Friday, December 13, 1996
There are a number of benefits to a vaginal rather than a cesarean birth, including less uterine scarring, decreased pain, increased mobility, faster recovery, lower cost, and the ultimate feminine experience. With a vaginal birth after cesarean (VBAC), there is a risk of uterine rupture, which can have disastrous consequences as chronicled in the following account of our daughter's birth. The good news is that rapid diagnosis of a uterine rupture and prompt intervention can virtually eliminate serious maternal and fetal consequences if the VBAC delivery is appropriately managed. ACOG says, "plans for appropriate management, rapid diagnosis, and immediate intervention should be in place prior to undertaking a trial of labor." This means that the fetal heart rate should be monitored regularly, especially during the second stage of labor. Virtually all uterine ruptures coincide with a sharp drop in fetal heart rate. Recession of the fetal head and bulging of the abdomen are the most accurate signs of uterine rupture. Other symptoms, such as acute abdominal pain and vaginal bleeding reinforce such a diagnosis. Upon recognition of such ominous signs, immediate surgery should be undertaken to assure a good maternal and perinatal outcome.
Unfortunately, the word is not out to the whole obstetric community. A comprehensive survey of obstetric textbooks at Stanford's Lane Medical Library shows that very few cover the management of VBACs. Detailed diagnostic information is really only contained in the professional ob/gyn journals. Sadly, most practicing obstetricians do not attend continuing education seminars, read their own journals, or in any other way keep abreast of new trends, info, and procedures. Then, they encourage their patients to have complete trust in them as the expert.
After going through our daughter's birth, I read everything I could about our situation, and I probably know more about this than most practicing obstetricians. Too bad we didn't do such reading before. We put too much trust in the experts, who assured us of their knowledge of the procedures, but not of their ability to handle complications. Next time, we're going to know everything about the procedures, statistics, complications, diagnostics and alternatives. Here's what happened when we just "went along".
Our first child, Stefan, was born by cesarean section because of fetal distress. We had already taken Lamaze classes, and we were all prepared to finally apply the breathing, coaching, and massage techniques we had learned to have the ultimate feminine experience: a vaginal birth. However, when variable decelerations dipped below 80 and then down to 60, our obstetrician, the nurses, and several anesthesiologists (including a few students) ganged up on us and strongly recommended to have a cesarean delivery. Within minutes, perhaps a dozen staff attached IV's, made other preparations, and whisked my wife Rita away to the operating room.
The OB acknowledged that the birth style was not the one that we had planned, but the most important thing was that we had a healthy child. Since then, the disappointment of the thwarted birth experience has faded because he's brought us so much joy, and has astounded us with his development physically, emotionally and intellectually.
But Rita still felt that she had been denied the birth experience she really wanted. There's so much literature about the positive aspects of a vaginal birth that we didn't even consider a second birth to be other than a VBAC (Vaginal Birth After Cesarean). The word was that with modern cesarean techniques (low transverse section), VBACs were just as safe as first time vaginal births.
We talked about our future, and both of us felt that we'd like to have another child, or maybe two more. Rita was especially interested to have a girl, because she loves to sew and make crafts, and was excited by the possibility of making pretty clothes for her, and helping her to make art and crafts.
We thought that the optimum age difference would be 2-3 years, so we started getting sloppy with our birth control after about nine months, since we knew that one doesn't usually get pregnant right away (although we did so with Stefan). Well, we did get pregnant right away, much to our surprise, and rationalized over the next few months how good it would be to have them so close in age (18 months apart) so that they'd be able to play together, so we'd be able to take more mature vacations sooner, etc. We were also thrilled that it was going to be a girl. We were a bit concerned that the uterine scar only had nine months to heal, but we were assured by the OB that Rita would be fine.
We started getting into the 41st week of gestation, and the OB recommended that we induce labor, because after the 42nd week, the umbilical cord starts to disintegrate, and we could jeopardize the health of our child. We had a bit of doubt about the actual due date, because one of the many earlier exams placed the date of conception one week later, making this 40 weeks instead, but the overwhelming number of estimates placed us at 41 weeks.
