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Pam’s VBAC of Raquel

This is Pam’s 2nd VBAC.  The story of her first VBAC was published earlier this week on the Blog.

Raquel’s birth once again proved the old adage: Expect the unexpected.

My pregnancy was nearly perfect, so while I expected to pass my due date, I was somewhat surprised to find myself still pregnant after 41 weeks. Though my doctors all supported me in waiting until 42 weeks to decide about forcing the issue, I recall sending an email to a friend, lamenting the fact that I “no longer look forward to this birth with a sense of anticipation and excitement, but with a sense of Good God, can we just get it the f— over with?”

I did try to stay positive, and we started walking, having sex, talking to the baby asking her to come out. I had a few episodes of false labor, but they all petered out after a couple hours of regular contractions. I was going for NSTs every other day, and the baby was doing really well, so we continued to wait. On July 24, at 41 weeks 5 days, I had finally made some positive progress toward labor! I had lost my mucous plug the morning before, and after my once again perfect NST I was found to be 3.5 cm dilated and about 80% effaced. Based on that progress, I asked to have my membranes stripped and scheduled an induction by artificial rupture of membranes (AROM) for two days later- 42 weeks pregnant. The end was in sight!!

By early that afternoon I was having regular contractions and thought I might be in latent labor. Around 3:30 p.m. my mother-in-law came over and said she’d take the boys for us so we could go to the hospital whenever we needed to. Tomas and I went out for a walk to see if my labor would intensify, and though I did have to stop for a few contractions, I eventually decided that it was going nowhere and we should just get the boys back and have dinner. Once the boys were home and I started cooking, contractions immediately intensified and starting coming every 3-5 minutes instead of every 10-15. That continued through dinner, and by around 7:30 we decided to ask Maria to come back and watch the boys again. She got here a bit after 8, at which point contractions went back to a 7-10 minute interval but stayed very strong. Some of them were extremely difficult for me to manage, so I called Kaiser’s after-hours service and told them what was going on; they agreed I should head in to the hospital.

We got checked in to the hospital uneventfully. I was hooked up to the monitors for the initial 20-minute strip and my cervix was checked. I was extremely disappointed when I was told I’d made no progress since that morning. All those contractions for nothing. After talking with the on-call OB (whose name was Dr. Payne, if you can believe it), we decided I’d stay for 2 hours of observation to see if the still-regular but still 7 minutes apart contractions were doing anything as far as progress. If not, it would be my call whether I’d go home with a sleeping pill or stay and do the AROM induction a day and a half early.

After a couple more hours of contractions, there was still no change! I was incredibly discouraged. I really wanted another natural labor and delivery, but also had to admit that a sleeping pill was not going to get me any rest because the contractions were just too strong. The baby was also having pretty steep heart rate decelerations during contractions (dipping into the 80’s and low 90’s), and while that is normal it was also a little disturbing since I’d been contracting for so long and making so little progress. Tomas and I decided to stay at the hospital, and I was admitted around 1 a.m. I hoped to be having my baby soon!

Before I continue with Raquel’s story, I need to take a second to acknowledge how critical Tomas was to me during this labor. Though he doesn’t appear consistently in my narrative, he was always there discussing our options, talking with me about my feelings, encouraging me to say no to intervention and continue laboring to see what would happen, reassuring me that we were making the right decisions.  Looking back, if it hadn’t been for him I would probably have allowed the doctors to intervene more and earlier than they did. I give him full credit for helping me be comfortable with all the intervention I had, and confident that the decisions we made were the best ones we could make.

Once we were admitted to the hospital, my birth plan was out the window. I wasn’t coping with contractions well and kept telling Tomas how much more this labor hurt than my last one did. It was very different, and I knew I wouldn’t be able to cope post-AROM so I discussed pain relief options with the OB (I should mention I talked with a number of different OBs at this point and am making no effort to keep them straight). I asked if I could get an epidural and still not consent to pitocin, and if doing that would reduce my chances of a successful labor. To my surprise, the answer was a definitive yes, I could still refuse pit and my chances of delivering vaginally would still be at least 75%. As I signed the consent form for the epi, I made a comment to my L&D nurse about wussing out. She sort of laughed and said something about how although my contractions were far apart, they were lasting 2.5 minutes, and I wasn’t wussing out. I also signed consent forms for a trial of labor and a repeat cesarean, and I specifically requested double layer sutures if I ended up in the operating room again. Everyone was very positive and supportive, and our plan at that point was to start an IV and have me get up out of bed while I was receiving fluids. If I’d made progress by the time I had enough fluid for the epidural, I would stay up and mobile and epi-free; if I hadn’t made progress I would get the epidural and go ahead with AROM. I got on a birth ball and Tomas stood behind me, supporting me through each contraction for about an hour. No progress of course, and though the OB wanted to break my bag right away I refused and insisted I get the epidural first. My L&D nurse (Lee, who had a VBAC with her 3rd baby) seemed pretty pleased that I wasn’t being intimidated by the doctors- she gave me a big smile and a thumbs-up when I refused immediate AROM.

