Why is constant monitoring insisted upon with a VBAC

[eastendmummy]

I'm 33 weeks with DS2 and am planning a VBAC. I had a very traumatic labour with DS1 resulting in an em c-s for fetal distress. It has taken a lot of talking with a counsellor plus being caseloaded by the hospital so that I now have the same midwife throughout care and delivery to make me confident that I can have a successful VBAC. I was absolutely petrified about the birth from the minute I got pregnant but now feel positive that my body is capable of delivering a baby vaginally.

My midwife is fantastic. She's promised to be my advocate in labour and is very confident that I can have a natural birth. My fear though is that she said that I will have to be monitored continually and I'm really not sure why and am really worried about the impact it will have on my labour. I am very keen to stay active and upright and although she has said that the monitor will allow me to be upright and bounce on a ball, it obviously won't allow me to pace about and generally feel comfortable.

Is there a genuine reason for the insistence on the monitoring? Is it for the hospital's benefit or mine?

It's taken me a really long time to get my head into a good place with regard to this birth and this is the one thing that is nagging at me and I'm worried that once strapped to a monitor, I'm going to start freaking out and then have a cascade of intervention. I would rather have an elective section than go through the trauma of an emergency scenario again.

My question is really, can I refuse continual monitoring? What are the potential consequences if I do? What about internals - can I refuse those as well?

Sorry that this is very long, and thank you for reading. Any advice would be gratefully received.

I had a VBAC and yes continual monitoring. It is because there is a teeny tiny risk your scar can burst when you are in labour. It is very very small chance like 0.001% but because of risk they would be neglegent if they didn't monitor. I was standing and walking about (in very small circles!) with monitoring until it got too much and I laid down.

Good luck

It's tricky to monitor all the time and have an active birth.

They're antsy in case your scar ruptures which is very rare. I think you'd know about your scar rupturing long before any monitor picked it up any change. Read more here

Don't let them strap you to monitor all the time if you don't want to be. You don't have to be. 'They' can't make you do anything you're comfortable with.

I agreed to being monitored every two hours for 30 mins and I insisted on standing up whilst this was happening, although as you say, not able to pace about. But I had a vbac with my dd and then a home birth with my ds2.

Good luck. Have faith in your body. Let us know what you decide.

Well, im having a vbac (due 2 days ago!) and the consultant has said i DONT need constant monitoring if i dont want it (which i dont). I think Winkys advice is good - meet them halfway by agreeing to intermittent monitoring.

Ive been reading the archives online of the association of radical midwives. They are of the opinion that monitoring actually leads to DELAY in action when needed as people assurme the monitors are on the blink, and dont use their eyes and ears for signs that something isnt quite right.

they can't insist on continuous fetal monitoring, just recommend it - up to you if you want to take them up on their offer or not

there is some evidence out there that CFM is not necessary as it does not change the outcome, IFYSWIM, i does not really make any difference to rupture/no rupture etc

i had a VBAC, did have CFM, but was encouraged to get off the bed, move around, stay upright and work with the contractions

you can sit on a birth ball and kneel on the bed or stand leaning on the bed with CFM

or you can make an informed decision to decline cfm and have intermittent ausculation

winky's compromise of 30 mins monitoring every 2 hours sounds like a bearable one

there are , as heas been said, other signs of rupture other than a change in the CTG

you can refuse internals too, there are outward signs of labour progressing

do your research and make your choices

Hi Eastendmummy
I have supporteding women having VBAC's that chose to be constantly monitored and those that had intermittent monitor(with a handheld doppler).
You do not have to have continuous monitoring, or vaginal exams or to have your baby in hospital if you dont want to, although these are usual protocol and also usually having a cannula fitted in your hand (just in case).
The continuous monitoring is just in case you have a rupture of the scar from your CS. A rupture is very rare- sometimes the scar gets thin, but its rare for it to actully come apart.
If it does this can be dangerous for your baby. There are signs midwives can look out for but sometimes these are missed and only picked up from continuous of the babies heart rate.
Women that choose not to have continuous monitoring (may choose half hour on and half hour off the monitor or just intermittent monitoring) beleive that this is a biggeer risk than that of uterine rupture and that there is more chance of them ending up with more intervention if they have the continuous monitoring.
More info here-
www.homebirth.org.uk/vbachome.htm
HTH
Selina

Hi eastendmummy. Well done you for going for the VBAC, it is a tough decision to make and it has obviously taken you some time to work through your feelings about your last labour.
It sounds like you have a fab midwife caring for you and that can make a huge difference in itself.

