge concession and that was all I was willing to give. We went back and forth about the dilation check a bit, mainly because the method of induction was AROM, which would only be really effective if I were already dilated. I was sure I was, based on the previous membrane sweep, and also the fact that two days of on-and-off labor couldn't have left me untouched.

In the end, I prevailed and left with my pants on again. My midwife, who had been with us, advised me to go home and get some sleep. I didn't need to be told twice. The kids were still stashed, so our house was abnormally quiet. I slept for three or four hours, knowing it would likely be the last solid sleep I got. When I woke up, Kurt and I reclaimed our kids, and we had dinner together, and since it was Monday, we had Family Home Evening as well, our last before our family expanded.

That night, I again woke up with strong regular contractions. This time, I ignored them. I did not want to spend my last night before caring for a newborn waiting for my fruitless labor to pick up. They still woke me up every few minutes, but I felt much more rested than I had over the weekend.

We woke up early that morning, the 22nd, and packed our three older kids off to another friend's house for the day. I remember thinking it was ironic that it was the school holiday week, so it was sort of like a weekend. We got the the hospital at 7 and met our midwife. I don't know why I forget how slow hospitals are, but I was amazed how long admissions and all the prep took. Although I'd slept better the previous night than I had that weekend, I was still exhausted. I had pictured getting in and napping while we waited for the induction to take effect. Oh well.

In our prep work for this birth, I had drafted a birth plan, gone over it with my midwife, had it signed by my doctor, and sent ahead to the hospital. I think that really paid off. My nurse turned out to be a midwife in training, having had all of her children at home. I know that wasn't just luck of the draw. Unfortunately, while I liked her in general, she botched my IV. She put it in my wrist and hit a nerve. I almost passed out, and I'm sure I looked a bit pathetic, that here I was planning a drug-free birth and I couldn't even handle an IV, but wow, did it hurt. And it still does, if someone grabs my wrist. Part of my index finger is also numb. Who knows how long that will last. But I digress.

After I had the IV in place and had my full history taken, and repeated for a resident, the doctor finally came in after 9 to break my water. That was the only check I had for the labor, and he declared me 3-4 cm and 80% effaced. My midwife sounded relieved, as that meant the AROM was likely all it would take to get labor into high gear.

Afterward, I kicked everyone out with the plan to sleep. Ha. Contractions started right off, strong and regular. I got a good 20 minute strip on the monitor, and then the nurse said I could take it off. I was quite surprised. We had expected continuous monitoring, but we weren't going to complain. I got up, used the bathroom, and sat on the birth ball for awhile. That's when the anesthesiology resident came to talk to us, giving us the whole rigmarole of what would happen should I need her services, and why it was so important that I not eat or drink anything. (Later, my midwife and I had an eye-rolling conversation about that.) I wish she had stopped by earlier. I had to take several breaks from the conversation to deal with contractions. But I'm convinced hospital time exists outside the experience of ordinary mortals.

Maybe an hour later, our nurse came back and said I could go without the IV for a little while. That meant I was completely unhampered as I changed positions. I did spend some time in bed, partly due to a questionably high blood pressure reading. I rested until it was normal again, then I wandered back into the bathroom and found quite a bit of bloody show. I tried the shower as well. There was absolutely no water pressure, which makes me wonder just how often those showers are used. But still, the warm water trickling down my back felt great.

Somewhere around noon, I was back in bed resting on my left side when I started vocalizing through contractions. My midwife encouraged me through that, helping me focus and relax. But things were getting intense. After one particularly long strong contraction, I opened my eyes and said "Is it alright if I admit I don't want to do this for hours?" I still had it in my mind that this labor would be like my previous labors, and I would be at this at least until late evening. My midwife said that was fine, we would take things one contraction at a time. She also said she wouldn't tell anyone I said that. Minutes later, she told the nurse what I'd said, which confused me at the time, but looking back, that was code to the nurse to get everything ready. And indeed they did get everything ready. The equipment was brought in and set up on the corner table. I watched and shook my head, thinking they were getting ahead of the game. That was right before I had a contraction that included a push. I was incredulous. Could I really be that close? "Is that a push?" I said. "You tell me! It's your body!" was my midwife's response.

The exact sequence and timing of things at that point are a little fuzzy. I remember a new resident coming in and saying "Are we ready for a check?" My midwife held her off and said we needed the doctor. This resident obviously didn't know who my midwife was because she launched into an explanation about how important it was to make sure I was fully dilated before I started pushing or I'd swell my cervix. If my body hadn't been working on pushing out a baby RIGHT THEN I might have laughed at her. As it was, I was thinking "Congratulations, you read your OB text. Now throw it out and watch how it's done with an unmedicated woman listening to her body!" Thankfully she was called away. I think she needed to finish up for my doctor who had been in the OR with a set of twins.

My midwife was stationed at the foot of the bed, holding the place in case any other residents decided to plant themselves there. She told me she could see the baby's hair. Now I knew she was pulling my leg. My previous pattern included bald babies.

Contractions had really spaced out by this point, giving me a second wind, but I could no longer deny that I was indeed about to give birth. I don't know exactly how many times I pushed. I only remember two and a half. The half one was the one that first caught my attention. The other two were Lenore's head and body emerging. Either way, the pushing phase was not very long. I was again hooked up to the IV, for third stage pit, and the doctor finally came back just as Lenore was crowning. My midwife did move aside for him, but they were both side by side as I pushed my baby out. Lenore had a loop of cord around her neck, but that was easily slipped off, and she was handed straight to me.

I was in awe. I'd done it. I'd pushed out my baby, despite all the naysayers. I had read many VBAC birth stories and always marveled when the woman said she never worried about her scar. Now I can say the same. I was well into labor before I even remembered I had a scar. And even that thought wasn't worrisome. I can also say that I honestly never entertained the thought of asking for any pain meds. I'd had one drug-free birth already, and by the end had been begging for something. But I didn't this time. I think two things made the difference. One was that this birth was much quicker. Transition and pushing took me by surprise, and having to grapple with just what state my body was in drove out thoughts of asking for intervention. The other was my midwife. She was by my side the whole time, talking me through contractions, feeding me ice chips, massaging my back, and being there to help me let my body do what it had to do. Things would have gone much differently without her.

As I was basking in the afterglow and holding my minutes old baby, I thought of a more practical matter. During pregnancy, we had been scared by the possibility of placenta accreta. That was the main reason for the third stage pit. If the placenta didn't come right away, there would need to be more intervention, the ultimate of which was a hysterectomy. So roughly 5 minutes after birth, I looked up and said "At what point do we worry about the-" My midwife didn't let me finish. She said the placenta was right there and would come out with a quick push. And indeed it did and looked whole. That spiked me right back up on my high. Not only had I successfully pushed my baby out with my vertical scar, my anterior placenta had behaved perfectly. Things couldn't be better. I had a beautiful healthy baby who was nursing well and would be mine to take home to rejoin the rest of the family.

Hours later, in a sort of debriefing conversation my midwife said "You really didn't know how close you were, did you?" Nope, I really didn't. I was so set on expecting patterns to repeat themselves that I was completely taken by surprise. Not a bad thing at the end of the day, but one more piece of evidence that I need to let go and let be.

It's been one month since my victorious VBAC. I have had an easy recovery and the the whole family has loved getting to know Lenore. Six-year-old Dorian eagerly showed her picture at school. Five-year-old Faith loves having a sister. Almost three-year-old Quinn doesn't quite know what to do with her, but he is slowly learning. We all keep learning. That is the point.