Double X Science: Childbirth and C-sections in pre-modern times

There is a timely post over on Double X Science today- Childbirth and C-sections in pre-modern times.  I found it particularly interesting for several reasons:

1.  Almost 6 weeks ago I had my second C-section.

2.  Yesterday I finished reading The Crossing Places by Elly Griffiths a mystery novel about a female forensic bioarcheologist who studies bones.

So when I saw the Double X Science post, I was intrigued.

I’ve written before about my birth experiences (with Mabel, and with Nemo) and my desire to avoid a repeat C-section.  However,  with both of their births, the thought crossed my mind that without modern medicine childbirth very well may have killed me and my child, at the very least jeopardized one or both of us.  It’s a scary thought.

Mabel was born at 42 weeks and 1 day gestation.  It is known that going past 42 weeks of gestation can increase the risk of fetal death (source) and at 41 weeks and 5 days, I showed no signs of going into labor on my own.  I was induced and 36 hours later had been stuck at 7cm for hours and hours.  With my midwives, we made the decision to have a C-section.  Turns out, Mabel was acynclitic, meaning her head was crooked and tilted to the side preventing her from descending into the birth canal.  When she was born, she had the crooked cone head to prove it and the OB, upon seeing her, exclaimed, “This was never going to come out on her own!”

With Nemo, I was in labor for 24 hours, including 7 hours of active labor in the hospital, and was only 1 cm dilated.  He also didn’t descend and enter the birth canal.  After all of that time, and with me in excruciating pain at the site of my scar from the previous C-section which was very distinct from labor pains, the decision was made to proceed with a repeat C-section.  When my OB performed the surgery he said that, unlike most of his patients that need a C-section, Nemo hadn’t descended at all.

It would seem that I am a true case of cephalopelvic disproportion– meaning my pelvis just can’t fit the enormous heads of babies.

I’m grateful for the modern medicine that helped me safely deliver my two little ones.

Progress! Recovering from a repeat C-section

As I mentioned in a previous post, I had a minor complication post-delivery with my blood pressure being high (165/85 instead of my usual 120/70) and lots of swelling with pitting edema.  Oddly, while I was recovering in the hospital, none of this was a problem.  I had some swelling that was thought to be just from all the IV fluids I got with the surgery, and my BP was totally normal for me.  However, once I was discharged, things got worse instead of better.  Finally, about 6 days postpartum I had a splitting headache that not even the percocet and ibuprofen could help and my swelling had gotten precipitously worse.  None of my rings fit because my hands were so swollen.  I could only wear my house slippers because my feet didn’t fit in ANY of my shoes (not even flip flops!).  When I got on the scale at home, I weighed only 2 lbs less than I did when I went into the hospital to deliver a 9+lb baby!

Nine days postpartum. This was right around the worst of the swelling and blood pressure issues.

My OB was concerned I could be developing late-onset preeclampsia and has been monitoring my blood pressure as well as doing some blood work and urine analysis.  Thankfully, other than the swelling and the blood pressure, I’ve had none of the other symptoms of preeclampsia.

I was put on bed rest for a week, basically from from 7 to 14 days postpartum.  It was really hard to sit/lay around doing nothing while Mac picked up all the slack- diaper changes, meals, cleaning, bathing, errands, etc.  It was tough with him having Nemo, Mabel, and I to take care of.

Thankfully, it was only for a week, because I got my birthday wish!  The 6th of June was my 33rd birthday and started off with a visit to the OB.  I was hoping he would take me off the bed rest and he did!  While my blood pressure wasn’t much improved (about 140/86), I had lost about 15lbs since I’d seen him the Friday before.  So in 4 days, I dropped 15 pounds!  I was able to wear my shoes again.  My wedding rings (while a little snug) would actually fit on my finger- instead of getting stuck at the knuckle.

Two weeks postpartum, celebrating my 33rd birthday!

I was so relieved to finally be improving.  I’m happy to say the progress has continued.  I’m still taking it easy, but I’ve since dropped over 10 lbs more- for a grand total of 28 lbs lost in a matter of less than 2 weeks!  It’s crazy.  I gained very little weight with this pregnancy (about 11lbs), so I’m actually weigh less now than I did when I got pregnant with Nemo.

I go back to the OB next week for a 4 week postpartum check and I hope the progress continues.

This past Saturday, 2.5 weeks postpartum, at my hometown’s bicentennial parade.