The day before the scheduled induction, Rita went in for an ultrasound, which indicated a perfectly healthy baby girl, sucking joyfully on her thumb.
We arrived at Stanford University Hospital at about 9 am on March 23, 1995, and had a little discussion with the OB about what we were about to do. I asked if there were any risks to a VBAC, and she responded that there is a small risk of uterine rupture, during which the baby is thrust into a hostile environment, resulting in a number of nasty things, such as infection. When we asked for further information, she brushed us off a bit, implying that there's a number of things that could happen, that we don't have much time, it's too depressing, and the probabilities are negligible. So we got on with the induction.
To monitor the fetal heart rate (FHR) and uterine contractions (UC), the OB felt that it would be most accurate to use a probe that is attached to the fetal scalp with a hook. We both cringed at the thought, but we were assured that the mark it would leave wouldn't even be noticeable.
One of the staff inserted an IV into Rita's arm to feed the pitocin which would induce the labor. It was fed continuously by a pump at a rate that was increased and decreased slowly over time in response to her progress.
However, in order to attach the probe, Rita's water needed to be broken. The OB used a small tool, and a small movement of her hand caused a prick of the membranes, resulting in a slow discharge of fluids. After draining completely, she attached the probe to the fetal scalp in a few seconds. She then went home to spend some time with her infant/toddler son.
Over the next few hours, we'd watch the chart strip recorder trace out the FHR and UC lines. Several times, the traces disappeared, fluctuated, or became noisy, but we were assured by the attending nurse that it was nothing to be concerned about, because if we just move a bit or jiggle the wires, the trace would return. Rita rotated to lie on her left side, or her right, and the traces would come back. Sometimes, she'd have to readjust her position several times over a few minutes in order for the traces to clear up. The nurse called the OB a few times to consult with her about the traces.
Neither of us really knew how to read the chart (although we know a lot more now), but we were happy to see regular oscillations. We kept track of the time between contractions, anxious for them to become more frequent.
When the OB came back to check on progress, she was satisfied that the cervix had dilated to 2 cm at 2 pm. She studied the FHR charts for a while, showed some concern, and readjusted Rita a few times to test something.
About 2:30, Rita felt that she'd like to have the epidural, so she sat up while a technician inserted it into her back. The FHR charts were very noisy at this time, and I assumed that this was caused bit sitting up and squirming. For 41 minutes, the traces sometimes disappeared with occasional blips. About 3:15, the pitocin level was reduced to 6 mU/min, and more "normal" traces came back, except that these had variable decelerations that went down to 90. Normal FHR should be 120-160 (180). About 3:45, an oxygen mask was put over Rita's face. After 5 minutes, a chart paper change and recalibration, the variables only dipped down to 110 or so.
Of course, since Rita and I knew nothing at the time about VBACs, we thought this was normal management procedure. We would chat while I watched the chart, noting that Rita was oblivious to the contractions due to the epidural.
At 4 pm, the OB found the cervical dilation to be 4 cm. At this rate, it seemed like we'd have to wait until 10 pm to be dilated 10 cm. But shortly the chart recorder was being stubborn again! About 4:20, we were getting late decelerations down to 70, 80 and 90. About 5:00, Rita got the oxygen mask again, and the FHR stabilized by about 5:15.
At 7 pm, the OB returned. Rita said that she thought she was ready. Though the OB thought she was ludicrous at first, after she checked, she announced that Rita was fully dilated and 100% effaced.
The time had come to finally put the Lamaze technique to work. Rita squeezed with the contractions. The probe had come out, but a nurse attached an external one. Unfortunately, this one was more noisy and didn't show the uterine contractions, only the fetal heart rate. The FHR fluctuated from 90 to 150. The OB told Rita to squeeze harder, and she squeezed until her face was as red as a tomato. The OB pushed on Rita's abdomen to help out.
