C-Sections are Births Too!

After writing my last post, a "block" seemed to have been moved; story after story of amazing births I've been privileged to attend just seem to tumble from my memory; I sat down at my computer to start writing about them, and then I thought about E.

E. gave birth to her third child, a precious little girl, several weeks ago. It was E.'s third C-section, her second attempt at VBAC, her third attempt at a vaginal birth. With both of her previous birth experiences, the argument could be (powerfully) made, that mismanagement of her labor led to each C-section. With her third birth, only God knows why events unfolded as they did, and led to a third surgical birth, this one an emergency situation, that occurred with E. under general anesthesia.

E. had tried so hard to "do the right thing". She takes excellent care of herself. She's well educated, seeks out the right support for herself, does everything she can to have a safe, healthy birthing for her children and herself. For her first birth, she chose to be attended by very well-known Certified Professional Midwives; for her second, she chose to attempt VBAC with a physician who works very hard to be "hands off" and encourage her patients to give birth on their own terms; for this third birth, E. was fortunate enough to live in a city in which a prominent (it could be argued the national expert) physician-researcher (responsible for probably the most comprehensive study on VBAC ever published) practices. She chose this physician to attend her for her third pregnancy and birth, and together, this patient/physician team worked very hard to secure a healthy pregnancy and safe birth. In the end, that is exactly what they did...although with a significant "hitch" that both of them would rather not have experienced.

After an uneventful pregnancy and smooth first few hours of labor, no pain meds, no epidural, with an attentive husband and doula at her side, E. had progressed smoothly to nearly transition labor. I was so pleased for her! Having popped my head into her labor room to welcome and encourage her, and a share a quick hug with her doula, a close friend of mine, I picked up my bag and clocked out for the day (she had arrived near the end of my shift, and I would not have the good fortune to be her nurse). There was a celebratory mood in the room, and I was nearly floating on air out of happiness for her.

On my way off the unit, a barrage of nurses, residents, and the prominent attending physician suddenly came barreling out of the nurses station, clamoring towards E.'s labor room. The flurry of activity, calls for help and surgical preparations (anesthesia! OR!) that were occurring made it clear that something had gone wrong. The amazing emergency "machine" of our unit had mobilized. When a true emergency occurs, this is a thing to behold. The nurses, techs, clerks, anesthetists and physicians on the unit truly become a single entity, each individual a cog in a wheel that is rotating furiously, each performing nearly automatically, and almost always expertly, their own function, with the goal of getting the mother into surgery, and keeping her and her baby safe. While I admit that the "adrenaline addict" in me gets a bit of a "high" from situations like this, and while my main goal is to avoid having any of our mothers go to the OR, times like this make me feel grateful, and humbled to be able to call myself a part of this amazing team.

Already out of my scrubs, and off the clock, I felt helpless and powerless as I watched in dismay the "machine" thunder down the hall towards the OR with E., hunched over in "knee-chest" position in her bed, her doula and her husband running behind as they pulled on the white, zip-front "bunny suits", caps and masks they would need to accompany E. in the OR. I knew she would be OK. I knew the baby would survive...because I know that machine; but I ached that she seemed to be losing her last chance to have the vaginal birth she had always dreamed of having.

After the commotion had settled, the baby was out, and both she and her mother were deemed safe, I learned that E. had experienced a uterine rupture! This blew my mind. Why her??? She had worked so hard! She was well nourished, it had been several years since her last birth, plenty of time for good tissue healing, and from her previous op reports, she had had a strong, "double layer" repair after her second C-section. She had labored naturally, without the aid of Pitocin, and had (gratefully, in retrospect), had no pain medication or epidural to mask the symptoms of uterine rupture. She had labored to almost complete dilation. The odds were so in her favor for a vaginal birth that this occurrence was a true stunner.

Fortunately, the tear in E.'s uterine wall was repairable, and with the skill of what I am convinced is the best surgeon and surgical team in the country, E. was safe, her baby is healthy, and I know she will heal well.

Physically, at least.

But emotionally?

E. knows that what happened to her was a random, unlikely occurrence. She is grateful and happy to be alive, and to have a healthy daughter to love and raise; but still she grieves for her lost opportunities to experience birth as she had always expected she would; to give birth the way she was designed to. To give birth the way most mothers take for granted. To feel her baby emerge from her body as she worked and pushed to bring her forth under her own incredible power.

