induction or planned c/s for pre-e?

[ithappened]

One of my good friends who 37 weeks today has a bad case of pre-e.

She was really hoping for a vaginal natural birth and her MW feels she should be induced as soon as possible if she wants to try vaginal birth because the rate which her pre-e is getting worse.... The midwife agreed to wait until 38 weeks to start the induction and has offered to do a more 'natural' induction over the period of a few days by using gels to ripen her first and homeopathic methods. etc..

However, her bishop score is pretty low.

In her situation, would you try the induction or go right to a c/s? The theory she feels is having a scheduled c/s would be less traumatic then a failed induction which would lead to an emergency c/s 4-5 days later.

thoughts on this?

Edit to add:
baby is in a good position (head down etc), but her cervix is still high and unripe and she, e.g. the baby, just hasn't dropped yet.. my friend also hasn't lost her plug or had any sign of bloody show..

is it possible to have a 'good' induction, e.g. actually leading to a vaginal birth, medicated or not, in all the above circumstances? I guess that is her concern.

[Shellie]

I had an urgent c/s after a failed induction due to pre-e and then 18 months later I had a scheduled c/s. That one was much easier on me...I figure because I hadn't been through the induction and long labor beforehand and also because I wasn't suffering from pre-e beforehand.

But there's really no way of knowing in advance. My first c/s was my 3rd child and I'd delivered a 10+ pound baby vaginally a few years before...it was bad positioning that caused the FTP with my induction for my third baby. Without the bad positioning, the vaginal birth would have been the right choice.

[jeminijad]

I had an induction at 39 weeks with a very low bishop's score with my first birth (19 and ignorant, not due to any good medical reason.) The induction was "successful" in that I delivered vaginally, but the poor thing ended up with a scalp monitor due to poor readouts on the belly belt monitors and a ventouse delivery. That said, I consider myself lucky that it was not a cesarean section. I still have all of my birth options for if I want to have 2 or 10 more children, because I avoided the section.

If I were her, I would be chugging about a gallon of RRL tea a day and taking plenty of EPO (these things very much worked for me.) Then I would consent to the induction... it may end up more traumatic for a few days if she needs a semi-emergency section due to a failed induction, but at least 1)the babe will then have experienced some labor, beneficial from a respiratory and immune point of view, and 2)she may very well end up with a vaginal birth... a cesarean limits your future choices so much, and I don't think anyone (including doctors) take that in to consideration enough.

[ithappened]

jeminijad- what amount of EPO would you recommend if the induction is in about a week?

[sam1980]

I would go with the induction. I can't remember my Bishop score, but I think it was low as well. I was induced at 38w1d due to pre-e with a dangerously high BP.

I am actually surprised they are offering c-section, because the maternal-fetal medicine group I dealt with for my GD and pre-e said a vaginal birth is much safer when there is a high BP, because there is less risk of bleeding out.

I was induced at on Tuesday morning (not planned, sent from MFM visit to be induced because of high BP). They started with Cytotec (I think 1/8 or 1/4 of the pill), which got thing started. I was in labor by about 2PM. Pitocin was added, which stopped my contrax, and so they stopped it and I went in to active labor on my own. My water was broke at midnight to apply a monitor because of heart decels. I had an epi at 530AM because they *thought* I might need a section due to LO's poor tolerance of my contrax. I told them I didn't want one unless it became a true emergency, and delivered vaginally at 12:48PM on Wednesday.

Granted it was a long labor process, but it went okay. More intereventions than I wanted (including the epi), BUT I did avoid a c-section.

FWIW, my SIL had two kids and both times had really bad pre-e and high BP. Her doc never suggested a c-section without a trial of labor, and she delivered vaginally both times.

[amyjrn23]

induction

I think we need to work on our vocabulary. Having a c-section for a failed induction is NOT an emergency c-section. Neither is having one for CPD or FTP.

Having a vaginal delivery is significantly safer than a c-section in someone with true pre-eclampsia. I say true pre-eclampsia because there is a big difference between PIH and being pre-eclamptic. If your friend has true pre-eclampsia then her MW would not be "allowing" her to wait a week. This leads me to believe that she is having elevated BPs with no other signs of symptoms.

