VBAC coming up, hospital want continuous monitoring, canula, etc etc.....what do I do?

[WhatFreshHellIsThis]

So up until Friday I wasn't sure I was going to be able to go for a VBAC as the baby was breech (am 34 weeks) but it has obligingly turned over and is currently head butting my bladder. Nice.

However, had meeting with my consultant on Friday and he tells me that the hospital want me to be continuously monitored in labour as 'foetal distress is an early indicator of the CS scar weakening' - I'm not keen on continuous monotoring particularly as it means I can't use the birth pool.

He also says they want me to come in as soon as contractions are strong and regular, rather than doing most of it at home and coming in when they're a few minutes apart.

And they want to put a canula in as soon as I get there, in case they have to rush me to theatre, which isn't a massive deal, but I'm worried about all this messing around making me tense and inhibiting labour.

He said I have a 1 in 220 chance of scar rupture, that sounds high to me, I thought it was slimmer odds than that?

I had a horrid medicalised time with DS, who was induced, didn't work, ARM, Syntocinon, the lot, then emergency CS, and I was really hoping to be able to spend quite a lot of this labour at home.

Any thoughts on this? I like my consultant but he was pretty firm on all this, and I'm feeling a bit railroaded.

stripey...just out of interest...what would be the symptoms of uteral rupture?
Would the woman feel that something was amiss, etc...

No, the woman wouldn't always feel anything amiss.

Clinical signs could be a drop in blood pressure and a rise in pulse rate. Bleeding is another sign as is contractions decreasing.

Fetal heart rate showing signs of distress is another sign.

Woman having severe pain and/or feeling unwell is another sign.

Can come in any order, maybe just one sign, maybe more than one.

so, if not continously monitored...how would one manage it?
I am jsut trying to go through the scenario really...and it might clarify things for OP, iykwim...i.e. she would be able to make an informed riskassesment...

How would you diagnose it for sure, Stripey? Would you scan or what? It's always been painted as a kind of drastic emergency type scenario, but H20's post makes it sound a bit more like there are degrees of emergency involved?

If you decline to be continuously monitored then the m/w would normally do intermittent ausculation where they listen in for 1 minute with a handheld sonicaid every 15 minutes.

Some women may even want to decline that though.

Or you could ask for something half way inbetween where you could agree to be continuosly monitored but not for the whole labour - maybe 20 minutes here and there?

No you wouldn't scan.

If you suspect it then you go to theatre and do a section. Diagnosis is by seeing if its ruptured or not in theatre.

Its always an emergency but sometimes you can have a smaller rupture. However once there is a small rupture the uterus is VERY weak and the rest of it could go at any second.

thank you!

By the way, both myself and baby were fine.

But if I had been stubborn and carried on labouring/not followed their advice, who knows what would have happenned?

I'm glad to hear it h20 - sorry, didn't mean not to respond to your post properly!

going to bed now, thanks for the advice, all x

night

some useful links are

Mary Cronk on detection of rupture

chochrane review on CFM

for my VBAC attempt I managed to get supervisor of midwives & consultant to agree use of pool during labour (not delivery) & intermittent monitoring + no cannula, unless/until there was the first sniff of trouble then I would get out & go on CFM. (Ended up with an el c/s at 40+10, but that's another story )

It's all down to what level of risk you are happy to accept vs how you want to labour.

They can advise you, but they can't FORCE you to do anything. I always found that the registrars & below were always "by the book" but once you got to speak to the consultant & they were happy you understood the risks then they were a lot more willing to be flexible. (Particularly if you have the supervisor of midwives "on side" first )

Yes a cannula would be a good thing if you are unluckly enough to rupture and bleed heavily, but that is also true for a placental abruption which has a similar level of risk (also requiring crash c/s & for any pregnant woman, not just VBAC) and I don't see them fitting a cannula in every labouring woman

Similar level of risk for a cord prolapse (again for any pregnant woman & requiring crash c/s) but I don't see them scaring every pregnant woman with these possibilities, so I find it a little frustrating that they scare a VBAC woman to death & making her think she is a walking rupture...

Telemetry (wireless CFM) is a good compromise if your hospital has it, but not available everywhere.

Oh & in terms of cannula I had one in after my el c/s, but it had stopped working when they tried to use it when I had a massive PPH & neither midwife of obs registrar could get another one sited - fast bleep to anaethetist and he appear a minute later & had one in within seconds - not ideal obviously - but what I'm saying is that if a cannula has been in for a while who's to say it would still be working anyway?

Hope that helps?

good luck with your VBAC

the RCOG green top guide is also a good refernece point

They tend to want to site cannulas because of the risk of haemorrhage with a rupture. If you have a large bleed then the veins can 'collapse' making it very hard to site a vein. On the back of this doom and gloom advice I had to wear a cannula for the month I was in hospital before my twins were born (I had placenta praevia and recurrant bleeds). I hated them as they were very uncomfortable and had I been allowed to have a natural delivery I would have found them quite restrictive. They were very painful in the back of the hand.

There's also no guarantee that the bloody things work. I had a fresh one sited the night of my final and biggest bleed - some anaethatist marched in and put one in my hand whilst everyone was in the room dithering over what to do with me. And yet when they finally took me to theatre for the section it turned out that he'd missed the vein. It took four go's (in the crook of my elbow, my other hand, my mid arm - the latter really painful...) before they finally got one in again. So much for being prepared.

