International Cesarean Awareness Network

Education. Support. Advocacy.

Megan’s HBA3C Birth Story

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Share your story with ICAN to be featured on our Instagram and Facebook! All cesarean and birth-after-cesarean stories are welcome: the difficult, the triumphant, the still-processing, and the stories which haven’t yet been shared. Sharing your birth story can be freeing, healing and profoundly powerful. It can bring others hope, comfort, and reassurance that they are not alone on their birth journey.

Submit your story HERE: https://airtable.com/shrJOtXla9O9MVBaj

Megan shares her HBA3C birth story. Thank you for sharing your story for all to read!

William Tyler was born after 40 hours of labor at my midwife’s house. He was my first vaginal birth after three Cesareans!

On Wednesday the 6th, my husband had left town for work. I felt like I should tell him to stay but nothing was happening so he had to go. Then, of course, as the evening progressed, I kept having the occasional, strong contraction. I knew this baby was gonna come soon, so by 9 that night I made the decision to drive the two hours to Spokane and stay in a hotel for the night. I knew I didn’t want to be in active labor in the car. An hour into the drive, my contractions started coming 10 minutes apart and I was starting to vocalize a bit through them. (I am not the silent labor type, haha.)

I stopped by my midwife’s house to get a quick check before heading to the hotel. My blood pressure was still high (it had been for a few weeks but labs were clear and everything else was fine and it was stable) so I made sure to get my electrolyte drink to help control it. She sent me off with her peanut ball and after a quick stop at the store I made it to my hotel by midnight. With contractions 10 minutes apart all night I didn’t sleep. At 6 am on the 7th, little man’s due date, I got breakfast, took a shower, then left the hotel around 7:30. At this point I called my birth team to head to the midwife’s house. (My husband and birth photographer were 2 hours away while my doula was an hour away.)

I have to say that whole first day was pretty enjoyable. Contractions were between 6 and 10 minutes all day though they did increase in strength. My doula and photographer and husband made it a fun day. We were laughing and watching movies between contractions and having a good time. 

I found that the birth pool was my saving grace. When I got too tired or the contractions were coming too fast and strong and I needed a break, if I got in the pool they would space out so I could rest and even get little micro naps. By that evening my birth team needed to sleep so I labored throughout the night, laying down when I needed to. I don’t know how anyone slept through my yelling!

The morning of the 8th came and things were getting quite serious. (I was disappointed he didn’t come on his due date!) My husband got breakfast from Denny’s and it was a strawberry crepe. It was seriously the best thing I’ve ever eaten.

At 6:30 that morning I got my one and only check. I was 5-6 centimeters and felt like I had so long to go since I’d already been in labor so long already. My team assured me that that was great and I was doing great.

At this point I felt like my contractions were on top of each other and I was starting to lose a little control and panic at how much they hurt. I did a little crying and needed to get in the pool to gain control again and rest. After I got out, I decided next time I got in, I wouldn’t get out until the baby was born. 

For the next few hours or so I was having to bear down during contractions. I was excited cause it meant baby was coming down and would be born soon. When I couldn’t take it anymore, I knew I needed to get back in the pool. I was actively pushing during these contractions. I was starting to get scared at the force of my body and feeling like I couldn’t possibly do it, but also knowing I was way past the point of no return. In between one of those contractions I remember asking my husband if we had told anyone to feed our dogs.

My water broke during a contraction and immediately after I was taken over by the fetal ejection reflex. Let me tell you, I didn’t think it was possible for the body to handle that level of intensity and pain, and the sounds that came out of me were ones I didn’t know I could make. After several of these contractions, he started to crown. Ring of fire, baby! I held his head as it was born. Feeling his body wiggle and rotate while still inside me was such a strange feeling! I was kneeling while pushing but pulled up one leg after his head was born. One final contraction and his body slid out. I pulled him onto my chest then helped back into a sitting position. He cried right away. His back was covered in a thick layer of vernix so I sat there and rubbed it in while he cleared his lungs.

The placenta detached within minutes and the pressure was awful on my tailbone so I got out to deliver it. I sat on the birth stool and guided it out myself. It was such a relief! After I got settled in the bed and William was latching, I slept. I didn’t know I slept until they told me he had been born for 2 hours and I couldn’t believe it! We got a few pictures with the placenta and then my husband cut the cord so we could do measurements. 7 lbs 9 oz and 21 inches. Everyone was surprised at how big he was! (I had two previous IUGR babies)

Looking back I can say it was a beautiful, incredible journey. It wasn’t peaceful and calm. It was raw, and primal. And that’s ok. Because while birth looks different for everyone, it is still beautiful.

Jessica’s Induction VBAC Birth Story

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Share your story with ICAN to be featured on our Instagram and Facebook! All cesarean and birth-after-cesarean stories are welcome: the difficult, the triumphant, the still-processing, and the stories which haven’t yet been shared. Sharing your birth story can be freeing, healing and profoundly powerful. It can bring others hope, comfort, and reassurance that they are not alone on their birth journey.

Submit your story HERE: https://airtable.com/shrJOtXla9O9MVBaj

Jessica shares her VBAC birth story. Thank you for sharing your story for all to read!

Blake’s birth story starts with Lexi’s. After a day and a half of intense induction with her I ended up having a cesarean. One I very much didn’t want. She has her own unique story, though. And I’m proud of all I went through to have her. 

Even before I got pregnant with Blake I knew if we had another baby I would be doing everything I could to avoid another cesarean. 

Through my pregnancy with him I stuck to my strict diet in hopes of having a smaller baby this time, I saw a chiropractor to make sure he was in a good position; unlike his sister, and I did exercises at home to do the same. I also kept my weight gain to just 20 pounds, rather than the 75 I gained with Lexi. 

This time around I was able to avoid bed rest for high blood pressure, which kept me even more active. However, by 39 weeks my BP was slowly creeping up again. Nothing dangerous, but we were watching it. 

I had an appointment with my midwife the day before Thanksgiving, and the day before my due date. The labs I did the previous week showed I had a little protein in my urine, but she wasn’t concerned because I had very little swelling, my BP at home while resting was perfect, and my blood tests came back great. 

