Marci’s New Year’s Day Blessing: The HBAC of Cayla Ariel
This is the story of the HBAC of Cayla. In many ways, it begins with the birth of her older sister, Annalise, so I’ll start there. Forty-nine hours into labor, I was transferred to the hospital, and after fifty-six hours of pain-med free labor, Annalise was surgically delivered via caesarean section. I had the classic occiput posterior labor with Annalise: back labor, painful contractions that inhibited rest, very little dilation for all the laboring done. I was fortunate that labor started soon after PROM with a gentle nudge from homeopathy and acupuncture, but since her amniotic sac was gone, once she turned from ROT to OP position she had a really difficult time turning into either the OA or LOA positions that are ideal for vaginal birth. Although I only had maybe three vaginal exams during my labor with her, my temperature started to creep up at home, at which point we abandoned our plans for a homebirth and heeded our midwives’ advice to transfer to the hospital. By the time I got to the hospital, I had a full-blown fever, and both my heartrate and Annalise’s were tachychardic. They managed to get my heartrate down after administering antibiotics and fluids, but her heartrate remained high. The OB on call recommended pitocin to expedite delivery, because there was only so long I could go on laboring now that Annalise’s heartrate was tachycardic. She also wondered if the tachycardia might be due to Annalise being in a sleep cycle, but as labor progressed, it became clear that this wasn’t the case.
I did all the things that generally increase the chances of successful, non-traumatic vaginal birth: I remained pain med free until they wheeled me into the OR and gave me a spinal for the c-section; I was active during my whole labor, trying to use various positions to help Annalise move out of her malposition into optimal birthing position, and I only accepted interventions as they became truly medically indicated. Despite this, Annalise was born with an APGAR of 2, was a “Code pink” baby and had to be resuscitated for a long time after birth. I’ll never forget what it was like to hear the terror in the pediatrician’s voice. He hadn’t intubated Annalise, thinking she’d be okay. (The OB was going to go ahead to surgery without the pediatrician present; my midwife intervened and insisted that the pediatrician be there specifically because Annalise’s heartrate was so high and she thought he might well need to intubate her at birth. [sigh]) Turned out she had thick meconium and mucous blocking her airways and the suction device got clogged and stopped working. A back up suction device wasn’t handy, and he started to shout to the staff “I need suction! I need stimulation! Code Pink! Within seconds, people were pouring into the room from all doors, and working on Annalise. After all that, her breathing still wasn’t okay, and she was in the NICU for 48 hours.
I figure I did my best, and in life, there really are no guarantees. Most times, what you accomplish will reflect your efforts. But sometimes, what you accomplish won’t be what you envisioned. I tried to give Annalise a good birth and that didn’t really happen, but I really did try my best….so I leave it at that. Despite the fact that the birth didn’t go as planned, I am so thankful for those in my immediate and church family who prayed for me during the birth. I truly do still feel that God protected Annalise and helped her to be born just in time.
When I returned home five days after my c-section, the waterbirth tub we’d rented was still full of toasty warm water….and I’d never gotten in because of the hospital transfer. Ouch.
When I got pregnant with Cayla, I knew I was going to try for a VBAC. I had done research into the risks and benefits of VBAC versus RCS, and knew I wanted to at least try.
What I didn’t know was whether or not I was going to attempt VBAC at home or in the hospital.
[Well, I knew what I wanted....]
I live in Ontario, Canada, and here, we have one of the best midwifery systems in the world. So I could choose to have my birth at home or in hospital, and because midwives here must attend both hospital and homebirths, I knew that if there were signs I needed to be transferred, the midwives would recommend transfer because – unlike some other places in the world – transferring to the hospital setting would not prevent them from continuing all my care and would allow them access to any necessary interventions. Still, the question of birth location is one I discussed at length with my husband Orett, my doula Jo-Ann, and my midwives, Kara and Edie.
