QuestionDear Dorothy,
I have two children born via c-section almost 3 years apart. First birth, was at 28 second at 31 years of age. I switched to a new doctor the second time around, who said he supports VBAC.
We would like to have 4 children with about 3 years apart. I am thinking about my 3rd pregnancy now, and would like to know my options and risks ahead of time. Although health is the most important to me, to this day I am plagued by the thought that maybe my doctors didn't wait long enough for natural labor to occur.
Both pregnancies were similar. I never wrote down the days of my period, so I could only give a very rough estimate of the last period, yet that's what the expected delivery dates were based on. My periods were regular, but the cycle about 35 days long, not 28. In case of my first baby, they waited 11 days after the expected date (to factor in my longer periods), with my second baby only 1 week, before they did a c-section. In both cases the doctors said that according to the sonogram alone, the babies were mature (regardless of the date of my last period) and further waiting would increase risks to baby. In both cases my cervix remained closed, I never had any contractions, the babies never descended into the hip, but remained high up. With my first baby, they tried an oxytocin (if I remember correctly) stimulation to start labor, but the baby didn't budge. On the 9th day after the expected date, the sonogram showed decreasing, although still normal levels of amniotic fluid (I had to stay for 1 week before the birth in the hospital, so they could monitor the baby closely). The doctor at that point gave me no option but to have a scheduled c-section 2 days later. The baby was grabbing with her feet to my ribcage during the operation. The umbilical cord was wrapped twice around her neck, but the doctor said that alone would not have been a problem in natural delivery. The placenta was ripe, but not old yet (as was the case in the 2nd pregnancy too). In both cases, the babies were a full pound heavier than the sonogram estimated, they weighed 9.48 lbs upon birth. Agpar 9/10 and 10/10 respectively. In my 2nd pregnancy the difference was that I had to keep a strict low-carb diet to make sure I didn't develop gestational diabetes (only one value in my blood test was off, not two, which would mean diabetes). With my 2nd baby, the doctor offered that I could stay in the hospital the day before the scheduled operation, and they would artificially dilate my cervix overnight with a substance the name of which I forget. He said if I dilate enough by the next morning, and go into labor spontaneously, I could try a natural birth (he would not induce me though, because of my previous c-section). But he thought its success was highly unlikely, and I might have to have a c-section nonetheless and he did not really recommend it after all. I consulted with my doctor acquaintances, and they said it is much safer for both me and the baby to undergo a scheduled c-section with a planned and full staff around, than to risk a natural delivery which then could turn into an emergency c-section. And that is what I did. My scar from the 1st incision was 5 inches, the 2nd almost 7 inches long and curves up a bit on the left side. Up until 12 months after the operation I had sometimes not quite pain, but sensitivity above my uterus in the bowels in the left side. Now I don't feel this anymore 20 months after birth, but when I bumped into a chair the other day and hit my incision site, it did hurt.
After the story of my pregnancies here are my questions and concerns:
1. Should I have tracked my period (which I normally don't do) to help the doctors to calculate my expected delivery date? Or is the sonogram enough to precisely determine the length of a pregnancy?
2. Can I plan for two more pregnancies (I would be around 38-40 years old at the 4th) with c-sections? VBAC out of question?
3. I am a slow person in general, have long, 35 day cycles: could it be that my pregnancies also tend to be longer than 40 or 41 weeks?
4. Could it be for a psychological reason, that my cervix remained closed? (One doula remarked at toward the end of my 1st pregnancy, that I have to let go of my work and tasks that I was involved in, and tell the baby it is ok to come out finally. At the time this sounded very silly, but now keep thinking about this remark. Especially after I read an article about functional infertility, when a woman cannot get pregnant for carrier-related or some other psychological stress, even though she states that she wants to get pregnant and she is biologically capable. Along these lines, could it be that I held on to the babies in the womb for some unconscious reason and that's why the labor didn't start? For certain, I never for a second was concerned about premature delivery and was very active until the last minute of my pregnancies.)
5. Do I now have a bigger risk to fully develop gestational diabetes in a new pregnancy? Should I refrain from sugar (or reduce intake) even before conceiving, as a precaution?
6. The fact that my 2nd outside incision scar is longer than the first one mean that the newer scar on the womb is also larger? Why? Do doctors always cut the womb in the same place with repeat c-sections?
7. Will the doctor be able to tell me at the next c-section for sure if I can have fourth baby by looking at my womb? Or is this also a matter of personal philosophy: one doctor woud say yes, another one may say no?