We talked about how I didn’t want to go much further than 41 weeks and I asked about my induction options if the baby wasn’t there by the following weekend. My midwife said she would ask around to the other doctors. 

I was told to go to the hospital on the Saturday after Thanksgiving to have some repeat labs and a non stress test for the baby, and we went on our way. 

Cut to Thanksgiving. Nick, Lexi and I enjoyed one last family outing as 3. We saw The Good Dinosaur at Alamo DraftHouse and ate our lunch there. It was really the perfect day. I teared up as we were leaving the theater knowing soon we would be a family of 4. Little did I know how soon. 

We got home and were relaxing on the couch when my phone rang. It was the on-call midwife at the hospital. The on-call doctor had looked over my chart and was concerned about the protein in my urine from the previous week. They wanted me to come in for monitoring and labs. I was in shock. I was assured it would take less than an hour and it was ok to bring Lexi. So the 3 of us loaded up in the car and went to labor and delivery. 

Once at the hospital they took blood and hooked me up to monitors to check the baby. About an hour later the doctor came in and said I was still spilling protein and they were concerned it could get worse and we should induce that night. 

I was blindsided! We had Lexi with us and no family in town. I didn’t have a bag packed. I also knew my best chance at a VBAC was to go into labor on my own. I asked to go home and come back in the morning. I wanted to put Lexi to bed one last time and pack my own bag. 

After talking to the doctor and the on call midwife and our doula we decided it was best for me to stay and start a slow induction that night. 

Nick took Lexi home and we called my parents to come watch her. 

Around 10pm the on-call midwife, Ava, came in to start my induction. Because of the risk of uterine rupture we couldn’t use the same drugs we used with Lexi. Instead we used a cook catheter. They filled a balloon like catheter with water to manually dilate me. It was uncomfortable but not painful. They gave me a sleeping pill to help me relax and get some rest. 

After it was place Nick came back to the hospital because my parents had arrived from Chicago to watch Lexi. He brought me dinner. It was the last solid food I would eat for 24 hours. 

At 7:30am on Friday Ava woke me up to remove the catheter. It had gotten me to 4 centimeters, which was the goal. And I was having light contractions on my own! She gave me a huge hug and told me I was going to get my VBAC. 

The nurse then let me order some Jello and an Italian ice. Because I was a VBAC patient I was treated like I could be taken for surgery at any moment. It was very frustrating. I was so hungry and thirsty all day long. I snuck drinks of water whenever possible. 

At 9am my nurse, Kelsey started Pitocin. I had the drug with Lexi after I stalled out. It makes contractions very intense without a break in between. 

We started it very low, though, since I was having some on my own. 

At 10am our doula, Jessica, arrived. After that she and I walked the halls and sat on the exercise ball to get me progressing more. 

Over the next few hours they slowly increased the Pitocin and I alternated waking, bouncing and laying down using a peanut shaped exercise ball to help keep things moving. 

Around 2pm things suddenly got very intense! It was a very sudden change that I had trouble coping with. I asked to get into the bath tub, which helped so much with Lexi. 

Just before 3pm I got into the huge soaking tub in my room. I was expecting instant relief like I had during Lexi’s labor. Instead things got even more intense. I wasn’t getting a break in between contractions. They were coming one on top of each other. I felt like I couldn’t even catch my breath. On top of that the monitors around my belly kept sliding as I was trying to find a comfortable position so Kelsey had to keep trying to put them back on. Having someone constantly touching me and pulling at the monitors hurt my focus even more. 

After only 40 minutes in the tub I said I needed an epidural. It was not at all in my plan but I knew my body was very tense from the back to back contractions and I knew that would slow me down. Jessica tried to talk me out of it- like I had requested prior to labor- but I told her I knew I needed it. I was afraid of stalling for hours like I did with Lexi and knew I needed some way to relax. 

The anesthesiologist arrived about 20 minutes later and I requested a very light epidural so I could still move. Placing it was much easier than it was with Lexi, but it was still very uncomfortable. I hate the feeling of a needle in my back and with non stop contractions it was hard to hold still. I think I almost broke Nick’s hands holding him so tightly to keep from moving. 

The epidural was a walking epidural so while it took away about 80% of the pain I still felt pressure with every contraction and I had most of my movement. We spent the next few hours getting me into multiple different positions using the peanut ball. I was even able to get onto my hands and knees. Anything to move the baby lower and help me dilate. 

Around 6pm after our nurse kept having to fix the monitors on my belly we decided to break my water and put in some internal monitors. 

The new midwife, Megan, checked me when she broke my water and I was 7cm. She also noted that Blake’s head was “like a bowling ball.” She said he was very low and his head was still very round with no molding. She said it was a great sign for my VBAC because it meant he had plenty of room. 

With the internal monitors my stomach and back got a break from the bands that had been around them since about 2pm the previous day and we could really move me into different positions to get past the last 3cm. 

Around 8:30pm I felt different. I could feel intense pressure and suspected I was completely dilated but I tried to ride with it and let Blake get lower on his own. With in about 10 minutes my whole body was shaking. 

We called the on-call midwife, Theresa, at about 9pm to check me and she said I was complete! It was time to push! It brought me to tears to know my body had done it. Now I had a little more work to do to get Blake here. They turned down the epidural so I could have even more feeling and mobility. 

About 20 minutes into pushing Blake’s heart rate dropped very low and then shot way high. Theresa called the on-call doctor, Dr. Winter. I had been told before that he was the most VBAC friendly doctor in the practice so I was hopeful he would help me keep fighting since we were so close. 

Dr. Winter asked me to stop pushing and breathe through some contractions. That was so hard to do! I now had full feeling and they were intense. They gave me oxygen to try and help Blake. 

The room started filling with more and more people and they were all just watching the monitors and Blake’s heart rate. 

I kept my eyes closed tightly. I just kept telling myself it was going to be ok no matter what happened. If I needed a cesarean I could do it again but I just tried to stay positive. 

Jessica asked if we could try pushing again and Dr. Winter agreed it was worth a try. She grabbed a sheet and she and I played a sort of tug of war game with it. Using the leverage I got from pulling on the sheet helped a lot. And instantly Blake’s heart rate stabilized. He was ok. We could continue pushing!

