Please help me figure out what led to my c-section and whether I'd be a good HBAC candidate. Thanks!

[mamacolleen]

 Hi all, I mostly lurk in this forum but will likely be on here a lot this coming year as I try to prepare for a VBAC. I really value the advice and information I've read on here in the last few months.

We are currently TTC and I am hoping to be pregnant again within the next few months. My DD is 17.5 months. I have thought A LOT about her birth and gone over and over the cascade of events in my head and I want to get your thoughts/feedback on what I can/should do differently with the next birth to make it more likely I’ll have a VBAC. So I’m posting my story here.

I was planning a homebirth with DD. Living in Ontario, where midwives are regulated like other health care professionals, there’s a window of time within which homebirths can legally happen (37 – 42 weeks). Well, I got to 42 weeks with no hint of labour starting. I had consented to a couple of stretch and sweeps starting around 41 weeks and so know that I was not effaced at all and only a fingertip dilated at 42 weeks. Also, DD was I think still at +3 station, not engaged at all. I wasn’t having any BH or contractions really at all. She was conceived through IVF so we were sure of our dates. Had a couple of BPP’s done near the end and passed them with flying colours. So she was still good and happy but I could feel the stress of counting down to losing our window of opportunity for a home birth. Tried a TON of things to help the labour along naturally: EPO orally and vaginally, the stretch and sweeps, lots of bouncing on my birth ball, acupuncture, walking, acupressure, and eventually castor oil in desperation at 41+6.

Morning of 42 weeks, we met my midwife at the hospital for a required consult with the OB, and agreed to a medical induction. (mistake #1). Had cervedil inserted and told to go home and return 12 hours later. About 10 hours later started (finally!) to get some cramping. When I returned to the hospital, there was NO changes in my cervix. So, a second round of cervedil and at this point I was admitted to the hospital (yuck!). Midwife went home and returned at noon the following day (12 hours after the second cervedil was inserted). By this time I was having reasonably regular contractions. My friend who as acting as labour support came and we walked a TON, all over the place for most of the day. Cervix was checked at noon and I think I might have gotten to 70% effaced and about 1 cm dilated. DD was still not engaged. So I agreed (mistake #2) to AROM. I kick myself now with what I know. Got to walk around a ton some more after the AROM to try and kick the contractions into gear. Was getting regular painful contractions for a couple hours. Got checked again. I don’t remember much significant progress in dilation/effacement. Agreed to pitocin (almost in tears because I knew this meant I would be limited in my walking because of the damn EF monitor). Pit seemed to really get things started. Contractions were regular and painful, but I feel strong and in control. Midwives were great about letting me out of bed as much as possible and bouncing on the birth ball and all that (well hooked up to the monitor).

After a couple hours (every ½ hour pit dose increasing), I remember the contractions started getting excruciating and they were longer and I wasn’t getting a break in between them (typical pit contractions I guess). Also starting getting terrible terrible back labour. I laboured like this for about an hour or so and had agreed to another cervical check because I was starting to think about needing an epidural and didn’t want to get one if I was close to transition or something – it felt like transition to me as a FTM, I was feeling out of control, all the things that I was told transition feels like. Cervix was 1-2 cm and 100% effaced. That was the most miserable feeling. After another hour or so of labouring with these non-stop contractions, I started to get worried about whether I would have the energy to push since I had gotten much sleep since all this induction started and who knows how much longer it was going to be. So I requested and received an epidural.

It was about midnight by then and so we all got a little sleep. At about 4am, midwife did another cervical check. I was about 4cm. She called the OB in and explained the situation to her and also said that when she was doing the last cervical check she could feel the baby’s head was “facing my hip” and thought baby was not in the right position. The OB was incredibly rude and condescending to everyone and asked midwife if she wanted to transfer care since she “didn’t seem to know what she was doing” or some other such nonsense. Didn’t believe her that baby was facing the hip. Decided to do her own cervical check and proclaimed I was a 6 and baby was in a good position. Finally got rid of the OB. Laboured for another couple hours. By this point, I was starting to notice (on the EF monitor) that my contractions would pick up with every increase in pit dose and then within a few minutes peter out again until the next increase.

