[lexbeach]

I am feeling so conflicted right now! I am 28 weeks pregnant and have thus far been planning a homebirth. I've wanted to have a homebirth since I was a kid, and my first birth (c-section for breech twins) totally devastated me. I was so happy to find a homebirth midwife practice that was more than happy to take me on as a vbacer. I've also been seeing a back-up hospital midwife for in case of transfer and for blood work (I've only seen her twice). She is not supportive of me vbacing at home, but has still agreed to be my back-up (and is very supportive of hospital vbac).

Lately I've started to feel like we live really far away from the hospital. We live about 25 minutes away in no traffic and good conditions (and since we're expecting a November babe, the conditions may not be great when I'm in labor) from the closest hospital, and it's not very VBAC-friendly. The VBAC-friendly hospital (where my back-up midwife is) is 45-50 minutes away. My placenta is anterior, and for some reason this is making me nervous. Also, I just have a history of "very rare and unusual" medical stuff happening to me. I almost died from internal bleeding after a burst ovarian cyst, and so I guess bleeding is my biggest worry.

BUT, if this wasn't a VBAC, or if we lived within 10-15 minutes of the hospital, I would absolutely be wanting a homebirth, no question. So, I don't know if I'm having unreasonable worries about the increased risk of vbac. I feel like homebirth may even be safer than hospital birth for vbac since there's less risk of intervention, but still the idea of a hospital birth does put my mind at ease a bit. I just want to make sure I'm someplace that I feel safe since I think that's probably the most important thing (to not be afraid in the moment).

My homebirth midwife situation is also a little unfortunate. I'm seeing a "group" of two midwives, both of whom would attend the birth. One of them left a few weeks ago to go to Nepal where she is trying to adopt her baby. She is not planning on being back until my 36-week home visit. I only had two prenatal visits with her, so that won't give me a whole lot of time to really feel connected with her. The other midwife is just much harder to connect to anyway. I don't feel like I can discuss my current concerns with her which makes me think that I don't feel very safe with her (I completely trust in her midwifery skills, but I'm kind of intimidated by her). Also, she's not the most attentive person, and my last prenatal with her was very disappointing (she was on the phone for the first half hour, and then only had 20 minutes to meet with me. . . it felt like an OB visit).

I could just start seeing the back-up midwife along with the homebirth midwife (every two weeks now since I'm in the 3rd trimester), and then decide in the moment, but if I decide sooner, I'll save a whole lot of money (since the homebirth midwives are not covered by insurance), and I would be able to afford other things like acupuncture, hypnobirthing, and chiropractic work in preparation for the birth.

Any advice? WWYD?

Thanks!

Lex

 

[crunchymomof2]

You have to do what makes you feel comfortable and safe. I was about the same distance from the hospital. But I really liked my midwife.

 

[kathan12904]

Does a relative or friend live closer to the hospital you'd rather be at? If you and they felt comfortable, maybe you could birth there. Also, consider the option of getting a hotel room. You can just go check in whenever your labor starts, and the upside of this is that you don't have to clean up that much and your room might have a hot tub in it. I know that neither of these places are actually your home, but they would have much more homelike atmospheres than a hospital while still providing you with the piece of mind of being closer to medical help should you need it. On a philosophical note, your attitude and fears affect a lot of what your birth experience ends up being. If you are carrying around this much anxiety at the time of your labor, you will have difficulty no matter where you are. I encourage you to spend time focusing on your fears, where they stem from, and meditate to release them. I'll be attempting my first HBAC in Feb '07 and I know that letting go of my fears is going to be key. Have you read Spiritual Midwifery or Ina May's Guide to Childbirth. They are excellent resources to assuage your fears about homebirth, as well as realligning your perception of what birth is or should be like. In our highly medicalized society, sometimes it is hard to shake off all the images and information we've already collected about birth.

 

[wifeandmom]

The hotel closer to the hospital option is one I've seen work for many women who were just too uncomfortable with the sheer distance they would have otherwise been from medical back up if they'd birthed at home.

