We are a statistic.
My daughter is small. She always has been. We go to the pediatrician and get the charts and she’s way at the bottom of the bell curve. 5th percentile, 10th percentile, sometimes 15th but always small. Her doctor said to me once, “Don’t worry. Someone has to be at the ends to create the averages.”
That someone is us. Our children hold down the statistical ends and create averages. Defying the odds. Statistically unlikely. Nothing to worry about.
“Fortunately, a uterine rupture from a prior cesarean with a low-transverse scar is a rare event and occurs in less than 1% of women laboring for a VBAC.
Medical experts state that the risk of a uterine rupture with one prior low-horizontal incision is not higher than any other unforeseen complication that can occur in labor such as fetal distress, maternal hemorrhage from a premature separation of the placenta or a prolapsed umbilical cord.”
What happened to Harvey could not be explained. A healthy pregnancy, a normal labor with neither of us showing signs of distress, a fetal heart beat heard just minutes before the final push. And then, dead baby. The midwives worked on him, the medics worked on him, the doctors in the ER worked on him and got him back. Well, got his heart started again.
Harvey’s doctor in the NICU chose her words carefully. She focused solely on the 24-27 minutes without a heartbeat. Something was wrong with his heart, it stopped beating, he suffered brain damage from lack of oxygen to the brain due to stalled circulation for “an extended period of time”. Her concern was the 24-27 minutes after birth, she said repeatedly. So much so that, she would not look at the homebirth chart notes. She would focus only on the moment of birth on. I said, “But he his heartbeat never faltered during birth”. I said, “He had a heartbeat just a few minutes before he was born.” With her carefully chosen words, she basically said that we couldn’t know those things for sure. And she wouldn’t look at the chart notes. (I don’t know if you have ever seen home birth chart notes but there are an extensive documentation of everything that is happening. I don’t know how they do it and take such good care of a laboring mother and then her newborn, but somehow the notes are just minutes apart. I have never seen chart notes for a hospital birth, perhaps it is the same. Perhaps they are documenting every significant event, vital sign, shift, words the mother says and other observation several minutes apart for hours but I doubt it.) And so here it comes: the first judgement, the first person who knows better than I, the first criticism, now thinly veiled since my baby is about to die. Behind her carefully chosen words was “You had a home birth. This is a bad choice that put your baby at risk. The only relevant information begins when you entered the hospital system”. I want to say, “I didn’t hire a bunch of teenagers to birth my baby. I want you to be a scientist and be curious and use every spec of information available to figure out what happened.” My friend, who has no opinion on birth venue says, “You should get a new doctor. Why doesn’t she want to know what happened during the birth?”. But we don’t have it in us. We just put our trust in the opinion of this lady who thinks our baby is dying because we weren’t at a hospital. Later, when his death becomes absolutely clear, she says, “This happens with babies born at the hospital, with babies born at home or anywhere else. They suffer insults during birth that we cannot explain, that come with no warning, and they die. And I’m so very sorry.” I appreciated hearing her say that, her attempt to absolve me or at least give me a little peace.
For a week after Harvey was born, I stuffed and muffled and attempted to ignore the voice that said, “You killed your baby.” The voice that ran all the scenarios, that also focused solely on those 24-27 minutes, that told me “If you were at the hospital, they would have gotten his heart started right away and saved him.” If there wasn’t time it took for us to realize he was not okay, for the ambulance to arrive, for them to get him from the house to the vehicle to the hospital to the ER doctor who finally got his heart started. That series of events was a result of my poor choice, that felt like the right choice. If I had not put my baby in a position in which he could not be resuscitated for nearly a half an hour, he would be alive. Another voice quietly wondered, “How are you ever going to live with yourself?”. My husband and I got on the same page so that when we talked about what happened to him that we would not reveal that we were at home when he was born: “Something was wrong his heart, they couldn’t get it started in time and he died.” I had such intense judgement of myself that even the slightest insinuation, even that little bit that crept through the doctor’s words, was unbearable for me. The inside judgement, guilt, shame, anger were exactly as much as I could take. Any sideways word from the outside would literally break me. How would I ever live with myself.
