Use of continuous monitoring during labour due to VBAC and diabetes

Christy Shell

Use of continuous monitoring during labour due to VBAC and diabetes

Good evening

I have been told that I will need to be continuously monitored during labour as I am attempting a VBAC and I also have gestational diabetes. I understand why they want to monitor and am ok with that but I am petrified of ending up strapped to the bed like with my first labour (I had PROM and then was induced unsuccessfully 3 days later ended up having a C section) unable to really move about. Is it unreasonable to ask that I be given 3 lots of 10 minutes every hour where I am completely free to move about? or something similar? The midwife I have already tried to talk to this about basically told me that I would be putting y babies life at risk if they couldn't monitor the whole labour.

Is there some reason that monitoring is more important in a VBAC and in gestational diabetes?

I really appreciate your assistance

Henci Goer

RE: Use of continuous monitoring during labour due to VBAC and diabetes
(in response to Christy Shell)

First let's get the gestational diabetes issue out of the way. There is no evidence that what should more properly be called "carbohydrate intolerance of pregnancy" in an otherwise healthy woman increases the likelihood of fetal distress in labor.

Having had a prior cesarean delivery is a more complicated issue. The two studies we have on the topic agreed that the most reliable symptom of uterine scar rupture is a profound slowing of the fetal heart rate (FHR) either continuously (bradycardia) or during contractions (decelerations). Theoretically, then, continuous EFM could improve outcomes by shortening the time between recognition of the problem and delivery. The studies disagreed, however, on whether continuous EFM would improve outcomes. One found more newborn morbidity with delivery in after 17 min when abnormal FHR was the only symptom while the other did not. (Often, although less reliably, scar rupture is accompanied by other symptoms such as heavy bleeding and severe pain.) Still, the benefit was minimal even in the study claiming to find it. Of the 5 infants delivered after 17 min, 4 required mechanical ventilation, but within 24 hrs, they had recovered. The 5th, delivered 32 min after diagnosis, had "asphyxia," which sounds awful, but is a catch-all term for low blood oxygen. No information is given on the eventual outcome for this baby. What we don't know, though, is whether the infants delivered by 17 min in good condition would have developed problems with further delay or whether the infants delivered after 17 min likewise would have had more serious problems with additional delay. Even so, if continuous EFM had no harms, it would make sense to use it as a precautionary measure, but that isn't the case. Several other harmless events can cause FHR decelerations such as rapid descent during pushing or maternal positioning or epidural analgesia causing low blood pressure, and these false positives could lead to unnecessary surgery. In addition, trials of continuous EFM in the general population have shown that EFM increases the likelihood of cesarean and instrumental delivery.

Where does that leave you? I think your best bet is to find a solution you can live with and that won't get you labeled a "difficult patient." EFM needn't confine you to bed nor does being in bed confine you to one position. You can stand, "slow dance" with your partner by rocking from foot to foot, sit in a chair or on a birth ball, kneel upright in the bed or on get on all fours in the bed with a birth ball supporting your upper body and head, etc. I searched on "positions for labor" and picked the Mayo Clinic one, but there were others as well. And it wouldn't be unreasonable to insist on being detached for brief periods so that you can use the toilet or take a turn or three around the room. A doula could be a big help with ideas, and I strongly recommend hiring one. She can also help you and your partner with some of the emotional issues that may arise in a VBAC labor.

I hope this helps.

~ Henci

Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors? Am J Obstet Gynecol 2002;186(2):311-4.

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; 2003 March 2003. Report No.: AHRQ Publication No. 03-E018.

Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol 1993;169(4):945-50.

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