Induction Risks with VBAC
Birth.
Foreword by Jackie Mawson.
Choosing an induction as the way to get labour happening,
in the hopes of birthing your child vaginally, is still a
personal decision that each woman must make for herself,
after reading the literature that is available. I
"personally" think a c/section is better than the choice of
induction after a previous caesarean - shock, horror! I just
have 'heard' of some bad outcomes from artificial
inductions/augmentations, and honestly what is it all about
when we try to force labour? Even the 'natural' forms of
induction, which are still trying to force the body to do
something that it's not ready to do for some reason, should
only be used to augment a labour that needs to continue for
the safety of baby/mother.
If we have faith in the wisdom of our bodies, then we
have to ask 'Why isn't my body going into labour? Is it
because my baby isn't ready to be born yet? Is it because I
am fearful? Is it because of past traumas that I haven't
dealt with? Is it normal (within my family) for me to have a
42 week pregnancy? Is my baby in the wrong position for
birth, and stuck there?..."
There are so many questions we need to ask ourselves, we
carry a heap of subconscious stuff that we don't even know
is there and this could be the reason. Or it could just be a
physical reason (baby not actually the age determined by
ultrasound, in the wrong position, etc). Maybe that pelvis
really is too small, or the wrong shape - I'm sure it must
occasionally happen that way, though don't think I am a
supporter of the CPD label which is so abused as a general
incorrect diagnosis. It has, sadly, become a catch-all for
so many other less specific problems.
Yes, there are natural methods of induction that are
gentler than artificial methods - though how artificial are
they really when they are based on 2 hormones produced
within the human body itself, to induce labour &endash;
oxytocin and prostaglandin? The artificial aspect is that
they are introduced into our bodies from externally, and in
doses that can be far too strong as this strength is needed
to 'get labour happening' when our body may not be quite
ready to birth our baby.
If you tried the natural methods; sex (prostaglandins),
walking (jolt that baby down), nipple stimulation (oxytocin
release), etc. And the others that cause uterine
stimulation, such as castor oil which irritates the bowel
and thus causes the uterus to become irritated by all that
action in the bowel, etc. You would find they don't always
work and again we should ask "Why?"
Artificial induction may work when these others don't,
and when it does work then everything may turn out
perfectly. But sometimes it doesn't and the amazingly
interventional treatment becomes necessary. Hopefully no
damage is done, or serious traumas result. Sadly these do
occasionally occur, and that is why I question the use of
these drugs and artificial methods.
All of us who have experienced a c/section do have a scar
on our uteruses, don't we? Yes, natural birth after a
previous c/section has been shown to be safe, and a much
more viable option than an elective c/section for no
specific medical reason. But once we start adding drugs, and
interventions of any kind, into the equation then the risk
factors will be affected, we can't assume that we still have
the same percentage risk of uterine rupture as a woman who
is having a natural uncomplicated vaginal birth. Our risks
of uterine rupture will increase, and I can't (personally)
tell you what that increased risk will be.
So, I encourage 'natural' birth, especially after a
previous c/section. I can't give advice on inductions, of
any kind, that has to be a personal choice, as do all
decisions in regard to our pregnancies, childbirth and
family. Each woman must weigh the risks, talk to the
professionals, honestly look inside herself to ask why these
choices have become necessary, search for the literature,
then take responsibility for the choices that she makes.
There are no guarantees in life, even surrounding birth.
Life would be extremely boring if their were no risks to be
taken, ever. We must recognise the risks, acknowledge them
and then choose our path. We mustn't hand our responsibility
over to another, not to our partner, not to our family, not
to a health-care professional that tells you that if you do
something a certain way then everything will be fine. Ask
them to guarantee you that perfect outcome and watch them
'back-pedal' themselves out of their guarantees and point
out the possible risks still present.
Has this 'digest' email helped in any way? Or is everyone
still as confused as me in regard to the many choices life
is always presenting us with? I'm sorry I can't offer any
concrete advice here, but it's your choice, not mine, to
make in regard to how your children will be born. I can only
offer my concerns and my support for natural childbirth
after a c/section. And where that is not possible, then I
offer my support for a wonderful, positive and empowering
caesarean birth for your child, and yourself.
Birthing Beautifully,
Jackie Mawson.
====================
From the website: http://www.nihs.go.jp/dig/infodrug/136/136oxy.html
[Commentary] Proper Use of Drugs
Oxytocic-Induced Serious Adverse Reactions Such as
Uterine Rupture and Threatened Fetal Distress
?@Oxytocin (OXY) and the prostaglandin preparations
dinoprost (PGF2ƒ¿) and dinoprostone (PGE2) are
oxytocics used for induction of labor and stimulation of
labor. Excessively strong uterine contraction and threatened
fetal distress have been reported as adverse reactions to
administration of these oxytocic agents and are given in the
current "Precautions" to call the attention of health-care
professionals. The PAB further urges caution against these
adverse reactions.
(2) Actual Precautions
…@patient selection
?@Induction of labor
?@Oxytocics may be administered to medically indicated
patients whose clinical conditions justify the induction of
labor. Oxytocics should be used under conditions sufficient
to ensure the safety of both the mother and the fetus.
?@Indications for oxytocics include both fetal and
matemal factors. The former include post-term pregnancy,
placental hypofunction and growth retardation in the uterus,
i.e., an unfavorable intrauterine environment where induced
delivery for extracorporeal management of the infant is
preferred. The also include early membrane rupture and
toxemia of pregnancy where continued gestation maythreaten
the health or life of the mother. In any case, it must be
ascertained prior to use if both the fetus and mother can
tolerate oxy-tocic administration, and the drug should be
used under careful observation so that if any abnormality is
noted in the fetus or mother during oxytocic administration,
the drug can be immediately discontinued and appropriate
measures be taken.
