“Have you really thought this through?” Rachel’s experience of planning a homebirth after caesarean (HBAC)

There is always a wider context in which we make decisions. It’s too personal for me to explain all of the reasons why I felt so strongly about delivering my babies under my own steam. At the very least, it was a right of passage I wanted to go through, as well as likely to be best for the health of mother and child. I was extremely disappointed to deliver my first baby by caesarean, particularly when it became clear to me that it could have been avoided. As we didn’t intend to have more than two children, this time was my only remaining chance to give birth vaginally. No pressure then!

“Have you really thought this through?”

It can be hard for VBAC mothers to get people to understand how important it is to them to give birth vaginally and why. Moreover, it is sometimes suggested that the mothers are being selfish or haven’t thought about what they are doing and the potential risks. I’m lucky that I am surrounded by people able to empathise or to keep their reservations to themselves but still, to those who don’t get it, let me say this:

It has not been fun, devoting countless hours to reading about risks and awful things that can happen, comparing the likelihood that my baby would die from one cause or another. As I genuinely believed that a vaginal birth was the best thing for both me and my baby, I wanted to maximise my chances of this happening. Moreover, I needed to get to a point where my husband and I were comfortable that we were making a fully informed decision, based on all the relevant information – a balanced picture that I did not feel was being presented by the medical profession, despite good intentions. In the extremely unlikely event that something terrible happened, my husband and I needed to be able to look at each other without any blame. Marriages often fall apart if a child dies, so this felt like I was working to protect my marriage and existing family, not just my unborn child. Please don’t say we VBAC mothers have not taken this seriously. We are probably better informed than many and are making very carefully considered choices.

Interestingly, maternal mortality didn’t really factor in it for me. That might seem selfish, given I already had a daughter who would then be without a mother, but that is how I felt. I was far more concerned about my physical and mental well-being if I lived, rather than ending up dead.

The more I thought and read about what does and does not facilitate birth – and I read a lot – the more I felt that a homebirth would give me the best odds of delivering vaginally. We agreed to proceed with planning a homebirth, on the proviso that my husband could veto it if new information gave us sufficient cause to reconsider.

Last time

West Suffolk Hospital invites all potential VBAC women in to review their medical notes from the previous birth – a great idea, as events might be blurry. I was shocked to find it recorded that I had asked for the caesarean, as if a request from me out of nowhere were the only reason it happened. For three years, I had viewed it more as something that had been done to me, a medically unnecessary recommendation that I had gone with rather than a path I had instigated myself. How was it possible that someone who had always dreaded the idea of labouring on my back and having a caesarean had ended up with both things happening, apparently at her own request?

Re-examining things, I could now see my part in the decision that was made. Basically, I couldn’t take the responsibility for our baby’s safety any more. We had waited a long time to get pregnant and wondered if this would be our only chance at parenthood. I was at 42wks+ and had turned down an induction against the generic advice (as there was no reasons specific to me as to why it was necessary). We had had a 1am dash to the hospital the night before I went in to labour because I had fallen asleep and missed her usual 10pm dance and couldn’t feel any movements when I woke up. (A colleague’s baby had died in the womb at 39wks a month earlier, so I was very conscious about reduced foetal movements.) After all this and nearly 30 hours of labour with a back-to-back baby, it felt like I was reaching my limit of risk that I was prepared to take, particularly given the vibes I was getting from the consultant. “Just get her out in one piece.”

From a medical perspective, I don’t know why they said yes. The baby was never in any distress at any point. I had only been pushing for an hour, if that. An instrumental delivery was not even discussed, nor any further changes of position. The baby’s chin wasn’t tucked in, so the presenting part of the head wasn’t ideal but she was not stuck. Failure to wait, failure to encourage.

