Not Your Typical Cesarean

My very first article written for Special Scars women everywhere!  

An Intro to Special Scars by Jessica Tiderman

Most people know at least one person that has had a cesarean. Not many realize that there are a variety of incisions that can be used on the uterus during that cesarean. The most typical incision is a low transverse incision, which is a horizontal cut in the lower portion of the uterus usually called the lower uterine segment (LUS). Due to the lack of shorthand to describe the more unusual uterine incisions such as classical, inverted T, J, upright T or any cesarean incision other than the low transverse incision, I started calling them Special Scars. Without a way to describe these incisions, women weren’t getting the information and support that they needed.

An inverted T incision starts out with a low transverse incision and then the OB makes a vertical incision upward in the center of the uterus. A J incision also starts out with a low transverse incision but the OB makes the vertical incision up along the side of the uterus rather than the center, perhaps because the placenta or the baby was in the way. An upright T incision can happen in two ways; either the OB started with a low vertical incision and then needed more room at the top of the incision or started with a low transverse incision and made a vertical incision down toward and sometimes reaching the cervix. These three incisions are usually used for babies that are severely malpositioned and/or very stuck. The vertical portion of these incisions can range from a few millimeters to several centimeters. These are also usually contained within the LUS, but can extend into the upper uterine segment (UUS).

Classical incisions are vertical incisions and can be placed just about anywhere on the midline (middle) of the uterus but tend to be in the UUS. There is some dispute about the standard placement of a classical incision. They are still commonly used for early preterm cesareans although some doctors have switched to using the low transverse incision for those as well. Finally, low vertical incisions are simply that, a vertical incision on the midline that is contained within the LUS. This is used when the baby is in a transverse lie or if the placenta is in a location where they would typically cut.

Clearly, the Special Scars are a more complicated matter. The cesareans that end up in these incisions tend to take longer due to baby’s position, which leaves the mom more vulnerable to infection or other adverse effects from being open for so long. Moms with these incisions are more likely to have a host of problems that are less likely to occur with low transverse incisions – wound infection, endometritis, septicemia, transfusion, ICU admission, hysterectomy, and maternal death. These incisions can also increase the mother’s length of stay in the hospital. Babies born from these incisions also have increased risks – stillbirth, neonatal death, APGAR less than 7 at 5 minutes, ICU admission.(1)

Emotionally, the moms may suffer from postpartum depression or post-traumatic stress disorder. It is very likely that they were told many times during their stay in the hospital after their cesarean that they would never be able to have a vaginal birth after cesarean (VBAC) after that particular surgery. They likely heard that statement so many times that they believe it. When they find out that it is possible to have a vaginal birth after their Special Scar they may feel shocked, angry, betrayed or any combination of those. Sadly, there is no research about the emotional effects of these incisions on women.

Once the woman decides she wants to have a vaginal birth it can be very difficult to find a care provider who is willing to assist a VBAC after a Special Scar (VBASSC). The search usually requires calling many doctors and/or midwives before locating one that will attend a trial of labor. When a care provider is not initially open to the idea, it is usually best to not even try talking them into it. It is unlikely that you will be the one to change his or her mind. University hospitals tend to be more willing to assist due to their size and staff. Some home birth midwives are willing to attend VBASSCs when not legally restricted from doing so by their state.

Many care providers are unwilling to assist a VBASSC because the risk of rupture is slightly higher than the risk of rupture after a low transverse incision. The generally accepted risk of rupture for low transverse incisions is 0.4-0.9% while the risk of rupture for inverted T, classical and J incisions is 1.9%.(2) Interestingly, low vertical incisions have no more of an increase in the risk of rupture than low transverse incisions.(3) If the cesarean was performed preterm there is a minimal increase in the risk of rupture.(4) As we know from Dr. Sarah Buckley’s writings, if a woman is allowed to labor unhindered her birth much more likely to go as it was designed.