?@Labor stimulation
?@Oxytocics may be prescribed for labor failure due to
uterine inertia, or for protracted delivery. In such cases
it is essential that safe transvaginal delivery be
accomplished by stimulation of labor without any fetopelvic
disproportion. Stimulation of labor may at times lead to a
labor trial in delicate cases. In such cases the physician
should be ready to switch to Cesarean section at any time.
…Aprecautions for use
?@The medical history of patients to undergo induction or
stimulation of labor must first be considered. Oxytocic
administration should be avoided if possible in patients
with a history of Cesarean section or myomectomy for myoma
uteri. Administration must be performed with extreme caution
if it is inevitable. For induction of labor, the cervical
maturation is important. Induction of labor in a state of
cervical immaturity with a low Bishop's pelvic score is not
only ineffective but frequently results in protracted
delivery. Efforts should be made to improve the maturity of
the uterine cervix by adequate means before oxytocic
administration.
?@ Administration must be started at a low dose in order
to avoid excessive uterine contraction, preferably via an
infusion pump with which the dose can be adjusted. Labor and
fetal heart sounds should be monitored and recorded with a
tocomonitor. Tbe dose may be slowly raised by carefully
monitoring the course of labor.
===============================
The results of the paper, below, published in 1999, are
among the most recent of the VBAC studies and we can assume
that the researchers will have been familiar with previous
research on the matter. Its findings are worrying.
"Uterine rupture during induced or augmented labor in
gravid women with one prior cesarean delivery."
Am J Obstet Gynecol 1999 Oct;181(4):882-6
Zelop CM, Shipp TD, Repke JT, Cohen A, Caughey AB,
Lieberman E
Department of Obstetrics and Gynecology, Massachusetts
General Hospital, the Department of Obstetrics and
Gynecology, Brigham and Women's Hospital, Harvard Medical
School, and the Department of Obtetrics and Gynecology,
University of Nebras.
The study looked at 2774 women attempting VBAC at term,
after 1 prior cesarean delivery and no other births. It
compared the rates of uterine rupture associated with
spontaneous labour, oxytocin induction or acceleration, and
prostaglandin E2 gel induction. The analysis controlled for
other factors which might confuse the result, such as birth
weight, use of epidural, duration of labour, maternal age,
year of delivery, and years since last birth.
Of 2774 women in the analysis, 2214 had spontaneous onset
of labor and 560 women had labor induced with oxytocin or
prostaglandin E(2) gel. 1072 women had their labours
accelerated ('augmented') with oxytocin.
The overall rate of rupture among all patients with
induction of labor was 2.3%, in comparison with 0.7% among
women with spontaneous labor. Among 1072 patients receiving
oxytocin augmentation, the rate of uterine rupture was 1.0%,
in comparison with 0.4% in nonaugmented, spontaneously
laboring patients.
After adjusting for birth weight, use of epidural,
duration of labor, maternal age, year of delivery, and years
since last birth, induction with oxytocin was associated
with a 4.6-fold increased risk of uterine rupture compared
with no oxytocin use. Acceleration with oxytocin made
uterine rupture was 2.3 times more likely, and use of
prostaglandin E(2) gel made rupture 3.2 times more likely.
These differences did not qualify as statistically
significant though, because of the small numbers involved.
CONCLUSION: "Induction of labor with oxytocin is
associated with an increased rate of uterine rupture in
gravid women with 1 prior uterine scar in comparison with
the rate in spontaneously laboring women. Although the rate
of uterine rupture was not statistically increased during
oxytocin augmentation, use of oxytocin in such cases should
proceed with caution."
===================
This is the most recent of the VBAC induction
studies:
"Uterine Rupture During Induced Trials Of Labour In
Women With A Previous Cesarean Delivery"
American Journal of Obstetrics and Gynecology, January
2000, in two parts, part 2, volume 182, number one
D. Ravasiax S. Woodx J. Pollard
University of Calgary, Foothills Hospital, Calgary, AB,
Canada
OBJECTIVE: To determine the rate of uterine
rupture during induced trials of labour (TOL) after previous
cesarean delivery compared to spontaneous TOL.
STUDY DESIGN: Rates of uterine rupture were
determined for all inductions in women with a prior cesarean
section and for each mode of induction, including
prostaglandin E2 gel (PGE2), intracervical Foley catheter
(This is like a mechanical version of a slow stretch and
sweep of the membranes), artificial rupture of membranes
(ARM) and oxytocin. Comparisons were made with Fishers's
exact test.
RESULTS: Between 1992 and 1998, there were 2119
TOL, 575 of which were induced (27%). The overall rate of
uterine rupture was 15/2119 (0.71%). The uterine rupture
rate with induced TOL (8/575, 1.4%) was significantly higher
than with spontaneous TOL (7/1544, 0.45%), p=0.036. The
relative risk of uterine rupture with induction was 3.09
(95% CI 1.12 to 8.42).
CONCLUSIONS:
1. The rate of uterine rupture with induced trial of
labour (TOL) is significantly higher than with spontaneous
trial of labour.
2. PGE2 exposure during TOL is associated with more than
a 6-fold increase in uterine rupture when compared to
spontaneous TOL.
3. Foley catheter induction is associated with the lowest
rupture rate in the induced TOL group and is comparable to
spontaneous TOL
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