I am 27 yrs old and 32 weeks pregant with my 3rd baby. I am needing advice on which way to give birth to this one as neither of my previous ones were straightforward and I have also moved countries and they have no notes on me except on what I tell them and they are not being very helpful on advice.
My first baby was 2 weeks late so I was induced, they decided to monitor me just before and found that every 20 mins the baby's heartbeat dropped and then picked up again. They then gave me oxytocin and an epidural and then after a time the baby's heartbeat kept dropping and they decided for an emergency caesarian - she was only 5lb 15oz and I had a poor placenta.
My second baby I was advised to have normally, so I went into labour naturally 2 days before due date, I was getting contractions every 3 mins so went into hospital but these contractions were weak and they weren't doing anything so after a time they decided to give me oxytocin again, I was closely monitored and everything seemed to go well, I had another epidural as well. When I got to fully dilated everything started to go wrong again - the heartbeat kept dropping every contraction and the problem is that with oxytocin I was getting contractions every 40 secs, I started pushing and I was told I had to be quick as they were losing him and I was too far gone to caesarian, this all happened in a period of about 10 mins from full dialation. I got him out before they could gown up for forceps etc but still he came out with an apgar score of 2. After 20 mins he was fine but it was a close call. This baby was 8lb 15oz but still had a poor placenta.
From this I am not sure which way to go this time - weather to have an planned caesarian or to try normally again. I am afraid of losing the baby but also don't necessary want a caesarian as its harder to get over and especially when looking after 2 other children as well. I am not a marter and would probably want another epidural as it worked so well, also I am aware that I will be closely monitored so therefore will be bedridden anyway in childbirth. Any advice would be wonderful. For your information I had both my children in Poole Hospital in England and I am now living in Australia, Adelaide.
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Dr David
Moderator posted 02 February 2001 11:00 PM
Debbie, it's not possible for me to give you specific advice, but I can comment on the information you have given, and give you sources of information to help you plan your next birth.
First labour: Given that you were 2 weeks overdue, that the CTG was abnormal prior to induction and that your first baby was small, it is reasonable to assume that the placenta was not functioning ideally, and that your baby could not tolerate the extra stress of uterine contractions.
Second labour:
Oxytocin augmentation in VBAC. Zelop showed a uterus rupture arte of 1.0% in VBAC augmented with oxytocin, compared with 0.4% in spontaneous labour not augmented. Numbers were small however and the difference may have been due to chance. "We suggest that the use of oxytocin proceed judiciously". http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10521747&dopt=Abstract
Without being at that labour, I would point out several possible causes for fetal heart rate changes in the history you give. A vaginal examination flat on your back, or the vasodilating effects of epidural, but especially a combination of both can cause changes. Overstimulation with oxytocin also can. The uterus becomes more sensitive to oxytocin as the labour progresses, so sometimes we need to cease it for a time, and if still needed, start it back at a lower rate. Were you still on your back when getting ready for forceps? The best position is on your side, oxygen on, oxytocin off, extra IV fluid. The carers may have been readying for an assisted birth, though, may have been concerned about cord compression or uterus rupture, and as I say, I wasn't there.
I know of no documented correlation between the look of a placenta and its function, but there certainly is a correlation between the size of a baby and the placental function. With a 9 pound baby and a normal labour, we can safely say that your placenta did its job very well, whatever it looked like.
You should be able to get details of your labour records for your carer. You or your carer could ring or fax the hospital in the UK, and speak to the medical records department. They may require a "release of medical information" form which they could send. You would be interested in the "labour ward record" or 'partogram", and "delivery summary" or "discharge summary". You could go over the events hopefully detailed in the notes with your carer, or one of the labour ward midwives.
Chance of a baby dying in VBAC labour due to uterus rupture (which is really the only unavoidable extra labour risk you have) in an Australian study was estimated at 1 in 2000.
Mozurkewich looked at 39,525 women in a meta-analysis comparing trial of labour with elective Caesar and found chance of death 0.2% (1 in 500) for labour trial and 0.1% (1 in 1000) for elective Caesar. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list _uids=11084565&dopt=Abstract
Other large series have shown no deaths attributable to uterine ruptures. Risks of VBAC need to be balanced against fetal and maternal risks of elective Caesar also.
Rate of uterine rupture is lowest (0.2% or 1 in 500) in those with prior vaginal birth. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11084564&dopt=Abstract
Caughey found a successful VBAC rate of 92.8% in the third pregnancy among 500 women who had caesar followed by a vaginal birth. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9790374&dopt=Abstract
"I am not a martyr":
Every labour is different. Many women find they can avoid epidural by surrounding themselves with good support, preparing themselves fully, trying to leave past experience outside the labour ward door, and believing in their own untapped strength and capability. Perhaps you could seek some advice from Cares in SA or on the discussion forum.
Close monitoring does not necessarily mean being stuck in the bed. Speak to the labour ward staff.
Good luck in making these important decisions.
Dr.David
DISCLAIMER:
This advice is of a general nature to help in decision-making. It
does not constitute recommended treatment for an individual. You must
consult your health care provider for individual
advice.