If someone truly wants to have a vaginal delivery and is being offered an induction vs c-section. Then my opinion is they need to try....they will regret it if they don't at least try because what's the worst that could happen...it doesn't work. Also....I would ALWAYS ALWAYS request (no demand) a foley cath bulb for cervical ripening vs cervidil or cytotec.

#1 cervidil only works about 50% of the time in an unfavorable cervix. (in my opinion)

#2 cytotec causes fetal distress due to hyperstimulation of the uterus in a significant portion of the population.

#3 foley cath bulb ripening works like 95% of the time and your not giving any labor inducing drugs into your system that could lead to fetal distress.

If your friend really wants natural labor then I suggest a foley cath bulb....then when the bulb falls out and she is 3cm. Then just to an amniotomy induction vs pitocin. However you have to be flexible. If you ruptured for lets say 4 hours with no cervical change...then start pitocin. Works like a charm.

[AlexisT]

"Emergency" section doesn't mean crash. It means unscheduled. A scheduled CS is "elective", even if you've had 6 sections, a transverse lie and a complete placenta praevia.

I was not even in labor, but my section was coded as emergent. My monitoring went bad and that was that.

How do you define "true" preeclampsia? Some providers do use PIH to be synonymous with PE; others use PIH for hypertension only. She may well have "true" PE (hypertension + proteinuria); it's just not severe yet. (When I showed up at the antenatal clinic with severe PE, I was not permitted to leave. They told me to go to the ward and send my husband home for pyjamas and toothbrush.)

I had a section for severe PE. The risk she is taking by waiting is that she may no longer be a candidate for induction. I was never even offered induction because my PE put my daughter into distress.

In her position, I would induce, I would use prostaglandins and I would do it sooner rather than later. If she waits too long, she may be in the same position I was, where the baby needs to come out NOW. I will always be haunted by the fact that if I had showed up at that clinic even a day earlier, I might have been a candidate for induction. (They had to wait for the results of my 24 hour collection.)

The other thing she should know is that if her BP is high they may push epidural for its BP-lowering effect. Having been through a section--I would take that epidural if it meant a vaginal birth.

[kltroy]

I think there are so many advantages to having a vaginal birth over a c-section that I'd try for an induction. Deep down, they are really really good at inductions these days. It is quite likely that even with a low bishop's score, the induction will be successful, esp. with the use of prostaglandins combined w/ pitocin. Pre-E is a legit medical reason to do this. I would give it a shot, and if it seemed like the baby wasn't tolerating it, you can always do a c-section. The other thing is that if they induce a couple days before you "have" to, they can always give a try and back off if things aren't working, or give the induction more time to work, or even leave and then come back in to either try inducing again or for a planned c-section.

[sam1980]

Originally Posted by amyjrn23

I think we need to work on our vocabulary. Having a c-section for a failed induction is NOT an emergency c-section. Neither is having one for CPD or FTP.

Having a vaginal delivery is significantly safer than a c-section in someone with true pre-eclampsia. I say true pre-eclampsia because there is a big difference between PIH and being pre-eclamptic. If your friend has true pre-eclampsia then her MW would not be "allowing" her to wait a week. This leads me to believe that she is having elevated BPs with no other signs of symptoms.

If someone truly wants to have a vaginal delivery and is being offered an induction vs c-section. Then my opinion is they need to try....they will regret it if they don't at least try because what's the worst that could happen...it doesn't work. Also....I would ALWAYS ALWAYS request (no demand) a foley cath bulb for cervical ripening vs cervidil or cytotec.

#1 cervidil only works about 50% of the time in an unfavorable cervix. (in my opinion)

#2 cytotec causes fetal distress due to hyperstimulation of the uterus in a significant portion of the population.

#3 foley cath bulb ripening works like 95% of the time and your not giving any labor inducing drugs into your system that could lead to fetal distress.

If your friend really wants natural labor then I suggest a foley cath bulb....then when the bulb falls out and she is 3cm. Then just to an amniotomy induction vs pitocin. However you have to be flexible. If you ruptured for lets say 4 hours with no cervical change...then start pitocin. Works like a charm.

I had true pre-e and my MW and MFM group let me wait it out until it was absolutely necessary for induction. I started with PIH at something like 24 weeks, and by 34 weeks was doing 24-hour urines 3x a week because of very high protein, had worsening liver and kidney function, and even hgiher BP.