By early morning, I had maxed out on pit. Midwife was required to consult with OB again. Thank goodness it had been shift change and there was a new OB in who was SO much nicer and respectful. I was still at 6. And DD was still at like +3 or +2 station (hence the contractions that kept petering out). OB started to talk about c-section. Requested time to think it over and prayed I would dilate more. Couple hours later, still at 6 and in tears agreed to c-section. I should point out that in no time throughout this did DD show any fetal distress. Since I wasn’t technically an emergency therefore, I had to wait another couple hours while they dealt with another emergency section and who knows what else. When they pulled DD out, she was indeed “pointing towards my right hip” – still don’t know what that means – and posterior. My hospital records label me as failure to progress. DD was 9lbs 6oz. and born at 42+2 (the whole thing from insertion of first cervedil until c-section was 50 hours)

So, I know a few things I will do differently next time:

1. far less cervical checks, especially before labour even starts
2. absolutely no AROM
3. no agreeing to induction unless I have a more favourable cervix
4. if I get to 42 weeks again, agree to consult only with OB and not to induction, since I can actually legally keep a midwife until 43 weeks, at which point it’s an automatic transfer of care.
5. Regular chiro care and attention to my positioning during pregnancy to try and get DD into a better position.

Is there anything else? I think the things that led me to having a c-section was: induction when my cervix wasn’t favourable for it, AROM which cemented DD into a bad position to come out, being tied to the EFM because of the pit and less ability to MOVE, possibly the epidural? Oh, and I was told that the pit couldn't be turned off. Is that true? I distinctly remember at one point asking if the pit could be turned off and if I could just get up and walk this baby out... but the midwife told me no, once the pit was started, it couldn't be turned off.

I am really worried that I went to 42 weeks with absolutely NO labour changes at all. With a VBAC, how likely is it that they’ll let me just go as long as my body needs to? I know a lot of people on here think a woman WILL go into labour spontaneously if allowed, but how common is it to get to 42 weeks with no BH, no cramping, no cervical changes?

Do you think I’ll be a good HBAC candidate?

Thank you so much for getting through that long post!

[mwherbs]

Sure I would say go for a VBAC , you have some good ideas,

One comment an engaged baby is expressed as 0 station and the plus +, and not engaged is expressed with minus - .

So if they are checking engagement via your vagina -3,-2,-1,0,+1,+2,+3

There is another way to check engagement from the top it is measured from your pubic bone and how much of the baby's head can be felt above the pubic bone, the baby' head is thought to be 5 fingers, sometimes you can put 1 finger between the bqbys head and moms pelvic brim but usually not much more than that, so the numbers would be 6,5,4,3,2,1,0 engaged is 0 sometimes this can tell you more about how much the baby has moved
Edited by mwherbs - 12/19/10 at 5:06pm

[mamacolleen]

Oh jeez... I always mix up the + / - with stations!! Thanks for pointing it out. I have a mental block about remembering that for some reason!

Thanks for the vote of confidence.

Any one else with thoughts on what went wrong with this birth?

[cristeen]

Honestly, you know what went wrong. Ultimately, it can all be tracked back to 1 decision. And next time you know better. Never agree to an induction when you've had no cervical changes. Its a virtually guaranteed c/s. Everything else that happened was just a part of the cascade.

[mamacolleen]

Yeah I hear that and I know that. There are two things that make me really anxious about next time though. One is that I was actually quite well-informed going into this birth (read Ina-May's books and the one by Henci Goer and a bunch of others). I had very supportive midwives, an amazingly supportive DH and great labour support. I REALLY thought I knew my stuff and what to avoid and all that and I still ended up consenting to a ridiculous medical induction at 42 weeks. So, if I knew all that then and still ended up with all those interventions, what would make this next birth different?

