Safer Than a Known Way

The express route from elective repeat cesarean to homebirth

It was around six months before Misha was conceived that I sat in the obstetrician’s office, smiling and nodding. I had begun to imagine a new pregnancy, four years after the birth of my son Sam, and I had a question. Sam had been born by cesarean section after I developed complications during an induced labour. I had wanted a natural birth and, well, it just hadn’t been that way the first time. Now I wanted to know if there was actually any physical reason that I couldn’t birth a baby naturally next time. I wanted to address this well in advance of my hoped for future pregnancy, just in case I would require an x-ray, or some sort of scan. I was being responsible, you see, and I had come to a specialist, an expert for my answer. I was doing the right thing…

So why was I so concerned about some possible flaw, some irregularity in my body that would prevent me from giving birth, that, if it were not for the wisdom and expertise of medical professionals, would risk the lives of myself and my babies? Obviously, there was my primary cesarean surgery. Further back, my mother had a birthing history that had seeped doubt into the next generation’s birthing minds and bodies. Mum’s first baby, my eldest sister, was breech. I don’t know if they tried to turn her; Mum has never mentioned it. I’m not sure that the breech position immediately precluded a natural birth for Mum because her doctor ordered x-ray pelvimetry for 36 weeks gestation. Did he suspect a pelvic irregularity based on the breech position? In any event he was able to seal his case for elective c-section based on a diagnosis of android pelvis in Mum.

Obstetrics 101

There are four pelvis types found among women. The gynecoid pelvis is considered the “ideal” shape for normal vaginal delivery. With a round to slightly oval inlet, this model is your best chance. In an anthropoid pelvis we find that the inlet transverse is greater than the inlet obstetrical diameter. Labour is usually straightforward. A platypelloid pelvis is characterized by a flat inlet with shortened obstetrical diameter. This pelvic shape favours transverse presentations and shoulder dystocia can be an issue.
Then we have the android shape, more often found among women of African heritage. When found among anglo types, these women tend to be taller, narrow-hipped. This pelvic shape is reminiscent of the male pelvis, narrower, with a triangular outlet. Normal delivery can be a challenge. An upright, active birthing style is known to be helpful.

My mother is under five feet tall and of Anglo and European Jewish heritage.
Mum delivered my sister by c-section. She had a classical incision under general anaesthetic. All Mum’s cesareans were booked two weeks early. For her third surgery she had to wait until term because her OB had a skiing accident. How nice for him that he could organize his holidays around his work. Shame about the accident… Mum almost bled to death on the operating table this last time. I was transferred straight to a humidi-crib and didn’t meet my mum for three days…

Mum is very grateful for her cesareans and remembers her obstetrician with great fondness. She marvels at the wonder of being put to sleep and waking up to find you have had a baby. What could be more civilized? But sometimes, only sometimes, she’ll start talking about what it was like in hospital, what happened, how she felt. And it just doesn’t seem to add up with her espoused reverence for the OB and the miracles of modern medicine.

So that was Mum. When it came to my first pregnancy, and the first from among my sisters, I didn’t let all that faze me, at least not consciously. I pretty much assumed I would have a natural birth, no problem, and I flipped impatiently through the pages on cesarean section in my many books on birth. I didn’t see why I would be needing any of that. Homebirth crossed my mind as something that sounded nice to me, as did water birth. But I would be responsible. I would do the right thing. I would go to hospital “just in case”. Birth, after all, could be dangerous.

So there was some societal conditioning there as well, obviously. I’d never seen a natural birth, only Hollywood dramas. I’d heard only hospital horror stories. Unbeknownst to myself at the time, I would have my own…

At 42 weeks pregnant, healthy and with a healthy baby inside me, I sat in my OB’s office being told that I wasn’t being asked if I wanted an induction, but when. A muffled scream of “Nooooooo!” resonated somewhere deep in my great, pregnant belly but I didn’t feel I had a choice. I felt backed into a corner.

I’m not going to write Sam’s birth story here. Suffice it to say I had every intervention know to modern maternity “care”. Suffice it to say that if I had felt trapped in the OB’s office, I felt tortured in the delivery suite. When it came time to be wheeled off to theatre after ten hours of violent syntocinon-induced “labour”, still only three cms dilated, I felt relieved…

A couple of days later I spoke to my mum. She wasn’t surprised. From her view of things the cesarean just ought to have been done in the first place. And from my view of things, now that I had experience the horrors of labour, I was inclined to agree. So where would I go from this place into a subsequent pregnancy and birth? Many women go straight for an elective cesarean and, coming from this place, who can blame them? Unless, of course, the narrow path to a new place should open up. Where I was at after my first experience, there seemed no such place.

