My daughter's birth

[skepticalmother]

My daughter just had her second c-section and I have questions about what happened. Back in the 70's when I had my babies there was no talk about cesarean births. I was overdue with both of my children and they were both over 9lbs. My OB never even mentioned the possibility of a cesarean birth. Both were born vaginally in the hospital without any complications. Obviously things have changed drastically. So here is what happened. My daughter's first pregnancy went to 41 weeks with the OB and an ultrasound suggested a 10 lb baby so the OB told her that her baby was too big, would never fit and that it was safest for her to get a Cesarean. She consented without any labor and her baby was born 9 1/2 lbs. For her second pregnancy she didn't want to have a repeat surgery so she looked for an OB who would allow her to delivery vaginally and had a difficult time finding one. She joined the ICAN list and learned as much as she could about the birthing climate and decided to try to go with a midwife and birth at home. She followed a protein diet, exercised daily and took really good care of herself. She started out at a healthy weight and managed to gain only 25 lbs during her pregnancy. She really thought that she could pull this off except that she went too far passed her due date and the midwife had to pass her back to the OB who was quite negative about the possibilities of her birthing a big baby. The first thing he did was order an ultrasound to determine the baby's weight and it said the baby was 10 lbs. He said that she would have to have another c-section. She fought with him for a trial of labor so he gave her the weekend and said she had to go to the hospital on Monday morning. She went to the hospital that Monday morning contracting and he said she was 2 cm and he wanted to break her water to speed things up. He said he couldn't release her because of the risk of her rupturing. He broke her water and found mechonium. He put in a line of saline to flush things out and her labor completely stopped. After hours of no progress she gave in to the cesarean. Now when I research online I've read that this saline flush is not recommended for VBAC's because it increases the rupture rate and also does nothing to prevent mechonium aspiration. Her baby had no distress. So my question is was this a fair play on the part of the OB or was he just backing her into a corner so that he could give her a repeat section? She said that he kept badgering her about the shoulder distocia that her baby was going to have and telling her how her labor was not progressing because the baby's head was too big. How should this have played out? Is the signs of mechonium a really big problem even when the baby shows no sign of distress?

The second question is regarding her future births. She wants more children but she doesn't want more c-sections. She doesn't want to go with another midwife because she thinks that she will just go passed her date again and then be transferred to OB care. She feels like there aren't any OB's willing to let her go passed 39 weeks and she doesn't want to consent to another repeat. So what are her options?

This was very cut and dry back when I was having my babies. Women were allowed to wait for labor and push them out normally. Only if there were serious complications did women get wheeled into the OR.

Any advice would be appreciated.

[kltroy]

How very frustrating for your daughter. She is lucky to have a mom who cares about her so much. It sounds to me like she did all the right things in choosing a care provider for her VBAC, but had the bad luck to end up with the same unsupportive OB at the end of the day. This OB did not "play fair" - he should have sent her home at 2 cm in early labor, and told her to come back when she was in active labor. Even if she stayed in the hospital things could have gone ok but it sounds as though your daughter was receiving a lot of pressure from the OB to consent to interventions. Hindsight is, of course, 20/20, but one tactic that might have served her well would have been to have her midwife, who had to transfer her care, come with her in the role of a doula.

As for your second question about additional children, there is very good evidence now that repeat c-sections are no more or less risky than VBACs after multiple c-sections. It may take some looking to find a provider who is comfortable with this - the ICAN group can almost certainly help with this. As your daughter has unfortunately learned, choosing a care provider that is supportive is not always sufficient - getting good advice during labor and delivery so that she can make good informed decisions based on real medical outcomes (and not just subjective opinions) is very important too. She can learn to advocate for herself and ask the right sorts of questions, and this will help next time. For example, here's the thought process that could have occurred when her doctor suggested the saline IV:
what is the purpose of putting the saline IV in?
what are the benefits of doing this?
what are the risks of not doing this?
is this something we need to do now? what are the risks/benefits of doing it now versus waiting an hour?
If there is a specific medical condition you are worried about (like rupture or distress), can we simply monitor the situation and wait?
What are the warning signs you would look for? How likely is this condition to occur (require actual NUMBERS here, from real articles)? What would the consequences of it be? How much time would we have to react to the situation?
If you detect something concerning with the monitor, how can you be sure it's real and not an artifact? What is the positive predictive value of the test? (for example, if there are 100 babies "in distress", how many of them actually have bad outcomes?)

Anyway, you get the picture. This discussion and thought process is really important. The other thing that she can remember for next time is that if it is not an emergency, she has time. And if it IS an emergency, it won't just be one person coming into the room saying she needs a c-section. It will be 10 people running into the room saying, "you need a c-section NOW!"

