Monday, April 14, 2014

My Failed VBAC Attempt

I attempted VBAC (vaginal birth after c-section) for all the right reasons. 

To run down the list: under 35, not overweight, no gestational diabetes, had only one previous c-section, more than 2 years ago, with a transverse incision. I went into labor before my due date and my daughter was only 7.1 pounds. 

My prenatal care was with a well-trained CNM (Certified Nurse Midwife) with 15 years of experience delivering babies, including VBAC babies, in a hospital setting. The hospital was welcoming to appropriate VBAC candidates, and the staff even had a recent experience with uterine rupture which thankfully had a healthy outcome. I felt confident in their ability to handle an emergency situation. 



My midwife told me not to frighten myself by looking up a bunch of uterine rupture stories, but of course I was going to at least do some looking into the issue. Uterine ruptures are rare, but not that rare - about 7 in every 1000 births. They are a life threatening complication for both the woman and especially the baby. Even for the survivors, it is common for a woman to end up with a hysterectomy, and for the baby to suffer brain damage. 

If you Google "uterine rupture stories" you can find plenty with happy endings (I imagine the people with sad endings don't like to share their stories as much), but they all happen in a hospital and after a terrifying ordeal for everyone involved. 

Of course having another c-section carries its own additional risks, so I decided that as long as I remained low risk throughout the pregnancy and did my VBAC with a CNM (opposed to a non-nurse midwife) in a good hospital, I'd be okay. 


The hospital didn't stop me from keeping Bee in my room.
Thank goodness I took the necessary precautions, because I did have a uterine rupture! After almost two hours of pushing and the baby almost coming out, the OB told me, my husband, and the CNM that she "strongly recommends a c-section." That was enough for me; just show me where I sign the consent form and get this baby out. 

It wasn't until after they opened me up that she saw the ruptured uterus. Apparently my daughter's body was blocking the opening, thus preventing anything from coming out or in. Had I managed to push her out vaginally, everyone at the hospital would have gone into red alert mode trying to save both our lives. 


Mom, Dad, big sis, and baby Bee, all healthy and together.
After they whisked my daughter Eulabee, my husband, and the CNM out of the room I closed my eyes. Thinking I was asleep, the staff went ahead and expressed their shock over what had happened. 

OB: So.... when I opened her up, the baby's shoulder was sticking out of the open scar. 

*a couple soft gasps and some awkward silence* 

ANESTHESIOLOGIST: She's not going to try this again, is she? 

No, siree, I am not! I'm quite happy as the mother of two, and this birth scared the bajeebers out of my husband so bad that he ran out and got an vasectomy as soon as he could. 

I attempted VBAC for all the right reasons, and it failed. 
Because I took all the precautions recommended by the medical establishment, I'm fine and Eulabee is fine. What about those who don't take such precautions?  


I have only ever written about birth and the Natural Childbirth Movement once before. It is still my most frequently read post, attracted the most comments, many of them attacking me for criticizing aspects of that movement. When I wrote that post, I had not yet delivered Eulabee. But I was pregnant, and wrote: 
When I found out I was pregnant again, I immediately called the Birth Center. I found out I couldn't have my second baby there, so I asked for recommended options. I was given a short list of CNMs who work at or with hospitals, which was great. 
But then the person on the phone said, "I can also give you the names of midwives who do homebirths." What!? If it isn't considered safe enough for me to attempt VBAC at a top notch Birth Center across the street from a hospital, why the hell would it be safe for me to try it in my home that is a 20 minute car ride (not accounting for traffic) from the nearest hospital? If the Birth Center is responsible enough to not take on clients with higher risks, why would they be so irresponsible as to recommend alternatives which are even less safe? This is the influence of natural childbirth, a movement that is more motivated by crackpot theories and warm-and-fuzzy feelings than science and evidence.

That evaluation stands. To promote a VBAC for women who fit all the low-risk criteria and who are giving birth in a hospital with staff poised and ready for an emergency is fine. 

