Ruining my chances, or a standard precaution?

[PhotoJournMama]

I am 11 weeks pregnant and met with my midwives for the first time earlier this week. They seem like a really great practice, very nice and attentive, super friendly.

However, while we were talking about VBAC the midwife told me that a) they strongly recommend giving birth in a hospital (which I knew going in and was willing to compromise on - er - let them decide for me) and b) that I would have to have continuous fetal monitoring! That I was NOT expecting and my first reaction is NO NO NO. They said that it is to make sure if I have uterine rupture (0.8% chance) that their reaction time is quick. Is that reasonable or should I be fighting about this? I went in thinking that I would fight for and HBAC but DH is really not comfortable with it, so I'm willing to try out the hospital option. But this just seems like overkill!

Can someone help me on this?

[ShwarmaQueen]

It does seem like you're being set up for failure, I'm afraid. Can you opt to give birth at home, or are they insisting on that just because you're a VBAC? And continuous fetal monitoring has been shown to not increase mother/baby outcomes- there are early warning signs of UR they should be able to recognize.

They sound pretty medical-model centered to me, but if they're a good middle ground for you, then go for it. If you feel suspicious now, you might want to keep looking. GL!

[CookAMH]

From my reading, it is VERY common to have continuous monitoring. It is advised by some. Do they have a telemetry unit where you can move around?

I have read that irregular patterns in the babe's hr are the first indicator of rupture, before other symptoms. It's hard to pick that up intermittently. Just have to balance that with the very small risk of rupture that exists (a choice to make in choosing a hbac).

ETA: I have known of women to have great hospital vbacs with continuous monitoring (and I don't know whether they had portable units or not). Bottom line, you MUST need to move around during labor. I would look for a different midwife that offers telemetry unit.

[Climbergirl]

The hospital where the nearest midwives deliver requires continuous monitoring. I talked to the hospital and they do not have a telemetry unit. So, I was decided to do an HBAC. Honestly, I know I am going to need to move (I really don't tolerate an epidural well), and the leads are only 8 feet long (so while I would be able to move some, walking would be out of the question). There was "no way" according to the midwives or the hospital that I could refuse it. Not sure how that would go, but I did not want to push it.

I almost died after my last c-section, so I am particularly wanting to not have another.

[AlexisT]

The intent is not to set you up for failure. it's also the NICE recommendation in the UK.

The studies on cEFM that showed it did not improve outcomes excluded VBACs, so it's difficult to use those studies in this context.

[CherryBomb]

I don't think it's ruining your chances. I had continuous monitoring (my OB had actually okayed intermittent, but I was 7cm by the time they got there and didn't want to get up anyway, so they just left it on). I had a great vba2c . It might be an issue if you come in at like, 2cm and then can't walk around, but if you come after labor is well established I don't think it's a death sentence for vbac. Anectdotal, I know, but that was my experience.

[CookAMH]

Originally Posted by Climbergirl

I almost died after my last c-section, so I am particularly wanting to not have another.

Wow, I am really sorry about that

[PhotoJournMama]

Thank you for the responses. They are the only midwives that practice in my area, I'm afraid. I would have to go to the larger city adjoining mine to find someone else, and in that case they certainly wouldn't do homebirth either (on account of my home being far away). So it is either these midwives, or an OB.

I was told that they have a telemetry unit so I would be able to walk around. I'm not sure how much better they are regarding outcomes. I'm also not sure if I would 100% be able to get one, or if I would have to have the other kind if there happened to be another woman in labour at the same time (all questions to ask at the next appointment).

Thank you for responding and helping me work through this problem! I am still so confused about what to do.

[MsBlack]

One way to avoid the CFM is to go into the hospital later in labor. You can rent a doppler fetascope if it makes you feel more comfortable to be able to know how the baby is doing while you're still at home--and you have plenty of time to learn how to use it, common 'danger signs' via fetal heart tones, etc. You can also learn the signs of rupture/impending rupture.