Here is one recent reference for the risks of repeat c-sections (3rd or 4th c-section) versus having a VBAC after 2 or more c-sections:
http://www.rcog.org.uk/news/bjog-rel...ior-caesareans

Here's a good reference about the risks of VBA2C - in a nutshell, risk of rupture is not significantly higher after 2 cesareans than it is after one.

Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.
Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM, Gabbe SG; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.
Obstet Gynecol. 2006 Jul;108(1):12-20.PMID: 16816050

Best of luck with your daughter's healing, and congratulations, grandma!

[skepticalmother]

My daughter did try to ask these types of questions but the OB told her that if she wanted answers, she should get a medical degree. She didn't consent to the saline. He had the nurse put it in after he left. Should she have been allowed to labor without intervention with mechonium present or does it pose a risk to the baby? My granddaughter was at no point in distress. Also, the OB told her to go to the hospital for a stress test and then would not release her because he said that because she was contracting she could rupture so she essentially had to stay. She asked what would happen if she just left against his will and he said that she would have to go to the ER to deliver her baby with whoever was on call which certainly would mean a c-section. She had called her midwife for advice but I think that the midwife was more concerned about preserving her relationship with her backup than helping my daughter because she advised her to follow the doctors advice. Backup OB's who support VBAC are far and few between.

It makes me very sad because I have such beautiful memories of my children's births and my daughter can't even talk about it without sobbing. Not to mention she had a really hard time breastfeeding her babies after the surgeries.

[kltroy]

The OB sounds like someone whose practice I would avoid at all costs.

As for the risks of laboring with meconium, the Cochrane Collaboration has a good reference for this here. They conclude, "CONCLUSIONS: Amnioinfusion is associated with substantive improvements in perinatal outcome only in settings where facilities for perinatal surveillance are limited."

Here's another reference, which concludes, "There is little research evidence on the benefits or otherwise of obstetric interventions such as expedited delivery for meconium-stained liquor without other evidence of fetal distress...There is insufficient evidence to support the use of amnioinfusion for meconium-stained liquor in settings with adequate peripartum surveillance."

In a nutshell, if your daughter had continuous monitoring, the saline would not have made much difference probably, because they would know whether baby was in distress or not. I'm so sorry again that she had to go through that. I, too, had a rotten first birth, and my VBAC was very healing. I hope she finds a way to heal emotionally from the experience.

[skepticalmother]

Thank you!

Thank you for the information and references!

[shenanegans]

My grandmother and my aunt both had big babies, all over 10lbs. the biggest being 13lbs and they both always delivered around 43 weeks. They are not big women. They both figure its genetic for that side of the family to have big babies and a longer gestation. They both had all natural births with my grandmother having 6 children and my aunt having 4. I think that "big baby" excuse is baloney and it sounds like that OB was a huge jerk unfortunately.

[maotmsmi]

*

Edited by maotmsmi - 5/21/11 at 12:55pm

[skepticalmother]

My daughter has Aetna insurance and this is what they have to say about amnioinfusion:
http://www.aetna.com/cpb/medical/data/400_499/0417.html

Did ACOG change their stance (ie. they did not recommend it for mechonium stain) on this since 2006? Also, I'm curious about the license issue mentioned since my youngest daughter went into her 43rd week before they were willing to induce. They kept moving her dates and giving her more time in the hopes that she would go into labor on her own.

[cathicog]

Originally Posted by skepticalmother

My daughter did try to ask these types of questions but the OB told her that if she wanted answers, she should get a medical degree. She didn't consent to the saline. He had the nurse put it in after he left. Should she have been allowed to labor without intervention with mechonium present or does it pose a risk to the baby? My granddaughter was at no point in distress. Also, the OB told her to go to the hospital for a stress test and then would not release her because he said that because she was contracting she could rupture so she essentially had to stay. She asked what would happen if she just left against his will and he said that she would have to go to the ER to deliver her baby with whoever was on call which certainly would mean a c-section. She had called her midwife for advice but I think that the midwife was more concerned about preserving her relationship with her backup than helping my daughter because she advised her to follow the doctors advice. Backup OB's who support VBAC are far and few between.

It makes me very sad because I have such beautiful memories of my children's births and my daughter can't even talk about it without sobbing. Not to mention she had a really hard time breastfeeding her babies after the surgeries.

My Opinion(fwiw) is she had a railroaded c/s, probably both of them...If she really wants to have a non-surgical birth she NEEDS to STAY HOME. About the only way most women have VBACs is if they homebirth with a CPM, Certified Professional Midwife(many Certified Nurse midwives are unable due to thier licensing regulations and backup docs to do homebirths- your daughter should check carefully.) Most CPMs do VBACs and are the generally accepted go-to people for homebirth- its what they are trained for. About 50% of the births I have seen outside a clinic situation are VBACs, including a few moms who have HBA2C....There is hope, but not in most hospitals. There are a few, but they are swimming against the current...and come into a LOT of heat for doing VBACs....there is more money and less litigation (usually) with repeat surgery....I hope she has any future babies at home...(I am a grandma too, 3x)PS, I have seen 12 lbers birthed at home, no problem...

