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doulala I have a question!

Posted by on Sep. 14, 2011 at 2:44 PM
  • 21 Replies

I'm going for a VBAC this time around. My doctor was talking about how they use low dose pitocin and breaking of waters to induce. I do NOT want to be induced but recently I've learned that inducing a VBAC is a bad idea. Can you share some links for that? I've tried googling but didn't find much.

by on Sep. 14, 2011 at 2:44 PM
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Replies (1-10):
bonnebell81
by on Sep. 14, 2011 at 2:45 PM

BUMP! Good luck hun, good to see you in this group too!:)

doulala
by on Sep. 14, 2011 at 2:46 PM

Sure.


WHY induce at all?
Let's save interventions & risks for a true need.

;-)


Autumn19
by Ruby Member on Sep. 14, 2011 at 2:47 PM

bump

.Angelica.
by on Sep. 14, 2011 at 2:51 PM

I agree. I don't want to induce and plan to be refusing it unless there is a true need to do so. I just wish I had this information when I had my son, I could have avoided a c section.

Oh and I told my doctor artificial breaking of waters and pitocin was how they tried to induce last time and it did nothing, but she just said that all pregnancies are different.

Quoting doulala:

Sure.


WHY induce at all?
Let's save interventions & risks for a true need.

;-)



doulala
by on Sep. 14, 2011 at 3:01 PM

 

 

 

Rates of Rupture: Spontaneous vs. Induced/Augmented Labors

When attempting to approximate your risk for uterine rupture, it’s important to differentiate between spontaneous and induced/augmented labors. Landon (2004) featured the VBAC labors of almost 18,000 women and found varying rates of rupture based on spontaneous vs. augmented vs. induced labors.

Spontaneous means that labor starts on its own. Induced means that the laboring mom is given drugs, usually Pitocin, Cyotec, and Cervidil, to start labor. Augmented means that the laboring mom is given drugs during labor, usually to speed things up or to restart a “stalled” labor. Specifically, they found the following rates of uterine rupture: 0.4% (N = 24) in spontaneous labors, 0.9% (N = 52) for augmented labors and 1.0% (N = 49) for induced labors.

They further broke out rupture rates by type of induction: 1.4% (N = 13) with any prostaglandins (with or without oxytocin), 0% with prostaglandins alone, 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with or without oxytocin), and 1.1% (N = 20) with oxytocin alone. Overall, they found 0.7% of women experienced a true uterine rupture with an additional 0.7% experiencing a dehiscence. Lyndon-Rochelle (2001) found that women with spontaneous labors had a rupture rate of 5.2 per 1000 (0.52%) while labors induced without prostaglandins (7.7 per 1000, 0.77%) and labors induced with prostaglandins (24.5 per 1000, .24%) experienced rupture rates 4.7 times and 1.5 times higher respectively.

I find it bizarre that multiple studies have found drug induced labors result in more ruptures, yet OBs go on inducing. If OBs are so concerned about uterine rupture, why do they continue to induce VBACing women, especially with prostaglandins (misoprostol aka Cytotec and dinoprostone aka Cervidil), which are the most risky labor inducing agents to use in a VBAC labor?

Oxytocin (Pitocin) is widely used, so it is not surprising that this uterine stimulant has been administered in a majority of ruptures. One center found that oxytocin had been given in 77 percent of their ruptures and was typically used to stimulate labor in women with a prolonged latent phase. Misuse of oxytocin carries significant risks in any mother, and this risk may be increased during VBAC, especially at high infusion rates. ACOG guidelines and other authors indicate that oxytocin use during VBAC is acceptable. Induction of labor, regardless of the method used, is increasingly recognized as a risk factor for uterine rupture. Recent VBAC studies have shown three to five times more ruptures among induced mothers compared with those having spontaneous onset of labor. (Toppenberg, 2002)

Kayani (2005) concluded “in women with previous caesarean section and no vaginal deliveries, induction of labour carries a relatively high risk of uterine rupture/dehiscence despite all precautions, including intrauterine pressure monitoring.”  Landon (2004) found that inducing or augmenting labor resulted in a doubling of the uterine rupture rate and Kayani (2005) concurs a year later.