You might also hire a good/experienced doula, to help you labor most comfortably at home as long as possible, and help you keep an eye out for warning signs.

[AlexisT]

I suspect that the EFM is a hospital policy, and that the only way to avoid it would be to use another hospital... which would probably also have that policy. I think it's going to be tough to avoid. Unless you know for sure that another hospital does not demand cEFM for VBACs, you're probably best sticking with these midwives, as long as you like them otherwise.

[mediumcrunch]

Most hospital based CNM's will require CFM. Ironically the CNM's at the practice I used for my last birth insisted on CFM but their back-up OB (who attended my birth) did not.
Ask if they have telemetry units, if they don't make sure they understand that you *will* still be remaining mobile during birth and the monitors will be moved and if necessary held (by you, dh, doula or nurse) to suit you not the other way around.
Also, laboring in the bathroom is a good way to get off the monitors.

If it makes you feel better, most of my VBAC's have had CFM although I do admit being off the monitors is MUCH easier/better/simpler....way to labor.

[lyterae]

This is actually one of the primary reasons we are having an HBAC... I don't want to be in a hospital because I'm afraid of it being one intervention after another and resulting in another c-section. We'd have to travel 1.5+ hours to the nearest hospital that would "allow" a VBAC which means I really wouldn't be able to labor at home because I don't want to be driving during transition. If I had to have a hospital birth I'd prefer to show up pushing or close to it. We decided we'd much rather have the midwife (also 1.5 hrs away) travel and come to us.

I hope you are able to find something that you are comfortable with

[limette]

You're in Ontario right?

The governing body for Ontario midwives states that they have to support a women's choice to hbac if she decides to do that.

Whether or not they will actually be supportive when they get to your house is another story completely.

I'm in NWO and while they have to attend the birth my midwife (who seemed fine with it prior) was absolutely horrible to me during my attempted hbac last time. I did manage a vbac but it was in the hospital. If it wasn't for my doula I'm sure they would have talked me into another c-section.

I have a new team this go around and I'm going for another attempt at homebirth (if I haven't moved) but there is only 1 out of the three midwives that I think will be supportive during the birth. The fear of backlash from the OB's in town is too great for the other two.

[PhotoJournMama]

Originally Posted by AlexisT

I suspect that the EFM is a hospital policy, and that the only way to avoid it would be to use another hospital... which would probably also have that policy. I think it's going to be tough to avoid. Unless you know for sure that another hospital does not demand cEFM for VBACs, you're probably best sticking with these midwives, as long as you like them otherwise.

That is an interesting thing to look into - but I got the feeling it was the midwives policy, not the hospitals. We are only about 10 minutes from our door to the hospital I am birthing in so it's convenient, but I'm willing to go the distance to give myself every chance at this.

Originally Posted by MsBlack

One way to avoid the CFM is to go into the hospital later in labor. You can rent a doppler fetascope if it makes you feel more comfortable to be able to know how the baby is doing while you're still at home--and you have plenty of time to learn how to use it, common 'danger signs' via fetal heart tones, etc. You can also learn the signs of rupture/impending rupture.

You might also hire a good/experienced doula, to help you labor most comfortably at home as long as possible, and help you keep an eye out for warning signs.

I think that I will probably stay home as long as possible. I will call the midwives to let them know I'm in labour, but downplay it and stick myself in the "early labour" category for as long as possible. I was really looking forward to support from the midwives, but maybe a doula would be a better way to go.

Originally Posted by limette

You're in Ontario right?

The governing body for Ontario midwives states that they have to support a women's choice to hbac if she decides to do that.

Whether or not they will actually be supportive when they get to your house is another story completely.

I'm in NWO and while they have to attend the birth my midwife (who seemed fine with it prior) was absolutely horrible to me during my attempted hbac last time. I did manage a vbac but it was in the hospital. If it wasn't for my doula I'm sure they would have talked me into another c-section.

I have a new team this go around and I'm going for another attempt at homebirth (if I haven't moved) but there is only 1 out of the three midwives that I think will be supportive during the birth. The fear of backlash from the OB's in town is too great for the other two.

