VBA2C again!! Saw registrar yeaterday to discuss birth and I'm being pressured to accept CFM...need some reassurance please

[LackaDAISYcal]

I'm currently 35+2 and had my routing AN appointment at the hopsital clinic so that I could discuss my previous wish for a VBA2C.

I didn't see the consultant, however the registrar that I spoke to seemed very good and helpful and was respecting all my wishes until the subject of CFM came up . I had been previously told at my 12 week appointment that I would have to have CFM but in the meantime I have researched this to the nth degree and can find no reason for the CFM other than to make their job a little easier. However, I presented her with some of the research to demonstrate, and was hoping for a frank and open discussion about it, but it was like the shutters came down. The main bargaining chip from her pov was the fact that I am trying for a VBA2C which she admitted the hospital doesn't see a lot of as most women who have had two sections opt for an elective.

She suggested that I could have a scalp clip attached to the baby rather than the belt which would give me a greater range of mobility (one of my concerns), however, I'm not sure I'm happy about the fact that this will mean possible ARM if they haven;t broken naturally by the time I get to hospital.

she also scared us by saying we needed to get into hospital as soon as possible as if my scar were to rupture at home then it wuld be unlikely that the baby would survive and I was putting my own health at risk. She also talked about risks of stillbirth, although was open to me opting for expectant management after 41 weeks whereas before I was told baby had to be out naturally by 41 weeks or it was under the knife for me.

My doula is keen for me to refuse the CFM and although she isn't pressurising me, I'm feeling a bit torn as to what is the best thing to do.

On one hand, I know these interventions are likely to increase the chances of the need for a repeat section, but on the other hand I don't want to do anything to jeopardise the health of my baby or me as I know I would never be able to forgive myself.

And although i know that there is a school of thought that says it doesn't matter how the baby comes into the world privded mum and baby are healthy and well; I need to at least try for a natural delivery to put to bed the ghosts of my pretty traumatic birth with DS. I feel at the minute that it's their way or the highway and that if these interventions are going to cause me to need a CS anyway, why not just get booked in and avoid all the unneccesary pain .

Thanks for bearing with this....I needed a bit of a vent

Not sure what I can say to help, but just to let you know that I had a VBAC without CFM. However, it was with the blessing of my consultant, and he was the 'top man' in obstetrics at that hospital at that time so no-one dared disagree with him. I asked him to write in my notes (and sign!) that CFM wasn't necessary, and - bless him - he did! None of the midwives questioned it when I went in, and they even got a portable monitor that could be used under water so I didn't have to get out of the bath (where I spent most of first stage).

A scalp clip might be marginally better than the belt, but you still wouldn't be able to pace the corridors or sit in the bath, would you?

I can see their point about going in straight away, although in my case it was a while... Waters started going (slowly, not in a gush) at about midnight, decided this was definitely 'it' at about 3-ish, then had to wait for friend to come round to be with dd1 (and finish packing hospital bag ) and finally got to hospital about 6.00. Dd was born before 10, so not bad at all. (And I was home again by 6 that evening )

I decided that I was willing to take the risk of not having CFM, balancing it against the fact that I would not allow myself to be induced (would prefer elective section) and that I would not have an epidural (so I trusted myself to feel any pain from the scar). It is a balance, obviously, but it felt right for me and I wasn't scared at all when I was in labour.

The only other thing that might be worth thinking about is why you had your previous sections. Mine was for a non-repeating condition (placenta praevia) so once I knew my placenta was in a safe place there was no reason why the need for a section would recur.

Good luck!

I had a vba3c with no CFM. Midwife using the doppler every 5 mins was just fine.

Oh, sorry... meant to say under bit about consultant that one thing you could try would be to ask to see a different consultant (or even try a different hospital). Not sure where you are, but my VBAC was at the Royal Berks in Reading...

Daisy this is spooky - I saw a post from you on another thread this morning, and was just wondering how you were getting on.

