Water Labor & Intermittent Monitoring

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 VBAC. 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 http://www.ican-online.org/.  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. http://childbirthconnection.org/article.asp?ck=10084.  While you’re at it, Childbirth Connection has a lot of excellent, evidence-based, and clear information about VBAC versus repeat cesarean surgery, which you can review here: http://childbirthconnection.org/article.asp?ClickedLink=293&ck=10212&area=27. 

The rationale for using continuous monitoring in VBAC 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 VBAC 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 VBAC 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 VBAC 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 VBAC 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 VBAC. 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

 

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.

 

Madaan M, Trivedi SS. Intrapartum electronic fetal monitoring vs. intermittent auscultation in postcesarean pregnancies. Int J Gynaecol Obstet 2006;94(2):123-5.

 

Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. J Midwifery Womens Health 2004;49(6):489-504.

 

It appears to me that the biggest hurdle to your great birth isn't your Dr but yourself.   Choices are always available.  I know of no study which shows that continuous monitoring is any better than intermittent auscultation for reducing adverse outcomes.  I am in Australia and the VBAC rate is 16% for hospital birth.  The HBAC rate is 97% with the only adverse outcomes being at the hospital following induction of labour or augmentation and epidural as pain relief.  All of which are contraindicated in every piece of research produced on VBAC.  The first sign of uterine rupture is debatable and a raised maternal pulse is an indicator way before any sign of distress in the baby.

I'm not sure what you would constitute as an excellent candidate for VBAC, surely every woman with a scar on her uterus is an excellent candidate.

Lisa Barrett

I feel the need to clarify and tweak the information Lisa has provided. The 16% VBAC rate in Australia is the rate of vaginal birth after cesarean in all women who have had prior cesarean surgery. I am not aware of Lisa's source for home birth VBAC stats (Lisa: If you have a published source, I'd love to have it because I'm working on the VBAC chapter for the new edition of Obstetric Myths Versus Research Realities, and, as you may imagine, the safety of out-of-hospital VBAC is a crucial issue), but her 97% statistic represents the percentage of women planning VBACs who give birth vaginally. As you can see, these are different stats. I am not surprised, though, that the rate is higher than that typically found in hospital VBACs, which is in the mid 70 percents. The sole study of VBACs in freestanding birth centers also reported VBAC rates substantially higher: 87% overall and 81% in women with no prior vaginal births. 

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.

Also, I have never seen a report finding that raised maternal pulse rate was an indicator of scar rupture. As Amy wrote, severe fetal heart rate abnormalities is the most reliable sign, although it does not appear that picking those up via continuous electonic fetal monitoring has much effect on improving outcomes.  

Epidural analgesia is not contraindicated in VBAC labors, although it has drawbacks. Labor augmentation--intensifying labor with oxytocin--is often required with an epidural, and augmentation is associated with an increase in scar rupture, although the risk almost certainly would depend on how aggressively oxytocin was being used. In addition, epidural analgesia occasionally causes fetal heart rate decelerations, which might erroneously lead caregivers to think that the scar has given way.

Finally, I cannot agree that every woman is an "excellent" candidate for VBAC, although I will happily argue that there are few cases where the risks of a planned VBAC outweigh the benefits and that no one should have the right to decide that a woman should have cesarean surgery, planned or during labor, other than the woman herself. That aside, Robin happens to be an optimal candidate for VBAC by virtue of having had multiple prior vaginal births and a nonrepeating indication for her prior cesarean. As it happens, I have just finished reading the set of papers on the effect of prior vaginal births, and not only is the likelihood of VBAC the highest of all, as Amy wrote, but the likelihood of scar rupture is also reduced.

-- Henci     

In the same year the Independent midwives had 97% successful HBAC rate which is a 3% repeat c/s rate.  Our stats are submitted and reproduced in the same book, however they do not give us the courtesy of breaking our our stats.  So apart from the extra babies that show up you can't tell VBAC or twins or breech.   I obviously know what my own figures are.  In this state Obs don't have to individually publish their stats only the overall hospital stats are shown.  Clarity is a two way street.