Everything had happened so fast. It must have taken quite a bit for it all to sink in, for E. and her husband. This is a couple that has always wanted a big family. Even as they counted their blessings from this averted tragedy, I heard that E.,s husband had asked their doula if they would ever be able to have more children. "Maybe...but only if you schedule a C-section at 39 weeks", she had replied...and this coming from a woman one of whose main missions in life is to help get our country's C-section rate down from it's current outrageous high of 33 percent. For a while I worried that E. just was not coping with her loss...that she was so focused on having a vaginal birth that she was letting the first precious weeks with her new daughter slip away ruminating about her lost opportunities and planning for a future VBAC. While most would feel that decision would be unsafe (and I even include myself in that number), there are midwives (who's judgement I reject) out there who might accommodate such a request. Indeed, well meaning posters on our local birth-support email lists tried to encourage E. by questioning whether she experienced a "true" rupture (she did) rather than "just a dehiscence", by questioning the decision to perform the surgery (!!??), by questioning her memory of the events, and by encouraging her to look forward to a VBA3C in the future. After a couple of unreturned telephone messages to her, and several emails without response, my worries increased...for a while.

My worries were unfounded. As much as I know she cares, I think right now I'm a reminder to E. of her lost dream of a vaginal birth. I understand that, and I won't pursue contact that she might be uncomfortable with, even though I mean only to support and care. Through the community of women who support birthing women in my city, I've learned that E. is doing well. From time to time I will see a post from her on our local ICAN (International Cesarean Awareness Network) email list, and I can tell that she is working through her grief in her own way. One post in particular that she made, was an impassioned plea to the leaders of ICAN in our community to provide more support for "those of us who will never have a vaginal birth".

My heart goes out to her. She is correct to make such a plea. While I support the work that ICAN does both nationally and locally, I've been concerned for a while that the focus on avoiding C-section, and the focus on VBAC neglects those women who may never experience another pregnancy after their C-section; that those whose C-sections were truly life saving or health-preserving might doubt their caregivers, or more importantly, their acceptance of their care-giver's decision. What aggravated me most in this particular situation, was how quick E.'s "supporters" were to second guess both her trust of her medical team, after she had put so much time and effort in choosing it, and in that team's decision, particularly when those supporters were so far removed from the situation. Hindsight is not always 20/20, and I did not consider that support.

I don't think this is or was intentional; but I think some of the printed materials, and particularly those mothers who were able to achieve a successful VBAC after a truly unnecessary c-section can inadvertently give off the "vibe" that ICAN is only for those mothers who are recovering from, or avoiding abuses of the medical system. Knowing that it will be a fine line to toe, I would like to see the group, while avoiding the risk of "normalizing" the procedure, provide more overt support to mothers who, as E. has so passionately phrased it, will never have a vaginal birth.

C-Sections are Births, too. No one would deny that, but I think in our zeal to reduce the c-section rate, to avoid that first c-section, and to promote VBAC, we have inadvertently minimized that. We in the medical community, in our rush to protect the safety of a mother and baby needing an emergency or emergent c-section, or to keep a busy, even over-loaded maternity unit running efficiently, are guilty of the same. That "machine" I spoke of, the one that I so admire and am so proud to be part of most of the time, continues to, on a calmer level, run much the same, even when the surgery is planned. It's what we do; it's our culture; it's what we are accustomed to; it's our turf!

Well, it may be so, but it's also the birth of a human being. A woman becomes a mother, a couple becomes a family, or a family grows by one (or two, or more ;-}). I've read about calm, quiet, lowly-lit (for the emergence the baby) surgical births where the baby is delivered slowly, in full view of the mother and her support person(s), sometimes even to be placed on her upper chest before being whisked over to a warmer to be dried off, examined and bundled up by nurses or pediatricians; of babies who have even breastfed while the mother was being sutured post-delivery. Even in my own experience on a unit made sometimes over-conservative as a result of being a referral center for high risk pregnancies, I know of at least one physician, one who is conservative himself, who is frustrated at the business-as-usual way in which our cesarean deliveries are usually carried out. I suspect he would balk at the slow, dimly lit delivery with a newly born, wet baby being placed immediately on the mother, or of baby nursing during surgery (I can also envision the hysterics of our very conservative chief anesthesiologist, LOL), but I know he would prefer that we keep baby with the mother and her support people during recovery, and get breastfeeding initiated, rather than whisk baby away to the nursery after a few moments in Dad's (or whoever the mother has chosen for her support) arms, while he (or she) sat next to the mother. On a busy unit such as ours that can be a challenge...particularly because our recovery room has limited space and no infant warmers...but we have done it from time to time, for those assertive mothers who have requested it. It can be done. I'd like to see it done more often.

Likewise, I'd like to see members of ICAN be more conscious (although I know they already try to be) of the feelings of mothers who have given and will continue to give birth surgically. I understand the triumph of a woman who has "beaten the system" to have a VBAC; but that is not reason enough to, even unintentionally, and even sympathetically, view a woman who has had a c-section as a woman who has had a negative birth experience...who has not researched all of her options...who has "given in" to the system.

No, we don't want to risk normalizing surgical birth; but we certainly could benefit from humanizing it much more...both those who perform surgical births, and those whose (admirable) goal is to avoid it.