Clearly, there is a need for further studies on these scars, the effects on future pregnancies and the effects on the mother emotionally. The few studies that are available used a relatively small number of subjects. Therefore, without clear evidence of exceptional risk the woman and her partner should be the ones to make the decision whether or not she attempts to have a vaginal birth. Care providers should not be making decisions about VBASSC due to a level of fear or a lack of information. Indeed, if the care provider does have that much fear he or she should excuse themselves from serving the woman and let her find a care provider who is willing to serve her and trust her body to work as it was designed. There are already a number of women who have succeeded in having a VBASSC. To read their stories, for more information about this topic and access to the studies that I have mentioned, please visit http://www.specialscars.org.

(1) Patterson et al. Maternal and Perinatal Morbidity With Cesarean.Obstet Gynecol 2002;100:633-7
(2) Landon et al. Trial of Labor after Prior Cesarean Delivery. N Engl J Med 2004;351:2581-9.
(3) Shipp et al. Intrapartum Uterine Rupture. Obstet Gynecol 1999;94:735-40.
(4) Sciscione et al. Preterm Cesarean Delivery and Uterine Rupture. Obstet Gynecol 2008;111:648-53.

First published in Whole Woman Magazine, Winter 2011.

My son is 8 wks old :-)

This was originally posted on my old blog on July 9, 2010.

I'm such a dork when it comes to this blog.  lol  I fail at Twitter too.  ;-)

I posted a while back that I was almost 40 wks and then didn't post anything else.  My son was born May 11th at 2:24pm, his story is here - http://www.jessicas-haven.com/pgnb/thales-birthstory.htm.  He's so beautiful.  :-)

We've had our share of breastfeeding problems, mostly latch issues.  He's really run me through the gamut.  :-/  He's really lucky that I like him and that I really want to breastfeed him.  ;-)  It would have been really easy to give up a few times, I nearly did.

There is a lot on my mind that I'd like to post about, but can't sort it all out enough to make a post that actually makes sense.  lol

Cesarean Awareness Month gift

This was originally posted on my old blog on April 29, 2010

I almost forgot to post this here:

In honor of Cesarean Awareness Month my gift to all of you is the NIH VBAC New Insights Conference 2010 videos split up by session so they won't crash your computer. Enjoy and share freely!

http://birthaftercesarean.com/Home/NIHVBACNewInsightsConference2010/tabid/277/Default.aspx

Almost 40 wk Update

This was originally posted on my old blog on April 29, 2010.

I'll be 40 wks tomorrow.  Can't say yet if anything exciting is going to happen or not.  Doubt it given my history, but this little boy acts like he's going to be doing things his own way.  I just hope that my pelvis doesn't start hurting anymore than it does right now.  Feels pretty good at the moment so...

Student Midwife update:  I'm on hiatus at the moment.  I did finish Phase 2 and had sort of started Phase 3 before I started this hiatus.  I'm still working through the Midwifery Explorations class, would have liked to have finished it before the baby came, but diapers are a little more important.  lol

The diapers, well that has been a long project that started over a year ago.  When I was pregnant with my nearly 3yo I had bought 36 Bum Genius (BG) cloth diapers, 12 pink, 12 white, 6 yellow and 6 green.  I love them, they make cloth diapering so easy!  However, after nearly 2 years of use I noticed the elastic in the legs wasn't as snappy as it used to be.  Being the crafty do-it-yourselfer that I am, I took one diaper apart to see how hard it would be to change that elastic.  It was fairly easy, just take out one seam and the old elastic, put in new elastic (guessing how long that should be was kind of tricky) and sew the seam back up.  So, winter before last I replaced the elastic in maybe two-thirds of the diapers.  My daughter was only using them about half time so I didn't really *have* to fix them all.  I got pregnant again last fall and new I would have to finish fixing the rest of the diapers.  I heard that you could get the new BG diapers with snaps rather than velcro and was a little jealous.  The only thing I don't like about my BGs is the velcro, it's just a pain in a variety of ways.  I had just bought a snap press last year for some other sewing projects.