Hope that helps clear up what I meant.

Mary Cronk as well known British midwife has done lots of work on pulse and VBAC and has developed a set of guidelines for the Independent midwives there.  They are available on her site to look at and on homebirth.org.uk.

Henci I wonder if you could elaborate on who you wouldn't feel was suitable for VBAC? 

Also with excess pain being an indicator of ruptured uterus I would really think that an epidural is contraindicated just on a common sense factor.  I trained in 1988 in the UK.  one rare epidural is all we could cope with and a VBAC ( we only had a 9% section rate as did the country at the time so they weren't so common) was definitely not seen as a candidate for any kind of intervention whatsoever.  We only had 1 ctg machine so that wasn't an option either!!

Let me see if I have understood you. I think you are saying that Australia's independent midwives keep collective track of their statistics and that among home birth clients who plan VBAC and who are still eligible for home birth at the time labor begins, 97% have a vaginal birth. Is that correct? If it is, it would be good to know how many women planning home VBAC we are talking about, what percentage have prior vaginal births, and over what time period.

I would like to take a look at Cronk's VBAC guidelines and her sources for the usefulness of maternal pulse for signaling scar problems. Rather than my searching for this on the website, save me time by sending the link or links to these specific pages. The way to do this (hopefully your posting screen is like mine) is to highlight a word or words and click on the taskbar icon with the green circle and the chain link under it. It will ask you to type or paste in the URL and will create a link between the highlighted words and the address of the URL.

As for who is "suitable" for VBAC, that isn't a word I would use. I think that we are talking about a scale. At one end are ideal candidates such as Robin. At the other are women for whom planned VBAC would almost certainly end in disaster. One I can think of off the top of my head is a woman with a complete placenta previa (placenta overlaying the cervical opening). In between are individual women with individual variables that affect their likelihood of VBAC and their likelihood of scar rupture. Clouding the issue is the degree to which provider management and philosophy impinge on those variables, which means that whatever the rates reported in the research, we do not know the true rates under ideal conditions. For example, women who have had a prior cesarean for labor dystocia are less likely to have a VBAC than women who had a cesarean for a nonrepeating reason, but they are also less likely to be given as long a time to labor in the VBAC labor than women whose prior cesarean was for a nonrepeating reason. For another, almost all studies show that inducing labor in general and with an unripe cervix in particular increases the risk of scar rupture compared with spontaneous onset. Your extremely high HBAC rate is yet another indicator of the impact of care practices and philosophy. In almost all cases, it can be demonstrated that planning VBAC is the better option and that planning VBAC with an enthusiastic provider who knows how to care for women optimally is the best option. I would recommend that women who may be at higher risk for scar rupture or other severe complications of prior c/sec, for example, women with single-layer suturing or women with multiple prior c/secs, who are at greater risk for placenta accreta (placenta grows into the uterine muscle and sometimes through it and invades other organs), give birth in a setting that can deal  24/7 with need for an urgent cesarean and a baby in trouble. I believe, though, that once a woman has accurate, unbiased information, only she can or should decide if she is a suitable candidate for planned vaginal birth--and that includes women with relative or even absolute contraindications. 

I agree with you that women planning VBAC should avoid epidurals. They slow labor and interfere with mobility and pushing, which could lead to a preventable cesarean; they can cause a drop in fetal heart rate, which is also a symptom of scar rupture and could lead to an unnecessary cesarean; and they pretty much guarantee need for oxytocin to augment labor, which several studies show increases risk of scar rupture. I would not, however, call them "contraindicated," with its implication that women should not be allowed to have them. As with VBAC itself, I want the woman to make an informed choice, understanding the potential benefits and harms of all her labor coping options. For some women, the benefits would outweigh any risks.

-- Henci

Please do keep us advised of how things are going.

-- Henci

Congratulations!  Wonderful news.  It is extremely unfortunate that in some parts of the country, the only women who can VBAC without a fight are those who arrive full dilated. But I'm certainly happy that is what happened in your case, bumpy ride not withstanding!

Enjoy that new baby of yours.

Best,
Amy

Congratulations! I am so happy for you!