Uterine rupture in pregnancy is a rare and often catastrophic complication with a high incidence of fetal and maternal morbidity. Numerous factors are known to increase the risk of uterine rupture, but even in high-risk subgroups, the overall incidence of uterine rupture is low. From 1976-2012, 25 peer-reviewed publications described the incidence of uterine rupture . . .yielding an overall uterine rupture rate of 1 in 1,146 pregnancies (0.07%).
It didn’t make sense. His heart was the only donatable organ in his body. It never faltered during the whole pregnancy, nor during the labor and birth. It was there and then 5 minutes later, it was gone. How could it be that there was something wrong with his heart? I trusted that doctor because she must know something that I don’t. She is not grief-stricken, post partum and in physical pain, so there must be something that I am missing. She is an educated and experienced neonatologist. Sure she wouldn’t look at the birth notes, but she must be confident enough that it was his heart to tell us so, even though she did say that there truly is no explanation. It rolled around in my head. It was an annoying fly buzzing around in there. “It just doesn’t make sense. His heart was fine.”
One week after Harvey was born, my parents took me to urgent care. I had run out of pain medicine, they didn’t prescribe narcotics over the weekend and so I had to go in to get reevaluated. The advice nurse on the phone, after hearing my circumstances, attempted to get them prescribed for me so that I wouldn’t have to leave my bed. To no avail. I had to go in. So, before we grabbed lunch, they drove me over for a quick evaluation, a prescription and off we’d go.
Eric M was a physicians assistant who saw me. He came in and talked to me for about 15 minutes about my grief first, how I was handling it, what they could offer me in terms of support. He then examined me. He asked me many questions. Sometimes, he asked the same question more than once. I didn’t down play that my pain had increased from the previous day, but it had been changing day to day, I had walked more yesterday, sat in the park for hours, it could have easily been explained away. He very easily could have done what I was asking: just give my pills so I could get out of here. He gently but firmly suggested I have an abdominal ultrasound. I reluctantly agreed.
My step-mother wheeled me towards the ultrasound room. I didn’t realize until I was standing up out of the chair that I was about to lay down on the table and look at the grainy, blue-black and white image of my empty uterus. The techs at this hospital do not know the details of patient’s case that they are working on, so she happily bopped into the room and began the procedure. I asked her to turn off the TV monitor, positioned so that the patient (aka happy mother about to see her baby) can see the whole thing. She did so and asked questions that ended up in my having to say I was pregnant, I am postpardum and the baby died. And that was the first, not the last nor the hardest, time I had to tell an unsuspecting stranger the tragic news, hear the initial gasp of air, the slight squirming, hands to her heart, embarrassed and apologetic and so, so sorry for my loss.
I was wheeled back to my room and then the wonderful PA, who as it turned out, could very well have just saved my life, came back into the room. He told me clearly but compassionately that the found a large hematoma between my uterus and bladder and that I would be taken to the hospital by ambulance, right now. He continued speaking about internal bleeding, abdominal surgery and emergency and then he became Charlie Brown’s teacher, “mwaht maht maht mah mwah” as I was flung right back into shock. There I sat, dumbfounded and unfeeling, staring again at a hospital wall thinking as a lady came in to take blood and out in an IV. People were coming in and out of the room, making preparations, my family decided my dad would ride in the ambulance and my step mom would take the car back to my husband. “Oh,” I thought slowly, “I should probably tell Danny about this” and slow as molasses, I dialed his number. He was scared but calm because now we are old hat at this, a good ol’ boys team at emergency situations. He would meet me there.
