Thursday, July 10, 2008

The battle for VBAC

I've been thinking alot this week about vaginal birth after caesarean (VBAC).

I had the care of a woman early this week who was keen for a VBAC after her first labour ended in a CS for non-dilation in first stage. Her cervix had not dilated past 4cm 6 hours after reaching that stage. She wanted a VBAC because she had found recovery from the CS to be very difficult, understandably, and was keen to avoid the same again.

She had presented to the assessment area of LBS, a day or so past her due date, contracting strongly but irregularly and was keen for an epidural. Her cervix was dilated about 1.5cm, but was fully effaced- a bit early for an epidural. She was given a shot of opiate - which knocked off the contractions and had a sleep. When she woke up she started contracting strongly again, and was very anxious to get an epidural. This was not a method of pain relief she had used with her previous labour. She was transferred around to the labour room where she tried to settle in and get the contractions started again, as they had died away. I was assigned her care and after an initial chat it was clear she felt under the pump to labour that day as there was a CS scheduled for her the following day. She was also quite cross that she had been given the opiate earlieras she felt it had dampened down a happening thing. I spoke quietly to her, encouraging her to set aside everything else that was going through her head, and to give herself time and space to just be in the room, in this moment. We worked together quietly to create a space where she could feel safe, dark and quiet.

After a while, and a rupture of membranes by a doctor(2cm), she recommenced contracting. They were strong and lasted for 45 secs or so, but were irregular in their pattern. 2-3:10, then a gap, then 5-6:20. The baby was lying in a posterior position, which does cause an irregular pattern, but something just wasn't convincing as the pattern was too easily disturbed.

When planning a labour after CS the accepted wisdom is to avoid the use of artificial hormone stimulation i.e. syntocinon/pitocin, as this is technically contraindicated as a use of the drug when there is a uterine scar. The big scary bugaboo is uterine rupture along the previous scar. The incidence in natural labour is quoted at 1:80 - 1:200. That's 79:80 and 199:200 where it doesn't occur (if you're thinking positively). Under syntocinon augmentation/induction the incidence rises significantly. This woman had done some reading and consulted some people in the lead-up to this labour and her understanding was quite clear. Avoid use of synto.

Four hours after the ARM I examined her again, very little change (2.5-3cm). There was a different doctor hovering outside the door, who demanded the information and ordered an epidural and another examination in an hour. Then synto was to be started if there was no change. AN HOUR! She hadn't even met the woman, felt the contractions, heard her fears. The next shift came on as this occured and we collectively decided that this was not in her interests and she could decline this plan if she wanted. She declined, I documented it.

I was torn in many directions. I felt psychologically that this woman needed to do something different in this current labour to change the script from her previous labour. Her first labour had been induced from scratch, building up to maximum synto use, with a stalled dilation under a theoretically adequate pattern of contractions. She herself had little faith in the ability of synto to cause cervical change in her. We had been keeping upright or on all fours to encourage rotation of the baby to a more favourable position. She had been off for walks. She was trying nipple stimulation to encourage contractions.

We're taught that there are often mental blocks to cervical dilation related to fear of pain, anxiety of other nature, insecurities of all sorts. One of the challenges for the midwife is to identify and work with the woman to push through, allay or dissolve these factors, making the conditions right for relaxation and cervical dilation will follow. It so happened that the next shift midwife was one who had cared for this same woman in her first labour! I was unsure whether this was a positive or negative factor for the woman. Was this to be a re-living of the script?

The next midwife was having a quiet and assertive advocacy argument with the doctor in the corridor outside. I was very grateful to see it, as I don't have a lot of experience in caring for VBAC candidates and felt a little shocked and out of my depth at this challenge. There are practical factors to be faced either way.

I can see the doctor's point of view - no amount of standing around watching and creating a nurturing environment is going to establish a truly effective trial of contractions. Except that I felt we had been getting somewhere psychologically up until the point of that examination at the time of shift change. If the cervix had been dilated 5cm at that point I felt we would have been home and hosed. But honestly, there had been very little change in nearly 4 hours of strong but not always regular contractions. Her body clearly wasn't quite ready to do this.

There was the question of pain relief. This was a back labour, and was pretty painful. The afternoon midwife felt an epidural was not the way to go, as it often knocks off contractions a bit if used too early - which this was on the borderline of being. Her recommendation was for a shot of opiate - which the woman herself didn't want because it had diminished the labour 12 hours earlier. The doctor didn't care which method was used as long as the synto went up, sooner rather than later so the woman and the baby were less tired than they would be if we held off for a further two hours, which was the general preference in the room. Tick tock tick tock. Bloody hell, we felt we were getting nowhere.