In the situation you describe (ESPECIALLY the anterior placenta IF it is low in the uterus as well which causes concern as to whether or not it's actually embedded in the scar tissue from your previous section), I wouldn't be comfortable with being that far away should an emergency arise.

There are lots of things that can and do go wrong during even the most low risk delivery, and being able to access quality medical back up in those instances can very well mean the difference between life and death.

If you were to rupture in a hotel 5 minutes down the road from the hospital, there would certainly be hope for the situation. If you were to rupture at home 25-50 minutes from the nearest L&D, probably the very best outcome you could expect would be to come out of it alive, without your baby and without your uterus. That's just too far from the time you suspect a problem til you could get there, they could get you prepped and into the OR, etc.

BUT...the hotel sounds promising if you're against hospital birth. I'm assuming of course there are no birthing centers or anything like that closer to a hospital. And a hotel with a comfy jacuzzi sounds really nice, labor or not.

 

[kathan12904]

I also want to add, that the chances of your uterus rupturing are .2%. That meand 2 out of every 1000 women have that problem. In that .2% are mostly cases of small dihesion or "windows." While that can be a scary experience and a situation where you definately need to go to a hospital, it is highly unlikely to result in permenant damage to you or your baby. You have the same risk of rupture that a woman who has never been pregnant before has. I know that it is important to prepare your self, especially mentally, for any possible problem, but I think the UR threat is one that is greatly exaggerated in the healthcare community. I just had my first meeting with my midwives today, and one of them had three c/s with classical vertical incisions before she went on to successfully homebirth 2 more babies without problem. I read on the internet about a woman who had a c/s with #9 and went on to birth smoothly with #10.

 

[lexbeach]

Thanks for the responses.

I'm honestly not that worried about Uterine Rupture. It's more the low-lying anterior placenta that concerns me, and I think all the scary stories about VBACs gone wrong have just put me on edge even though when I really look at the statistics, the chances of anything truly terrible happening are very, very small.

I have had some anxiety about the birth from the very beginning of the pregnancy, and went through times in the first trimester where I really thought I should plan a hospital birth instead of a homebirth, but I worked through it and got to a place where I felt like if I just went ahead and planned the homebirth, I'd come to feel better and better about it. BUT, here I am, entering the third trimester and still not feeling sure. If I'm going to end up at the hospital, I want to make sure I have a really good relationship with all of the midwives there, and so that would mean stepping things up with the back-up midwives now (as is I've only even met one of them).

I am about to start a hypnobirthing class, so I hope that will help me deal with my anxiety. In general, I've had a much, much less anxious pregnancy than last time. I really only worry about the birth this time (whereas last time I was constantly afraid that one of my babies was going to suddenly die inside me). I actually have a lot more trust in my body than I did last pregnancy. I don't want to be at all afraid once I'm in labor. . . I think maybe the hospital is where I should be. I just worry about all the possible interventions there, and the attitude of "what could go wrong next" that does nothing to help my anxiety.

Hopefully I will feel better about things one way or another after I meet with the back-up midwife next week. I haven't ever really talked to her about the possibility of a hospital birth, so I'm really interested to hear what her thoughts are about it (and learn what kind of interventions they'll want to do).

Thanks again for the comments, and please keep them coming if anyone else has anything to add.

Lex

 

[pampered_mom]

The thing is....it's not like you're choosing between two risk free options. Both options have their risks. When it all comes down to it, you need to choose the option where you feel that you will be the most supported and most successful in your efforts. You also need to be sure to pick an option where you feel comfortable. For some women that will never be in a hospital. If you aren't comfortable or safe where you are laboring then it ultimately is going to affect the way your labor progresses.

It's also important, as you have mentioned, that you work through the anxieties and fears you have at this moment in time the very best that you can. In some cases that's going to be dealing with your present situation, but in other cases that may point back to your c/s experience. I'm not suggesting that you will ever be able to work through those issues completely, but at least being able to come to a sense of peace about them is important.

