Information on continious monitoring for VBAC?

[sattygirl99]

I am looking for research to back my decision to refuse continuous monitoring simply because I am a a VBAC. I know its out there but I can't find it.

Just want to arm myself with this for when the time comes because I plan to only consent to intermittent monitoring, not continual.

Thanks!

[mamalade]

Bump!
any one?

[kdaisy]

Isn't there a reference cited in The Thinking Woman's Guide to a Better Birth? I do remember the author discussing it.

I wish you luck. I am facing a hospital VBAC myself and continuous fetal monitoring past 6 cm is their hospital policy on VBACs. I doubt I could refuse it. I am just going to labor at home as long as I can.

Good luck, mama!

[kltroy]

I don't have the citations at my fingertips, but here's the story about monitoring, as far as I understand:
-- IN GENERAL continuous monitoring has not been associated w/ better birth outcomes in terms of preventing birth injury - cerebral palsey etc. It was orig. designed for use in high risk situations and there is some merit to using it in that case (like during an induction, for example). The main problem with it is that it has a high rate of false positives - that is, the monitor shows something worrysome but really everything is fine. So this is why it doesn't make sense to use it for low-risk situations - because more likely than not the alarm bells will sound and it's nothing.
-- FOR VBAC fetal bradychardia is the most consistent and earliest indicator of uterine rupture. There are other signs and symtpoms - persistant pain even between contractions, bleeding, etc, but these frequently appear AFTER fetal bradychardia shows up on the monitor. It is possible to detect this using a stethoscope/manually, but would require a birth attendant who is there with the mom for much of the time. In many hospitals, even with a hospital MW, this may not be the situation.

So there are risks and benefits to the monitoring. Risks would include:
1. Changes the birth experience - annoys mom, may require you to be "plugged in"
2. Chance of false positive - the risk of UR is generally low (0.5%) so it is still entirely possible that the monitor would pick something worrysome up that is NOT UR and may or may not be "real"

Benefits include:
1. Potentially earlier/more reliable detection of UR and fetal distress if it occurs
2. Peace of mind for anyone who thinks it's important

At the end of the day, it's up to you. But very honestly, I decided that continuous monitoring was fine for a hospital VBAC (my own, 2 years ago). I didn't think it was that annoying and I believe that if you're going to bother being in the hospital at all, the reason that you're in the hospital is because you want to minimize the potential consequences of UR, should it occur. To me, part of minimizing the consequences would be the earliest possible detection of the event, and I believe that monitoring gives you that.

Best of luck with your birth.

[sattygirl99]

Originally Posted by kltroy

I believe that if you're going to bother being in the hospital at all, the reason that you're in the hospital is because you want to minimize the potential consequences of UR, should it occur.

This is a grossly wrong assumption for many mom's who VBAC in a hospital, just FYI.

I don't have a choice... I can't afford a home birth and I don't want to turn to an unassisted home birth simply because of finances. So, while I would typically NOT go anywhere near a hospital for my birth I have to because it's my ONLY option. Not because I believe it's safer or better or because I want to minimize consequences of UR. Even in a hospital a c-section takes time. The outcome of babies who suffer UR (which does happen in non-vbac patiens too) isn't any better simply because they are in the hospital. It takes time to get the surgical team together, nothing happens instantly.

I'm one of the unlucky ones who had fetal flucuations at transition (which happened in 90 seconds and she compressed her cord between the birth canal and her head) and ended up with a c-section even though my uterus was FINE. In fact, when the OB was closing me up, he asked who did my first c-section because he couldn't even see the incision. So I am not a believer in fetal monitoring being safer or better and had it not been for the stupid monitor, my daughter would have likely been born vaginally, considering that I was 9cm, +1 station and could feel her head when the OB decided a c-section was better.

[AlexisT]

I was told by a CNM that the changes in FHR can be seen on tracings, but can't always be spotted by intermittent ascultation. It's easier to see when it's drawn out like that. I don't have a study showing that, though.

[Climbergirl]

Sattygirl,

Are you going with MCA and delivering at Shady Grove? If so, you may want to check with the midwives as to the consequences of refusing CFM. Their OBs may decide that if you don't do CFM, you have to deliver with the OB instead. I have not heard this is the case, but from some of the other things they have to refer to them for, I would definitely check. I would do CFM with the midwives before declining and having to go with an OB.

Just a thought. This was the main thing that made me want to go with Joey.

Sorry to hear you had to decide on the hospital. I know your heart set on a HB.

[kltroy]

Originally Posted by sattygirl99

This is a grossly wrong assumption for many mom's who VBAC in a hospital, just FYI.

I'm sorry that you won't be able to have the home birth you want. It's very unfortunate that the political/malpractice/birth climate is so bad in this country, especially if you live in a state that does not license CPMs or allow birth centers. I do agree that there are many other factors that go into outcomes after UR, and that monitoring/early detection is only one piece of the puzzle.

