By Megan Kasper, MD
Read Part One here.
VBACs, or vaginal births after cesarean, have been on the decline over the last 20 years, for an unfortunate combination of legal, political, and medical research reasons. However, the controversy over VBAC has led to quite a bit of research data that is now available.
The primary controversy is the risk of uterine rupture with a TOLAC (trial of labor after cesarean). That risk is between 0.7 and 0.9%, or about 1 in 125 women laboring after a previous cesarean. This risk is higher than in women without a prior cesarean, and has to be balanced with the possibility of a successful vaginal delivery. The overall likelihood of a successful VBAC is 60-80%. Several factors affecting TOLAC success have been studied, and George Washington University has an online calculator that uses these factors to estimate a specific mother’s success. My own number was 70%.
I did everything right: I carefully selected a hospital with good, evidence-based TOLAC policies, I found a nurse-midwife practice with patient, yet thorough providers, I ate reasonably well, and I exercised regularly. I even did the Miles Circuit, and I tried a few Spinning Babies positions.
I knew my baby was getting big, and I knew he was not dropping. He was in an occiput posterior (“sunny side up”) position. I kept working on my exercises to help him rotate. At 39 weeks and 4 days, I started to go into labor.
From the beginning, my labor was far more painful than anything I’d experienced with my first. I had two days of on-and-off prodromal labor before entering active labor. I was about 6 cm when I arrived at the hospital. It took me another 16 hours to get to 10 cm. Again, throughout, we did everything right. I was constantly changing positions. My midwives gave me plenty of time. We eventually used oxytocin and an epidural appropriately. Then, my baby finally rolled over to a more favorable “anterior” position and dropped, and I was completely dilated. I pushed for 20 minutes and everyone could see head, and they were getting ready for his birth. Then, in between contractions, I felt him move his head all around. Everyone in the room watched my belly roll, and he was back to the posterior position. After another 2 hours of pushing, he never got as low as I had him earlier. We took a break, “labored down” with me in different positions to get him to roll back, and he never did. Finally, I knew we’d done all the things. And we’d done them correctly. It was time for my baby to come out.
My one request for the obstetrician who came in to do my second c-section was to drop the drape when my baby was born so I could watch. He happily obliged. It was amazing. I was calm, not in tears. I had done the entire labor thing almost to the point of birth. I got to watch my big, strong boy be born. I got to watch him immediately scream. I could see them weigh him and exclaim over how big he was. Nine pounds eight ounces was the number on the scale, and he was posterior and asynclitic (head tilted to the side in my pelvis).
My surgeon did a wonderful job, and I needed far less pain medication than I’d needed with my first section. I was able to go home the next day.
Then the emotional rollercoaster started. I was so proud of my big, strong boy. But the reality of how close I had come started to set in. I struggled to not replay over and over how my labor went. How pushing went. How close I’d come.
I struggled quite a bit with postpartum depression for the first 6 weeks, and my unwanted cesarean certainly contributed. It was almost an out-of-body experience, to know that we had done everything correctly and it was okay, yet having these uncontrollable emotions of disappointment, failure, and regret. With my first c-section I accepted that it was outside of my control. With my second, the “what-ifs” started to sneak in.
As my hormones subsided I felt myself start to come out of the fog. The facts that I kept telling myself finally started to take root. I started to get more sleep, and was able to relax and truly treasure each moment with both of my children. I am still disappointed, and I still don’t totally understand why me. However, on a spectrum of health suffering that happens in the world, having two cesareans is quite minor. I am actually beyond blessed.
And finally, the data about having a trial of labor after two c-sections is also evolving. Who knows, perhaps I will get another try?
As I take my own personal experiences back to my practice, several points come to the forefront of what I want to communicate to other women who find themselves with an unplanned cesarean:
- You DID give birth. A very real and very precious baby came from your body. The details of route are only that: details.
- Debriefing with your provider(s) is incredibly helpful. Ask questions about what happened, what you could have done differently, and what recommendations they have for the future.
- It can be healthy to think ahead to your next birth. Educate yourself on having a healthy pregnancy, finding a provider and hospital that are both supportive and safe, and understanding how to optimize your labor.
- Pregnancy and birth is not something that we can control. Sometimes, the process breaks. We are fortunate to have the technology to fix it when that happens. Many women in the world do not have that luxury.
- Postpartum depression is real. If you struggle with feelings of failure, blaming yourself when things go wrong, lashing out in anger, or have thoughts of hurting yourself or others, immediately contact your provider. We are here to help you!
Megan Kasper received her bachelor’s degree from the University of Oregon in her hometown of Eugene. Sadly, she never attended a football game while a student there. She graduated medical school from Oregon Health and Science University. She completed her obstetrics and gynecology residency at the University of New Mexico. Currently she practices at Saltzer Medical Group in Idaho. Dr. Kasper and her husband Eric live in Nampa, Idaho with their two children.