I would encourage you, if you haven't already to find a local ICAN chapter if there is one in your area. I can attest to the fact that there is nothing that replaces being able to speak with other women who have been there in real life. The next best thing is certainly talking here or signing up for the ICAN main email list. You'll certainly get more information that you can likely process all at once, but it's a tremendous resource (though certainly not for everybody). You can find a chapter/sign up for the email list at www.ican-online.org

 

[egoldber]

Quote:

You have the same risk of rupture that a woman who has never been pregnant before has.

I'm not sure where you're getting that info, but it is not correct. For someone with a previous transverse LUS uterine incision, the odds of UR with spontaneous, unaugmented labor are about .4 to .8% depending on the study you read. Many of these studies do indeed exclude inductions and also dehiscences from their stats. The odds of UR on an unscarred uterus are around 1 in 17,000. That's a HUGE difference.

Now the odds of other complications are certainly similar for a VBAC as they are for other non-VBAC labors (cord prolapse, placental abruption, etc.).

 

[doctorjen]

Lex - one thing that might help make your decision is to find out in as much detail what you could expect from your birth experience in each location. Find out if you are likely to have the hospital-based midwife you like actually at your birth, and find out when she has to consult with a back up doc, and when she'd have to turn over your care. Find out what type of monitoring would be required, how often you could expect to be examined, what they'd want to do if you were progressing slowly. Find out who can be with you, how much you can expect to be consulted about decisions about interventions. Find out what happens with the babe immediately after birth, and throughout your stay.

Find out the same info from your homebirth midwives, too.
Perhaps visualizing what each type of birth would be like would help you see if there are things about either situation that you feel like you can't live with.

From a risk point of view, I think if you have a catastrophic rupture your outcome is likely to be bad no matter where you are. If you have a less catastrophic rupture, you are probably safer in the hospital. Unless you live somewhere with really seamless transfer protocols, getting into the hospital, getting evaluated, and getting the baby out take time. The risk of rupture is about 0.5% (generalizing from many studies) and most seem to quote a risk of catastrophic rupture (where baby and mom are in instant danger and there is a significant risk of losing the baby) at around 1 in 2000.

With an anterior placenta you may be at a slightly increased risk of accreta, which is unlikely to be an emergency - although it can cause a postpartum hemorrhage, most often it is a more of a placenta won't come situation, and you may be bleeding slowly while it's still in. However, if you get some scar separation and the placenta is implanted under the scar, you are also at risk for an abruption. Ultrasound later on may be able to give you more detail on your placental site - "anterior" is a pretty big place.

I would encourage you to listen to your intuition and make your plans based on where you would feel safest and best able to birth your baby without worrying.

 

[USAmma]

I would try to listen good and hard to what your gut is telling you. Try to get all the noise about statistics and such, and just go with what you feel would give you the most peace when you think about giving birth in each of the locations. Go with your gut. There's a reason for intution.

 

[DreamsInDigital]

You need to feel absolutely comfortable with where you're birthing. Period. If it's home, great, have a homebirth. But if it's the hospital, do it and just try to avoid as much intervention as you can and try to have as natural a birth as possible.
Either way, the bottom line is you will have a better birth if the choice is up to you. Ignore the statistics for now and go with what your gut is telling you.

 

[citymama]

Oh, Lex, these decisions are difficult. I agree with others who've said to go with your gut. I think the doubt and second guessing are all part of the process many of us VBACers go thorugh at some stage in our pregnancies.

If you stick with your homebirth plan then it would probably be prudent to keep in touch with a backup hospital midwife and discusss her preferred VBAC protocol alongside your birth preferences. I know the financial pressures can be difficult, but have you looked into a doula? If you are not quite keen on one of the homebirth midwives, a doula might help with the fears and with the emotional support whether you labor at home, in a hotel room or in a hospital.

Also, what do your midwives say about the placenta being anterior? Mine is anterior and it didn't cause my OB to blink when I asked about its positon.

Be sure to take some time to relax in a safe, quiet place with your babe and try to put all the birth thoughts and fears out of your head for a bit.