8. Can I request the use adhesion barriers to promote better healing? Is this common in c-sections?
9. Do doctors routinely trim away bulky scar tissue at a c-section? How do I know if this was done in my case? Does this keep the womb in better shape for future pregnancies?
10. My external scars in general do not heal well, I have a lot of scar tissue from even small cuts. Does this mean I have tendency for more scarring in my womb too? This making me not a good candidate for over four c-sections?
11. The skin around my incision site does not feel as sensitive as the rest of my belly. Is this normal?
I am looking forward to hear your thoughts and opinion.
Sincerely,
T.
AnswerHi Timi,
I will do the best I can to answer your questions!
1. If you normally ovulate around Day 21, instead of Day 14, that makes your due date one week later than it would normally be if you calculated using your LMP. I would suggest keeping track, and having them calculate based on ovulation occurring on Day 21. Even with that, many women do not go into labor until 2 weeks after their due date, and that is within the range of normal. Ultrasounds in the 1st trimester are generally accurate, but you could go into labor 2 weeks after the u/s due date and still be within the range of normal.
2. I would advise you to contact a VBAC-friendly provider (you can contact your local ICAN chapter for recommendations) Have a chat with that doctor or midwife now, and let them know your history. ACOG (American College of Obstetrics and Gynecology) does not mention any additional obstacles for a VBA2C mom. If you were a candidate for a VBAC with your last baby, you should be a candidate this time as well. You can have more cesareans, although every cesarean does carry additional risks to you and your baby.
3. Many many women go more than one week past their due date, whatever their cycles.
4. It's possible of course, but highly unlikely. In future pregnancies, you can consciously let go of anything that might be holding back labor, but unless there is some huge thing that you can pinpoint that you were afraid of with your previous labors, this is probably not the reason that labor didn't start.
5. This would be a question for your doctor or midwife; it is out of my area of expertise. I don't think that limiting sugar before conception would reduce the risk of developing GD, but like I said, it's not my area of expertise. It probably wouldn't be a bad idea to go on the low carb diet when you do get pregnant, especially since your doctor would be putting you on it anyway.
6.Not necessarily. The internal incision is not related to the outside incision. and yes, they generally use the same location. I'm not sure why the 2nd incision was bigger.
7. You're absolutely right - it would be subjective.
8. I'm not familiar with those - definitely bring that up with your doctor. Adhesions after a cesarean are unfortunately very common, and more likely with the more cesareans that you have. From what you described, that may be what is/was causing your pain.
9. I would venture to guess that this is probably done, but you have to ask your doctor if this was done with your surgery. He or she should be able to check their records of your surgery to find out if this was done. I don't think it affects the integrity of the uterus one way or the other.
10. That is a great question. Again, because this is not my area of expertise, I can't give you a definitive answer. I would encourage you to definitely research this, because that could be a big reason for trying to avoid additional cesareans.
11. Unfortunately, yes. Even after 9 years, I still have that with my cesarean scar.
You do have a few strikes against you for having a successful VBAC - which has nothing to do with whether or not you are a good candidate for a VBAC -- it has to do with your doctor not being comfortable with a trial of labor. The strikes you have are:
(1) Two previous cesareans. Even though ACOG treats VBA2C the same as VBAC, that doesn't mean your doctor will. Not many doctors will want to give a mom with 2 previous cesareans a trial of labor.
(2) Your babies tend to take a little longer than 40 weeks to be ready. Especially if a doctor is calculating from your LMP, he'll be a week off, and then if your babies take closer to 42 weeks, it decreases the chances of your doctor being comfortable with you going into labor on your own. Many doctors and midwives put arbitrary limits on the length of pregnancy for VBAC moms, unfortunately, and will want to go to a repeat cesarean as soon as the mom is at 40 or 41 weeks.
(3) Your babies are not little. Now this doesn't mean you can't have a vaginal birth; I see many women with 9+ lb babies give birth vaginally) and it doesn't mean you are less likely to be able to give birth vaginally, but it DOES mean that a doctor or midwife will see this as a red flag, and may discourage you from going for a VBAC.
If you want to try for a VBAC, you need to find an extremely supportive VBAC doctor or midwife in your area. Be willing to travel a little, if possible. Even with that, find out how long can your pregnancy go before going to a repeat cesarean. You do always have the option to refuse, but as you know, that is easier said than done.
I wish you the best with any future pregnancies. I think if you can find a care provider that's comfortable with waiting for you to go into labor, and then if you go into labor on your own, you have a decent chance of having a successful VBAC.
Dorothy H, LCCE
