Oskar’s successful hospital VBAC

[erikandoskar]

Part 1 of 2

Our son, Oskar was born on 19 April 2008 in a much-hoped for VBAC. What an amazing experience. I owe so much to my wonderful husband, who supported my desire for a VBAC every step of the way; to our private midwife Gaye, who was instrumental in building our confidence that we could do it, and of course to little Oskar’s own resilience on the day.

A bit of background... our first son was born in November 2005 in Bangkok, Thailand where we were living at the time. Labour began spontaneously at 1am, 9 days past my due date. I got to about eight cm in hospital but labour then stalled. After seven hours with no progress it was 8pm and we were a bit disillusioned after hours of intense contractions. When our ob suggested we consider a c-section we pretty much agreed straight away. We didn’t have any other options explained to us. The c-section (under spinal) was uneventful, I got to hold our baby in recovery about an hour after he was born. We were a bit disappointed about not having a natural birth but very happy our son was born healthy.

When we became pregnant again I knew I wanted to have a natural birth. We hadn’t heard of the term VBAC but rapidly came to realise what the previous c-section meant – I had joined a category deemed “high risk”. We chose the path of private obstetrician, private hospital as that was the path we had taken in Thailand; we also wanted to have emergency facilities close by should they become necessary. However from the early days we began to feel that our choice to have a natural birth – which our ob said he supported – was going to be challenged many times along the way.

I should first say that our ob was always available and ready to discuss any aspect of the pregnancy. He was not condescending and never made me feel I was delaying him seeing other patients (which I certainly was on a couple of occasions – sorry everyone). We really did have some very frank discussions over the 40 weeks. I don’t regret choosing him as our ob, particularly as it all worked out as we had hoped in the end. However he did seem to favour c-sections in the way he discussed our options. He began by saying he would schedule a c-section if the baby looked like it would be big, or if I went overdue. He told me a scheduled elective c-section was the safest option as I was in a high-risk category for uterine rupture (and that an emergency c-section might have to be done under general anaesthetic). He didn’t discuss the benefits to baby of going into labour naturally, the risks to baby when elective c-sections are carried out too early (eg breathing difficulties), the much longer recovery time for mother after c-section, the higher risk of hysterectomy with a c-section. Booking me in for an “elective” c-section was a topic frequently visited during my appointments. I was told:
-At 20 weeks that “I would be booked in at 38 weeks” for an elective c-s if the baby looked big (I said we would have that argument at 38 weeks)
-At 37 weeks that “I would be booked in at 41 weeks” if I was overdue (I just smiled)
-At 40+2 that “I would be booked in at 41+3” (10 days overdue) (I renegotiated this to 42+2 – fortunately it didn’t matter in the end)
-In pre-labour (5pm, waters had broken 15 hrs earlier) that “I would be booked in for tomorrow morning if this baby hadn’t come by then”
-The day after Oskar was born (!) that “I was lucky – I would have been booked in for a c-section if he hadn’t arrived earlier”. Etc, etc.

I am certain if we had had a c-section he would have done an excellent job. But I would have loved just once to hear him say “I will be here if there are any problems, but I am sure you can deliver this baby naturally”.

After each appointment I spent hours Googling the things he told me. Thanks to wonderfully informative websites ranging from others’ successful VBAC stories through to medical journal articles, I learned more about the risks of rupture, including the lack of any evidence (that I found) that a big baby or being overdue increases those risks (An amazingly comprehensive “VBAC bibliography” containing results from many many studies can be found here http://www.worldserver.com/turk/birthing (http://www.worldserver.com/turk/birthing/rrvbac2005-9.html)
/rrvbac2005-9.html (http://www.worldserver.com/turk/birthing/rrvbac2005-9.html)).

I also began to learn about protocols which attach to VBAC labours at most hospitals – rules like continuous electronic fetal monitoring throughout labour – which limit mother’s ability to move around during labour and which, in my view (having experienced continuous monitoring late in my last pregnancy and also having gone through 19 hours of labour) I felt would seriously inhibit my ability to handle contractions without medical pain relief. I learned of studies which suggest CFM does not improve outcomes but seriously increases the risk of interventions including c-sections. I began to think of ways to avoid being drawn into the “cascade of intervention”. (There are lots of articles out there but one I found a particularly useful starting point was “VBAC: On Whose Terms?”)