At 7:15, the FHR dropped to 90. When it dipped down to 60 a few minutes later, the pitocin was turned off. At 7:20, Rita is given oxygen a third time. The FHR is fluctuating erratically from 40 to 240. We see the baby's scalp! It has somewhat of a grayish pallor, due undoubtedly to the stress of active labor. The OB wants to use the vacuum to assist with extraction, but the nurse is helping a delivery in another room. The student nurse manages to find the vacuum, but fumbles because she hasn't got a clue how to put it together.
While we wait for the nurse to return, Rita complains about a sharp abdominal pain, even though she was unable to feel the contractions. The OB says that pain is common in labor, and that it is nothing to be concerned about.
I notice an asymmetrical bulging in Rita's abdomen. I ask the OB whether this is normal, and she says this bulging is common in labor. I touch it and remark that I feel something long, like a leg, and maybe a butt.
The nurse returns and the vacuum is attached to the fetal scalp. The OB pulls once with the squeezing and contractions. Not much happens. She suggests that maybe a cesarean is in order and calls the OR. Rita ask to try one more time, and the OB OK's it because the anesthesiologist won't be there for a few minutes. So the vacuum is tried a second time, but the head retracts afterward. The OB calls for a stat C-section for real, this time.
We wait, but no gurney appears. No one seems to be around to help. The nurse scours the floor, and finally locates a gurney. But how does Rita get onto it? There's no staff in the room except for the doctor and two nurses, but they don't look too beefy nor willing. And I don't know what to do, so Rita volunteers to scoot onto the gurney herself, thrusting her pelvis into the air to do it.
Seven minutes after the call for stat C-section, Rita is in the OR. Four minutes later, general anesthesia is applied. One minute later the first incision is made, and in another minute the baby is out. It's 7:46 pm.
By this time, I'm dressed in my scrubs and ready to watch in the OR, but I'm immediately shooed out. "You can't come in yet", they say, so I watch through a one foot square window by the wash basin. I see about ten serious-looking people clustered around Rita. I few minutes later, I poke my head in, take a picture, and ask if I can come in yet. With an "oh, shit" look on everyone's faces, the doctor shakes her head no.
After a while I see about a half dozen people at the other end of the OR, where they suction the baby and count her toes. I sense trouble, because at our son's birth, there were only two staff at the same station. More time goes on. I'm really being kept in the dark. Eventually, a nurse comes out and gives me some news. Rita's OK, and will be able to have another baby, but the doctor will probably require that it be a cesarean birth. The baby, though, is having problems, and wasn't breathing. The Apgars are 3@1, 4@5, and 4@10, though, and she's got good color, so she's pretty healthy.
Eventually the doctor comes out. She says that Rita had a uterine rupture, and she found the head and shoulders of the baby thrust into the interabdominal cavity. Rita is fine, she hardly lost any blood, and she should be able to have another baby, but she wants to get an opinion from a uterus expert first. But the baby isn't doing as well. She is "very sick" (a term we would hear several times that night), and is having a hard time breathing. The doctors are using a bellows to give her air. There's a team of experts on her now to get her better. She's sorry, but I won't be able to go into the OR this time, because of the complications.
She goes back into the OR. I peek back into the OR, looking at the doctors' faces and the activity in there. I look for Rita and see her passed out with her arms at her side and her purse on her lap. But what's her purse doing there? How's she going to use it when she's under sedation? And then it hits me: that's not her purse, dodo, it's her uterus!
I glance toward the other side of the OR to the baby station, and everyone's gone! The door on the opposite side of the OR is swinging a bit, so I run through the otherwise sedate hallways, bash through the double doors, and demand of the first person that confronts me, "Where is my baby?", and he points me down the hall to the right. I bash through a second set of double doors, jogging past the guard at the entrance to the NICU, who stops me to ask my business, and when I say "they got my baby", she points me to the room.