Then I found out I was having a boy.  No way!  Me?  A boy!?  Are you sure??  lol  I looked at my diapers and knew I had a lot of work to do.  I ordered some fabric dye, which was tricky trying to find the right dye that would stick to a synthetic material.  So now, I knew that I had to finish replacing the elastic in the legs, dye at least the pink diapers, AND take all the velcro off and put snaps in.  :-)  At this point, I've finished replacing all of the elastic, the last four diapers that needed to be dyed are in the dye soaking at the moment, and I only have about 12-15 that still need snaps.  I'm so proud of myself, they look really nice.  I just hope that the dye really does hold.  We still have plenty left so we can re-dye if necessary, but I'd rather not have to do that on a frequent basis.

That's where I am for now.

P.S. A little note, there are some people that comment on my blog Anonymously, can you at least put your first name in your comment so I have some idea who you are??  lol  It's bugging me that someone is talking to me and I have no clue who it is.

Journey of a Student Midwife, part 1

This was originally posted on my old blog on March 17, 2010.

I started midwifery school a few months ago.  I've been wanting to start a journal of my journey, but couldn't think of anything cute, witty, educational, etc., to write about.  So, I'm just going to write and we'll see where it goes.

I'm already in Phase 2 in Ancient Art Midwifery's Advance Midwifery Studies course.  Sometimes, it still seems surreal that I've made this monumental decision and that I'm actually walking on the path already.  But here I am and loving every minute of it!  :-)  At times it all makes my head spin, there is so much to learn, so much to do, but I want to learn it all and then more!

On my current list of things I want to learn more about, not all necessarily directly related to midwifery:

• Myomectomy
• SCT (which I can't remember what that stands for at the moment, will have to look it up)
• Micropreemies and vaginal birth, what are the risks?
• At term, how much of the uterus is fundus?  (This is related to my special incisions research, to determine what "into the fundus" means on Surgical Reports.)
• Reactive Attachment Disorder
• Dermabond (I know what this is, but want to know what the pros/cons are.)
• Accreta/Percreta
• Newborn Physiology
• Thermogenesis
• brown fat

I have books on most of these.  I realize that some of these would only take a quick internet search to find the answer and some of these will be covered thoroughly in my midwifery studies.  I just felt the need to make a list so that I don't forget to look them up, read more, etc.

I haven't been able to get much studying done in the last week because I had yet another cold.  This one is almost over and I pray that it will be the last for the season.  Please gods, let it be the last!

Pregnancy, Birth and Civil Rights

This was originally posted on October 29, 2009.

I just finished watching the movie Ghosts of Mississippi. Being an Ohioan, I still have a hard time believing that there are people in the South that still think the way that they do about people of color and of the Jewish faith. The movie is based on a true story and a man that was assassinated in 1963, only 8 years before I was born. It was horrifying to me that the man who was finally found guilty had been flaunting his proud kill for nearly 30 years before they were able to convict him.

While I was watching the movie an email showed up on my phone from one of the lists that I’m on. A woman who is 39 weeks along and wanting to attempt a VBAC was told by her doctor today (a Saturday!) that she had scheduled a c-section for this woman next Wednesday unless she went into labor before then. The doctor also informed her that if she did not show up for the surgical removal of her new baby she would be recorded as non-compliant and would be reported to Child Protective Services. Civil rights? Since when did we hand over the right for our child to choose his or her own birth to these “care providers”? Why do these “care providers” think that they know better than our babies when it is time for them to come out? There are times when a baby needs to be removed early – but they are RARE and not just because the mother happened to have a previous cesarean. Why isn’t anyone (except for the women that these crimes are perpetrated on and sometimes their families) outraged at their behavior? Judges sign court orders for completely unnecessary surgeries before the mother even has a chance to get an atty, the surgery is done and over before she can argue her case or rebut the orders. How is that NOT a violation of our civil rights?? Why aren’t civil rights attorneys lining up to take these cases to court?

Why? Because they are un-winnable cases. The doctors have medical-ease that the judge and jury (if there is one) aren’t likely to understand. The doctors will make sure to explain it skewed in their favor. They claim the need for cesareans because of unstable heart tones as shown on the external fetal monitor. However, they don’t explain that the pitocin they insisted the patient needed may have caused those heart tones. Or the epidural that was necessitated by the pitocin may have caused those heart tone. Or simply the fact that the mother has been kept in a bed flat on her back with nothing to eat or drink for hours!