So what else? So far we have a family history of cesarean, crossing two generations. My sister went on to have her first cesarean baby two years after me. More confirmation, that, in our family, “we can’t”. And there’s the belief systems that we develop, or take on, to cope, to make sense of things. We latch onto half-baked explanations that doctors give us, myths and misconceptions that we’ve heard so often we don’t question their truth. Stuff that doesn’t even make sense. Unfortunately a lot of this is passed around among women themselves. And we don’t ever think to question what the doctor has said. He or she knows best, after all.

Birth Mythology 101

 

Labour is to be feared, dangerous, unpredictable, messy. Cesareans are neat, modern, civilized. So we can feel almost superior to those crude peasant women who can just give birth under trees like shelling peas. This makes us feel better. We are gleaming white and evolved, with slim, shining pelvises, disinclined for dirty birth, and far more suited to the sterility and stainless steel of surgery. Labour? Why, we’d never do that to ourselves…

This was the mythology suggested within my family, and more broadly. So how come I just felt like there was something wrong with me?

Obviously I wasn’t entirely sold on this or any other combinations of the many dysfunctional beliefs people have, and propagate, about labour and birth. If I had been, I would not have presented to the OB until pregnant and ready to book in for my elective c-section, no question. But there was still a tiny door, somewhere in the vicinity of my pelvis, that was open just a sliver and emitted a dim light.

So what did the obstetrician say when he heard my history, looked at my notes form Sam’s birth? Dr Darwin tinkered absentmindedly on his laptop as he addressed me. What he said, funnily, supported my family mythology nicely and was pretty much as follows.

Creative Obstetrics 101

Somehow, and unadvisedly, we, as a species, went and stood up. This has presented immediate difficulties for women in birth. Their birthing journey is far more perilous than in other animals. There is enormous pressure on the  pelvic floor. I wouldn’t get any medals for having a vaginal birth when I was weeing myself at the supermarket, now would I? My mother would have died in childbirth had it not been for modern surgery. Thus, nature breeds out the inadequate pelvises. I should without question have another cesarean for my next delivery. I may have two, possibly three children.

I was an inadequate pelvis who shouldn’t be alive, my line only to be sustained now by the miracles of modern medicine. As a bonus I wouldn’t have to suffer the vile indignities of normal birth and become a disgusting and incontinent middle-aged woman with a large, loose, flapping vagina.

The small door to my tiny, useless pelvis closed quietly, but with finality.

How all this new information from the OB didn’t seem immediately dodgy-sounding to me I don’t quite know. When the learned man has spoken, you don’t question, I guess. But doubts began to circle my head, Marge Simpson-like, as the weeks wore on after my consultation. “What about my grandmother? And her mother before her? They wouldn’t have had cesareans, surely? How did we get this far before the line was suddenly cursed with a plague of insufficient pelvises? And my mother’s sisters, my aunts… I don’t think they had cesareans… so maybe it was just Mum… and that doesn’t mean it has to be me… or maybe there was nothing wrong with Mum…”

A jolt came with a conversation that occurred between a friend at playgroup and myself. I was wary of this friend when it came to the topic of birth because I knew she had birthed her second baby at home after the unpleasant induced vaginal birth of her first daughter in hospital. I suspected she might not buy the line I had been given by my OB and I was correct. I suspected she might rock my precarious little world. She seemed hesitant to comment (we all know what dangerous ground this can be!) but comment she did.

“Ah, you know…” my friend ventured hesitantly, “sometimes they tell you ‘you can’t’…when you can…”
I became immediately flustered and defensive and banged on a bit about my family history and “we can’t” and “some people just can’t” and “blah,blah,blah”. My friend didn’t say anything else.

I was furious and vented to my husband about homebirthing hippies. I decided to do some research and began to brandish an article from OBGYN of all publications.

Grim Obstetrics 101- The VBAC

 “The worst outlook was said to be for women with a previous caesarean for ‘failure to progress’ and no previous vaginal birth where about two thirds will have a vaginal delivery.”

“Are we grappling with a chicken and egg problem? Are nervous obstetricians dissuading women from trying for a vaginal delivery? Are they calling a halt to the trial of labour too soon? Is it sabotage? Or is the average obstetrician more astute than we think? The data would support a pessimistic approach. As the caesarean section rate in Australia sits at one in four, we are all faced with increasing numbers of pregnant women with uterine scars. Knowing that, as a group, even highly motivated hospitals (the sort that would go to the trouble of contributing data to organisations like Women’s Hospitals Australasia) manage vaginal deliveries in marginally more than half of women, this is a tough sell. Add to the mix a small but important risk of uterine rupture (a complication that kills a quarter of babies and sterilises a quarter of women and things look less than rosy.