There isn’t a lot of research on HBAC, but my main question was whether or not, in event of emergency such as uterine rupture, I would actually get access to lifesaving surgery any faster by being in a hospital. Because of how close I lived to the hospital, and the hospital’s “decision to incision” time of 20 minutes according to my midwives (the OB I consulted with at the local hospital was reluctant to guarantee a “decision to incision” time of sooner than 30 minutes, but the midwives use 20 minutes to err on the side of caution when advising a client about whether or not HBAC is generally a safe option in her specific case), I actually wouldn’t receive lifesaving surgery any faster by being in hospital. Of course, people have become accustomed to believing in the inherent safety of all things hospital and most folks actually think that, should there be an emergency, lifesaving surgery is performed immediately. Even when the call for surgery is made and given priority status, real life just isn’t like it is on many medical TV shows: rescue efforts still take time. My distance from the hospital meant that should my uterus rupture, the midwives would make the call in immediately so the hospital could get everything ready for surgery and they would run all my IV lines and prep me for surgery in the ambulance: I would arrive at the hospital BEFORE the hospital was even ready to make an incision. Once the hospital was ready, they’d give me general anesthesia and surgery would commence. If I lived further away, or lived close to one of those rare but awesome hospitals that had a “decision to incision” time of five or ten minutes, the hospital would’ve been a safer place for my birth; however, my proximity to the hospital and its “decision to incision” time opened up HBAC as a safe option for me.
I hoped, though, to avoid needing surgery and interventions in general. So from July 2011 till I gave birth, I faithfully went to chiropractic care to get my spine and pelvis in optimal condition for birthing (I was in a car accident just before I got pregnant with Annalise, and – despite four months of physiotherapy – still had problems with my pelvis and spine). I ate healthy, tried to remain active, took lots of vitamin D (to lower chances of c-section birth), and vitamin C (to prevent repeat PROM scenario and increase my body’s natural oxytocin levels). I took Gentle Birth Formula, a tincture to promote uterine tone and prepare the body for labor. I prayed and asked others to pray for me when I felt overwhelmed by the idea that achieving a vaginal birth after caesarean is often harder than getting a vaginal birth as a first-time mom. (My immediate family and church family were AWESOME about praying whenever I asked!). I connected with VBAC support boards that could help me navigate the emotional and physical politics of achieving VBAC. I hired a doula who specialized in birth trauma and had worked with VBAC moms before to help me do the necessary emotional work before and during labor to have a successful outcome. And I had three sessions of craniosacral therapy, since spinningbabies.com suggested that body work like this could increase the chances of malpositioned babies turning to optimal positions either prior to or before labor. In my case, every time the craniosacral therapist did a session, my baby would shift from ROT to LOT/LOA, which are better birthing positions. So even though Cayla did shift back to ROT at the beginning of labor, she did finally shift to LOA partway through labor, and I do credit this to all the extensive chiropractic care and craniosacral therapy I received helping to balance my body for birth.
I had hoped for a shorter birth. It was shorter – 44 hours instead of 56 – but not as short as I’d hoped for. We don’t always get what we want, yet, as my story demonstrates, sometimes it’s still all for the best.
At my 37 week appointment, I asked my midwife for a vaginal exam, and I was not effaced or dilated at all. I wasn’t surprised, but because there are things in my medical history that make me more likely to need an induction, I did want my cervix to be at least ripe. Part way through the 37th week, I started using three capsules of Borage Oil and one capsule of zinc orally at night to ripen the cervix.
Around 5pm December 30th, 2012, I felt really nauseous. I didn’t throw up, but just wasn’t feeling very good. An hour later, I went to the toilet and had a serious bout of the runs. TMI, I know, but I was wondering at the time what on earth I’d eaten to have my system so upset: I was only 38 weeks pregnant, so I just didn’t quite connect it all to labor quite yet. In any case, I felt pooped and decided I would go to bed really early. I woke up at 12:30 am on December 31st to use the bathroom and noticed bloody show. Within 30 minutes, contractions 8-10 minutes apart commenced. They were long and strong right away, so that put an end to my attempts to fall asleep. Three hours later, the contractions were still strong, so I got out of bed and decided it was time to wash up the dishes I’d left in the sink the night before and do light cleaning. I made eggs and bacon, ate some, and then decided I would return to bed to try to sleep. After 20 minutes, my contractions finally stopped altogether, and I slept for about two hours, only to again wake to strong contractions, 8-10 minutes apart.
