I’ve Made My Birthing Choice And It May Surprise You


When I began seeing my doctor for prenatal services in June, I was surprised and a little overwhelmed to find out that my hospital had reversed its policy forbidding vaginal births after a c-section (VBACs), and was now encouraging the practice.  I knew I would have myriad issues to consider, and that I needed to spend a very long and serious amount of time trying to decide what was the best option for me birthing-wise. 

Now, having just entered my third trimester, I’ve finally come to a conclusion.  I’m having a repeat c-section.

Shocked?  I sort of was, too.  In fact, I was very much considering not writing about it once I made my decision.  I’ve read all of the material on VBACs I can get my hands on.  I know that the American College of Obstetricians and Gynecologists are fully behind VBACs unless there is a medical reason to avoid (like an induction, which increases the likelihood of uterine rupture).  I even know that VBACs are successful in most cases, and that the risk of uterine rupture is less than one percent.

I had discussed all of these facts with my general practitioner, who was overseeing the beginning of my pregnancy.  But because he cannot do a VBAC delivery, I was recently transferred to my OB/GYN for the duration of the pregnancy, and once more went back through my thought processes on delivery.

I trust my OBGYN implicitly.  When I learned I miscarried in October, he arranged for my D&C, coming in on a Saturday (and Halloween) in order to get me through the process as quickly as possible.  He walked me through numerous follow-ups as my hormones took months to get back to a “non-pregnant” state, was a supportive cheerleader in my efforts to come up with a plan to become pregnant again.  Appointments with him always became less about physical stats like blood pressure or weight, and more of a discussion about my emotional health and needs.

As we began to discuss the delivery, I was reminded of an exercise that we did during our parenting class before Violet’s birth.  We were given a stack of paper slips that had words like “epidural,” “induction,” “c-section,” “episiotomy,” “healthy baby,” or “no pain medication” on them.  We were instructed to pick the ones that mattered most to us,  eliminating them one by one until eventually we ended up with just one slip of paper, which, of course, read “healthy baby.”  Because in the end, that’s what every parent wants most.

I remembered the instructor laughing at me when we had narrowed it down to three, since my top three were “no c-section,” “no episiotomy,” and “healthy baby.”  I told her that I was willing to put up with any pain that was thrown at me, I just wanted to avoid anything that would make my recovery slower after the labor was over.  After all, how long could labor go?  Once it was done, at least it was finished, no matter how awful it is, right?

Like most moms, I went into labor with a birth plan — one that already went right out the window when the started the induction.  By the second day of the induction, after 12 hours on pitocin and still no dilation to show for it, the vow to avoid the epidural went by the wayside, too.  We would have stopped the induction all together and tried again the following day if my water didn’t decide to break the moment I got up out of the bed to change my clothes and go home for the night.

All I wanted, once we got down to two slips of paper in the parenting game, was no c-section and a healthy baby.  In the end, I didn’t get my wish for either.  I had an emergency c-section about 18 hours later and a baby in the NICU for 10 days due to infection.

This all came back to me as my OB/GYN asked me once more, what was most important to me about this birth.  I realized that I didn’t care about the labor, and I didn’t care about pain management, and in the end, I didn’t care even about the birthing process at all.  All I wanted was to do everything possible to ensure that this baby gets a better start than his sister did.  I want to eliminate all possibility that he could contact group b strep, of which I am very likely still a carrier.  Part of giving him a better start is ensuring that I, too, do not end up in another failed labor situation, with my own infection and massive blood loss impeding my recovery, as well as my body’s ability to perform basic functions like make breast milk.

The odds are totally in my favor that I would have a successful VBAC.  Yet the odds were even more in my favor to have a successful vaginal birth with my daughter, and I most definitely did not.  With one failed labor in my past, I already had one more strike against me than last time.  Did I really want to risk it again?

As we talked through all of my concerns, I admitted to my OB/GYN, “You know, part of me almost hopes that when we get near the end, the baby is actually breach so the decision is made for me and I can just have the c-section.”

“If that’s really how you feel,” he responded, “I think you’ve actually already made your decision, you just need someone to tell you that it’s a valid one.  And for you, I think it is.”

So the date is set.  I will be having a baby on December 10th, two days before my daughter’s third birthday.  In fact, the process is expected to be so simple that, should no complications arise in the first 24 hours, my OB/GYN has suggested giving me sutures rather than staples so that I can leave the hospital early and be home for her birthday.  Considering my last c-section ended in infection, a near transfusion and extended hospital stay, I couldn’t be more pleased to have an orderly plan that is organized to maximize the recovery time for myself and my new baby.