Maybe it wasn't smart that they let me wait, but they did let me wait.

[ithappened]

I believe what her midwife said exactly was they would try induction (first doing 2 gel applications, then perhaps move onto something else), as long as the pre-e didn't get extremely worse prior or during induction they could 'go slow', e.g. do it over 3-5 days and then if that didn't work, would look at other options. . .

I think her main concern was her bishop score is so low, she wasn't sure she had a chance, even with pit/epi...

I don't know the exact details of her situation just that she was hoping for some advice from more 'non-conventional types' so I immediately thought of my MDC

[Bokonon]

Originally Posted by amyjrn23

I think we need to work on our vocabulary. Having a c-section for a failed induction is NOT an emergency c-section. Neither is having one for CPD or FTP.

Having a vaginal delivery is significantly safer than a c-section in someone with true pre-eclampsia. I say true pre-eclampsia because there is a big difference between PIH and being pre-eclamptic. If your friend has true pre-eclampsia then her MW would not be "allowing" her to wait a week. This leads me to believe that she is having elevated BPs with no other signs of symptoms.

Having elevated BP without any other signs or symptoms can be just as dangerous as what you consider to be "true" preeclampsia. The seizure and stroke risk occurs with elevated BP. Even HELLP Syndrome can sometimes present with no evident symptoms other than elevated BP.

And there really isn't a big difference between PIH and pre-e - many practitioners use the terms interchangeably. PIH is preeclampsia without proteinuria. I had "true" preeclampsia for 5 weeks before delivery - BPs well over 140/90, proteinuria, severe headaches, visual disturbances, rapid weight gain - and was still allowed to continue gestating, and once my BPs went over 190/110 on bedrest, magnesium sulfate, and BP medication, I delivered. And my OB still put in my chart that I had "severe PIH", though I fit the clinical definition of severe preeclampsia for weeks.

I've never heard of c-sections being contraindicated in preeclampsia, except when the mom has been on Lovenox or Heparin and needs to be off it for a specified amount of time before delivery. My first was a c-section due to severe preeclampsia, because waiting for induction to be successful could have been fatal for my son and I.

When fetal indicators are concerning and there is central nervous system involvement, c-section is typically preferable to induction because time is of the essence.

[amyjrn23]

pih

There are only 3 types of c-sections.

Elective

Urgent

Emergent

The terms stat c-section and crash c-section are not relevant medical terms anymore. They used to be, but not now. Urgent c-sections are ones for cpd or ftp, maternal fever, meconium, fetal techycardia, fetal decels that have recovered, ect. It means we are going to walk to the OR.

Emergent means NOW DAM IT!. Emergent c-sections are for fetal brady cardia, prolapsed cord, actively bleeding previas with decels, abruptions...I can't stand the baby shows on TV where they say the patient is having an "emergency c-section" and everyone is calmly walking to the OR. If the doctor took greater than 60 seconds from incision to baby...you had a emergent c-section. If the doctor took 5-10 minutes from skin incision to baby out then you had an urgent c-section. Doctors will sometimes tell the patient that they are having an emergency s-cetion when in fact they are not....this makes them look like the hero. They do this on purpose. Other clues...if they took the time to wash your abdomen or count instruments and your doctor was present in the OR....then it wasn't an emergent c-section. In a true emergency you just splash and go.

Again pregnancy induced hypertension (PIH) means that you have elevated BPs with no other signs or symptoms of pre eclampsia. You MUST have 2 indicators of preeclampsia in order to be diagnosed. Protein in the urine is the most common one, but not the only one. 2nd most common would be swelling. But it could be anything swelling, hyper-reflexes, or a patient complaining of a headache. But you have to have 2 symptoms to be diagnosed with pre-eclampsia. Yes doctors use the term interchangeably because they either don't know or don't care to distinguish between the 2. Doctors can chart anything they want....it doesn't make it true.

"Having elevated BP without any other signs or symptoms can be just as dangerous as what you consider to be "true" preeclampsia. The seizure and stroke risk occurs with elevated BP. Even HELLP Syndrome can sometimes present with no evident symptoms other than elevated BP."