By this time, Annalise was stirring, so I got up and set about getting her fed and ready, etc. I sent my doula, Jo-Ann, an email letting her know that I had bloody show and had contractions 8-10 minutes apart. She wasn’t supposed to be “on call” for my birth for another 3 days, but she emailed me right back and said to consider her on call for my birth now. Contractions continued, and I closed my eyes and breathed through them. My husband Orett got home from working a night shift in the ER (he’s a Registered Nurse) and played with Annalise for awhile. I told him I was having strong contractions and that he needed to get the proper connector to attach the hose to the faucet, as I would never let him hear the end of it if I didn’t get a waterbirth this time round because he hadn’t got the connector in time! Realizing I was serious, he hustled out to purchase the right connecting piece. Contractions continued 8-10 minutes apart. I was tired because I hadn’t had much sleep, and was a bit concerned that this labor pattern might just indicate that baby was again ROT or some other malposition. The contractions stopped at 12 noon and I immediately went to lay down and sleep, only to awake to more too-strong-to-sleep-through contractions at 1:30pm.
I got up and got more things ready for the baby’s arrival. Contractions were still 8-10 minutes apart and I continued most of the afternoon the same way. At around 6:30pm I spoke to my doula about the labor pattern and the fact that I was a bit concerned about how this was playing out. She suggested taking a warm bath and then taking homeopathic pullsatilla to see what effect this would have on my labor. I did this, and an hour after taking the bath and homeopathic, my contractions stopped. So at 8pm, I dashed into bed….only to – you guessed it! – awake at 10 pm to contractions 8-10 minutes apart.
I had told Orett it was okay to go to work before I went to sleep because, at this point, the homeopathic and bath had seemed to stop my labor, so I actually thought I was going to be the very lucky lady who got a whole night of sleep before labor resumed: I thought this would be just the ticket to waking up with contractions 5-1-1. Orett promised to notify his work as soon as I was clear about the birth being imminent and return home. So I was really concerned when I awoke at 10pm with strong contractions 8-10 minutes apart. I was hoping for a whole night of sleep, not just a couple hours!
Finally, at midnight, I sent a text message to my doula and told her I was really concerned about the lack of sleep, yet I couldn’t sleep because the contractions were just too strong and I had to breath through them. She recommended Gravol, and then asked me if I’d contacted my midwives to let them know I was in labor. I said no – I’d kept waiting for labor to get to 5-1-1, and it hadn’t. She said that while she would recommend Gravol, I should really call the midwives and let them know what was happening and find out their recommendation. So I did, and my midwife, Edie, was concerned about the lack of sleep and how that might impede labor. She supported using Gravol…but we had none. Which isn’t surprising, because I rarely ever take so much as an Advil or Tylenol; I’m more of a ‘natural remedies’ type of gal. So I dug around in our First Aid kit, found and took Tylenol (which did nothing to make me sleep) and then called Orett to come home at 3:31 am, asking him to bring Gravol. Orett got home and gave me Gravol. No change – contractions still 8-10 minutes apart and incredibly intense.
So despite taking the Tylenol and Gravol that were supposed to make me sleep, I actually didn’t get a wink more.
I called Edie around 8am in the morning explaining that I still couldn’t sleep – contractions were just too strong. She offered to come do a home visit and assess me, to which I agreed. She also mentioned that if this situation continued, she might have to take me to the hospital to get morphine, as that would knock me right out and then I could sleep. But she explained that that was sticky, because an OB would need to prescribe the morphine and depending on what happened with my cervix, this could create a “transfer of care” situation. Even though she’d be able to stay on in a supportive role during my birth if a transfer of care took place, we both agreed that this option should be a last resort.
By 9am, both Edie and Jo-Ann arrived to see what we could do about my labor. Edie watched me during a few contractions and confirmed that I was, indeed, having really strong contractions. Edie did a vaginal exam, and confirmed that I was now 5 cms dilated and very soft, so there was no doubt I was laboring. She did a stretch and sweep to see if this would launch my contractions into 5-1-1 pattern sooner rather than later. She then checked the baby’s position, and baby was just as I’d suspected: ROT. ROT fetal positioning tends to result in protracted labor, and until the baby’s head is more firmly applied to the cervix and the baby rotates to a position like LOA or OA, labor and progress are slow. But I took comfort in the fact that my cervix had dilated to 5cms, because with Annalise, after all that labor, I’d only dilated to 2cms: she just got wedged into a bad position early in labor and couldn’t get out.