I know that a repeat c-section isn’t the right choice for everyone, but it is for me, and for my medical history.  I am still an advocate for VBACs for any woman who wants one and who feels that birthing vaginally rather than surgically is the better labor choice.  But having weighed the risks and benefits, that is just not me.  And, just as women need to speak out to have their rights to attempt a VBAC accepted as an option among the medical community, I feel it is just as important for me to explain why I was open to the possibility but in the end made a different choice.  The important part is that we are all allowed to make our own, informed choices, and be advocates in our own health.

It wouldn’t, however, be fair of me to write this article without admitting one additional fact that was in play when it came to my decision to chose a c-section.

Insurance.

It’s an issue that many women with due dates in December have to examine.  With higher co-pays and out of pocket deductibles, the cost of having a baby in a hospital can be high, even if you have coverage.  For us, we know that our maximum out of pocket expense for the year is $6000, something that we have come to terms with and planned for.

However, with a due date of December 17th, allowing things to proceed naturally could put us in the worst possible situation: having a hospital stay that would straddle two calendar years, in effect doubling our out of pocket costs. 

It shouldn’t be this way.  You shouldn’t need to factor in whether or not you can afford to pay your portion of your care when deciding what sort of health care procedure you need.  Giving birth should not have the possibility of costing as much as a new car, or a down payment on a small house. It’s ironic that I’m choosing a more expensive procedure in part to ensure that I can actually afford to give birth to a baby. 

I guess once again we are learning that health care reform only brings so much to the table when it comes to making health care accessible and affordable for all women’s needs.

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  • kevin-rahe

    Complications can never be predicted, of course, but my wife had three VBACs after our first child was delivered by C-section.  They went so well that in one case we actually changed her doctor’s perspective on VBACs to one less skeptical than he had before.  Even more convincing was that all our children were born when my wife was quite a bit older than typical birth mothers.

     

    You have to choose what you’re most comfortable with, though, and I hope it all goes well.  (And yes, the insurance thing can be an issue – we were lucky in our case that it never was and we never had to consider that.)

  • jillunnecesarean

    Robin, this is a great post. Is the big surprise that your friends thought you were going to VBAC and you’re not?

  • amie-newman

    I love your honesty. Not only are you making the best decision for YOU, you’re clearly making the best decision for your children, based on your own unique situation. Though I’m sad to read of the ways in which insurance issues must come into play, I’m not surprised.

    For what it’s worth, I completely relate (I think most birthing women can) to the “birth plan out the window” scenario. Intention is wonderful but, as we experience the birth we do, it’s a mix of intention, support from those around you, confidence in yourself, and the realities of medical issues that may arise.

    Thanks for writing this, Robin. Great work!

    Amie

  • ellec

    I found your blog from your post on the 40 Days problem and I have to say thank you for sharing your story.  I learned a great deal about VBACs, c-sections, miscarriages, and pregnancies that I didn’t know before.  Your story is a powerful one and I appreciate you sharing it.  Best wishes for a safe birth and a healthy child!

  • gina-crosleycorcoran

    I appreciate any woman’s right to make the birth choices that make her the most comfortable, and I’m glad you’ve found the decision you’re comfortable with.  However, I can’t let this go without pointing out a few things in the article that may mislead other women struggling with this choice too.  First off all, of course birth plans go out the window with an induction – inductions are the number one cause of cesareans.  Inductions without a REAL medical reason are not the healthiest start to birth.  Our bodies are not meant to handle Pitocin contractions, and frankly I think anyone who does handle them for any amount of time (whether medicated or unmedicated because even an epidural sometimes cannot mask the pain of that chemical crowbar) deserves a medal of honor.  Honestly.  They are THAT bad.  I’ve been there.

    But that doesn’t have to occur in a second birth.  Just because chemicals complicated one’s labor the first time does NOT mean that a woman’s body is broken, and that the birth will be a repeat of the first time.  If a woman makes different choices, the outcome can be dramatically different.  I just hate to see women assume that their first (sabotaged) labor is indicative of their ability to birth vaginally at all.

    This is not said to change your mind – I’m glad that you’re comfortable with your choice.  I just don’t want other moms on the fence to read this think “Well, my induction-turned-cesarean was terrible, which means that I AM a medical condition, which means I shouldn’t bother to consider that things can be different.”  They can.  Very much so.  I VBAC’d after a failed induction.  It took a lot of education about what went wrong the first time, how I could make different choices the second time, and finding a way to regain some confidence in my body – but I did it.  And I’m not special.

