On clexane- induction or not

[Casmama]

Looking for some opinions please.

I am 37 + 3 with dc2 and taking 40mg clexane in the morning due to a past DVT.

My dc1 was induced at 39 +3 due to being small and whilst the prostin gel was enough to get me to 10cm dilated overnight, I ended up with a kiellands forceps delivery as he was in distress.

Growth scans show this baby is growing well and is on 50th centile as he has been all along. I have been offered induction at 40 weeks if I want it but am not sure what to do.

I would not be allowed an epidural within 12 hrs of taking the clexane so if I went into spontaneous labour and something went wrong within 12 hrs then I would need a general anaesthetic for an emergency section.

On the other hand I managed to get to 10cm dilated the last time with just a tens machine for pain relief despite dc1 being back to back so do I chance it to get the natural labour I would really like?

Sorry it's so long, any thoughts?

[mudpiesfortea]

I asked my consultant about clexane and epidural during my last pregnancy and he advised I give myself the injection in the mornings as it would give me more chance of being our of the 12hr window.

In the end I did have an epidural and all was fine

[Casmama]

Thanks mud. I am doing it in the morning.
I was all set to go for natural birth but my dh would really prefer I go for induction as he is worried about me in pain and disparate for a epidural they won't give me or us both missing the birth due to GA.

I wish I had a crystal ball!

[mudpiesfortea]

I know what you mean! It's crazy that with all the advancements in medical treatment we still can't predict when we'll go into labour

[Casmama]

All part of the fun I guess!

[Mummymidwife87]

So you're on clexane because of a previous DvT.... Why do you want to induce you early at 40/40?

Surely you want to avoid another DVT, therefore why are they offering you one of the biggest interventions in obstetrics for no actual reason? Unless you have other medical things going on you haven't mentioned.

IOL drastically increases your risk of Instrumental birth, augmentation, post partum haemorrhage, CS, which all increase the risk of DVT...

Your best option would be to await spontaneous labour in my opinion, unless like I said there were actual reasons for an early IOL.

Good luck whatever you choose

[Casmama]

Thanks mummymidwife. The reason for offering induction is that it would be planned so I would not take the clexane on that day and therefore would be able to get an epidural/spinal if I felt I needed it or if something happened during the labour which meant that I needed an instrumental delivery or c-section.

I did ask the consultant if induction would increase the likliehood of other interventions and she said that the evidence doesn't support that which surprised me.

Thanks for your perspective.

[Mummymidwife87]

No correlation between IOL and complications... jeebus. Thats worrying coming from a consultant...

theres a 67% increased risk of requiring an emcs with an IOL

[Thumbwitch]

That's mad, what that consultant said!

I was on prophylactic clexane in both my pgs due to having Factor V Leiden thrombophilia, no DVTs though, so I was only on 4.0mg daily. I had inductions with both of mine and was just told not to take the clexane once I'd started the induction. As soon as they were born, I had to take clexane again though, and wear the surgical stockings (lovely!) and continued to take it until my warfarin levels were checked post partum.

DS1 was induced at 40+14, eventually turned up 30h later, with no further intervention, just 3 pessaries.

DS2 - completely different scenario because he was transverse oblique unstable lie, head up under my ribs, and I had polyhydramnios - I was induced at 39+1 and he was born at 39+3. I needed an ECV, ARM and the bloody drip because he was in no way ready to be born - but it all worked and he was born naturally with no further medical intervention.

So in neither induction did I have epidural, ventouse, forceps, or proceed to emCS - but I think I was lucky with the second one! (first one was very straightforward).

[Casmama]

Thanks both - 67% increase is pretty scary!

Thumb witch I have factor V Leiden too and will need to take clexane for 6 weeks afterwards, along with the stockings - oh the glamour! What a time of it you had with DS2, I'm hoping ds1 was the dramatic one for me.

I spoke to my dh last night about my concern that he would resent me if I refused an induction and then ended up with an emcs under general anaesthetic so neither of us were "present" and he was horrified.

I feel like a weight has been lifted that he is fully supportive of me avoiding induction as long as I can so hopefully this little boy turns up of his own accord in a straightforward way!

Thanks again for your advice.

[Thumbwitch]

Ah yes, they offered me to continue with the clexane for 6w after too but since I'd been stabbing myself since I got a +ve pg test, I'd about had it with the daily stabbing and said I'd rather be on warfarin!

[Casmama]

Having done the 6 months of warfarin after my DVT I couldn't bear the thought of the inr checks!

[Thumbwitch]

Haha, it's funny what you can stand, isn't it? I preferred being bled a couple of times a week to the daily stabbing, but it's all about individual feelings. :)

[Jcb77]

Most recent paper (Canadian medical journal, April this year) shows that induction at term does NOT increase section rate. In fact it can even reduce it by up to 13% depending on reason for induction. So your consultant is up to date. Not sure it'll help you in your decision making, but inductions are not completely the evil things they're made out to be. Increased chance of instrumental delivery and many women in synto want an epidural but by no means a given. Hth.

[Casmama]

Thanks Jcb, food for thought!

[Whiteshoes]

I took clexane and waited for labour. My waters broke both times in the small hours, and I did injections in the morning.

I'm glad I waited, although because of the waters breaking I did have the drip with dc1. I, like you, found it bearable with tens and gas and air.

Take it in the morning! You'll be fine!

[Thumbwitch]

I was told by the anaesthetist that having an epidural in induction would hugely increase my chances of needing further interventions, not necessarily emCS but more likely to need instrumental help. He didn't give percentages though but it was enough to talk me out of having the epidural.

[Casmama]

Thank you both. Definitely going to hold off on the induction as long as possible.

[Jcb77]

Instrumentals without epidurals - 7% of deliveries. With an epidural te rate doubles to about 14%. So yes, it increases it by 100%, but from quite small to small. However, some of the increase will be due to correlation, not causation (ie the reason an epidural is requested is the same reason that an instrumental is needed, eg big baby, poor presentation. The epidural doesn't cause either of these, but they are both more likely to lead to both epidural and instrumental).

[Casmama]

Just wanted to update and say thanks for the contributions to this thread. I went into labour myself yesterday at 39 + 5 and with my tens and gas and air delivered my gorgeous ds2 7 hrs later with just 6 minutes of pushing.
It was just the labour I wanted and so different from the first time so thanks all for giving me the confidence in the decision to avoid induction.

[squizita]

What a lovely ending!

I was just going to say that my consultant definitely said I did not need an induction unless I went overdue, but they would monitor me very closely instead (although I am on it for RMC not thrombosis so lower risk I think).