UHHHHH....this doesn't even make sense. HELLP syndrome means that you have elevated liver enzymes and low platelets. That means your lab values are abnormal. That would mean that yes you meet 2 criteria for diagnosis. When I said you have to meet 2 criteria that includes lab values....not just physical symptoms. Let me tell you....the ones who's BPs are normally 98/50 and know they are 125/75 with no "physical" signs and symptoms are the ones that are the sickest and at greatest risk of stroke and seizure.

C-sections are not contraindicated with pre-eclampsia....they are just not the best choice due to blood loss, BPs dropping and a number of other physiological reasons. If your preeclampsia is severe as in "we think she's gonna stroke out any second" then yes they will do a c-section right away.

BOKONON-they let you wait because you were 24 weeks and you closely monitored your lab values for changes. If you are 37 weeks and have any abnormal lab values or significant symptoms then there are no benefit to waiting. In your case there was a benefit.

PIH and preeclampisa can both be managed and instant delivery is not always needed. The decision to induce, c-section, or wait it out are based on BPs, signs and symptoms, lab values (and any changes there of), and most importantly the doctor's or MW's gut instinct. That is why practicing medicine is an art and not a science.

[Bokonon]

Originally Posted by amyjrn23

Again pregnancy induced hypertension (PIH) means that you have elevated BPs with no other signs or symptoms of pre eclampsia. You MUST have 2 indicators of preeclampsia in order to be diagnosed. Protein in the urine is the most common one, but not the only one. 2nd most common would be swelling. But it could be anything swelling, hyper-reflexes, or a patient complaining of a headache. But you have to have 2 symptoms to be diagnosed with pre-eclampsia. Yes doctors use the term interchangeably because they either don't know or don't care to distinguish between the 2. Doctors can chart anything they want....it doesn't make it true.

"Having elevated BP without any other signs or symptoms can be just as dangerous as what you consider to be "true" preeclampsia. The seizure and stroke risk occurs with elevated BP. Even HELLP Syndrome can sometimes present with no evident symptoms other than elevated BP."

UHHHHH....this doesn't even make sense. HELLP syndrome means that you have elevated liver enzymes and low platelets. That means your lab values are abnormal. That would mean that yes you meet 2 criteria for diagnosis. When I said you have to meet 2 criteria that includes lab values....not just physical symptoms. Let me tell you....the ones who's BPs are normally 98/50 and know they are 125/75 with no "physical" signs and symptoms are the ones that are the sickest and at greatest risk of stroke and seizure.

By evident symptoms, I meant outwardly physical symptoms. I know what HELLP Syndrome means, and I know that it is diagnosable by labs.

I'm still not really sure where your definitions of preeclampsia and PIH are coming from. Mine are from the Preeclampsia Foundation - two blood pressure readings of at least 140/90, taken at least 6 hours apart, AND at least 300mg of protein in a 24hr urine specimen. Having elevated BP and swelling does not equal pre-e, as swelling is a very common pregnancy symptom.

[etsdtm99]

I have a friend who was induced for no real reason (elective induction at 38ish weeks - her dr. had bumped her DD due to u/s but she kenw when she conceived overall fishy situation, i know) anyway, she was not dilated or effaced at all, baby was high .. went in for a pit induction at 7am and had the baby at 11 something am vaginally.. it is totally possible to have a successful induction with a very poor bishop score.. 2nd baby btw

[AlexisT]

I am not sure that the distinction between "urgent" and "emergent" is universally made. There is a move to distinguish between different types of "emergency" sections but I can tell you from experience, it does not always happen.

NICE in the UK recommends that CS be classified as follows:
1. immediate threat to the life of the woman or fetus
2. maternal or fetal compromise which is not immediately life-threatening
3. no maternal or fetal compromise but needs early delivery
4. delivery timed to suit woman or staff.

By this scale, mine was a 2. They waited for my husband to show up, but said if he didn't get there ASAP I was headed for theatre alone.

My hospital records read "emergency C-section". In multiple places. Specifically, they read (IIRC, I might have the exact order/phrasing slightly wrong, but I'm 100% sure of the key points) "Emergent CS for foetal compromise based on suboptimal CTG". That is not wording the doctor uses for the patient's sake.

[amyjrn23]

Originally Posted by AlexisT

I am not sure that the distinction between "urgent" and "emergent" is universally made. There is a move to distinguish between different types of "emergency" sections but I can tell you from experience, it does not always happen.

