Advice on natural birth while on anti coagulants

[flic22s]

Hi, I am currently 29 weeks and on twice daily injections of clexane , due to previous and current DVT. I was under the impression that my labour would be induced in order to halt the clexane over delivery.

Today was the first time I saw my consultant and she said I would be allowed to go into labour naturally as I only had to be 12 hrs away from injection time which was more than likely due to the length of labour.

This has some what worried me after thinking it was all going to be organised. I know the chance of a normal delivery ( this is my second child) is much better if I am allowed to go into labour naturally, however I am worried about post partum bleeding and I know, and it was indeed confirmed my OB that an anesthetist wouldn't come near me with an EPI within 24hrs of a dose of clexane. I am not planning to have one but am terrified of the idea of having GA if I have to have a section. With twice daily injections I have little chance of passing the 24 hr mark in a normal labour.

Any advice from Mums that have been through a similar experience would be greatly appreciated

Hi flic. I was on one daily injection of fragmin for both my pregnancies and had done my injection about an hour before I went into labour, both times. I had 2 very straight forward births and the bleeding was not nearly as bad as I expected. I think because I knew I wasn't allowed an epidural I didn't even think about it although the idea of being knocked out for a cs really freaked me out! My second labour was only 3.5 hours so hopefully yours will be really quick and you won't have to think about an epidural. Sorry if I have rambled on, this is my first ever post!!!!!

Thanks badsquishy, its good to hear a positive story its such a pain having to worry about these things hoping they at least change me onto a single dose leading up to my due date so I at least have a better chance of being 12 hrs away from injection. I guess I'll just have to accept the risk of GA in the case of a section, but on the upside I know that going into labour naturally will at least reduce the likelyhood of a section compared to induction

I was on clexane in both my pregnancies and had 2 natural deliveries

Second one was a very quick water birth!

Yes, it's very possible ...

Hi OP, I'm 25 wks and also on twice daily Clexane injections due to previous DVT. I've seen my OBs consultant a couple of times as well as haemotologist and OBs together and will do again in a couple of weeks to discuss labour options in more detail so I'll let you know :) Currently it's between natural and induction for me too dependent on some other factors.

You shouldn't be too worried about bleeds, one because they will probably take a blood sample to check your platelets when you go into labour and can give you an anti-jab if necessary. Secondly Clexane works in a different way to warfarin; it stops clotting in the deep arterial veins but doesn't 'thin' the blood. Epidural is just luck I think depending on your last jab.

Hope you're getting good batches of the sharp needles and not the stabby blunt ones that give you bruises!

Hi Lois, thanks for sharing ur situation. My OB doesn't seem worried at all about letting me go naturally. I am starting to get used to the idea now I am sure they wouldnt just let me go if if there were serious issues with bleeding and I'll just have to accept the epidural thing. I am seeing the OB in a fortnight so will ask about whether I should halt the clexane if I get signs of labour I clearly had lower back pain 12 hrs before my labour started last time, that would at least help the epi situation if I need a section.

I have been finding the clexane ok, it seems to hurt a lot less than I remember from 8 years ok. I find there is no pattern to whether it hurts or bruises or not but its never to bad. I might just stay on it afterwards rather than warfarin because I live in a rural area I don't really want to have to spend to long in hospital having my INR checked . Hope your meeting with OB/haem goes well

Yeah it's hard isn't it as from the research I've done, the birthing advice seems to vary hugely between doctors/hospitals. Oddly at my booking appt, the MW was asking me about a homebirth; not the least bothered even though she knew about the Clexane. Not right for me I don't think but sort of reassuring!

As you I'm staying on it afterward instead of warfarin, hate that stuff and the bloods checks are a pain.

Best of luck and I'll catch you nearer the time :)

Thanks I'll post how things went if I go first, I'm due 29th July my midwife thinks my OB is great so that should be a good sign :)

Hi there. Its interesting how different doctors have very different attitudes towards Clexane. I took 40mg once a day during both pregnancies. My consultant was adamant all the way through that because of that, I would need to be induced. This pregnancy, a much younger doctor said that was rubbish. For a whole host of reasons, I ended up with a section undet GA both times, but the GA was not because of clexane. However, if you do end up going this route, just to reassure you my recovery was great. I was home two days later and much less sore than friends who had natural births with stitches.
On the Clexane front, I would think very carefully before reducing dose in the run up to labour. My 40mg dose didn't prevent me from getting a pulmonary embolism and I know another girl in the same boat, so please take professional advice and get a second opinion as well if this is discussed.
Other bit of advice (and you probably know this better than me as I am knew to this compared to you!), if you end up breastfeeding and being relatively immobile like I was, please continue to wear your stockings as I am pretty sure this, combined with me being a bit slack with the clexane, caused my clot.
Lots and lots of luck to you for everything going smoothly!

I was on 40mg clexane throughout both pregnancies and was booked for ELCS, but for the first birth they'd booked me in too close to my last clexane dose. They did the section with a spinal block and it was fine.
It's not a matter of no epidural so your section/instrumental is under GA/can't be done, theres the option of a spinal too.

