Wednesday, March 21, 2012

A VBAC Story - Part 2

Continuing the discussion of the Vaginal Birth After Cesarean section. Now Part 2 . . . 
This is not my c-section; I actually searched vacuum delivery.

My VBAC story:

My induction took about 2.5 days, and it was very painful as the medications make labor when your body hasn't naturally arrived there. I had an epidural most of the time, which is generally necessary in case they need to quickly move into a c-section. They put extra monitors on my uterus and the baby's head. The same resident was always on the dayshift as I had 3 different attendings. She admitted me and broke my water 24 hours later which really started moving labor along.

By the morning of the third day, I was ready to deliver except Child2 had not fully descended. Also, Child2 was having 'variable decelerations' which is when the baby does not recover normally from each contraction. Early decels are normal, late decels are a danger sign the baby isn't getting enough blood, and variable decels are in the middle. They are often caused by the common issue of nuchal cord (cord around the baby's neck), but they can be harbingers of much worse problems. The OB team was getting concerned about how long my induction had lasted, the lack of descent, and the variable decelerations. They were seriously contemplating performing a c-section. In their eyes, it was a little like watching someone run into a brick wall over and over when they could just open the door. (If that metaphor was confusing, if my induction was not moving forward, I was going to need a c-section anyway. Rather than wait for things to get unstable, c-sectioning me while stable was much preferred.)

Fortunately for me, my second resident had my back and thought we could continue trying to push. She and my nurses told me I was a great pusher - I did ask her if she was telling the truth since I've been at many deliveries of women who are horrible pushers and get told the same thing. She assured me I was, but she really wanted me to get further along so she could convince her attending to hold off on the c-section. (Her attending knew we were pushing and was coming to see us last after the rest of the team finished rounding on the rest of the patients.)

At this point, my husband was a little freaked out, particularly when the resident said that we might have to vacuum deliver the baby since Child2's head looked like it might need a little aid. The attending came in and watched me push for a little bit and asked what I thought about a c-section or vacuum delivery. I said the equivalent of "I'm going to keep pushing until we get to late decels. I'm not scared of a nuchal cord or a vacuum." The attending was ready to discuss the risks and benefits of vacuum delivery until she remembered that I was the pediatrician who attended vacuum deliveries daily. I did ask that the pediatric delivery team come to my delivery just in case.

Now, if you've never been in labor, during contractions they have you push for a count of 10 three times per contraction. As they turned up the pitocin for stronger contractions, I was pushing for a count of 10 five or six times. Then suddenly they were breaking down the end of the bed and moving my legs into delivery position. I asked if they needed a vacuum still and they told me 'no.' Hubby JD wasn't sure he believed them and stood at the end of the bed. (OMG, I can see his head!!)

Three more pushes and Child2 was out. The resident unlooped the nuchal cord before cutting it - Hubby JD doesn't like blood much so he wasn't cutting it. Child2 was immediately handed off to the pediatric team who had to suction out his nose and mouth and give him a brief amount of oxygen. His apgars were 6 and 7 at 1 and 5 minutes and he was crying so I wasn't worried while the OB's sewed me up. At 10 minutes his apgar was up to 8 and he appeared stable enough to come to me, which was fine - and I reassure the team jokingly that I knew the signs of respiratory distress.

I was very happy with how things turned out; I recognized that my OB resident had a big part of that since she really fought for my VBAC. I even wrote her program director an email, highlighting how important the resident was to my delivery. (You should do that anytime you have particularly good service.) I jokingly told the attending that she could email all the doctors in her group with my result. One of the other OB residents, with whom I had trained, came by and told me she would have definitely c-sectioned me.

I wasn't upset that the OB team was close to doing a c-section. It's their job to assure the safety of the patient (me) and the passenger (Child2). Not everyone can or SHOULD do what I said or did. I am a medical professional who works significantly in labor and delivery. It is my particular area of expertise, and I would have been the first to ask for a c-section if anything more worrisome had occurred. I also had trained some of the OB residents in pediatrics or entered training with the senior OB residents. On the flip side, I would never have asked for a similar amount of leeway on getting my appendix taken out or my tonsils.

To speak briefly to the economics of VBAC versus c-section, a VBAC generally has a shorter recovery time because it has less limits on activity since it did not involve surgery. There are cases where it could be worse, like if the baby's head really tears up the vagina coming out - a 4th degree tear is pretty seriously painful. My hospital stay was not that different than a scheduled c-section. I was there 4 days, 2.5 for induction, 1.5 post delivery. A c-section generally is 48-72 hours post delivery. VBAC will probably cheaper from an insurance standpoint because it doesn't involve OR fees. My breast feeding wasn't significantly affected by either one, but I did have less time with lactation to confirm my milk coming in.

Hilariously, I spent my day prior to discharge peppering the OBs and nurses about vaginal delivery recovery. we'd spent so much time discussing the risk of c-section, we never discussed it would be like if my VBAC was successful.

Thanks for tuning in. After my next post, there may be a little delay since we are moving this week and I may have less time/possibly be without internet access.

Next post: Carseat Roulette - challenges of fitting 2 carseats into a tiny car!

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