Why don’t they wait for labor to spontaneously being?  As long as mom, baby, and placenta are fine, there is no reason to be inducing.  We know from Dr. Wagner’s book “Born in the USA,” that 40% of women in the US are induced.  We know that 40% of birthing women are not “high-risk,” so why all the inductions?

It’s because most OBs do not practice evidence-based medicine and there are other factors, such as convenience, which dictate their actions. It is hard to rectify a medical community that says VBAC is to risky to permit on one hand, but electively increases that risk through induction. Baring true medical complications – baby being “to big” and going “overdue” are NOT true medical complications – a woman should wait until 42 weeks for spontaneous labor.

“Medical studies have shown that the most common reason for a baby being ‘overdue’ is not that mother nature has made a mistake but rather that we have made a mistake in calculating the due date.” (Flamm, Birth After Cesarean) Size estimates based on ultrasounds are notoriously inaccurate (see Yagel, 1986; Egley, 1986; Yeh, 1982) and since most women do not have 28 day cycles, due dates are pretty useless (which is why it is important to chart.) If a mom really needs to be induced, there are non-drug methods of induction that are certainly worth a try, but all induction does is increase your risk for a cesarean section. It’s just not worth the risk unless you or your baby have some medical reason that birth must happen sooner rather than later, which is rare.

As a member of ICAN, I hear story after story of women whose primary cesarean section was performed due to “big baby” and then went onto VBAC a larger baby as well as women who really trusted their OB with their first baby and agreed to an induction, without a true medical reason, only to end up with “failure to progress” and sectioned. You will know when your body and your baby are ready for labor because labor will begin. Trying to force your body to birth will result in a more painful labor and an increased likelihood that your labor will end with a surgical birth. If you think waiting for labor to start is hard, consider recovering from major abdominal surgery and caring for a newborn. Take it from me – it is not fun! The fact is, the medical community has completely lost faith in a woman’s ability to birth without prodding and pushing through interventions, drugs, and timelines.

For more articles on uterine rupture, please click here.

 

 

The International Cesarean Awareness Network strongly advises women and health care practitioners to avoid induction of labor unless a true medical indication exists. Induction of labor frequently leads to further intervention in birth including the need for fetal monitoring, epidural anesthesia, instrumental delivery and cesarean section. Each of these interventions increases risks to babies and mothers.

 

First time mothers are especially vulnerable: Induction itself doubles a first-time mother’s risk of having a cesarean section.1,2

 

A cesarean puts a woman’s entire reproductive life, including subsequent pregnancies, at higher risk.

 

For all women, induction of labor increases the use of forceps and vacuum extraction as well as rates of shoulder dystocia.2,3

 

Women with a prior cesarean who are induced have a 33-75% risk of having another cesarean.4,5

Induction of labor has been shown to increase the risk of uterine rupture for women with a prior cesarean scar.6-9

 

Babies whose births are induced more often experience resuscitation, admission to the intensive care unit, and phototherapy to treat jaundice, which generally require separation from the mother. 10

 