I ended up spending my son’s one week birthday in a hospital bed as our friends and family from far and near were arriving and gathering at our home. My greatest fear was that I would miss his service the next day, due to the seemingly likely event that I would need to have abdominal surgery to stop whatever internal bleeding was happening. Seemingly every nurse, doctor, and CNA told me they knew about the service and were doing their best to get me out in time to attend. I had a CT scan and a morphine drip and life was good. I felt so normal. I knew my son was dead, I knew I was in for possibly more medical intervention and extended physical pain and recovery but I just felt normal, unconcerned, like everything was going to be okay. It was wonderful. The next day as the morphine slowly wore off, I felt my heavy heart pull my spine back into it’s new, defeated C curve shape, I felt the heaviness of my loss and the bubble of thick sorrow that surrounded my return. Having had the relief, the several hours of neutrality thanks to Morphine, my new reality seemed even harder to return to.
It turned out that the incredibly unlikely event of uterine rupture had happened to me. The uterine muscle tore apart at the scar of my previous c-section from the inside out. The hematoma they found in my abdomen was actually held just inside the outer most layer, the skin, of the uterus. I was one thin layer of tissue away from an internal organ bursting open. I was saved. By whatever luck that I had that was not shit, I did not die in child-birth, I did not continue to bleed internally, I did not have to have abdominal surgery, at least not today. I was saved.
But mostly my luck was shit.
“The initial signs and symptoms of uterine rupture are typically nonspecific, which makes the diagnosis difficult and sometimes delays definitive therapy. From the time of diagnosis to delivery, generally only 10-37 minutes are available before clinically significant fetal morbidity becomes inevitable. Fetal morbidity occurs as a result of catastrophic hemorrhage, fetal anoxia, or both.”
While the risk of rupture is only about .07% for all mothers laboring for a VBAC, birth professionals are always on the look out for signs and symptoms. I had exactly zero symptoms: no pain between contractions. As most birthing mothers, I greatly looked forward to the time between contractions when I could breath deeper again, when I would have a relief from what felt like the entire front of my pelvis being slowly but surely torn apart. No vaginal bleeding. No change in vitals. No change in frequency or intensity of contractions. Nothing. Harvey either. All we have to take care of our babies during birth is their heartbeats. His never faltered. He had one way to communicate to us and it failed him. He and I, too hardy for our own good.
So, my uterus tore open and killed my baby. My body turning on its precious cargo. The blood that was supposed to go to my baby was spilling out of the uterine cavity and he, slowly but surely, began to lose brain function. Not enough blood, means not enough oxygen, means death of brain cells. I imagine that it happened over several hours. The scar slowly continued to tear contraction by contraction, the blood slowly diverted into complete uselessness, the slow death of my son more and more inevitable. I believe that he had a heartbeat minutes before he was born because his brain stem was only starting to shut down. Perhaps the intensity of being born and the progress of the brain death culminated in a few minutes and at the time of his birth, 6:02am PST on Saturday, April 24th, 2013, he also died. The brain had suffered so extensively that it began to shut down even involuntary function, like heartbeat, circulation and life. They got him back and we go to have time with him but he was dead when he was born. I felt it in my bones.
None of this is true. No one can confirm it. It just makes the most sense. It is the most logical explanation. It confirms my suspicion that there wasn’t anything wrong with his heart. It gives me relief from an incredible amount of guilt and shame for being so committed to a VBAC and a home birth. It gives my grieving brain something to point to, soothes some important human desire to know “why”. It wasn’t the 24-27 minutes without a heartbeat (though that certainly didn’t help) but that my kid’s brain was significantly damaged already. Without symptoms, my baby would have died no matter where he was born. “We see this”, said the neonatoloigst, “seemingly healthy babies with normal deliveries die.” This is true.
“For term pregnancies, the reported risk of fetal death with uterine rupture is less than 3%.”
There is comfort in these numbers: less than 1% chance of uterine rupture and, within that miniscule amount, there is a less than 3% chance the baby will die. There is comfort in being the outlier, in holding down the ends of the bell curve. There is comfort in knowing that there were risks in a second c-section that held a higher probability of happening and I made the choice that made the most statistical sense.
There is no comfort however in shit luck. In being too hardy. In becoming a statistic.