Currently our practice overall is to encourage women to try VBAC. Yet if
we present the real outcome figures and ask women to make a choice and assert their autonomy, many will choose an elective caesarean deliver. When a woman plans to have only two children – a large proportion of the current Australian population – and chooses an elective repeat caesarean section for her second, knowing that risks of the surgery are low and that her pelvic floor is largely protected from the damage inflicted by vaginal delivery, ‘the evidence’ supports her decision.

I read the first chapter of “The VBAC (Vaginal Birth After Cesarean) Companion” and decided I was one of the women who had dealt well with her cesarean and would have no problem choosing a second one- after all, surely a thinking person just couldn’t go past that risk of uterine rupture?

I discovered a website called “Birthrites: healing after cesarean” and went straight to the page that helped you plan a positive cesarean, by-passing everything else that was on offer. Oh, the things I could request- whoever knew? I could decline the green screen that excluded me visually from the process. I could have the baby passed straight up to me, wet, dripping, bloody, naked. And there was more… I would do it! I would go for that second baby and I would have the warmest, fuzziest cesarean I could negotiate!

 

Life went on… I maintained only a part-time interest in the topic of birth. I had, after all, decided what I was going to do next time. But doubts seeped in and became real questions. Things friends had said, stuff I’d accidentally read while trying to justify my decision with research, began to pierce my consciousness. Then, early winter 2005, I developed a frenetic resurgence of interest in the topic of birth, and, namely, VBAC. I finished the VBAC Companion. I read other articles on Birthrites like “Relative risks of uterine rupture”. I marveled at the fact that getting in your car every day is actually much more dangerous than VBAC. I joined the discussion forum. I even went so far as to telephone a woman who was listed as a contact for VBAC information in my area. I wanted to know the name of the best VBAC doctor in my area. I now wanted a VBAC and would begin my journey to getting it.

 

The woman I telephoned gave me the name of an obstetrician at a private hospital about forty minutes from where I lived. OK, I thought, I will travel for my VBAC. She said he would probably be my best bet for a VBAC in hospital in Southeast Qld. His name was Dr Milton Case. She told me that she had had two cesareans before enjoying a natural birth at home, with a midwife She told me there was a local homebirthing group that I could attend if I wanted to check out that side of things. I didn’t consider it. If, in the admittedly unlikely event of a rupture, I wanted to be able to access a fully staffed and equipped operating theatre, thank-you very much.

Practical concerns aside, the old desire for a natural birth had been rekindled. I reflected on the way in which, over the years since Sam’s birth, I had always felt like crying whenever I heard or read descriptions of “pushing” or “crowning”. Clearly, there was a primal need in me still unfulfilled, and repressed for so long. What was bringing this out so strongly now? All of a sudden I needed to know that out there somewhere, was a safe place to birth my baby, yet to even be conceived. I had no idea at this time that this place would be metres from where I sat at my desk, searching, reading, contemplating, telephoning. That the place where I did all my other mundane living stuff would be the scene of another of life’s simple, homely processes.

After some weeks of posting “I’m not pregnant yet, but…” on various VBAC discussion forums I started to wonder whether perhaps I actually was. In a temper I had fired a handbag in the direction of my husband- a clear sign of early pregnancy hormones doing their work in me. I have a nasty first three months… We had planned to start trying in September, after our wedding, but I had admittedly loosened my grip on my natural fertility management, knowing that soon we would be officially “trying”. Surely it would take a few months to conceive- some couples tried for ages. Even if I was a little bit pregnant at the wedding, that would be ok.

Turned out I would be fourteen weeks pregnant walking down that aisle.

Now everything made sense, the intense need to find a safe place to give birth, to know that there was a chance and somewhere to go for it. The fact that I had instinctively begun to mark out my journey, not knowing yet that I was pregnant, gave a great boost to my confidence in my instincts and intuition. It was something I would look back on later for confidence and strength when doubts came up. It was the beginning of the building of trust in myself and the process I had been wonderfully designed for. It was the beginning of belief.

Emotionally there wasn’t much support for my decision to VBAC, outside my husband Ismail and a handful of friends. My mother walked in on me doing yoga in the living room one afternoon. “This posture opens the pelvis”, I explained meekly.
“Oh why don’t you just have another cesarean and be done with it,” she said crossly.

I went ahead with attacking practical issues. First, I had to do my rounds of the hospitals and the obstetricians and the midwives in my quest, still at this point, to do the perceived “right thing”.

Dr Milton Case’s rooms were very civilized. Classical music was piped through to the waiting room (no, really!). He was friendly, grey, with an open face and welcomed us through to his office. It was large. There were sculptures. There was a massive, chunky, wooden desk behind which Dr Case seated his slim frame. My five-year-old approached several of the unwisely-positioned sculptures, which was met with anxiety by Dr Milton Case.