They can only advise you on the risks - they can't force you to have a cannula. Just as they can't force you to come in as soon as your contractions start. I think ending up in hospital with a monitor strapped to you and with a cannula in your arm is probably not the greatest set up for a successful VBAC and you're right to feel disappointed about their recommendations. If I ever manage to get pregnant again I'm aiming for a VBAC and plan to hire a doula to take me through the early contractions at home and then go to hospital with people on my side. No CFM (there's no evidence it helps) and no cannula unless they can provide me with a fixed reason for it.

Good luck. I hope you get your VBAC.

Following this thread with interest and would love to hear what you decide. The continuous monitoring thing is something that had bothered me from day one in the pregnancy and I've been unable to decided what I want to aim for. Its getting closer now so I guess I'll have to make a decision. This thread is very informative,

kitswins -odd you should say that about the canulas. I spent a month in last time with various canulas being placed in case of emergency. when it did happen and I came round I found they hadn't used the one they had had put in anyway and had done a new one. Makes me wonder what the point was.

my thread asking about how much monitoring.

Right, have written an email to go to my consultant and also to Head of Midwifery with all my questions - below. Shall see what they say!

"Having had an extremely medicalised birth with my son (induction of labour at 40 + 15, artificial rupture of membranes, Syntocinon and then finally emergency c-section), if I go into labour spontaneously before 42 weeks I?m very anxious to avoid too many interventions in labour. As a result of this previous birth experience, and the fact that I felt under pressure throughout to conform to hospital policy on inductions rather than labouring at my own pace, I am not confident of being able to deliver naturally this time round if put under stress or pressure, and would like to make sure that any measures taken to manage labour are taken in a way that encourages me rather than making it harder.

My main questions are as follows:

• Does the hospital have a VBAC policy or procedure that I could read or that could be outlined to me?

• Does continuous fetal monitoring mean I would have to stay on the bed throughout labour?

• Having read the literature on outcomes linked to continuous fetal monitoring, I am not keen on being hooked up the monitor throughout, particularly if it inhibits my movements and prevents me from using water (bath or pool) to help with labour. Would the hospital be prepared to do intermittent monitoring instead?

• Does the hospital have wireless monitors that would allow me to move freely?

• What is the hospital?s position on using the birth pool for a VBAC? And the bath?

• At what point in labour would the hospital want me to come in to the Delivery Suite rather than staying at home?

• Does the hospital have a policy of not allowing first or second stage of labour to go on past a certain length of time before intervening, or is each labour assessed individually? I don?t want to be labouring against the clock."

Thanks so much to BetsyBoop for the Green Top Guide - although it has put me right off a VBAC as I have lots of the risk factors that are associated with an unsuccessful VBAC - short stature, previous C-section for shoulder dystocia, male baby, probably over 4kg I could go on... but at least I'm now armed when I go to see the consultant.

Yes, I just read it too - seems my best chance is to go into labour spontaneously before 39 weeks and have a girl! This baby is large though, so I might be in trouble there....

I was interested to read that epidurals are associated with more successful VBACs than births without epidurals. I thought it was the other way round?

thanks BetsyBoop, and everyone else - very useful advice and links

Good email. Mind if I 'borrow it'
I think you're on april with me so I'll keep a look out for how things go for you.

"I do want a VBAC but then I get scared and think 'maybe I'll just go for the elective' cause it all seems so much easier

But I know I'd be really disappointed with myself afterwards. "

I could have typed that myself whatfreshhell ! I am 36+2 and planning a VBAC. Previous c-sec was the result of a failed early induction due to dd having IUGR, me possibly having pre-eclampsia.

Generally I have had great support from Kingston - hopefully just not lip-service and every doctor I have spoken to has said there will not be a need for CFM although they vary as to whether they would say I should have it in established labour or not. However, they say at the moment that it might be I have to monitored for a while and if all ok, they'll set me free.

I am dithering over the cannula thing. I was very much of the frame of mind that they would be able to bung one in if necessary but from reading experiences such as some of those here I wonder if it might be a compromise to have one. My DH was recently in hospital and because he was quite squemish had his covered by an elastic bandage - I wonder if this might help feel less conscious of it. I mean to buy one to put in my hospital bag in case one wouldn't be provided.

I did try on friday to ask if I could go in the MW led unit and was told that it wasn't very likely but they could assess the situation at the time and possibly consider it if all was ok. TBH, they appeared more concerned about my BP being monitored than scar rupture. I have not had scar rupture cited as a major risk at Kingston.

This week my BP had a slight wobble (although not officially) so I started to come to terms with the idea of an elective c-sec and could see the merits but I agree, I will be disappointed if I don't try (other than if there is medical need for me to go for a c-sec).

Good luck ! Let us know how you get on.

oh and I also meant to say (not that my post wasn't long enough ) that I have written in my birth plan that if CMF is considered necessary I want support to remain as active as possible.

When I was being induced last time I had a change of midwives - the first one wouldn't let me leave the bed to wee and then another came in and said 'why are you weeing in a bed pan ? I'll unhook you and you can go to the bathroom and I'll get you a ball to rock on'.

I've hear that it helps if the birth partner holds the CMF belt in place during contractions if you trying to remain active so that it doesn't lose contact which would probably make them more likely to tell you to stay still.

Hi, Just to add my twopennorth, I'm only 22 weeks but planning a VBAC and just had my appt with the consultant midwife at Kings to discuss VBAC on Fri. At Kings they recommend CFM, but she said you can compromise and do half hour on, half hour off or something similar. She also mentioned the canula, and I didn't think this would be a big deal to me.

She did stress however that nobody could force me to do anything, only recommend, and she also said better to stay at home for as long as poss and not come in too early, I think on the grounds that coming into hosp can slow early labour down...but I guess it depends what your first c-section was for.