  • robin-marty

    I’ll be honest, the surprise was as much to me as anyone. I really did think very hard and was planning for the VBAC. It wasn’t until I began really talking the whole thing out with my OBGYN that I wasn’t *choosing* the VBAC exactly, but trying to talk myself into it. I kept saying things like “sure I couldn’t birth last time, but if I go into labor on my own it will be ok, right?” or “I need to experience a real labor all the way through or I bet I’ll never have my milk come in again.” Part of me even felt like I would be letting everyone down by choosing the csection, as if surgery was failure, even though deep down inside I knew I would rather have the small risks associated with it under a controlled situation than the much larger risks that come with it in an emergency situation.

    When I did my first labor, there was a point at about 11 am where I knew that no matter what we tried, it wasn’t going to work and I was going to end up in surgery. My doctor and the nurses told me every woman thinks that, and to keep going. It was three hours later before they told me that yes, I was becoming less dilated (apparently I was unconsciously pushing and that caused swelling), the head wasn’t even engaged anymore, and that I had developed a fever of 101. I always wondered if I could have convinced them then that I knew my body and I wasn’t just having pregnant woman cold feet, if I could have avoided endangering the baby and putting her in NICU, as well as all the damage to my body from the bloodloss.

    So this time I decided to trust myself before I even start.

  • heater99

    Robin, I get why you are choosing a c-section, in that you can’t bear the trauma again of a failed vaginal birth attempt, for many reasons.  But some things in your story are haunting me.  Gina clarified the induction issue, so I won’t touch on that, but the blood loss and the infection–I am not sure how scheduling a c-section reduces those chances?  Seems to me they increase those chances? 

    Also, I was so saddened by your childbirth instruction class and how they used those cards to manipulate you into being OK with your birth no matter what.  Makes me think OB’s taught the class!  How sad to try to insinuate that any woman would consider avoiding an episiotomy more important than having a healthy child.  This is what is wrong with the childbirth culture in America–we are told to shut up about our experiences and accept the medical model that is killing us moms and not making things much better for the babies, because “at least we have a healthy baby!”  And in your case, you didn’t even have a healthy baby-sounds like the induction and c-section made you both very unhealthy.

    I am so sorry for your first experience-it was pretty much mine except the NICU.  I have heard that repeat c-sections can be much better and I am happy you are at peace with your decision.  But I hope you won’t stop fighting to undo the shame we are made to feel about our births –whether choosing repeat c-section or VBAC-our experience DOES matter.  That the baby is healthy goes without saying.  We mommas will do anything for our babies. 

    Good luck and congrats!!

     

  • robin-marty

    Gina – I hear what you are saying. I don’t think that the induction was a sign that my body can’t do a labor for real, just that I’m not willing to take the risk this time around. My other option was to wait and see if my body goes into labor on its own, and if not, set the date for a csection rather than do the induction. This is where the insurance came into play. With a due date of Dec 17, I would be allowed to set my csection date for Dec 29th, which is as late as my OBGYN felt comfortable letting me go without possibly endangering the baby. That’s where the straddling calendar years would occur, and how our birth would go from $6000 out of pocket to $12,000 out of pocket. So the risks are both physical and financial.

    heater – I should clarify: the infection was not from the csection, the infection was from group b strep, which crossed through when my water was broken for almost a day. Both my daughter and I came down with an infection that way, and as labor progressed my fever rose and her heartbeat accelerated, which is how we ended up sick after. it was all over. Both of us were put on anti-biotics right after her birth via IV. She had to stay on for 10 days, I had a one week round of pills.

    So again, I know my situation is not in any way normal. But that’s also why I know that a repeat can be the right decision for me when it isn’t for others.

  • gina-crosleycorcoran

    I hear you on the insurance part of it, and it sucks that any woman would have to make a choice based on the finances.  I’m still concerned that you aren’t informed about the various factors that could have contributed to your “not normal” situation.  The thing is – it’s QUITE common for all of these things to go wrong in a woman’s labor when she’s induced.  I also think that women considering between these choices should consult both a midwife and an OB because they each have VERY different perspectives on birth.  Most OBs are quick to tell women that their bodies are broken without “medical advancements” because Obstricians often do not understand the natural progression of labor (they aren’t even trained on it).  Again – none of this is said to try to change your mind, it’s simply important that other women know that many outcomes like yours are caused by the various medical interventions that are supposed to “helping.”  (for example – no induction may have meant no prolonged rupture of membranes, meaning no risk of infection.)  Have you seen the movie “The Business of Being Born?”  Any woman of childbearing age (and anyone who cares about them) should watch this movie.  It explains a lot about why so many of us think that our bodies just don’t “work right” when really it’s that our bodies are being messed with.  I’m sure I’d be signing up for a third cesarean right now if I had never learned the truth about what had been done to me and my baby.  Instead, this time I’m having a homebirth with a skilled attendant who believes in me and my body.

