Thursday, May 15, 2014

VBAC Preparation: The Consulting Doctor, the Ultrasound, and the Green Light

I don’t play the idle waiting game very well, so I've spent the last few weeks tackling a long "before baby comes" to-do list. Now yesterday's due date has come and gone, and we're still waiting! With my list practically finished, I decided to use the remaining pregnancy time to catch up on the blog posts I've meant to write throughout the pregnancy. In particular, I want to record the steps I've had to take to pursue the home birth VBAC (Vaginal Birth After C-section) that I’m hoping to experience in the very near future.

Passing the days with my energetic toddler!
If you want to plan a home birth with a Certified Professional Midwife in the state of Wisconsin, you essentially have to find a midwife who will take you on as a “low-risk” patient. While still being bound to their license and standards of practice, each midwife is allowed to determine her own level of expertise when it comes to judging what they consider “low risk.” In Wisconsin, VBAC, twin, and breech births are all allowed in a home setting. However, an individual midwife may not personally feel qualified to service a VBAC, twin, or breech pregnancy, and can decline a client who fits one or more of those categories.

My own midwife has never delivered a breech baby or twins. Though she has been trained in how to coach breech births, she has always been able to successfully turn a breech baby to the more optimal head-down position before labor has begun. When we discovered that Jadon had turned breech during labor, my midwife made it clear that she was willing to stay at home with me if I chose to do so, but stressed that breech deliveries were outside of her realm of expertise. I decided to transfer to the hospital for a likely c-section, rather than put my midwife, and myself, in a risky position that neither of us felt prepared for (check out Jadon's birth story here).

A year after Jadon’s birth, Jon and I were thrilled to discover that Baby #2 was on the way, and that my midwife was perfectly comfortable delivering the new baby in our home. However, in order to legally assist a VBAC, Certified Professional Midwives in Wisconson have to follow a few extra rules. First, the midwife must have a protocol for fully disclosing the risks of VBAC to their client. Second, the client must not have a vertical incision from the previous c-section, nor a low-lying placenta. Third, the midwife must consult with a physician to have confirmation that the client is a good candidate for a VBAC.

How did we find a doctor who was "home birth friendly?" Check out my previous post.

Meeting the Consulting Doctor 

I met with Dr. W for the first time when I was 12 weeks pregnant. He listened attentively as I recounted the details of Jadon’s c-section, reviewed what I had researched about VBAC births, and shared that I intended to birth at home. “However,” I continued, “I’m not a home birth nut who would avoid a hospital birth at all costs. I’m not seeing you just because I have to have a consulting doctor in order to get my home birth. I value your opinion as a medical professional, and I would really want to know if you considered my pregnancy unfit for a VBAC in any way.”

And then I held my breath for what he had to say.

He began by affirming what I had researched about VBAC’s, especially that I was an excellent candidate for one. Not only was Jadon birthed by c-section simply for being breech, but my incision was cut in a "low transverse" fashion, and my uterus was closed with a "double layer uterine closure." He said that I was especially likely to succeed because, before I got on the operating table, my cervix had completely dilated with Jadon's labor. He said that most VBAC patients are nervous about uterine rupture, but the odds of a rupture are still less than one percent of all VBAC births. Then, he complimented me on how informed my plans are. "You know, Alison," he went on to say, "If I were a betting man, I'd put down money on your successful home birth VBAC. I can't wait to congratulate you when you've accomplished your goal."

Honestly, I was a little speechless at that point. He then proceeded to ask me questions about the role wanted him to play in this pregnancy. First, he asked how often I would like to see him since I am receiving dual care with my midwife. 
“Maybe every other month until the final weeks of pregnancy?” I posited.
“Done,” he replied.

Did I want his office or my midwife to do my blood work in the coming weeks?
“I’d prefer for my midwife to do my blood work.”
“No problem.”

