Note: While I do have complete permission from the mother to share this story, names have been changed to protect their privacy. We will call the mother Emily and the baby Loribeth. I'll refer to the doctor as Doctor S.
Birth should bring feelings of anticipation and excitement, not feelings of fear and hostility.
After a primary cesarean for a malpositioned baby and a second cesarean for multiples, Emily desired to have a vaginal delivery. She made her wishes known early in her pregnancy and felt very supported all throughout her pregnancy by her care providers. Unfortunately at 37 weeks, the tables turned drastically. Emily was informed that she would not be allowed a TOLAC (Trial Of Labor After Cesarean). The doctor informed her that the risk was too great and she would need to be scheduled for a cesarean section before her body had a chance to labor. The doctors had originally categorized her as a good candidate for a TOLAC since she had over 12 months since her last cesarean, her prior cesareans were non-emergent and were not 'failed' labors, and her uterus had double layer sutures each time. She had also had an uncomplicated pregnancy thus far. She wasn't comfortable with this at all, but was so shocked at the sudden change that she left the appointment in tears. She went to her next appointment at 38 weeks and received the same treatment and the same information. At that point we began to consider other options, but she felt trapped. Her 39 week appointment arrived and when she got to the office she learned they had scheduled a cesarean for March 5th - nearly an entire week before her March 11th due date. She requested that they at least push the appointment to her due date, but was denied. She did reschedule her cesarean for March 7th which is the latest they were willing to reschedule for. Emily voiced her deep concern to the doctor she saw that day, expressing her desire to at least attempt a vaginal delivery. If anything went wrong before or during labor, she wouldn't hesitate to consent to a cesarean. She reminded him of the recommendation of the ACOG that now says it is acceptable and encouraged to offer mothers with two previous cesareans with low, transverse uterine incisions a TOLAC. He gave her a piece of paper with the risks of a VBAC and told her the risk was too great. She again pressed him and asked what would happen if she just came to L&D in labor? He told her she would either be forced to have another cesarean, or the entire practice would be notified not to touch her. Emily left completely shattered.
When we arrived at the consultation, the practice had already received and read the letter and it was in Emily's chart. We were ushered directly to the Dr S's office instead of an exam room. We sat down and began to discuss the issues at hand. I was providing moral support while Emily took the lead. Dr S. explained that he believed this was all simply a big misunderstanding. He said that while they have very strong feelings on things such as this, they could not and would not force her to do anything and that no one would come and drag her out of bed tomorrow for her scheduled cesarean. He said that this was clearly a misunderstanding and miscommunication and that it didn’t deserve legal attention. That statement alone tells me that the point and purpose of the letter had worked!! I knew when I read the letter that it was either going to upset the practice tremendously and they would seek a court order for a cesarean (possible and has happened in the past unfortunately), call DSS/CPS for her endangering her child’s life in their opinion - since SC is a personhood state, or something similar. Alternatively, the letter may shake them into reality and make them realize they are dealing with a mother who is fully informed of her rights and ready to take action and they would back down. Thankfully, the second option ended up happening!! You could tell it was obvious he was shocked that someone went to such lengths to get their attention and fight for what they wanted. He had the ACOG guidelines book on his desk bookmarked to the VBAC policy and showed us that VBAC after two or more cesareans is contraindicated and the ACOG doesn’t support it. He explained that the risk of rupture was 1-2.6% after 2 cesarean section. He explained the risk and that if my client were his wife, he would advise she have a RCS (Repeat Cesarean Seciton). He was very calm and we remained very calm as well. Dr S. said that now the ball was in Emily's court. When he was done explaining his position, Emily began to explain hers. Her first question was the publication date for the VBAC ACOG guidelines he had looked up because she believed they were out of date. He looked surprised to be challenged and we took out my binder that had the most recent, revamped ACOG recommendation that is to allow a TOLAC in mothers with two prior low transverse uterine incisions. He was shocked and had no idea that the guidelines had changed…. She explained that she understood the risk involved, but she also understood the risk of a 3rd cesarean section and all she wanted was their blessing to have a trial of labor. She explained that she wouldn’t hesitate to agree to a cesarean section should there arise a true need. They talked further and agreed that she would be allowed to be left alone until 41 weeks – March 17th - to go into labor and be allowed a TOLAC. No induction methods would be used. If no labor and no changing cervix by March 17th, a cesarean will be scheduled and Emily was fine with those grounds. Everything looked great at her appointment. There was no cervical change and the baby was very high still - floating according to Dr. S. He did mention before he left that rarely does he ever see a mother go into spontaneous labor within a week or so when the baby is still that high and mom has a completely closed, thick cervix. That didn't get Emily down, she knew that the baby would come and she was over the moon to be granted the blessing from the practice to at least try for a vaginal delivery!! We talked for a few moments in the hall before I left - lots of congratulations and tons of hugs. One of the last things I said to her before leaving was now that there was no stress, no "what-if's", no being worried about someone forcing surgery on her, the baby would happily come. Little did I know how right I was.