Next time will be different

I learned many lessons from my first labour. My husband and I were overwhelmed and exhausted after the first nine hours at home, where I had no pain relief other than a quickly-fashioned wheat bag. I had no sleep, water or calories for most of the labour. The gas and air left me incoherent. I laboured in a brightly lit, medicalised room (I was excluded from the MLBU for being past their cut-off date). No-one reminded me to push through my bottom.

This time we would have a doula to help us cope. I would have people making sure I had sugar and water, that I went for a wee. We could have a pool and a TENS machine at home. My husband learnt some massage techniques and my mum made special bolsters for me. I went to yoga and practiced positions and breathing.

I was not the same person anyway. I understood what was and was not helpful, what support I needed. I was prepared to question the advice I received and decline what didn’t ring true for me. I found the BRAIN acronym a really useful tool, particularly the “what happens if we do nothing” part. For those who don’t know, it’s: Benefits (what are the benefits of doing this?), Risks (what are the risks involved?), Alternatives (are there any alternatives?), Intuition (what is my gut feeling?), Nothing (what would happen if we did nothing for a while?)

The care I received at West Suffolk Hospital

I have been extremely impressed with the care given to me by staff at West Suffolk Hospital. Even when we have not seen eye to eye, they have been able to state their point of view and listen to mine without applying guilt or pressure. That’s not to say that it hasn’t been a stressful process. Each time I have prepared for confrontation, feeling the need to arm myself with all the facts to add some balance to the picture presented. So much focus is place on certain risks but not others.

At 30wks pregnant, I met with a WSH midwife to review of the previous delivery and discuss what the plan might be for the next one. They agreed that I was a good candidate for VBAC. I had laboured spontaneously last time and got all the way to the end, with no medical reason for the c-section. Low BMI, no health conditions. Being 40 didn’t seem to count against me. West Suffolk are very pro-VBAC and that message really came across. Great.

We reviewed their care pathway for VBAC women and discussed the risks of both VBAC and caesarean. I wasn’t happy with various parts of their protocol. Their own stats showed that VBAC women are just as likely to deliver vaginally as first time mothers, so why would I not be treated the same? Shorter time limits imposed for stages and progress, canularisation and anti-acids in case of emergency cs, being in the Labour Suite not the MLBU unit just in case and so on. This time round I was aware that one can decline any and all recommendations, as well as having a better understanding of the disadvantages of different interventions and approaches. It felt like they would be camped out with stop watches waiting for me to fail, and I knew that was hardly conducive to a good labour for me. I explained that I wouldn’t be happy with that protocol but actually it was irrelevant as we were planning a homebirth. At this point, the MLBU magically became a potential option. I said thanks but no thanks as I did want a homebirth. The midwife did her best not to look alarmed and invited me back to have a chat with a consultant.

Dr Jac Reeve

I nearly didn’t go to the appointment with the consultant as I was happy with our decision and thought it would just be undue stress and pressure. I am glad I did go. I researched my socks off and went armed with facts and figures about the risks and benefits of each element. I felt like I was preparing for battle. On the day, I was totally disarmed by the wonderful Dr Jac Reeve. In the six years she has been at WSH, the caesarean rate has gone from 29% to 20%. She is massively pro-VBAC. She herself had two homebirths. I cannot praise the care this amazing woman gave me highly enough. Jac was honest about what she would prefer me to do but I never felt pressured. At our first meeting, we respectfully disagreed on HBAC and were still able to have a productive discussion.

Breech VBAC

At 39wks, I took myself in to WSH for some monitoring as the baby’s movements had changed to pushes and stretches rather than kicks and jabs. I saw an experienced midwife who suggested the baby might have turned breech as the heartbeat was further up than expected, and a scan confirmed this. It was Friday night and I would have to wait until Monday to see Dr Reeve to talk about a new plan.