I had CFM for both dd2 and dd3 following em c-s with dd1, so I can't really offer any thoughts on not using it. I didn't find it restricted me too much but then I had no desire to be out of my delivery room so the leads were long enough to accommodate me moving around the room. I can't remember if I said this before, but there are telemetric monitoring units now, where the monitors are wireless so you can move more.

I can so completely identify with your need to try for a natural delivery. I had what some folks would consider a medicalised delivery for dd2 (epidural, episiotomy, forceps, second-degree tearing) but it was pretty fantastic to me.

It sounds like scaremongering to me, to go on about getting to the hospital in a hurry - I was advised to come in earlier than someone who hadn't had a section before, but not to rush in at the first sign. Although you are in a higher-risk catgory, the actual incidence of uterine dehiscence is low here. This was pointed out to me by the Foetal Medicine consultant I was seeing during my pg with dd3. As an aside, my induced birth with dd3 was by a country mile the best of the three, down to an excellent midwife - have you talked to the consultant midwife at your hospital, as (s)he may have a different viewpoint to the medics?

thanks for the responses. hi Poledra

right...reason for first CS was a cervical lip that got too swollen for DS to get past. I'm sure that this is because I was knackered and was on the bed rather then mobile; hence my need to be as ,obile as possible this time.

second CS was an elective as although I had originally decided to go for a VBAC my nerves got the better of me and combined with DH and I's situation at the time (him at work three hours away) we felt that it was the best option.

This time around, an unplanned surprise, we feel like we have been given a final chance to give the real deal a go and want it to succeed.

I too am aiming for as pain free a birth as possible and have ruled out epidural anaesthsia, even though it isn't contra-indicated in VBAC. And we are a 15 minute drive from the hospital and know (from previous call outs) that ambulances can reach us within five minutes so I'm not worried about distances.

she did say that they would want me in sooner rather than later, but that if I decided to stay at home as long as I was comfortable then there was little they could do about it! One thing she was very supportive of was the fact that I have hired a doula. the consultant I have is a locum as mine (who was very supportive of VBAC) has left. I'm not sure about changing and I hadn't considered talkking to the consultant MW. I'll speak to my doula who is on the maternity services liaison committee and see what she thinks. She feels that if I were to change to the other Leeds hospital I might get a more favourable response as they are less interventionist all round. Not sure what the protocol for that it this late in the day.

Induction isn't on the cards. They have stated that I won't be induced but obviously have to balance up the risks and how long overdue is acceptable before having a section.

The CFM thing is more about not feeling in control poledra than anything else, and the fact that as there is no clinical reason for it (studies have shown it isn't the most reliable indicator of feotal distress, especially if I'm wandering around the room with it attached and that it is likely to increase the need for a CS) then why do it?

I know the risk of dehiscence is small ~(less than 2% iirc) and rupture something like 0.3% and are on a par with serious probelms in a normal pregnancy and delivery, but there is still that little nagging voice that says "listen to the nice lady in the white coat, she knows things"

Daisy, I had a swollen cervical lip with dd1 too - I was labouring in water but I was incredibly tired by then too. How supportive is your hospital generally re VBAC? It might be worth investigating whether there is another consultant who would be more supportive. Perhaps the locum is playing safe as (s)he doesn't know the hospital policies/politics as well as a permanent member of staff? I found my greatest help in getting both the birth plan I wanted (which went out the window due to induction) and a great birth was the midwives, who helped me with the arguments I needed and also backed me up. As far as the birth plan went, getting the consultant MW onboard was the key, so I would recommend it.

Hi
I changed consultants at around 36/37 weeks for one who was supportive, although I understand now that I could have done it all WITHOUT a consultant, and just opted for MW care alone. As it turned out, I had a fantastic consultant who was very supportive of my VBA3C.

