VBAC, consultants and continuous monitoring - AGHHHH

[willum]

I had my first appointment with my new consultant today who told me that if I wanted a VBAC I would need to be continuously monitored - suprise suprise! When I told him that I did not want this and my research had shown that it was just as effective to use 15 min obs with a hand held machine he disagreed. He told me go to away and re-read my research (with the insinuation that I had read it incorectly) and to bring back my proof next time.

Has anyone ever won this battle or am I wasting my time trying? If you have won this one how did you do it?

Mears - thanks ! I found that leaflet very helpful. I have to hope that the midwives will be more understanding. Becasue it is a private ward, I worry that the consultants are too involved, when sometimes they need not be, but I do not really know as I had my first baby elsewhere. I had a well-being scan yesterday and the growth and the amniotic fluid were all good so my consulatant was thankfully happy to postpone the planned c-section. Hopefully, this baby will be ready to come soon!

I think that at the end of the day most obstetricians genuinely want what is best for the patient and unborn child. Have you discussed with your consultant why he wishes to continuously monitor you? The recommendation from the RCOG is that cfm should be carried out when a trial of vaginal delivery after CS is being carried out. There is a risk of scar rupture which can be devastating for both mother and baby and research has proven that a change in the fetal heart can be the first and most sensitive sign of scar rupture. Pain may be present but initially can be masked by the pain of labour A rise in pulse is also an indicator but is related to a compensatory mechanism secondary to a la rge b;ood loss and therefore can also be later than CTG changes. It may also not be as rapidly acted upon as pain, anxiety etc can cause a riise in pulse. A drop in BP can also be associated with rupture again secondary to blood loss. The best outcome where scar rupture does occur is where baby is delivered quicly. Where 15 min obs(BP and pulse) and 15 min fetal heart rate is being depended upon this time delay can have a profound effect on outcome. Scar rupture has been reported to have as high an incidence as 1 in 200 VBAcs .

When a woman who has had a previous C/S spontaneously labours, the best way to avoid uterine rupture is to facilitate physiological labour. That cannot happen when you are strapped immobilised to a CTG machine. Uterine rupture is associated more with augmented and induced labours with syntocinon. Immobilised women invariably feel more pain, are more likely to have an epidural and are therefore more likely to need syntocinon. That is not to say women cannot be induced - all individual factors need to be taken into consideration. Continuous monitoring is a requirement definately when epidural or syntocinon is required. Intermittent monitoring with one-to-one care from a midwifehas been very successful in our unit for VBAC. Continuous CTG has caused more problems than it was ever meant to solve.

There is no doubt that the risk of uterine rupture is increased where syntocinon is used injudiciously and definitely where induction is carried out. In fact the most recent recommendation from CESDI is that induction should be avoided where labouring after previous CS is being considered. CFM does limit mobility but does not necessarily mean you are tied,immobile to a bed as has been pointed out in previous postings.Uterine rupture does occur in completely physiological and completely unmedicalised labours. From the obstetricians point of view, he may feel that the possible early warning of imminent rupture by CTG outweighs its negative aspects. There are also big issues of midwifery staffing levels which are very different in England than up in Scotland there being fewer midwives per delivery. At the end of the day a woman can only be advised of all risks and all benefits - it is rightly her decision but where a professional disagrees with her views it would be unethical not to state their opinion based on their knowledge, training and experience and I do not think this makes them an "arrogant rude s*"(aloha)

Therein lies the crux of the matter. Women sometimes feel that their views are not taken into consideration and unfortunately not all medical staff are able to give women information to make a choice - they tell them what they will or will not ALLOW them to do. Totally unacceptable. Not all women who attempt a VBAC require continuous monitoring.

Women will deliver vaginally without incident after CS with intermittant monitoring because a lot of women have successful VBACS and would do regardless of what was or was not done during their labour. The arguments against the use of CFM are important and well supported in so called non high risk labours and it is probably true that in these cases it may well increase the likelihood of intervention. VBACs are high risk labours and it is when things do go wrong during trials of VBAC that time is absolutely of the essence and this is where CFM may give an edge. Iwould imagine that risk management within a unit would strongly advise use of CFM during VBACs because of RCOG and CESDI etc guidelines and to reduce insurance costs. From the litigation point of view Iwould imagine it could prove quite difficult to defend a lack of CFM in VBACs because of such guidelines. I know that money should not come into it but it does - we live in the real world. The amounts paid in litigation every year would finance a lot of midwives and extra monitors/birthing pools/ante and post natal care etc.
Also, interestingly you can't please all the people all the time - I noted one posting where an elective section was going to be "demanded" which is almost the opposite of what we are discussing as it is so medicalised - by the way I am not saying it is right or wrong, just interesting.
This also comes down to a bit of a moral argument too - should the wishes of the mother always be paramount and should aprofessional do what the mother wants despite their belief that to the best of their knowledge it is not necessarily the best for mother and/or child. (Thought I might just throw this one in although not entirely relevant to this thread.)