Edie had me pee on a stick to check for keytones, which I had, so I then ate some more and she and Orett ran an IV line into my arm with fluids because the dehydration was so severe. She also gave me more Gravol, hoping it would knock me out and I’d sleep. No luck – the contractions were just too strong and I couldn’t even sleep between them. She brought in some things for the homebirth and I stayed in bed laying on my left side for hours, trying to ride out the contractions and wishing I could sleep. Because we didn’t want baby to descend before rotating to an ideal birthing position, lying down was a good option at this point in my labor. Edie would come in at intervals to monitor the baby’s heartrate. I kept hoping and praying that things were going to progress.
Edie didn’t want me to feel like a watched pot, so she and the doula left for a bit. Before Edie arrived in the morning I’d called Kitty, my naturopathic doctor who does acupuncture, to find out if she could use acupuncture to change the course of my labor. It was New Years Day and I KNEW she might not come, as it was a holiday. But she knew my story and that I really wanted a VBAC, and I called, hoping that she just might help me out. She called me back and said she would come to my home, but was concerned about using acupuncture for labor augmentation if I was already running on such little sleep. She suggested instead giving me herbs to reduce the contractions so I could sleep, and then – after a good sleep – seeing about bringing things on more strongly using acupuncture.
Now, by this point I was becoming skeptical of the notion that my labor could be quelled enough for me to sleep – after all, I had ardently been trying to sleep through contractions to no avail. But I recognized that if sleep could be had, it would be fantastic. So I agreed. While I waited for her to come, I got out of bed and labored on the toilet. It felt really good to do that and I started to feel rectal pressure. I labored there for an hour and then switched to the birth ball beside my bed to labor more. Kitty arrived after 2pm and did a full history on my current situation. She gave me a homeopathic remedy and then gave me some Crampbark tincture to help labor subside. She said that if the tincture were going to work, it would work within an hour, and said that I should take a ½ tsp dose every 10 minutes for an hour then wait a bit. She also mentioned that getting in the tub might also help to dissipate contractions. She asked my permission to speak to my midwife, and I granted it. She relayed her recommendations but asked what my midwife felt and left it up to her. My midwife agreed that if I could sleep, that would be best. But if I couldn’t, it was what it was. Kitty stayed with me for about half an hour, softly helping me breathe through contractions, then left.
I waited over an hour for the tincture to do its work.
And then I came to my senses.
Now faith is the substance of things hoped for, the evidence of things not seen
~ Hebrews 11:1 KJV~
Contractions were just getting stronger. I realized that our baby had decided to be born today, and it was time to get about the business of birthing my baby before severe maternal exhaustion set in and I would be unable to have a vaginal delivery without some variety of hospital drugs to assist me. I spoke to Orett about my feelings and he agreed 100%. I called my doula Jo-Ann around 4pm and told her that I felt sure that the baby wanted to come tonight, and that I was sure that if I could just birth my baby in the next four to eight hours, I would get my HBAC and all would be well. And I accepted the fact that if I couldn’t do it in that timeframe, I was probably looking at having to transfer to the hospital for drugs so I could sleep and then deliver vaginally. This was hard to say, as I really believe in not using drugs during childbirth unless truly medically indicated. But I know all interventions under the sun have their time and place, and if it was truly needed because I was exhausted, I would accept interventions. I also acknowledged that there was the chance of a repeat c-section if some complication cropped up if I transferred, but for right now I just had to focus on birthing Cayla. Jo-Ann mentioned that she loved the determination she heard in my voice and that I should continue to focus on welcoming labor now.
