HELP - “planned” premature baby, should I have a C-section or an induction??

[MrsRose2018]

Hi ladies,

You may have been a previous post of mine saying that my waters broke at 25 weeks. I am now 26+3 and trundling on ok with no signs of infection or early labour!

I haven’t had a meeting with a consultant yet but am looking for advice as to what is “best” in terms of delivery? The hope is I can get to 34 weeks and then will induce me but I believe I also have the option of an elective cesarean as well!

My “birth plan” before all this happened was to go for a midwife led vaginal, non induced birth with a section as a last resort. I’ve accepted I will have a premature baby (just about) but I don’t know whether to go for a planned induction and have an emergency C section as a back up or to have a planned section!

Everything is giving me conflicting advice! Some resources say a planned section is better because it is “gentler” on a premature baby and reduces the risk of them getting into distress during labour - this risk is increased in my case due to having no amniotic fluid left!

Other resources say an induction is better as the vaginal birth gives them a “kickstart” and gets their lungs etc going.

A final consideration is that I could possibly get to 34 weeks, be fine and be able to carry on bit by bit with a maximum gestation if 36/37 weeks but that makes a planned section unlikely as I obviously can’t just shuffle that back.

I don’t care about myself - I’ll deal with the pain and difficulty of recovery post section if that’s what’s best for my baby but as this is my first I just don’t know...

Advice/perspectives would be greatly appreciated!

xx

Bumping this for you. I don’t have any experience sorry.

My only thought is that if you would like to have another one day (crazy to be thinking right now) then it is better to go vaginal. But I’m sure that’s not at the forefront of your mind right now. Your consultant will give you good advice I’m sure.

Congratulations for getting to 26! Every day is a big plus at this stage.

Ask them how many inductions end in an emcs. If it was more than 50% just have the c section. A long/induced labour and then a c section is hard to recover from, even if the actually c section recovery is fine.
If you’re thinking about more children, 2 sections are fine and I know a few women who’ve had 3. I will have my second cs this summer.

I had a 34 week baby who now has cerebral palsy (very mild, but still...) as a result of her vaginal birth. She got stuck, which I now understand is quite common with tiny babies as they don’t have the momentum/force to get down the birth canal (or something like that). As you say, VB is pretty tough on a tiny, not fully developed baby and she was not breathing at birth and had to be resuscitated. I went into labour naturally, I imagine an induction would be even tougher on the baby.

I was very pro natural labour but now, for a pre term or low birth weight baby, I would always say planned c section. Wish I’d had one. (If you make it to 36+ weeks and go into labour naturally I would say stick with VB though.)

Hope everything turns out well for you x

My cousin had a premature baby. Her consultant recommended a c-section as it would be less stressful for the baby. All are well and no problems.

Planned section.

I had an EMCs at 31 weeks but had been booked in for 34. I had twins so perhaps slightly different but I wouldn't want to go through induction for a perm or low birth weight baby

Best to wait to see what the consultant says.

I’ve not had your problem, but going off what you said, I would think an elcs would likely be better because it’s planned and they can take baby out and be prepared for any complications that could arise.

Induction can take days. Mine took about three and ended in emcs. I never got past 3 cm even after they broke my waters. My cervix was nowhere near ready.

If your cervix is soft or you’ve already started dilating you have a better chance at a successful induction. However, It still carries the risk baby could become distressed by the contractions and you need to be taken quickly to surgery.

Emcs have a higher risk of complications than a planned Elcs

Again, talk to your consultant and they should discuss the risks for both procedures so you can make an informed choice.

I had an induced twin labour at 35w.

The babies were (eventually) fine and despite the fact that it was mismanaged, I still think it was the best choice.

BUT. I had given birth before so I knew my body was okay doing labour. In your shoes, I would listen to dr advice but lean towards ELCS.

Please take the advice of your obstetrician rather than anecdotal stories from strangers.

I was thinking of you earlier, so glad to hear you have got through another week and baby is still inside! Having had experience of 2 PPROM babies (much later gestation though) I would say don't worry about it top much at this stage, you will spend a lot of energy thinking about a scenario that may well not be relevant (eg if you go into labour spontaneously or there is a clinically clear reason for either induction or CS). And as others say, take the advice of your consultant - remember to ask the risks and benefits of both options.
I was very lucky and had 2x sub-1 hour natural labours with both my premature babies (at 35 and 33 weeks), but I remember going through the whole "what should I do if I get to 37 weeks") thing in my head!