[courtenay_e]

Hello, Ladies!

I am sorry that I had to delete some posts, but they contained name calling, which both the User Agreement and the Forum Guidelines clearly state that we do not tolerate.

Please remember that, though a care provider's behaviour may be poor, even deplorable, we do not host posts that call them names or characterize them in a negative manner.

Thank you all so much for your cooperation. The VBAC forum has helped and continues to help so many women, and we want to keep as many posts as possible!

Warmly,
Courtenay_3, Moderator of VBAC

[courtenay_e]

Skepticalmother, if your daughter truely wants a Vaginal birth with her next baby, and you are in a highly regulated midwifery state, she might consider traveling to another state nearby, where midwifery is not so regulated, and have a "homebirth" in either a hotel room or a rented house, there.

The Farm, in Tennessee, has cottages you can rent as you await the arrival of your baby, and I believe they take VBAMC, though you want to check with them to be sure.

I say this only because if she really enjoyed the midwifery model of care up to the point where she was transferred to OB care, she could still get that care in other places...even if she hired a midwife elsewhere with the expectation that she would get prenatal care for the most part from another midwife and then transfer care at the end of pregnancy to the out of state midwife if she went post dates.

Just so that she knows that though she might have to work for them, she might have options outside of a hospital birth in a hostile environment!

[prancie]

Next time if your daughter chooses another hospital birth she needs to hire a good doula who will help her have the birth she intends. Doulas can make all the difference in a hospital birthing setting and I wouldn't do a hospital birth without one.

The other option is a CPM (not a nurse midwife) or a lay midwife. I don't know what state your daughter is in, but there may be midwives who operate somewhat clandestinely in order to offer women like your daughter the chance to have VBACs without having to abide by regulations.

[roadfamily6now]

if she cooks her babies for a long time, she should fudge her dates to give her more time.

[milkybean]

Originally Posted by skepticalmother

My daughter did try to ask these types of questions but the OB told her that if she wanted answers, she should get a medical degree.

It makes me very sad because I have such beautiful memories of my children's births and my daughter can't even talk about it without sobbing. Not to mention she had a really hard time breastfeeding her babies after the surgeries.

It is incredibly disturbing that a health care "professional" would say something like that. Now she knows that if someone says something like that to her, they have asked her to fire them.

Your last paragraph made me burst into tears. My mom died almost 10 years ago, before I met my husband or had a baby. If there's an afterlife and if she's watching me, she feels the same way you do. She had two lovely births, and wanted so much for me to have the same. I know she's so sad for my horrible experience with DS.

From my perspective, when your DD cries, hold her. Just be there for her. And, not that you would do this, but just in case...even if you don't know why she's "still" upset, even years in the future, even after she has a VBAC (whether at home or hospital, car, or hotel), don't say that to her. The pain is so long-lasting...

Originally Posted by roadfamily6now

if she cooks her babies for a long time, she should fudge her dates to give her more time.

I agree, especially if she doesn't 100% trust her provider.

I told the midwives I hired that all women in my family have LONG pregnancies, and birthweights are all over the place.

A little aside...I recently read that there's some genetic marker that seems to go along with preterm birth...it only makes sense that there must be a marker for longer pregnancies. My husband himself was a 44 week baby, with rock solid dates, and he was under 9 lbs...she was offered surgery back in '72, but only b/c they thought he was dead, b/c she had had bleeding during her entire pregnancy. She simply said no, and continued on.

So anyway, knowing that there's a heavy tendency for long pregnancies and big babies, she has to interview her providers. In the first years after my experience, I thought of the bumper sticker 'friends don't let friends choose birth practitioners while pregnant'. I felt that way b/c I was SO affected hormonally from the first week post-conception, and I had a VERY hard time knowing who to trust. And I WANTED to trust, I've read that oxytocin is the "trust" hormone, because while laboring you have to be able to trust someone, and it brings it out. I was strong enough to fire my first midwife, and then I just went from the frying pan into the fire, hiring midwives that didn't trust me, believe me, believe my MIL, etc etc etc. I already have a list of midwives, a SHORT list, that I will interview once pregnant, though honestly I'll probably end up UBAC'ing (unattended), my trust for practitioners was SO destroyed because of the midwives I hired.

My midwives told me lie after lie, they put them in writing in the notes from my labor (I still can't read through the whole thing without hyperventilating with the TRUE memories of those days), the OB lied repeatedly...they have no problems with lying, and neither do I, if I don't trust the person absolutely.



I am so so sorry for your daughter, having had these experiences. And I'm so sorry for you, to be so rightfully bewildered by it all. But I'm also very glad that she has you there to help her and comfort her.