When You Fail TOLAC: Accepting Your C-Section
Sloane is perfect. She has ten fingers and ten toes. She doesn’t have any health issues or concerns. She was born at exactly 41 weeks, at a 7lbs 13oz, 21 inches long, pink and with a loud cry. But when I look at her tears well up in my eyes, I look at her and I feel so guilty. I look at her and feel like I’ve failed. Failed to bring her in to the world the way that I was made to, failed my sweet toddler whom I can’t pick up or rock to sleep or put to bed, failed my family who has to come and help me to care for my two girls while I’m recovering, failed my husband. With our first, Tess I feel like we were as prepared as we should have been. But we were scared, what new parents are going to question the doctor who tells them their child has been experiencing decels for an extended period of time and is in distress? We wouldn’t have done it differently. But with Sloane, we were so educated and prepared, so ready for the push back. We knew it would be difficult, but I wasn’t prepared for the end result. I hadn’t come to peace with a second cesarean, I didn’t allow myself to even consider that as an option.
At 20 weeks, that’s when the first OB/GYN in the practice informed me that I had a “narrow pelvis.” I guess that was the first time I felt irritated leaving their office. Throughout my pregnancy it was the little comments here and there about how I had a “big baby” the last time and the “same thing could easily happen again.” Now, Tess was 8lbs 2oz, 21.5 inches long — I don’t consider that a huge baby but I guess when you compare it to a 5 ft 1 inch, 115lb female the ratio is a little bit off. Regardless I was not discouraged. I did everything in my power to ensure a healthy baby and a natural vaginal delivery. Starting earlier than recommended at the tail end of my second trimester I incorporated 6 dates a day and red raspberry leaf tea to my diet. I squatted, 200-300 squats a day to get ready for this delivery. Stayed as active as I was able while chasing my toddler around, working part time and maintaining everything else in our lives! At 35 weeks during my group B strep swab, the second OB-GYN in the practice mentioned my narrow pelvis. I left the office again, a bit flustered but not deterred. CPD is a term thrown out m often in Obstetrics today, but cephalopelvic disproportion is actually quite rare and occurs in about 0.4% of pregnancies.
Then during my 37 week appointment I was told that my baby was breech. This by yet a third OB-GYN in the office who also asked me if I was “Sure I wanted to tear up my vagina” rather than schedule a c-section. I had a difficult time trusting this doctor, especially considering that I has asked others during previous appointments to check her position and each had determined that she was head down. Even up to just one week prior. But he “checked” with an ultrasound, which he did not show me by the way, and ushered me out of the office asking “Are you bummed?”
My part time role is as a medical scribe for a doctor at a private family practice. He is a physician I know personally and trust wholly. After my 37 week appointment on Thursday I asked him to check on Monday to see what he thought. He is no longer practicing OB care or he would certainly have been my doctor throughout the entire pregnancy. In fact he delivered me along with my siblings, cousins, and lots of my friends (small town family medicine at its finest). He spent about twenty minutes with me explaining what he felt and allowing me to feel what he was feeling, and at the end of that “appointment” I was sure that I had been right, and my baby girl was not breech.
Later that week, during my 38 week appointment I asked the nurse to be sure that the OB seeing me that day (yet a different doctor, by the way) checked and verified with ultrasound so that I wouldn’t be forced to schedule a c-section. The doctor who I saw that day was actually much better, he validated my concerns and apologized that I’d had a week of worrying about my baby’s position. He also mentioned that there was no documentation in my chart to suggest that the baby was breech. He faced the portable ultrasound toward me and moved the wand over my pelvis. “See that?” he asked me, “Skull. Baby is in a great position.” He also checked me that day, which I asked him to do, and let me know that I was between 1.5-2cm dilated but my cervix was still in a posterior position. For the first time I walked out of that office feeling confident. My baby was in her position and my body was gearing up for labor, I knew we could do this. I had been feeling the pressure, because I knew they did not like to induce VBAC mamas and if I did not go into labor spontaneously they would push for a cesarean. Trust me, we were trying everything to induce! Fast forward to 39 weeks, another OB (there are 7 in this office, and I saw them all and none of them ever remembered any details about me or my previous c-section. I just wanted to say, “Before you open your mouth, could you just open my chart and skim it real quick so we’re on the same page? Thanks”) I didn’t have her check me, so it was your typical 5 minute appointment. Blood pressure looks good, weight has been stable since 35ish weeks, all good, but I would need to be monitored during my next appointment since it would be after my due date (40 weeks and 2 days). So, I scheduled my follow up 40 week appointment and I left the office. That appointment came, I was hooked up for a nonstress test and monitored for about fifteen minutes, the OB started by just “double checking” to see if baby was in fact head down. Uh, that’s be a triple check actually (quadruple if you count my out of office check with my trusted primary care doc). Surprise surprise, baby was head down. This OB then told me that “Baby looks great but it doesn’t seem like much is happening,” regarding the NST. She followed that by telling me my cervix was “still closed and pretty far up there,” and that I’d need a plan, basically to schedule c-section since they only allow women wanting a TOLAC to go one week past their due date. I let her know a