VBAC, and Bonding of new Dads

It is now Saturday morning, about 10:30 AM. I just finished doing a repeat Cesarean Section of a 38 year old woman at 39 weeks. Her last baby was born by a different Ob. For her first baby she labored for days, eventually the labor obstructed, and she even got a fever. Then she got a section. That kind of a labor, with obstruction, and eventually infection, really stresses the mother and her baby. The risks to the mother and the baby increases over time. If those risks are not mediated and managed, then eventually there will be a catastrophic outcome. In those situations, the Cesarean is lifesaving for both her and her baby. And, it will likely save the baby from terrible brain damage or something awful if the infection is unchecked. If the labor obstructs beyond reason, then she would have had what we call a "neglected labor". These are deadly. Neglected labors still happen around the globe. We must all work towards a just and compassionate world where every human being is allowed a safe birth. Fortunately, around here, neglected labors are rare. They show up once in a while though. Usually it is a women who makes an ill advised attempt at a home birth, using incompetent assistants.  This might might be an untrained or unlicensed midwife. Or, someone who has no midwife at all. Last year I met a mom of a quadriplegic baby who attempted an unsuccessful and ultimately traumatic home birth. It was tragic. This happened in the next town over.

My patient this morning recovered from her prior labor and section just fine. Even though she was quite tired. I believe that her prior care was provided in a competent and timely manner, she received her antibiotics, and everyone was happy in the end. The problem was that the labor obstructed. One will never know if a labor is destined to obstruct, unless one tries to labor. Sometimes a malpresentation can make the obstruction obvious even before the labor begins, such as a transverse or sideways baby.

So at the beginning of this pregnancy, we had a discussion about the possibility of attempting another labor. I discussed with her the possibilities, and under what conditions it might be safe enough to try for a Vaginal Birth After Cesarean, a VBAC. VBACs are still allowed by the medical establishment. The risks are well known. About one in 300 uteri will actually rupture open in labor, through the old CS incision. This can permanently injure or kill that baby, and/or the new mom. VBACs can only be conducted by a hospital and medical team that is available for "Immediate" surgical intervention. With immediate intervention, most of these new moms and their babies can be saved from a uterine rupture. VBACs can only be conducted if the labor seems medically "easy". That means there is no sign of obstruction, the labor starts naturally, and it progresses well. Without that, the new mom must have a repeat CS.

Our hospital and my practice does provide this level of care. To maintain this level of care, we need an obstetrician on the OB unit, at all times ready to go. I personally volunteer to take my shifts on the OB unit to provide this care. We also need an operating room open and usable at all times. We need an anesthesia provider always available. We need nursing staff ready, able, competent, and confident enough to intervene at a moments notice when the signs of uterine rupture are present. Many, if not most, hospitals, do not have such depth of resources. And, even more importantly, the skill set of all the involved personnel must stay fresh. A hospital that delivers one baby a day may see a uterine rupture once a decade. Or never, if VBACs are not allowed. A hospital that delivers 10 babies a day, with a big high risk population, will see it routinely.  I have personally saved more than a few babies from abrupted placentas, uterine ruptures, knotted umbilical cords, and other various catastrophes. It feels really really good to save a life. I have a wonderfully rewarding life and I am very very glad to be here doing what I do.

Anyway, this morning, we had a 39 week mom, of advanced maternal age, with no sign of labor, and some risks if she did. The baby was biggish, in the 8 pound range, close to 4 kilograms, and the baby remained very high out of the pelvis. We both chose to repeat the CS and get the baby out while the baby is good. Other women might want to keep trying for a vaginal birth, to give it a few more days or weeks. If she understood the risks then of course we would honor her request for more time. If she understood and wanted her baby out now, by CS, then of course we can do that too.

Typically I don't provide a "take it or leave it" approach. I tell the woman and husband what I think. I give them my recommendations, and my thoughts, and my estimate of odds, and I let them come to the conclusion that is best for them. Almost always, people are happy to think these thoughts. Sometimes, they really ask penetrating questions about what I think they really should do. If they ask like that, I go back and review what I think might make them the happiest, I might review the risks either way, and tell them what I think. Sometimes it is a section, sometimes it is to wait.  But the time crunch is always a problem. Usually, I wish I had more time to do these things. I do my best to allocate enough time. There is never enough time.

So I was doing a CS about 8:45 this morning and everything is going well, and we are listening to nice music, and the baby seems really happy, and the mom is smiling while we are working. I noticed that the new Father is really bonding well with his new baby. He is holding the baby close, talking to her, getting to know her really well, and looks super comfortable. I had him hold the baby up to the mom for a kiss. All together, it took about 30 minutes to do the whole delivery.

What struck me was that the new Father was the big winner here. Here he is, holding his baby nicely, and getting a whole lot of new baby time, even before the mother gets the baby. In a vaginal birth, the mom gets the baby. We do "skin to skin" now, so the baby gets delivered right onto the mom. She holds the baby. We hope to give them an hour of bonding. It seems to me that the babies like it a lot more. The babies seem much more peaceful with their mom. The babies know that dinner is but one mouthful away, in the beautiful way that babies find the nipple and nurse. But in a Section delivery, the new Daddy gets most of the baby time. I asked him to remember this moment and this day. Because I still remember my babies in my arms when they were born. That is how I think of my babies, really little, in my arms. In most C-Sections, the new Daddy gets to hold the baby for a prolonged period of time.

I am certain that this is a positive and wholesome experience for the new Daddy and his baby. He loves his baby with Agape, which means unconditionally and forever. And that bond is unusually strengthened to a great degree when he can hold his new baby like this.

It is really beautiful to watch that bond strengthen in the delivery room.

Thank you sincerely,

Dr John W Marcus MD 
Board Certified Obstetrics and Gynecology 

89 North Maple Ave
Ridgewood NJ 07450

Phone 201-447-0077
Fax     201-447-3560

Blog at https://doctorjohnmarcus.blogspot.com/