I also had no CFM - there was no way I would have allowed them to do an ARM to attach a foetal scalp clip either (my oldest "child" at nearly 22 still has a scar on his head from the clip used on him - I found the whole thing barbaric)

Like you, I knew that ultimately, the most important thing was not how the baby was born but whether she was healthy or not, but again, like you, I felt I'd been given another shot at birth. For that reason, I wanted to do everything possible to optimise my chances of success - no CFM, labouring at home for as long as possible, no epidural, having a doula etc etc. Obviously I weighed up the risks along the way, and I did reams of research so that I felt fully informed when making my choices. It's a personal decision that only you can make but the best bit of advice I can give you is to plan for all eventualities but to BELIEVE that you can do this. As you say, there is no reason why you shouldn't be able to - it's just a matter of organisation and patience

Good luck, whatever you decide. I'll be cheering you on from the sidelines!

thanks vbacqueen

That's interesting about the scalp clip. the registrar told me that it wouldn't leave a scar, but that aside, I'm not too sure Ilike the idea of my baby being hard-wored to a machine!

The locum consultant doesn't know anything about me . The registrar tried to get hold of her to come and talk to me so "you won't be a surprise to her when you come in in labour" but she was busy on a telephone call the whole time we were there. The registrar said she would talk to her about me to make sure she was up to speed. It isn't really instilling me with confidence in the system!

Where do I start if I want to arrange a different consultant or speak to the head of midwifery or even change hospital? I'm a bit stumped about it all!

oh, and they seem OK with VBAC, but VBA2C seemed to be a bit of an anathema to them and she admitted they don't deal with a lot of VBA2C, but they always go for CFM when they do.

I think a couple of days doing research and on the phone is going to be in order.

they told me vba3c was impossible. Shows what they know.
But you have the right to refuse anything you're not happy with. I insisted on a homebirth which got a lot of knickers ina noodle.

lol riven; that was the next line of attack...tell them I wanted a homebirth and they would agree to anything

did you get your homebirth?

Hi sorry to be dumb what does CMF mean please?

I think the biggest drawback with a scalp electrode is the fact that they'll have to break your waters to do it. Not something I'd particularly want to have done early on in labour if I was aiming for a normal physiological birth.

Re: CEFM - I'm sure I remember reading somewhere that the (albeit dubious) value of it for VBAC is that because it monitors uterine activity as well as fetal responses to it it might flag up the signs of scar rupture earlier than intermittent monitoring, before fetal distress becomes a significant issue. I'm not aware of any research evidence in support of this.

But isn't it your choice? If you understand what the risks are, and the benefits, and you are happy to decline it? You'd hope the midwife will be watching you very closely for other signs of scar rupture (like an increase in heart rate and pain between contractions which you sometimes get with scar rupture/dehiscence) if you decline CEFM. I'm sure you'll be well cared for whatever you choose to do.

Would like to add - I'm a bit surprised at your doula encouraging you to decline CEFM. I've just booked my second doula client, also VBAC, and I've been very careful not to sway her in one direction or another, just help her get her thoughts straight about what the issues are for her, and to support her whatever she chooses to do. Maybe it's my lack of experience that makes me a bit tentative on things like this. I know if it was a friend or sister I was supporting I'd be singing a different tune.....

bekkaboo CFM is Continuous Foetal Monitoring, where you have 2 electrodes strapped to your abdomen to record the foetal heartbeat and also your contractions.

fabsmum, thanks for that . Does the scalp electrode pick up uterine activity in the same way that the belt does? I certainly don't want ARM or any sort of intervention really. I'm hoping that the fact my waters broke naturally even though I was induced with DS and at about 4-5cms bodes well for this labour too. (although I suppose they could have broken naturally because I was induced? rather than inspite of it)

My doula isn't pressurising me, but she knows how strongly I feel about the monitoring issue and is supporting my choice really rather than discouraging me from accepting it iyswim. She is a bit of a champion for VBAC as well, having done it herself 20 years ago, which is one of the reasons I chose her.

I've read all the risks and am reasonably happy that the risks are within what DH and I consider acceptable, but there is still that wee voice that says "What if....?" And should anything go wrong, I'm hoping that my doula's experience will stand me in good stead. She is happy to help me monitor my temp and pulse at regular intervals which as I understand it are far more reliable indicators of scar rupture than foetal distress.