Sweet baby Loribeth didn't make her mommy wait long at all!! Less than 12 hours later, Emily sent me a text at 2:30am on March 7th and told me that her water broke. Because she was GBS+ she and her family headed right to the hospital because she would require IV antibiotics every four hours during labor to prevent infection. Unfortunately I didn't get the text immediately since Emily had forgotten that I live in the boonies and my phone doesn't regularly have a signal. Around 10am I checked Facebook and saw that Emily had mentioned her water broke!! I grabbed the phone and called her. Sure enough she told me she had SROM early that morning and gave me a quick update about what was going on. Thankfully, the same doctor she had previously had the consultation with the day before was on call for the next 24 hours. He very clearly knew her goals for a vaginal delivery and supported her choice. Unfortunately there was one key component mission - contractions. Emily explained that she had only had a few random contractions since her water broke about eight hours prior. I thought for sure that the doctor would have suggested another cesarean by that point considering she had two previous sections, had never labored, and wasn't having any contractions hours after SROM. Thankfully however, Dr S. was comfortable letting her go until about 7pm which would be 18 hours after SROM. He gave that amount of time to most GBS+ women with SROM and no contractions or progress. If there was progress at the 18 hour mark they would consider extending the deadline providing Emily's temperature was ok and baby Loribeth was doing ok as well. Emily seemed happy with that and we brainstormed a bit about how to get some contractions going. I told her I'd arrive at the hospital and give some hands-on help in a few hours and gave her some suggestions to try in the meantime as well as suggesting she rest for the labor ahead.
I arrived at the hospital around 1:30pm and she was getting a few contractions here and there, but nothing much. The atmosphere was joyous. Emily's mother, other children, and hubby were all there supporting her. She had one of my favorite nurses on the L&D floor - an absolutely wonderful women. Dr S. had been in to check her a bit earlier and she was a fingertip dilated and still completely thick. I reassured her that we would try our best to get her body to start responding and contracting and for her not to worry. She sat on the birth ball for quite awhile doing pelvic rocks, figure 8's, and hip circles. While she circled on the ball, I worked on the accupressure points on the hand, finger, and foot. The pressure point on the thumb and foot triggered several nice contractions. She moved to the bed in a sitting position to rest for a bit and then decided to stand and sway. Standing seemed to give Emily that "sweet spot" and her contractions started to come a little closer together. She stood and swayed and did hundreds of hip circles. Contractions continued to remain pretty regular at every 5-9 minutes. Dr S. had planned to come in around 5:30pm to check her cervix again, but instead came around 4:45pm. We all waited and held our breath - hoping and praying for just a little change to reassure Emily and Dr S. that this was possible! Dr S. announced that there was indeed some change - she was now 2cm and 70% effaced. Everyone encouraged Emily, and Dr S. seemed happy with that progress. He felt like labor was actually just technically beginning and he'd keep a close eye on infection signs. Providing nothing pointed to infection, he was good letting her keep on plugging along. After her cervical check, the contractions just seemed to fizzle out completely to the point where she would only have 1-2 in a 30 minute period. We tried various positions, we tried rocking in the rocking chair. She tried sitting on the birth ball doing pelvic rocks, tilts, and figure 8's. I massaged the pressure points that yielded such good contractions earlier, but unfortunately nothing happened this time. We tried quite a few other things and absolutely nothing I could think of would work. We consulted with her awesome nurse and each thing she suggested, we had already done. Dr S. decided that because she had come this far only to hit a wall that wasn't moving after trying all natural approaches, he would start a very, very, very low dose of Pitocin through her IV. The maximum dose he was comfortable with was 4 milliunits/hour. A mother with an