different doc in her office had estimated me further than that 2 weeks prior and she brushed it off by saying “Well I can’t get my finger in there, so I think it’s closed.” Hmmm, OK. This was the most irritated I had been when I left the office. They had me schedule an appointment for the following Monday to be NST monitored again, then schedule a cesarean for Tuesday, at exactly 41 weeks. That night when Jared and I sat and talked about what we were going to do, I was finally frustrated to tears. I had done everything, prepared in every way, baby was in a good position this time, and still I was being told my only option was a c-section. Jared had only been to a few of the early appointments, which was what we had decided would be best since most of the late term appointments are brief and worthless anyway, but I asked him to come for the NST and we would confront the option of refusing a c-section together. My twenty-seventh birthday, and I was spending it without a new baby in my arms, who I’d anticipated would come early. Instead we sat in the office for over an hour while I was being monitored, (we’d already waited over an hour in the waiting room too) Jared had literally started placing a to-go order for Five Guys when the OB finally came in, med student in-tow. She told me she had me on the monitor for so long because she saw that the baby’s heart rate had been hanging around 120-130, which was concerning to her. I wanted to say, her heart rate has been in that range literally since the first time it was detected with a Doppler, but I bit my tongue and let her talk. She checked my cervix and told me that I was maybe 1cm, definitely not more. I knew I was having contractions, and the NST monitor was picking them up, pretty consistently every 1-2 minutes. But I would have only called every 4th or 5th contraction a “real” contraction. Nonetheless she told us “Basically it would be malpractice for me to not send you to the hospital right now. Your contractions are frequent enough they need to be monitored to make sure the baby is tolerating them OK.” We told her we live about 30 minutes away and we’d have to go home and gather up our hospital bag before heading to the hospital. She said “No rush, but I can’t in good conscience let you go and labor at home for like 20 hours or something without monitoring this baby.” So we headed out of the office thinking that I was in the early stages of labor but knowing it would take time and was hardly dilated at all. We didn’t rush, and even though the office called to tell me not to eat anything — you know, in case of surgery — we picked up our burgers and headed home to gather our things. Best choice ever, by the way. Once we made it to triage at the hospital I was hooked back up to the monitor and the nurse ran through all the formalities. She, along with every other person who had seen me and the contractions I was registering, seemed to be surprised “Oh wow, you are really having contractions.” Frankly I know I have a relatively high pain tolerance but, truly I would not have even considered coming in to the hospital for these. And aren’t people prepared for the discomfort labor will bring? I mean, the last month or two of pregnancy is not really a cake walk. It’s full of bigger discomfort than early labor contractions, in my opinion. When the attending came in to talk with us about what was going on I was actually convinced most of my stronger contractions had stopped, he explained that if I was having these frequent contractions without any cervical change there would only be a few options since I was trying for a VBAC. Inserting a catheter balloon to mechanically force my cervix open was our top option at this point, then see if I’d dilate further on my own. Which he didn’t think was likely but if the baby’s head was engaged he might be able to break my water and “get things moving.” But at only 1cm he guessed that I would be looking at another c-section.
So, I took a deep breath and let him check my cervix. He looked at the nurse and said “Shockingly, you’re at about…5cm and 50% effaced.” He had a smirk on his face and literally laughed with relief. The nurse didn’t know how to take it and she said “Are you being serious, because I’m charting this.” He said, he was serious and we should plan to have a baby today. I was so overjoyed. I knew we could do it, from 1cm to 5cm in two hours and feeling great. He even called the OB who’d checked me in the office to see if she was certain on her earlier check, to which she said she was, of course. The attending instructed us to begin walking the halls so that the baby could become more engaged, and once that happened he would plan to break my water. This was around 3:30pm. Luckily the hospital where we were delivering had cordless monitors and I was able to be up walking in the halls. Close to 5:30 he came in to check and see how I was doing, I was still standing and walking, not showing much distress with my contractions, honestly I felt great. I was still able to manage them by simply swaying and breathing, no problem. He checked me and was again surprised to find I was about 7cm dilated, so he broke my water and I mentally prepared for my labor to kick into full force. Shift change happened and the new nurse about dropped her jaw on the floor after she’d spoken with me a while and I got out of the bed to pee — I was trying to let most of the fluid drain before walking again. “You don’t have an epidural?!” She asked me. “The way you are handling this, I thought for sure…” I just shrugged and thought that once the harder contractions came I would consider an epidural if I needed it. Maybe I should have acted as though I was more uncomfortable, because the attending also commented on my contractions “not making you uncomfortable and maybe not moving things along.” Well, at 11am that day I was at 1cm dilated and having regular contractions, by 9:30pm I was at 7cm and about 80% effacement, to me — that seems like progress? Apparently not fast enough for a woman attempting a VBAC, he was considering me “stalled” at 7cm. We had two options, Pitocin or c-section.