I had CFM for induction and 7 hour labour. My birth plan consisted of little more than "I want to be as mobile as possible," I had to rethink this after prolonged rupture of membranes.

First 4 hours were spent bouncing lighlty on the ball, standing supported. I had TENS only in this time, my DP and I did lots of massage and yoga breathing (and humming ) I had two 5 minute toilet breaks unmonitored in tis time.

The remainder of the labour I was as upright as possible on the bed, with TENS, gas and air and then morphine (it made me dilate v fast). She came out with a kiwi ventouse (in the room) after 60 minutes of pushing, as the morphine addled my brain and I needed a wee hand. she was and still is fine.

DP made a fab "labour mix" for me, lots of really relaxing music. I also had lavender oil warming. TBH the scritchy electodes pissed me off, but my partner and the midwives made the whole thing so calming, I barely think about them now.

sorry to ramble on, but I regard my labour as a really positve experience.

It sounds like you had a lovely positive induced labour experience twoboots . I wish mine had been the same.

The difference for me and a lot of women where CFM is concerned is that using CFM in a woman who has previously had a very difficult birth that ended in CS can put her right back there and the stress of that can interfere with the natural physiological process of labour and increase the need for a repeat CS. I want to avoid a CS if at all possible (my recovery after my CS with DD was awful and I couldn't stand for more then 10 minutes until well beyind three weeks) and want to maxmise my chances of a natural delivery. For me that means no CFM.

also, my birth won't be induced, so on that basis alone there is no need for CFM.

Just a quick update......

Met up with my doula this afternoon and had a very positive meeting. She was talking to the head of midwifery at the other maternity hospital who said that she would treat a VBA2C woman with no pregnancy complications like any other labouring woman and only monotor using a hand held device at 15 minute intervals. she also said that she would write up an individual care plan based on the woman's individual circumstances. so, my doula is going to chase it up futher and get something from her in writing and then I'll be changing hospitals and getting my natural delivery....woohoo .

She also said that they wouldn't rule out the pool if it was available either

fingers crossed!

ladies, ladies.

youre all using these acronyms and i dont know what they are. are you all health proffs or just well up on the old jargon. please help a 2nd time mum whos last birth was 6 years ago and is 2 weeks away from 2nd. things like vba2c and cfm and please tell me someone if the tens machines really help with labour pain!

Could you have a scan to determine the thickness of the uterine wall where the cs scar is? I've had one cs and after vbac's. For the vbac my doc went on about cfm, scalp electrode and that I'd have to have a ARM. I refused all of this as the scan showed no prob's with the muscle thickness. Labours were quick. Only thing afterward the births was each time I've had a heamorrage.

lol kiff5

VBA2C...vaginal birth after two caesarian sections.

CFM...continuous foetal monitoring (ie strapped up to the the bleepy/trace thingy)

ARM...artificial rupture of membranes (big plastic crochet hook)

and just up on the jargon afte being slightly obsessed with having a natural delivery since I found out I was pregnant

cupchar...I think I would probably need to go private for that as it isn't routinely done here. I'm sure I read something about it not being done because it isn't conclusive, but not sure. I know that it is routinely done in some other countries though. Also, I think the concern is that the length of time since my last CS is smaller than the average gap at only 17 months, which can increase risks apparently although I can't find any statistics for it.

oh, and not sure about the tens machines, but I have one on board for this time around. As far as I know they are good for early labour, but not much use when things really get going. some women love them, others get really annoyed by them when in labour.

If you can borrow or hire one you have nothing to lose really and you might find it works for you just fine

Am dubious about the benefits of having a scan to check muscle thickness as that really does not give you the full picture or tell you about the integrity of your scar and how it will hold up in labour.