The doctors claim they are only operating in the best interest of the child. How is evicting a newborn baby from the womb of his or her mother before that baby is ready? Labor starts on it’s own exactly when the baby is ready. When the baby’s lungs are ready they release a hormone that sends a signal to the mother’s body that it time for labor to start. During labor the baby and the mother both receive a variation of hormones designed specifically for labor and birth. If you skip that entire process by removing the baby surgically before labor begins they both loose out on those beneficial hormones and the baby’s lungs may not be ready. If you interrupt that process by insisting that it isn’t moving fast enough they both loose out on those beneficial hormones and the mother’s body may not be ready to give birth.

Why can’t these “care providers” be patient?

“Midwives see birth as a miracle and only mess with it if there is a problem; doctors see birth as a problem and if they don’t mess with it, it’s a miracle!” - Barbara Harper, Gentle Birth Choices

April is Cesarean Awareness Month

This was originally posted on my old blog on April 7, 2009.

It's April again and Cesarean Awareness Month.

I had my first cesarean almost 12 years ago because my 2nd daughter got stuck in a brow presentation.  (Her forehead was the presenting part, her chin was not tucked.)  I had chosen a hospital that had all the right stuff, birth balls, birthing stools, a rocking chair that you could labor in, etc.  I didn't get to use any of it even though I was in labor for 18ish hours.  When I went to the hospital I was already 5 days "overdue" and had suspicions that my water had been leaking for a few days.  If I only knew then what I know now, I would have never had either of my c-sections.  When I got to the hospital my OB confirmed that my water had broken and that I had a fever.  She ordered an IV antibiotic and admitted me even though I wasn't in labor.  :-(  If I did know then what I know now I could have just rested, pushed a lot of fluids and taken vitamin C to help fight any infection, even though a fever is NOT a definitive sign of an infection.  My OB also told me that she'd been up all night with laboring women and was in no shape to stay and help me.  So, one of her partners that I had already met took over.  I was induced, laying flat on my back, no surprise I ended up with a malpositioned baby.  :-(  I was on the highway to a c-section and didn't even know it.  Induced before labor began, early epidural because baby was pushing on a sciatic nerve which the epi didn't help, catheter (that was a COMPLETE nightmare), unable to leave the bed.  I knew as I began to recover afterward that if I'd had a midwife, I would not have had a c-section.  I would have been able to use all those cool things like the ball and the stool, etc. and move around.  I also drew into myself, I can't say exactly why, but I knew my labor/delivery wasn't right.  I'd already had one baby vaginally.  I did but didn't understand why my 2nd baby ended up in such a bad position.  I felt betrayed, by my body, my baby and mostly by the OB and nurses.  No one ever suggested that I lay on my side, get up and walk around, sit in the rocking chair right next to the bed, sit on the birth ball across the room.  The room was flipping huge, there was PLENTY of room to move around.  WHY didn't anyone suggest that I try that??

For the entire time I was in the hospital after my surgery (5 days total, I think) I do not remember seeing one lactation consultant.  I barely remember seeing the nurses except for that time when I stood up (after laying in bed for 2 days after my surgery) and watched blood just gush out of me and run down my legs.  I naturally started to freak and my poor husband and the time went completely white and ran for the call button.  I only nursed my daughter for 2 weeks, some of it was me, but I blame part of it on my c-section and the lack of nursing support that I received at the hospital.

I cannot say when or if I ever really bonded with my daughter that was born of my 1st c-section.  I know that I did not bond with her the same way that I bonded with any of my other three daughters.  I love her with all of my heart, but the bond just wasn't the same.

I wish that I'd tried to find a midwife that I could barter with.  I hadn't really considered a midwife as a possibility because our insurance wouldn't cover and we didn't have much extra money at the time.  I really wish that I'd at least had a doula.  I was so ignorant at the time I had no idea what a doula was.  :-(

If you want to read any of my complete birth stories they are here:  http://www.jessicas-haven.com/pgnb/  Enjoy!