Some quiet time can also allow you to relax and let yourself mourn the past and really see what you want for the next birth. Just today I had some time for my yoga practice in a quiet studio all alone. At the end, with the distractions of daily life subdued, I started thinking about birth. I cried about the fact that I was separated from my first daughter for 4 hours after she was born. And I envisioned how beautiful and right it would be to hold my next daughter from the moment she enters this world. The image of having her with me, never separated after birth, was so reassuring and I know that my choices are right despite all I hear from moms I know who've opted for planned repeat cesareans, or the UR stories from my OB who wants me to have epidural (note- i'm switching to a midwife).

I hope you resolve all this soon and enjoy your third trimester!

 

[Jane]

I just wanted to throw in a recommendation for birthing from within classes/book as a great place to explore your fears about birth.

I don't think there is better advice than to find your comfort zone. For some women, being at home is the ultimate comfort. Others like *new* spaces, even in times of stress, and find the creature comforts of a hotel (or hospital) inviting. For some people, any safe provider is good, for others, knowing who exactly is going to be there and exactly how she will respond is of utmost importance. These things don't really have anything to do with risks or VBAC. I know you will pick safe, competent care providers who will help you make good decisions in labor. But your most comfortable place is the place you'll labor best. Because you had a cesearian, you may labor more gently. You will (statistically, of course) have lots of time to enjoy or not enjoy your environment.

 

[wifeandmom]

Quote:

Originally Posted by citymama Also, what do your midwives say about the placenta being anterior? Mine is anterior and it didn't cause my OB to blink when I asked about its positon.

The placenta being anterior isn't so much of an issue unless it is ALSO lying low in the uterus. THEN the concern becomes whether or not the placenta is actually attached to the uterine wall where the previous incision was made.

Obviously if the woman in question has never had any type of uterine incision and/or the placenta is not ALSO low-lying, then this whole discussion is moot.

However, a low lying anterior placenta is less likely to 'move' upwards as the uterus grows and is also much, much, much more likely to also have a co-existing accreta associated with it.

Accreta is serious business with about a 7% mortality rate for mom based on the studies I've seen. It is possible to detect *some* cases of accreta with the higher tech u/s available today, but not all cases are detected via even the best u/s. Accreta is on the rise, and almost every study or article you read attributes the rise in accreta to the increase in c-sections since simply having had any type of uterine surgery (including D&C's and abortions) dramatically increase your risk of the condition.

Now, all that said, I'd want to know exactly HOW low they are talking when they say it's anterior and low lying. I'm assuming they've ruled out any previa, which is a good sign in terms of accreta risk.

But you are right IMO to be concerned simply because of the location of the placenta at this point. Add in the lengthy time it would take to get to the hospital, and it's even more concerning. I know a hotel or friend/relative's house closer to the hospital is NOT the same as home...BUT it's definitely something to consider if you truly feel like you'd be safer closer to a hospital but still not IN a hospital unless the need arose.

Good luck with your decision!

 

[wifeandmom]

Quote:

Originally Posted by kathan12904 I also want to add, that the chances of your uterus rupturing are .2%. That meand 2 out of every 1000 women have that problem. In that .2% are mostly cases of small dihesion or "windows."

I'd be interested to read the studies that back this claim up. I am sure there are *some* studies that show a 0.2% rupture risk, perhaps even some that included small openings/windows along with catastrophic ruptures.

However, this is certainly NOT the generally accepted risk of catastrophic rupture with VBAC attempts. Roughly 1 in 200 women will experience a catastrophic rupture (that is, roughly 0.5%) IF they are NOT induced, NOT augmented, and NO cervical ripening gels are used. Add in ANY of the above and the catastrophic rupture rate just goes up.

Obviously if we're talking about a homebirth, there won't be any Pit running, so the 0.5% rate is probably fairly accurate for a homebirth setting since none of the other interventions mentioned would be in use.

Quote:

You have the same risk of rupture that a woman who has never been pregnant before has.