How many ultrasounds did I want, when did I want them, and would like I to use the hospital ultrasound equipment, or use another provider?
“I would like one ultrasound at about 20 weeks, and I’d love to use your hospital technician.”
“So, we’ll be seeing you in about 8 weeks then!”

My spirit was practically soaring out of the examination room from the joy of making all these decisions for myself with no pressure to do anything differently! Who is this member of the “medical establishment” that was giving me all this decision-making power for my baby and pregnancy?!

The Ultrasound

Eight weeks later, Jon, Jadon and I returned to the hospital to see Baby #2 on the ultrasound screen. Jadon loved running down the wide, open hallways while Jon and I walked behind.

Like any expecting mother, I hoped that the ultrasound would confirm that the baby was measuring properly and had all of its organs developing normally. This ultrasound was especially important to me because we needed verify that the location of the placenta was a safe distance away from any c-section scar tissue. If the placenta were to be on top of my scar, I would be at a greater risk for a condition called placenta accreta, in which the placenta attaches too deeply into the uterine wall. If the placenta is attached too deeply, it may not separate from the uterine wall on its own after the baby is delivered, which can result in hemorrhaging and other dangerous complications. I certainly wouldn’t want to deliver at home if my placenta was in a “high-risk” location.

Finally, we were anxious to find out the sex of Baby #2…would Jadon be getting a baby brother or sister in May?

Once in the examination room, Jadon was very curious about the table on which I reclined, and all the fancy buttons and screens nearby. I was so thankful Jon was there to keep him from getting into trouble.

The technician soon started scanning Baby #2, pointing out all the organs and limbs as she measured and recorded. I was so relieved to hear that the baby appeared to be developing as it should be. I was especially thankful to know that the placenta was located high up on the uterine wall, safely away from the surgery scar and the opening of the cervix. Thank you, LORD!

I see a nice round head like Jadon's! 20 week ultrasound
When it was time to find out the sex of the baby, she kept scrolling the wand over my belly, trying to approach the baby from different points of view. While we waited for her to get a good angle, I asked what they do in order to identify the baby as a girl. Do they only look for the absence of male genitalia, or do they actually look for the presence of something? She explained that you can usually see "three white lines" in a girl's genital area. She continued to scan and pause, and then start scanning again. Finally, she admitted that the baby really wasn't giving her a good angle, and that the best she could tell us is that we have a 60% chance of having a girl, and a 40% chance of having a boy. Although we clearly couldn’t see male genitalia, she was not convinced that we had a clear enough view to confirm that it wasn't a boy.

Having scheduled my next appointment with Dr. W immediately following the ultrasound, we shared our initial disappointments with him. To our surprise, he offered to schedule another ultrasound free of charge so that we could find out what we’d be having! I was definitely tempted to take up the offer, but Jon gently reminded me that we really wanted to minimize our baby’s exposure to ultrasound technology. I agreed that having an ultrasound simply to confirm the sex was trivial. With no other medically necessary ultrasounds needed on the horizon, we resolved to wait until the delivery to see if we are having another boy, or our first girl.

The Green Light

As the long winter wore on, Baby #2, and my belly, steadily grew. I saw Dr. W again at 28 weeks. Our meeting, as always, was brief, pleasant, and completely respectful of my wishes.

Jadon, enjoying the view from Dr. W's waiting room
At the same time, I continued to see my midwife every month until the third trimester, when I started seeing her every other week. At each visit, I was pleased to hear that my blood pressure was excellent, weight gain was steady, urine samples were normal, and the uterus size was right on schedule. Baby #2 has even been keeping that head down!

When I reached 36 weeks, my midwife called Dr. W to have the official “consultation” required for her to oversee my labor at home. At my next appointment, she reported the good news that Dr. W considered me an excellent candidate for a VBAC.

I have the official green light to proceed with the home birth VBAC plans!

My last appointment with Dr. W was last week, at 39 weeks pregnant. Unless I develop “high risk” pregnancy complications, or go past 42 weeks, I won’t need to see him again. 

And now, the waiting game continues...where did I put that to-do list?

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