unscarred uterus typically maxes out around 36 milliunits/hour the nurse told us. Pitocin drip was started at 2 milliunits/hour and it began to do the job it was designed to do! Within about 10 minutes Emily's contractions started to come a little more frequently. She initially was in bed but decided to get up and do some of those wonderful hip circles that we believed really helped her progression earlier. Unfortunately this time it wasn't a good position to detect the heart tones of the baby and because now she had Pitocin on board, it was important to watch for any indications of a problem. The nurse came in and bumped her pitocin up to the 4 milliunit/hour limit Dr S. was comfortable with and very soon her contractions were on top of each other. With the contractions so close, Baby Loribeth started experience some late decelerations in her heart rate which indicate fetal distress. Emily's nurse immediately noticed this and the decided to back the Pitocin off to 2 milliunits/hour again. Dr S. came in and Loribeth's heart rate was still dipping during each contraction so the decision was made to turn the Pitocin off completely. Loribeth's heart rate stabilized with no more decels, but had a lower baseline than before. All during labor the baseline had been around 140, but the baseline fetal heart rate was now about 110. Dr S. explained to Emily that Pitocin was causing some distress so that was no longer an option and since she wasn't contracting at all on her own, and to progress you need contractions, he wasn't sure where to go from here other than a cesarean. He also said that the lower baseline was a little worrisome and that he could give her another little while with a lowered baseline before they'd probably need to go ahead and do a cesarean. Emily was given oxygen and rolled onto her side to try and help Loribeth's heart rate to completely recover. Emily consulted with her mother in law, and then her husband, and finally with me. The entire room could see that despite Emily's best efforts, this little girl just wanted to come into this world through the sunroof!! I explained this to Emily - that she had done such a great thing by fighting for the right to simply try, that she had done beautifully during labor, but that what mattered now was that her baby was born safe and healthy. She agreed. What happened in the next few minutes was a complete and utter shock to everyone in the room.
While discussing how to proceed next, baby Loribeth's heart rate dipped down into the 60's and remained there. Normal fetal heart rate is 120-150. Dr S and the nurse watched for just a few seconds and then her heart rate went into the 40's and then became undetectable. Immediately a STAT cesarean was called. Dr S. ran out of the room to scrub in - thankfully we were in a room extremely close to the OR. Immediately the room filled with nurses, and while Emily was being wheeled out a nurse explained that due to the critical situation, Emily would be put under general anesthesia and no one would be allowed into the room. The Special Care Nursery was called to the OR in case the baby needed resuscitation, and Emily's husband followed her to the OR door and waited outside. Meanwhile Emily's mother in law called Emily's mom up (she had been downstairs with Emily's other children) and we gently informed her of what was going on. We all paced, thought, and prayed for what seemed like an eternity. I stood at the door hoping to catch a nurse and ask if someone could please let us know the condition of mom and baby as soon as possible. A few seconds later a nurse came towards me and let us know that the baby was out and that she was ok! I asked about Emily, but she didn't have any information on her yet. I looked down at my phone - less than 10 minutes had passed. TEN minutes from the time everyone realized the baby was in grave danger until a nurse was telling us that she was ok! Absolutely amazing. The grandmas, daddy, and siblings were ooh'ing and ahh'ing over this beautiful baby girl, but of course were still worried about Emily. Soon Dr S. emerged from the OR and informed us that Emily was stabilized and headed to recovery. He explained that she had suffered from a placental abruption. Thankfully he was able to very quickly control the bleeding and she hadn't lost much blood. No extreme measures such as a hysterectomy had to be taken. He said there was no indication of uterine rupture, it was most definitely a placental abruption. Dr