Soon I could feel a change. Everyone kept saying they could see more and more of Blake’s head. Nick announced Dr. Winter was taking off his watch so we must be close. That made me laugh and gave me the energy to keep going. 

At 10:11pm, about an hour after I started pushing, I felt a pop and out came Blake’s head. He was already screaming before my next push delivered his shoulders! 

Instantly he was on my belly. The nurses worked to clean him up without ever taking him away. 

I couldn’t believe it! I had done it! I dreamed of this moment ever since Lexi’s birth and we had done it. I couldn’t stop laughing and crying. I was just so happy!

Nick gave me a hug and said “I told you it was going to work out.” He was right. He had faith the entire time even when I worried I wouldn’t be able to do it. 

Soon Blake wanted to nurse and latched on with ease, just like his big sister. 

With in a half hour our room was about empty. The nurses tucked him in on my chest and said they would come back in a few hours to weigh and measure him. We had uninterrupted bonding time. 

As the last nurses were leaving one asked if anyone had called the OR to tell them we weren’t coming. That’s when I realized how close we had come to needing a cesarean. If it weren’t for Dr. Winter, I would have been rushed to the operating room. He took time to let Blake recover and saw how effective my pushes were and let us continue. My midwife told me the next week that he told her it was the right call to give us time. He said Blake came out screaming and so responsive that he knew there wasn’t ever an issue. 

I am so thankful for doctors who believe in a woman’s right to options and those who trust our bodies to do what they are made to do. 

It was a lot of hard work and some scary moments but I am so happy with how things went. I knew instantly it was the right decision when Lexi came to visit the next day and was able to jump right in bed with Blake and me and I never had to worry about her hurting an incision on my stomach. 

This picture below shows all of the emotions that flooded out when Blake was born. I’m still so happy and proud we were able to have the birth we wanted.

Thank you, Jessica, for sharing your story!

Autumn’s HBAC Birth Story

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Share your story with ICAN to be featured on our Instagram and Facebook! All cesarean and birth-after-cesarean stories are welcome: the difficult, the triumphant, the still-processing, and the stories which haven’t yet been shared. Sharing your birth story can be freeing, healing and profoundly powerful. It can bring others hope, comfort, and reassurance that they are not alone on their birth journey.

Submit your story HERE: https://airtable.com/shrJOtXla9O9MVBaj

Autumn shares her HBAC birth story. Thank you for sharing your story for all to read!

“March 2nd – I had woken up after having a few random contractions through the night. I woke up around 7am to nothing but my back was hurting like period cramps pretty much on and off all day. Around 2:30 pm I started feeling contractions. I decided to make me and the kids a pizza while we waited for my husband to come home from work. My husband got home around 3ish. Contractions picked up a bit once he got home, like my body and baby knew, “Okay you don’t have to be solely in charge now, let’s do this”. When I was up and moving they were every 2-3 minutes lasting about a minute. If I was just relaxing they were every 5 minutes lasting about 40 seconds. Our neighbor asked us if we wanted to let the kids play outside for a bit, which thinking it would be a bit still, I said of course. I decided to take a quick shower first though around 4. At 4:30 we all went outside to let the kids play. I was having contractions every 2-3 minutes at this point. I ended up going into my basement because I couldn’t socialize and needed to breathe through them at this point. I called my mom/doula and had 2 contractions on the phone with her and she said, “Yeah you sound like you’re in it right now, let me know when you leave”. I called my midwife next and let her know what was going on. As the next contraction hit I knew we had to go. So I opened the door and called my husband and told him we needed to get going that things were getting intense fast. So he told everyone it was time and they had to leave and got the kids ready. I threw my cold drinks in our cooler bag and grabbed my birth ball. My husband threw it all in the car and we got on the road around 5:15pm. I texted my photographer, midwife and mom and let them know we were headed out. We got to my midwives house around 6pm.

At this point I completely felt like I was at my breaking point and done. I would moan “low” through my contractions. I held my son for a bit through a couple of them while my team got the birth book started and everything ready and set up. I moved into the living room and tried leaning over my birth ball but that HURT more so I just stood and rocked over the back of a chair. I ended up putting my headphones in and throwing on some meditation music that had lots of low tones. I was getting good breaks in between contractions but when they hit it was HARD and I would moan or growl through them. At some point my dad came and picked up our soon. Our daughter stayed with us and would hug me or rub my belly.

Around maybe 6:45pm I was growling and grunting through contractions and there was a lot of pressure. My midwife asked if I was pushing and I said no, she and my mom chuckled to each other because they knew I was. But I said no because *I* wasn’t. It was my body. Finally I had enough and stripped down and got into the pool around 7pm.

As soon and I got in my contractions shifted and each one my body was pushing my baby down and out and I could feel all the pressure of his head coming through my birth canal. I broke for a bit saying how I couldn’t do it and just needed a break to breathe. My mom told me I was and had to. My husband reminded me that I was and that this was the point of him coming. My daughter said to me, “Mommy you have to push the baby out now. He has to come out, you can do it”.

A few more contractions and the ring of fire happened and I yelled, “It burned!” (LOL). I felt down though and his head was right there behind a bag of waters. Another contraction and his head was out, with my waters breaking right before. There was a pause before the next contraction to push his body out. Fetal Ejection Reflex is so strong and so crazy! Baby boy S was born at 7:10pm.

We sat in the tub for a few minutes before getting out and moving to the bed. On the bed we delivered the placenta. I did consent to a shot of Pitocin because I was having a little trouble delivering the placenta. Once it was out everything was fine though. No tearing and no hemorrhages. Our daughter was with us the whole time and cut the cord once it was white. It was such a fast birth and took me by surprise especially because of how quick I went from, “Okay I’m laboring” to “Okay he’s coming” and because I was so aware between contractions of what was going on. Baby S is perfect though. 10/10 APGAR weighing 8lbs 6oz and 22in long with a 14.25cm head. He is the calmest, happiest baby we’ve had. “

Congratulations, Autumn and family, on your newest addition! Thank you for sharing your story!