The doctor’s first port of call was to confirm my pregnancy via an ultrasound scan performed in an examination room adjacent to his office. After studying the small screen for a few moments he smiled and turned to address me and my husband. “Well there’s definitely a live fetus in there!” he exclaimed triumphantly.

Funny, I could have told him that…

The ultrasound confirmed my estimated due date of the seventh of March. Then, Dr Case did a most unusual thing. He made a gesture which would pay off in most unexpected and blessed ways later on. He added five days to my EDD. “Oh, I always give women an extra five days for the time they would normally bleed.” Big of him. And although I found it hugely arrogant for anyone to presume that they “give” you the time that your baby will be ready to be born, I was grateful I had this up my sleeve. Sam, after all, had been sixteen days overdue, according to ultrasound dating.

We resituated ourselves back at the altar…er…the desk. I immediately announced my decision to VBAC.

Dr Milton Case asked me a bit about my history. He didn’t seem perturbed by the family thing. “OK, well, let’s just concentrate on you for the moment.”

Promising, I thought.

The doctor’s frown deepened when I related a brief description of Sam’s birth. The lack of progress seemed to trouble him. “I think I just wasn’t ready. And I was terrified- that could have been a factor couldn’t it?”

“Well, yes, it could have been a factor. But an epidural will often relax a woman enough to make some more progress. And you only got to three centimeters.” I felt the invisible finger again pointed accusingly at my birthing body. He wasn’t coming round to the idea. He didn’t seem to realize that I wasn’t going to be discouraged. I had made my decision and was now just looking for a supportive care provider. And I was becoming a bit disappointed with the much-lauded Mr VBAC, Dr Milton Case. Then, the qualifier. He announced that he would schedule x-ray pelvimetry for 36 weeks. He didn’t shy away from the fact that covering his own pelvic area was high up among his concerns. “What happens if something goes wrong, I end up in court and they ask me why I didn’t order pelvimetry for you?” Yeah, and what if I end up on the operating table again unnecessarily, which is far more likely. What will that cost me and my family?

In my lovely pristine folder that Dr Case had given me, adorned with his beautifully calligraphed business card, was a sheaf of informative handouts. Two A4 pages were devoted to VBAC and the risks involved. Nowhere were the risks of cesareans and the escalating risks of repeat surgeries detailed.

In between visits to the OB, I had decided to go and see a local independent midwife who had been recommended to me by the VBAC woman I had contacted and had also attended my friend from playgroup’s home birth. I wasn’t in the market myself for a homebirth, you understand, but felt that perhaps here I could get some support for my VBAC- the much longed for enthusiasm. I looked forward to this appointment much more eagerly and hopefully than I did my next appointment with Case. I waited with bated breath outside Lydia’s room. The young , serene-looking woman welcomed me through to the small room where we sat on pillows on the floor. Sea air tossed the simple curtains and I felt …refreshed…

At no time did this beautiful, calm person express even a whisker of doubt as to my ability to birth a baby. She knew Dr Case’s reputation and was surprised that he had ordered pelvimetry. She recommended a good osteopath and offered me a flyer for the upcoming “VBAC seminar” at a Brisbane university campus, a National Cesarean Awareness Day event. I asked a final question before it was time to go. “ If I did happen to decide to have a homebirth, would you attend me?” Unwaveringly she replied in the affirmative.

At our next appointment I decided to present the good doctor with a long list of questions garnered mainly from “The VBAC Companion.” He was very amenable to this and listened intently, answering carefully only when he was sure I had finished. At no time did he show any sign of impatience with my long list of detailed questions. He addressed each one seriously and thoughtfully. All this I appreciated very much. My confidence in Dr Milton Case as care provider began to burgeon somewhat.

It was the content of his answers that were largely disappointing.

There would be a shunt inserted into my hand immediately upon admission.
I would have to be monitored by EFM. Most of the time.  Which would mean my movements would be restricted and my access to the bath and shower limited. I would most probably not be “allowed” to labour beyond twelve hours max.

“Of course we must keep in mind, the desired outcome from all this is a live birth,” was his closing observation. Was the only difference between Dr Case and the Dr Darwins of this world that when he played his “dead baby” card, he did so with finesse?

Creative Obstetrics 202

The woman attempting a VBAC is a uterine explosion waiting to happen. Therefore she must be completely immobilized during labour. Yes, I know, it’s not ideal, but it we have to monitor her, you see. What? Skilled practitioner? Stethoscope? Yes but no-one uses those anymore… she’s got to be strapped up to the most useless pieces of machinery in maternity “care”. The electronic fetal monitor. Oh wait, it’s not quite useless. It effectively increases cesarean rates in hospitals. She can have half hour breaks off it if she must. She must also be immediately prepared for surgery on arrival at hospital in labour, by the insertion of a shunt in her hand. You know, in the likely event of her needing to be put on a drip… Of course the psychological preparation or “drip of fear” can begin much earlier in the process… from her very first antenatal visits actually… the risks will be discussed, of VBAC of course, not elective repeat cesarean. If that’s what she wants we’ll book ‘er straight in with a sympathetic, slightly relieved smile. After all, it’s her choice, her right. It’s familiar to her and to us. Predictable, controllable, measureable.  She can stock the fridge and clean the house, knowing she’s off to hospital tomorrow. And we know when to expect her. Everyone’s happy.

