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Normal Birth Forum Featuring Henci Goer

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Water Labor & Intermittent Monitoring

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<div class="NTForums_Quote">Posted By n/a on 07/20/2008 5:27 PM Robin,
Henci is out of town (accepting a research award from DONA International – go Henci!). She has asked me to take care of the Forum in her absence. I am a nurse-midwife, co-author of the upcoming edition of Henci’s book, Obstetric Myths versus Research Realities, and a research and advocacy consultant to Lamaze International. 
 
I’m sorry to hear about your predicament. From what I am reading, you are an excellent candidate for a <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:stockticker>VBAC</st1:stockticker>. You have had several uncomplicated vaginal births, which greatly increases your likelihood of a vaginal birth this time and may lower your chance of uterine scar rupture. In addition, your c-section was for a reason that is not going to repeat this time. From the size of your family and the fact that you have been a gestational carrier, it seems that you might be planning future pregnancies, which is another factor in favor of avoiding another cesarean, as risks in future pregnancies increase with accumulating cesarean scars. Additionally, you have hired a doula, which should be a great benefit to you both for staying as comfortable as possible and advocating for good care. It seems the greatest barrier to you achieving a safe and satisfying vaginal birth is your doctor. 
 
So my first recommendation is to continue scouring the community for a provider who might be more supportive of VBACs. It sounds like you have done your homework on this one, but you should consider getting in touch with your local ICAN chapter to see if they can offer recommendations. See <a target=_blank href="http://www.ican-online.org/">http://www.ican-online.org/</A>.  You should also make sure you are aware of your rights of informed consent and refusal. The Rights of Childbearing Women from Childbirth Connection is your best resource for this. <a target=_blank href="http://childbirthconnection.org/article.asp?ck=10084">http://childbirthconnection.org/article.asp?ck=10084</A>.  While you’re at it, Childbirth Connection has a lot of excellent, evidence-based, and clear information about <st1:stockticker>VBAC</st1:stockticker> versus repeat cesarean surgery, which you can review here: <a target=_blank href="http://childbirthconnection.org/article.asp?ClickedLink=293&ck=10212&area=27">http://childbirthconnection.org/article.asp?ClickedLink=293&ck=10212&area=27</A>.  <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
The rationale for using continuous monitoring in <st1:stockticker>VBAC</st1:stockticker> labors is that a decrease in the baby’s heart rate known as bradycardia is often the earliest sign of uterine rupture, so it potentially provides the most time to intervene and do a life-saving cesarean sooner. However, some decelerations of the fetal heart rate are harmless and resolve on their own, yet with continuous EFM they may result in cesarean surgery regardless. Also, just because hospitals can intervene quickly does not mean that they do or that it makes a difference. I recently reviewed the whole body of literature on the “30 minute rule” – i.e., the requirement that a cesarean should occur no more than 30 minutes after the decision is made. I found that most published reports showed very poor compliance with the 30-minute rule, with most studies reporting at least a third of cesareans occurred after the 30-minute mark. Moreover, the vast majority of babies born after 30 minutes are born well and require only routine care, even if the reason for the cesarean was “fetal distress”. And the majority of babies who either die or are severely compromised at birth are born sooner than 30 minutes after the decision to operate. So it is clear that in most cases, babies have plenty of reserves and can handle even a considerable delay before being born, and in a few cases, there is unfortunately no interval of time short enough to save a baby, so the method of fetal monitoring in these cases is moot.
 