VBAC After Cesarean for Arrest of Descent or CPD

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VBAC after Cesarean for Arrest of Descent or Cephalo-Pelvic Disproportion –  written by Pamela Vireday

A cesarean for “Arrest of Descent” means a cesarean done after a woman has dilated fully and pushed for a while without the baby descending. The amount of pushing time required for the diagnosis varies from source to source but is usually at least 1-3 hours.

When a woman has a cesarean for Arrest of Descent, she is often told something is wrong with her pelvis. She might be told she has:

  • A “flat” sacrum
  • A “prominent” sacrum
  • A pubic arch that is “too narrow”
  • Ischial spines that are “too prominent”
  • A pelvis that is “too small”
  • “Too much soft tissue” (fat) lining the vagina/pelvis
  • A pelvis that is the “wrong shape”
  • A baby that was “too big” for her pelvis
  • “Cephalo-Pelvic Disproportion” (baby too big and pelvis too small, causing baby to not fit)

Often women who have been told these things are strongly discouraged from tryingfor a Vaginal Birth After Cesarean (VBAC). There are documented cases where women have been told their pelvis is too flat or too small to have a VBAC, that they have “soft tissue dystocia” (a.k.a. “fat vagina“), that their pelvis is the wrong shape, or that since they couldn’t push out a baby before, chances are they never will be able to because CPD is a recurring condition:

Yesterday, at my appt, while speaking with one of the midwives – she asked if I wanted her honest opinion & that if I was unable to push out a 7 and 1/2 pound baby and 2nd babies are normally larger then she didn’t think it would be successful.

The bottom line is that providers that are not truly VBAC-supportive often make women believe that something is wrong with their bodies and that they have little chance of having a vaginal birth, implying it’s better just to schedule a repeat cesarean. Then the care providers conveniently have fewer VBAC labors to attend.

However, many women who have been told they have an abnormal pelvis or soft tissue dystocia or who have had a cesarean for Arrest of Descent or CPD have gone on to have VBACs anyhow.

And a new study just out confirms that many women with a prior cesarean for Arrest of Descent do indeed go on to have a VBAC and should not be discouraged from trying.

New Study on VBAC after Arrest of Descent

A recent American study (Fox 2018) shows that VBAC after prior Arrest of Descent is often successful.

In the study, one hundred women who had one prior cesarean for Arrest of Descent had a “Trial Of Labor After Cesarean” (TOLAC or TOL). A whopping 84% ended up having a VBAC. This is an excellent rate and better on average than many VBAC studies.

The authors concluded (my emphasis):

This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD [Cesarean Delivery] for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.

The fact that the authors state this so strongly in an obstetrics journal is a big deal because it goes against what is commonly taught to many OBs, so let’s reemphasize those points:

  • Arrest of Descent is NOT usually due to an inadequate pelvis
  • “CPD” is not necessarily a recurring condition
  • Women with this history should not be discouraged from trying for a VBAC
Many women can and DO have VBACs after diagnoses of CPD and Arrest of Descent. Yet strong discouragement away from VBAC is exactly what happens to many of these women, even today.

Other Similar Studies

Was this study just a fluke? What do other studies on Arrest of Descent say?

There are only a couple of studies that specifically use the term “VBAC after Arrest of Descent” so you have widen the search a bit. Other search terms to consider include “CPD + cesarean,” “cesareans after full dilation,” or “cesareans done during second stage of labor” (pushing), or “prolonged second stage,” or similar terms. Carefully vetted, these are essentially Arrest of Descent cesareans too.

If you just look at studies that examine VBAC after a cesarean for CPD, research reviews show that about two-thirds of women will have a VBAC. This rate is lower than for those whose first cesarean was for breech or fetal distress, but is still a very good rate. If all those women had been discouraged from VBAC or pressured into repeat cesareans, two-thirds of them would have had unnecessary cesareans!

There is very little data on women who have had more than one cesarean for CPD. However, one 1989 study did contain some data on women like this. If you crunch the data in the full text of the study, women with 2 prior cesareans for CPD had a 56% VBAC rate. So although we don’t have a lot of data on this, what we do have suggests that even among women with more than one cesarean for CPD, more than half will have a VBAC.

The doctors who like to discourage VBAC cite a discouraging 1997 study that found a low VBAC rate (13%) in women who had reached full dilation and pushed in their previous labor. However, the rest of the research is much more encouraging.

In one Californian study from 2015, 54% of women with no prior vaginal birth and a prior cesarean during pushing stage went on to have a VBAC. In other words, they were just as likely to have a VBAC as not.

Similarly, a Danish study found a 59% VBAC rate in women whose cesareans occurred at 9-10 cm of dilation (9 cm often represents a fully dilated woman with a cervical lip, likely due to fetal malposition). Again, more than half had a VBAC and avoided the risks of additional surgery.

But some studies have results even better than that. In a New York study, 74.5% of women with prior pushing-stage cesareans went on to have a VBAC, some of them with forceps help, which suggests that fetal malpositions were an issue for quite a few.

Echoing those numbers is a Canadian study that found a 75% VBAC rate in those with a prior second stage dystocia cesarean. A very small, older Irish study found a 73% VBAC rate in those with a prior cesarean in the second stage.

Similarly, an older Dutch study found an 80% VBAC rate in those with a prior Arrest of Descent cesarean. This echoes our current Fox 2018 study that found an 84% VBAC rate after prior Arrest of Descent.

In summary, the majority of the research clearly supports the idea that women with a prior cesarean that occurred after full dilation and pushing can be offered a “trial of labor after cesarean” and will have a quite reasonable chance for a VBAC.

In the end, the decision whether to go for a VBAC is the mother’s, but she should be reassured that she is just as likely to have a VBAC as not, and in many practices, especially with proactive care regarding fetal position, her chances are even better.

The Importance of Fetal Position

So what causes Arrest of Descent? Why does it happen in some births but not others in the same mother? The answer is usually fetal position.

In Arrest of Descent/CPD cesareans, the problem is usually the BABY’S POSITION, not the mother’s pelvis.

If the baby is not well-positioned, labor tends to be slow and extra painful. It often slows or stalls between 4-7 cm of dilation. Often the mother eventually dilates fully but there is little or no progress during pushing. Fetal distress may occur.