But if she wants a VBAC, she’ll have to be “informed”. We’ll be hypervigilant for anything that comes up during the pregnancy that may preclude her as a VBAC candidate. If we discover a low-lying placenta by ultrasound at twenty weeks, then we’ll offer an early diagnosis of placenta previa, even though we know 97% of these cases resolve themselves as the pregnancy advances. We’ll be watchful for a fundal measurement that’s big for dates, a “big baby” revealed by ultrasound technology, a “small pelvis” by x-ray pelvimetry… If she’s still determined, then, grudgingly, we’ll probably give her a go. But if it goes on too long we’ve got to put a stop to things. You just never know when she’s gonna blow

…drip…drip…drip…

I cried in front of Dr Milton Case’s awful desk as I related my anxieties about monitoring, about how it had been last time when all I had wanted was to get into a warm shower. “Well, you obviously still have some unresolved issues around the last birth…”
“Monitoring: v. anxious” he scrawled on my card.

Our next stop was the VBAC seminar, this year’s primary event for National Caesarean Awareness Day. We drove to Brisbane full of hope and loaded up with snacks for our four-year-old. The room was a hive of bustling activity. There were stalls, tables laden with morning tea. There were chattering women, smiling men and beautiful children. I finally put a face to the woman I had contacted from the Birthrites website. Soon everyone settled down and the program began.

All the talks were informative and inspiring. We were transfixed. That new path was opening up, like a yellow brick road in front of our feet.

Among the most compelling of the speakers was a woman doctor who described the chemical dance between mother and baby that occurs in physiological birth and the things that help or hinder that process. Ismail was particularly struck by the benefits to mother and baby of this interplay. “They miss out on so much…” he murmured. I grieved quietly for myself and my son…

Inward grief turned to open tears when a woman related her two cesareans and then a birth center VBAC, accompanied by a beautiful slide show and a touching original song.

On the way home my husband turned to me with consternation and said “Maybe we should have the baby at home, darling?”

I still wasn’t sure…

We trooped back to Dr Milton Case’s rooms for a third time. This time we popped up to the delivery unit for a look. It looked like a hotel. A mild but somewhat impatient midwife showed us around. I had a list of questions for her too which she answered somewhat cynically. When it came to my question about how soon I could be in theatre in the event of a uterine rupture she said “Oh we don’t have round the clock theatre staff on duty. A team would have to be called in. It can usually happen within the hour. But in light of that we really shouldn’t do VBACs at all…” Such enthusiasm…And the disappointments didn’t stop there. At this visit I saw Dr Case’s midwife for a short consultation before I went through to the great man. She, I was certain, would applaud my decision to VBAC. She was, after all, a midwife, a midwife like Lydia. Sure, the woman up at the delivery unit hadn’t been at all like Lydia. But she was probably run off her feet; she was on duty, after all, there were babies being born, or about to be, as we trawled through my great list of questions. This midwife would be different. I had her all to myself.

I disliked Simona immediately. She was not warm. She was kind of…brusque and flashy. I informed her of my plans to VBAC. She frowned down at my notes through tiny, rectangular purple spectacles. She looked up at me anxiously, “But you didn’t progress at all…” she whined. There I was, in trouble again…

I’d dutifully and without question had my nuchal translucency and all my bloods. Dr Case beamed down at all my lovely results and looked up at me smilingly “Well- next thing is your eighteen week scan.” He briskly wrote me up a script for it, passed it across that great expanse of desk and folded his nimble surgeon’s hands, still smiling. But what was really next for us?

During the time between then and my next trek back to the doctor, I did a bit more research. What I discovered about x-ray pelvimetry made me wonder if anybody but a small minority of parents, midwives, other non-mainstream birth workers and activists actually took any notice of an often inconvenient thing called evidence.

Pelvimetry 101

 

“The available trials of X-ray pelvimetry show an increase of interventions like caesarean section, but no benefits in terms of reduced neonatal morbidity (Parsons and Spellacy 1985). X-ray pelvimetry during pregnancy and labour increases the incidence of leukaemia in infancy, and should be abolished (Stewart et al 1956, MacMahon 1962).”

