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    Questions? Ask Henci!


    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

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    Archived User

    Hi, I am really hoping that I might be able to find some sound, evidence-based advice on a tricky situation.

    My first child was born via emergency c-section in July 2009.  My dr wanted to induce on my due date and I managed to negotiate 3 more days but it still wasn't enough.  My cervix was long and closed and baby was not engaged.  I did not know much about induction or how much it increased the liklihood of surgical intervention.  My baby was not ready and went into fetal distress.  Meconium was then found in the amniotic fluid and I had an emergency c-section.  I was thrilled to have a healthy baby boy but devastated to have had a c-section.  In hindsight, I wish I had been more comfortable questioning the advice of the dr.  Now that I have done more research and see that the average gestation for first time mothers is 41+ weeks, what I agreed to seems crazy!  I think I knew this at the time but felt like I didn't have many options.

    When I became pregnant the second time, I was very clear that I wanted to VBAC.  My dr (same one) agreed but said he would only let me go 3 days over.  I sought a second opinion and was told the same thing.  I live in the Bahamas and there are not as many birthing options here as there are elsewhere and again, I felt like I had little choice.  All the way along, I have just hoped that I might go into labour spontaneously before the 40 weeks +3 days that my dr is suggesting.  So, I am 40 weeks tomorrow and a c-section will be scheduled for Thursday if nothing is happening naturally.  Again, baby has not decsended, cervix is long and closed.

    So, my question is... what can I take to my dr tomorrow in terms of research that might help me beg for more time to go into labour spontaneously? 

    Thanks so much for any help you can offer.

     

    Archived User

    PS - I should add that there were no medical complications in either pregnancy. 

    Henci Goer

    It may be difficult, but it is every person's right to decide on medical care, which means the right to refuse treatment as well as agree to it. The research evidence is very clear  that inducing labor in a woman with a prior cesarean and an unfavorable cervix not only substantially reduces her chance of vaginal birth but increases her chances of having a scar rupture. Here are the data from my forthcoming book, Optimal Care in Childbirth: The Case for a Physiologic Approach, now in press:

    Seven studies comparing scar rupture rates in inductions involving prostaglandin E2 (trade names: Cervidil, Prepidil), a cervical ripening agent, with inductions not involving PGE2 all reported an increase in scar rupture rates with cervical ripening (Delaney 2003; Kayani 2005; Kwee 2007; Landon 2004; Ravasia 2000; Taylor 2002; Zelop 1999). Differences amounted to 2 to 20 more scar ruptures per 1000 women. Even without use of PGE2, risk of scar rupture with induction is higher. Nine of ten studies comparing scar rupture rates with labor induction not involving PGE2 with spontaneous onset of labor reported higher scar rupture rates with induction (Ben Aroya 2002; Bujold 2004; Delaney 2003; Hoffman 2004; Kayani 2005; Kwee 2007; Landon 2004; Lin 2004; Ravasia 2000; Zelop 1999). Differences amounted to 2 to 19 more scar ruptures per 1000 women. As for chances of vaginal birth, all ten studies comparing VBAC rates in induced labors with labors of spontaneous onset reported fewer vaginal births with induction (Delaney 2003; Elkousy 2003; Gonen 2004; Goodall 2005; Grobman 2007; Gyamfi 2004; Kwee 2007; Locatelli 2004; Ravasia 2000; Srinivas 2007). Seven to 14 fewer women per 100 had vaginal births with induction. Some studies have found higher scar rupture rates when women go past their due date, but differences disappeared when investigators controlled for increased use of induction (Hammoud 2004; Zelop 2001).

    I should add that the book doesn't cover studies of misoprostol (trade name: Cytotec), another cervical ripening agent, because scar rupture rates with its use in VBAC labors are so high that some years ago it was banned. (It should be banned, period, VBAC labor or not, but that is another story.)

    ~ Henci

    Archived User

    Thank you so much for your quick response, Henci. 

    My doctor and I have actually already agreed not to induce for this second birth because of the danger of uterine rupture.  The issue is really more that he feels that I should have a planned c-section at 40 weeks and 3 days (this already required some negotiation on my part... he would prefer to induce on due date today), whereas I would prefer to wait for spontaneous labour.  Is there any evidence to suggest that uterine rupture is more likely for VBACs (without induction) beyond 40 weeks?

    Thanks again!

    Henci Goer

    As I wrote in my previous reply, some studies reported an increase in scar rupture in postdates pregnancies but the difference disappeared after the researchers adjusted for induction. In other words, the excess risk of scar rupture after 40 weeks is iatrogenic, meaning "caused by doctors." It is due to doctors being more likely to  induce labor once the woman reaches her due date, not to anything intrinsic to longer pregnancy duration.

    ~ Henci

    Archived User

    Thank you again, Henci.

    I appreciate your clarification of the research re. postdates as I missed the significance in your original response.  The great news is that I just saw my dr and after hearing my perspective, backed up with real research thanks to you, the Lamaze site, ICAN and other great resources I found, he agreed that I seemd to be fully informed and he respects my decision to wait a week.  When I first walked into his office today, he said c-section Wed (2 days) and now I have a whole week!  May not be enough but still feels like a huge victory... thanks for your help!  Now, to get labour started...

    Henci Goer

    I suggest a compromise if you can't get labor started on its own: if the cervix is favorable, you will agree to the induction, but if it isn't, you will keep waiting. With a ripe cervix, and therefore, no need for cervical ripening agents, the risk of scar rupture is much lower than when cervical ripening is involved, and VBAC rates once the cervix is ready to go are similar to those with spontaneous onset. In addition--and this is a bit trickier than a straight "yes or no" agreement because it may be perceived as telling your doctor his business--this study and this study of the same group of women found that the risk of scar rupture is dependent on maximum dose of oxytocin and length of time at maximum dose, not length of labor per se. Many doctors use unphysiologic levels and increase the dose before the current one has had a chance to take full effect. The recommended (and I may say evidence-based) dose regimen mimics oxytocin levels your body would produce naturally. It is part of the Pitocin (alternate trade name: Syntocinon)  label information. I would love to hear how everything turns out.

    ~ Henci

    Archived User

    Thanks again, Henci.  I am still hoping for spontaneous labour but I'm not sure that I can convince my husband and doctor to go any further than 41 weeks (Monday).  I just came back from another appt and baby is nowhere close to engaged.  A c-section has been scheduled for Monday and I am pretty devastated at the thought.  I think I could convince them to maybe wait another day or two but I feel like I would be all alone, out on a limb, and then if something did happen because we waited, I would feel responsible.  It just feels like I worked so hard to get an extra week of waiting.  Anyway, maybe a miracle will happen on the weekend and I will go into labour.

    Henci Goer

    I feel for the difficulties of your position. Here's what I recommend: Sit down someplace quiet and review everything you know about the pros and cons of your options. Figure out what you would prefer to do and why you feel that way. Next, sit down with your husband and share what you are thinking and feeling. See what he has to say and listen to his thoughts and feelings. Then find a quiet time to seek inner guidance as to what you believe is best, whether that be in prayer, meditation, or reflection. Once you have made your decision, own it, and don't let yourself second guess it. Move forward in peace knowing you have done the best that you can for yourself and your family.

    ~ Henci 


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