Tuesday, March 17, 2009

What do I do now?

(written to a woman who transported from a homebirth and had a cesarean)

Control. Seems to be a strong theme in my life right now. Or rather, my ultimate lack of it. I may get a bit spiritual here, so reader beware.

One thing that I can guarantee is that your next pregnancy and labor will be different from your last one. Every pregnancy, every baby, every labor is unique to itself.

As I wrote in my last letter, in the end, the only responsibility we have is to plan the safest birth we can. There are lots of things we can do, techniques we can learn, knowledge we can gain, expertise we can hire, wisdom we can cultivate, trust we can give, surrender we can make....and all of these things are really important. All of these things can be something that the outcome of a birth hinges on. And every single one of them can be trumped by the universe. And the universe resolutely refuses to give us the guarantee we demand. If you believe in a deity, then you may believe that you are guaranteed an ultimate outcome to your life....but my experience has been that specific outcomes are often, quite deliberately, not revealed to me -- all I'm given is the assurance that there's a plan I'm part of and it is bigger than I can understand....if I believe my God is good, then that needs to be enough in the end (not saying this is easy or that I'm any good at it. I'm not.)

Most of the time, left alone, women have vaginal births. You have the extra burden of not having made the usual mistakes you could then blame your cesarean on. You get to face the universe not caring the same way you do a lot sooner than many. You "should" have had a vaginal birth; after all, you really did do so much "right". That's a scary place to be...what if there's something fundamentally wrong with you? Hang around ICAN long enough and you'll have the opportunity to meet some women who've had to deal with that -- planned a homebirth with a good midwife...ended up cut. Now what? What more can they do? A former president of ICAN had 3 cesarean, the third a failed homebirth...while president of ICAN. And then she had a homebirth with her fourth. Why? I don't know.

I don’t know.

I hate that phrase. Everything in me rebels against not knowing. Why was I in the 10% of clomid users to have twins? I don't know. Why was I then in the 10% with double breech twins? I don't know. Why did this happen to me, who cared SO much about not having a cesarean. I don't know. To make me stronger, bring me to ICAN, this excuse, that rationalization and so on? If any of those are true, that's not good enough. I didn't want a cesarean. Period. I don't know why I had one, not really, and I have a feeling there's no reason out there that I can understand that would make me say "oh, ok, that's why." What I do believe, because, well, that's my world view, is that there was a reason and that no matter what the reason, good or bad, for my betterment or because this world just sucks sometimes, the experience can be (and has been to a great degree) redeemed....over a lot of years with a lot of mileage between then and now.

So what? Well....chances are good that you'll never find a "reason" for your cesarean that you can "fix" and then not have to worry about another cesarean. I can tell you that you'll always have to worry about another cesarean because all pregnant women have to worry about it. Even if you do find a thing to
fix....there are other reasons to have a cesarean and we just can't control most of them (any of them? I guess we can control elective repeats by not signing up for them and we can control for failed inductions by not consenting to induction but are there any others?)

I don't like fake it till you make it. I believe it’s fundamentally dishonest to one's own self. But, sometimes we do have to keep moving even while we look back and try to figure stuff out. If you don't find something to pin your cesarean on, what will you do the next time you are pregnant? Will you plan a repeat cesarean? Or will you go ahead and plan another vaginal birth, maybe at home....and do it, even though you are scared to death you'll have another cesarean? You do have control over what you plan. So keep asking the questions, keep picking through the wreckage and know that ultimately, we all reach that moment when we have to surrender to something that's just a lot bigger than we are, whether you call it birth, universe, fate, karma, evolution, luck, random chance or god.

I've really come to believe that those women who have the sorts of births (or VBACs) where they pat themselves on the back and say "see, I did this, that and the other thing and that's why I got my VBAC" are mistaken about how much credit they can take. They may have made good choices and that may have made a difference (then again, saying "no, I won't sign up for a repeat" might be all it takes for some women to have a VBAC – heck all it takes for a lucky few is to go into precipitous labor before the scheduled cesarean – talk about the importance of plans and choices! ) but in the end, they were blessed that the universe had an outcome in mind that fit what they wanted. Don't get me wrong, bad choices can certainly change an outcome...but think about all the bad choices that end in a vaginal birth.

This is like trying to resolve free will and predestination if you believe such things...they are both true and they are both at work. I guess birth really is life. I don't know why you had a cesarean. I really wish you hadn't. And I really hope you have a VBAC next time. And I know that chances are, you will. And until you do, you won’t know whether it will really happen or not.