I would ask for research to back up this particular tidbit, but I already know it simply does.not.exist. It simply is not true. Not even CLOSE to true actually. Catastrophic rupture in the unscarred uterus is something like 1 in 15,000, or maybe even less than that. The risk during a VBAC attempt is most assuredly higher than 1 in 15,000.

Information is only useful for decision making if it is accurate. And these two statements are simply false, therefore I'd hate for anyone to come along, read it, and make decisions based on faulty information.

 

[citymama]

Quote:

Originally Posted by wifeandmom Roughly 1 in 200 women will experience a catastrophic rupture (that is, roughly 0.5%) IF they are NOT induced, NOT augmented, and NO cervical ripening gels are used. Add in ANY of the above and the catastrophic rupture rate just goes up.

Hmm. I've been trying to track down my studies again, but I don't believe this is true. The risk of UR ranges from 0.2-0.8% depending on the study. My understanding is that these do not differentiate from a full UR and a dihesence. Certainly, using prostogladins or pit to induce increases the risk to aboug 1.5% give or take depending on the study and this is why no OBs I know of would induce. Also, the fetal mortality rate is something like 6 in 10,000 for VBAC and 3 in 10,000 for cesarean delivery.

I always like Henci Goer's articles. To start with see
http://parenting.ivillage.com/pregna...,,9rft,00.html

 

[egoldber]

Citymama, the problem with Henci Goer's stuff is that her books are old and do not include the most current literature. If you read the NEJM study, then you will see where the PP got her stats. The .5% for UR (not including dehiscences and augmentation) os from that December 2004 article. The risk of neonatal death was about 1 in 2000 for a VBAC in that study.

 

[aisraeltax]

have you considered a birthing center? i birthed at a B/C with a wonderful MW. i dont know how far from Milford NH you are but if you are interested pm me.
i agree that you absolutely MUST be comfortable when birthing.
i liked my B/C b/c we were very close to a hospital. having said that, if i had been IN the hospital i would have had c/s #3 b/c 1. my labors are very long 2. i would have given in had someone said "would you like something to help with that pain? you don't have to be superwoman, you know? and 3. i woudl have probably begged for somethign at one point and that woudl have led to more interventions, and a c/s.
thats just my .02!

 

[kathan12904]

Quote:

Originally Posted by wifeandmom Obviously if we're talking about a homebirth, there won't be any Pit running, so the 0.5% rate is probably fairly accurate for a homebirth setting since none of the other interventions mentioned would be in use.

Since the calculated .5% is based almost solely on hospital data, there isn't an accurate way to apply it to homebirth. I'm sorry to be unable to find the study on the internet that quoted .2%. Every midwife I have spoken to has supported that number and I bet if you attended your local midwife support group, the people there would verify it as well. ACOG might not, but since they are the ones with the 20+% c/s rate, they might not be the best source.

 

[wifeandmom]

Quote:

Originally Posted by kathan12904 Since the calculated .5% is based almost solely on hospital data, there isn't an accurate way to apply it to homebirth. I'm sorry to be unable to find the study on the internet that quoted .2%. Every midwife I have spoken to has supported that number and I bet if you attended your local midwife support group, the people there would verify it as well. ACOG might not, but since they are the ones with the 20+% c/s rate, they might not be the best source.

Hmmm, I personally think if the NEJM published a large scale study quoting much higher stats, I'd trust something published and easily accessible when making my choices that concern the safety and welfare of myself and my children, but others might prefer taking the word of a group of professionals that they trust.

0.2 or 0.8...those are both less than 1%, so very small numbers in the grand scheme of things. I'd think mom is more likely to experience a whole lot of other things during childbirth if we're just talking statistics. And in any of THOSE circumstances, being as far as the OP states she is from medical back up would really cause me great concern. I'm not sure how one would go about putting that out of their mind while trying to relax and labor at home, KNOWING that if a TRUE emergency occurred, there would be pretty
much no hope of saving baby without brain damage or death. THAT would certainly hamper my ability to birth peacefully at home, but others certainly might be able to get over this fact.