Induction after a section?

[nearlythree]

I'm asking for a special friend of mine. She is about to have her fourth baby; the first two came early and naturally but her last baby was a breach section. She wants to have this baby naturally, but has been told that if she goes to her due date she will be induced. I've had three sections myself and was told that induction was out of the question, and I am wondering if the hospital is trying to keep its elective section figures down.

Hopefully this lo will come soon anyway, but if not does she have to get the baby out as soon as she reaches her due date? How risky is an induction after a section? Could she wait until, say, 41 wks before deciding? Or should she opt for a section at 40wks?

TIA, this lo is extra special so needs to get here as smoothly as possible!

she doesn;t have to be induced at 40 weeks...can wait until 41

the problem is...with induction...stimulating labour to start or to augment labour with synthetic hormones can overstimulate the uterus and there is an increased risk of uterine rupture. the risk of rupture per se is small..and i am not sure how much the risk is increased by inducion, i;m afraid

the yahoo group on this can help;..but don;t have a link...and the radmid website will probably have some good info.

an induction on a woman who has had a previous section is limited and will be well monitored and controlled...the downside is that she might be restricted in her wishes for an active birth....also induction can be more painful and full on than spontaneous labour...

if she has laboured early and spontaenously before..there is no reason this should not hapen again....

i wouldn;t neccesarily opt for a section at 40 weeks...but will depend on how the pregnancy is progressig...but she has had 2 vaginal delvieries..and the c.s was not for a medical reason, IFYSWIM..so it bodes well for a spontaenous natural delivery...

HTH

Thanks, lulumama.

I did know about the risk of uterine rupture, which is why I am surprised at it even being suggested. My dd1 was induced at 42 wks and I know that it is incredibly painful, and for me it all went horribly wrong and poor dd1 was delivered under a ga and was in NICU - thankfully she is okay but it was touch and go.

My friend says that if she is induced she would opt for an epidural but I think I heard somewhere that this can mask any pains that could indicate that a rupture is starting.

Oooh, hope this baby just comes soon!

it is true about the epidural masking pain of rupture.but there are more signs than the pain...but i personally would not want an epidrual ..also, unless mobile epidural..she would be confined to bed and an active labour tends to progress quciker...if she has had 2 vaginal deliveries...this labour might well be too quick for an epidural !

she has to make the right decision for herslef and her baby and based on the info of what her previous labours were like and how overdue she goes....etc....

HTH! xxx

Thank you!

I had emergency section 1st time round after induction. Due with no.2 in 2 weeks, my consultant said I can be induced (not until 41 wks + though) but she'll only give me one tablet (prostoglandin or whatever it's called). This will be after 2 stretch & sweeps, the 1st at 11 days over (due to Christmas). Normally, she would do 1st stretch & sweep at 41 weeks, then another 2 days later, then induction 2 days after that. Quite a lot of room to manoevre, I think. My dad sent me a BMJ article about the increased risk of uterine rupture after a section, and it is v.small but your friend ought to be aware that once she's in established labour, she'll be constantly monitored due to the risk - at least that's what I've had to agree to. Given that she's had 2 normal births, I would have thought any consultant wld be prepared to give her until at least 41 weeks before intervening.

My hospital has a policy of not inducing after a c-section.

Thank you. What worries me is that we had our babies in the same hospital and I know that two yrs ago I was told no way for induction following a section.

So she can go to 41 wks. That is reassuring.

Are the chances of her going over 41 weeks with 4th baby that high anyway? Or is it just she wants reassurance that she won't be pushed into section again?

She just needs reassuring I think. She has two dss aged three and 18 mo and wants to get well asap for them. Also she has lost her eldest ds this yr and obviously wants to be as safe as possible for this lo.

That's really awful nearlythree, your poor poor friend, so she's lost a child whilst expecting another? Of course she wants to have it naturally & be around for her other lo's, I hope the consultant gives her every chance to do that. good luck to her with it all.

The yahoo group link for anyone who needs it.

Also, just wanted to say that you don't have to be induced/have a repeat cesarean at 41 weeks. Many hospitals will wait till 42 weeks before offering induction to non-VBAC women, and I know of no evidence that increases the risks with VBAC by going past 41 weeks. There are many people who've gone past 41 weeks on the yahoo group, and I personally went to 41+5 with my HBA2C which everybody was quite relaxed about.

Thank you, daisymoo and accessorizequeen. Let's hope there's good news soon and she doesn't need any of your lovely help!

Am J Obstet Gynecol 1999 Oct;181(4):882-6
Zelop CM, Shipp TD, Repke JT, Cohen A, Caughey AB, Lieberman E
Department of Obstetrics and Gynecology, Massachusetts General Hospital, the Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, and the Department of Obtetrics and Gynecology, University of Nebras.

After adjusting for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use. Acceleration with oxytocin made uterine rupture was 2.3 times more likely, and use of prostaglandin E(2) gel made rupture 3.2 times more likely. These differences did not qualify as statistically significant though, because of the small numbers involved.

Am J Perinatol 1997 Mar;14(3):157-60
Flamm BL, Anton D, Goings JR, Newman J
Department of Obstetrics and Gynecology, Kaiser Permanente Medical Centers, Los Angeles, Riverside, CA 92505, USA.

5022 women attempted VBAC at California hospitals after prior cesareans. Of these patients, 453 (9%) were treated with PGE2 gel. There were no significant differences between the rates of uterine rupture in the two groups, and "indicators of maternal and perinatal morbidity were not significantly higher in the prostaglandin treated group".

VERNACULAR TITLE: Geburtseinleitung mit Prostaglandin-E2-Gel bei Zustand nach Sectio.

Geburtshilfe Frauenheilkd 1994 Mar;54(3):144-50
AUTHORS: Behrens O; Goeschen K; Jakob H; Kauffels W
Frauenklinik der Medizinischen Hochschule Hannover.

The authors analysed data from 385 trials of vaginal labour induction in a total of 522 patients with previous Caesarean section. Single or multiple cervical doses of prostaglandin-E2-gel were administered because of an unripe cervix in 161 women for induction of labour for medical indications.

The VBAC rates in this study were impressive: 84.9% of women delivered vaginally, and 70% of the mothers who had two prior Caesareans gave birth vaginally.

The highest success rates were seen after previous Caesarean for breech presentation, while there was still a vaginal delivery rate above 60% even after Caesarean for cephalopelvic disproportion or failure to progress.

There was no difference in complications for mother or baby between the induced and non-induced groups. There was a 0.5% incidence of uterine rupture, only in the NON-induced group. However, because of the small numbers involved, it is difficult to draw any further conclusions without reading the full study.

Sorry for the long post! I know the studies are inconclusive, research often is, however there are some statistics for your friend to look at from Angela Horn's Homebirth site (have posted stats rather than link as my links never work!)

There is absolutely no need for induction at all, if she went over 42 weeks (the usual term for a human pregnancy is between 27 and 42 weeks so 40 weeks is not over her dates!) then she could think about expectant management with weekly scans for liqour vol and twice weekly ctgs.