The doctor entered the room for the first time (uninvited). It felt like an ambush. There was a lot of 'baby getting tired' language (the trace was excellent), contractions have to be effective (she hadn't palpated a single one), the pattern isn't established yet (well, I'd pay that one). She asked who had done the last assessment and insisted that I repeat it now (2 hours later) and a plan would become clear if there had been any change with the spontaneous (under pressure, very disturbed, doubt creeping in) contractions.

The woman agreed. The doctor left the room, her views and orders were clear. I did the deed. There was very little change.

What I know is that to achieve any vaginal birth, whether the first or the seventeenth, for VBAC or not, the cervix must dilate. The baby cannot be born through a closed or semi-opened door. End of story. No matter what one believes, or what the environment one creates. Babies are born with their mothers clinging in trees to avoid being swept away in floodwaters. Does that desperately unfavourable and exposed environment inhibit cervical dilatation? Clearly not.

My emotions were swirling. I would not lie to this woman. I felt her crumbling hopes acutely, her self-belief, her visualisations for cervical opening evaporating by degrees. I felt she had spent the last two hours being undermined by a series of factors, but was that really true? What if her cervix was one of those that just didn't dilate? Sure she was anxious and a bit nervy, but I would be in her place too. Was it my belief in her that was wavering? Or was it a growing acceptance of reality?

I saw the logic of the doc's plan. Let's have this labour declare itself one way or another sooner rather than later. Was I being pie in the sky waiting for spontaneous labour to 'win'? As much as I wanted nature to take over if I could protect the environment and sing Kumbayah sincerely enough, was it always going to be a losing battle in this woman? I have seen VBACs achieved before, with and without the use of synto. I just wish it didn't have the reek of 'doctor getting all her ducks in a row by knock-off time' about it.

I stayed for the discussion about synto Vs pain relief. They looked to me for guidance and I felt like a traitor discussing the benefits of a compromise, with a trial of synto under controlled conditions, yes, start with an opiate for pain relief (not my first preference for this woman, an epidural may have been the psychological script change she needed), you can always move up to epidural (oh God, that trace is going to suffer with morphine and an epi, hope the baby is alright when he/she is born around 8-10pm - my estimate - probably by repeat CS). It was time for me to leave.

I phoned later that night and she ended up with a repeat CS at 8-ish pm. A little girl. They already had a boy at home. They would be really pleased to meet her, I know. I confess I had a bit of a tear about the outcome.

I have been troubled for days about this 'failure'. Was the failure mine for not creating the environment appropriately? Did I do her a disservice by holding on to her birth plan too solidly - trying to create a safe space for her with time to get into labour. I wasn't convinced she was in established labour except for maybe the last hour before the lunchtime assessment. The contractions were sneakily irrregular. Yet only days before I had seen a woman give birth to her 7th child with a similar pattern of contractions. Through a cervix that had dilated. Was this woman doomed to a repeat CS by a physiological anomaly of her own body, regardless of my supportive touch and words? Kumbayah humbug! Did this anomaly cause a script re-run?

I am trying hard to love this question. I suspect there are different answers in each woman. I was always taught that the CS to avoid is the first one. With the syrocketing CS rate in this country, state and the facility I work in I am certainly keen to work to avoid the first in all women in my care. Have I seen any soft decisions for CS? Hell yeah. I have also seen many vaginal births that may have not been achieved in other facilities. Some women have one CS for breech and then just never think about not having a VBAC with the next. In some countries it is the same, one just assumes she will have a VBAC unless there is another really good reason (placenta praevia, severely bad trace, placental abruption - which can give a subtly bad trace, cord presentations, delayed progress in first stage of labour). Breech presentation in first-timers is another common reason for a first CS- I am in two minds about this one. One school of thought says that this leads to de-skilling of midwives and obstetric staff as they never get to manage a breech birth, so never develop confidence in it. Others think that the consequences of a bad breech birth for the baby and woman can be catastrophic, e.g. with a trapped head. I know of a recent case of this, the staff still pale at the memory, the baby was not good (i.e. nearly died) but is coming good now apparently.