But there are lots of people out there promoting HBAC (Homebirth after c-section) and HBA2C, HBA3C, and even HBA4C. Since the increased risk of HBAC is relatively small (although I imagine in hindsight it seems huge for the parents who watch their babies die or suffer brain damage) there are, of course, far more success stories than tragic ones, and these happy endings are blasted all over the Internet as if they are proof that HBAC is generally as safe as VBAC in a hospital. 

On MotherBloom, midwife Christy Tashjian tells the story of one successful HBA4C, frames it as a women's rights issue (opposed to a health care issue - as if the mothers are the ones who would be held accountable for malpractice), and emphasizes feelings over medical facts.

Holly on Homebirthers and Hopefuls tries to downplay the risk of uterine ruptures by saying: 
The main risk that midwives and consultants are concerned about with VBACs is uterine rupture, however, this is a much misunderstood and extremely rare occurrence. The vast majority of uterine ruptures will not result in mortality for mother or baby. Rupture can also occur in an unscarred uterus and can happen before labour begins, which means that it can happen whether you plan a VBAC or an elective caesarean.  
The majority of uterine ruptures do not result in mortality for mother or baby because of treatment that is only received in a hospital! More importantly, if treatment is delayed even by minutes, that severely increases the chance of death or brain damage. 

Also, extremely rare? The overall rates are 7 uterine ruptures for every 1000 births. Given how many women are giving birth every day, that's a lot of uterine ruptures! 

The CNM attending my prenatal care and birth had already done over 1000 births (I'm not sure how many VBACs) by the time she got to me, and she boasted that she'd never seen a rupture. After mine, I jokingly apologized for ruining her stats, and she jokingly said, "no it's fine, now I've had my one so I hopefully won't see another before retirement." But I could tell she was really shaken up. Uterine ruptures are no joke. When they happen they are serious threat to the lives and health of the mother and child. 

What this means is that midwives who attend HBACs have resigned themselves to needlessly endangering the lives of seven woman and their babies for every thousand, for the sake of giving the other 903 women a more pleasant birthing experience. That hardly seems ethical.  

Vicki Williams, a "Birthkeeper, Doula, Breastfeeding Specialist, and Lactation Consultant" (so no medical credentials), goes so far as to encourage a homebirth after a uterine rupture

Some women, such as Aneka who managed a successful HBA3C, are portrayed in the media as rather heroic. After watching Ricki Lake's documentary The Business of Being Born, she said she realized:
I'd been robbed of the birthing experience. If possible, all women should be allowed to birth naturally.

Aneka wasn't robbed of her good health and success in having three healthy children by c-section. Yet she expresses only disdain for the medical establishment that delivered those healthy babies. Had she been one of the minority who experience uterine rupture and lost her fourth baby because of the time it took to get to the hospital, would that have been worth the "birthing experience"? 

Then you just have this sort of insanity on website such as MamaBirth, which really hypes the "pride" and "empowerment" and how it "feels" to give birth naturally at home, and just outright disregards the increased risks of complications such as breech, as well as VBAC. 

Really, I've just touched the tip of the Natural Childbirth iceberg when it comes to advocating homebirth for VBAC and other higher risks pregnancies. Surf around the Internet for an hour and discover gobs more crazy for yourself. 

Since so many people seem to be moved by personal birth stories, Dr. Amy of Skeptical OB writes a lot about the unfortunate and grieving minority whose babies die or experience brain damage because they attempt high risk homebirths. HBAC examples include baby Vera, whose mother attempted an HBA3C, just like Aneka, baby James, baby Liam, a baby whose mother was hoping for an "awesome HBA2C story", the mother who attempted a VBAC at a birth center without continuous electronic monitoring, the mother of 6 who attempted an HBA2C, a mom who bragged online about her HBAC, despite the fact that her baby suffered brain damage, and many more. (I can only stand reading so many of these before I want to crawl into a closet and cry.) 