Some providers become impatient and intervene with procedures (like breaking the waters) which may do more harm than good. Frequently, they are too quick to move to surgery when more patience might see the position resolve or the baby be born just fine in the “less-optimal” position. Recent research suggests that more than three-fourths of women with prolonged pushing stages (more than 3 hours) will deliver vaginally if just given a little more time.

What kind of fetal positions can cause problems? Read here for illustrations and specifics of the different fetal positions. The Spinning Babies website also has many helpful articles and illustrations on fetal position and how to help create maximum room in the pelvis. In the meantime, below is a brief introduction of the most common fetal malpositions.

Keep in mind that Presentation refers to which part of the baby is presenting first, and Position refers to how the baby is oriented in the mother’s body in a head-down position. Also keep in mind that when describing fetal position, obstetric texts reference the back of the baby’s head (the occiput) and which way the occiput is oriented in relationship to the mother. Most laypeople find it easier to understand by thinking of which way the baby is looking, so I use both in my descriptions.

Both the Spinning Babies website and The Labor Progress Handbook by Penny Simkin et al. have many ideas for various ways to help malpositioned babies resolve their position, and for creating more space in the pelvis. We will discuss this further in future posts.

Occiput Anterior (Easiest for Birth)

Occiput Anterior or OA

The easiest fetal position for labor and birth is usually Occiput Anterior. This is abbreviated OA and means the baby is head-down with the back of the baby’s head against the mother’s front; in other words, the baby is looking towards the mother’s back. This position is considered the norm and the vast majority of babies will be born in this position.

Direct OA is when the baby is looking directly back at the mother’s sacrum. LOA is when the baby is mostly facing the mother’s back but his back is a bit towards the left side; ROA is the same but a bit towards the right side.

Ideally, the baby’s chin is tipped towards its chest so the smallest possible diameter of its head presents. If the baby’s head is not well-flexed, the presenting diameter is a bit larger. If the baby’s head is tipped to one side or the other, it can be even larger. More on that below.

Occiput Posterior 

Illustration by Gail Tully, Spinning Babies

One of the most common fetal positions that can cause problems during labor is the Occiput Posterior position. This is abbreviated OP; the back of baby’s head is against your back and baby is looking at your tummy. If the baby is directly facing your back, that’s direct OP; if it’s a little to the right or left, then that’s ROP or LOP.

Although many babies enter labor in less-ideal positions like OP, only about 5% stay posterior all through labor and deliver that way. Babies that come out in the OP position are sometimes called “Stargazers” or “Sunny Side Up.”

By itself, an OP position does not have to mean a cesarean, since most OP babies turn during labor and become OA before birth. The labor may be a little longer and more painful but it often proceeds just fine with a little patience. However, babies that are persistently posterior all the way through labor and birth have a high rate of problems.

Research clearly shows that persistent posterior babies have higher rates of cesareans for CPD or Arrest of Descent. This is because the presenting head diameter of a baby in OP position is larger than the baby in an OA position. In addition, the back of the baby’s head is against the mother’s back and that makes for a more painful labor, with lots of back labor and a slower dilation. This in turn often means lots of interventions from care providers that may make the situation worse, like breaking the waters, which takes away the cushion for baby to turn more easily and may lead to fetal distress.

However, OP babies do not always end with cesareans. With time and patience, an OP baby with a flexed head (chin to chest) can often be born vaginally. Alternatively, a vaginal birth may be possible if the care provider is patient and allows extra time for the baby’s head to mold enough to descend into the pelvis. When it hits the pelvic floor, it often then rotates from OP to OA on the perineum and may be born quickly. Often an OP baby can be helped to rotate to OA through manual rotation, an instrumental delivery, or maternal postural changes like the all-fours position.

But because of the impatience of many providers, the fetal distress that can occur, and the extra-painful, longer labors associated with OP babies, many persistent OP babies end up being born by cesarean.

Deflexed Heads

If a baby’s head is deflexed (not chin to chest), this can cause problems as well. A deflexed head makes the baby’s presenting head diameter larger. This means the baby may not fit through very well, or the baby needs extra time for its head to mold enough to get through. OA babies with mildly deflexed heads experience longer labors, but with a little patience, are usually able to be born vaginally.

However, significant problems can occur if deflexion is extreme. Extreme examples of deflexed heads include a brow (forehead first) or face (face-first) presentation. Although vaginal births of brow and face presentations have been documented, most often they end in cesarean these days unless the baby’s position can be resolved. Fortunately, brow and face presentations are quite rare.

Deflexed babies in an OP position are fairly common and result in many long, difficult labors. OP babies already start out with a larger presenting head diameter; when they also have deflexed heads (known as a “military” position), this makes the head diameter even larger. Big OP babies often have deflexed heads, making their head diameters even larger. These babies often have extremely long and hard labors, and many end in cesareans. Turn the baby around and/or tip its chin towards its chest so that the head is flexed and the baby would likely fit much better; many cesareans could be avoided.

Occiput Transverse/Transverse Arrest

Occiput Transverse, which can result
in Transverse Arrest

When a baby’s head is directly sideways, facing the hip, this is called Occiput Transverse or OT. Often OT positions are able to resolve to OA, but sometimes they do not and result in a vacuum extraction, forceps delivery, or cesarean.

OT often occurs when the baby was posterior earlier in labor, tries to rotate to anterior, and gets stuck in the process of turning. Sometimes it is iatrogenic (caused by the provider). If labor is slow, the care provider may break the mother’s waters in an effort to speed up labor. This removes the buoyant cushion that can make it easier for the baby to finish its turn and the baby may end up “stuck” in this position. This is called “Transverse Arrest.” A fair amount of cesareans are caused by transverse arrest.

Compound Presentation

A nuchal hand presenting alongside the head

Babies who have their hands up by their faces (a “nuchal hand” or sometimes a nuchal elbow/arm) can present another challenge.

The baby is basically OA and in a great position for birth, but the hand or arm beside the head causes larger-than-average presenting parts that must fit through at the same time. If the care provider can get the baby to pull back its arm/hand near birth, the baby is likely to then be born quickly. If the arm/hand remains by the baby’s head, pushing is likely to be slow, painful, and difficult. Usually babies with nuchal hands can be born vaginally, but there may be quite a bit of tearing and damage to the mother. If the provider is not patient during a slow pushing stage with a nuchal hand/arm, it may result in a cesarean.