During your labour you may refuse any intervention you like but it sounds like you have good relationship with your midwife and I would expect that she will keep you fully informed as to her reasoning for any intervention.

Continuous monitoring can be a little restrictive, but to be honest midwives can come up with some fairly ingenious ways of keeping you mobile even with the monitor. I would expect a birth ball and a certain amount of walking to be completely possible. It is worth checking with the unit where you are delivering as some have systems that don't need wires - they are few and far between tbh though.

As you already have a scar on your uterus you are classed as a high risk mother. The monitor can inform your carers how your baby is coping with labour and help to identify any early problems with how the scar tissue is coping with the stretching that labour causes. When you have a VBAC there is a tiny chance that your scar will not cope with the rigours of labour and start to open - your midiwife should be able to give you some figures for this based on your own hospital.

Internals are usually reasonably regular with a VBAC so that you are not left labouring for too long (without your labour progressing), as again it might be put extra stress on your scar.

Usually you would also have a cannula in your hand and blood sent to the lab for blood group and iron level testing, early on in your labour, so everything was in place quickly just in case there was a concern.

Hope that some of this helps.

Thanks everyone for your replies. I'm keen to avoid the continual monitoring, but happy as Winky said, to have intermittent monitoring.

I'm hopeful that my midwife will support me in this as she's incredibly positive in her attitude but obviously she does have hospital policy to consider. I'm seeing her in a week so will discuss it with her then in more detail. I'm also going to ensure that DH knows clearly how I feel about it so that he can be my advocate when in labour and I can just try to relax and let my body do what it's designed to do!

I've had a brilliant pregnancy so far so I just hope that I can keep my brain in a positive place when labour starts and have borrowed a hypnobirthing CD to help me.

Thanks again

You don't have to have CFM if you don't want it and there is evidence to suggest it doesn't make any difference to outcomes.

Most of the paranoia about VBACs and ruptures has occurred due to some very badly managed VBACs (using dangerous induction or augmentation techniques such as Pitocin) or by VBACing with a vertical scar.

A properly managed VBAC with a low, horizontal scar has a minute chance of rupture (less than 1 in 200) and generally, these start slowly and are spottable early on (vertical scars had more of a tendency to 'burst' open). In fact, you stand far more chance of all sorts of other problems that any labouring woman might have. It just comes down to insurance and the fact that people have been very litigious where VBACs are concerned.

I'd argue that you might well be safer NOT having continuous monitoring as such a thing restricts your labour and makes the chance of an instrumental birth higher. Ruptures have been associated with forceps use.

FWIW, I've had two VBACs both with intermittent monitoring. Many midwives suggest that they can see a woman's condition (and likelihood of a rupture) better through observation than through watching a monitor. CFM can actually lull your caregivers into a false sense of security that everything is ok.

Good luck with it, BTW. I loved my VBACs. I've seen people have really good results with hypnobirthing - wish I'd done it!

Hospitals don't monitor mums for their benefit. Seriously, what could that be?

It is for your and your babies benefit and having 2vbacs after an emergency section I only get the band put round my stomach once I was pushing and it isn't a problem at all.

I was very close to scar rupture and would always advise mums to be monitored in this situation.

Monitoring also helps as as a general rule if mum is okay, baby is.

I understand that Fab, but what I meant was, if the incidence of scar rupture is so low (as the midwife and consultant have already told me), then why would they want to restrict me having an active labour by insisting that I was monitored from the moment I arrived at the hospital? It doesn't seem as though it would do me or baby any more benefit than if I was monitored intermittently and allowed to be active as restricting my movement could well lead to another section which I definitely want to avoid and I'm sure they do too. I obviously want to ensure the best outcome for the baby and for me and would never do anything to put the baby in danger.

When I had DS1 I had 2 bands around my stomach for hours and hours, and was laid flat on my back and not allowed up. I suppose that I'm just frightened that by being attached to a monitor, this will happen again and then my chances of a successful VBAC are greatly reduced.

Fingers crossed that DH is able to put my point across on the day as I think that intermittent monitoring is definitely the best solution.

It might be low but someone has to be the one.

Why not just play it by ear a bit? Very few births go according to what one wants or expects.

Don't I know it - the last one was a catalogue of disasters from start to finish!

I've had to get my head around relinquishing control and allowing my body to just do it's job and although it's been hard, I think I've just about done it. This is the one thing that keeps nagging at me and it's good to hear that there are other options to the 'continual' element of being monitored - I obviously want to be monitored to check all is OK, but just want a balance with it and not being tied to a machine.

