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Induction for Post Dates - Dilemma(9 Posts)
Hello all. Need input as no easy answers to current dilemma. This is my third pregnancy. Apologies for length! In a nutshell..
First pregnancy. Had GD and reduced foetal movement. Decision was made for IOL at 39 weeks, with my full consent. Admitted with a Bishop Score of 0. Spent two days on synthetic prostaglandins and had horrible side effects... by the time I went into labour on day three then I hadn't even been able to keep down a glass of water for 24 hours despite anti-emetic tablets, and anti-emetic injections. Waters broke on day three, I quickly developed uterine hyperstimulation, and the baby became distressed. A paediatric resus team and specialist OB team were called to Delivery Suite, and there was a quick discussion... because I had a previous spinal injury, and I had not been assessed for spinal stability (I was never told I had to be), I was told I could not receive any anaesthetic. The decision was made for an episiotomy and immediate instrumental delivery in Delivery Suite without pain relief, although I was not fully dilated at the time. The baby was fine, although I had a third degree tear in addition to the episiotomy, and major damage to my vagina. I won't bore you with the rest about stitches, a long recovery (months/years, not weeks), and reconstructive surgery... suffice to say it was rough. Physically, I have never fully recovered, and probably never will. There was a lot of damage.
Second pregnancy... no complications. Second delivery was spontaneous at 40+4, despite having a Bishop Score of 0 at 40+3. Again, I had very intense contractions towards the end... every minute, lasting a minute. Fortunately, there was no foetal distress this time. Baby was lucky because she was born with her arm around her head, but because of the scarring from the previous birth then I pushed and everything down there basically exploded, so she came out easily. Only a second degree tear this time, but they had trouble stitching because there wasn't enough intact tissue left to stitch. After an hour and a half, I was given a choice... keep stitching in theatre, with input from the General Surgeon, or just stitch the worst of it and leave some holes, hoping they would close over time (if not, the idea was to use a skin graft). I chose the latter option and the holes did, indeed close. I recovered well, and quite quickly... within a few weeks.
Third pregnancy... no GD. Currently 40+8. Booked for induction at 40+12. Next appointment Monday... 40+10. Bishop Score of 0 at 40+3. OB thinks that my previous uterine hyperstimulation is unrelated to receiving prostaglandins for IOL. I'm unsure. I am under a LOT of pressure to receive prostaglandins and be open to the idea of an instrumental delivery. This is literally the last thing I want. If I had another delivery like my first, I would be physically unable to care for my children for an indeterminate amount of time. I am also terrified of going into uterine hyperstimulation again... what if it happens again and #3 is not as lucky as #1 was?
I also do not want expectant management. I have raised the idea of a CS but this has gone down like a bucket of cold sick. Obviously CS has disadvantages as well... not a great time to be an inpatient, for starters... plus I need abdominal surgery in March or April as I developed total diastasis after #2, which has now split and herniated down my midline. Although it shouldn't affect delivery, the hernia is very large and affects things like eating etc. The concern with a CS is that I might herniate along the incision line as well (ending up with two hernias) and also that I would then be looking at two abdominal surgeries within a few months of each other. OB also says that induction at 40+12 after a spontaneous delivery is a different experience to induction at 39 weeks... but won't my low Bishop Score be a factor?
This is really not an easy choice for me, and I don't see any obvious answers. What do people think? Hospital don't offer Foley Catheter induction as standard, although I suppose I could ask? I wouldn't mind ARM for IOL (although obviously that's not happening with a BS of 0)... I just really don't want drugs because of my previous history, and I'm not sure whether it's a great idea to be induced as an outpatient either....
What a rubbish hand you’ve been dealt. I would avoid c section given hernia issues and also the damage in pelvic floor area already. Don’t forget your bishop score improved overnight for #2 so try and focus on that and if it comes to induction, decline the prostaglandins and insist on physical induction. I had thought there was a drug they could use when uterine overstimulation happens but you could check what their plan of action is should same thing happen again.