Asynclitic Heads

Asynclitic baby in OA position

Similarly, babies who have their heads tipped to the side instead of straight (“asynclitic”) also have difficulty fitting. Instead of the top of the head presenting first, their parietal bone (bony side of head) presents first. The tipped head causes a larger than average head diameter that doesn’t fit as easily.

Many asynclitic babies will correct the tilt of their heads if the mother’s waters are kept intact and she is able to be mobile in labor. Asymmetric birth positions may help correct the tilt. Once the tilt is corrected, the baby is often born fairly quickly.

If the baby is not able to correct the tilt of its head on its own, then the care provider may be able to help through the use of a vacuum extractor or forceps. Sometimes the tilt of the head goes undiscovered or is not able to be resolved during labor; these babies often are born by cesarean.

Summary

Unfortunately, many women with a prior cesarean for CPD or Arrest of Descent are discouraged from even trying to have a VBAC. They may be told they have little chance at a VBAC and they should just schedule a planned repeat cesarean rather than risk another cesarean during labor. One woman was told:

You’ve already proven you can’t get a baby out of your pelvis.

Obviously, that OB believed that the pelvis itself was the issue, not the baby’s position, but the recent Arrest of Descent study suggests it is likely not true.

This kind of misleading “guidance” from care providers is not evidence-based. Most women with a prior CPD or Arrest of Descent cesarean who go through with labor actually have a reasonable chance at a VBAC, as this woman found:

The OB that did my c-section told me that my pelvis was small and also tilted and that because of that, a vaginal birth wouldn’t be possible. Well, I…went for a VBAC anyway and it’s a good thing I did because I had a wonderful amazing and natural VBAC with my next baby. And she came out in about 4 pushes. It was so easy! I had my second VBAC with my son a year ago and it went perfectly as well!

Here is a link to the story of another case where a woman who had a cesarean was told that her pelvis was too small to birth a baby and to forget about a VBAC. She went on to birth a 9 lb. baby ─ with a nuchal hand ─ as a VBAC. The Birth Without Fear blog has an awesome picture of it in their birth stories section.

That’s not to say that CPD is never real. Sometimes it is. Although most cases of “CPD” are actually situational (caused by a malposition), sometimes there are rare cases of true CPD. These are usually a result of significant malnourishment in childhood, severe scoliosis, a history of rickets, or a history of a bad fall or accident where the pelvis was damaged. And sometimes, women don’t have any of that in their background, really do try everything, and still end up with a cesarean because the baby just didn’t fit. It does happen and it’s important to acknowledge that.

But far too often, women who have had a cesarean after not being able to push out a baby are told that their pelvises are too small or defective, and they’ll never be able to push out a baby. This is not true. Many women with this history can have a vaginal birth, if given an adequate chance to do so. Anecdotally, many women who have been told this benefit from having a good chiropractor evaluate their back and pelvis to help maximize the space in it and get it well-aligned. See my story below.

Women with a history of cesareans for Arrest of Descent or CPD should be offered the chance at a VBAC if they want it. Chances are good they will have one. There are never any guarantees, but research clearly shows that trying for a VBAC is a very reasonable choice in this group and should not be discouraged.

My Story

Again, many women have had cesareans for arrest of descent and yet gone on to have a VBAC. Conventional wisdom is that you need a smaller baby to get a VBAC, but some women do have VBACs with a baby even bigger than their cesarean baby. Again, fetal position is key.

This includes me. I had my first cesarean after a difficult induced labor. I dilated to 10 cm and pushed for two hours in stirrups, but ended up with a very traumatic cesarean. With my second baby, I had a relatively easy spontaneous labor where I did all the “right” things including position changes but still had FIVE HARD HOURS of pushing with little descent of my deflexed OP baby. I ended up with a second cesarean for CPD.

Both of my babies were big. I was told I had a “marginal” pelvis by my first care provider, and unless I had a smaller baby I would probably not have a vaginal birth. After my second birth, a nurse-midwife told me I probably had a pelvic shape predisposed to posterior babies and my babies would likely always be posterior. After two CPD cesareans at full dilation and after hours of pushing, I was told I was extremely unlikely to have a VBAC. The “VBAC Calculator” gave around a 20% chance of having a VBAC if I tried again.

All these declarations were wrong in the end but it was difficult to have faith. In my third pregnancy, I wavered between choosing to labor again or just going straight to a repeat cesarean. The baby was consistently posterior again all through pregnancy and I had no desire to go through a long hard labor only to end up with another cesarean ─ but neither did I want to go through another surgical recovery. I was also worried about the increase the risk of placental issues from another cesarean if I decided to have another baby in the future.

Near the end of my third pregnancy, I found a chiropractor who did a lot of work on my pelvis, including the Webster Technique and releasing the round ligaments that attach to the uterus. She felt my history of car accidents was highly relevant to the malpositions going on. According to her, the significant back and pubic pain I was having indicated “in utero constraint” that was making it hard for my babies to be in the easiest position for labor. The chiropractic adjustments eased a lot of my discomfort and the baby moved pretty quickly into a more optimal OA position for the first time in three pregnancies!

I went on to have a VBAC after 2 cesareans (VBA2C), something many providers would have told me would be extremely unlikely with my history and risk factors (short, old, “morbidly obese,” big babies, two prior CPD cesareans, no prior vaginal births). Instead of pushing for 2 hours or for 5 hours as I did with my first two children, I pushed for 12minutes with that baby. The doctor didn’t even make it to the birth.

And it wasn’t just a lucky fluke. Several years later, I had another VBA2C, this time with a baby that was a pound larger than either of my cesarean babies. I only pushed for 24 minutes with that baby.

Afterwards I asked my midwife to evaluate my pelvis and tell me honestly if it was truly marginal or not. She examined me and said it absolutely was not. Either the prior evaluation was wrong or chiropractic care really did create more space in my pelvis ─ or maybe a little of both. I do feel that the chiropractic care was integral to my VBACs, given that I never had an anterior baby until I had chiropractic care.