The anesthesiologist had a couple other women before me, and I have to say that knowing relief was on the way made it more difficult to cope with contractions that were increasingly difficult anyway. I had a particularly painful contraction while the epi was being placed, and I was glad it was the last one I had to feel! The anesthesiologist gave me a huge bolus, and within minutes the worst part of my labor began. I was completely numb from the waist down and had absolutely no ability to move my legs- decidedly not what I wanted. The anesthesiologist apologized profusely and said she should have asked before she gave me such a large dose, and said that the numbness should wear off within an hour or so (which sounded like an eternity to me). When the OB came back to break my water I was at 5 cm with a bulging bag. It was about 5:30 a.m.

Immediately following AROM, contractions intensified quite a bit but still didn’t get any closer together. Raquel’s decelerations also intensified. When one particularly powerful contraction hit, I heard Raquel’s heart rate dip and when I turned to look at the monitor I was terrified to see it had dropped into the low 60’s and not recovered. I turned toward the door, knowing that at any moment someone would be running into the room, and there was Lee, holding an oxygen mask out to me. “That was really ugly,” she said, and I quickly grabbed the mask, willing the oxygen to my baby. Her heart rate recovered fine, but the pattern of huge contractions and huge decelerations continued. I sat there so numb I was nauseated, praying I wouldn’t puke into the oxygen mask, afraid things were really going to go downhill fast. Internal monitors were mentioned at that point, but never ended up being placed. I’m not sure why.

Shift change came. Juanita was our new L&D nurse and she was amazing, very supportive and reassuring that we would do everything possible to have a vaginal delivery. She checked me and I was at 8 cm, 90% effaced, baby at –1. Progress, anyway, slow but steady. The resident OB was Dr. Weatherwax, who had done my NST and AFI the previous Saturday.  The Kaiser OB was Dr. G. The anesthesiologist came in to check on me and I asked to have the epidural turned down as I was still too numb for my liking. He didn’t seem too excited about doing it, but went ahead and turned it down. Within an hour I could move my legs on my own, feel each contraction, even feel amniotic fluid leaking from me with each contraction, but I had no pain at all. That was the epidural I wanted.

Another 2 hours passed and Dr. Weatherwax checked my cervix again. He said that not only had I made no progress, but he thought Juanita’s assessment might have been generous and 8 cm was optimistic. He suggested that we start pitocin to see if we could increase progress, but I didn’t want to do it. I truly felt that if I was not progressing with the huge contractions I was having, pitocin could only make the situation worse. I asked to wait a couple more hours since baby was still doing fine, and then if I’d still made no progress I’d go straight to a c-section. It was about 9:30 a.m.

Then came Dr. G. She talked with me about my anti-pit feelings, and I told her that during my first delivery everything was going okay until pitocin came into play. I hate the stuff, and especially knowing how much Raquel’s heart rate was decelerating with natural contractions, I didn’t want to do anything to increase her risk. I also explained my gut feeling was that if my body wasn’t progressing, there was a reason. I just couldn’t go against my instinct in this situation. Dr. G. re-checked my cervix and made a comment about “stingy interns.” She said she’s been an OB for 14 years, and for 14 years she would have called me a good 9 cm dilated- not 8, and certainly not 7. She also said baby was at about 0 station. Then she said she needed me to know her bias toward my situation: her first baby was a c-section and she scheduled two repeats, so if I was sure I wanted to go into the OR at that point, she would support me. However, she also said if I’d never had a c-section, we wouldn’t even be considering it when I was 9 cm dilated. She strongly recommended I consider using a tiny dose of pitocin to see if we could get contractions closer together and hopefully get the last bit of progress made. I was encouraged that I’d made it to 9 on my own, and asked everyone to leave so Tomas and I could discuss everything again. We talked it over and asked for a couple more hours without pitocin to try to make it to 10. It was agreed, and I continued to labor pit-free. Juanita seemed pleased that I hadn’t caved in to the OBs, and said she felt they were often just not patient enough.

