Stopping by today to post something I wrote 5 weeks ago. Now that I am out of the pregnancy closet, so to speak, I can finally publish it. Most of these statistics and facts can be found in numerous places, but I’ve sourced a few references here to be direct. It’s an issue that I never thought would affect me and one that affects one in three American mothers.
As I write this, I am only 7 weeks pregnant and haven’t told many people at all that there is an exciting new chapter ahead for my family. I also can’t muster the energy to think about a nursery or baby names or much else that lies at the end of this part of the story because I’m right in the thick of that pregnancy icky-ness that overtakes you at about this stage of the game. The fatigue. The “morning sickness” that sticks around too late in the day. The sore boobs. The tiny cramps that make you wince in anxiety when it’s probably just the expected growth taking place in your body. I can’t think much about the end or how this baby will arrive here and how I’ll be at that time. But despite my inability to really focus on that, I know one thing for certain. I want a VBAC.
Want really isn’t even the right word to use here. I yearn. I hope. I pray. I need. And I have for the past 23 months and two weeks and some-odd days that I’ve lived in my post-cesarean body. Every time I undress and step in to the shower and glance at that scar, I pray for a VBAC.
Some people surely think I am unhinged, and I’m becoming okay with that fact. But that doesn’t change my feelings on the issue or what I want for my life as a mother, what I want for the beginning of a new life with the tiny one I’m growing. It’s so hard to explain to people, why my cesarean threw me so off-track. Why I hate that it happened. Why I still cry about it at times. And the truth is I don’t know why some of us are so affected by surgical birth and some women don’t mind it or even prefer it. Some movies probably make you cry hysterically, and I don’t even bat an eye. That’s life. I don’t know why humans are different beings affected differently by the world around us, but we are. And I wish I didn’t have a chip on my shoulder about this, but I do. It’s a wound that heals and reopens again and again, and I expect it to be that way for a long time.
The best I can explain it is that I feel like I missed it. Like I wasn’t even there for the birth of my own firstborn son. I wasn’t under general anesthesia, so I was kind of there, I suppose. But it doesn’t feel that way for me. My arms were tied down like a crucifix, and my baby was extracted from me. When I think back to my son’s first moments of life, that is what I remember. Then the anesthesiologist knocked me under without asking my permission, woke me up three hours later, told me my gown was so bloody my family would think I was massacred, and stripped me naked to change me in the bright lights of a busy recovery room. Then my husband walked up with my baby and there he was: my newborn son. I could not touch him or hold him where I was, so we went to get settled in my postpartum room where I could hold him finally. And as the days passed, I was so grateful for the 20 or so hours of intense pain and real labor that came before surgery because they seemed to tell me that he was really mine and I was really a mother.
I am fully aware that some of you reading this are thinking I should shut up and be grateful for a healthy baby, and you might tell me so in the comments. And to that I say, I know. I know I should be grateful for his health, and I am. I know there are women who don’t have healthy children to tuck in at night and women who have years of trouble conceiving those children in the first place. And of course my pain would multiply ten times over if he’d emerged from that surgery with health issues. But grief is not a competition, and while I hold a lot of gratitude for so many things in my life, I hold a lot of grief for the abrupt way that motherhood began for me, for some lost moments and feelings that won’t ever be returned.
Still though, despite a healthy baby, I spent the next month of my life crying daily about how I was defective and my body didn’t even work and I didn’t deserve a baby because I was not a real mother. I don’t talk about it much, and only my husband and close family really saw the full psychological result of my cesarean, but it was intense and painful. And slowly these wounds have healed, but I am swallowing a knot in my throat as I type this, so there is still so much work to be done.
As I was being prepped for the OR after almost four hours of pushing with an occiput posterior baby, I vowed VBAC for my next one, and I heard two voices in the room – both medical professionals – responding to me. One said, “Oh, VBACs are too dangerous. Nobody does them anymore” and another said “Of course you can and that would be better than repeat surgery and they are totally safe.” So immediately, I became acquainted with the VBAC debate, and I have researched so much since then. You have no idea (or maybe you do for those of you who know me well) how much this issue has consumed me.
In part, I was simply confused. Typically the medical community can agree on such a straightforward thing, right? Yet even as I was just beginning discussion of the idea, right there in my labor and delivery room, I was getting two vastly different answers. My cesarean was really emotionally scarring for me, and I yearn for a vaginal birth to replace some of those memories with a birth the way nature provides, but I also know that doing something dangerous would not be the solution, and I truly wanted to make a decision that (my emotions and baggage aside) would bring us the best chances of a safe outcome for mother and baby. So as the months have gone by, and I am reading and reading and reading every medical article I can get my hands on, I find this:
- ACOG endorses vaginal birth after cesarean (or VBAC), and ACOG is the governing organization of every OB in America. (source)
- Yet it is estimated that between 50-80% of OBs in America refuse to do VBACs. (source) I speak from personal experience that here in Atlanta, it’s more like 95% won’t even touch it.
- VBAC is an assumed course of action in other countries such as England, Australia, and the Netherlands, and every study you see lists their maternal care rates as far higher than ours. We have one of the highest cesarean rates in the world, and our maternal morbidity rate is the worst of any developed nation. (source)
- As a woman with a scarred uterus, I have a 0.4% chance that my uterus will rupture during labor. (Some studies show a bit lower for a mom with only one prior cesarean.) To put that in perspective, I have a 99.6% chance that my uterus will not rupture in labor. By comparison, as a first time, unscarred mom, I’d have a 0.7% chance that the placenta will detach from my uterine wall (source) which has dire consequences like hemorrhage, yet none of us think about that going in to labor, and doctors don’t just section everyone to avoid it. As a first time, unscarred mom, I’d have a 0.5% chance of dangerous placenta previa occurring (source), yet doctors don’t say surgery is necessary for all unscarred women and we should all avoid labor just in case it happens. Are you following me here, reader? American women are repeatedly cut for fear of uterine rupture when other dangerous complications are actually more common, yet we don’t worry or sign up for surgery to avoid those risks. Essentially, the risk associated with VBAC is about the same, or in some cases lower than, the risk of various other complications in birth. This table explains what I’ve just said in a simple and perhaps more easily understood way.
