Overdue and keen to avoid slippery slope of interventions. Help me strategise!

(38 Posts)
peacefuleasyfeeling Tue 25-Jun-13 21:25:39

I am booked in for a stretch and sweep tomorrow, when I will be 40+6. The appointment was booked preemptively a few weeks ago during my last MW appointment. I haven't had one of these before. Whereas I am not against interventions per se and where necessary, I am keen to avoid the text book chain of events which turned my attempted homebirth into a hospital horror story last time.

I am trying to get my head around how best to have a converation with my midwife about this. She is great, and very supportive of the idea of a homebirth, but I also know that she'll have her own set of guidelines to comply with. My main objective is to avoid a drip induction, which is what happened last time, in order to "speed things up" a little once we were deemed to have run out of time after the waters breaking. So, I'm looking for help with spotting angles I may otherwise miss or may just not have considered, bits of information that may come in handy. If you have anything to chip in, please do!

a) should I ask her to check my cervix and only perform the stretch and sweep if I seem to be ready-ish anyway? Or is it simply a case of "it either works or it doesn't"?

b) is a stretch and sweep likely to start things off but perhaps not have the oomph to carry it through in case I am not "ripe" enough (thus necessitating a trip down the IV induction route later)?

c) if I go much further overdue they will start to pressurise me for an induction, and I wonder if you can go in, have a pessary and then slink back home again and await the onset of labour and proceed with a homebirth as intended? Or are you stuck in hospital once you're in?

d) if during a homebirth, the MW considers things are moving too slowly, or if labour stalls, is a drip induction really the only way to go according to the medical model (leaving aside earthier nudges such as nipple stimulation etc), or could I ask for an alternative method of induction such as a pessary to move labour along?

Is there anything you would make sure you said / had recorded in your notes / asked?

Thank you very much!

RandomMess Tue 25-Jun-13 21:28:06

Did you not have any pessaries last time?

I've been induced 4 times and only needed the pessaries each time plus ARM twice?

How long will they let you go overdue - 10 days was standard at my hospital but as it was my 4th and I'd gone 14 days overdue with the others they were very happy to leave it to 14 days over.

RandomMess Tue 25-Jun-13 21:29:13

My birth plan for the last dc was a list of do and don't wants blush rather clincial! The midwives had a giggle but said it was good!

peacefuleasyfeeling Tue 25-Jun-13 22:01:01

Hi there and thanks for being so quick off the mark!

Nope, no pessaries last time, and I didn't really question it. They just went straight for the drip. Odd on reflection, perhaps. MW who came to attend homebirth noted a slightly fast pulse, and as waters had broken 36 hours previously deemed the risk of infection warranted a hospital transfer, despite labour being established and dilation progressing well (at that point 4.5 cm). Once we arrived at hospital constractions had slowed down and although fetal monitoring indicated DD was fine, the decision was made to proceed with a high dosage Syntocin drip, "to be on the safe side". Which was bloody painful.

I think our trust allows you to go for 14 days in theory, but by the time I was 40+5 last time they were very keen to book me in for an induction at 40+9, "just to get it over with". We didn't get that far, so don't know if they would have offered pessaries then.

My birthplan is super-brief this time, and the main thrust is avoiding an IV induction grin

Thanks again!

RandomMess Tue 25-Jun-13 22:04:09

Well I would ask for pessaries!!!

I would also insist on an epidural prior to drip I've heard they are horrific.

I had epidurals with 3 of mine and no assistance required. I knelt up so gravity helped etc so no forceps or anything.

I don't know about guidelines once your waters have broken though.

StiffyByng Tue 25-Jun-13 22:06:23

My experience of homebirth midwives is that they are far more relaxed about progression as long as there is no other cause for concern, although I can't speak for yours. My lot aren't fussed about the whole 1cm/hour thing and are happy to go at your speed providing obs are OK.

Good luck. I had a sweep when 1-2cm dilated at 40+3 with my second, and my baby appeared around 12 hours later, at home.

peacefuleasyfeeling Wed 26-Jun-13 10:29:26

Oh, that's good to know Stiffy. I'm getting quite into it now, I suppose it's just natural excitement. Let's see what 3.30 brings...

Thinkingof4 Wed 26-Jun-13 13:59:39

I think they don't give pessary is waters already broken hence why you had drip last time. You would probably be offered pessary first this time if waters still intact
Re sweep, I think if cervix not favourable then they probably won't do it as unlikely to work. Fx it does the trick, worked for me last time!

peacefuleasyfeeling Wed 26-Jun-13 18:24:30

Ahh, all done, cervix favourable and 3 cm dilated (not that I've felt it happen, but apparantly not uncommon with subsequent babies), and just as you said Thinking, the MW did think that should it go that far, it would be a pessary providing waters are intact. But yes, fingers crossed it'll come around much sooner than that!
Thank you people for posting!

