Giving birth

How my heart-shaped uterus changed my birth plan

They tell you not to get attached to your birth plan. Now I know why.

“You should have your baby at home!” crooned my midwife as she walked through my place for a six-month check-up. “Your house has great birthing energy!”

I’d been planning on a hospital birth with a midwife, but as I sat with it, the idea of having my baby at home started to sound kind of lovely. I pictured a swift and easy delivery in the late afternoon sun; my newborn falling asleep in my arms with my husband close at hand, making soup and tending to us. I couldn’t wait to share the idea with him.

Only I couldn’t, because he was on a ten-day silent meditation retreat, an eight-hour drive away. Clearly my epiphany would have to wait.

Instead, I bought new sheets, read up on home births, and started feathering my nest.

But the next morning, I started spotting. After an uneventful pregnancy, this development sent me into a panic. I anxiously consulted my baby books and learned that spotting during pregnancy was highly variable and usually not a cause for concern. My midwife was equally reassuring: she instructed me to stay off my feet for the rest of the day and said it would likely stop on its own. But that night, the spotting got worse, and I started cramping. Something was wrong—I could feel it. I called my midwife but couldn’t reach her. I called my sister and got voicemail. I knew I had no hope in hell of reaching my husband on his meditation cushion—so I called a cab and went to the ER on my own. I was 30 weeks pregnant, alone, and suddenly really frightened. This had not been a part of the plan. We were only halfway through our prenatal classes, we hadn’t even decided on a name or whether we were going to co-sleep or bank our baby’s cord blood—and what about those naked pregnancy portraits with my husband cradling my big nine-month belly from behind?!

Worst of all, what if something was genuinely wrong with my baby?

Close up of mom holding baby in the NICU providing skin to skin contact Life in the NICU: a case study in hopeAt the hospital, a transvaginal ultrasound revealed that I had a shortened cervix. Where the cervix should be long and thick until shortly before birth, mine was short and thin. The doctors gave me celestone, a corticosteroid to help develop my baby’s lungs in case I went into labour. They reassured me that even if I did deliver that night, 30-weekers tended to do well. But the thought of giving birth almost two and a half months early—alone—terrified me.

Thankfully, my message had somehow made it to my husband, who was high-tailing it back to the city, only partially enlightened—but fully scared.

I didn’t go into labour that night, but was placed on hospital bed rest for the remainder of my pregnancy, effectively ending my short-lived home-birth fantasy. After two weeks of this arrangement, I was fit to be tied. Stuck in a room with three other cervically challenged moms and required to be horizontal for all but an hour a day, I honestly didn’t know how I would make it to 40 weeks. Turns out I wouldn’t have to: At 32 weeks, just past midnight, I started having contractions. I cursed myself for “indulging” in the shower I’d taken that morning (my first in a week.) That, and my walk to the magazine rack at the end of the hall surely must have tipped me over my daily one-hour allotment of vertical time.

The team told us not to worry. Our baby would need an incubator, they said, but its heartbeat was strong. They predicted I’d give birth in the next 24 hours. But an ultrasound an hour later revealed our baby was presenting feet first as a “double footling breech,” which meant the umbilical cord could slip through my cervix and cut off the infant’s oxygen supply. With contractions now coming three minutes apart, I was quickly prepped for an emergency C-section. And just like that, the birth plan changed again.

The next several hours were a blur. My husband jumped into hospital greens; my sisters raced to the hospital; in my midwife’s absence, her colleague kindly came at 2 a.m. to support me. I was given a spinal epidural and at 4 a.m., the surgeon held up my three-pounds, ten-ounces infant, announced “It’s a girl!” and whisked her away before I could even touch her.

And then things got complicated.

After removing my baby, the surgeon discovered I had a bicornuate, or heart-shaped, uterus: a congenital abnormality that affects about 1 percent of women and is characterized by a left and right “horn” at the top of the uterus and a wall, or septum, down the middle. My baby had been growing on one side of the septum, and had ultimately run out of room. After delivering the baby, the team surgically removed the septum, but when they tried to take out the placenta they discovered it had grown into the uterine wall, a condition called placenta accreta. Eventually, they had to extract it manually, a process that increases the risk of haemorrhaging and in some cases necessitates a full hysterectomy. Fortunately, I was spared.

Because my baby was in good health and considered what was called a “feed and grow,” she was moved to a nearby hospital for low-risk preemies. Aside from briefly holding her the next morning in the NICU, I had to wait another 18 hours to see her again. While my husband travelled with our daughter, I sat in my hospital room waiting to be transported, and got a crash-course in pumping when my colostrum suddenly came in.

Finally, at 2 a.m., I arrived at the new hospital, exhausted and overwhelmed. I wheeled myself down the hall and into the deserted NICU to look for my baby. I’ll never forget the sight of her tiny diapered butt sticking up in the air, her teeny head to one side. She was so small—far too small to be in the world. I started to cry.

But after a month in an incubator, our scrawny chicken of a baby fattened up to a plump four and a half pounds, and we were finally able to take her home.

