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Archived User
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| 12/25/2006 9:33 PM |
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In about 3 weeks, I'm going to attempt a VBAC at my local hospital. I was just last week informed that the new policy at the hospital is that anyone attempting a VBAC must have continuous fetal monitoring (CFM). After looking at the research on the net, trying to understand this policy, I can only find research that shows that CFM increases the Caesarian rate, and nothing to suggest it helps in reducing mortality rates. It also seems odd that it's especially required for VBACs when the uterine rupture rate is low compared to some other complications such as cord prolapse and the placenta coming away from the uterus prematurely.
Are you able enlighten me as to why the hospital thinks this so necessary?
Thank you. By: Felicity |
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Archived User
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| 12/26/2006 12:09 PM |
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Your hospital requires EFM for VBAC labors because studies have established that a marked slowing of the fetal heart rate is the most reliable symptom that the uterine scar has opened and is causing problems. Because the change is likely to be sudden, clinicians have reasoned that only continuous EFM is likely to detect it and therefore allow for a cesarean soon enough to rescue the baby.
However, this is not the end of the story. The key issue is whether early detection improves outcomes.
A recent systematic review (see below for citation) of the research analyzed the two studies reviewers found on this issue. Their results conflicted, and the one concluding that delivery within 17 minutes improved outcomes raises issues: In 91 of 99 cases of scar rupture (92%), fetal heart rate disturbances signaled it. No deaths, symptoms of insufficient oxygen, or need for intubation (assisted ventilation via a tube down the throat) occurred in infants born within 17 minutes when prolonged slowing of the fetal heart rate (decelerations) was the only abnormal sign. However, three cases of intubation and one case of hypoxic symptoms occurred in infants delivered after 17 minutes. The tube was removed in the three cases of intubation within 24 hours, and they were discharged from the hospital without any further problems. If these cases are removed from consideration, only one case of neonatal hypoxia and no deaths remain. The other study also reported that fetal heart rate abnormality was the initial sign of scar rupture in most cases (87%), but investigators did not find a significant association between time between diagnosis and delivery and symptoms of brain injury (hypoxic-ischemic encephalopathy) or death.
Why didn't continuous EFM help? Probably because EFM may identify the problem, but in the rare catastrophic cases, no rapidity in performing the rescue cesarean may be fast enough to prevent harm. Those cases are also more likely to be signaled by perceptible symptoms such as pain or bleeding. In most cases of scar rupture where heart rate abnormality is the only sign, a cesarean will be needed reasonably quickly, but it isn't an emergency.
On the downside, as you point out, EFM increases the risk of cesarean and vaginal instrumental delivery somewhat, and it has not been shown to improve newborn outcomes generally in low- or high-risk women with the sole exception of women on high-dose oxytocin protocols for induction or augmentation of labor. In this situation, it reduces the incidence of newborn seizures but has no long-term benefits.
Speaking pragmatically, VBACs are so hard to obtain, and so many other aspects of VBAC management have no evidence basis (ex. routine IV, internal contraction monitoring, manual exploration of the uterine scar after vaginal birth) that you may not wish to draw a line in the sand on this one. Perhaps you can find an acceptable compromise. You may agree provided you can get off the monitor for bathroom breaks or to have intermittent monitoring until you are established in active labor. Consider as well how you could avoid the disadvantages of EFM: EFM needn't affect mobility. You can stand, sit in a chair or on a birth ball, take up any position in bed. To prevent its mesmerizing effect on your support team and you, have the sound turned off and cover the monitor with a towel. I encourage you to think creatively so that you can come up with a win-win solution for you and your care providers.
While I'm at it, I strongly recommend finding other ways of coping with labor pain besides an epidural. This is for two reasons: One is to avoid false alarms that could lead to an unnecessary c/section. One of the epidural's potential side effects is fetal heart rate decelerations. The other reason is that women having epidurals frequently require oxytocin to make contractions stronger. This increases the risk of the scar giving way. On the same subject, avoid inducing labor. This both increases the risk of scar rupture while reducing your chances of vaginal birth. To give you an idea of the effect on uterine scar rupture, a recent large U.S. study reported that 124 women experienced symptomatic uterine scar rupture among 15,800 VBAC labors (see below for citation). The scar rupture rate in women laboring spontaneously was 4 per 1000. Inducing and augmenting labor increased it to 10 and 9 per 1000 respectively. Based on these rates, if every woman had labored without stimulation, the scar rupture rate would have been cut in half.