Other than the blood pressure, the recovery has been pretty good.  I’m still dealing with wound care of my incision.  Unbeknownst to me, my OB used surgical glue instead of stitches or staples to close my skin incision.  I HATE surgical glue.  I have never had a good experience with it- whether it was when my dog needed surgery or a friend needed stitches.  It never holds as far as I can tell.  So, of course, I have a portion of my incision that has opened and is weeping.  Not only is it super gross and disconcerting to see, but it’s annoying to care for.

With my C-section with Mabel, I had staples for a few days, then steri-strips for a few more days, and then it was pretty much healed.  However, my pain was much higher, and I needed pain medicine for much longer.  This time around, even though the incision isn’t healing as quickly, I had very little pain and was off the percocet within a week and half.

I’m not sure why the recovery has been so different this time around.  Perhaps it’s because I was on bed rest and had lots of help those first weeks.  With Mabel, I was solo at home caring for her 6 days after the section.  This time, I have barely been alone at all since giving birth- with Mac and/or our families being here to help.

I was dreading the recovery, given my previous experience I am so glad that it’s been easier/quicker this time.  I’m looking forward to being 100% so I can enjoy my maternity leave like a vacation instead of a recuperation!

Should I choose my baby’s birthday?

Saw this on Facebook this morning.  Given my current predicament, it was timely.

Just like it was when I was pregnant with Mabel, I am 41 weeks (tomorrow), with a healthy fetus, no signs of impending labor, no complications that warrant intervention.  I’m grateful.  However, I’m also wondering when to draw the line.

I searched high and low for a doctor who would support my trying for a VBAC (Vaginal Birth After Cesarean).  I wrote a little about it here.  It took me 2 months of researching and in-office visits to see five practices and talk to several others on the phone.  Finally at 33 weeks I  had my first visit with my OB.  A doctor that comes highly recommended by strangers on the internet, acquaintances in my local ICAN chapter, and personal friends- moms who delivered with him, as well as nurses who work with him.

I really like him and I really trust him.  He’s very level headed.  He didn’t tell me my chances for a successful VBAC were nil.  He made a point to meet with me in his office before he examined me in an exam room.  He seems like an all around great doctor.

So far, all has gone smoothly in this pregnancy.  He’s been totally fine with me going past my due date (his policy is not to consider induction/surgery in advance of 41 weeks without a medical reason).  While he answered my questions about it, he didn’t even bring up scheduling me for a C-section (in case this baby is like his big sister and refuses to be born) until I was overdue.  Even then, he said let’s talk about it when you hit 41 weeks.

That’s tomorrow.

The only hard and fast recommendation he has made is, that he does not feel comfortable with me going past 42 weeks.  His reasons for this are valid.  According to my doctor, prior to 42 weeks fetal non-stress tests and biophysical profiles are predictive of the health of the fetus- meaning a good result predicts that the fetus will continue to do well for several days.  After 42 weeks these tests are no longer predictive, meaning something could be about to go wrong and you would have no forewarning.  I trust my doctor, I trust this science.  I have no intention of going past my due date.

I see him again tomorrow and Mac and I just cannot decide how to proceed.  There are basically two options (note:  induction is not an option given my previous C-section):

1.  Wait the full 42 weeks (as long as the monitoring continues to show the baby is healthy) to give me every/any chance of having  a VBAC.  This isn’t cut and dry.  The longer I wait, the less likely it is that I will be able to successfully deliver vaginally.  Nemo, this baby’s blog pseudonym, is already predicted to be around 9lbs (although the estimate has an error of 1lb in either direction), the longer I wait, the bigger he will get.  Also, the older he gets, the more ossified his skull becomes, the less malleable it is, the harder it is to fit through the birth canal.  It’s kind of like the law of diminishing returns- the longer I wait, the longer the odds of success.  Considering I was induced at 41 weeks and 6 days with Mabel and as of 40 weeks and 5 days with Nemo I show no signs of progress, I feel that the chances of my spontaneously going into labor on my own are slim to none

2.  Pick my baby’s birthday.  The 42 week mark is out of my hands, it’s a definitive cutoff in terms of medical necessity.  However, Mac and I could pick any day (assuming my doc is available to do surgery that day) between now and May 25th for our son to be born.  It just feels so wrong, so odd, to pick.  Also, it’s not at all trivial to willingly submit to a surgery that may not be necessary.  With most any other surgery, people would do their utmost to avoid an unnecessary surgery.  With C-sections, people seem very nonchalant, forgetting or ignoring that it is major abdominal surgery, with all the associated risks.  Not to mention 6 to 8 weeks of recovery- during which time my toddler will be hard to avoid.