World Health Organisation, “Care In Normal Birth”

Pelvimetry. I didn’t want it. Further, I wasn’t at all sure now that I wanted the care of Dr Milton Case, or his medwife (I was learning the difference!) Besides, there were two perfectly good hospitals just up the road. Why drive for forty minutes in labour when it could be five? All for a trumped-up obstetrician who in reality wasn’t going to offer me any more than grudging chance and beautiful ocean views. Beautiful ocean views as I recovered from another cesarean…

I wouldn’t go to the large public hospital that loomed large as life outside our living room window. I had gone up to have a look before I had known I was pregnant with Misha and the doors to the delivery suite reminded me too much of the entrance to some kind of detention center. I didn’t want to have my baby in an ugly place any more than a beautiful one. Just somewhere that felt safe…

There was a small private hospital even closer to our place. I had not even know it had a maternity unit.  It did not look greyly imposing and industrial looking- rather it nestled in a leafy knoll halfway down the hill. The windows of the delivery suites glittered and winked at me from between the trees through my living room window. Even more interesting was that a female obstetrician was available through the medical center there. This looked promising, I thought. The only black spot on the picture was her associate- Dr Darwin who I had gone to see for his expert opinion on my birthing body. Well, hopefully I would not have to have anything to do with him. I would be Dr Merryweather’s patient, my new, safe, female obstetrician. I rang her office and spoke to her assistant. How did Dr Merryweather feel about VBAC, was among my first questions, of course. “About what?” inquired the assistant.  I broke down the anacronym for her. “Oh. Well, she’s not against it…” Well, that was something, I supposed. I took the first available appointment, nine weeks away. My heart leapt with a quiet joy. Nine weeks! I would not have to see another obstetrician for nine whole weeks…

And the freedom I felt when I finally cut loose Dr Case was even more glorious. Nothing to do for nine whole weeks but be pregnant and visualize my VBAC.  Except my eighteen week scan of course. Well, that could wait. It wasn’t urgent. There was a couple of weeks grace…

I made quite a bit of footwork over those weeks. I went up to my new hospital’s delivery unit and was shown around by a serene and mother hen-ish midwife who was calmly confident and quietly encouraging in her soft Scottish brogue. “Och, don’t write yourself of yet, dear…” she advised, after I detailed my precarious obstetric and family history. She didn’t seem at all put off by stubborn cervices and doubtful pelvises. The delivery rooms were humble but reasonably homey and comfortable looking. I tried to imagine myself giving birth here…Well, it would come.

The next thing I did was to attend an HMA homebirth support group meeting. It was packed with healthy looking women and living, breathing children, the majority of whom, it seemed, had been born without dire incidence, in their own homes. In a pause between their stories I contemplated my looming 18 week-20 week scan, which was now hovering close to the outer limits of the acceptable time period. Suddenly I had a moment of sweet clarity. I didn’t have to have the scan! Just as I didn’t have to have an obstetrician, though I was still hanging on to what my November appointment might bring, I didn’t have to have a scan. A pregnant woman did not have to do anything. We could discover the sex ourselves, my husband and I, at the time of birth. My mother and sisters would be annoyed, even outraged, but I was exhilarated! And of course Ismail embraced the idea wholeheartedly as well.

I did more research. I looked further into homebirth as an option for VBAC. I encountered a knowledgeable and forthright woman through an internet group who urged me to consider homebirth. I had needed to hear someone say it in no uncertain terms and she did, “Get a midwife, and stay home.” Everything seemed to point towards those words being the wisest I’d heard yet.

 

 

Birth Physiology 101

 “For birth to proceed optimally, this part of the brain must take precedence over the neocortex, or rational brain. This shift can be helped by an atmosphere of quiet and privacy with, for example, dim lighting and little conversation, and no expectation of rationality from the laboring woman. Under such conditions a woman intuitively will choose the movements, sounds, breathing, and positions that will birth her baby most easily. This is her genetic and hormonal blueprint.”

Dr Sarah J. Buckley, “Gentle birth, Gentle Mothering” 2005

 

Before I opted for yet another change of course, I examined my motivations carefully and came up with the following statement penned into my pink VBAC journal.

I feel that I would be safer labouring and birthing at home unless I was in a situation where my labour was obstructed in a way which required medical attention. I feel that to labour and birth in hospital would leave me open to unnecessary interventions which might make me more likely to end up with a cesar. Additionally, I feel that common hospital practices would be counterproductive to normal, activ , comfortable, private and safe labour and birth for me and my baby. I feel that the best chance for normal, gentle birth for me and my baby is at home. I feel that I am in ideal circumstances should I need medical attention as full hospital facilities are minutes away. I would keep my hospital booking.

As it turned out, I was unable to keep my hospital booking. The little private hospital on the hill was closing the doors to its maternity unit in December. Its two hundred births a year were not sufficient to make it feasible. This gave me an excellent “out” with my female OB, in whom I was rapidly losing interest as my search for a homebirth midwife began.