[erikandoskar]

Part 2

At about 35 weeks I attended a VBAC Choices for Childbirth forum with my husband here in Melbourne, run by the Maternity Coalition. This was a turning point for us. The information session gave women who wanted a VBAC the chance to tell their stories and hear a midwife perspective on birth (the first time for us!). It was a great evening. I felt part of a greater group of people all struggling with the idea that our pregnancies and labours were medical problems to be solved by doctors. The midwives at the forum all told us what noone seemed to have told any of us to that point – that our bodies could do this. I came away feeling that I was no longer going to “attempt a VBAC”; my obstetrician was not going to “let me try”. I was actually going to do it.

After that forum, I informed my ob that I did not want continuous fetal monitoring during labour, explaining that my experience of the monitoring was that it seriously inhibited movement and changing positions, and this would affect my ability to deal with intense contractions and avoid medical pain relief. (The hospital did not have telemetry.) I said I would be happy to have Doppler monitoring which appeared to me to provide just as much information about baby’s well-being as continuous monitoring, and I was happy for this to take place as often as liked during the labour. At this point we nearly parted ways. While he initially appeared to agree, he then called me the next day to say he was not comfortable with my decision to refuse CFM and would be “happy to refer me to another obstetrician”. I said that at this late stage it was unlikely I would find anyone to take me and that chances were if he “sacked” me I would have to have a home birth with a private midwife. After a lengthy discussion he agreed I should come to the next appointment after all.

I spent the next week in furious research about continous fetal monitoring. I learned about baseline heart rates, short- and long-term variability, tachy- and bradycardia, early, late and variable decelerations and so forth (among others, I looked at “VBAC, C-Section and EFM: How Safe Are They?” on the gentlebirth website). I went prepared to argue that Doppler monitoring would be just as adequate in identifying problems. Mainly though I went determined to stick to my decision to refuse CFM. I mentioned that under the Code of Conduct of RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) my ob was not required to do specific things (like monitor me continuously) but did have to give me the right to make decisions about my own care, and inform me that I must take responsibility for my choices. I said he had certainly done this and that this was my informed decision. We finally came to a compromise of 20 minutes continuous monitoring per hour of active labour.

My husband and I were very relieved not to have to change our plans for the birth at such a late stage. However, this interaction – and the constant references to c-section becoming necessary in this or that eventuality – confirmed in our minds that we needed something more for our labour team. We needed someone who had confidence in us to birth this baby naturally; someone who could be our advocate on the monitoring issue and any other issues which came up; someone who could help us stay home as long as possible during labour. We decided to ask one of the private midwives whom we’d met at the Choices for Childbirth session, Gaye Demanuele (“birthwisemidwives”), to help us during the labour.

I wrote out our birth preferences and had my obstetrician sign the form.

My waters broke at 40+6 days, at 1am. We thought we would be meeting our baby by midday or so, but things took a while to pick up. I had contractions about every 10-15 minutes all day, which was frustrating although exciting. Gaye visited us to check on the baby and encouraged us to stay home as long as possible. We decided to go into hospital around 5pm although the contractions were still not coming closer than 10 minutes together. The hospital staff were great and encouraged us to go out for dinner and walk around. We did that, and returned and rested and waited for the contractions, which were pretty strong, to pick up. Some time between 11pm and 11.30pm the contractions started to get much stronger and come much closer together. I suddenly needed to be up and about, and started making lots of noise with each contraction. My husband decided to call Gaye and she arrived soon after.

From then on it is all a bit of a blur. I got through the contractions by moving around a lot and using the birth ball, a chair, the birth mat, and standing leaning over the bed as different positions. I used “stress balls” a great technique from Juju Sundin’s book Birth Skills, squeezing them to try and distract myself from the pain. Throughout it I had my husband and Gaye by my side as the contractions intensified. Each time one finished I didn’t think I would be able to get through any more but the support from my husband and Gaye’s helpful suggestions made all the difference. As I began to use my voice to help me through the contractions, Gaye helped me keep the tone of my voice deep and low rather than high. She watched as the labour intensified and suggested different positions but mostly observed how I was behaving and reassured me. She was an absolute rock. She didn’t make any false promises like “not long now” just urged me to stay in the moment.

