I have had one previous emergency c-sec after a failed induction & am planning a VBAC. I have been informed by the hospital that I would have to have a bung inserted as soon as I arrived & EFM. I have agreed to a short period of monitoring only. My question is do I have the right to refuse to have the EFM as I really want to be more active with this birth. Are there any situations that you believe EFM is absolutely necessary apart from obtaining a trace & how long do you believe this should be for i.e 20 mins to 30mins or longer? I would appreciate your feedback.
tj
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Dr David
Moderator posted 27 March 2001 05:59 AM
Insertion of a bung and the taking of a sample of blood for "group and hold" is part of the VBAC protocol for many hospitals. I've read no research on these matters, but have certainly heard women talk of these interventions as being significant &endash; of reminding everyone of the "danger" of VBAC, of undermining the woman's belief in her ability to birth naturally.
The rationale for the insertion of the bung is to prevent any delay in instituting emergency management in the rare event of uterine rupture. I would suggest that an anaesthetist needing to give an emergency anaesthetic would take less than a minute to insert an IV line. One could argue that this is not a significant delay when considering the time needed to get a Caesar organised, and considering the rarity of rupture. Most pregnant women have "good veins" (easy to get an IV line in) due to the vasodilation of pregnancy. The longer an IV is in, the more likely to get an infection (though the risk is very small) and the more likely to get clotted/blocked and not be useful anyway.
Use of continuous EFM is believed to give the earliest warning of uterine rupture and is part of the protocol in nearly all VBAC studies.
One exception is a large well-known Irish study (Molloy et al) between 1979-84 which used EFM in 982 of 1781 women labouring with one previous Caesar. "When a patient was adjudged suitable for vaginal delivery (1781 out of a total of 2176) she was managed as a normal multiparous woman." 1062/1791 had spontaneous labour and no augmentation. 301/1791 had spontaneous labour but with oxytocin augmentation. 418/1791 had induced labour. Elective repeat caesar rate was 395/2176 (18.2%). VBAC rate for those who tried 1618/1781 (90.8% - which is high, but they did have a high proportion of women &endash; 62.3% who had also had previous vaginal birth). Uterine scar rupture rate was 8/1781 (0.45%) with one neonatal death and one cerebral palsy (similar intrapartum death rate to other women in the hospital at the time). All ruptures occurred in women being continuously monitored.
Epidural rate was low (by other studies standard) at 85/1791 (4.8%). 4 of the 8 ruptures occurred in this group and they suggest "clearly great caution must be exercised before considering the combination of oxytocin infusion and epidural analgesia", but "on the other hand, the patients who needed this form of treatment would, otherwise, have been delivered by emergency caesarean section".
The form that intermittent monitoring took is not stated, but another Irish study around the same time used listening each 15 minutes for at least one minute with an individual midwife. (MacDonald et al. AmJOG 1985;152:524-39) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3113567&dopt=Abstract
The Canadian Obs society guidelines suggest EFM if oxytocin is used. http://www.sogc.medical.org/SOGCnet/sogc_docs/common/guide/pdfs/ps68.pdf
Any person has the right to refuse any treatment, but generally a process of negotiation with caregivers, if possible, will serve you well. EFM can restrict movement, but you should usually be able to sit or stand out of bed.
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.