Monday, March 16, 2009

What If?

I do not think you are kidding yourself about planning a VBAC and this is why. Your responsibility as a mother is *not* to not have a cesarean or to have a VBAC. Your responsibility is to plan the safest birth for you, your baby and your family. That's it. Now, obviously and for lots of really legitimate and important reasons, we all hope that the safest birth for everyone involved is a vaginal birth, because no matter what the circumstances, necessary or not, surgical delivery can really suck. So the question I would ask you is this -- are you planning the safest birth you can? If your physical condition does change for the worse, will you continue to plan the safest birth you can even though doing that might be incredibly painful and disappointing? Are you doing everything you can to keep as healthy as you can? Do you understand your risk factors and how they could impact the choices you have? Are your circumstances now different from what they were the previous two times? If you answer yes to these questions, then I can't see that you are fooling yourself or kidding yourself or in any way delusional.

The part of all this that is so hard to come to terms with is that there are very real factors that can make or break plans for a vaginal birth that are completely out of our control...boy, does that grind...but in the end, it is possible that your body will not stay healthy enough for a planned VBAC in spite of you doing everything you possibly can. It is also possible that the events of your last 2 pregnancies will NOT repeat, because this is a different pregnancy. Previous pregnancies can seem predictive but often they are not. Each pregnancy, each labor, each baby is different. That you CAN be sure of. You can't do anything at this point about having had 2 previous cesareans. Oh, we wish we could! But we can't. You can make plans with those 2 cesareans in mind, and you should. You do have control over all sorts of things. But what you (and anyone else -- ICAN, midwives, physicians) don't have control over is the final outcome.

Remember -- it is NOT about having a VBAC. It is about planning the safest birth you can. Period.

Sunday, March 15, 2009

What did I do wrong?

I have 2 good friends who’s VBACs turned to repeat cesareans for "no good reason" that anyone can figure out....yes, the babies were likely (subtly) malpositioned, even after prenatal chiropractic care and great attention to optimal fetal positioning and they hired midwives who knew many tricks to straighten out babies...and the tricks didn't work. They labored for many many hours...they did "everything right"....and still ended up back in the OR...it is heart breaking. And both have asked, many times “What did I do wrong?”

What did I do wrong?

And I have to say that the "answer" I have is two-fold....first, the baby is an independent player in the whole labor and we can't always predict or dictate what the baby will do. Second, there is a very real element of "luck". Just plain bad luck. It is SO much easier if we find something that looks like a cause. A reason gives some closure, some sense of "if I'd just" to help it NOT mean that you really don't have control over the outcome....but the truth is, for those women who make all the plans, "do everything right" and end up with a VBAC? They were lucky too. We almost automatically take credit for "doing it right" being the reason we have our VBACs but we are fooling ourselves if we think we have that kind of control. The flip side of believing you have that control is to then believe an unwanted outcome means you didn't do something you could have or should have. I'm convinced, after a decade of hearing stories, that this just isn't true. Sometimes you do everything you can and it doesn't work. I don't know why.

When the labor is done and you are in that soul searching place, the compulsion to second guess decisions made during labor is overwhelming...because we forget the intensity and immediacy of labor. My friends had good and patient midwives. There was a reason they trusted them -- with the labor and when the decision was made to transfer to the hospital. Whatever that something was that led them to decide on transfer and ultimately to agree to the repeat c/s, it was real. And since no one can recreate that inarguable something now, its compelling to say "if I'd only"....but there *was* a real reason they didn't just keep laboring, even if no one could put it into conscious thought or words then or now. It is SO tempting to think "if I'd just labored for another x hours, I would have had my VBAC" but we have no idea if that is true or not...maybe yes, they would have. Or maybe they would have transferred later. Or maybe the baby would have been in a lot of trouble by then. Or maybe the baby would have been fine but nothing else would have changed. Or maybe something else would have happened...we just have no idea.

I don’t tell women to stop asking questions or to stop trying to understand what happened. I don't think they can stop, I know I couldn't when I was trying to figure out why I made the decisions I did around my c/s. But the advice I do give is to consider that the answers you may get through your searching may have more to do with your understanding yourself rather than you understanding that birth. There are answers there but they may be to a question that you don't yet realize you are asking. They likely will come later than you hope and slower than you think you can handle, but you will.