As agreed, I was attached to the CFM machine for 20 minutes each hour once in active labour. I barely noticed it, since I remained in the position I was in and the midwives held the sensors to my belly to try and get the baby’s heartbeat. Noone suggested I get up and lie on the bed for the monitoring. I felt that having made my position clear about this beforehand made it much easier to stay where I was. It was dramatically different from the approach of “just stay in that position for a bit longer, please” which I had when I was monitored for 20 minutes on admission to hospital earlier in the day.

I began to develop the urge to push and after a few contractions like this was encouraged to get up on the bed in the position I wanted to give birth in. I got into a hands and knees position on the bed, actually leaning over the back of the bed (which was in the upright position) and grabbing the bar behind the head of the bed. I almost pulled one side of that bar out. In fact I think it did come loose a couple of times!

I had several strong pushing contractions and was encouraged to push. I remember saying “I don’t know how to do this!” Gaye was very calming, reassuring me that my body knew what it was doing. It helped to relax me and remind me to trust what my body was doing. My husband was right at the head of the bed reassuring me and holding my hand. I was glad he was there particularly as everyone else in the room seemed to have gathered around my other end. My husband said their expressions were similar to footy spectators – leaning forward, waiting for the exciting moment of a goal at last!

Everything was progressing so fast. I had gone from the stage I reached in my last labour, to a completely new zone, without any kind of stalling zone in transition. From what I had read, I thought transition would be me stomping around swearing at everyone and wanting to go home. But there was no time for that. It all kind of blended together. I didn’t have any internal examinations at all – I just trusted Gaye’s observations of me and when she thought I was ready to push, in fact I was. Suddenly someone said “you can feel his head now” and I put my hand down and indeed could feel this hard skull through an incredibly soft outer layer of rumpled skin.

Through the blur of rapid pushing contractions – all of which felt like the baby coming out, but weren’t – I heard talk of “calling the ob” and at some point – almost too late – he arrived and took over. His approach was unsurprisingly much more aggressive – encouraging me to “push harder, just one more push” – but it worked really well coming when it did so close to the end. As I had felt supported by the midwives so I felt encouraged by him to make a final sprint for the end. Finally the baby’s head crowned and that kind of stung. One push and the baby’s head was out. One more push and his ENTIRE BODY just flew out of mine. What an incredible sensation. I will never forget it as long as I live. I heard him cry, I couldn’t really see what was happening as it was all behind me, I was helped to turn around and lie on my back, and then I was handed my bright red, screaming baby boy and he nestled into my arms while someone put a blanket over the two of us. Through the hubbub I heard people confirming the time of birth – 4.32am. I looked into my husband’s eyes, we both gazed at our newborn son, I think I might have cried a bit. It was the most amazing moment of my life.

I had a few stitches for a first degree tear and the placenta came out about ½ hr later (I didn’t have the syntometrine injection). We stayed all morning in the delivery suite as it was very busy on the ward. The midwives were all wonderful. Gaye ensured I fed Oskar for the first couple of hours before he was weighed and measured. His measurements were 3.86kg, 51cm long, and a 36cm head circumference.

We were ecstatic that the birth had gone so well, had progressed (once it started in earnest) so quickly and of course that Oskar’s heart beat had never flagged, it had always remained strong and reassuring. We truly were lucky. I also feel so happy that the research I did gave us confidence that a VBAC was the right choice for us, and led us to decide to bring Gaye into our support team. It helped counter the feeling I got in my interactions with our ob and the hospital, that to try to do this was to put everyone at risk and was not the appropriate course of action. Modern obstetrics of course is responsible for saving the lives of many mothers and babies. And we wanted to be able to take advantage of that if it became necessary. What we didn’t want were the interventions which seemed to go hand-in-hand with that approach, based on the pessimistic view that what can go wrong, probably will.

In the end we had the right support team to give us the confidence to believe that I have the right to refuse treatment like CFM – or a c-section at 38 weeks for a threatened large baby (!) – and to feel that women are made to give birth naturally and that I too would be able to do it with the right mental attitude and support. My heart goes out to all women who have had a c-section in the past and don’t want to repeat the experience. I encourage everyone to do lots of research, have a strong support team, and, as much as you can, ask your questions and fight your battles before the big day comes.

[MumtoJordan]

What a beautiful birth story. :crying: :D Congratulations and welcome Oskar!

I hope to have a VBAC with my next baby and your story was absolutely inspiring.

[~Emmylou~]

:yelclap::yelclap::yelclap::yelclap:

I wish there was a standing ovation emotion! :laughing:

Congratulations on your beautiful baby boy and having the birth you both wanted and deserved.

