TLAC vs Scheduled section

cookderosa · Feb 25, 2010

Hi all.
I am a Student nurse Anesthestist. My wife is pregnant with our second child and I have a couple of questions.
A little background- our first child was born via C-section after FTP . She only dilated to 6 cm after 26 hrs and started having decels so they decided to cut. Also our son was 9#12oz when born.
Now that she is pregnant she was thinking about trying a TLAC/ VBAC but there are some downfalls. Our hospital is a large woman's hospital that is also a teaching hospital. This is the hospital that we must go to due to insurance. She would like to try to labor in water but after the water is broke she was informed that she would have to get an internal monitor and have to stay in bed. She does not like this option and feels pretty helpless with her choices.
Based on her FTP and the fact that the first child was very big, she is already measuring at 33 weeks but is only 30 weeks, and her history of C-section- I tend to think that maybe a section is the best route. Now I know that a C/S is usually not the best thing but given her limited options to do things the way she wants I tend to lean that way (yes I am aware that I am the one who does not have to recover). Also with her first pregnancy- the epidural really hurt her bladder- she has a bad bladder. She was HTN but not spilling proteins, but after our child was born, went full blown preeclampsia and had to be readmitted and put on Mag which slowed down her healing and made for an overall awful expererience. Right now her BP is okay so we are hopeful.
I am just looking for some opinions on maybe she should try the TLAC and get the internal monitors and have to stay in bed- it is this groups policy or should she schedule a C/S at 39 weeks and go that route.
Thanks

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I'm not a CNM, however, let me encourage you to let your wife drive this decision. There is something primal about the desire to birth lady partslly, especially if she had a c/s from FTP. Sometimes women feel that they failed ("failure" to progress) as if they in some way could have done something to avoid the surgery. If she feels like this is something she wants to do, for whatever reason- maybe that she can't even articulate, then I'd say to support her. Guilt is often a factor in postpartum depression, so HER feeling like she had a voice is very important to alleviating that tendency toward guilt. It's true she may end up being over managed at a teaching hospital, but it's also possible that she would VBAC! I don't know where you are, or your hospital/state protocol but you might find a CNM with hospital privilege who would attend a VBAC, or at least would be part of a team with an OB to allow a trial of labor.

Lastly, for a bit of encouragement, I have had big babies too. I have had 4, my smallest was my first who was 8# 12oz, and my second baby was 12 pounds even. After him, I had a 10 pounder and an 11 pounder. These were all delivered lady partslly and without an episiotomy. I know big baby can be a reason for FTP, but if she is comfortable, enjoying the water, moving around, and isn't lying down too early- her labor might progress nicely. My labors were very very slow, certainly much slower than the 1cm/hr rule of thumb. Patience is part of the package too, and a midwife will certainly have more patience. I wish you and your wife the best, and CONGRATS on your little one!!

papapump · Feb 25, 2010

Thanks.

I want her to do what she wants but I get the feeling- this is going to be done more by the protocol and not with the patient in mind.

Thank you for the words of encouragement.

blueindigo79 · Feb 26, 2010

i am not a cnm either (not yet,hopefully in the future!). i would get a second opinion - is there a more pro-vbac practice that she can see? what about a practice with cnms? was she induced with your first child? was she allowed to labor in different positions? often i am wary of the ftp b/c sometimes it is based on protocol and a clock.

here are some sites that might help:

vbac.com

www.ican-online.org/

http://childbirthconnection.org/article.asp?clickedlink=293&ck=10212&area=27

http://www.mayoclinic.com/health/vbac/vb99999/page=vb00001

http://www.peacehealth.org/kbase/dp/topic/aa37799/dp.htm

http://www.vbac.com/informedconsent.html#additional

babycenter.com also has a great vbac board. i would educate myself then make an informed decision.

best of luck!

nurselizk · Feb 26, 2010

Her best bet if she wants a trial of labor & attempted VBAC is to labor at home as long as possible & forgo the epidural. At the hospital she will be managed the way the hospital is comfortable, not necessarily her preference. And there are people whose labor slows down with an epidural despite what you will be told. I was one of them. Happened every time. Be her support system, have her walk &/or squat as much as she can during labor to aid her progress & help her deal with the pain. I'm not suggesting not to go to the hospital, but don't go earlier than you need to. You might even arrange for a doula. The program I looked into provided them at no cost, I don't know if that's the case everywhere.

CEG · Feb 27, 2010

Failure to progress is often called "failure to be patient" and can mean anything from an unsuccesful induction to a slow laborer to a doctor who had something planned. So I wouldn't take FTP as a sign of doom for future labors. Certainly there are ways to reduce that risk - avoid induction, avoid epidural, change positions frequently, avoid artificial rupture of membranes, avoid pitocin if not warranted for slow labor.

As for the internal monitor after her water breaks and in bed, there is absolutely no evidence base for that and I would question it. The only indication for an internal as opposed to external monitor is that in some cases it is better at showing us variability (the most important indicator of fetal well being). In the absence of complications there is really no reason to put in an internal monitor. And water being broken is not in any way predictive or a risk for uterine rupture so there is no basis in putting one in after the water breaks except that it can't be put in when the water is intact.

It sounds like this provider is not supportive of VBACS. Are there any other options? Is this by chance a big hospital by the lake in Chicago? No matter where it is, I would look at other providers. Call L & D and say you want a VBAC and who should you see. That's really the best way to get the info on who is supportive?

Remember that she does not "HAVE" to do anything. They can make it very difficult on her (and you) but she has the right to informed consent and refusal of any procedure. The tough part is when providers will often call into question the safety of the baby even when that may not be the case. It's hard to know who to trust and when.

Remember that a succesful VBAC is always better for mom and baby than a c-section. The risk of uterine rupture is about .4%. Individual practices vary widely on VBAC success rates so ask your current provider for that info.

Check out the International Cesearean Awareness Netwotk (www.ican-online.org). They have local chapters and give referrals for VBAC friendly providers.