    Again, all the respect for your choice – I just want women to know that what went wrong during their first births should be examined very closely.

  • robin-marty

    I understand exactly what you are saying, but my article is explaining why it is the right choice for me. It’s a choice each woman should make on her own, totally informed, and once made, shouldn’t need to be justified repeatedly or questioned in the name of making sure other people aren’t somehow swayed by why I chose a csection. I understand your concerns that you are addressing any other woman who might take my story and apply it to theirs. And frankly, if it fits, I hope that they do, as well as get as much information as they can about VBACs, too.

    I wrote this because I know that women who chose a csection don’t talk about it for the very reason that is occurring here — that there is a sense of “well, fine, but I hope you don’t convince others to make your mistake.” It is the same argument that happens when those of us who can’t breastfeed discuss formula. Those of us in that situation are put on the defensive, feel the need to repeatedly justify, and state over and over again that this is just OUR situation, and not the choice everyone else should make. Or we don’t talk about it at all, and then any woman who is in this spot feels like she is the only one.

    So again, I definitely appreciate your perspective, Gina. But I’m comfortable with my decision, and I hope all other women who make the same feel as comfortable as I do, don’t feel pressured into not discussing it because it may make other women “choose wrong,” and can have the joyous delivery that she wants in whatever form it takes. I don’t feel that I’m somehow persuading women off whatever path they were going to choose nor that what will work for me is somehow an advocation against VBACs that needs to be countered.

  • courtroom-mama

    First of all, Robin, I have been so happy to hear that this pregnancy is going well, and now that you have made a decision that you are at peace with. I’ll be sending you my thoughts for a good birth and speedy recovery for all. My birthday is a couple of days before my little brother’s (that in itself is an interesting story about how women choose to induce or not to induce because of external factors like family, which I won’t hijack your thread with!) and joint birthdays aren’t so bad ;)

    The ongoing conversation brings up some sort of half-formed but full-serious questions, and I’d love to hear what you think. In the birthing world, we spend a lot of time asking “why don’t The Feminists listen to us?! We’re ghettoized because we choose to bear children, and they just can’t understand why we would make the un-liberated choice!!” Setting aside how totally problematic this is on so many levels (who are THE feminists? Aren’t you just reifying the idea that feminists don’t make babies, ad nauseam), I think that I’m seeing the ostensible problem reflected. If the problem with straw-feminists is that “they” think that “we” are operating under a false consciousness for deriving pleasure and fulfillment from childrearing, isn’t it similarly ascribing a false consciousness to say that women wouldn’t ever voluntarily choose cesarean surgery if only they had all the facts? (see also the reasonig behind compelled “informed consent” scripts for abortion in some states) And if we’re actually all Third Wave and so over this whole false consciousness crap, isn’t it sort of anathema to the ideas of the personal being political and women being intelligent enough to make their own decisions to assume that just because a woman tells her story, other women will be somehow duped into making the “wrong” choice? Could that be some part of the disconnect between feminism and birth activism? Kinda sounds like a job for Exhale – we, as a movement, need to be pro-voice about birthing choices too.

    That, and the “armchair quarterbacking” of other women’s births sounds to me like the people who tell women things like “well how do you KNOW that the fetal anomaly was incompatible with life” or “sometimes ectopic pregnancies resolve themselves!” That sounds more like sowing the seeds of self-doubt and guilt than empowering women to make decisions.

    Just thinking “aloud.” Thanks again for sharing your story!

  • momtfh

    I want to support you and your decision to have a repeat elective cesarean instead of a VBAC attempt, and your choice is indeed valid. 

     

    I have to join in the chorus challenging some of your points, however. On the one hand, I am hesitant, since I cringe at the thought of how judgmental people are towards pregnant women and their choices. However, there are a few reasons why I am choosing to do so. First of all, I think you have some statements in your article that are medically inaccurate. And, this isn’t a personal blog. This is presented as journalism / advocacy. Journalism on medical topics needs to be held to a higher standard. 

