Tuesday, March 22, 2011

Setting the Stage for Baby Number 2

Having (hopefully) read the first four entries here, you now know all about my rather unfortunate birth experience with my first son. That whole sequence of events at first made me swear off baby-having at all, but it also made the whole idea of having another baby simply terrifying. I was sure my uterus was completely messed up, between the scar tissue from the c-section and whatever had caused the bleeding and clot. My OB at the time had said during labor that I should be able to have a vaginal birth in the future if I wanted, but after the bleeding, decided it would be safer if I stuck to scheduled c-sections, "because labor might put too much stress on your uterus."

I was also devastated that I hadn't been able to successfully breastfeed. At first, I was defensive about our use of formula. "The baby is perfectly healthy. Look how big he is!" (Constantly over the 90th percentile for weight and height - still is at 4.5 years old!) "Formula is working out just fine." "I did try to breastfeed, but I didn't really like it." And so on.

But after a while, and not that long of a while, I really started to regret it. I felt I had deprived my son, and myself, of something very important. I mentioned in my last post that I had tried to relactate. It didn't work, but I also didn't try very hard.

I also starting thinking forward to a future baby. I had some very definite ideas about what I didn't want a second time around, and began to feel like if we had a second baby, maybe I could get it "right" this time. I had twinges of guilt, like I shouldn't think that I had done something "wrong" the first time, because that really wasn't fair to my son, but there was something missing inside me. I felt like I had been deprived of an experience that you only get a few chances to have.

So I started reading. I read forums on LiveJournal. I read articles about VBAC (vaginal birth after cesarean). I discussed it with women who'd been through it, women who were practicing doulas, women who knew more than I did in general about pregnancy, childbirth, and breastfeeding. I watched other women breastfeed. I listened to their birth stories. And I became a huge breastfeeding advocate, despite feeling slightly hypocritical. I also learned that in almost EVERY case, VBAC is safer than a repeat c-section. I learned that the risk of uterine rupture with VBAC is lower than any of the other risks associated with having a c-section. I learned all about the benefits to mother and baby of a vaginal birth. I learned all about the benefits to mother and baby of breastfeeding. I learned how amazing breastfeeding is, and how amazing breastmilk is, and I couldn't believe I didn't know any of this before my son was born. How could I not have listened when people tried to tell me? How could I not have wanted to know?

These are the topics I expect to cover in future posts, so I'm not going into a whole lot of detail now. Each heading deserves one or more articles of its own! So don't worry. I'll get to all of this!

Anyway, I decided that when it was time to have a second baby, I would go in with eyes open and armed with information. This time, I knew what I wanted.

When our son was about 18 months old, we decided, heck, let's go for it. Let's have another. Now, it had taken us almost a year to conceive our first son, so we thought we had some time before I got pregnant a second time. My body had other ideas. By the second cycle off birth control, I was pregnant! Our kids would be about 26 months apart, which we actually felt was a good age difference. I was due December 31, which I thought was pretty darn cool.

We had since moved from Philadelphia to San Diego, so I had a new set of doctors and new insurance - Kaiser Permanente. I had heard good and bad things about Kaiser, and I wasn't sure what my experience would be, but I didn't have much choice.

My pregnancy was quite ordinary, which was good. I read La Leche League's publication "The Womanly Art of Breastfeeding" cover to cover while I was pregnant. I read and re-read information about VBAC and breastfeeding. My new set of prenatal caregivers - a nurse-midwife and an OB at Kaiser - were both on board with the idea of a VBAC, even though they knew my history and what my previous OB had said. Neither was overly concerned. The OB was willing to let me have a "trial of labor," but she wasn't terribly confident of "success." She felt that the conditions that "required" the first c-section - a large baby with a large head - could easily be repeated, since the babies had the same parents as before, and that significantly lowered the statistical chances of a successful VBAC. As the pregnancy went on, she started making not-so-subtle hints that I should just schedule a c-section. ("If it were me, I would just schedule a c-section" was one comment she made. I was annoyed.) I was SO hesitant to agree. I asked, "Couldn't I wait until I go into labor, then have the c-section at that point?" That way, I would know for sure that the baby was ready to come. I was concerned about having a baby early and the problems that could cause. She didn't understand why in the world I'd want to do it that way. She assured me that 99% of the time, babies born by c-section at 39 weeks don't have respiratory issues. I asked if I could schedule it for 39 weeks, 5 days, very, very close to the due date. She said sure. I think I was subconsciously hoping that I would spontaneously go into labor before the scheduled time so that I wouldn't have to worry about it. I never did actually commit to a schedule because, while I was annoyed at the lack of support from my primary OB, I saw a different OB for one appointment. And his advice was totally different.