I called Edie and told her that the tincture didn’t work and I was still in labor. I asked if she would come to my house and check my cervix to see if I had progressed since the 5cms I was at 9am that morning. I knew that she had recommended me calling her when contractions were five minutes apart, and even though they weren’t, I was completely going on my gut instinct now and asking her to trust my sense that this was going to happen. Most careproviders ask women to follow the 5-1-1 rule for their first planned vaginal delivery, as a woman is usually consider in “active labor” if her contractions are 5-1-1 and her dilation seems to confirm this diagnosis. It was ultimately because I was not experiencing contractions five minutes apart when Edie checked me in the morning that we were all still waiting for this signal of “active labor.” But by this point in my labor, I knew that although my labor was not conforming to standard medical definitions of active labor, there was no doubt that I was laboring hard.
I also told Edie I wanted to know if the baby had shifted positions, because I’d been feeling a lot of flailing around in there. And I told her that after she checked, I intended to get into the birthing pool for at least an hour to see if the natural oxytocin increase that water labor creates would send us full steam ahead; or alternately, if this wasn’t “it”, stop labor. I was not going to transport to the hospital until I’d at least gotten into the water this time round!
[By this point, I really doubted that anything would stop labor....but I wanted to sound rational, because I knew my labor was not fitting textbook parameters and definitions]
I suggested that after doing all these things, we could all decide on the best course of action. Edie agreed.
I walked up and down our house, trying to focus as I listened to my birthing tracks, and feeling the labor intensity soar.
I had Orett call my parents and ask them to pick up Annalise, as I was in my birthing time and felt I needed less distractions now. They came, combed Annalise’s hair and got her ready, said a prayer for me that that Cayla would get into the right position for birthing, that my labor would progress, and that she would be born vaginally. They also prayed for wisdom in all our decision making as we went through labor. They asked us to keep them posted and then they left.
I continued to walk around our house, stopping for focused breathing when contractions would hit, and felt renewed faith that the Lord would hear the prayers of myself, Orett, our families, and the community of faith (huge shout out to The Campus Church – our home church in Aurora, Ontario!) we knew had been praying about this birth for so long.
At 6pm, Edie and Jo-Ann arrived. Contractions were still 8 minutes apart. Edie checked my cervix – I was 7cms dilated and Cayla had now shifted from ROT to LOA: the optimal position for vaginal birth. The energy in the room was just amazing and Orett still talks about how my countenance registered complete relief when I heard that Cayla was FINALLY in the optimal position for birthing. We all knew that her newly-altered position dramatically increased the odds that I was going to have a vaginal delivery, and I was so excited.
Jo-Ann gave me some homeopathic remedies to gently encourage labor on. I hopped into the birth pool. For an hour, my contractions didn’t get any closer together. Edie thought I should stay in the pool longer and felt things were going well. She even suggested she could break my waters. Since I had PROM with Annalise, I really didn’t want to get rid of my waters just yet, because AROM can cause a baby to get into a bad position and be unable to maneuver enough to get out….but decided I would do it before transport to the hospital if it came to that. For now, I would just labor with my amniotic sac intact.
Around 7pm, my contractions suddenly dropped to 2 minutes apart. I instinctively shifted to hands and knees during each contraction in the water. Jo-Ann and Orett talked me through visualizations with each contraction. Before I knew it, I was in transition, and contractions were double-peaking. I felt my body bear down and water from my amniotic sac shooting out of me like a rocket. Finally, Edie said she wanted to check me. I asked her if she could just check me in the water. She chuckled and said she could, but it would be more accurate if I got out of the tub.
So feeling quite grumpy about having to leave the birth pool, I got out and lay on the couch. A contraction hit and I sat up to ride it. When it was done, I lay back down. She assessed me and said, “Well Marci, you are 9 ¾ dilated with an anterior lip.” I was so excited and asked if I could just get back in the pool. Everyone laughed and said that I could.
The urge to bear down just took over. When Edie realized that I wasn’t trying to push, my body was just ejecting the baby, she walked over to the phone. I heard her say “client has the uncontrollable urge to push, come right now.” With this, midwife #2, Amanda, was on her way.