This is where I am today.  This is why that Facebook image was so timely.  Mac and I need to decide tonight what to tell the OB.  Option 1- do nothing and just wait it out.  Option 2- do something and pick a date prior to the 42 week mark.

While I’m eager/impatient to meet my little boy, that’s a really stupid way to make a medical decision.  I’m sick of coming to work EVERY SINGLE DAY to the same barrage of STUPID questions from my coworkers (i.e. “Wow!  You’re still here?).  Not to mention how bad it is for one’s productivity to leave EVERY SINGLE DAY ready to not come in the next morning.  Again, stupid reasons for making a medical decision.

What to do, what to do?

Didn’t think I’d be here.

I’m 21 weeks pregnant today and having a consult with a new OB.  When I first got pregnant and went to a well-regarded midwifery group that was comfortable with taking me as a VBAC (Vaginal Birth After Cesarean) I thought I was all set.  At my first appointment, they mentioned I would need to have a consult with an OB from the hospital where I’d deliver, but did not seem concerned that I would not be an acceptable patient.

Fast forward a few months and last week I finally met with that OB.  True to form for the narrow-minded, lawsuit-fearing, fat-hating, knife-happy bad guy OB stereotype, the OB was not on board with my having a VBAC at his hospital.  His reasons- my weight (I am obese) and the size of my first child (9lb 6oz, deemed by him to be “humungous”).

Now, both of those reasons are medically accepted risk factors (although from what I gather, the “obesity means increased C-section rate” isn’t well-studied to correct for doctor-perceived risk, meaning OBs are more likely to insist on a C-section because they think there is a danger, versus a C-section is actually necessary).

If the doctor had said, “We are a small community hospital and don’t have surgical teams at the ready 24/7 or a NICU, thus your risk factors exclude you as a VBAC candidate under our hospital’s VBAC protocol,” I wouldn’t have been mad, disappointed, but not mad.  However, he didn’t leave it at that.  He had to tell me how poor my chances for a successful VBAC were and advise me of the futility of trying.

Um, he’s a medical doctor not a fortune teller.  My single previous pregnancy and birth are not a sufficient sample-size on which to extrapolate.  Also, even if my chances of a successful VBAC are low, it doesn’t mean it isn’t worth a shot to try and avoid major abdominal surgery.

So frustrating.  And thus, I am 21 weeks and searching out another practice/hospital that will take me so that I may attempt a VBAC.  After my c-section with Mabel, the midwife and OB who attended the birth assured me that there was no reason I couldn’t try for a VBAC in the future.  They chalked my failure to progress with her poor positioning (neither face-up, nor face-down, but cock-eyed) and felt it was a fluke and not an indicator that I was incapable of a vaginal delivery.

I’m a scientist.  I know there are risks.  I also know that you can plan all you want and you aren’t guaranteed the birth you planned on.

However, I also know that the American College of Obstetricians and Gynecologists (ACOG) issued the following guidelines:

Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today by The American College of Obstetricians and Gynecologists.  Source.

Based on the science and recommendations, the doctor should have said, “You don’t fit in this hospital’s protocol, I encourage you, based on ACOG guidelines to find another provider at another hospital that is better equipped to help you attempt a VBAC.”

Thusly, I am searching for a new provider.

With impeccable timing, today, my cousin posted a link to this article in The Sun about Ina May Gaskin- the most well-known and well-respected midwife in US and probably the world:  Oh Baby:  Ina May Gaskin on the medicalization of birth.  I love that Gaskin speaks in citations- she mentions her facts and data and their source.  When there is insufficient evidence for her to draw a conclusion, she doesn’t offer an opinion, she states that there hasn’t been enough research.  What a breath of science-minded fresh air.

The two particular quotes (out of many) from Gaskin that stood out to me are below:

The U.S. maternal death rate steadily decreased between 1936 and 1982. At that point it leveled off for a few years and then began rising. Women today actually face twice the chance that their mothers did of dying from pregnancy-related causes.

…..

A vaginal birth has always been safer for the mother. The risk of death of the mother is three times greater for c-section than for vaginal birth. If we’re talking about emergency c-section only, this figure rises to four times greater. (Source)

I will continue to advocate for myself, I will push to receive care informed by science and medicine, not unsupported opinion and baseless predictions.  That I have to go to such great lengths to find a practitioner to provide such care is a terrible shame.