He explained that repeat c-sections carry great risk, because every repeat c-section increases the chances of placental accretion (I think), which is when the placenta is absorbed into the uterine wall. This is a very bad thing. Also, each new scar makes the uterus weaker, which increases the risk of rupture or other complications. Plus, c-sections always carry risks, including blood loss, infection, and whatever else might go wrong while they rearrange your internal organs. Not to mention the risks to the baby of not having a vaginal birth, which are still somewhat unclear but are becoming clearer by the year. He was all for a VBAC. He agreed that my statistical chance of "success" might be low because of the circumstances, but that was no reason not to have a trial of labor.

I was convinced. I ignored any further plea from my primary OB to schedule a c-section and told her I intended to have a trial of labor. She said that was fine. Not that she had a choice.

Everything was perfectly fine, up until the end. By the last month, I was having problems with high blood pressure. High blood pressure can mean preeclampsia, which can lead to seizure or stroke in the mother, and if not treated, eventual maternal death. It's a Big Deal. The only real "cure" for preeclampsia is to deliver the baby. So they monitored my blood pressure very closely and took urine and blood samples regularly. If any protein showed up in my urine, there would be cause for greater concern, because it meant there was kidney involvement.

On December 5, my blood pressure at my usual checkup was quite high - 150/105 - and didn't come down after resting for a while. The doctor said I needed to get myself down to the Kaiser hospital in San Diego, which is 45 minutes away without traffic, and this was at rush hour on a Friday. My husband and I scrambled to find care for our son, then went on down to the hospital. When we got there, they hooked me up to a blood pressure cuff and fetal monitors. The baby was fine, I was having very mild but frequent contractions (not labor), and my blood pressure, thankfully, came down nicely and everything went back to normal very quickly, in about 90 minutes, and I was sent right back home. Whew! But that scared me, because they said if the numbers didn't come down, or if the baby showed any distress, they would induce right away. I was so not ready for that! So it was a relief that everything was fine.

An induction was just about the last thing I wanted. It made me feel like the universe was conspiring against my plan to have a VBAC. You see, if you go into natural labor, avoid an epidural, and allow yourself to move around, and keep medical interventions to a minimum, your chances of success are quite good. An induction, however, is less likely to end up in a vaginal birth regardless of whether it's your first baby or a VBAC. This doesn't mean you will have a c-section if you're induced, just that it's more likely than if you aren't.

Here's why.

Scenario 1) They try an induction and it fails. If this happens, the only other option is a c-section. If your body isn't quite ready to give birth, an induction may just simply not work - you won't go into active labor. So if it's necessary for the baby to come out, say, in the case of preeclampsia, then they'll have to do a c-section.

Scenario 2) The induction results in active labor. Okay, this is a good thing. You're in labor. You're having regular contractions. Your cervix is opening up like it should. Here's the problem: An induction using Pitocin results in contractions that are MUCH stronger than those your body would produce in natural labor. This means they are MUCH more painful than a typical labor contraction should be, which means that most women simply cannot handle them without external pain relief. This means epidural. With an epidural, you are pretty much stuck on your back in bed. In addition, sometimes the epidural can slow labor, which means they'll need to up the Pitocin to keep labor going. Which means the contractions will become even stronger. You can end up in a pretty vicious cycle. Now, if you're going for a VBAC, the stronger your contractions are, the greater your risk of uterine rupture, so they can't push the Pitocin as much as they might do otherwise. If your contractions aren't strong enough, or regular enough, your cervix might fail to open fully, and you will be labled "failure to progress" and be advised to opt for the c-section. Or, even if labor does continue successfully, the Pitocin contractions are so strong that they can cause more stress on the baby than natural labor contractions would. This can cause the baby to go into distress, represented usually by a sharp drop in fetal heart rate. If this happens, you will probably need an emergency c-section to save the baby.

I pretty much knew all of this. So the idea of an induction was very frightening. I thought that if it came to an induction, a c-section was almost certainly in my future after all. I desperately hoped I would go into labor naturally instead and that my blood pressure would stay under control.

When my blood pressure was worryingly high again on December 16, I assumed that it would be another "go down to the hospital, go on the monitors for an hour and a half, and be sent home." So I went down there by myself, rather than shlepping my husband along on another useless trip. That, apparently, was the wrong decision.

How's that for a cliff-hanger? Stay tuned for the story of my second son's birth! (You already know the end - I got my VBAC!)

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