I am aware of only one published study comparing intermittent auscultation with continuous EFM in <st1:stockticker>VBAC</st1:stockticker> labors. Unfortunately, the study only enrolled 100 women (50 in each group), which is far too small to detect differences in uterine scar rupture, perinatal mortality, hysterectomy, or other poor outcomes. The study in fact found no clinically important differences in the two groups at all. More women in the intermittent auscultation group had vaginal births (72% versus 64%) and more women in the continuous monitoring group had cesareans for fetal distress (47% versus 18%), but these differences did not achieve statistical significance. In other words, they may have been the result of statistical chance rather than a true difference between the two groups. However, we can extrapolate from a large study of women planning VBACs in birth centers, where intermittent auscultation is the norm. Of the 1453 women planning VBACs who were admitted to birth centers in labor, 87% vaginal births, with the remaining 13% having unplanned repeat cesareans. No women died, one woman had a hysterectomy resulting from uterine scar rupture, and two babies died as a result of uterine scar rupture. In both cases of perinatal death and the single case of hysterctomy, the mothers had had two previous cesareans. Additionally, five other babies died for reasons unrelated to uterine scar rupture, most of which were in labor at or after 42 weeks or had had more than one previous cesarean. The perinatal death rate including these five deaths was 0.5%, which is significantly higher than the 0.1% rate reported in other studies of hospital-based <st1:stockticker>VBAC</st1:stockticker> labors. (Excluding the deaths occurring in “high risk women,” i.e., those with multiple previous cesareans or beyond 42 weeks, the perinatal mortality is approximately 0.2%, or about 1 more death per 1000 <st1:stockticker>VBAC</st1:stockticker> labors occurring in birth centers versus hospitals.) In other words, the excess risk of mortality or another adverse outcome in a setting where intermittent auscultation is the norm is low. Moreover, the method of fetal monitoring is unlikely to explain the excess. Rather, the time it takes to transport from a birth center to a hospital is more to have played a role in these poor outcomes. 
 
As for the use of water in labor, I am not familiar with any studies of water in <st1:stockticker>VBAC</st1:stockticker> labors, but there is good evidence of the benefits of water for pain relief in labor in general, as you yourself can attest to. A systematic review of all of the published literature on immersion in baths in labor concluded, “baths in labor are effective in reducing pain and suffering during labor, and should be available as a pain relief option to all laboring women” (Simkin & Bolding, 2004). I am also aware of some hospital units that have fetal monitoring equipment that may be immersed in water. You may want to ask about this at your hospital.
 
You may also ask about the availability of “telemetry monitoring”. Telemetry monitoring uses radio waves rather than wires to send the signal from the belts around your belly (or internal probes, if internal monitoring is used) to the machine that records the data, so you are not attached to the machine next to your bed but can walk around the room or through the halls of the hospital. Even if telemetry monitors are not available, there is absolutely no reason you can not sit on a birth ball or stand at the bed side, or use various positions in bed. If position changes or movement make it difficult to follow the fetal heart rate, your nurse can often fix the problem by adjusting the belts. If that doesn’t help and your doctor insists on continuous monitoring, you may decide to request internal heart rate monitoring. Although it raises the risk of infection and requires a probe to be placed under the skin of your baby’s scalp, it provides continuous heart rate data no matter what position you are in. And with your history of short labors, the excess risk of infection is likely to be low. (It is increased with longer labors because there is more time for germs to enter.)
 
Finally, you are absolutely right to be upset about the breach of patient confidentiality. Although your doctor probably did not break any rules under HIPAA (because the person he spoke to is an employee and has access to your protected health information), it was clearly inappropriate and, as you said, reveals his bias against <st1:stockticker>VBAC</st1:stockticker>. If you are comfortable doing so, you should tell your doctor that you are aware that he discussed your case with your doula’s daughter and would appreciate that he not communicate with your doula via his employee. You may offer to bring your doula to an appointment so that if he would like to collaborate with the doula on your plan of care, he can do so. Of course, if your doula does attend a prenatal visit, she will advocate for a vaginal birth, not a planned cesarean.
 
Best wishes and I hope you can garner the support for your plans that you so very much deserve. Please let us know how things go for you, and remain confident in your ability to birth naturally. I believe strongly that you will do so despite your doctor’s attempts at interference.
 
Sincerely,
Amy
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References: 
 
Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42. <o:p></o:p>
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Madaan M, Trivedi SS. Intrapartum electronic fetal monitoring vs. intermittent auscultation in postcesarean pregnancies. Int J Gynaecol Obstet 2006;94(2):123-5. <o:p></o:p>
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Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. J Midwifery Womens Health 2004;49(6):489-504. <o:p></o:p>
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