- Cesareans do not come without physical risks. It is major abdominal surgery where your internal organs are removed and reinserted. Compared with a vaginal birth, cesarean mothers are at a sharply increased risk for hemorrhage, blood clots, bowel obstruction, and infection. (source) None of these things are harmless or pleasant. Future reproductive problems also sharply increase with each cesarean birth – placenta accreta, ectopic pregnancies, and placenta previa. (source)
- While I thought I was bizarre and defective for feeling so many psychological implications after my surgery, I’ve since found that there is a correlation between cesarean sections and rising rates of postpartum depression. While every cesarean mother doesn’t feel this way, many of us do. In fact, even orangutans with cesarean surgeries often don’t recognize their own offspring. (source) Clearly I am not a monkey, and I sometimes feel like I bonded with my son even more powerfully in a we-went-through-hell-together sort of way in those early days. But my point is that nature provides an exit route for our babies, and the cocktail of hormones that facilitate early bonding doesn’t happen with a cesarean. It makes the early days much, much harder for many mothers.
- It is essentially common knowledge by now that babies born by cesarean are more likely to have asthma, allergies, and breathing problems for the rest of their lives. (source)
- Infections result from cesareans in about 1 out of every 20 surgeries. (source)
- I am three times more likely to die from a cesarean birth than a vaginal birth. (source)
So if VBACs are safe, I hear you say, why do doctors refuse to perform them? Litigation, ignorance, insurance.
VBACs were in vogue in the late 80’s and early 90’s here in America, and doctors were using Cytotec constantly in VBAC inductions. (For more on the dangers of Ctyotec, read here.) If you look at the statistics from that time period, using Cytotec to induce a VBAC patient multiplies their risk of rupture more than twenty times over.(source) Yet instead of just assuming it was the off-label use of the drug that led to ruptures (eventually realized because nobody uses Cytotec any longer, even on non c/s moms), doctors stopped doing VBACs all together and assumed they were dangerous. [Tangent, but the drug is supposed to be used for the treatment of ulcers. It wasn’t even developed for use on pregnant women, and the packaging actually lists a warning that pregnant women should not use it, but it was used by doctors in labor inductions for over a decade!]
So fast forward a decade or two, and you have the National Institute of Health, the World Health Organization, and the American Congress of Obstetricians and Gynecologists all telling physicians that VBAC is safe and even preferable, yet most obstetricians still won’t touch the VBAC question, and they’ll quickly tell patients that vaginal birth would just be far too dangerous because of a risk that is 99.6% likely NOT to happen. As Dr. Shelley Binkley says, “It’s a numbers thing. You don’t get sued for doing a C-section. You get sued for not doing a C-section.” (source)
So safety and the recommendations of professional accrediting organizations are cast aside, and my personal health decisions are left to the preference of insurance companies and doctors who have more regard for litigation-shaped practice than they do for research-based practice. Obviously, some doctors see a problem with this, and the debate continues. Dr Robert DeMott of Bellin Memorial Hospital explains, “Patients are being hoodwinked into choosing cesareans by overblown fears …… Putting it bluntly, it’s unethical to recommend a practice that leads to more patient deaths.” (source)
So this pregnancy, I am driving 50 minutes to and from my provider for standard pregnancy appointments. On the way there, I pass countless other offices who refuse to do VBACs or say that they do, but records indicate they see only a handful every year which is not a level of expertise I am comfortable with. If you want to go with a tried and true VBAC provider in the metro Atlanta area, one who has seen hundreds and is experienced in how to handle them and how not to handle them, you have two choices. Two. In a major metropolitan area swimming with babies and obstetricians.
So do I have a chip on my shoulder about the VBAC issue? Absolutely. But not because I am some nutcase who measures my macho maturity by my ability to push a baby out my vagina. Not because I am willing to put my baby’s life at risk for my own experience. I have a serious issue with this subject because I am forced to fight so hard to achieve something that is a standard of care in many other developed nations, something that major research institutions have proven is safe. Something that, plain and true, leaves me with a lower risk of death and complication than the alternative.
I don’t think well-informed women who choose a repeat cesarean section are necessarily making the wrong choice. They are entitled to choose what works best for their health and their own family. What I desire is that same choice for myself. If a vaginal birth is possible and, according to leading health agencies, not posing incredible risk to myself or my infant, I should be entitled to make that decision about my own health and my own body.
Birth comes with no guarantee. It can go beautifully with absolutely no complications (as it usually does) or difficult and dangerous things can happen. I find that’s the case with most things in life though, no? All we can do is research, make the decision that leaves the lowest foreseen chance of damage, and trust that things will unfold as they should. For me and for the baby I’m carrying, I’m confident that choice is to pursue a vaginal birth. And do I know I will have a vaginal birth? Of course not. It’s why I am giving birth in a hospital with an OR in the case that I need to have surgery to save the life of that baby. But unless that surgery is truly necessary, I don’t see why I should sign up for something that is no trivial matter.
ETA: I did have a beautiful vaginal delivery about 7 months after I published this post. To read my birth story, click here.