thinking through my VBAC plans - midwives/experiences/your thoughts welcome!

[LadyMaybe]

I've got an appointment with my OB tomorrow to talk through the plan for next 2 1/2 weeks - am currently 37+4. I have gestational diabetes (well controlled with slow-release insulin at night only), also have a clotting disorder for which I'm on clexane and aspirin. Previous birth was C-section after failure to progress from 8cm dilated. DS was born at 40+10 and 9lb 11oz, although very long legs rather than chubby tummy or big head. Reading through my notes again, I noticed that on scanning before finally deciding on the c-section his head was asynclitic, and I had a epidural at 8cm after being forced out of the birthpool (panicked when I felt pushy, nauseous and hot...midwife thought I might faint, fair enough, but in hindsight I think it was probably onset of transition - doh) which meant that together we weren't able to get him into a better position to progress dilation, I feel pretty strongly that this is what led to the eventual CS.

Ok, that's probably enough history/background!!

So, my decision so far has been to attempt VBAC but I've got a few hurdles to get through.

• Because of the combination of clotting disorder, GD, tendency to large babies anyway (serial growth scans indicate this one is likely to be 8-9lb), I have been recommended to not continue pregnancy past 40 weeks: both for placenta safety and size

• Because of previous c-section any induction will avoid prostaglandins and augmentation. It's fairly common here (in NZ) to use a Foley catheter + ARM for induction in VBAC candidates and that is what has been proposed if induction is agreed.

• If labour is prolonged or induction fails, or fetal distress is found, c-section will be recommended sooner rather than later. HOWEVER - discussion with OB & MW has been quite positive on this front, they have waterproof & cordless monitors so remaining active and using water for pain relief is fine (as long as I get a room with a pool and aren't the only one with mobile CFM requirements!)

Over the next couple of weeks I'll very likely be having a series of stretch & sweeps, each Tuesday & Friday. They'll hopefully either send me into labour spontaneously, or give us an indication of whether my body is readying itself.
If nothing happens by about 39+5, but my Bishops Score is ok, I'll go in for induction with Foley Catheter and I suppose rupture of membranes.
As far as I know, 90% of women go into labour once their membranes are ruptured (I guess that includes spontaneous rupture as well as artificial?).

I'm just a little worried about the impact ARM induction might have on labour. Does having ARM mean baby is more likely to get distressed because waters aren't there to cushion? Or be less able to turn/move head if it gets into a dodgy position? or is it more painful for the woman? (this actually doesn't worry me because I had SROM before labour started with DS, it was painful but I did cope with Gas & Air and Water until 8cm when I got pushy and panicked (didn't understand midwife didn't seem to realise that it could just have been premature pushing feeling due to head position - sigh)).

Does anyone have any thoughts about ARM in induction? At the moment I'm planning to discuss timeframes with OB, for example, how long could we leave making the ARM decision post-Foley catheter (would cervix just close up again??)

Here's a link about Foley catheter induction for those who haven't heard of it

It seems to me that the thing you might be most up against is how to prevent a cascade of interventions. Research shows that this significantly increases the likelihood of caesarean birth.

From what you have written you seem pretty certain about the VBAC route, but I am just wondering if you have read anything about the differences between emergency caesareans and planned caesareans. In terms of both risk and experience there is a great deal of difference. I wonder given the set of indicators you are presenting with whether it might be worth considering planning a caesarean as close to wk 40 as you can. Or at least planning the VBAC but if you go over wk 40 converting to a planned caesarean rather then going down the induction route?

There is a great book 'Caesarean Birth: A positive approach to preparation and recovery' by Leigh East www.csections.org which has loads of information including a full risk/benefit analysis and loads of ideas for turning a caesarean experience into an equally rewarding birth.

Good luck with your decision-making.

Hi MsMoo,

I don't have any problems with having another emergency (although I tend to use 'unscheduled' in my head) c-section if that's how it turns out. I think that's why I've concentrated more on the VBAC route, and attempting to optimize those chances (in the face of a lot of complications).

I don't feel that an elective c-section is the right choice for me or my baby while VBAC option remains open, mainly because the gestational diabetes is associated with increased risk of respiratory problems in the baby - and so is c-section (elective or planned), surgery is associated with increased risk of clotting, and I already have an increased risk of that, and both c-sections and GD can be associated with delay in milk coming in, and if my baby has problems with blood sugars as a result of GD, then I don't want to delay things if s/he ends up needing some sort of supplementation.

I will have a look at that link though - I've put some thoughts down regarding my wishes if we do end up with a c-section again, and re-thinking the decision can only be a good thing. One thing I'm planning to ask tomorrow is when ELCS need to be scheduled (ie. how far in advance or whether it could be scheduled with a day or two notice if things aren't looking favourable).