In his article Ten Thoughts On VBAC, Nicholas Fogelson of Academic OB/GYN - who favors VBAC attempts in hospitals and under the right circumstances - writes: 


VBAC should not happen at home.   I have recently referred to that as a game of Russian Roulette, and defend that view here.   In this case the gun has 100 barrels, but the bullet will kill the baby just the same.  If a woman can honestly say they are willing to take a 0.5% to 1% risk of disaster, then fine, but to me that risk is way too high.  I think home birth is an acceptable option in many cases, but VBAC is not one of them.
HBAC? Please! I could have died, mama!
Note the lack of touchy feeling bullshit. 

I attempted VBAC for all the right reasons, and it failed, because birth is inherently risky, even more so after having a c-section. 


To any women out there thinking about VBAC, I strongly advise only doing so if you are low risk, and then finding a OB or CNM working in a hospital that is totally supportive. 

For those planning an HBAC, I urge you to reconsider. HBAC is simply not safe enough. Had I made such an attempt, my spunky toddler Eulabee would not be here to make funny faces as she grabs for my cellphone. 

As any adoptive parent knows, welcoming a new son or daughter isn't about the birth experience. It's about bringing them home. 

12 comments:

  1. Thank you so much for sharing your story! I know two women who experienced UR during VBAC attempts. One was in a hospital, and like you, the rupture was not discovered until they proceeded to a c-section. Both she and her baby survived. The other had a HBAC at home, attended by a CNM who transferred at the first sign of a problem. Her son died. When she shares her experience, she is accused of being a "fearmonger" by the NCB community. There is no compassion or sorrow expressed for her loss, only anger that she would dare to harsh their mellow.

    I have had two vaginal births. The first was unmedicated, in a hospital with CNMs. It was more painful than anything I could have imagined, and would have resulted in my death had I been at home (I had a massive pph caused by a cervical laceration that required repair in the OR. Even with prompt care, I still came very close to requiring a blood transfusion). My second was born with the aid of a fantastic epidural, and it was a wonderful birth. Both of my deliveries left me with an enduring respect for the wonders of modern medicine that alleviate pain and prevent death during childbirth. We are so fortunate to live in a time and place where we have access to these obstetric interventions, and I fail to understand how it is feminist to degrade women for choosing safety and comfort during their births.

    ReplyDelete
  2. Thank you for sharing this, and keeping the touchy feely BS out of it.

    ReplyDelete
  3. I am also a uterine rupture mom. Like you, my VBAC attempt was at a hospital, which is what saved both me and my daughter.

    It's been four years, and I'm still waiting for the people who pressured me to have a HBAC to say that it was a good thing I didn't listen to them. I don't think that day will ever come, unfortunately.

    Thank you for sharing your story. I know that there are plenty of HBAC fans who don't want to hear what you or I have to say, but there are other mothers who will take your words to heart and will make a better choice for themselves and their babies.

    ReplyDelete
  4. Thank you for sharing your story and your thoughts on the matter! I just wrote about HBAC last week.... comparing HBAC mortality rate to hospital VBAC mortality rate.... it is shocking. It's very sad, actually, b/c it shows how many babies are dying preventable deaths at home attempting VBACs.

    ReplyDelete
  5. Thank you for sharing. I am currently pregnant and hoping for a vbac. I knew there was a risk of rupture, but I thought it was fairly insignificant. I will definitely find an experienced doctor and listen to her advice (as I did the first time when I wanted a natural drug free birth).
    I am interested to know if there are signs of rupture to watch for. It sounds like if they didn't switch to csec when they did your rupture would have either been much worse or gone unnoticed for much longer.

    ReplyDelete
  6. Bravo. For sharing your story in an honest, open and non-accusing way. Birthing for each woman in person and should be unique and each person's issue taken into consideration. Congrats on 2 healthy children!

    ReplyDelete
  7. I'm an artist, not a doctor, so I can't answer any specific medical questions about signs of uterine rupture. What I have assessed is that birth is inherently risky (there are high death rates of moms and babies during the pre-modern medicine era and in countries with poor access to modern medicine.) It's not something we can control or predict how it's going to go. The best we can do is follow the advice of actual experts who have spent their careers studying birth and treating pregnant women, and hope for the best. If someone is going for a VBAC, I think that's fine so long as you are getting care from medical professions - even better if they are experienced with lots of VBACs. I would have loved to avoid a second surgery.