References:
1. Maslow AS, Sweeny AL. Elective induction of labor as a risk factor for cesarean delivery among low-risk women at term. Obstet Gynecol 2000 Jun;95(6 Pt 1):917-2.
2. Dublin S, Lydon-Rochelle M, Kaplan RC, Watts DH, Critchlow CW. Maternal and neonatal outcomes after induction of labor without an identified indication. Am J Obstet Gynecol 2000 Oct;183(4):986-94
3. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 1998 Aug;179(2):476-80
4. Learman LA, Evertson LR, Shiboski S. Predictors of repeat cesarean delivery after trial of labor: do any exist? J Am Coll Surg. 1996 Mar;182(3):257-62.
5. Sims EJ, Newman RB, Hulsey TC. Vaginal birth after cesarean: to induce or not to induce. Am J Obstet Gynecol 2001 May;184(6):1122- 4.
6. Blanchette H, Blanchette M, McCabe J, Vincent S. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001 Jun;184(7):1478-84; discussion 1484-7.
7. Baskett TF, Kieser KE. A 10-year population-based study of uterine rupture. Obstet Gynecol 2001 Apr;97(4 Suppl 1):S69.
8. Shimonovitz S, Botosneano A, Hochner-Celnikier D. Successful first vaginal birth after cesarean section: a predictor of reduced risk for uterine rupture in subsequent deliveries. Isr Med Assoc J 2000 Jul;2(7):526-8.
9. Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial of labor among women with previous cesarean delivery. Am J Obstet Gynecol 2000 Nov;183(5):1176-9.
10. Boulvain M, Marcoux S, Bureau M, Fortier M, Fraser W. Risks of induction of labour in uncomplicated term pregnancies. Paediatr Perinat Epidemiol. 2001 Apr;15(2):131-8.

 

 

 

 

Some consultants continue to induce mothers with a scarred uterus routinely despite the additional risks. Prostaglandin gel pessaries came into widespread use in the late 1980s and concerns have been growing over the effect they could be having on the uterine scar tissue of susceptible women. Previous articles in this Journal (see AIMS Journal, Autumn 2001) have dealt with the serious concerns relating to the use of misoprostol in particular and prostaglandin gel pessaries in general. There is certainly enough evidence now to suggest that routine induction of VBAC mothers should be avoided and when it is necessary it should be conducted with great care.

Mothers who go overdue are therefore in a difficult position and often under pressure to accept an elective caesarean section. They are fed scare stories of placentas that begin to fail at 42 weeks, and of babies that grow so large that the strain on the scar is sure to result in a rupture.

Although there is evidence that reducing the numbers of women going over 42 weeks gestation does improve outcomes, the risks involved in post term pregnancy are very small. Due dates can also vary by several days depending upon which method of calculation was used.

There is no evidence to support the fear that larger babies are more likely to result in caesarean scar rupture, and indeed many twin pregnancies also result in successful VBACs. VBAC mothers have given birth to some very large and healthy babies, some of which followed caesarean deliveries of much smaller siblings. Failure to progress and fetal distress are rarely evidence of a small pelvis or a mother’s inability to labour effectively – they are much more likely to be caused by poor support and over-medicalisation of labour.

Little, if any, consideration is generally given to the case of the mother who has passed a healthy pregnancy, who perhaps has a long menstrual cycle, who many have conceived later in her cycle, whose family history tends toward longer pregnancies, who may well naturally be destined to have a longer pregnancy, and whose baby is active and healthy and simply not quite ready to be born yet.

Providing a mother is confident that her baby is doing just fine, she may prefer to avoid the risks of induction or an elective caesarean, preferring instead to let nature take its course unhampered. The onus should not be on the mother to refuse routine medical intervention, it should be on the health professionals to convince an individual mother that any intervention is necessary or advantageous in her particular case.

 

 

 

 

An induction of labor is a complex and painful process that often requires additional medical interventions to keep the mother and baby safe from subsequent potential complications. Confining the laboring mother to bed, the use of continuous fetal monitoring, an epidural for pain, and the use of an IV, are standard with an induction. Induction of labor is a risk factor for several complications for both mother and baby including a higher risk for a cesarean section.  Inducing labor with pitocin when the cervix is unripe (long and closed) sometimes causes the mother to labor for long hours with little progress. Cesarean section after a failed induction with pitocin is not uncommon.

Elective induction also impacts newborns. All induction agents increase the risk for stronger than normal contractions (uterine hyperstimulation), affect the baby’s oxygen supply and consequently its heart rate (fetal distress). Newborns are more likely to experience shoulder dystocia (a life-threatening complication of secondstage) with labor is induced. At birth they are more likely to need neonatal phototherapy to treat jaundice, to need resuscitation, and to need treatment in an intensive care unit.Elective inductions are also a risk factor for preterm birth.