It was obvious which station to go to, because there were a half dozen people surrounding it. I walked up to it cautiously, almost tiptoeing, and asked if it was my baby. They moved aside and revealed a baby under strong lights with all sorts of tubes and wires attached. I see her tongue quivering, but she is otherwise limp. Her labia were pink and swollen (that's a girl, all right!). They told me what everything was: several cardiac pads on her chest to monitor her heart rate, a catheter into her umbilical cord to supply most of her drugs, another catheter into her wrist for something that shouldn't go directly to her heart like the umbilical does, a red light clamped onto her toe to monitor oxygen, and a tube inserted down her throat to help her breathe because she wasn't breathing on her own. They said I could touch her and talk to her. I'm a bit aghast, because she looked so..., I don't know, half girl and half machine. But I hold her hand and tell her that daddy's here. They take a Polaroid picture. I tell her I'm sorry she had such a hard time coming into the world, but that the doctors were going to get her better.
I was in shock. There was a lot of stuff happening that I wasn't prepared for. Having a scientific background, I was able to ask scientific-sounding questions without thinking much. How long would she be on the ventilator? What were her Apgars? What was her time of birth? How long before she is conscious? How long do you expect her to be in the NICU? When do you think we can bring her home?
I'm not sure I heard the answers. I couldn't really concentrate on much when looking at the baby (my daughter!) and the pity and hope I felt for her. The memories of that first visit are a blur (except for that picture) and I was starting to feel dazed.
Eventually, I snapped to attention, said I had to check on my wife, and raced out of there, back to the OR. I peeked into the window, and she was still there on the table, unconscious with open abdomen, 45 minutes after the birth! I called Rita's dad and mom, who were watching Stefan at our house, and I told them about the rupture and the NICU, and I asked for her dad (because he can drive) to come to the hospital because I felt that Rita needed him now. I went back to the OR, then visited the NICU, and eventually found Rita and the obstetrician in the recovery room. Rita was still unconscious, and was fitted with a breathing tube, cardiac pads and an oxygen clip. The doctor was analyzing the FHR charts and filling in an operative report. She got on the phone, and after a while called me over to talk to Dr. Matt, Stefan's pediatrician. He said our daughter was "very sick" (why don't they just say "damaged" and be more truthful about it!), and sympathized with us, offering to help in any way he could.
Rita was still unconscious, so I went back to the NICU. Dr. Marian there said that our daughter started to have seizures, so she was given Phenobarbital and Dilantin to sedate her. The doctor figured that there was some brain damage (including the brain stem) caused by oxygen deprivation during the uterine rupture, and the damaged cells were hyperactive and secreting a chemical that would overstimulate the nearby cells, causing a chain reaction of hyperactivity and destruction. So the solution was to put the whole brain to sleep by heavily sedating her. I asked what the prognosis was, and she said that depending on the extent of the brain damage, she could suffer learning disabilities, seizures, cerebral palsy, or possibly even vegetation. Rita and I both considered ourselves to be pretty intelligent, having attained masters degrees and all, and this was a heartbreaking disappointment. How would we cope with the extra care this damaged child would need? Would we ever be able to break free to take a vacation again? What a drastic change it would have on our lives! How could this happen? What did we do to deserve this? I was starting to feel numb.
I went back to the recovery room, and Rita's dad was there with Rita regaining her consciousness. They heard the news about the brain damage as soon as I had. Rita was cold from the chilly OR and shaking from the narcotics. I held her hand. Over an hour passed in the recovery room before we were transferred to the maternity ward with Rita in a wheelchair.
Rita's dad drove home and walked in the door with tears streaming from his eyes. "How could this happen at a [tertiary care] hospital like Stanford? How could this happen?"
I'm not sure how we slept that first night. We were both in shock and Rita was on pain-killers, recovering from a major surgery. The next morning I went to visit our daughter several times, but Rita said she didn't feel well enough to visit, even though it was only a hundred yards away. She eventually admitted that she didn't want to visit, because she didn't want to get attached, as she felt, from the moment she awoke from her anesthesia, that the baby wouldn't make it. I finally convinced her to visit later that evening.
Her face was so pretty and soft! She looks so much like Rita's grandmother, especially her hands! Poor thing! Such a sweet child to be sentenced to life in that condition!