RandomMess Wed 26-Jun-13 19:25:46

Oh good news, my naughty cervix never did anything like that not even at 17 days over grin

TarkaTheOtter Wed 26-Jun-13 19:43:03

I'm surprised that they'll bother with the pessary of you are 3cm already. That's plenty of room to break your waters and get things moving.
All sounds very positive though and like your body is gearing up for things!

StiffyByng Thu 27-Jun-13 14:52:01

Yes, good luck! Another who sees no point in the pessary. You just need a nudge.

haloflo Thu 27-Jun-13 15:42:45

I was told no pessary needed after I had a sweep at +8. They would have just broken my waters at +12. I had my baby 10 hours after my sweep though so there is every chance things wont get that far. Good luck!

peacefuleasyfeeling Thu 27-Jun-13 20:33:52

Well, no sign of a baby yet, and am booked for a 2nd sweep tomorrow, once 48 hours have passed since the last one. And induction by breaking waters -of course, so simple, it hadn't occurred to me, I've been so focussed on avoiding that Syntocin drip!

Thanks again, everyone!

Blessyou Thu 27-Jun-13 20:57:06

You can ask for scans and monitoring rather than induction - and if there is cause for concern obviously proceed with a justified induction.
I declined induction at 40+10, much to the disgust of the registrar, but accepted sweeps and suggested monitoring as an alternative, which turned out to be unneccessary as he was born next day (at home!).
Told my midwife not to bother booking me in at the hospital to discuss induction until 40+14 with DS2 who came 11 days late too!

fuckwittery Fri 28-Jun-13 04:49:17

I'm really surprised you are having sweeps at only 6 and 9 days after due date, I wasn't offered til 40+10

You are not overdue until 42 weeks, normal pregnancy is 38-42 weeks

Just say no thanks and ask for daily monitoring and a scan if you get to 40+10 if you want to avoid intervention, you can review at 42 weeks, but 12 week scans have a +\- 7 day margin of error as well so you could only be 41 weeks! From someone who went into labour at 40+18 and had a tightly closed cervix until the day before!

StiffyByng Fri 28-Jun-13 09:51:06

I've been offered sweeps at 40 weeks in both pregnancies. Everywhere is different.

peacefuleasyfeeling Fri 28-Jun-13 20:59:48

Hm. Had an interesting conversation with the MW following 2nd stretch and sweep this afternoon (still 3cm dilated, favourable cervix, although had small mucousy show this morning), which I am relaying in case someone else is reading this who is in a similar situation, and may find it interesting.

The MW has, as per trust protocol, booked an induction for Tuesday, by which time I'll be 12 days overdue (the thinking being that if induction is performed at 12 days overdue, most babies will be born by +14, which is deemed a "safe" cut off point). This is, according to her, because after 42 weeks, some placentas cease to be as effective as they need to be in order to provide the baby with enough oxygen and nutrients; in other words, they have reached their "sell by date" and begin to deteriorate, putting baby at risk. I'm going to look into this a bit more...

I asked whether it would be induction by pessary, and she said that all the pessary really does is to ripen and dilate the cervix to the point at which it is possible to get in to break the waters, and at 3 cm I'm already "there" (meaning she could have broken my waters today, had she wanted to), so therefore a pessary would be redundant. The breaking of the waters is the "real" induction, and may or may not get labour started. This is when the IV syntocin comes into play.

She also said that new guidance does make it possible for some women to have a pessary / waters broken, and be allowed to go home to await the onset of labour in order to proceed with planned homebirths, but she said that very few women manage to "tick all the boxes", both with regard to maternal health and that of the baby, for such a discharge to be recommended. And in our trust, you get 24 hours following rupture of the membranes before they get twitchy about syntocin induction (which is what happened to us last time).

So, I'm going to think about suggesting monitoring and a scan as an alternative, as BlessYou and fuckwittery suggested (and accept induction if justified, of course), as it seems sensible to keep my waters intact for as long as possible, given that once they're popped I'll be on a 24h race against time... I'm sure there is such a thing as a personal natural gestation period, and I'm naturally a late one.

Thanks again!

nannyl Fri 28-Jun-13 21:36:34

im 40+ 6 today

and just back from a midwife appt (and planning another home birth)

first thing midwife said to me was "so where do YOU want to go from here?"
She then told me about a homebirth she attended last night where lady was 40+16 smile

I said i didnt want a S&S and would not be booking an induction.

