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    Oct 08

    VBAC & electronic fetal monitoring

    Archived User
    I read your book The Thinking Woman's Guide to a Better Birth and have a question for you.  I am having a VBAC (second pregnancy, first ended with a c/s due to failure to progress) and am due Oct 24.  In chapter 10, Elective Repeat Cesarean, one of the factors you list that promotes a safe vaginal birth is to consider having continuous electronic fetal monitoring since an abnormal fetal heart rate is the most common indication of uterine scar problems.  I'm puzzled by this since having the belt strapped around your tummy during labor makes it harder to move around & do what you need to do during labor.  You also say to avoid EFM every other place in the book (I think).  The paragraph I'm referencing does leave it up in the air a bit, but I am wondering what your advice on EFM with VBACs is - do it to catch the potential problem or avoid to avoid the risks of EFM.
    If it matters for my specific situation, I am 38, my son will be 20 months at my EDD, this is my second pregnancy and I have a low transverse scar with a triple closure.
    Thanks for your insight!
    Henci Goer

    I said "consider" having continuous electronic fetal monitoring because studies at the time agreed that fetal heart rate changes were the most reliable symptom that the scar has given way and was causing problems, but we had no evidence that continuous EFM improved outcomes in VBAC labors. On the other hand, as I wrote in the book, EFM had known adverse effects: Women who have continuous monitoring are more likely to have cesareans and instrumental vaginal deliveries (which increases risk of pelvic floor weakness and injury) without any better outcomes for the baby. The book was published in 1999.

    A systematic review of the VBAC research published in 2003 reported on two studies looking at the relationship between EFM and newborn outcomes in VBAC labors. Both studies agreed that fetal heart rate abnormality was the most reliable sign of the scar giving way. One study concluded that delivery within 17 minutes of diagnosis improved outcomes on the grounds that no deaths, asphyxia, or need for resuscitation at delivery occurred in babies born within 17 minutes when the only abnormal symptom was prolonged slowing of the fetal heart (lasting more than 1 minute) whereas three babies required resuscitation and there was one case of asphyxia in infants delivered after 17 minutes. Based on their finding, study authors recommended prompt delivery with a prolonged deceleration to prevent morbidity. (When the prolonged deceleration was preceded by severe late decelerations, severe morbidity occurred before the 17 minute mark.) The reviewers point out that the three cases of resuscitation and ventilation were fine within 24 hours and were discharged in good health. If these cases are removed from consideration, one case of neonatal asphyxia and no deaths remain, and the case of asphyxia occurred at 32 minutes after the first episode of slow fetal heart rate. They also point out that any number of factors can cause temporary slowing of the fetal heart, including as a side-effect of an epidural, from maternal positioning causing low blood pressure, from rapid descent through the birth canal, and during cervical examination. In other words, using an episode of slow fetal heart rate as the sole indicator for urgent cesarean is likely to result in unnecessary surgeries. In contrast to the findings of the first study, the other study failed to find an association between time between diagnosis and delivery and newborn neurologic injury or death.

    Here is what I think can be gleaned from this: Continuous monitoring seems to confer some benefit, but not all bad outcomes can be prevented regardless of rapidity of delivery, and there is a strong potential for ending up with unnecessary surgery because an episode of slow fetal heart rate is not specific to the scar opening. To this must be added that random assignment trials of continuous electronic fetal monitoring in nonVBAC labors has shown it increases risk of cesarean surgery and instrumental vaginal delivery. If electronic fetal monitoring were harmless and could accurately identify scar rupture, a strong case could be made for using it in all VBAC labors, but it is not. It might make sense, therefore, to reserve continuous monitoring for those women at higher risk of scar rupture such as women being induced or augmented or who have other than low transverse or low-vertical uterine scars or who have single-layer uterine closure. This policy would limit its use to the women most likely to benefit and minimize the number of women exposed to its harms.

    Where this leaves you, I do not know.  As a practical matter, it's hard enough to get a VBAC at all, and I would think it would be well nigh impossible to get a care provider, much less the hospital, to agree to forgo continuous monitoring. I suggest ways to avoid EFM's drawbacks in the EFM chapter. Perhaps some of those will be an acceptable compromise for you. 

    -- Henci

    Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD: Agency for Healthcare Research and Quality March 2003. Report No.: AHRQ Publication No. 03-E018.

    Archived User
    Thank you.  I have wanting limited EFM on my birth plan - I'm planning to bring it to my appt tomorrow so we'll see what the doc's response is to that.  Either way, I'll make sure my DH & I are up to speed on reducing the negative impact of EFM and make sure my doula is up to speed on that as well (I'm sure she is).
    Henci Goer

    I happen to be working on the VBAC chapter for the new edition of Obstetric Myths Versus Research Realities. Yesterday, I reread the two studies looking at the association between fetal heart rate patterns and the uterine scar giving way and time from onset of fetal heart rate disturbance and delivery and newborn outcomes. It caused me to revise my thinking, and I have edited my previous post accordingly.

    -- Henci

    Archived User

    I was going to ask the same question, thank you.

    I wish I had more information to go on in regards to what percentage of the time an emergency cesarean is performed for a suspected rupture (detected by EFM) but nothing turns out to be wrong with the baby or the scar. 

    As things stand I'm having a hard time weighing the pros and cons.  My hospital does require continuous monitoring, but of course if I do the "walk in pushing" thing, that doesn't matter very much.  I guess I just have to figure out how comfortable I'd be with waiting that long.

    Henci Goer

    Unfortunately, I don't have any numbers on false alarms, although they undoubtedly occur. None of the research I've seen collects data on this.

    As for your dilemma, I would think very carefully before deciding to "walk in pushing." You would essentially be having an unassisted home labor, if not a home birth. If you feel you can work with your care provider and hospital and there are no deal breakers, then it makes sense to spend active labor, at least, in the hospital. If hospital and doctor policies are so unreasonable that you do not want to labor there, then you would be better off trying to find a midwife and planning home birth.

    -- Henci

    Archived User

    Thank you for your insight.

    I really wish I could have an HBAC but my health insurance emphatically will not cover a home birth and I cannot afford to pay for it myself.  I looked into the cost and it was nearly $4,000.  Might as well be 4 million.  So I'm stuck with what is covered.

    It's a hard decision to make.  I suppose I can always practice informed refusal at the hospital. 

    Henci Goer

    Before you throw in the towel, if there are midwives doing HBACs in your area, you may be able to work out a mutually agreeable financial arrangement. If not, it might be a good idea to find out who you can talk to at the hospital ahead of time to discuss your concerns. If you and your DH can present yourselves as the reasonable, rational people that you are and come to agreement with hospital staff, you could save yourself some problems. I'm not sure on how to get to the right person or persons, but I would start with the nurse manager of labor and delivery. She should know the ropes. I think it would also be wise for you and your husband to talk with your ob for the same reason. If you try this route or if you don't and there's a nonemergency decision to be made during the labor, here's a tip I got recently for nonconfrontationally getting what you want: When someone proposes something you don't agree with, say nothing. Just wait. Silence is uncomfortable. If you sit tight, the person is likely to make another suggestion. When you hear something you can live with, then respond. If you try this, let me know if it works.

    -- Henci

    All Times America/New_York

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