-- Henci
Guise, J. M., McDonagh, M., Hashima, J. N., Kraemer, D. F., Eden, K. B. B., M, Nygren, P., et al. Vaginal birth after cesarean (VBAC) report/technology assessment no. 71 (No. AHRQ Publication No. 03-E018). Rockville, MD: Agency for Healthcare Research and Quality.
Landon, M. B., Hauth, J. C., Leveno, K. J., Spong, C. Y., Leindecker, S., Varner, M. W., et al. (2004). Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med, 351(25), 2581-2589.
By: Henci Goer |
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Archived User
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| 12/26/2006 4:45 PM |
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Thank you so much for this Henci - this is what I was looking for.
As it happens, I'm having a midwife birth in the hospital, with a VBAC-friendly OB on call, and a doula who is an acupuncturist (in Canada - we may or may not be more lenient here). When I spoke to my midwife about CFM vs. intermittent fetal monitoring, she said that if I was comfortable with the research I could sign a waver forgoing continuous in favor of intermittent. I'm leaning towards doing this because of my first labor. I had a four day first stage, with no real sense of gathering momentum (contractions without any real pattern, and not increasing in intensity), and then lacking any other advice, checked into the hospital on the fourth morning at 2 cm, and had an epidural with augmentation. The baby didn't descend even when I dilated to 10 cm so they did the Caesarian.
This baby has been estimated to be on the big side also (my first was 8lb4oz), and I'm concerned about doing everything I can do ensure that labor progresses this time. My feeling is that CFM might significantly interfere with that goal. If there's no solid evidence that it will help in a very unlikely catastrophic event, it does suggest that it might not be too risky to forgo it (especially if I agree to intermittent monitoring).
I agree with everything you've said about avoiding an epidural, but I was wondering what to do in the case of my labor going on for several days again. Do you think there's any value in a temporary epidural in order to get rest? Or do you think that any epidural, for any length of time, will significantly increase my chances of a RCS?
Thank you again for this expert advice - very much appreciated! By: Felicity |
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Archived User
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| 12/27/2006 10:16 AM |
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Oh, you are in Canada. Looking at what you wrote, I can tell you that things are much more lenient in Canada. Anyone in the U.S. wanting a VBAC would think she had died and gone to heaven if she had the options you describe. South of your border, the VBAC rate has dropped below 10%, and a recent survey, Listening to Mothers II, found that over half the women wanting a VBAC were denied that option.
As for how to cope with a long, slowly progressing labor, I remember Penny Simkin recommending rotating among activities to stimulate labor such as walking, activities that helped women rest, and distracting activities such as playing games, movies, or strolling the mall. I suggest you have a heart-to-heart with your midwife and doula and brainstorm what you will do in the event that this labor proceeds like the last one and how they can be helpful and encouraging in getting you and your partner through it. The best website I know (posters to this Forum feel free to chime in with ideas and websites) for info on lots of ways to cope with the pain of labor is Labor Pain on Childbirth Connection.
Here's hopes your labor goes more smoothly. It likely will. The first labor I attended was to take pictures, but, of course, I ended up acting as a labor companion. Labor, as they say, is not a spectator sport. She also labored for days and would have had a cesarean in the hands of almost anyone other than her doctor. Her next labor was 17 hrs start to finish, long for a second baby, but a breeze by comparison for her.
Sometimes psychological issues such as prior sexual abuse can hold up a labor. Another woman I attended after becoming a doula but before I knew this had a long, slow labor with no obvious physical reason why. I first started learning about the effect of psych issues after her birth. When she got pregnant the second time and asked me to be her doula again, I brought up this possible explanation. I said that if that were the case, I felt sure she had worked through her issues at the first birth and probably wouldn't need to repeat the experience. She acknowledged that it was, and, in fact, she zipped through her next labor, giving birth easily to a 10 lb baby. If you fall into this category, I suggest getting a copy of When Survivors Give Birth. You can find out more about it on Penny's website.
-- Henci By: Henci Goer |
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