Climbergirl: how *weird* that they would want you to be with an OB if you decline EFM??! After all, an OB is barely there, while a CNM is there most or all of the time. Crazy!

[sattygirl99]

Yeah, that's who we'll be going with... My other option was the midwives at MG but they don't take my insurance.

My plan of course, is to leave home early (only because of the drive) and labor in a hotel nearby until I'm steps away from pushing and forego most of the monitoring, if not all. For what planning is worth, lol. Who knows if it will work out that way or not but that's the thought behind it right now. I can handle monitoring if I have to and push come to shove, I'll spend a ton of time in the bathroom as I did with DD (I ended up with an epi and AROM though and was bedridden).

The person I spoke with said that the OB's are extremely VBAC/VBAMC supportive so I didn't need to worry about that and that I could even schedule with the OB's for an appointment if I wanted to. The hour drive for appointments is going to suck though... Especially at the end when it's once a week... LOL.

Thanks... It'll all be OK. My focus was on where I was going to birth when what matters the most to me is the HOW... My VBAC is the most important aspect of it to me and if that means changing how I was thinking it would happen to it being a hotel and a hospital then so be it. It will still be my birth, my way, even if that means I have to fight a little more for it. Supportive caregivers and birthing team make all the difference!

[sattygirl99]

Originally Posted by kltroy

After all, an OB is barely there, while a CNM is there most or all of the time. Crazy!

And this was the first clue that I should have requested another MW when I was laboring with my daughter... We saw our CNM three or 4 times in the 12 hours I was in the hospital.. That was it. She came in to check the paper trail, cervix and that was it. She was no physical or emotional support whatsoever. The longest she was in the room was when I transitioned and DD's heart rate went all outta whack... My joke is that I transition like a freight train and had I been on my feet, she may not have stopped! I felt her head ram into my pelvis WITH an epi... There is nothing like looking at a friend (now mind you, my first even close to vaginal birth, DS I stalled at 3CM after failed induction) and saying 'um... yeah there's a bowling ball between my legs'.

She didn't even come to see us after DD was born... Every MW in the practice (freestanding center) came to see us post birth IN THE HOSPITAL but never once did we see her... She told my friend the baby was born and left. It was a Saturday and she never wanted to be there...

[Climbergirl]

kltroy, I am not sure that would be the case. But, they seemed to be very tied to the OBs (they used to be a freestanding group at a birth center and now they are under an OB practice). I think for the most part, that they do a good job of keeping things as birth center like as they can, but when I asked them if I could refuse CFM, they told me a resounding "no". Which tells me they are pretty bound to the hospital policies (for the most part, I know they get away with a lot) and to the direction of the OBs. In Maryland, OBs have to "supervise" or "backup" a CNM for them to be legal to practice. With a VBAC or VBAMC, you never know what may be the sticky point.

Although, they did say the monitoring is not required until "active" labor. Which, you could just refuse the vaginal exams for a while and get yourself a few extra cms. Oh, Shady Grove currently has a telemetry unit (so you could walk around and get into the water) that is on loan from the manufacturer. I would call the coordinator at Shady Grove and have her "reserve" it for you if they still have it then. A lady contacted the manufacturer and talked the sales rep into loaning one to the hospital for her birth. SG is hoping they will leave it a while longer and you may be lucky enough for it to be there. But I would definitely ask them to "reserve" it for you around the time of your due date since you are VBAMC.

Sattygirl, I live close to Shady Grove. If you need anything, let me know. I can ask around about hotels and what not. I am totally rooting for you

[sattygirl99]

LOL I wonder how that works if you're not consenting to ANY vaginal exams? If I end up in the hospital earlier than pretty much pushing, ain't no one sticking their fingers up there! A very empathetic NO and they can't make me.

I would hope to get there post water break, honestly... Because once my water is broken, they absolutely will NOT check me. Just won't happen, too much risk. And after my daughter getting an infection after birth, I'm really sticking to it this time.

Someone told me 'don't go in with a list of demands'... Okay but what do I do about the general consent form they ask you to sign when you arrive? I want verbal consent for everything... A blanket consent gives them the right to do whatever they see fit, without first consultiing you. I won't go in and demand anything unless I have to but heck if I'm going to give a general consent for whatever they feel is best.

I'm going to talk to my doula too. We had dicussed the possibility of going this route and she was very reassuring that it would all be OK!

[Climbergirl]

Hum, I would call the coordinator (the info is on MCA's website) and see if you can get the consent forms early in order for you "to review with your DH" prior to being in labor. I think that is definitely a legitimate request and then you can go over with MCA anything you do not agree with (and decide with DH how to modify the document so you don't have to worry about it).

I know when my aunt gave birth in AL, she went in and presigned all her paperwork before she was in labor. Honestly, I think that makes 100 times more sense than throwing something at you to read while you are in labor. Who can understand that legal crap when you are trying to concentrate on birthing a child?