It is "normal procedure" to book an appt at hospital to book and induction at +12, but as that the day of OHs grandmother funeral i said that wont be happening and i wouldnt be doing anything before +14.... (which is a saturday)

so at +13 i will have another midwife appt (to check all is still ok)... and i may consent to a S&S then

then at +16 i will have my first hospital monitoring, which will be every 48 hours. (luckily for me this is done in my local hospital (which is not a hospital where you can have a baby))

should i get to +21 i will re-think things, BUT in the mean time (so long as monitoring suggests all is fine) i will continue with my plan to homebirth until at least 43 weeks.... all fully supported by NHS

just thought id add that for reference for anyone else reading smile

peacefuleasyfeeling Fri 28-Jun-13 21:51:47

Nannyl, that is really helpful! I have a friend who went to +22, but with a very supportive independent midwife. I'm taking a leaf from your MW's book and will be asking myself "Where do I want to go from here?" from now on.

I just popped back on again to say that as fuckwittery said, there is always a margin for due date error based on scans, and I have always been suspicious of my EDD, as I KNOW when we "did it" and that conception itself probaby wasn't instantaneous. Which puts EDD at close to a week too early. Thanks for reminding me!

RandomMess Sat 29-Jun-13 10:48:26

With my 4th pregnancy I saw the consultant who is very pro women going overdue and not intervening etc, she had no issues with me waiting until +14 even though the hospital protocol is +10 with subsequent babies. I am one of those people with a naturaly long gestation as was my mum.

However when we discussed waiting up to 3 weeks she was pretty blunt and honest and we talked about the slight increase of risk of stillbirth. At +17 days dc2 had grade 3 meconium in my waters and had clearly been there for sometime. Anyhow I personally decided that as I couldn't have my homebirth at +14 that I may as well go in and be induced at that point rather then perhaps have an increased risk of stillbirth. We discussed daily monitoring too and as she said baby can be absolutely fine and within 12 hours it's a different scenario.

I don't wish to scaremonger but it is a point of view to consider, sadly of the several people I know that have had a stillbirth all but one have been due to unexplained placenta failure and they've mostly been post 40 weeks.

I want to congratulate your cervix at being 3cm and favourable - mine never ever did that on it's own, even with my last 6 hours after the first pessary my bishops score was only 1 shock

Hopefully lots of activity will get thinks going and you'll have a really positive experience. I certainly think being relaxed and ok about it does help make a huge difference, I could not believe how easy my last birth was - the only real difference was that I had accepted that I would be induced, wouldn't get my homebirth, was going to have another whopper and I just really didn't mind anymore - I was much more focussed on not having another baby that screamed for 6 months due to undiagnosed acid reflux - 3 hellish days of labour compared to that were nothing in comparison ITSWIM.

All the best x

cakebaby Sat 29-Jun-13 11:05:34

OP and nanny sorry to barge in, but WHAT are they monitoring? My MW & cons have both told me there are no reliable indicators of placental degradation and they don't offer it, which is odd given all the references to it on MN!

The policy here is to induce at 40 wk/edd regardless which frankly I'm not keen on at the moment!

RandomMess Sat 29-Jun-13 11:07:46

I think they look at the blood flow to and from the placenta?

40 wk/edd OMG shock - nope I wouldn't be keen either (been there tried that with dc3 - my choice)!!! Where do you live?

They can't force you to agree to induction though..

cakebaby Sat 29-Jun-13 11:53:53

Thanks for swift reply random, I'm in east Anglia, I will literally just be 40 at edd hence cons appt & induction. Seems bit heavy handed to me! No other indicators for induction at present (32wks). Know everyone is keen for safe delivery but not sure induction on an arbitrary date is necessarily best way to achieve this if everything else is going fine?

They had a bit of a giggle, saying I'd change my mind by edd, hot, fat, sweaty, uncomfortable etc! hmm

nannyl Sat 29-Jun-13 14:22:28

i was told they would monitor heart rate for at least half an hour.... and listen that they didnt hear any decelaration

fluid levels

and something else that i cant remember.

worth remembering that risk of placenta failure increases significantly from 37 weeks.... so going to 39 weeks is more risky than 38 etc etc...

the increased risk from 42 - 43 weeks is not really that much more than from 41 - 42 weeks.

and given that normal pregnancy is seen world wide as 37 - 42 weeks, i fail to see why at 42weeks and 1 day its just going to stop working..... and in all liklihood it wont & doesnt. (same way as it doesnt just stop for most people at 37 / 38 weeks either...... but it might)

Lots of things that people routinely agree to during pregnancy carry more risk than going beyond 42 weeks.

and of course there is the fact that scan dates can and often are inaccurate... my sonographer told me only to + / - 1 week anyway....

then there are the risks of induction to consider (absolutely not risk free) and then if you are planning a homebirth (like me) the increased risks associated with birthing in a hospital in the first place.

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