Choosing the VBAC and getting past the complicating factors

Here she is - my VBAC/gestational diabetes baby who weighed in at 3.7kg and was born in 5.5 hours in a drug-free, intervention free labour. Praise God!

At the beginning of my pregnancy, I hadn't done much thinking about the way I wanted to give birth. At my first antenatal visit, I was booked in to see the staff doctor. He was pleasant, brisk and efficient, looked at my history and said straight out, "So, what do you want to do?"

"Um, have a baby?" I answered.

"Yes," he said. "But how do you want to have it? VBAC (Vaginal Birth after Caesarean) or c-section?"

"You mean I get a choice?" I asked.

"Of course you do," he said. "You don't have to decide now, but take some time to think about it and we can talk later."

He then presented me with a piece of paper outlining all the risks of a VBAC and said, "You'll have to sign this if you want a VBAC."

I took it home, read it through and felt terrible. The major problem with VBAC was going to be the risk of uterine rupture - where the scar on my uterus could open up again. From the sound of this piece of paper, if I opted for a VBAC, it seemed like I'd be putting myself at a huge risk for harming the baby. On the other hand, I knew how hard recovery from a c-section was, and I didn't want to go down that route again.

So I began to canvass opinions of family and friends. "What do you think I should do? What would you do? VBAC or c-section?"

People had a variety of answers, but I still wasn't sure, so I started to read up on both sides. The stories of baby deaths from uterine rupture were terrifying. But the risks involved with a straightforward c-section didn't sound so hot either. I wavered between both options for a number of weeks.

Finally, I asked some of the women with babies at church what they would do. All of them said, "Have you talked to Fiona about it?"

Fiona was a midwife who attended our church at the time. I could see how she might have an opinion, and probably it would veer towards the VBAC, but I didn't see how she could change the risk factors or make anything different for me.

"But seriously - even if I did the VBAC, I have such trouble giving birth anyway, what difference would Fiona make to the whole equation?" I asked.

One of my friends leaned in with wide open eyes and said in a hushed voice. "I truly think she's supernaturally gifted. She will make a difference. Talk to her."

So, Fiona and I talked. She gave me plenty of reasons why a vaginal birth was going to be better for the baby and for me - if it worked out. She gave me a few good tips as to ways to make sure that it was going to work out. And she talked practically about trying a VBAC with parameters, with an option for the c-section if things went wrong.

And, she said she'd come to the birth with me.

I still wasn't entirely convinced, but I began to think it might be ok. I read everything I could find on birth, on c-sections and on midwifery. Every time we went to the library, I scoured the women's health section for new books on the subject. I ploughed through the material I could find on the net. And bit by bit, I became more and more convinced that I was going down a good path.

However, I hit two roadblocks.

The first was electronic fetal monitoring. This is where the labouring woman is asked to wear two belts, one to monitor her heartbeat, the other to monitor the baby's heartbeat. If the heartbeats go down at any point, a trace will show it up and action can be taken to get the baby out more quickly.

EFM is generally used during a VBAC labour because one of the signs of uterine rupture is a deceleration in fetal heartrate.

By this time, I knew I wanted to do the VBAC. I knew that with Fiona's help I could have a better vaginal birth because I'd be active. But I also knew from past experience that being hooked up to EFM meant that I couldn't move around and have an active labour.

I felt like if I went down the EFM route, I'd be committing myself to another instrumental delivery at best, and possibly another c-section. Fiona had talked about intermittent auscultation - listening with doppler every 15 minutes before, during and after a contraction and keeping an eye on the fetal heartrate that way. It sounded ok to me, but no-one else wanted to know about it.

"EFM is for the health of your baby," was the response I kept getting from the midwives at the hospital. "Do you want to endanger your baby's health?"

I felt like yelling, "Of course not! But surely you can do this another way?" A few interviews ended in tears (me, not them) and I felt like I was being blocked at every turn.