So,VBAC is quite a fraught issue in my profession. It is not the case that all vaginal birth is better than birth by CS. They say that recovery from a good CS is much better than from a bad vaginal birth (i.e. instrumental births with minimal analgesia and 3rd or 4th degree tears). There is definitely a place for the use of CS. The World Health Organisation accepts that CS is appropriate for births in about 10-15% of women, and women die daily for lack of skilled surgeons to support the needs of these women. Would the woman of this story be one of those who falls into this category? Whose cervix hasn't fully dilated with either an induction of labour or a spontaneous and augmented labour? Would she be the mother of two living children? Albeit recovering from a second non-elective CS? We'll never know.


sue said...

Hi Laura

Thought I'd drop in! This is Sue

You know my stance on VBAC and the paranoia of the medical model of 'care' of these poor women.

Reading this post I feel that this woman was never actually in established labour, why was it so painful then that she wanted an epidural? Fear? pressure of the looming c/s booking? Or just a badly positioned baby trying to sort out where the exit sign was? I can't say but a cervix of 1 - 2 cms with a posterior presentation is not established labour. If a dose of pethidine knocked the contractions off, then it was not established labour.
Long latent back early labours can be very challenging to cope with, for both midwives and women!

I had a very similar labour with my 2nd (H) which was my first VBAC. He was posterior and I was in very early latent labour when I went into hosp. In hindsight I should have stayed home until things were waaaay more established but at least 'in those days' VBAC was the norm and people were more patient. I eventually did establish, with ARM and synto, etc and finally pushed him out......but I know from my own experiences with VBAC women recently in the place you work, that I would not have been 'allowed' to labour in that way were I in the same situation here today
Was the rupture of membranes spontaneous or artificial? If ARM was done (however well-meaning) it would have locked her into being committed to be induced, with all that follows, as you describe.
Just also read your blog about the large lady who had c/s and again she obviously was not in labour - failure to progress be damned... High head + firm cervix = not in labour. Her instinct to go home was probably the best option ....but again we have that old shroud waving factor and as she'd already lost one baby......yadayadayada...poor woman would have had to be really determined and sure of herself to do that having started the process of induction (although I have seen IOL's which have done nothing after 2 days of prostin, synto etc, stopped and the woman sent home to await events!!!! Unusual yes, but I have seen it - what's more, it worked!)

In contrast, I recently had a girl who's cervix was 7 cms dilated who was not actually in labour! It was just a very good multi os :-)

In both these situations you obviously tried your best to achieve good outcomes for these women and gave them excellent care - it is the system that failed them, which sadly does not understand 'normal' birthing physiology and locks women into unrealistic perameters within which they must labour and birth.

Good on you for trying and caring so much...never lose the passion!

Also thanks for the photos of our mutual friend's birth - recieved them today - lovely! Discharged her yesterday - bub now fat and gorgeous, but chucking up lots (way too much of that good stuff methinks, obviously absorbing enough :-).)

In sisterhood

Laura Jane said...

Thanks Sue, lovely to hear from you.

I sent a copy of this post to a researcher into VBAC that I respect and she called me and we had a long chat about it. She bascially said the same things you did.

I wasn't exactly looking for reassurance about my passion per se, but more I needed to think about ways to address the interdisciplinary stuff, and the language used in front of the woman, that I felt had undermined her efforts. That's apart from the REALLY valid point that she should have gone home and kept far, far away from the bloody hospital for as long as possible. However when she had first presented in the middle of the night from home she had been contracting 3:10 - which is when we would have expected her to be presenting.

Thanks for your comment

Frogdancer said...

I never considered having a vaginal birth after Jack's caesarian delivery. He was a normal sized baby (7lb 14 oz) and I wasn't able to fit him through my delicate ladylike pelvis, so my doctor just said, "I think considering that fact, it'll be caesarian with each delivery." (Not that we were expecting 4 in 5 years....)
Jack ended up being my smallest baby, so it was probably a good thing.

(I'm waiting for the postman!!!! Woo hoo!)

Alby Mangroves said...

Hi Laura Jane, I had an emergency CS with the Ratbag. I'll never forget the poor midwife who had a feel in the afternoon after I'd been in induced labour for several hours (he was over a week overcooked), confirmed the Docs and other MW opinions that he was definitely engaged, I was just slow to dilate - 3cms after 6 hrs. Hours later, some bright spark did an internal and said "I hope that's not a bum I'm feeling". Of course it was, and the rest is history. That same midwife came to see me on the ward and proclaimed "I thought he might be breech!" You bloody well should have said something then !!! I screamed. Anyway, you handled it well I thought, your main concern was always the mum-to-be, and you tried to keep her calm and well informed. I never wanted to experience labour again after that, and even though recovery was horrible the first time, I went back for an elective CS, with great results - recovered so quickly and without pain, probably because I hadn't laboured.