The second night, the preceding events finally caught up with me. I was heartbroken. Our daughter's life was shattered! She would never experience the joys of life as we had. I sobbed quietly all night, although my frequent sniffles may have given me away. Our daughter was so different than the adorable preemies in the NICU with her. She was like a frankenstein creature, so human looking but acting so subhuman! I felt that her soul had left her, that whatever was left was trapped inside a body restrained by a crippled mind. GOD, pity her! I kept thinking of the psalm, "The Lord is my shepherd; I shall not want," and broke into deep sobs. My pillow was soaked in the morning.
We talked about names. Before the incident, we had several names, but somehow it didn't seem appropriate to use our favorite. We decided to call her Catherine Grace. Catherine as a symbol of strength, and Grace because it was only by the grace of God that she was still with us.
Our pastor came to console us. Before he left, he said that he wanted to read some passages from the Book of Psalms. I broke down and cried just hearing the word "psalm." He came back a day later, with Rita's parents and Stefan, to baptize Catie (or Katie) in the NICU. Stefan (18 months old at the time) reached out to touch Catie and console her. Somehow I think he knew she was hurting.
For something like seven days, Catie was heavily sedated. After three days, she started losing weight, so they inserted another IV and pumped hyper-al (sugar water and oil) into her blood as food. I pleaded with the doctors to take her off the sedatives, so that we could see what she was really like. It took days for her body to flush the Phenobarbital out of her system. She eventually was able to breathe on her own, and the hyper-al IV was removed, instead feeding her by pumping liquid through a tube inserted through her nose into her stomach.
It took a long time to get a diagnosis. Most of the information I had to get by reading the doctor's reports while visiting Catie. One of our nurses said that Catie's umbilical blood pH of 6.6 was "incompatible with life." We never saw the attending physician. The doctors avoided giving us detailed information. We were starved for information! Finally I found Dr. Marian, a Fellow at Stanford, who spent as much time with me as I wanted. She was the same person that had accepted Catie in the NICU after birth, and gave me much of the information I wanted.
Catie's diagnosis was severe encephalopathy (brain damage) with feeding intolerance due to metabolic anoxia (oxygen deprivation) secondary to uterine rupture. She had no corneal reflex, no gag reflex, no sucking reflex. Her eyes were wild and moved robotically; her cornea was dry and crusty because she could not blink. Spastic quadriplegia with clonus means that she shakes, the joints of her limbs are stiff and bent at right angles, and her fists are clenched with her thumb between the first two fingers. Food sometimes doesn't stay in her stomach, and refluxes back up to irritate her mouth and nose. She moans a lot. She is considered to be in a persistent vegetative state.
The numbness, my numbness, didn't wear off for months. Since no one seemed to know how this happened, I spent days in the medical library learning all I could about VBACs, uterine ruptures, pitocin, and anoxia. I researched books, journals, even nursing guidelines. I looked at everything published by ACOG (American College of Obstetricians and Gynecologists). I wrote a Parents' Report to complement the myriad medical reports (neurology, gastrology, physical therapy, etc.). It was the only thing I could do to keep myself sane.
Catie spent 10 days in the Stanford NICU (Neonatal Intensive Care Unit), was transferred to the IICN (Intermediate Intensive Care Nursery), and eventually to an offsite subacute care center, where she died three and a half months later. At her funeral, we read her these poems:
You were our hopes and dreams.
You were perfect, up until the moment of your birth.
The doctors told us of miracle babies that survive this type of insult.
Then you got better, and we were overjoyed.
We visited you every day; we visited you every week.
You showed us the value of life, and the dignity of death.
Now that you are free from your body, you can frolic with the angels.
Rest in peace my sweet child.
|Catie, We Love You
Our little baby girl,
May your journey to your eternal home be filled with peace and joy.
While your time with us lasted no longer than the first bloom of spring,
We will keep your memory safe in our hearts until we meet again.
|Catie, My Little Flower
Every new spring blossom will reflect upon us your perfect face.
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