Take no notice of me. I am a bit ott as I had problems and are a bit of a worrier.

No worries Fab - all advice and experience is very much appreciated and I need to hear both sides of the story, not just what I want to hear!

I am in the exact same situation eastendmummy and wonder if last time if I hadn't been strapped to the monitors from 2am until 9.30am, in the reclining position with a back to back labour whether I might not have ended up with an emcs? This time (going for vbac) the hospital tell me they now have the telemetry (non wire) monitors so I csn be monitored and therefore be mobile - although this relies on no-one else using them when I go in! - I think the way forward if they don't have remote ones is to be more assertive, refuse, cry etc! A friend of mine had a vbac where she was allowed to get in the bath when she begged enough and said she knew she would be able to relax into it if she could do that - and it worked - she was allowed, labour picked up, she got to 10cm, vbac was successful. That said, a friend's friend had a still birth after a perfectly normal pregnancy and unmonitored labour (meconium released early on in waters was not picked up) - if she had had reason to be monitored perhaps her baby would have lived? So I kind of bear that in mind too - would obviously rather go through any length of horrible labour and emcs than lose the baby.

PS Am 33 weeks too

Good luck Zoonose - it's a scary prospect isn't it after a traumatic 1st labour. Very sorry to hear about your friend too - that's so sad. It is important to strike a balance between having the birth that you want and having a healthy baby at the end of it. I just hope that the two aren't necessarily mutually exculsive!

A couple of people asked what benefit the hospital get from CFM. Well, two things. First, it's an arse covering measure. If something goes wrong, they can claim they 'did everything' and weren't 'neglectful' - you were 'well managed.' Secondly, it makes their life easier because they can just keep an eye on the monitor and use the monitor to do their job. They don't have to watch YOU so closely.

Another point made is that not being monitored is an unnecessary risk.

The problem with this is that monitoring carries its own risks. No-one is going to opt out of monitoring because the belt is a bit uncomfy or something trivial.

Inactivity in labour is a risk. Not being able to use water is a risk. Being restricted is a risk.

The whole thing is weighing up the risks and benefits. To me, the risk of a rupture is pretty small. If it does happen, there's only a certain chance monitoring can pick it up quicker than the midwife. If the worst happens, there's only a small chance it will effect the outcome anyway.

Personally, I felt the benefits of CFM are miniscule compared to the risks. Inactivity makes it highly likely you will have a stalled or slower labour and raises the chance of an instrumental birth considerably which in turn heightens your chance of a rupture. Most ruptures happen during medicalised births (due to Pitocin use or instruments). You may be the very unlucky 1 in 200 (probably less than this figure if you have a natural birth) but the chances are CFM won't benefit you much over intermittent monitoring and an observant midwife even if you are.

Thanks for starting this thread - has been really useful for me too. I found last time that once I was at the hospital they just say 'well, this is our policy and it must be done' but maybe with a second labour you have learned a few things and can be a bit more assertive - first time round certainly I found I just had to accept the advice given as I couldn't know better than the medical staff. This time having read a lot more about foetal positioning, the importance of relaxation and blood flow to the womb (panic and fear achieving the opposite effect) I know that the number one aim is to try and relax and to do that I need to be mobile. Thanks CarmenSanDiego, what you said is really helpful.

I would like to point out that uterine rupture doesn't just put the baby at risk it puts YOU at risk as well. 1 in 200 is NOT a teeny tiny risk and it's NOT 0.001%. By all means make your own decision about whether to be monitored or not but make sure you know all the FACTS about what could go wrong.

I had continuous monitoring with my (failed) VBAC, and I absolutely hated it. I felt totally trapped and was stuck on the bed because of a utterly unengaged midwife. It was especially upsetting as I had been told (by the much nicer midwife who I started off with) that here were lots of ways that I could keep moving. If I were you I'd do as much research about the potential consequences and risk factors, talk more to your midwife, and then see how things go. You may find that you are OK with the belts so long as you move around, or that you really need a break from them. The most important thing though is having a supportive midwife, if she listens to you and you feel supported by her then things will go well for you. I really think that a lot of what makes a good birth experience is to do with trust.

DD2 was a VBAC on gas and air after DD1 was a CS after undiagnosed breech.
If it is any help I laboured at home as long as I could and went into hospital when I couldn't speak or walk properly. I was like you and insistent I wanted an active birth and no monitoring.
I was 7cm and strapped to the monitor but TBH I wouldn't have noticed it as I couldn't move off the bed anyway