Year in review: Labor, delivery, and recovery

It turns out that one of Maya’s daycare providers, Roz, is also a midwife.  She, another mom, and I had a long conversation a couple weeks ago upon afternoon baby pickup about all of our respective labors.  During the conversation, it was clear that I’ve spent this whole year - and it’s taken a whole year - processing my birth experience and truly coming to a place of peace about it.  In any case, that’s when I decided that I really should do a “Year in review” post on it, even though at least some of you (especially husband) must feel like it’s definitely been beaten to death.  But I have arrived in my happy place of tranquility and I want to share!

It’s been a fun week in our household, reliving all the memories associated with last Christmas - or rather, the lack of memories since most of it is a major blur in my mind.  That’s probably the part that I’m most surprised about, that I don’t remember so much of it.  After I post this entry, I’m going to post husband’s version of the birth story that I promised you guys so long ago.  He actually never let me read it until this week, which is why it never got posted.  As a teaser, there are two things that I kept repeating the entire time I read it: 1) “We/I did what?!?!?!?” and 2) “That’s utterly disgusting.”  But again, I was struck by the haze that surrounds the whole experience - I literally remember like 10% of the two days I was in labor and the week after delivery.  Actually, maybe 10% is generous.

But the fraction I do remember is...haunting, for lack of a better word.  However, the way I have found peace with it was to tackle the one big question I was left with post-delivery: Was my labor handled in a way that promoted the best possible outcome?  Answering this question involved a fair amount of primary literature analysis, lurking l/d message boards, and coming to some brutally honest assessments of my birth situation.

My final conclusion?  Yes, my labor was managed well, and I absolutely did get the best possible outcome.

I have concluded that there were three challenges I faced that, especially in combination, pretty much made it impossible for me to give birth vaginally to this particular baby.  Unfortunately, all three are interdependent, so it’s not surprising that they happened as a unit.

• Malpresentation: The baby didn’t present well, end of story.  I originally thought that the baby being posterior was the bulk of the problem, but it turns out that the extended head (nearly a brow/forehead presentation) was probably what sealed the deal.  One of the many primary lit papers I read put it like this: “It is generally accepted that vaginal delivery in brow presentation is virtually impossible due to the large presenting diameter (mentovertical - 13 cm) unless the fetus is small and the pelvis is capacious.”

Although brow presentations are rare overall, look at the percentage that resulted in c-sections!  From Bhal et al 1998, J Obstetrics & Gynaecology.  

• Postmaturity: By early ultrasound dating (the most accurate of any dating methods we used, since it was my first cycle off birth control and I was otherwise only using a cheap thermometer to detect ovulation), the baby was born a full 14 days late.  I think that the two main complications this created was that 1) her skull was super well-ossified, and 2) her neck muscles were strong enough to pull her head out of a “normal” flexed position (a number of papers suggest that this is why post-dates babies are more prone to brow presentations).  Maya never had any palpable posterior fontanelle, and only a small anterior one.  All c-section babies have heads that look nice and round rather than the cone-shaped heads of vaginally delivered babies, but I pushed on that head with everything I had for FOUR HOURS, hard enough to break a bunch of blood vessels on the presenting part of her scalp (which is one reason we know for sure that her head was extended instead of flexed), and her head shape still looked perfect.  Her cranial plates didn’t even budge - yikes.

• Large size: While 8 lbs isn’t particularly large when viewing the entire distribution of newborn girls (~70% percentile), I have a very small frame.  I’m tall-ish, but to give you a general sense for my build, my ring size is 3.25 (average is about a 6).  I’m a totally regular sized person, just on top of an itty bitty skeleton (I’m probably going to have awful osteoporosis when I’m older).  Anyway, I totally bought into the Ina May Gaskin/Ricki Lake “Women don’t grow babies that they can’t birth” thing hook, line, and sinker, but in doing so, I conveniently forgot to take into account my own data.  Husband is pretty big, and was a big baby at birth, so it’s not that surprising that his genes would contribute to a bigger baby than my frame could handle well.  However, I definitely forgot all of this in the fervor of all the “birth empowerment.”

If any one of these things had been more “normal,” I think I would have had a good chance of getting her out.  A large, late baby who was anterior (with a nicely tucked chin!)?  A 6lb posterior baby?  A 38-weeker?  Yep, I think I could have done any of those.  But, brow presentations are more common with postmaturity, and of course the late baby is often a bigger baby, etc., etc., and thus I ended up with an untenable situation.

While perhaps an argument could be made that when seeing my frame size, my midwife could have suggested an induction at 40 weeks when we would have had a better chance at turning the baby into a better position, but brow presentations are indeed rare and I think that my outcome could not have reasonably been anticipated. I was also still in la-la-land of birth empowerment at 40 weeks, so there’s no way I would have consented to an induction then.  

So the one and only thing that I think could have been handled differently was more communication from the midwives about the progression of - and problems with - my labor.  I think the midwives and nurses are very careful not to discourage laboring women, but that was not the right approach for me: I needed to hear their factual, clinical assessment of my labor and what to do about managing it.  The fact is that I had clinically disordered labor from before I arrived at the hospital.  Specifically, the coupling (and sometimes tripling) of my contractions was absolutely not normal, and it was a clear, early sign that the baby was positioned poorly.  One of the best treatments for coupling is an epidural, which is exactly how we ended up managing it - and it worked!  The coupling stopped, AND I managed to dilate completely (many women with coupling and posterior babies have arrested dilation).  But no one discussed any of that with me, it was me yelling for the epidural after 7 hours of coupled contractions with no dilation progress that resulted in the correct management option.  It was only months later that I learned that OB’s recognize coupling as disordered and that the best treatment is an epidural.  So to some extent, I feel like husband and I stumbled into the proper management plan instead of being guided there by our birthing team, and although I would ask for a different communication approach from any future birthing team, any regrets I have with them really just boil down to a difference in philosophy between the hospital and me on how to talk to scientists who happen to also be patients.  I still ended up with the best management I could have asked for, even with the luxury of time to critically (and obsessively) assess every component of my labor and pick the “ideal” approach.

So rest assured, I feel completely at peace with my birth experience now.  Basically, I had bad luck with the presentation, and there wasn’t anything more or different I really could have done to avoid a c-section.  Best of all, there’s no data to suggest that I’m at any greater risk of a repeat situation - my odds of bad presentation in a subsequent pregnancy are simply reset to exactly what they were before I had Maya.

I just want to take one paragraph here to also say that in terms of physical recovery from pregnancy and delivery, one year out, I’m doing great.  With exception of my fatty c-section scar, you’d never know from looking at me that I’d ever been pregnant.  Other than the weird suture knot that tried to escape through my incision (we named him George), I had zero complications from the surgery and a near perfect recovery.  I have most of the feeling back in the skin above my incision, my abs are fine, I’m in all of my old clothes, and I physically feel SO MUCH BETTER than I did last fall when I was steeped in the mental fog of pregnancy and napping like 4 times a day :)  While I’m not in any rush to do it again, pregnancy and childbirth ironically ended up being much less transformative on my body than I had originally anticipated!  I’m out of shape because I haven’t been working out much, but well, we have a New Year’s resolution coming up soon, don’t we....

So to any female readers who haven’t procreated yet but want to - don’t let my birth story scare you!  Statistically, I had a really rare situation.  To all of you: may your birth experiences be as peaceful and beautiful as the ones they show in birthing class.  And if they’re not...well, then you know who to call to get a sympathetic ear :)