I am very pro vaginal birth. That said, in your position, I'd plump straight for the c section.

Hi!
Good news on no infection or Labour!

At 34 weeks I was informed that my baby needed to come out due to placental insufficiency and being very small.

At 34 weeks or if baby will not make it to term you will be given steroids to mature the babies lungs.

I was in the exact dilemma. C section or induction.

With induction and a premature baby the threshold for becoming an EMCS is lower therefore if the baby is distressed they would/could opt for csection anyway

I asked docs to check to see if my body was anywhere near being ready for birth. But my cervix was high and closed and not yet ready at all.

Also a planned section is much calmer than an emergency one where they are rushing to get the baby out.

I say this in case you end up in a situation where you have to make this decision quite quickly.

I was so torn between giving birth naturally and a csection. My decision came down to my baby. I did not want to distress him or cause him any harm. I wanted him out safely and quickly where I knew what was going to happen and the outcome. I didn’t want to go through induction for it to become an emergency section.

I’m glad of my decision. And there’s too much nonsense around vaginal birth and c section and what’s natural etc etc. A safely delivered baby in your arms is all that matters imo.

Good luck!

@MrsPatrickDempsey

I will absolutely and obviously listen to my consultant but as of yet I have had NO contact with a consultant, NO advice and NO idea when I will get anyat this time!

I'm not making a decision right now and I know it to really depends on how things play out but certainly for me, i would never enter an important situation or make a decision without first doing my research, attempt to understand things better and speak to people who have literally been there. Especially something as important as this.

Ladies thank you all so much for your input!

It's really helping me understand things better!

I am in hospital 2 x a week every week till it's go time for monitoring/CTG so I will ask to make an appointment with a consultant as soon as one is available!

Right now I'm poooooosibly leaning towards a planned section. If there are risks of baby's lungs with both an induction and a section, I think having "gentler" section with no risk of distress maybe tips the scales marginally!

I'll see what the Consultant says nearer the time and if it transpires that an induction is the better option then I'll go from there but I feel so much better having come to a vague personal decision.

I'm a bit of a type A and having lost every ounce of control over everything right now it's quite upsetting for me.

For me knowledge is power and knowledge is calming!

Thanks for all your help :) xx

Whatever is safest. I know it’s horrible not to be in control but things will change over the coming weeks that will hopefully make the best option clearer. DGD has a planned section with twins but ended up with an EMCS at 32 weeks due to a complication. Research all options but always go with the safest option for both of you.

Hi

Good luck and I hope you get to term or near there. As a consultant in neonatal intensive care, let me assure you that the advice given Mrs Dempsey and Propergator is quite right. Those who have posted that a section is gentler on the baby are sadly wrong. A section comes with its own risks for both baby and mother. As someone who deals with premature babies every single day, let me assure you that a well monitored natural birth is usually the safest for both baby and mum. But, if your obstetrician feels that on a balance of all the risks for you and baby a planned section is safer, then that too is fine.

Your obstetrician and midwife's focus right now will not be on mode of delivery but getting you as far as possible into your pregnancy before delivery. While an emergency section in labour may be stressful, let me assure you that except in very rare cases of major fetal anomalies, it makes no difference to me as a neonatologist if the baby comes with 2 weeks notice or 1 hours notice. We don't book places on neonatal units. We deal with whatever happens and the care we can provide is the same pretty much 24 hours a day.

I am sorry to say, that a lot of the opinions posted here are personal anecdote and frankly wrong. While I understand your need to get some advice, and right now your obstetrician is probably not in the same place you are about planning a mode of delivery, please get advice by reaching out to your midwife or obstetrician.

Morning @Docstf! Thank you so much for commenting!

I know MN can be a minefield in terms of conflicting advice and I honestly have done a lot of my own reading and research! I've scoured the Cochrane Library, I've read every piece of NICE guidance on CS and inductions and PROM. I've spoken to my midwives at hospital and my friend is actually a neonatal registrar!

Ive made a Pros and Cons table with what I've found and honestly the MN advice that it is "gentler" on a baby is only one point! It seems to show that an induction/VB undoubtably reduces the risk of respiratory distress syndrome compared to ELCS and obviously has significantly less risk in terms of maternal complications/morbidity/death. However it does seem to suggest that ELCS is gentler and less stress on a preterm baby’s body and allows for an expedited delivery. May I ask for your professional opinion on why that isn't the case?