S. went on to tell us that she would need some x-rays done before she could go to recovery since they didn't even have time to count the surgical instruments and supplies before they began the cesarean and they needed to make sure nothing was left behind. We went back to Emily's room to wait for her to get out of recovery. Thankfully there are some truly amazing nurses at this hospital and one of them took the baby to Emily in recovery and helped her breastfeed - good news is that Loribeth is a breastfeeding champion!! Soon Emily was back in her room and processing through everything that had taken place. She was feeling very groggy from being put under general anesthesia, but it was clear she was extremely thankful that everything was ok. I reassured her that there was absolutely nothing to be disappointed over, that she had done exactly what she needed to do to keep her precious baby safe and that I was so proud of her and so thankful that both she and baby Loribeth were both ok. She completely agreed and while she was happy that she had given it her all, she was also extremely thankful for the cesarean that saved the lives of her and baby Loribeth. I left her with her family to rest and assured her I would check on her the next day.
I checked in with the family today and baby Loribeth and her mommy Emily are doing absolutely wonderful! Loribeth is a champion nurser and Emily isn't even requiring any pain medication after her cesarean. She is already up and moving around and feeling surprisingly well. Emily again reiterated to me that she has no regrets. She is very thankful she didn't take the suggestions of some - to call in an underground midwife, to have a homebirth, to go to another state and deliver, to labor at home until she was feeling pushy. Any of those suggestions could have had deadly consequences for Emily and her baby. She is thankful that she was given the opportunity to attempt a vaginal delivery, and she is thankful that her body tried to labor. Ultimately though, she is so very thankful that there was an amazing medical team who jumped right into action and essentially saved the lives of both her and her sweet baby girl. She let me know that if she could go back in time, there is nothing she would have changed.
According to Emily,
"I don't think I would have done anything different. I might have said hey lets keep it [the pitocin] at two [milliunits] but hey it [the abruption] would have happened either way. It was God's way of saying, hey this baby needs out and isn't coming out the normal way. I let you try it now it is time for you to go ahead and meet her."
Baby Loribeth's birth has left me in a whirlwind of emotions. It was the first true emergency I have witnessed during labor and it was an eye-opening experience. I am in true awe at the medical team and how they came together in an instant and saved two lives that hung in the balance. Oftentimes you tend to brush off reality when you hear risks such as the tiny percentage of VBAC moms who will suffer a uterine rupture, the miniscule numbers of mothers who will suffer a potentially life-threatening placental abruption, or the incredibly small number of women who suffer from something such as an AFE. Because it is so rare, it doesn't often hit close to home. Never have I been able to visualize these rare and potentially life-threatening complications until yesterday. When you witness tragedy strike, suddenly those miniscule risks become a shocking reality and I found myself a bit shaken and questioning my views on several things. When a dear mother and friend is whisked to the OR and you can't say for certain if both she and her baby will make it out ok, it becomes a devastating reality. I've heard so many times that labor can be going completely fine one second, and literally become a life and death situation the very next second. Until I witnessed this with my own eyes, I couldn't grasp the gravity of that phrase. Until I saw the look in a man's face, not knowing if his wife and child would survive, I couldn't grasp that concept. And until I saw the pain in a mother's face, worrying about her precious baby and grandbaby, I couldn't fathom the change that could take place without warning. I can not reiterate enough that birth is not to be trusted, it is to be respected. I am very thankful for this perfectly imperfect birth that has taught me many things and opened my eyes to things I've never been able to grasp the concept of before.
