Dear Henci,

I have a low lying placenta at my 36 week U/S (1.1 cm from
cervical OS measured through transvaginal ultrasound). My OB is not ready to okay an attempt at labor since he wants a 2
cm clearance. I'm really hoping my placenta makes it to that distance (it seems
so close). I'd like to be as informed as possible before I go in for my
OB visit next week in terms of what seems reasonable as far as interventions go.
I have not had a single bleed and have had an active, normal pregnancy. So these
were some of my questions:
>
> 1) Is 2 cm from OS a reasonable guideline to allow labor? What are the risks
of laboring with a placenta closer in distance (but not a previa) than that? Any studies I could
look up?
>
> 2) My OB has indicated that even if I do get cleared for vaginal birth at
2cm, the labor would be considered high risk. He wants me on an IV and an epidural in
case they need to go to surgery quickly. He definitely wants to administer
pitocin for the afterbirth since, in his opinion, the lower uterine segment does not contract as
efficiently and detachment of the placenta and excessive bleeding may be problems. Are these over the
top? Can I refuse these interventions?
>
> 3) If vaginal birth is okayed, the OB may be more comfortable with a controlled induction since he
wants a high quality medical staff on hand (I'm due over Memorial Day weekend) .
Again, is this reasonable?
>
> 4) Finally, how long should I hold out before I agree to a scheduled
c-section? 39 weeks or longer?
>
> Sorry if I've asked too many questions here.  I just want to make sure I'm doing everything I can to
get a chance at vaginal birth. This is my second baby. The first was a vaginal birth. Thanks!
>
> Shalini

You can refuse any intervention, but the question is "Would it be wise to do so?" I certainly am not qualified to tell you that, and based on what you write, the conversation with your care provider that would allow you to answer this question hasn't happened. Your ob appears to be telling you what he plans to do, and you are to like it or lump it. He has not explained all your options to you--including doing nothing--along with the potential benefits and harms of each. In particular, you have not been told the risks of cesarean surgery.

The Childbirth Connection website has a great webpage on informed consent and refusal, but I think your first task is to determine whether you can trust your care provider's judgement, because his failure to provide the information to make an informed decision is already a red flag. The touchstone for this is to ask his cesarean rate. If it is more than 15%, the rate established by the World Health Organization and numerous studies as the reasonable maximum, you will know that you can't. If he hedges, for ex., "I only do them when they are necessary," or won't tell you or says he doesn't know, consider that another red flag. Should either of these be the case, I strongly advise consulting with an ob willing to assist you in arriving at an informed choice and whose judgment you can trust. That, by the way, almost certainly won't be another ob in the same office. One practice partner is unlikely to openly disagree with another. If there is a birth network, an International Cesarean Awareness Network chapter, or a birth resource center, they are likely to know who the progressive obs are. The local doulas are also likely to know as well. Failing that, you might call your local hospital(s) and ask the L&D nurse manager which of the obs is the most encouraging of natural childbirth. You can also see if any of the local obs has been reviewed on the Birth Survey. Hopefully, your insurance will cover seeking a second opinion, but even if it will not, this will be money well spent.

-- Henci

P.S. FYI: I'm working on the induction chapter for the new edition of Obstetric Myths Vs. Research Realities, and I can tell you that in women with prior vaginal birth, inducing labor with a ripe cervix does not increase risk of cesarean. Inducing with a cervix that isn't ready for labor does, although the difference is much smaller--a few more women per 100--than in first-time moms. Also, if you decide to go the induction route, don't induce before 39 completed weeks (the week that ends with your due date) to minimize the chance of the baby having respiratory difficulties, and refuse Cytotec, A.K.A. misoprostol.