One of my journal entries this month started off, "I've made a breakthrough! I can visualize a calm birth." All my fear had lifted and I had total confidence that my home birth was going to be quick and manageable.
Then this week, I had an appointment at UCSF to establish a relationship with them as my backup hospital and all my mental strength turned upside down. Fear crept in again. I cried at dinner that night when I told Zack about my appointment. It was so emotional for me to have a traditional OB office appointment. I've only had three home birth midwifery appointments but the difference in care is quite stark. At UCSF, I interacted with three people and had four inch sweat circles under my arms before I even saw the midwife with whom I'd made the appointment. That's four people poking and prodding; and asking sensitive questions.
A midwife-in-training asked me the reason for my last cesarean. I said, "failure to progress, that is why I am doing a home birth." She asked if I or the baby showed any other signs of distress. I said, "No, it was 11:30pm, I had been pushing for three hours, and the doctor had to be called in from Marin so they didn't want it to get too late." She smiled and said, "well, that's CPMC, pushing for three hours is normal for a first baby."
Even though my appointment was just a meet-and-greet, I was shuffled through the routine visit protocol. I peed in a cup and undressed completely. As I sat in a pile of paper on the exam table trying to hold up the paper that had ripped and was falling off my shoulder, I thought, "No regrets." When the midwife came into the room, she said, "Oh, it looks like we asked you to get undressed unnecessarily. We aren't going to do an exam so why don't you get dressed and we'll just sit down and talk for a bit." The rest of the visit went well until the end.
She explained how UCSF works with home birth patients. UCSF views themselves not as a backup but as a parallel caregiver. I can use their advice line, make an appointment at anytime, go on a hospital tour, participate in their pregnancy classes, check-out books from their library; in the event that I do need to go to the hospital, I don't go into the emergency room, I go straight up to the maternity care center. On the record, the doctors don't support home births, but they do support everyone's right and ability to make decisions for themselves. I felt very welcomed and happy to have this new support group. Then, I ask her what her opinion was on vaginal birth at home after a cesarean.
I had planned to ask this question because I don't want to hide from the other side of the coin. I want to listen to all the information out there because that is what has given me the knowledge and security that I need to make the home birth decision. I was prepared for the, "I don't think it's a good idea" response. Or, at least, I thought that I was.
She was very matter of fact about her response and managed to be quite frank without being at all hostile towards me. Her explanation was about ten minutes long. To summarize, she felt that home births were a good choice for women with no advanced warning of a problem. Having had a previous cesarean is an advanced warning, so she does not feel that it is a good choice. She feels like the choice for a home birth with my scar is emotional. And then, there was a long awkward silence.
I did not reply. I agreed with her for the most part. I know that women in my situation with one previous low transverse scar have a 0.6% chance of a uterine rupture, but the risk of a uterine rupture is the same at a hospital and it isn't any greater then a lot of other complications that could happen to anyone. The difference is that I am closer to an operating room if I am already at the hospital. So really everything boils down to the 10 minute drive to the hospital.
Until 1999 the American College of Obstetricians and Gynecologists allowed a maximum response time of 30 minutes for a VBAC emergency cesarean. The guidelines have changed since then but are controversial. It remains 30 minutes in Canada. The American Academy of Family Physicians believes that an emergency management plan is suffice.
And then, there is everything else that needs to be looked at when deciding on a home birth after cesarean. And I believe everything else includes the emotional side too. Birth is not just science and statistics. A woman's emotion and sense of security has a lot to do with it. I believe that I stopped my labor when I saw the nurses roll in three carts of equipment after one of them said the baby was coming.
From what I've read, most uterine ruptures are not explosive and unforeseen. Most of them come with a lot of advanced warnings like pain much different from labor pain, vaginal bleeding, sharp pain between contractions, contractions that slow down or become less intense, abdominal pain or tenderness, recession of the fetal head (baby's head moving back up into the birth canal), bulging under the public bone (baby's head has protruded outside of the uterine scar), and sharp onset of pain at the site of the previous scar. I will be closely monitored and taken to the hospital at the first sign of something out of the normal spectrum.
Uterine ruptures are more likely to happen if I am given pitocin, which I could only get at the hospital. And then, there's the risk of another unnecessary cesarean at the hospital which I am guessing is around 16% (my own estimate current rate, 31.1% - optimal rate, 15%). A second cesarean holds risks to me and my baby that are equally as dangerous as a rupture.
The bottom line for me is I only want to go to hospital if I have to. I need to feel safe to have a successful birth. I trust my body to do what it needs to do and I trust my midwife to take me to hospital if she sees any sign of complications.
So, maybe my encounter with UCSF was a blessing in disguise, it made me doubt my decision for a few hours and force me to study everything again and come to the same conclusion again. Home birth.
Reference for list of uterine rupture signals here.