Yes the wishes of the mother should be paramount. It is to be hoped that there will be a relationship of trust between the mother and the professional caring for her. Should a course of care be recommended by the professional then it is hoped the mother will agree. However, unless it can be proved that the mother is incompetent of making a decision (ie. court order), the mother has the right to receive the care she wants. This is where doctors can withdraw care, as in the case of homebirth, but midwives cannot. Midwives must continue to deliver care as per The Midwives' rules and Code of Practice.

Very interesting debate. Arnold, out of interest, what is your background? You sound medical?

I had a VBAC with dd2, induced with syntocynon after breaking my waters had no effect. I had CFM, which was scary as dd's heartrate was all over the place and she had already passed meconium when they had broken my waters earlier. I was so fixed on not having another CS that they did go along with this (they did a couple of fetal scalp blood tests, which were OK) and dd was eventually born quite quickly, but with blue hands/feet. I can't help wondering if CS might have been the more sensible option (dd has turned out to have severe learning difficulties, which they insist had nothing to do with her birth, but I still have lingering doubts). Mears, don't you think that perhaps occasionally a mother's view in the heat of the moment is not the right one? (PS I do respect your views and agree that, most of the time, the mother's wishes should be paramount).

arnold, the risk of rupture with a VBAC was quoted to me as being 1 in 500. In addition, and more importantly, only a very small portion of those (I forget the figure) actually end up in any injury or death to either the mother or baby. What about the risks involved in a c-section. No one ever talks about those when discussing VBACs. Shouldn't those risks be weighed up against the risks of the VBAC when making the decision.
And I think the problem is that most of the consultants I interacted with during my pregnancy/c-section/delivery were unbelievably arrogant and not at all interested in treating me like the intelligent educated persona that I am, and insisted on telling me what to do rather than making recommendations backed up with information that would allow me to make the final informed decision regarding my own bodya nd child.

Caroline5 - women usually have thought long and hard about what they want, it is rare for decisions to be made in the heat of the moment I find when talking about things like monitoring.

SofiaAmes - you are quite right about risks with repeat C/S. I have seen some pretty horrendous adhesions needing to be negotiated through before even getting to the uterus during repeat C/S. It makes me wonder whether VBAC would have been a better option especially when no indication for repeat C/S is present.

This is a debate that will go round and round. Ultimately the woman should feel that she has a say in what happens to her. When women really want to labour in water despite previous C/S in our unit, every effort is made to accommodate her wishes. Very successful it has been too.

The true rate of uterine rupture in the UK is very difficult to define because there is no systematic collection of this information. However best guess secondary to the largest reviews would suggest a rate of as high as 1 in 140 to 1 in 300 of women who labour with a previous scar.. By no means do all these result in ill effect to either mother or baby. However in a systematic review of infant mortality in England and Wales approximately 5% of the neonatal deaths considered to be due to labour events was because of uterine rupture. These ruptures occured in women with preexisting scars(the largest group) and also those who had never had previous CS. CS is not without risk as you point out however elective sections are much ,much safer than emergency CS as you would expect. There is no evidence to say that 1 management is the "correct"one. Every case is different and every woman feels differently. However does the argument have to be vaginal versus section. Is CFM during a trial of VBAC a very unreasonable compromise? Perhaps for some it is and that is OK but everyone involved should be aware of all the facts and figures. Definitely some obstetricians should try harder at communicating but (just to be a little controversial) perhaps some women need to consider advice which may be contrary to their wishes knowing that ultimately they have full rights over their care.

My Sil had a sucessful VB After c section number 2. Hospital did advise here that another c- section was inevitable but, being an awkward man, her ds decided to enter the world 4 weeks early and in 35 minutes. As she felt her first contraction, we headed for the hospital and ds was born in the car park!. He weighed 6lb 13oz and is none the worse for wear after his unusual experience.

Mears, is that standard procedure, a compulsory third c section? and is it also true that you are not suppose to have more than 3 sections?

Certainly the 'norm' is that women who have had 2 previous C/S are advised to have any future deliveries by C/S. Also many women will be advised that 3 C/S are more than enough, but I have seen many women have more than 3. Unless a woman is sterilised you cannot prevent her having more than 3 C/S.

There is some interesting information about VBAC here

Here is another bit of info about VBAC after repeat C/S. Interestingly the American College of Obstetricians and Gynaecologists (ACOG)
states that it does not matter how many C/S you have had, you can still have a VBAC
VBAC

My friend had a HWBA3C - home water birth after 3 caesareans.