I once more dove into research, this time about breech VBAC. It was an incredibly stressful weekend but also one of overwhelming generosity from strangers. I sent out pleas for information on my Facebook groups. I spent hours on the phone to doulas and independent midwives, getting advice. I found an IM team (Andy Parker in London) who would attend me for breech HBAC or in hospital if they could get an honorary contract. My local TCM guy squeezed me in for some moxibustion, and supplied me with a kit to continue doing it at home. (I also hung upside down off the ironing board with frozen peas and a torch on my tummy…) My doula came over to show us how to do some rebozo. Teddy Brookes the osteopath in Cambridge came in specially to treat me on the Sunday. Shawn Walker, a Norfolk independent midwife, offered to come in and train the WSH staff if they felt lack of training was a barrier to a breech VBAC. I am humbled and very grateful for all the kindness I was shown over those two days.

I should also give my husband a special mention at this point. He did an incredible job of supporting me, as he had done throughout. I think a lot of people would have baulked at this point but he managed to keep his concerns contained whilst I explored all possible options. Yet another thing I am grateful for.

A home breech VBAC was probably beyond even my comfort zone at this point, so I went in to discuss what my options in hospital would be. A growth scan confirmed a frank breech but otherwise healthy and appropriately-sized baby. I met with Dr Reeve and a senior MLBU midwife. I had been discussed at the consultants’ meeting that morning and it was made clear that the consensus of opinion was to recommend a cs. But Dr Reeve was prepared to support my choice. Risks were discussed calmly and rationally, with their recommendations made clear but my decisions respected. Unbelievably, I left with an agreed plan for a frank breech birth (not a breech delivery) in the MLBU, along the lines of my previous VBAC MLBU plan. Note: in a breech birth, the mother typically delivers in a gravity-aided position and the midwives do not touch the emerging baby. In a breech delivery, the mother lies on her back with feet in stirrups, and an episiotomy is often done to aid the use of forceps to deliver the baby’s head.

Dr Reeve and I agreed that she would try to turn the baby by ECV, so I went back in the next day (40wks by their dates, 39+3 by mine). Dr Reeve’s technique is unusual – I’d liken it to a Thai massage – but her success rate is the best in the region (73%). It didn’t hurt and it did work. The woman is a genius.

Change of plan

In theory, with the baby now head down again, the HBAC was back on but my husband and I had been shaken by the past few days. Moreover, I had been utterly reassured that my wishes to be treated like any other low risk mother would be respected. Every time I attended WSH, someone from the MLBU had been present, which mean that I met many of the team. Each one took the time to ask about my past experience and try to allay my concerns about labouring in hospital. At my final appointment, the head of the MLBU herself gave me a personal guided relaxation to try and help let go of any baggage I had! They really did go above and beyond for me.

My husband and I slept on it and decided that we would opt for a hospital VBAC in the MLBU. The community midwives came and took their homebirth kit away. I was fine with the decision. We could still labour at home until it was time to head in. Whilst I would have preferred a homebirth, it was VBAC that was my priority. The home bit was mostly about maximising my chances of doing so. The baby was now back to back (having been LOA until 39wks!!) but at least I knew what kind of labour I might be in for. All would be well.

And finally…

In the end, our second daughter was born at home on the sofa after a rapid labour, a HBAC after all. I was attended by two stellar community midwives, yet another credit to the NHS.

Throughout this journey, the support I have received from the local and online birthing communities has been amazing. I am extremely grateful to live in the UK where choices are available to us. A massive thank you to all who have played their part in the birth of my second child. We did it :0)

COMING SOON! Rachel’s homebirth after caesarean (HBAC) story. Her partner has written about the birth from his perspective and her doula has too.

If you would like to connect with other local women, like Rachel did, planning birth after caesarean, join our private online support group, you can read more about it on support page.

There’s research, blogs, birth stories and hot topics on the resources page.

And there’s FREE monthly face-to-face support at Cambridge Birth Choices free drop-in group, held on the second Friday of the month at Cambridge Women’s Resource Centre and the last Friday of the month at Satyam Yoga Centre.

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