Hi, it is strange how different the advice is I am on 160mls a day because of active clot and prevention and they don't seem to have an issue with natural birth. I am planning to discuss the coming off clexane with them at my next appointment and I have an acquaintance that is an Obs and Gyny consultant that I will try and get in touch with. One school of thought says don't do it then another is happy enough to halt it for induction its so hard to know what to think.

I am not so worried about the recovery of section its just the idea of not being aware of the moment my baby is born , but I guess if it has to be it has to be.

I aim to be very careful after delivery, they think my previous DVT full leg and pelvis was caused because my son was in SCBU for three weeks as he was a premy , so I was lying about in bed all the time. I was just lucky that I recognised the symptoms having trained as a Radiographer and that it didnt embolise. This time I hope to be home quickly to keep myself mobile, if they let me stay on clexane I can avoid the 2 week stay I had last time with my INR going up and down the scale with warfarin.

I just wish there was more info out there on DVT in pregnancy my midwife says they are seeing it more and more these days and have no idea why, and from what I can see there is still so little in the literature about it compared to other conditions. I only managed to catch my current one ( very small behind my knee) because its just felt familiar , I don't think any one who hadn't had one before would have recognised it.

Thanks for the advice it will prob all be a breeze after all this worrying about it ... hopefully xx

Another case of different advice bag of Holly I have been told they won't come near me with an EPI for 24hrs coz of the risk of spinal haematoma it could be the higher dose of 120 though

I think there's a big difference in the management of patients with a known history, and much lower risk/dose patients like me. The lead haematologist at Addenbrookes, Dr. David Perry, has written a protocol for the management of pregnant women on anticoagulant therapy, and he does a joint clinic with the obstetricians. He's a lovely, lovely man and I'm sure he would share his protocol if you felt your own healthcare professionals needed a steer.
Very best of luck.

haemophiliaspecialists.co.uk/about-dr-perry.php

I am on my fourth pregnancy on fragmin and because I asked and it's convienient to me they are inducing ( for the third time) . I am in a twice daily dose so the 12 hour thing would be really difficult to get to happen for me.

They would be happy for me to go in to labour naturally but wouldn't be allowed an epidural for 24 hours. Due to other factors I don't want an epidural or spinal anyway so that suits me.
Having 3 other children does Mean childcare is a lot easier if I know when its all going to start and do far apart from fragmin I have had 3 vaginal deliveries with gas and air and diamorphine which suits me.
I am also kept on fragmin for 6 weeks after birth and do not want to move onto warfarin because of the stupid blood tests !
I go in on the 21st to be induced which is very exciting!

Thanks for the info Holly I will look into that. Hi Susiey thanks for your comments. I am also on the twice daily jags so it looks like epi is out the window unless they let me stop if I suspect labour , I was gas and air and diamorphine previously too and I managed mind you he was a 4lb premy. Good luck with your induction I still have 11 weeks to go , I'll be glad when I get past the finish post, it was so nice last time ,up until early birth, to not to have any worries.

Thanks to all the mumneters for there help :)

bagofholly Dr Perry is my doctor too :)

He is very sweet (looks a bit older than his website photos now though bless!)

www.kingsthrombosiscentre.org.uk/cgi-bin/kingsthrombosis/SISite/runpage.pl?runpagemime=application/pdf&runpageaction=binread&runpageuri=files/A11.1%20Venous%20thromboembolism%20prophylaxis%20in%20pregnancy%20and%20puerperium.pdf&runpageattachment=A11.1%20Venous%20thromboembolism%20prophylaxis%20in%20pregnancy%20and%20puerperium.pdf

Loislane thanks for the link, it made interesting reading . It has clarified the epi issue, I am on a high therapeutic dose of clexane hence the 24hr window before spinal can be administered. So it looks like natural labour is ok and I will just have to hope I avoid emergency c-section. I think I will still discuss the option of induction at my next clinic appointment but as the risk of section is higher with induction I think natural will be the way to go xx

Hi, I have not much knowledge on your condition, is it that your blood is too thick or you have an above average platelet count resulting in you taking thinning drugs to prevent clotting??

I'm in a similiar position if so but at the other end of the boat. I have chronic ITP a very low platelet count. I am currently 30+3 & due 19th July. I have had similiar info from my specialist at the hospitsl, I too cannot have an epi and I run the risk of bleeding so a possible cs is making me very nervous. I just keep getting told to wait closer to the time & they will decide if I need to be induced & what kind of birth I will be having. Its all very nerve wrecking this waiting game. :-)

I have no known underlying condition, I had a spontaneous dvt postnatally which was prob just one of those things, but I am now more likely to get them in pregnancy. I had awful morning sickness this time round so spent several weeks attached to the sofa so it could just have been immobility . I have had 8 years of no problems until this pregnancy. I dont think bleeding from a normal delivery will be a problem , it just the section problem. I guess I'll just have to accept that as long as he gets here safely and I am ok. Yeah its not nice having all the extra worry but it will so be worth it :)