And WELL DONE YOU for taking charge, and refusing to be frightened or bullied into anything that you didn't need. You did an absolutely wonderful thing for yourself, your son and your whole family :)

[GeorgiaAnne]

Congratulations - what an amazing story :yelclap::yelclap:
Welcome to the world Oskar!:flowerz:

[MoonstoneMumma]

Congratulations! What a fantastic story. It just shows that if you have done your research and trust your body, then anything can happen

[V8]

Congrats on your VBAC, glad you got yourself info and a great support team, and that your experience was so worthwhile. :) Congrats again!

[k2ma]

COngratulations!:yelclap::D:sunshine::smiliedance:

What a fabulous and encouraging story for us potential vbacers - thanks for the research references.

[Sammilee]

Wow, what a wonderful birth story. Thanks for sharing. You are definitely an inspiration for all women who want to achieve a VBAC.

[Mia]

I really enjoyed reading this one, particularly the detail about how you had to research and negotiate determinedly each step of the way. If you can be bothered, I'd be interested in any tips you have for negotiating stuff like that (declining this and that test or intervention etc) because I would find that extremely useful. It sounds like you really did your research and were very assertive without being aggressive or crazy.

[erikandoskar]

Hi and thanks for the nice messages everyone! Mia - I would be happy to chat any time about the negotiation process. It was a learning curve for me as pretty much each risk that was mentioned was new to me at the time. So a lot of our discussions began with me saying "About what you mentioned last time...". And it's tricky to introduce research you've found without appearing to dismiss the fact that they are the one with a degree in obstetrics. I tended to say that I'd found evidence which appeared to suggest the risk of such and such was fairly low, etc...

I also started out thinking I could convince my doc of my point of view (for example, that rupture is a very unlikely event, that cfm is no more useful than intermittent monitoring). But in the end, convincing the doc is not important. It is in fact very unlikely as I think most obs are fairly conservative in outlook and if there is an intervention which will give them more information they are more likely to want it even if it inhibits movement by you, or leads to more intervention.

So the really important thing is to do the reading which will give you the confidence to be sure of your position, and then stick to it and make sure the people around you know your feelings too (I can really recommend hiring a private midwife who agrees with your course of action, even if you'll be in hospital). Once you're certain you want or don't want something, it's important just to be clear about your intentions and take responsibility for your decision. Saying "this is my informed choice" is their kind of lingo, they may not like to hear it, but they will understand you are deciding this on the basis of research and not simply emotion. I also made sure the ob understood I would be open to changes in my plan should there be any cause for concern. (Again, I really recommend having a private midwife or doula to help you get the space you need on the day to think about these decisions should they be needed.)

In the end, it's about responsibility for choices. You are unlikely ever to get a green light from the doc and he may try a range of scare tactics "it's not safe for you, it's not safe for your baby" etc, but if he chooses to continue your care despite the decisions you've made, then he is for all intents and purposes happy enough. It's a confrontational way to look at things as I think we all like to think a compromise should be reached. But in the end it is your body and your pregnancy.

When it came to the crunch with me and the ob, and it did a few times, I just tried to be as calm as I could and argue in a non-emotional way, and maintain that it was my right to say no to certain interventions. I take it you are hoping for a vbac yourself? If so, did you experience any labour last time? I found speaking about my own experiences one aspect that he couldn't argue with. Eg. I know contractions are painful and from experience I know I can get through them better if I am able to walk around. Hence - no cfm, etc.

If you can attend a VBAC information session run by midwives as I did i'm sure you would really enjoy it - it really is refreshing to hear their confident view that women are able to birth babies naturally, as a starting point, rather than the medical view that problems are likely to arise and need to be fixed.

Best of luck with the rest of your pregnancy!

[Mia]

Wow, thanks! I am not actually trying for a VBAC - I had a very fast and straightforward birth last time and the ob says that he expects me to have another successful natural birth. But I am super conscious of feeling that medical people are in charge and that there are so many things they can hold over you - as you say, scare tactics, or bullying, that I am not very assertive about. Like you, I don't want any continuous monitoring or drips or anaesthetics or anything, and I am hoping to decline diabetes and group b strep testing too. I have done my research. I just want to be left alone to let it happen. Why is this so hard?

And it looked to me like you did a really good job of setting out your position on things and getting your way (or at least a good compromise) so I wanted to hear more. So thanks!