Lesley said...

Hiya mate! It's my pleasure to bestow upon you the "Brillante Weblog" award; stop by my place to pick up the graphic, then spread the cheer to 7 others.

widget said...

happy anniversary. happy anniversary, Happy anniversary, ha - ppy anniversary.

Heard on the blog web we weave that it is your anniversary today.

And yes I'll be there too with Froggie.....I'll be in a mask.......

Just thought I would pop on by.

petvet said...

I found this blog, in one of my googles. I must say it is great to hear commentary from someone well informed who does this for a living. I'm hoping not to relive the scenario you've described here, and many of the questions you ask yourself are ones running though my head. I'm currently expecting my second child, and my hopes for VBAC are starting to fade. I'm at 40 weeks + 3 days and had my ultrasound and non stress test this morning. Baby is fine. I'm feeling great, but I'm seeing a repeat of my first pregnancy.
With my first child, I went into labour at 39 weeks, but from the get go I knew something wasn't right. The contractions went from regular to irregular, but stronger. After about 10 hours we went into the hospital and they checked me out. Only 1.5-2cm dilated, no effacement. I was waiting for the doctor to come back (presumably to send me home) when my water broke. Lots of meconium. (Turns out we had a touch of chorio) It all went down hill from there. The contractions blended together and I writhed for about 4 hours. I couldn't stay still. I was up to the washroom every few minutes, but could barely stand up so my poor husband carted me back and forth and kept me from rolling off the bed. I think I puked on him at one point. The nurses were somewhat frustrated as I couldn't sit still long enough for them to get a reading on the baby. I was so out of it I can't remember whether I asked for drugs or someone offered. At about 9:30 am, a little over 4 hours after my water broke, I got an epidural. My cervix was 4cm dilated and still not showing any sign of effacement. They put me on pitocin to make sure things didn't stall out. According to the charts, the contractions evened out and were fairly strong but by 5:00 pm I hadn't dilated any further. I couldn't feel a thing, the block was great from that point of view. I wonder now if things would have turned out differently if I'd said no to the epidural. I know I needed something! I was worn out and starting to panic. But the hospital here doesn't like opiates without an epidural. I don't know why. (My mom said she loved Demerol :)) So we ended in a fairly routine C-section. Aside from my little girl being green from head to toe.
I didn't mind the C-section really. It was way, way better than my laprascopic appendectomy.
Within four weeks I was feeling pretty dang good.
I still don't like the idea of being a Darwinian reject though. I come from an veterinary background, and I don't like having anything in common with a cull cow. Cows get one shot. A cow that has a C-section becomes hamburger next year. Be it bad genetics or bad luck. (As an interesting cases where the calf is too big, we always blame the bull!) I know many vets who refuse to do a C-section in a dog or cat without also doing a spay. The idea being that it is wrong ethically to allow animals to be bred if they need intervention at delivery. That's just cruel after all.
So in my own mind, I think VBAC is important to justify that I'm fit to take that place in my ancestors unbroken line. It's stupid, but I can't shake it. I realize that we are not animals. Nor does a c-section make me any less of a woman than my Granny who birthed five kids in her kitchen. But no one wants to be the reject either. Its unsettling to think that had I been born a hundred years ago I could have made my husband a widow in childbirth, or lost the baby. Or both.
I find it ironic that so much about birthing is about me, when five minutes later I wont give a crap about how the kid got into the world, just that its finally here!
So here I sit, waiting. I'm at 1cm dilated with no effacement. The obstetrician offered "gentle induction" (pitocin drip) or planned C-section a week from today. I need to be decided by three days from now. I get the impression that he doesn't think induction will work, but he wont close the door on it either. Is mine one of those cervixes that just wont dilate? How could anyone tell? Where I live the C-section rate is 20%. Thats with all breeches being by section. So am I in the 10-15% that's necessary or the 5% that isn't? I hope to God that I go into labour before I have to decide. I either give up faith in my body, or put myself though an ordeal that may well end up the same or worse than last time. We have no midwives here, otherwise I would have loved to consult with one. My obstetrician is good, but has horrible bedside manner. When he's worried you can read it on his face. He's worried I'll pick induction, and that worries me back.
I'm sorry to dither on, but I needed to vent today. Thanks for the opportunity.