I’m glad I didn’t know just how much danger I was in that night. According to Sebastien Hobson, a maternal-fetal medicine physician at Mount Sinai Hospital in Toronto, placenta accreta is very risky. “It’s the most challenging obstetrical surgical situation that we have,” he says. “We can manage breech, and deliver babies by C-section, but placenta accreta can be life-threatening.” Even though my daughter is perfectly healthy—she’s now 17 and downstairs texting instead of emptying the dishwasher as I asked her to—the more information I learn, the more panicked I feel about how that night could have ended up.

How do you know if you have a bicornuate uterus?

It’s so strange to me now that my bicornuate uterus wasn’t picked up during my monthly ultrasounds. Hobson tells me the condition is usually discovered before pregnancy if a woman is experiencing infertility, heavy bleeding or painful periods, or recurrent pregnancy loss, classified as three or more. (I had none of these.) “That’s when we would start to investigate whether there is anything structurally different with the uterus,” Hobson says. The anomaly carries a miscarriage rate of 13 percent and a premature delivery rate of 25 percent. Other clues to a malformed uterus include a fetus whose growth isn’t progressing as expected, or a baby who is improperly positioned in utero. A bicornuate uterus can also be discovered early in a pregnancy if a woman has symptoms like spotting. The farther along the pregnancy, however, the harder it is to detect. “As the pregnancy grows, it distorts everything and becomes more challenging to diagnose,” says Hobson.

If a woman delivers vaginally and has no complications, a heart-shaped uterus might not be picked up at all, says John Semple, an obstetrician who sees both low and high-risk patients at his practice in Toronto. However, Semple says the accompanying risk of placental problems—including placenta previa (placenta covering the cervix,) and placenta accreta, often tip doctors off. “We’ll say ‘wait a minute, ‘why did that happen?’ and in fact, that person has a bicornuate uterus,” he says.

Can a bicornuate uterus be fixed?

Semple explains that in some cases, a woman with a bicornuate uterus who is trying to conceive can have a type of septoplasty, a minimally invasive procedure using a hysteroscope to remove the septum and return the uterine cavity to normal. “Risk of miscarriage will now be the same as someone who didn’t have an anomaly,” he says. This procedure isn’t suitable for everyone, though; doctors have to tailor the approach based on the type of anomaly a woman presents with.

Bicornuate uterus is often discovered only during a C-section. In my case, removing the septum paved the way for a successful subsequent pregnancy that included extra monitoring, and a cervical cerclage, or stitch, in my second trimester to keep my cervix shut. (Cerclage does come with risks though, including infection and cervical laceration, and so obstetricians are divided on its use.)

Semple explains that women with uterine anomalies, including a heart-shaped uterus like mine, are also at risk of having shortened cervixes and that the length of the cervix can predict preterm birth. Semple monitors this by measuring the length of the cervix weekly between 20 and 28 weeks. “If the length remains normal, that’s reassuring,” he says. “If it starts to shorten, then we talk about what that means as well as any additional interventions.”

Can women with bicornuate uteruses deliver with a midwife?

Semple advises that anyone with a known uterine anomaly, such as a bicornuate uterus, be seen by an obstetrician in tandem with their midwives. He says that lots of women with a uterine anomaly go on to have a completely normal pregnancy and an uncomplicated delivery, and include their midwife as part of the team.

Any plans for a home birth should be scrapped in the event of a bicornuate uterus or placenta accreta diagnosis, due to the risk of increased bleeding during delivery. “The uterus doesn’t always contract properly after the baby’s born, which is necessary in order to stop the bleeding,” says Hobson. Because of its heart shape, the condition also increases the likelihood of breech, in which case a vaginal birth is usually not recommended. But in the case of placenta accreta, a hospital birth can be the difference between life and death: “The reported blood loss is somewhere between two to five litres on average for placenta accreta,” says Hobson. “Losing that amount of blood is profoundly life threatening.”

Although my placenta did have to be removed manually, the blood loss was minimal. Did I just get lucky?

“You were very lucky,” he says, adding that the revised guidelines now advise against manual removal of the placenta during C-section. “If we tear off the placenta and we expose all of those blood vessels to the uterus, it has no way to stop that bleeding,” he tells me.

While my second baby fared better than my first, she also came early via C-section at 36 weeks, because she had stopped growing. According to Semple, someone with a high-risk uterine anomaly is twice as likely to have growth restriction. “This means the baby is two times more likely to be smaller than it should be,” he says.

Is a bicornuate uterus genetic?

I’ve been wondering if my two daughters could have this condition, too. Robson tells me that while there are no specific genes to identify a bicornuate uterus, an ultrasound down the line still might be helpful. “Changes in any organ in our body can sometimes be passed down through the genes, through our families,” he says.

Thinking back, I’m not sure I could have handled the stress of carrying my baby for nine months, knowing the risks. Perhaps I should be glad I was blissfully unaware. Then again, knowledge is power, and I was one of the lucky ones. Gaining clarity about my experience all those years ago has given me renewed gratitude for the Canadian medical system—and for my kid.

Now if I could just get her to empty the dishwasher.

Read more:
I was so judgmental about home birth—until I had an unplanned home birth myself
5 health problems that could be affecting your fertility