In the end, I changed hospitals. I rang every hospital within 100kms and asked what their policies were. They all did EFM, but at one, the midwife in charge sounded like she understood where I was coming from. "You can always refuse it," she assured me. "No-one can make you do it. You'd have to be strong and insist on what you want, and you might get some pressure, but it is up to you."

I did more research, decided I wasn't doing a stupid thing, and made up my mind to be strong, but flexible. If the VBAC was going to work, I'd have to be active, and the EFM wasn't going to help that happen. Of course, if it seemed necessary later on down the track, I wasn't going to be pig-headed about it, but I knew where I wanted to begin.

The second complication came in the form of gestational diabetes. I had to keep my blood sugar levels (BGL) down because of the risk of getting a huge baby. As I knew from my last pregnancy, if I had an enormous baby, vaginal birth became more difficult and risky. 

So I began what was the most seriously carb-free diet I've ever gone on in my life. 

"You can't have bread, rice, pasta, cereal, potatoes or pumpkin," said the endocrinologist. 

"What can I eat?" I asked.

"Anything from the vegetable section, dairy of course, and the whole cow," he said. "And don't eat unless you're hungry."

It was too bad I was hungry all the time! But I went on the diet, kept my BGLs at 'gold standard level' according to Dr Strict and remembered every day that my motivation was to keep the baby's weight at a normal level so I could have a better chance at the VBAC.

Meanwhile, the antenatal visits at the midwives clinic at the new hospital continued. The midwifery manager was still supportive, but she was also keen that I see one of the obstetricians in town. I decided it would be sensible to do as she asked and duly made the appointment.

Unfortunately, it wasn't a positive experience.

"VBAC? OK, well, you've got about a 60 per cent chance of making it happen. And you'll have to do continuous electronic fetal monitoring," he said. I tried to ask him for alternatives, but he shut me off and said, "If you want to be my patient, that's the way it's going to be. I won't take you if you don't."

"I'll have to think about it then," I said and we moved on to the next topic of gestational diabetes.

"Well, you know I won't induce you because of the VBAC," he said, "but if the baby doesn't come before 40 weeks, I'll have to do a c-section because of the risk of stillbirth with the diabetes."

"Stillbirth?" I asked. "Nobody has said the word stillbirth to me in the same sentence as diabetes. What's going on there?"

"There's a higher risk of stillbirth after 40 weeks - actually, after 39, so I'm being generous - with gestational diabetes. You'll have to go before then, or it will have to be a c-section," he said. "And also, you might have a big baby too because of it."

"But I'm keeping my levels under control," I spluttered. "What's the point of me going to all this effort with my diet if it's not going to have any effect? That's what I've been told I'm doing this for."

"It doesn't necessarily correlate," the doctor said. "You still might have a big baby. We can check it by ultrasound at 40 weeks or so."

"I understood that ultrasound size scans can be out by at least 10 or 20 per cent," I said. 

"Well, it will have to come by 40 weeks," he finished. "Now, let me take your blood pressure."

Unsurprisingly, my blood pressure was a little bit high. "Hmmm. You should watch that," he said. "When's your next hospital appointment?"

I went home cross as anything, spent the evening looking up stillbirth and gestational diabetes (only a higher risk for women with untreated diabetes) and decided not to go back to that doctor unless he would have a change of heart. In fact, my next evening's work was to write him a four page letter outlining what I wanted and the reasons and the research to back it up.

I didn't really expect an answer, and I never got one, so I told the midwives clinic what had happened, gave them a copy of the letter for the file and proceeded on as a patient of their clinic, trusting that if I needed emergency medical rescuing on the day, I would be treated by whichever OB was on call at the time. 

And it worked. I didn't need emergency help, I got my intermittent ausculatation for monitoring, I went into labour before 40 weeks so I never had to have the c-section discussion, and I had a beautifully-sized 3.7kg baby as well as an emotionally satisfying five and a half hour long birth experience. 


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