    ReplyDelete
  8. I am a proud and happy HBAC mother and I am extremely offended by your article. I'd be really interested in knowing where you found a uterine rupture statistic of 7%? The actual number is LESS THAN ONE PERCENT. You can find the actual literature here: http://ican-online.org/vbac/home. Maybe before you go scaring off pregnant women, you should actually do your research. Birth is inherently risky? Less people die from uterine rupture than from car accidents every year. Do you drive?

    ReplyDelete
    Replies
    1. Djenney, I cited the stat .7% twice, not 7%. I also quoted academic OB/GYN who wrote .5-1%. I'd advice you to read articles more carefully before you comment.

      Driving is inherently risky, but if done with caution, we deem the risks worth taking. Birth is also inherently risky, but again the risks are worth the benefits. Are there any benefits to not buckling your seatbelt that are worth the added risk to your life and safety? I'd say no, and that's why we have seatbelt laws which save lives. Are there any benefits to homebirth that are worth the added risk of having a uterine rupture while not in a hospital? No, there aren't. If a midwife agrees to do HBACs and over the course of her career attends 1000 births, statistically speaking she is likely to see 7 uterine ruptures, each with a much higher than in-hospital chance of mortality or brain damage for baby or mortality or loss of uterus for mom. Is that worth the warm and fuzzies?

      Delete
    2. So why are you so offended by this, djenney? Are you realizing that you took a real risk by having a HBAC? If you're so confident in your decision, why do you need to respond?

      I'm glad that you weren't in that .5-1%. I know other people who weren't so lucky.

      Delete
    3. I'm really glad you and your daughter are okay. Homebirth can be wonderful for low-risk women in the hands of a skilled midwife. It is clearly not safe/appropriate for other people. My first midwife (home CNM) and current midwife (hospital CNM) - both low-intervention providers - think home VBAC is not worth the risk, and I trust their medical opinion. I personally wouldn't do an HBAC, either. I agree with much of what you and the people you quote have said. I totally support trying for a VBAC, but you obviously made the right call by doing it in a medical facility.

      But I think the statement "this is the influence of natural childbirth, a movement that is more motivated by crackpot theories and warm-and-fuzzy feelings than science and evidence" is extremely unfair. There are actually many subsets of the natural birth movement (if you can characterize it as one movement). Generalizing and condemning "the natural birth movement" is not much different than making blanket generalizations about ALL doctors, or ALL members of a certain religion.

      There are obstetricians who support spontaneous, unmedicated birth and do everything they can to help their patients have one when that's what they want. No crackpot theories there. There are highly trained hospital midwives and nurses who do the same. There are doulas who love natural birth but also support women who are having elective inductions and elective c-sections, because everyone who wants support deserves it. And the GOOD/smart homebirth midwives, in the U.S. and all over the world, refer high risk clients to have hospital births.

      All of these people support and celebrate natural/physiologic birth when that's what a mother wants and it's medically possible, making them part of "the natural birth movement."

      I assume what you are referring to is the subset of the natural birth movement that is disdainful and hostile to all Western medicine and technology. These are the people who criticize and judge women for going to a hospital or choosing pain medication. These are people who think birth is always safe and should only go one way (their way). These are the people who willfully ignore facts to support their agenda, and give the rest of us a bad name.

      They suck. But not everyone who considers her/himself a natural birth supporter is one of those people, and I think it's important to recognize that. The people who originally started the "movement" were not trying to pressure women to stay home and have medically risky births! They were simply trying to counterbalance a medical system in which healthy, low-risk women were being subjected to painful, non-evidence-based, sometimes humiliating routine procedures.

      We can support natural birth AND be thankful for and take advantage of technological care that saves the lives of mothers and babies.

      Delete
  9. Thank you for this! This is a fantastic post. I am so happy that you and your daughter are both safe and healthy! Thank you for sharing your experience and your knowledge and opinions.

    ReplyDelete