My midwife told me they try to get mothers with PROM post 34 weeks to deliver naturally as the “stress” of labour produces prostaglandin which kickstarts their body and I don't dispute that but I’m hesitant to go down the route of an induction as I’ve read you have an increased rate of instrumental delivery/emergency section in the end anyway. I'm concerned about the need of forceps or ventouse as I see far too regularly in my job complications involved in this and actually my friends little girl has nerve damage to her arm from forceps - however it was an emergency delivery and they had to get her out immediately as her cord became detached...so I appreciate the complexity of the situation.

I’ve also read that babies with no amnio get distressed quicker/easier during labour and can produce/aspirate on their meconium which in turn causes lung compromise.

I know you can’t really advise on the obstetrics side of things but do you have any professional insight on how neonates do pre 34 weeks respectively or have an opinion on what is the best course of delivery?

I’m not concerned about the risks to me with an ELCS, I’ll deal with the recovery, it’s what’s going to get my baby out alive and the healthiest in the long run I care about. And as of yet I'm just so unsure as to what that is! My Reg friend (I appreciate you're a consultant and obviously are far more senior said experienced) said a section is the better option in his option on balance....

Also I promise you I'm not looking at an ELCS for ease. I'm not afraid of labour and prior to this was looking forward to my nice midwife led, gas and air only water birth! I was going to chant to Enya and slog out the 14 hours of labour

I really appreciate your response

@Propergator also just FYI I am 28 weeks to the day :) we made it to our first milestone

Sorry that tag was for @Docstf x

Hi

Good to hear you are at 28 weeks.

The issue of vaginal delivery being somehow less gentle on a baby is just a bit of a subjective thought. Vaginal birth is a fairly gentle process for the baby, even if not so for the mum. Babies are designed for this. I don't see preterm babies getting birth injuries from vaginal birth. We see no benefit to babies born by section, and the speed of a delivery has no relationship to stress levels or outcomes. Indeed, the normal birth process may have a number of long term benefits for babies that do not exist with sections. This includes colonisation of the baby with the appropriate microbiome which may also be beneficial in the long term.

Sections without labour do cause greater respiratory problems and the interventions we do for that are definitely not gentle. Also, don't forget that once you've had a section, there are risks in future births. That includes risks (relatively low) of complications that can harm future babies.

As for the question of meconium aspiration: This is not something I have heard of or experienced in very premature babies. Pre-term babies, especially under 30-32 weeks, do not tend to pass meconium even if distressed. Most births, at all gestations, happen after membranes have ruptured, often for hours. This is no different to preterm rupture of membranes in terms of effect on birth. I have never seen a preterm baby with meconium aspiration. The lung problems are related to the lack of amniotic fluid and its effects on lung development. at 25 weeks, the consequence of membrane rupture for lung development will be less than if it had happened at less than 22-24 weeks. Even with scans showing a lack of fluid, there is almost always some fluid there and enough to support continued lung growth and maturation.

I won't offer any recommendation on the mode of delivery you should have. It's not to be difficult. It is just that the mode of delivery is something that is influenced by a number of factors. Your obstetrician will have read and debated the evidence more than anyone else. But they also have something that no-one on these forums can replicate: Experience.

My only reassurance to you as a neonatologist is this: under 26 weeks, I am more upset when a baby is born by a section if normal birth would have been possible because I think that the mother has genuinely been harmed without any advantage to her or the baby (different if a normal birth is not possible because the mothers life is in danger). After that, I do not allow myself to be bothered by the mode of delivery - it's between the woman and her obstetrician. But I see no advantage to the baby from a section in the short or long term.

I suggest (and I'm not being patronising, I promise) that this is really not something to let yourself get stressed about now. Relax, do nice things, let nature do it's thing. What happens now is not really under your control. But, how you experience it is within your control.

So practice Enya and stun those midwives with your rendition. Pamper yourself. Eat some more chocolate. or cake or both. (Unless you are diabetic in which case don't!).

Try to make these next few weeks (and lets hope there's 10 more of them) as relaxing as possible.

I had a planned premature baby as I had vasa previa and going close to term would have been too risky (95% of babies with vasa previa die if the waters break). Because I had vasa previa it had to be a section, so I didn’t have to choose, but the calm planned nature of it was very reassuring. The baby did very well and didn’t need any special treatment; we were able to go to the normal ward rather than to special care.