Remember, each labor and birth is unique and previous problems do not necessarily happen again.

Even a history of more than one Arrest of Descent or CPD cesarean does not mean it will continue to happen, especially if the mother is very proactive about fetal position. I had a history of TWO cesareans for Arrest of Descent and still went on to have two VBACs.

I have known women who have had VBACs after 1, 2, and even 3 prior CPD cesareans, including full dilation and pushing for hours each time with no vaginal birth. Yet they still eventually had a VBAC. The International Cesarean Awareness Network (ICAN) has a number of stories of women who have had a prior cesarean (or more) for CPD or Arrest of Descent and yet went on to have a VBAC. You can see some of them in their “Question CPD” video below.

There are never any guarantees, of course, and there are important risks to consider with both VBAC and an Elective Repeat Cesarean. However, if you choose to labor, your VBAC chances are good, anywhere between 50-80% based on the research. Don’t let care providers convince you out of trying for a VBAC based on a past history of CPD or Arrest of Descent. In the end, it’s your decision.

References

J Matern Fetal Neonatal Med. 2018 Feb 27:1-5. doi: 10.1080/14767058.2018.1443069. [Epub ahead of print] Vaginal birth after a cesarean delivery for arrest of descent. Fox NS, Namath AG, Ali M, Naqvi M, Gupta S, Rebarber A. PMID: 29455594

…This was a retrospective cohort study of all patients delivered by a single MFM practice from 2005 to 2017 with a singleton pregnancy and one prior CD for arrest of descent. We estimated the rate and associated risk factors for successful VBAC. RESULTS: We included 208 patients with one prior CD for arrest of descent, 100 (48.1%) of whom attempted a trial of labor after cesarean (TOLAC) with a VBAC success rate [of] 84/100 (84%, 95% CI 76-90%). Among the women who attempted TOLAC, women with a prior vaginal delivery >24 weeks’ had a significantly higher VBAC success rate (91.8% versus 71.8%, p = .01). Maternal age, body mass index, estimated fetal weight, induction of labor, and cervical dilation were not associated with a higher VBAC success rate. CONCLUSIONS: For women with a prior CD for arrest of descent, VBAC success rates are high. This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.

J Matern Fetal Neonatal Med. 2017 Feb;30(4):461-465. Epub 2016 May 5. Prolonged second stage in nulliparous with epidurals: a systematic review.Gimovsky AC, Guarente J, Berghella V. PMID: 27050812

…A systematic review of the literature was performed… for case series evaluating the morbidities of prolonged second stage of labor. Search terms used were “prolonged”, “second stage”, and “labor”. Prolonged second stage was defined as three hours or more. Retrospective case series of prolonged second stage in nulliparous women with epidurals were identified. The primary outcome was the incidence of cesarean delivery. RESULTS: Two retrospective series with 5350 nulliparous women with prolonged second stage were identified. 76.3% (4 081/5 350) had an epidural. Of all nulliparous women with an epidural, 11.5% (4 081/35 469) had prolonged second stage. Cesarean Delivery occurred in 19.8% of these cases (782/4 081), while 80.2% had a vaginal delivery. CONCLUSIONS: Over three quarters of nulliparous women with epidural diagnosed with a prolonged second stage deliver vaginally.

VBAC After CPD Diagnosis
 
J Obstet Gynaecol Can. 2003 Apr;25(4):275-86. Vaginal birth after Caesarean section: review of antenatal predictors of success. Brill Y, Windrim R. PMID: 12679819

“…Even with a history of CPD, two-thirds of women will have successful VBAC, though rates decrease with increasing numbers of prior CS…There are few absolute contraindications to attempted VBAC. Attempted VBAC will be successful in the majority of attempted cases.”

Obstetrics and Gynecology. February 1989. 73(2):161-5. Twice A Cesarean, Always a Cesarean? Phelan, JP et al.  PMID: 2911420

[My summary of highlights from the full text] 501 women with 2 or more previous cesareans had a TOL, and 69% had a VBAC overall. Women who had had at least one previous cesarean for CPD had a 64% VBAC rate. Those who had had 2 successive labors both ending in c/s for CPD still had a 56% VBAC rate. In other words, even those women with a previous ‘failed’ trial of labor had a better chance of a VBAC than another cesarean in labor.

Other Studies on Arrest of Descent or Similar Definitions

  • Am J Obstet Gynecol. 2015 Dec;213(6):861.e1-5. doi: 10.1016/j.ajog.2015.08.064. Epub 2015 Sep 6. Effect of stage of initial labor dystocia on vaginal birth after cesarean success. Lewkowitz AK, Nakagawa S, Thiet MP, Rosenstein MG. PMID: 26348381
  • Acta Obstet Gynecol Scand. 2013 Feb;92(2):193-7. doi: 10.1111/aogs.12023. Epub 2012 Nov 5. Cervical dilation at the time of cesarean section for dystocia — effect on subsequent trial of labor.Abildgaard H, Ingerslev MD, Nickelsen C, Secher NJ. PMID: 23025257
  • Obstet Gynecol. 2001 Oct;98(4):652-5. Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor?Bujold E, Gauthier RJ. PMID: 11576583
  • Obstet Gynecol. 2000 Apr;95(4): S38. https://doi.org/10.1016/S0029-7844(00)00660-8 Obstetrics Prognostic indicators for successful vaginal birth after cesarean delivery. Marshak J, Cooperman BS, Fried WB, Shi, Quihu. Available here.
  • Br J Obstet Gynaecol. 1998 Oct;105(10):1079-81. Vaginal delivery after previous caesarean section for failure of second stage of labour. Jongen VH, Halfwerk MG, Brouwer WK. PMID: 9800930
  • Obstet Gynecol. 1998 Nov;92(5):799-803. First delivery after cesarean delivery for strictly defined cephalopelvic disproportion. Impey L, O’Herlihy C. PMID: 9794672
  • Obstet Gynecol. 1997 Apr;89(4):591-3. Correlation between maximum cervical dilatation at cesarean delivery and subsequent vaginal birth after cesarean delivery. Hoskins IA, Gomez JL. PMID: 9083318  

Blog reposted with permission of Pamela Vireday. You can check out her original post here.