     

    Secondly, you are defending a choice, elective repeat cesarean, that is really not in need of defense – it is presented as the most reasonable choice, and in many cases only choice, for the vast majority of women in the U.S. The <a href=”http://www.ingentaconnect.com/content/lamaze/jpe/2010/00000019/00000003/art00009″>power balance</a> is dramatically tilted against women being able to choose VBAC. How is it surprising that it was your choice? Of course it’s valid – it’s almost guaranteed!

     

    Let’s start with some of the inaccuracies. 

     

    I am in medical school and just completed a research fellowship on labor interventions. I think the exercise you did in your childbirthing class was atrocious. We do not need to choose between a healthy baby and evidence based, women centered medicine. Avoiding non-evidence based interventions that have worse outcomes for the mother and baby make it more likely we can have healthy babies. They should not be presented as competing priorities.

     

    For example, we can have a healthy baby AND not have an episiotomy. Episiotomies <a href=”http://jama.ama-assn.org/cgi/content/abstract/293/17/21″>should be avoided at all costs</a>, according to substantial research. They do not make babies more healthy. There is not one situation in which they save a baby’s life. It is even recommended that they be avoided for operative vaginal delivery (when an intervention such as vacuum extraction is needed) – they lead to <a href=”http://www.ncbi.nlm.nih.gov/pubmed/19035943″>more maternal and neonatal morbidity</a>. I consider episiotomy use to be a litmus test for an obstetrical health care practitioner. 

     

    As other people have pointed out, non medically indicated inductions, especially those in a first time mother, carry <a href=”http://www.aafp.org/afp/20000215/tips/39.html”>more than double the risk of cesarean</a>. In fact, some hospitals are now banning elective inductions on first time moms as a quality assurance measure. Rixa has a good synopsis of links on this topic at <a href=”http://rixarixa.blogspot.com/2010/10/lamazeicea-conference-part-3.html”>Stand and Deliver</a>. The Bishop’s score is an important indicator of whether an induction is likely to be successful, as opposed to a several day long ordeal that ends with a cascade of interventions, leading to an emergency / iatrogenic cesarean. If there is a compelling medical indication that one would get a cesarean for anyway, that is one thing. But, in our society, many women are told to get induced before their baby gets to big, or because the baby is looking a little small, or because the obstetrician is going on vacation, or the calendar year is changing, or because they have a certain amount of time off from work and they really want to plan their maternity leave. These psychosocial factors for induction are all indeed valid, and birth is not the only medical decision in which psychosocial factors are weighed, but they do sometimes increase the risk of not having as healthy a baby or as healthy a mom. More than an episiotomy would.

     

    Or an epidural. Epidurals are <a href=”http://www.springerlink.com/content/1u581263m7290008/”>associated with maternal fever</a>, especially longer lasting epidurals, such as those associated with inductions. If a mom’s membranes break, or more likely, are artificially ruptured during active management of labor or an induction, and she subsequently develops a fever, many practitioners will consider that to be an indication for cesarean section. 

     

    Group B Strep is present in up to 40% of healthy women – a cesarean is not the recommended intervention for prevention of transmission of group B strep to a baby. The current standard of care is to <a href=”http://www.nejm.org/doi/full/10.1056/NEJMoa0806820″>administer antibiotics during labor</a>.

     

    As for the VBAC vs. elective repeat cesarean issue – it is obviously a highly personal choice, and one I am happy you were able to make without apparent pressure from your hospital system or your chosen practitioner. Please don’t present VBAC as higher risk, however. The larger risks of an emergency situation are very, very uncommon in a VBAC. In fact, they are <a href=”http://www.ncbi.nlm.nih.gov/pubmed/17400862″>identical to the risk of perinatal mortality in a primary vaginal delivery</a>. There is a definite imbalance of risks to the mother (increased risk of hemorrhage, need for transfusion, and infection, as illustrated by your anecdotal experience) with a cesarean, and increased risk of neonatal trauma or morbidity with a VBAC. But, these risks are vanishingly small. One set of risks is not large and uncontrolled and scary, compared to one set being small and manageable and acceptable. 

     

    Anyway, I wish you a safe and uneventful birth, regardless of your chosen method of delivery. I am always happy when this site steps out of the zone of reproductive choice just being about preventing birth. And, you were very brave to put your personal decision our there. Just, please remember that when you are writing for a site such as RH Reality Check, a little reality checking may be in order. 

  • arekushieru

    Of course it’s valid – it’s almost guaranteed!

    Except that you seem to be unaware that this is a blog about birthing choices, where women usually support v-bac’s over cesarean.  Perhaps, now, it is not so surprising that she thought it might be surprising…?