@Docstf thank you so much!! That is possibly the most helpful thing anyone has said to me in two weeks!

I had a call this morning from my midwife to say my consultant app on Wednesday had been cancelled as It seems like the Consultant didn’t know it was to discuss delivery and thought it was for my PROM management and cos I’m doing so well she doesn’t need to see me! I know just an oversight and I appreciate it’s a good thing she doesn’t want to see me - I’m doing so well they don’t need to pull out the big guns - but I still have had no consultant contact since my waters went 2 weeks ago and they told me on their ward rounds that I would be induced at 34 weeks if I got that far! Hopefully this will be rebooked soon though after I spoke with the MW.

This is my first baby and we have had a sad history of MC so this shunt from low to high risk pregnancy is just perpetually terrifying! You're right that google and MN are my worst enemy and I tell myself I will stay off it but then something pops into my mind and I need to look it up!

It's incredibly reassuring to hear that about the meconium aspiration. If there genuinely is little risk to his lungs and his premature body in a natural birth then I will absolutely go for that - I have my own fears about instrumental delivery but if that's not a real concern in terms of risk
of damage to my baby then my remaining fears are mainly for my vagina 😂

I work for a Regulator for many years and I've seen too much and I know the worst that can happen but hearing the perspective from a consultant neonatologist is one perspective I haven't had - my friend's perspective as a Reg in Neonates is helpful but I am mindful of his experience...

I'll queue up the Enya and add chocolate cake to my next online delivery! Can't thank you enough for your perspective

Hi, I replied to your post on the pregnancy board where I mentioned I was in a similar situation to you. I also had these two options weighing on my mind and was leaning towards the planned section.

Well just an update - I ended up having an emergency section a day before I was scheduled to go in, just a few days ago! My baby was born at 34w and he has additional needs in that he was extremely small for gestational age. He weighed 2lb 10oz at birth. I'm pleased to share that he had no respiratory issues. They did say they would support him with oxygen for a while however by the following day the oxygen was off and he is breathing totally by himself. Currently on the special baby care unit but doing well. He was given steroids a week before arriving which I believe helped.

In a way I am glad the decision was taken out of my hands. I do not believe he would have coped with the stress of a vaginal induced birth as the EMCS was to due babies heart rate plummeting during routine obs. So glad we caught it in time. Also the fact induced early labours are notorious for failing to progress/interventions/ending in an emcs etc etc. Recovery from section is another story though! Lol.

This is just my experience and there is some great advice below! Obviously each baby has their own story and you just never know how it'll go until it happens. Good luck with the pregnancy and upcoming birth, whichever way it turns out for you :)

Goodness @greenemerald under 3lb for a 34 weaker!! You must have been so scared! I'm in for my monitoring tomorrow so going to ask what the situation is with my next growth scan! I think I'm due one actually... baby was measuring a week ahead in head and tummy circumference at 25 weeks so hopefully that plus the steroids he is now a lil' hulk! 😂( I know that can't happen).

I'm thrilled your baby is doing well and is off the oxygen!! Did you get skin to skin/cord clamping btw if I you don't mind me asking? Also are you expressing any milk/colostrum for him?

Sorry if these are personal questions xx

Haha here's hoping for a little hulk!

No, don't mind answering at all. So they did say they provided both delayed cord clamping and skin to skin. We managed to delay clamping the cord for a few mins, however I was unable to have immediate skin to skin. Only as he had to be seen by the paed doc to do checks right away as they weren't sure if he'd continue to breathe unaided. If there were no concern they said they would have put him on my chest straight after.

We got to have skin to skin the next day and they've been encouraging us to do so all the time. The staff at my hospital have been amazingly supportive. I managed to express colostrum for him the same evening with their help, and continued to do so two days on. Now my milks starting to come in so we're trying to get him to latch but I'm using the pump to express which is fed to him through his tube. So this is all possible and definitely encouraged.

@greenemerald did you have to wait a whole day to hold your boy?? That must have been torture! Are you getting lots of cuddles now? Only one parent is allowed in at a time at my hospital which sounds awful - even though I understand the reasons for this!

If I can get a bloody app with my consultant I'll ask what the procedure is at my hospital! I'm gonna assume that anything under 34 weeks he will need to be whisked away to be checked!

I've actually purchased a hospital grade breast pump just in case I can't get him to latch when the time comes/he needs an feeding tube! Everything you've said all sounds very promising though!!!

How's your little guy doing? Xx