I think the problem arnold, is that the information is generally not given to women as "advice," but rather as an imperative. Regarding CFM, my understanding is that being mobile during labor (difficult with CFM) greatly increases your chances of a successful VBAC. Of course an elective c-section is safer than an emergency one, however, elective c-sections are not what is generally offered to women in the uk as an alternative to an attempt at a VBAC. And I think that the rates you are quoting of 1 in 140 - 1 in 300 include induced labors, which I believe greatly increases the chances of uterine rupture. If one attempts a VBAC without CFM, but also with the indication that an emergency c-section should take place rather than induction, I think the statistics change greatly. One really needs to compare the risks of the reality, not the ideal.
By the way, my understanding was that there is some questions about the efficacy of CFM (versus other indicators) as an effective indication of uterine rupture.

SofiaAmes - to answer your points:

1. I think it is wrong to suggest that generally consultants give information not as advice but as an imperative. There are many obstetricians working extremely hard to give a high standard of service and satisfaction to the women they care for. 2.Being mobile during labour does enhance the physiological process of labour however CFM does not have to entirely limit this as mears posting of Aug 19th illustrates. 3.You are wrong to say that women in the UK are not generally offered an elective CS as an alternative to trial of VBAC. There are 2 ways to plan to deliver a baby after a previous section a) by trial of VBAC with whatever monitoring whether it be continuous/intermittant/non existant, in a hospital/at home/in a pool etc.- should this fail during the process in any way an emergency CS will be carried out b) by elective CS These are the 2 alternatives offered to women with previous CS. Induction is not an alternative to VBAC but is the starter for VBAC or indeed any labour where labour does not ensue naturally by itself. Induction of labour and emergency CS are not interchangeable options in this situation. 4.Induction with a previous scar can increase the risk of rupture but where it is used appropriately and carefully can often result in a successful VBAC. 5.The huge problem with uterine rupture is that there is no very effective indicator of imminent rupture -most physiological signs such as rise in pulse, drop in BP occur once the rupture has taken place. Literature reviews support that when CFM is properly interpreted it CAN be a useful early indicator of rupture, CTG changes often being the earliest warning. When a uterus ruptures, mere minutes saved in diagnosis can make the difference between a live baby or a dead or profoundly adversely affected one. There is no 100% warning system. Surely therefore it is not unreasonable to advise CFM because of this and surely it is understandable why some obstetricians may feel strongly about it. However, as always the advice does not need to be heeded. The patient has the final say. 6.As I have said before there are only best guestimates when looking at rates of rupture therefore one cannot compare the risks of reality as the reality here is unknown - only ball park figures can be offered. 7.Surely we should all be striving for the "ideal"!

SofiaAmes - I was certainly told, not asked, how things would proceed. It was almost as though I was made to feel that letting me try a VBAC was a compromise and that I would have to stick to the rules. I was first told of all the risks, which sound a bit scary, and then told that CFM would reduce the risks. My sense then was that of course I would have to go along with what the professional told me. I am glad I have now received more information. So much in labour seems to boil down to how calm the mother is throughout. If being very restricted gives the mother anxiety then surely intermittent monitoring MUST be better.

Not just anxiety issue; When I had CFM, because the wires got crossed and gave weird readings whenever I tried to kneel, & my legs wouldn't support me thru contractions, the only position I could give birth in was on my back. That can't be a good thing.

Eva3 - an obstetrician is legally and morally bound to tell you all the risks even though some of it may be scary - how else can you make an informed decision. Some women are actually reassured by CFM and are happy to put up with its limitations because should things go wrong it can be helpful. The debate on CFM will never end because everyone is looking at it from a different angle - you and many woman like you wish to have as natural a childbirth as possible and therefore will never support CFM and that is fine. The obstetrician is often keen on CFM in this situation because there is widespread evidence in the literature to support its use and possible efficacy in reducing the risk of damage should the worst case happen.
At the end of the day, when the S* hits the fan the buck stops with the obstetrician who then may face delivering a very ill or dead baby and patching up a very damaged abdomen/pelvis. Oh yes, then they may be sued for not explaining all the risks and not fighting for intensive monitoring etc.
Anyway, I see that you were 5 days overdue on the 19th - any news yet. All the very best of luck. Let us know.

Arnold - I do understand all of that now, just wish I had been given more information from my doctor instead of having to search for all of it myself. I will see how I go with CFM and see what the midwives say when(if) I get to hospital.

I am now 11 days overdue and feeling "twinges". It feels like a mild build up of period pains but I have had them for 2 hours now and they are not getting stronger or faster....perhaps false alarm?

hope something happens for you soon Eva. Good luck

hope something happens for you soon Eva. Good luck

hope something happens for you soon Eva. Good luck

Sorry about that