Birth Story: Elisabeth’s VBA2C

by 6 Comments

Originally published 2012

andrew-branch-191920On the day of my 2nd cesarean section (C/S) I was nervous, anxious and just wanting to get it all over with. I had asked my OB about the possibility of a vaginal birth after cesarean (VBAC). She said she was supportive but also told me of her colleague she had just sectioned who (with her expertise) had chosen a repeat cesarean section (RCS) over a VBAC. With no encouragement and little knowledge on my part, I agreed to the RCS. I remember lying on the operating table. My arms strapped down. I had a mini-panic attack and knew right then that I would NOT be going through this again. Ever. So, for the next three years, I had NO desire to ever be pregnant again. Then, baby fever hit and hit hard!

With my first baby, I had decided to go about labor all-natural. No pain medicines. I thought just choosing that was enough. But before I knew it, this snowball effect of standard hospital interventions smothered my plans in IV’s, routine Pitocin to augment labor even though I was in active labor on my own, ephedrine to counter-act my reactions to the Pitocin, artificial rupture of my waters (AROM), epidural to counteract the unnatural Pitocin induced contractions, stalled labor, distressed baby, emergency C/S. The recovery was no fun. I took the prescribed pain meds and have little memory of the first week with my new baby. I healed well and quick but it was not the birth I had envisioned for my first baby.

Fast forward to 2011, we finally, after 4 years of trying to get pregnant, found out in December that baby #3 was on his way! After the initial celebrations settled down, I began to pour myself into all the resources I could get my hands on about natural childbirth and VBAC’s – I was doing my homework this time around! I had my Husband’s full-support as he wanted a better birthing experience as much as I did.

We hit many obstacles! After consultations with several OBs and a midwife, I was told over and over again that I was a great candidate for a VBA2C (vaginal birth after two C/S) but that hospital policy prevented me from being allowed a trial of labor (TOL). At 18 weeks gestation, I finally found a midwife group and get this… a hospital (!) who would allow me to attempt a VBA2C!!! I also found an excellent Doula who had a high VBAC success rate!

At 1:00 pm, at 39 weeks and 1 day, my water broke! An hour later the contractions his hard and fast! We were 1.5 hours from the hospital and thankfully my dear Husband completely ignored me when I assured him we had plenty of time before heading to the hospital! By the time he loaded up the MommyMobile and we got on the road is right when my contractions hit! When we got stopped in traffic I remember telling him there was no way we were going to make it to the hospital! But, God got us there safe and sound and just in time!

After some hassles through triage, I was in my room pretty quickly. Somehow when I called ahead the staff had alerted the midwives about a different patient coming in so for a while they didn’t realize I was their VBA2C patient! This blip allowed me the opportunity to strip down and jump in the tub (that my Doula started filling for me immediately) and avoid the baseline monitoring they wanted on the baby and the IV which was mandatory for VBAC patients!

The water didn’t bring the degree of relief that I had anticipated but the thought of getting out of the tub was unbearable. The pain was more intense than I had anticipated. At some point, they realized I was indeed their VBAC patient and the room was buzzing with people. I tuned them all out. I remember an OB coming in to get my consent to a C/S “just in case”. I just ignored her for as long as I could and continued tuning everyone out. At one point the pain was too much. I remember talking to God and just resting on Him. At this point, I knew people were around me but I had just checked out and no one had any effect on me. I was just resting in God’s strength because I didn’t have enough on my own. (My husband later told me he thought I had fallen asleep!) All of a sudden, my body just took over and started pushing. It hadn’t even dawned on me what was happening until I heard the midwife call out, “Is she pushing?”. That snapped me out of my God time and the energy in the room consumed me again. That darn OB was still there trying to get me to sign that C/S form despite my best intentions to ignore her.

The midwife checked me and I was complete. My body was expelling my baby anyhow so it didn’t really matter to me at that time if I was complete or not! As per hospital policy, I was only allowed to labor in the tub, but not allowed to deliver in the tub, so the midwife began trying to coax me out of the tub. I ignored her, yelled at her, refused but then finally gave in. My Doula and husband helped me out and dressed me in the gown I had packed.

On the way to the bed, that pesky OB handed me that form to sign again… I scribbled something on it but I doubt it resembled a signature at all. Before making it to the bed, a pressure wave hit so hard I just lowered myself down the ground. Squatting was all I could accomplish at that moment. The nurses and midwives were in a rush to get me on that bed and hooked up to the monitors and IV’s. But, after the way my first labor went downhill with the onslaught of interventions, I refused everything! They monitored baby the old fashioned way while I labored beside the bed.

After a bit, my legs felt too weak and my Doula suggested laboring on the bed but on my right side (I was not about to labor on my back)! My body was still pushing through all of this. The nurse kept trying to get me to agree to the IV all the way up until I was delivering the baby which I continually refused. I’m not sure how many pushes but after about 45 minutes of pushing, I succeeded in birthing my baby! My body was not broken. It knew exactly what to do when left to its inherent devices!

Sweet baby Elias Walker was born at 5:27 pm, just 2.5 hours after we made it to the hospital! No pain medicines. No interventions. He was born the old-fashioned way! I had succeeded at my VBA2C!!! After giving the umbilical cord time to quit pulsating on its own, my dear husband got to cut the cord!

I have to add that through the entire labor, even with contractions right on top of each, no break in between, I never once feared a uterine rupture. To me, that was one of my top reasons for hiring a Doula. I wanted someone who was on MY team, had a vested interested in my success who also knew enough to assure me when everything I was experiencing was completely normal but also would alert me if something I was feeling was NOT normal! Janet was my rock and my husband and I are eternally grateful for her role in VBA2C!

I have absolutely no regrets! What I gained from this experience, other than some frustrations over hospital “policy” and “standard care”, is that our bodies know how to birth our babies. Yes, there are exceptions to that rule, but I truly believe that when we set all the inventions that get in our body’s way aside, it is fully capable to do what God granted it the ability to do – bring life into this world!

As a Childbirth Educator In-Training, I am so thankful for the personal experience I will be able to share with families planning the birth of their babies!

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