Patient perspective: Trial of labor after cesarean birth

INTRODUCTION — This topic was written by an individual who experienced labor after a cesarean birth. It is intended to offer clinicians insight into the experience of a single individual from that individual's point of view. This description of a particular individual's experience is not intended to be comprehensive or to provide recommendations regarding diagnosis, treatment, and/or medication information. It is not intended to be medical advice or to be a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances.

For related clinical topics, please see:

●(See "Choosing the route of delivery after cesarean birth".)

●(See "Trial of labor after cesarean birth: Intrapartum management".)

FIRST PREGNANCY — I was diagnosed with type 1 diabetes when I was four years old. I have had regular visits with a pediatric endocrinologist since then, including during my first pregnancy. During that pregnancy, I also received care from Maternal-Fetal Medicine (MFM) specialists. I trusted the professional training and expertise of my doctors and assumed that I was being adequately monitored and tested to ensure a successful birth.

My hemoglobin A1C was in the low 7s prior to getting pregnant. My first trimester blood sugars were low, and I kept having extreme lows. They were higher in the second and third trimesters, so I had to increase my insulin by approximately one-third.

When I was 38 weeks, I went in for a routine nonstress test (NST) on a Monday. The doctor was concerned about some things that she saw during the test and said she wanted to induce labor on Wednesday to prevent any problems from happening by waiting longer. I know that I had a lot of amniotic fluid, and the estimated weight of the baby was around 7 pounds on my last ultrasound.

I was in labor when they broke my water. I had the baby 32 hours later by an emergency cesarean because it was stuck and started going into distress. I had pushed for four hours. The doctor was unable to move the baby into a better position or deliver it using forceps. My son weighed 8 pounds 12 ounces (3969 grams). He did well but needed to be on bilirubin lights for approximately a week and a half after we left the hospital.

Postpartum — Postpartum, my MFM gave me statistics about my personal chance of a successful vaginal birth in the next pregnancy, which was 30 percent. She was of the opinion that my next pregnancy would ultimately end in a cesarean – despite the fact that I wanted to attempt a vaginal birth.

My thoughts about my first pregnancy — I believe that diabetes was a major factor as to why I had an unplanned cesarean birth. I knew very little about how diabetes impacts pregnancies other than the fact that mothers with diabetes tend to have large babies if the diabetes is mismanaged during pregnancy. I felt uninformed as to why and how my diabetes impacted my pregnancy. I assumed everything was fine. In retrospect, I believe that had I truly been informed about what was happening and what the results of the tests actually meant, then perhaps the cesarean could have been avoided.

SECOND PREGNANCY — I sought an endocrinologist who could manage my health and diabetes as an adult female, provide specialized care as new pregnancies occurred, and communicate with my Maternal-Fetal Medicine (MFM) team. These things were lacking in my first pregnancy.

From the first meeting with a new MFM team, I was able to discuss my concerns about my previous pregnancy and cesarean birth and my concerns about the recommendation for repeat cesarean birth. My overall experience communicating with my new endocrinologist and new MFM team was excellent. I felt that there were no barriers to communication, but my appointments lacked attention and consideration for my goals and desired outcomes. The new MFM did not provide care that encouraged or supported my desires to have a vaginal birth and more pregnancies. I was given a forecast of a poor success rate and a placating "we will see how it goes" attitude that did not reflect a sincere effort to help me achieve my desired outcomes. To be clear, the care team did seek to provide care and support for a healthy and safe pregnancy and birth, but my desired outcome of a vaginal birth was not taken seriously. The new MFM rigidly based her opinion on statistics of situations like mine, showing little support for what my overall goals were and what I felt I was capable of achieving. We discussed my particular situation and my personal risks. She said that if I had another cesarean birth, I would be advised to not have any more pregnancies due to the increased risk of more severe complications. Because of this, I had to find additional support outside of the care of that MFM.

In this pregnancy, the main focus was my diabetes care and its effects on my pregnancy. I was able to understand the impact of good control of my diabetes. I understood why certain blood tests were ordered, what specifically was being monitored by the extra ultrasounds, and why additional nonstress tests (NSTs) were performed. The new MFM team reviewed the results and explained them to me, and we discussed what was needed to maintain my health and ensure the health and safety of my baby. I was more confident about speaking up about what I wanted, asking questions, and making sure that information regarding tests and procedures was clearly provided. I also felt that the new MFM team was willing to explain what a procedure involved and why it was necessary, rather than simply ordering a test without any explanation.

At every ultrasound, they checked the scar in my uterus, and it always was okay. They never had any concerns that they shared with me about the scar. The risk of uterine rupture never came up in the appointments. I wasn't even aware that it was a possibility. If the dangers that could result from my trying for a vaginal birth had been made clearer to me, I probably would have been more aware of how I was feeling and what I was doing during pregnancy, but I don't think I would have changed my focus on having a vaginal birth after cesarean (VBAC).