NICE in the UK recommends that CS be classified as follows:
1. immediate threat to the life of the woman or fetus
2. maternal or fetal compromise which is not immediately life-threatening
3. no maternal or fetal compromise but needs early delivery
4. delivery timed to suit woman or staff.

By this scale, mine was a 2. They waited for my husband to show up, but said if he didn't get there ASAP I was headed for theatre alone.

My hospital records read "emergency C-section". In multiple places. Specifically, they read (IIRC, I might have the exact order/phrasing slightly wrong, but I'm 100% sure of the key points) "Emergent CS for foetal compromise based on suboptimal CTG". That is not wording the doctor uses for the patient's sake.

Very interesting to know how they do it in the UK. That system seams to make more sence. It would seem under some circumstances it might be difficult to distinguish between a 2 or a 3.

I would assume on the information that you gave me that you had a fetal heart rate deceleration in which it was decided that the baby was not tolerating labor (or something like that) then it came back up so they waited for your husband. If it would have stayed down....they wouldn't have waited. If they waited....then by the newest US classifications it would be an "urgent" CS. Doctors in the US are very hesitent to use the words "emergency c-section" or "stat c-section" because that often sends up red flags for lawsuits.

[amyjrn23]

Originally Posted by Bokonon

By evident symptoms, I meant outwardly physical symptoms. I know what HELLP Syndrome means, and I know that it is diagnosable by labs.

I'm still not really sure where your definitions of preeclampsia and PIH are coming from. Mine are from the Preeclampsia Foundation - two blood pressure readings of at least 140/90, taken at least 6 hours apart, AND at least 300mg of protein in a 24hr urine specimen. Having elevated BP and swelling does not equal pre-e, as swelling is a very common pregnancy symptom.

If your BPs are normally 90s/50s and now they are 130s/80s and you have 200mg of protein in your urine then you don't meet this foundations criteria? That sounds a little wierd. All I am saying is this. There are many MDs who will take a women who has a few elevated BPs and no other symptoms (outwardly or otherwise) tell her she is preeclamptic, scare the crap out of her, and pressure her into an induction that she might not need.

The OP stated that her sister was being offered an induction or a CS in a week or something like that. The point is that if she is being offered this week to gestate then she most likely isn't really sick. She most likely had 1 or 2 elevated BPs in the office.

[AlexisT]

No decels. I was being monitored because I'd been admitted for preeclampsia. Her heart rate went up and stayed up. One minute, the senior house officer (junior resident) was saying they'd induce me in the morning when the consultants (attendings) came in, next thing she said she'd spoken to him on the phone and I needed a CS, now. All I could think of to say was, "my husband is on his way to the hospital; can we wait till he gets here?"

[ithappened]

The OP stated that her sister was being offered an induction or a CS in a week or something like that. The point is that if she is being offered this week to gestate then she most likely isn't really sick. She most likely had 1 or 2 elevated BPs in the office.

She has had a pretty severe jump in her BP readings (the last 2-3 to my knowledge) and high amounts of protein in her urine for the last 2-3 stick test.... The fetus doesn't appear to be under stress as of yet, they did an u/s which looked ok but not great.. the MW basically said, if you really want to do this vaginally, we shouldn't wait another 3 weeks because she felt she could literally lose that option anytime... She said if things continue at this rate, she would be lucky to make it until 39 weeks before it became an emergency c/s and/or cause her or the baby harm.. her MW is very anti-intervention from all my other friends who have used her and seems to have very good judgment/experience with these things..

I think my friends really really wants a vaginal birth, the MW knows and respect that and is trying to give her that option as long as possible before it because medically not her choice.

I guess my friends concerns is and has always been if an induction with a low bishops score will end in a c/s most of the time.. and if it does.. is it better to just plan a scheduled c/s to avoid the possible maternial and fetal exhaustion of a prolonged failed induction?

[bicyclingbethany]

Can your friend set a limit on the induction? Like, not go over 24 hours of labor or no more than 48 hours of trying to start labor? Maybe then she would feel more comfortable about it?

Trying to induce (although jumping to pharma prostaglandins wouldn't be my first choice- I second the EPO recommendation) and having a vaginal birth DEFINITELY seems preferable to just scheduling a c/s.
But if it's not moving along quickly enough and she is becoming exhausted, or if baby's heart rate is causing concern, then she can always have the c/s.