(She didn’t make it before Cayla came out)
Once my body started pushing on its own, I remember trying to scheme in my head how I could get this baby out of me in no more than 10 minutes. A mom in one of my VBAC support groups had recently pushed for only eight minutes and that sounded like a pretty sweet deal to me…except I really had no control over the pushing; my body was just chugging her out and the pressure was incredible. Orett sat by the pool and held my hands and told me I was doing it, that our baby was coming to us just like we’d prayed for, that the pressure meant she was almost here, that my uterus was strong, that he knew I could do it. Almost thirty minutes after I started pushing, I felt the ring of fire. I gasped “I’m splitting!” as I felt her head crown. Edie asked me to flip from hands and knees to my bum after Cayla’d crowned and push through the burning.
And at 8:07 pm on New Year’s Day, Cayla Ariel Brown was born, a mere two hours and seven minutes after Edie had returned to check me at home and found me to be 7 cms dilated with contractions still eight minutes apart; an expeditious one hour and seven minutes after my contractions had finally dropped from every eight minutes to every two minutes. Her APGAR’s were 8 and 9, and she was seven pounds, six ounces – six ounces heavier than Annalise had been at birth. It was so surreal when Edie lifted her out of the pool and placed Cayla on my chest, and Orett cut Cayla’s cord. I couldn’t believe I’d done it; I’d pushed a baby out the old fashioned way! I was so overwhelmed with emotion and felt so incredibly happy and lucky to have helped her have a gentle entry into this world through waterbirth, with the hormones of birth the Lord designed uninterrupted by labor drugs, and with lots of hugs and cuddles and skin-to-skin. Birthing Cayla in a pool of warm water – in my living room, beside my fireplace and the twinkling lights from my Christmas tree – was such a blissful, peaceful experience, and I am truly thankful for this blessing.
Once Cayla was born, we figured out why – besides her pesky ROT positioning – it’d taken so long for her to come: she had a long cord, and somehow managed to get the cord not only around her neck, but knotted at the base. My midwives are sure that the cord was a significant part of why the labor took so long: with the cord knotted at her neck, she needed time to rotate and descend through my pelvis. We’d planned for delayed cord clamping, but at this point, removing the knotted cord from around her neck was the priority. Her cord was clamped and then cut off her neck, and she took her first breath. In a lot of ways, I am fortunate that I had an amazing birth team at home. Were I admitted to the hospital at 7 cms dilation with contractions 8 minutes apart, it would’ve been typical for the on-call OB to recommend pitocin augmentation to “establish contractions and labor.” But with the cord so tightly knotted at her neck, the oxygen deprivation that pitocin regularly causes could’ve easily produced another distressed baby, caesarean birth, and NICU stay. I am thankful for all the people who prayed for our VBAC birth, as I know the Lord protected us, guiding our decision making, so that we would chose the path most likely to result in the healthy birth of Cayla.
I hemorrhaged and was hypotensive after the birth, and my midwives were recommending that I be transported to the hospital. Despite the shot of pitocin and running pitocin through my IV line after birth, I was still bleeding. There are other PPH drugs they carry to births, but my uterus had already clamped down, so some of them were no longer medically indicated. But Orett asked if they could run one more bag of IV fluids, administer more meds, and monitor my bleeding and blood pressure for a further 30-60 minutes. Once the bleeding stopped, they agreed to let me stay home because Orett had the nursing skills to continue to monitor me through the night. (When Edie came for her home visit the day after Cayla’s birth, she told me that had Orett not been a Registered Nurse who worked in an ER, she would’ve insisted on transport. I’m such a lucky gal!!!). Once it was under control, they applied some anesthesia and sewed up my second degree tear. (No, I wasn’t even TRYIN’ to get stitched up sans anesthesia lol!) It was so nice to have Cayla on my chest while they worked on me, as after my c-section with Annalise, they whisked her off to the NICU because of her breathing and I never got to see her till 6pm the next day. It’s so wonderful to be able to bask in skin-to-skin bonding time after birth.
Even though my first day and a half were challenging because I was a bit lightheaded from blood loss, baby Cayla and I have both been doing well since delivery. Orett and I are so thrilled with Cayla’s HBAC birth and hope to do this again for any other children with which we are blessed.
MY BODY IS NOT BROKEN!!!!
I will praise thee; for I am fearfully and wonderfully made: marvellous are thy works; and that my soul knoweth right well
~Psalms 139:14 KJV~