To address the issue of CEFM: More and more hospitals are now moving away from this being standard for vbac women. If your hospital has a consultant midwife you should make an appointment to go and discuss your care with him or her because their role is promoting normality and they are more than happy to make individual care plans for women asking for things which are outside of policy.

The thing with CEFM is that it only really shows you a very small portion of what is actually going on with that baby, it monitors it's heart rate, not what it's oxygen levels are or how it is coping with labour overall. If a uterus were to rupture then actually, the baby's heart rate is the LAST thing to go haywire and by this point it is definitely an emergency rush to theatre. It is far better (in my opinion) to have a woman remain upright and mobile through her labour to help speed the process up, thereby putting less pressure on her uterine scar. Maternal observations (pulse and temp) should be watched closely as these observations will deviate long before the baby's heart rate would and the mother should be asked to be aware of and to mention any unusual (non-contraction) pain, particularly across the area where her scar is. This is obviously impossible to do if the woman has an epidural - something which is more likely when you are having CEFM because you are less mobile and therefore may find contractions more difficult to deal with.

My main concern with CEFM is that many HP's may see it as a "safety net" and therefore may not necessarily pay attention to the other things I have mentioned, thinking that the woman can be left for periods of time because the "machine will keep an eye on her".

The other thing to mention is about the FSE (clip on baby's head). You would definitely require to have an ARM (waters broken for you) to have this clip applied and this would obviously be being done fairly early in your labour which can cause problems if your baby is not in the best position as it often uses it's bag of waters as a cushion to help it turn.

I would definitely be keen to use a hospital which was happy for me to use the pool in labour. Even better, get a pool yourself and stay at home!

As far as the statistics are concerned. The risk for uterine rupture with 1 previous c/s is around 0.5% and with two previous c/s around 0.7%. Statistics for 2/+ c/s are less reliable as the numbers are so small they can be thought of as statistically insignificant.

Howdie, independent midwife

Hi Daisy, I'm posting under my Halloween name (waves)

As Doulas we are not supposed to give advice but your doula is 'encouraging' you to avoid certain things in order to maximise your chances of successful outcome.

It is my personal opinion, and this is arrived at from reading the opinion of several respected mw and childbirth experts, that intermittant monitoring is best unless, or until, there is a clinical need to change to CFM. See Mary Cronk's Scar thoughts on scar monitoring.

With my previous VBA2C client her cons had signed her off to use the pool, as you know, so that meant she would have had intermittant monitoring in the water. However, circumstances prevented that. Because of the mec mw put the belts on her but did not insist on her being on the bed. When it seemed the baby's belt kept slipping she merely used a second belt to support it and so we no longer worried about the trace. As it happened baby's HR was never an issue, although I checked it frequently (cos we could hardly hear it as mw turned the volume down very low) we were focused on mum. Me and dad were on either side of her, CTG machine was out of the way, mw did all her obs frequently and we all worked great as a team. Mum was the focus.

FSE is a pain! I know from personal experience that they don't always work even!

Anyway, I'm glad you are feeling so supported by your doula and that she is helping you to plan YOUR birth. I feel sure that if you decide anythign she disagress with in any way she will still support that choice.

As for the 'as long as mum and baby are both well it doesn't matter about mode of delivery' reasoning..... It actualy matters a whole lot! Part of being well is good mental health, so planning the birth you want is vital. IF you need a CS it still needs to be on your terms and so planning for that eventuality is important. Have you prepared your list of Birth Preferences in case you need a CS or instrumental delivery?

Other Daisy - have you asked about telemetry monitoring where you are not physically attached to the monitor? It is also waterproof so you should be able to use the pool whilst still having it on.

Howdie, can I just ask, what is the physiology behind the maternal pulse reacting more quickly to a potential/actual uterine rupture than the fetal heart? Is this verified by evidence or speculative?

If one of the problems with CFM is the potential for false positives leading to an unnecessary CS, isn't this also a real possibility with monitoring the maternal heart rate as this can be affected by things such as infection, dehydration etc? (Hope that doesn't come across as aggressive, I'm just interested)