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AUSER on 10/3/2006 5:08:37 PM |
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VBAC with Classical Incision |
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OK. Project is done, and I'm back online.
Let me start by saying that I am neither a midwife nor a doctor, so, I don't give medical advice. That being said, I am aware from the research that all of the medications used to induce labor have been shown to increase the risk of scar rupture in at least some studies, likewise, making contractions stronger with oxytocin. The effect on the scar almost certainly depends on who is considered eligible for labor induction or augmentation and what medications, combinations of medications, and dosages are used. Since he doesn't want to induce you, you may wish to discuss the reasons he might normally recommend induction and your alternatives. In many cases, you will want to weigh the potential benefits and harms of awaiting labor vs. a scheduled cesarean. For more information on making an informed decision, go to Informed Decision Making, Informed Consent or Refusal on the Childbirth Connection website. I would guess that your care provider just wants to take a cautious approach in your case.
I'm not sure why he wants to avoid pain medication -- although there are some good reasons for avoiding it in general -- but I could speculate that the use of epidural analgesia increases the likelihood of needing oxytocin to make labor stronger, which, as just mentioned, may increase the chance of having scar problems. A fairly common side effect of epidurals is episodes of slowing of the unborn baby's heart rate (bradycardia). Such episodes are also the most reliable symptom of scar problems. He -- and you -- may wish to avoid a "false alarm" leading to an unnecessary c/sec. However, if his concern is that an epidural may mask the pain of the scar opening, you should know that pain is not a reliable symptom.
I strongly recommend that you hire a doula. This is likely to be a more than usually anxious labor for you and your partner, and continuous support from a trained and experienced woman can be helpful. If you are trying to avoid pain medication, a doula can really help you out there. For more information on doulas, go to Options: Labor Support, also on the Childbirth Connection website.
Continuous electronic fetal monitoring has been shown to be the most reliable way of picking up scar problems as the most common symptom is, as I said, a substantial, sudden drop in the fetal heart rate. What is less clear in the research is whether picking it up via EFM actually improves outcomes. You may wish to discuss the pros and cons of external vs. internal monitoring. At one birth I attended as a doula where there was concern about the baby, the doctor compromised on using external monitoring as long as they were getting an accurate enough recording.
You may also wish to know whether your care provider wants to put any other restrictions on you. For example, will he set limits on the estimated size of the baby? Set time limits for making progress in labor? The informed decision making page will help you here as well if you want to make informed choices about other elements of your care.
You didn't ask me this, but you may be interested in knowing what the odds are of the scar opening and causing problems with a c/sec uterine incision that is not the standard type (low, transverse). A large recent study of 17,900 women planning VBACs reported a rate of scar rupture of 2% (2 out of 105) in women with classical (vertical), inverted T, or J incisions. This is compared with a rate of 0.4% in women with the usual type of uterine incision who labored spontaneously (no induction, no augmentation). Keep in mind, though, that while a scar rupture is serious and will almost certainly require an urgent cesarean, the baby is almost always fine. Here is the citation for the study in case anyone is interested:
Landon MB, Hauth JC, Leveno KJ et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-2589.
Because you are at somewhat increased risk, you will probably want to labor in a hospital capable of handling an urgent cesarean 24/7. You describe your care provider as a "maternal-fetal medicine specialist," so you probably have that base covered, but it might not hurt to double-check. Hospitals in this category have obstetricians, anesthesiologists, and pediatricians in-house at all times, have at least a level II nursery (capable of handling fairly sick babies and stabilizing very sick babies for transport to a level III nursery -- a neonatal intensive care nursery), and 24-hr blood banking.
As you ponder your choices, be sure to take into account whether there is any chance at all that you will have another pregnancy. The risks of a number of serious, life-threatening complications escalates for the next baby with each successive c/sec. There is also increasing risk of dense surgical adhesions, which poses increased risk to you of surgical injury, should you ever need abdominal or pelvic surgery in the future, as well as increasing your risk of experiencing chronic pain and the possibility, although still rare, of experiencing a twisted bowel at some time in the future.
-- Henci
By: Henci Goer |
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