Alas, I had left it too late to secure the lovely Lydia for my upcoming homebirth. Though disappointing, this setback turned out to be a blessing in disguise, as I was yet to meet the perfect midwife for me and for this birth. Diane had had her own HBAC (Homebirth After Cesarean) after two cesareans. She was confronting on the phone, “You have to ask yourself how much you really want this,” she challenged.

We were traveling again. “You better believe how much I want this…” I thought as we negotiated the winding country roads towards our prospective midwife’s home. There was, of course, no piped musak. There were no sculptures. There was a large television, a comfy lounge, snacks and company for Sam. By the end of our visit we were all confident we made the right combination for this birth.

 

 

A family visit

I am sitting at my sister’s kitchen table with her as she experiences beautiful, twenty-minutely warm up contractions, two days before she is due to present for her elective repeat cesarean. Words form and die on my lips. My sister is concerned about her contractions. She is not ready to go to hospital today- she hasn’t done the floors. Apparently, Ethan’s head is down, he is ready to go. Even my sister’s surgeon has told her she can “have a go” if she wants to. “But I wouldn’t put myself through that!” she says…

The afternoon after my sister had “put herself through” major open uterine surgery, Mum and I went up to the hospital. Another gilt-edged and hotel-like private institution. “This is where you should be going” Mum snapped on the way through the lobby. Again I attempted to explain myself. I was having a VBAC. This hospital had a fifty percent cesarean rate. The public hospital was just up the road. They were very nice. My midwife would come with us. Needless to say I had not told my family I planned to give birth at home. I didn’t want to have to deal with the panic. “Oh you always have to be different!” My mother was very cross. My sister lay palely tucked up in bed. Her baby boy slept, snuggly wrapped in his plastic crib. He looked good. I was thankful that it seemed, at least, that he had been ready to come out. My sister breastfed half-heartedly for a few weeks. She began complementary bottles almost immediately, against the advice of the midwives and her doctor. Although Ethan was in terrific nick, my sister, haunted by the poor shape of her first baby and the results of the bad advice she’d been given then, insisted he be bottle fed. After all, she didn’t have much milk, she thought. And some women “just can’t”, you know…

Yet another crossroads presented itself a little way along the road we now shared with our midwife Margaret. To make a transfer booking at the big, grey, local hospital…or not? I decided to go ahead and book in, but to keep my plans to homebirth strictly to myself. I wasn’t walking in blind this time, but I still managed to walk out frightened, anxious and upset. An otherwise healthy, happy pregnant woman. I had no issue with the midwife I saw- absolutely great. Another wait, and I was called through to see a doctor. I was pleased to note that it was a young, smart, funky-looking woman.

She sat in front of me and surveyed me sharply. Everything about her oozed efficiency and, was it, ambition?

I had been a bit anxious about several things anticipating this visit, not the least of which was stating my preference for a stethoscope rather than a Doppler to record the baby’s heartbeat. But I knew I had to do it. I was learning to remain true to myself, and to be less concerned with inconveniencing or displeasing people. Dr Andrewartha didn’t bat an eyelid, she simply swept off to find a stethoscope, reappearing with a pinard which she went on to apply quite expertly to my belly. All was not lost then, thought I. But by the end of the consultation I was pretty twisted up. Apparently, in this short space of time, major concerns had developed. Although the doctor claimed to support VBAC, she admitted to being pessimistic in my case, as I had only dilated to 3cm last time. She also suspected that there was a “size issue”, as Sam had been nearly 9 pounds and my fundus currently measured about two cms “too big”, even allowing for a full bladder. She was also concerned about a high blood sugar result I had had in my very first batch of bloods, even though, I explained, I had unwisely consumed a bunch of black grapes in the waiting room that day. So a glucose tolerance test was now of urgent significance. As was an ultrasound scan to confirm the “size issue”, to check if the baby was “normal”, and to make sure I had “enough water”. She shuffled my paperwork briskly on the desk and made one startling concluding comment on the topic of my choice to VBAC. “Well I’ll have to check it out with the boss, of course.” Funny, I had been beginning to think that I was the boss…

In my notes it was recorded, “Wants VBAC, informed of risks”. Once again, at no time was I informed of the risks and sequelae of elective repeat cesarean section.

When it also came to light on further perusal of my notes that “the boss” was none other than the omnipresent Dr Darwin himself, I began, in consultation with my midwife, to formulate a plan to avoid having anything more to do with the hospital. Diane knitted her brows at the idea of a “size issue”. An isolated larger measurement was absolutely no reason to panic, in her estimation.  I decided I would placate Dr Andrewartha by having the glucose test. I would be evasive about the proposed scan. I would make my 36 week appointment. And between now and then, I would devise a way to get out of it.