 

 

Quick facts about VBAC:

  • On average, 74% of VBACs are successful.
  • Uterine rupture occurs in about 0.5% of spontaneous VBAC labors.
  • Use of chemical induction or augmentation agents is known to increase the risk of uterine rupture. Pitocin augmentation increases rupture risk to 0.7%, pitocin induction raises risk to 1.1%, and prostaglandins carry a risk from 2% to 8% depending on the agent used.
  • The NIH found no maternal deaths related to uterine rupture. 
  • Neonatal outcomes following rupture can depend on the speed with which an emergency cesarean is performed. Best results have been found when the baby is delivered within 17 minutes of identifying the rupture.
  • Maternal mortality is 3-4 times lower for mothers who choose VBAC.
 

Uterine rupture

(US rates unless otherwise noted)

Without labor (scheduled repeat cesarean):

0.2%

Average rupture risk in all VBAC labors:

0.7%

Spontaneous VBAC labor:

0.4%

Spontaneous VBAC labor, augmented with pitocin:

0.7%

Pitocin induced VBAC labor:

1.1%

VBAC Labor induced with prostaglandins:

2%-8% (higher rates with use of cytotec)

Risk of rupture in an unscarred uterus

0.012%  (in developed countries; 0.07% worldwide)


Risk of delivery complications (per 100,000 births)

VBAC

RCS

Maternal mortality

4

13

Hysterectomy

157

280

Deep venous thrombosis

40

100

Placental abnormalities

 

significantly increase with multiple cesareans

Fetal mortality

130

50*

Brachial plexus injury

180

30**

.Angelica.
by on Sep. 14, 2011 at 3:25 PM

thanks for the links and stuff. I might end up making my doctor mad but I will not go in to be induced if there is no medical reason to do so. And I also plan to stay home as long as possible when I am in labor.

.Angelica.
by on Sep. 14, 2011 at 3:26 PM

Also, another question, I know someone who recently had a c section because she wasn't dilating past a 4. I think they only gave her a few hours. not sure if she was induced or anything. If anything like that happens where I'm not dilating fast enough it doesn't mean anything is wrong right?

PrincessGemini
by on Sep. 14, 2011 at 3:44 PM

I'm not like an expert or anything, but I don't think that means anything is wrong. A friend of mine went into labor a couple days ago and she was stalled dilated to a 4 for several hours, and then all of the sudden she jumped to a 7 and then an hour or two after that she was at a 10. Oh, and she was induced because the baby was in distress. I think that if she hadn't have been induced she might have progressed quicker than she did, but her son was perfectly healthy when he was born nearly 24 hours after her labor had started. Sometimes doctors are just lazy, and they would much rather do a c-section even if nothing is wrong because it means they can hurry and finish up and go home, but babies work on their own schedule and come when they are ready. C-sections are convenient for the doctor but doesn't mean they are always necessary, even if a doctor makes it sound like it is. Just thought I'd comment on what you said, hope this helps you feel a little better.

Quoting .Angelica.:

Also, another question, I know someone who recently had a c section because she wasn't dilating past a 4. I think they only gave her a few hours. not sure if she was induced or anything. If anything like that happens where I'm not dilating fast enough it doesn't mean anything is wrong right?

 



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doulala
by on Sep. 14, 2011 at 3:46 PM


Quoting .Angelica.:

thanks for the links and stuff. I might end up making my doctor mad but I will not go in to be induced if there is no medical reason to do so. And I also plan to stay home as long as possible when I am in labor.


That would be his/her problem (if doc has a God Complex and thinks he/she can rule you!).

Your doctor is a hired caregiver NOT there to make your decisions for you but to inform you on what your options are and how to approach any possibilities~ and then to work with you to achieve that.
Of course care providers give their recommendations but this is biased and you still have to think for YOURself, too.

;-)



"If you don't know your options you don't have any"          ~Korte & Scaer

"If you choose not to decide you still have made a choice."    
           ~Rush

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