ARM

[runnyeggsareyummy]

Just a quick question. Am due to have a VBAC with DC2 and have already agreed with consultant that they will not do an induction (would rather move straight to c-section if necessary). Had induction with pessary and drip last time, followed by epidural and EMCS for fetal distress - to be honest it was fine in the end but would prefer not to repeat and concerned about risks of scar rupture etc with induction. Consultant agrees with me and is fine about this.

However, does anyone have any thoughts about ARM? It sort of falls under 'induction' but I can't find much about the pros and cons of it?

Thanks

The evidence shows that induction with a syntocinon drip is ineffective if the membranes are intact so that's kind of a given if they are happy to use syntocinon with a VBAC situation. Most consultants prefer not to as the risk of scar rupture is obviously higher with the strain on the uterus.
Tbh, it depends at which stage the ARM occurs. Evidence shows that it may speed up labour by around 30 minutes but it very much depends on the woman. For example, for many multiparous women (laboured and given birth vaginally before) as soon as the waters break, labour seems to put a sprint on but for others, it simply adds stress to the baby and makes the contractions more painful. Of course there is an increased risk of infection for mum & baby once the protective membranes have ruptured.
Midwifery thinking goes something like, if it ain't broke, don't try to fix it. In other words, if labour is progressing normally don't rupture membranes 'just because.' Doctors tend to like to perform an ARM so that they can see the colour of the water (is there meconium present) and because they like to be 'doing something'!
It's one of the few things in induction that cannot be undone, so once we have performed an ARM, we have committed to delivering the baby.
The Cochrane database of systematic reviews is a good place to look for evidence based information on things like this. good luck

I've been looking at the NICE guidelines about induction methods so I'm prepared for possible discussion about induction for VBAC. I think I would prefer to go straight to CS rather than attempt induction.

From the NICE guidelines (not relating to VBAC), prostaglandin gel/pessary is the most effective thing to start induction. However this isn't recommended for VBAC as there's some evidence it increases scar rupture quite considerably. So you're left with syntocinon drip combined with ARM. However, risks of ARM are that there's then an infection risk, and given that if you have syntocinon it's recommended you have frequent (2hourly I think?) internal exams, there is a lot of opportunity for infection to be introduced. Plus, the baby then is unlikely to be able to get into the best position for birth once the waters are broken. Also, sytocinon plus ARM will only work if the cervix is already very favourable. And if you had planned to refuse CFM and opt instead for intermittent, that would be quite a risky strategy with an induced VBAC so you might end up strapped to the bed.

The other thing is that if you haven't delivered vaginally before, an induced VBAC labour has only 40% chance of success.

Are you overdue already? I'm 40+2, had had one attempted sweep, another booked for Sunday, and been told to ask midwife on Sunday to book me an appt with the consultant to discuss induction. Actually I was told by the registrar I "would be booked" for induction at 40+12 but I'm not agreeing to anything without having a proper discussion with a consultation. Aaargh, it's such a hard decision, rock and hard place.

Thank you ladies! Both your comments are really helpful. I've already had a look at NICE but will also check out the Cochrane database. I'm not due for another month or so but would like to have all the facts before anything starts to get going!

Zimbah, I hope your little one puts in an appearance soon and doesn't force you into making the decision of induction vs c-section - good luck!