Dr Andrewartha phoned a few days after my glucose tolerance test, to “congratulate” me on not having gestational diabetes. A few days after that I phoned the hospital myself to cancel my 36 week appointment. I had hired an independent midwife, I explained and was also seeing my GP so I felt no need to come in. All was well, and I would see them in labour. This was accepted hesitantly but relatively well, and noted. A 41 week appointment was made for me, should “post-dates” become an issue. As I put down the phone I smiled gently to myself. How nice that Dr Andrewartha had dutifully recorded Dr Case’s generous EDD on my record.

All that was left to do, it seemed, before Misha arrived, was proceed through some family issues. My son had walked into my mother’s house and announced proudly “We just bought a birth pool. We’re having a homebirth.” Nothing was said but I spent the remainder of the visit perched anxiously in my chair. The following day I received a call from my sister. With great skill she managed to get it out of me that I was having a homebirth. She was surprisingly supportive, not neglecting of course to remind me gravely that last time I had had to have an “emergency cesarean”. Naively I had not suspected that she was on a fact-finding mission for my mum. Duly, the next day, I received that call. As my sister, I gathered, had borne the brunt, it was a calm, if not a little resigned, Mum who also pledged her support. I felt betrayed by my sister. I had been thinking about telling mum, I just wasn’t sure when and how. I had just wanted that choice to remain mine, and if I had decided to wait until I had my babe in arms then so be it. It was my business. Wasn’t it? There were heated words later on. My sister was not apologetic, insisting mum had a right to know. Why was this everybody’s birth but mine and Misha’s? I was answerable to “the boss” everywhere I went, very turn I made, except at home with my husband, with Diane or at homebirth group.

Although I ought to have known better from bitter experience, I had given my family my due date before Dr Case had, in his wisdom added his five days. So although the hospital was not yet hassling me, anxious phone calls from another source began on the seventh of March. I supposed that my family didn’t really know what to do with due dates, as they had always meant hospital bookings in our birthing history. They were, while not certainties, dates that were “given” by the doctor and his machine and must mean something. If you hadn’t given birth on or near that day, well, what were you playing at? The doctor had said. Add to that the fear of going “overdue” unless “they” “do something” and a pregnant woman can have to deal with some pretty noisy nerves jangling around her, if not her own then those of others, professional and otherwise. Just when you’re fancying a bit of quiet. Again I had to voice a preference. I had to take care of myself and my baby. I had to risk causing offence, which was a big deal in my family. So I asked my husband to make a couple of calls to announce that I wasn’t taking any calls. In the nicest possible way of course.  Mum was fine. My sister was offended. It became an “ishew”.
“She’s upset,” related my mother in hushed tones. And I’m nearly 41 weeks pregnant, thought I. I forced myself no to worry. After all, Ismail is a customer service professional, and a really nice guy, which is why I chose him to make the calls. If anyone was offended, it was their stuff. I got on with the business of preparing to have a baby.

One morning, after walking my son up the hill to pre-school, past the leafy hospital, past the grey hospital, I decided I was probably in early labour. I had had about two weeks of lovely sequences of warm-up contractions. This was encouraging. I hadn’t had this last time. My uterus knew what to do, without anyone telling it or doing anything to it. I sipped raspberry leaf tea eagerly and waited… And late morning-ish the next stage of the cycle began.

Then, my mum arrived unexpectedly. “Oh Ish said not to ring, so I thought I’d pop over…”

She oohed and ahhed over the birthing pool. We sat at the kitchen table and shared a pot of tea. My contractions died down to a background hum, like an engine on stand-by. After presenting me with a small frangipani candle for the birthing, she left. I marveled, both at her timing, and at how very far we’d come.

I won’t write Misha’s birth story here. Any frequenter of birthing websites, forums and publications is bound to come across it. Suffice it to say, we had an uncomplicated eight hour posterior labour at home.

Three days later, I was tucked up in bed with my baby, when the telephone rang. It was a polite and genuine-sounding young male doctor from the grey hospital.

“Oh, hello, is that Sarah Mehmet.”

I confirmed it was.

“Sarah it’s Doctor Flynn calling. You had a 41 week appointment at three o’clock yesterday at the hospital and you didn’t make it. I’m just calling to make sure everything’s OK.”
“Oh, Dr Flynn, I do apologise. I ought to have let the hospital know. I decided to have a homebirth and I’ve had my baby.”

He wasn’t at all perturbed.

“Oh, OK, well, great! You won’t be needing us then.”
“No, not this time, Dr. Thanks for calling.”

I replaced the receiver and snuggled back down under the covers, silently thanking God and, at least in a small way, Dr Milton Case and his complimentary five days.