When I was around 36 weeks, I talked with the doctor about my desire to have a VBAC. A decision was made that we would see if I would go into labor naturally by 37 weeks and if I didn't, then we would schedule the cesarean birth for the following week. The pregnancy ended around 37 weeks when my water broke on its own. On the way to the hospital where I planned to give birth, the baby seemed to be coming fast so we decided to detour to a closer hospital. I pushed for almost an hour before the baby was born, which was six hours after my water broke. The baby had a shoulder dystocia and was not breathing initially but was quickly resuscitated. She weighed 8 pounds 9 ounces (3884 grams). I had a fairly big third-degree tear because of the shoulder dystocia.

Postpartum — Postpartum was substantially better than after my first delivery. I didn't have the trauma from almost having the baby vaginally with forceps and then having a cesarean birth. I was able to heal faster with just the vaginal tear and my body was not as worn out from such a long labor that I had with the first pregnancy.

My thoughts about my second pregnancy — I believe that my determination and desire to have a vaginal birth was why I was successful in having a VBAC in my second pregnancy, despite data to the contrary.

THIRD AND FOURTH PREGNANCIES — My third pregnancy was a pretty easy pregnancy. My diabetes was in good control the entire pregnancy. I went into labor at 34 weeks. The delivery was quick. They broke my water, and on the second push, they rotated the baby because he was stuck. He was born on the third push and was 5 pounds 15 ounces (2693 grams).

My fourth pregnancy started out like the previous three pregnancies. Although they found that my cervix and cesarean scar were covered by the placenta at the anatomy ultrasound around 20 weeks, a repeat ultrasound a month later was okay (no previa or accreta). I had more ultrasounds and nonstress tests (NSTs). At 38 weeks, the decision was made that I could have a vaginal birth after cesarean (VBAC) because the baby seemed to be the same size as my previously successful VBAC. I was induced and successfully delivered an 8 pound 13 ounce (3997 grams) baby girl after a shoulder dystocia. Postpartum was challenging because of a third-degree tear and bleeding.

WHAT COULD BE IMPROVED — In my first-ever prenatal appointment, I really didn't know what I didn't know, and did not have enough knowledge to ask important questions. I had basic knowledge because of the years of experience I had living with diabetes, but I did not know specifics regarding pregnancy and diabetes. I wish there were resources or pamphlets that I could have studied to educate myself on my specific situation and condition. I received verbal information at in-person appointments regarding the ways my diabetes was affecting my pregnancy. But I feel that to have a resource of information that I could peruse on my own time or when a specific question arose would have been helpful. For me to have arrived at my first appointment with my first pregnancy, and to have had the Maternal-Fetal Medicine (MFM) specialist explain why my pregnancy was deemed high risk, what specific effect my diabetes could have both on me and the baby, as well as a preview of what I could expect and what I should be aware of – and then to have received a resource to refer back to on my own time – would have been optimal.

When discussing some of the complications that I could potentially have, I felt like the information they gave me was unbiased and respected my beliefs, values, and culture. But when the direction of care was discussed, I believe there was definite bias, stemming from what outcome the MFM wanted and thought should happen. Again, it was respectful in terms of delivery of information, but it did not respect my desires and goals. There was no encouragement to seek out other opinions or discussions with outside parties (apart from my spouse, who was not present in these appointments).

A suggestion I have to improve communication between patients and providers would be to have an initial conversation during which the patient explains what they know about the condition or situation – including anything they have heard, read, or been told. Then the provider would have the chance to clear up any misinformation and provide further details in a clear discussion about future care, management, and procedures to improve health outcomes. Included in this discussion would be resources for insurance questions, as well as resources for connecting with a postnatal care team. Having a clear direction toward resources early on can reduce the overwhelming feelings and frustration newly pregnant people with diabetes face.

The biggest lesson I have learned is that I am my biggest advocate. I am ultimately in charge of finding adequate care, and that my intuition is as important as the opinion and direction of care of my provider. I want to let others know that if it is important to them, they need to make it known to the doctor. I would also tell others that having a birth plan could assist the doctor and team to work more effectively to meet all of their needs and the goals for the care they would like to receive. Finally, I would tell other patients about the benefits of a well-trained doula, who can act as a support and resource outside the traditional health care team, although I did not have one.

IMPACT OF HAVING DIABETES — Type 1 diabetes, when I have managed it correctly, has had a positive impact on my life. It has pressured me to live a healthy lifestyle, to cultivate personal responsibility from a young age, and to develop resilience and the ability to manage future setbacks and unforeseen circumstances. However, when I got married and started a family and a new phase of life outside of my parents' support, diabetes put a financial burden on my family. It has had a negative impact on how we provide health care, health insurance, and financial obligations for our family. Despite this, diabetes is, in my experience, easy to assimilate into a lifestyle you choose. Work, play, interests, and life goals do not have to change due to a diagnosis of diabetes. Starting a family was a desire and goal for my life, and diabetes added a significant dimension of risk to achieving these goals. But overall, with the support and care of competent providers, I have been successful at delivering healthy, happy babies including three vaginal births after a cesarean.