I’d say ask for a second opinion and talk it all through with a different OB - it doesn’t sound right to me. That said there’s often more to factor in than what’s been written here obviously! There’s definitely a higher risk of hyper stimulation with PGs, I think avoiding Pg is a great idea for you, and a balloon is very easy to do and I guarantee they have the equipment for it (it’s the same as a catheter balloon). I also think a CS is totally reasonable - diastasis and hernia is Very different to incisional hernia. It would be very very uncommon to herniate along the incision made for CS - more common to have hernia when an incision is done in the midline. But I’m not sure whether they perhaps think there is an extra issue with tissues given you’ve had all this trouble? Also avoiding an instrumental is completely completely reasonable. Second opinion and discussion is your best course of action IMO. Hope all goes well for you.
Oh also have you seen an anaesthetist this time (or second preg?) - if not, ideally ask for An anaesthetic consultation - given what happened first labour they should have a plan for you if you need epidural/spinal/CS
Thank you very much for reading all of that (very long) post, guys! Appreciate it. TBH I've just been desperate to talk through my options with another reasonable adult... DH tries to be supportive, but biology is not his strong point, and whenever I use words like "cervix" then his face clouds over and he assumes the same pained expression our 5YO has when she is trying to do her homework.
Obviously the OB should be the one to discuss this stuff with, but I've seen several and they all seem to have an agenda here: vaginal birth at any price (probably hospital policy). The senior OB actually told me "oh, we don't take scarring and damage from previous birth injuries into account when planning C Sections here. We prefer mothers to have all of their children first, and then refer them for reconstructive surgery afterwards." I mean... cheers for that, pal!
I've actually been a bit alarmed by several OBs... baby was breech/transverse until almost 39 weeks and I had three different OBs try to get me to agree to an ECV. When I pointed out that this could rupture my hernia, they all looked shocked and had to recheck my notes, which they obviously hadn't read properly in the first place (it's written on the top tab of my notes, in capital letters, in bright red marker, along with my other risk factors... ).
Obviously, a vaginal birth would be ideal, but I'm certainly not prepared to pay a high price for it and, after my recovery with #1, I don't see how recovery from a CS could possibly be worse than a vaginal delivery with the type of complications I had previously.
@TenThousandSpoons0 I asked to be checked by an anaesthetist during pregnancy #2 and he said I can have a spinal anaesthetic (the bottom of my spine is partially fused, but apparently there's enough movement and stability to get a needle in safely). Checked to make sure I didn't need another referral this time around and apparently I'm good. Was not going to make THAT mistake again!
I think I'm going to reserve judgement, go in on Monday to MW and hope for a better Bishop Score. If BS is still crappy on Wed AM (when I go in for IOL) then I'll have to discuss my options with the on call there and then, concerning potential IOL with Foley Catheter. Definitely not looking forward to that discussion. Would be so much easier if I was allowed someone with me for support, because I always end up feeling like the arsehole. Very frustrating!
Update... Bishop Score still zero.
My local trust do not offer Foley Catheters as a method of induction as they have no staff trained to use them. They only offer prostaglandins.
They do not offer CS as standard in these circumstances.
Spent last night falling off the healthy eating wagon dramatically by trying to induce myself into a junk food coma whilst watching old films with Sean Bean. In a way it's good that the induction is tomorrow... I'm not sure my pancreas could take such a horrific battering in the longer term...
@2cats3kids - that sounds so rubbish. At least they know you’re sensitive to the prostaglandins and will keep an eye on it. Wishing you all the luck for the induction, let us know how it goes!
I hope everything goes really well with your induction - I’m sorry you haven’t had more options but I hope you’re stillfeeeling ok about everything!
@2Cats3Kids hey just wanted to say that you are allowed to insist on a CS - this is your right according to NICE guidelines.
If you haven't already, outright ask them if they are declining your request for a CS. If so it's your right to ask them to change you to an OB that will agree to/perform it. If none of the OBs agree it is your right to be transferred to a hospital that will perform a CS (appreciate though you may prefer to remain with your current hospital but wanted to let you know of your rights).
I've looked into it a lot as had a traumatic first birth and have chosen a CS for my second as a result after exploring both options.
Your care sounds awful so far, I really hope it improves. Wishing you all the best ❤️