And the fact that I made it to 42 weeks with NO indication at all of going into labour really really makes me nervous. I am really mad that if that happens again there is no way I can have a homebirth. And I am terrified that might happen again. I read on here a lot about how some women are just long gestators but they seem to refer to like 41+ weeks. How many women have gone to 42 weeks with NO signs at all? Especially when they were SURE of their dates. I'm anxious for that clock ticking again if it goes the same way next time. What if I just never go into labour? It might be a silly question since rationally I know all women if allowed to will go into labour spontaneously when their body is ready.... but it's a real big fear of mine.

[jenniro]

I hear ya.  I thought I was so prepared for my VBAC, but when I was in the heat of the moment, I gave in to interventions I knew I didn't want.  I had a CBAC, blah!  I don't know why that happens, but we are TTC this summer for #3 and I will be doing a homebirth.  I think it is the best environment for me to just labor the way I do, long with periods of stalling, without people hovering over me threatening pitocin because I'm progressing too slow.  And I will not be trying to induce, natural or any other way.  I am going to let my body do what it does. 

About going past 42 weeks.  I think if labor was allowed to start spontaneously in most women, going past 42 weeks would be more common.  And I have heard of women going from NO signs to baby in a matter of hours.  If you feel comfortable, you can lie about your LMP.  Give yourself 5 extra days, maybe a week if you feel comfortable.  40 weeks gestation is a number, that's it, an average.  Do you have access to non-stress tests if you go overdue?

[TiffanyToo]

Have you ever had anything like a LEEP proceedure or other cervical surgery? I know that LEEP can cause scar tissue on the cervix that has been known to keep it from dialating in a typical manner and that some midwives use a massage technique to break up the scar tissue. That could a cause for lack of cervical change.

My other thoughts are about your actual cycles. Do you have a longer than 28 day cycle? If so what does that typically look like? *IF* I were you I would make sure to keep very careful TTC charts. This so that you might be able to document that you ovulate maybe later than the normal cycle day 14? I would do a whole host of things to prove ovulation, temping per and post ovulation, Ovulation predictor kits or the monintor, and a cycle day 21 progestrone test. Depending on your health insurance I may even go so far as to see a reproductive endocrinologist to help with the documentation.

For what it is worth things to think about. Good luck with the TTC.

[weliveintheforest]

 You sound like a good HBAC candidate to me.  Just because you went over 42 weeks this time doesn't mean it will happen again, and if it does, you can say no to the induction and have a natural hospital birth with your midwives :hug

[MaryElizabeth]

You basically had the exact same birth as me except for the IVF  and I was actually 43 weeks. I was scheduled to induce (after lots of tears from me and my midwife) and I started having slight cramping that morning. They did the same procedures that you had and I ended up with a CS after 2 days. My DD never even came close to being in position, but in my heart of hearts I think that if I had just stayed home and not gotten induced, I would have gone into labor. After talking with my midwife and other midwives, mothers, and OB's, some women just take longer to gestate and to go into labor. It can take days and start with cramping or it can go from absolute zero-100 in a matter of hours. Unfortunately birth has become so rigid and formulated that we think things are suppose to happen 1-2-3 and well, they just don't! I'm hoping to have a VBAC and I refuse to go to the hospital before 43+ weeks. Especially if everything is fine. We can do it!!! These babies will come out... eventually  :)

[katelove]

Your story sounds similar to mine. My baby was born by c/s at 41+6 after I decided on an induction which I now regret. She also never engaged (head was floating above the pelvis) probably because she was a bit posterior. I suspect that that is why my induction failed but I don't know why she wasn't able to turn.

It sounds to me like you are a good candidate for a VBAC and I wish you all the very best with it.

Oh, and syntocinon/pitocin can certainly be turned off. However, it may cause the contractions to stop completely or become ineffective, especially if the baby's head is not well applied to the cervix. I didn't have single painful or cervix-altering contraction despite 4.5hrs of synto (to almost maximum dose) and walking. We turned it off once the decision to bail was made and  the tightenings, which had been increasing in strength and frequency, stopped altogether.

[maotmsmi]

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Edited by maotmsmi - 5/21/11 at 11:23am