I think they will assume you are in active labor if your water broke though. I do hope you can time it so that you are pushing when you walk in. That would be awesome.

[AlexisT]

Just FYI, a friend of mine had a really nice VBAC at Shady Grove last month. She did have an epidural, and there were interventions, but everything was her choice and the OB was very supportive. (This probably sounds like it wasn't great at all, but my friend had very significant issues with her pregnancy. Believe me, the OB did not want to deliver the baby when she did.)

[sattygirl99]

If I could get there even an hour before pushing time, that would be OK with me... I would like to show up between 8-10 CM because there is usually less time between 8CM and completely than anywhere else in labor... Especially if you're me and transition like a bat out of hell... LOL.

My DH asked me to ask you about hotels (decent ones that aren't too expensive) that would put us very close to the hospital. The closer we are, the longer we can wait before going over.

I do agree it makes more sense to have your sign all the forms BEFORE you arrive in labor... What happens when those mom's show up literally crowning? And if you can't do anything legally within 24 hours of surgery or certain medications, why are you able to sign a legal consent form during labor when your hormones and pain levels are altered? I'm planning to get all of the consent forms needed well prior to birthing day and will discuss with MCA, my doula and my husband as to what I do and do not consent to. DH knows that he may have to stand up for me... He didn't last time (my fault, I didn't really tell him what I needed from him) but he's more educated now (thank God!) and knows that he may have to be the one to think for me... And he's the only one who legally CAN make a choice... The doula cannot consent to anything.

Thank you for your support. I know that this simply changes the location of my birth, not my birth itself.

[kltroy]

The general consent form can be edited by you - you may want to get a copy of it beforehand. All you have to do is write in the words "subject to my verbal consent at the time" next to the general consent. Alternately, if there are passages that you do not agree with then cross them out and initial and date the cross-out.

Ethically, they need to verbally consent you before they do anything even *with* the general consent form signed. And to be perfectly honest, even if you do not sign the general consent form they have your implied consent to treat you simply because you voluntarily showed up at the hospital. With my VBAC I was sent over to L&D from a NST at 41+2 weeks and I think we ended up doing all of the consent stuff well after the fact.

So yes I would not go there looking to pick a fight - if you have a MW/OB on your side you probably shouldn't end up with too many problems because you will be on the same page as far as what your birth should be. For me the key thing was just to remind people that I trusted my body and to leave me alone unless there was a good reason not to. My doctor came in to check on me once every hour or two and "ran interference" between the OB house staff and myself so that I really didn't need to deal with anyone who wasn't on board with my plan more than once. (When the OB chief resident, who was not VBAC-unfriendly, but was unused to natural births, came in to introduce herself and suggested that my labor should be augmented based on the NST I politely told her that I was going to do no such thing and that if my labor did not progress in 6 hours we would discuss it then).

[sattygirl99]

Thanks...! That's why I figured it would be better to go to a practice that at least is accepting (and enthusiastically so) and supportive of VBAMC. I thought that would be better than staying close and being with a provider who is going to push me for a RCS before my EDD because they don't 'allow' VBAMC.

I've gotten both good and not so good reviews (though the not so good reviews aren't awful, things like 'they dressed my baby after they took her away fro meconium suctioning, I didn't even see her naked first' or a doula who told me she's had one MW be not so friendly and force a mother to be on a drip (which I'm trying to figure out... They can't force you to do anything...).

This hospital seems to be the lesser of all evils. Surely women do this in hospitals that aren't supportive, I can do this is in a hospital with providers that ARE.

I'm planning to get a copy of the consent forms prior to birth and discuss them with the midwives and my support team prior. As well as having a birth plan drawn up and packed IF we need it (I'm not going to present it unless it becomes an issue). The plan is truly to labor nearby in a hotel and go in darn near close to pushing... poor DH was told last night he's going to have to learn how to check my cervix... He said '... Oh... Kay... ' LOL.

It will all be OK... I keep telling myself that, lol.

[khaoskat]

Actually there was research within the past year, that fetal monitoring is not that reliable, because of how each person interprets things. Research has been done and shows that out of say 5 professionals reading a strip, you may get 3 different opinions on what that strip means.

I cannot remember where I read this, but can try to find it later this evening.

And we had a case about a year ago in Court that an incompetent nurse was reading a fetal strip wrong and failed to tell the provider pertinent information on a VBAC and the child has severe birth trauma because of oxygen deprivation, and also now has CP as a result.

[iris427]

This article isn't specifically about VBAC, but it's pretty interesting. It was written by an obstetrician and it's pretty damning in its assessment of continuous monitoring.

I emailed the author and asked him what he thought about VBAC and CFM and he wouldn't really give me a straight answer. He just said to ask my doctor. But I think the article actually makes a good case for NOT using CFM in a VBAC, even though he never specifically addresses VBAC.

[keeptryst]

A relevant article on EFM:
http://rixarixa.blogspot.com/2010/05...-sections.html