“What??” I was so taken back. Here I was laboring along on my own, no need for any pain medication or anything, and I had been at 7cm for about 5 hours, all the sudden I’m looking at another section?! Neither myself nor the baby was showing any signs of distress, so we asked if we could wait and see how I continued to progress for another hour or so, he flat out said he wouldn’t authorize that. So, with much hesitation, we chose pit. I had a horrible experience with Pitocin when Tess was born, my contractions went from 5/10 to 10/10 in about fifteen minutes. It seemed that they were aggressive when administering the Pitocin too, I was near the maximum dose in less than an hour. He assured me he would only use UP TO one tenth the maximum dose (2mL vs. 20mL) and I would only be on the drip for one hour. When attempting a VBAC Pitocin doubles the risk of uterine rupture so keeping it very conservative is the way to go. My OB also mentioned that he had had one uterine rupture with a VBAC attempt and it was a woman receiving Pitocin. Needless to say he was very cautious. I was fine with 1mL, but once it got bumped up to 2mL, I was hurting. I should have requested an epidural as soon as the Pitocin began, I should have known better. My body just does not tolerate the artificial hormone, which became blatantly obvious. I asked the nurse to have an epidural and she let me know that I was “in line” and three other women had requested one too. Within 30 minutes of asking for the epidural I was to the point where I had been with Tess, nearly blacking out with each contraction to deal with the pain. Wave after wave washing over me, each contraction would last 1-2 minutes and I’d have about 5-8 seconds between them. I told the nurse that I was feeling a lot of pressure and I was feeling like my body had begun pushing. She ran to grab the resident, I was on all fours trying to handle my contractions and she was trying to check me. I heard her say “she’s complete,” and I told her “I’m going to start pushing!” There was nothing I could do to stop my body from pushing at that point. All the sudden there were about 7 people in my room, including the attending. Someone was holding an oxygen mask to my face and someone was telling me to push with each contraction they saw making its climb on that monitor. I was pushing with everything inside of me, I broke many of the blood vessels in my face and some in my eyes. My nurse told me “We’re going to get this baby out, You’re doing great keep pushing Leah.” And that made me think this was really going to happen. I was doing it. She was coming. Despite the Pitocin we were getting our baby here the way we wanted. I pushed as hard as I could through each contraction and then had about 3-5 seconds break to try to catch my breath before pushing again. All the sudden I realized they were talking decels.
“Is that mom or baby? Make sure.” I heard him say, it was the attending. Whichever one of us it was, the heart rate was in the 50-70 range. After that he told me “One more push Leah, if she’s not out I’m taking you back.” Truly, I have never tried harder or wanted anything more in my life. But my little one did not come out, not that way. Before I knew it I was in the OR, still writhing with each contraction. One of the nurses, who was obviously in charge of charting, was asking “Failure to tolerate labor? Is that what we’re going with?” And I remember thinking…are you joking? Failure to tolerate labor? I’ve been laboring on my own without a single hiccup until you all started dropping Pitocin into my veins. Failure to tolerate labor? How about “reaction to artificial oxytocin”? Or maybe “not given enough time to push, because the doctor was paranoid about rupturing my uterus although there was no bleeding or indication of a rupture.”? My mind raced, but I could barely process what was going on, I was still on the table pushing. Someone was using betadine, someone was shaving my public area, another nurse came in with a sterile drape. The anesthesiologist who apparently could not be located for a few minutes, was telling the attending that he was ready to put me under whenever he was. Jared was not there. He wasn’t allowed back, I was all alone. It was chaos, I remember thinking that. I heard an edge in my doctor’s voice when he said “Do it now. I’ve been ready. Waiting on you.” And that is all I can remember before waking up, bleary eyed in the L&D pacu. Jared carried Sloane over and placed her on my chest and she began nursing almost immediately, praise the Lord. Honestly I couldn’t even see her for the first few minutes as the anesthesia was still clearing out. Fortunately they allowed Jared to have her and hold her and do skin to skin within minutes of me being put under. About 5, no more than 7, that’s how long it took to get her out through my incision. My heart was broken and my body was broken, but my baby is whole and I am alive with an intact uterus. Sure, I have another scar and it is now weakened further than before, but I will be able to have more children. That’s what I’ve held onto, that’s what I’ve tried to cling to when the disappointment and the resentment and the bitterness creeps up in my heart. It feels unfair. Failure to tolerate labor. That rings in my ears. I am someone who takes care of her body, who is healthy and active and I did everything right to get the VBAC I wanted, I there, 10 centimeters and pushing, and she was there, in a great position, chin tucked and ready to go, yet…here we are.
Obviously having a healthy baby makes it an easier pill to swallow, but I still struggle with this feeling of failure. My best advice is to take it one day at a time. Try your best to let go of the feelings of blame and guilt, because truly it is not something you can control. You are a warrior mama, who fought for your baby, your family. You were brave, you tried to do exactly what you believed was best for your baby and your body. You went against the grain and you didn’t schedule a repeat cesarean without a second thought, you worked for it. Everything you did was for your baby and your family, and that is commendable. Each morning wake up and look into that sweet face and know, the scar on your tummy does not make you any less of a mama.