Noon had been my arbitrary deadline to either give birth or go to the operating room. Around noon, I had just a very thin lip of cervix left and was 100% effaced. Contractions were still 7 minutes apart, and I finally agreed that I would have a low dose of pitocin to bring them closer together. I did a couple practice pushes to see if I might be able to push past the last little bit of cervix, and then we waited another hour to see if I would make it to complete. I was definitely starting to feel pressure with each contraction, and could feel the baby moving down into my pelvis. At the end of the hour, I still had a little rim of cervix left on my right side, but we decided to try to push past it. Juanita massaged the rim of cervix as I pushed, and I could feel the baby getting lower with each push. Dr. Weatherwax came back, and took over the cervical massage. After a few pushes, he asked if my other babies had been properly positioned, because this one was posterior.

In retrospect, I feel like I should have been able to put this together. Throughout my pregnancy, I’d said I wasn’t sure how big the baby was because, “it’s just in there different.”  I was having widely spaced intensely painful contractions, some of them extremely long, and I was making very slow progress. If I leaned way forward during a contraction, the pain was significantly easier to manage. The night before, I had told Tomas that as my pregnancy progressed toward 42 weeks, I was plagued by the feeling that something was wrong- I just couldn’t put my finger on what it was.  Had I known that Raquel was posterior, I don’t know how much would have been different- but at least I wouldn’t have spent so much time feeling discouraged and ready to throw in the towel on my VBAC!

Once we knew she was posterior, I set my mind to really pushing that baby out! I knew my second stage would end up being longer than it was with my last delivery, but I didn’t want to end up pushing for hours on end. I have to say that I loved having the epidural during second stage. I was able to focus all my energy on pushing and feeling the baby move down, instead of having a good deal of my focus taken away by the pain. Contractions were still spaced pretty far apart, so it was a little weird to have long periods of just sort of chatting with everyone, then feeling another contraction start and once again putting my all into pushing. I reached down to touch the baby’s hair once it was staying visible, and it was pretty amazing to know she was right there ready to come out. As I pushed, Raquel rotated 270 degrees so that by the time she was delivered, she was facing the right direction. I overheard Dr. Weatherwax saying he thought as soon as she was finished rotating, I’d have her out in one contraction, and that was such a great encouragement!! I pushed through a contraction and she was fully crowning, but instead of pushing again they asked me to wait and let everything stretch. During the next contraction, Dr. Weatherwax coached me to push slowly and used massage to get everything stretched around Raquel’s head; he then had me slowly push out her shoulders and she was delivered with no tearing at all!

Immediately once she was out, I looked down to see that she was a girl (we hadn’t found out beforehand) and when I saw her, I shouted “It’s a GIRL!” Tomas got to cut the cord this time, and then she was plopped on my chest all goopy and bloody, and it was absolutely amazing to finally hold one of my babies immediately after birth. The pediatric nurses took her shortly after because she wasn’t pinking up and needed some blowby oxygen, and as they were suctioning her it became apparent she’d swallowed a lot of blood on her way out. There was enough that they decided to pump her stomach- what a welcome to the world- and one of the nurses commented that she’d never seen a baby swallow that much blood before. As Raquel went through that, I delivered a “really big” placenta and started experiencing some heavy uterine bleeding.  The doctors checked to make sure I hadn’t torn my cervix pushing Raquel past that last lip, and then they cleared a bunch of clots from my uterus, started a full pitocin drip, and gave me a shot of methergine.  I was still gushing blood for a few minutes, but then it slowed and thanks to all the clots being cleared my postpartum bleeding has been pretty minimal.

Then all the drama was over. The nurse asked me which side I wanted to start nursing on, I pulled down that arm of my gown, and Raquel was placed on my breast. She latched on like a pro, and it was probably one of the most incredible moments of my life, holding my beautiful little daughter in my arms while she was still so new to the world. I remember looking at my husband while he was taking pictures of her, just being amazed that this tiny little girl was ours, and he helped me get her here.  I can’t remember another time in my life when I’ve felt so overwhelmed with love. All the hours of labor, all the moments of doubt, all of that faded away, and I am left once again amazed at doing this small part of God’s work. She is perfection.

Raquel Vivian

July 25th, 2006

7 pounds 13 ounces

20” long

14.5” head circumference