birth

VBAC Supportive Care

Like many moms out there, I’d never expected to be part of the “cesarean club.” Surgery didn’t exactly fit my natural birth plan — so much so that the hubs and I pretty much snoozed through that whole portion of the labor and delivery class offered by a local hospital. Things quickly changed upon the discovery that my firstborn was breech at my 37-week prenatal appointment.

Despite trying everything I could, she would not turn. At that point, I’d never heard of family-centered cesareans, and my providers never offered one as an option. However, I had a good cesarean and recovery. But it was a far cry from the natural birth I’d dreamed of.

It seems silly to admit this now, years later, but when I was pregnant with my firstborn, I selected where she would be born and who would deliver her largely based on convenience and ambience. I say silly because I ended up going to great lengths, including a transferring my care at 39.5 weeks and driving two hours to have my second child delivered by providers who practice evidence-based care that supported my wishes.

When I discovered I was pregnant with Baby No. 2, I searched for a provider who was supportive of VBACs and delivered in a hospital, our preference at the time. Unfortunately, no midwives offered VBACs in hospitals in central Iowa, where I live. So I chose a group with an OB our pediatrician said was VBAC-friendly.

Each physician with whom I met started off my prenatal office visit with, “You’re an excellent candidate for a VBAC.”  However, at my 17-week appointment, the ARNP said something that raised an alarm inside me. She said they’d do a “routine” ultrasound at 38 weeks to check my baby’s size given my firstborn was so “large” at 8 lbs., 10 oz. (for reference, my husband’s 6’4’’ and I’m 5’ 10’’).

This made no sense to me, so a friend suggested hitting up the local ICAN (International Cesarean Awareness Network) group for advice.

An ICAN leader told me about the American College of Obstetricians and Gynecologists’ (ACOG’s) guidelines for VBACs, which included that my firstborn did not meet its definition of macrosomia (a big baby) and that the group concludes that mere suspected macrosomia shouldn’t put a halt to the possibility of a VBAC. She was very supportive and mentioned some other options to consider, one being transferring my care to UI Women’s Health Center’s Midwifery Clinic (UIHC). However, at the time, I honestly thought driving two hours in labor sounded crazy.

At my 19-week visit I asked one of my OBs about the 38-week “routine” ultrasound. She said that so long as I was measuring normally, I wouldn’t have to have it.

During my following prenatal visits, I waited until after all of the other physicians said I was measuring right on schedule. Then I started asking them questions and began getting red flags when they did not concur on a definition of a “big” baby. One told me the ultrasound was mandatory and that if the results showed my baby was 9 lbs., I’d have to have a scheduled cesarean. Given the margin of error with ultrasounds, I wasn’t comfortable having a routine cesarean solely because of size, when I could be carrying an 8 lb. baby. Another physician made other comments to me, including suggesting another ultrasound at 35 weeks, which led met to believe we definitely did not have the same plans for the birth of my baby.

Then I learned that physician was known for pushing cesareans and that the group as a whole was known to “pull the rug” from plans for VBACs toward the end of pregnancy, leaving moms to feel like they have no other options.

At my 37-week appointment, after measuring right on schedule, the same physician whom had assured me the routine 38-week ultrasound wouldn’t be necessary so long as I was measuring on target tried to push the test on me three times within the short visit.

At this point, I was a mess, feeling like I could not trust all of the physicians in the group to honor what I believed to be in the best interest of my baby and me. So I called the physician in the group whom had delivered my firstborn and with whom I was the most comfortable to discuss my concerns.

After speaking with her, I came to the conclusion that I would continue to be an “excellent candidate for a VBAC,” should all the stars align (I happen to go into spontaneous labor before my due date, the right physician was on call, my labor progressed quickly, etc.). And for me, the answer I needed to hear was, We will support your VBAC and your wishes to withhold interventions so long as you and your baby are doing okay.

So I called the UIHC midwives who thankfully accepted me as a patient at 39.5 weeks. During my first and only prenatal visit there, the midwife told me, “In your case, it would be a real shame not to try for a VBAC.”

I went into spontaneous labor three days later. Despite having been in labor for 15 hours with mostly frequent, intense contractions, I was at two centimeters dilated upon admission. However, because I was a VBAC mom, the midwife on call wanted to admit me. I expressed my concern about “being on the clock” by being admitted so early, and she said, “We don’t have those clocks here.” And she meant it!

The next day, seeing my exhaustion after 31 hours of labor and going on a total of eight hours of sleep in two days, the midwife suggested Pitocin. Despite it being a “no” in boldface type on my birth plan, she said otherwise I could be one of the moms who labors for days. But she never pushed it on me, saying only, “I would offer you this…,” which made me not think twice about it. Had I not elected to receive the drug, I know I could’ve continued to labor there without being pushed into unnecessary intervention. But because of ACOG’s “immediately available” VBAC guidelines, I know in my heart that I would’ve been pushed into another cesarean, had I stayed in Des Moines.

I traveled to Iowa City because it was the only place I felt I could be guaranteed evidence-based care for my baby and me that supported my wishes. But the person-centered postnatal care at UIHC was far superior to my experience in Des Moines as well.

Mom and baby skin-to-skin immediately after birth.

Mom and baby skin-to-skin immediately after birth.

I’ll forever be indebted to the UIHC midwives, ICAN of Central Iowa and my doula for the blessing of holding my baby immediately after she was born for as long as I wanted, my birth “war” story, being able to pick up my firstborn (and shower upstairs!) upon returning home and for reduced risks, should we decide to have another child.

 

The “silliest” part of my VBAC story is the fight I had to put up to have it.

 More VBAC resources:

  • http://vbacfacts.com/
  • https://improvingbirth.org/induction-c-section-vbac-facts/
  • http://www.ican-online.org/

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