I am in Ontario. My DH was not convinced about HBAC to begin with, so dealing with all of this has made him even more adamantly against me attempting it. It's good to know that the doula helped your process - I definitely want to look into that now. Good luck with your home birth!

[CherryBomb]

I strongly second a doula. My doula was invaluable to my vba2c, imo. Good luck

[kcparker]

Here's the deal - changes in baby's heartrate are the most reliable indication of a uterine rupture. That is the major concern of a hospital-based care provider with a VBAC. You might have pain to tell you you've ruptured, you might not. You might bleed, you might not. These are less reliable indicators of a problem than the EFM, and if you are in the unlucky minority who ruptures, you want to know about it sooner rather than later so that the problem can be addressed before it becomes an emergency. I do know somebody who ruptured during a HB, transported, and had another c-section, so it is possible for one to be detected at home even if they can't be corrected in that setting (and how much time might be of the essence is another question). It's sort of sucky to have cEFM, but you have to weigh the risks/benefits of each setting and decide what level of and type risk you will tolerate best.

[_ktg_]

I wouldn't say this was a deal breaker or that you are being set up for failure. VBAC'ing in a hospital is not opening the door to having a c-section. I saw in your OP - you're 11 weeks. This is a great time to start having chats about policy, practices and getting agreements about what you choose to consent to while in labor with your midwives.

With my 2nd pregnancy - I was trying for a vbac, and my MD also stated CFM. I talked him down and got him to agree to intermittant by discussing the studies, outcomes and etc. If you want a partnership with your careprovider - advocate for what you want, listen to where they are coming from and get to an agreeing point.

[Climbergirl]

From what I have read, having the baby's heartrate monitored every 15 minutes by Doppler is just as effective as CFM. CFM is something that is interpreted, it is not a cut or dry kind of thing. 3 different people can look at a tape and will most likely say 3 different things.

For me, I don't think it is a good option, but that is my particular circumstance. My placenta is anterior (again). Last time, they kept picking up my heartrate (because of the location of the placenta), and not the baby so I had to lay still on the bed so they could find the baby. Now, my BP at my last two midwife appointments have been 80/58 and 80/55. Low. So, if I am not allowed to walk (because there are no telemetry units) AND they make me lay down (very still) to pick up the baby, I will probably need an epidural. AND, since my BP is so low to begin with and last time I reacted with my BP dropping, we are looking at a pretty ugly situation (I think I may have gone down to 60/30). And for me, as a VBAC, I could see them saying, ya know, this is not good, lets do a c-section. Yeah, there are a lot of maybes in that, but for me, I could easily see it going that way and I am not willing to have a c-section because they could not find the personnel to manually monitor the baby. Sorry.

And yes, I have asked tons of people if this can be negotiated and I have been told no at every turn. It is CFM, period. Which is annoying, because it limits my options.

[Meg08]

The SOGC recommends cEFM for VBAC, stating that it's the "most reliable first sign of uterine rupture". It is likely hospital policy. Feel out the midwives though - at least to know how hard they will push it. They might just have to record that they informed/advised you on a number of occasions that you should have cEFM, but might still be perfectly fine with you objecting.

I thought I read somewhere (in the SOGC recommendations) that intermittent monitoring was ok for stage 1, and cont for stage 2, but I can't seem to find where I read that.

I wonder if they also require maternal monitoring.

Good luck!

[kltroy]

Meh... I think continuous monitoring for a VBAC is ok. For my hospital VBAC it was also a requirement and it was fine. I moved around as much as I wanted to (mostly sat on a ball) and "unplugged" whenever I wanted a break to go sit on the toilet or whatever. They got over it. I think the actual implementation of "continuous" monitoring may not be quite as continuous as it's made out to be. Most nurses and doctors are fine as long as you're "mostly" monitored. Personally, I found the monitors to be a minor annoyance and not much more. I don't think it's setting you up for failure. I do agree that you "should" be allowed to consent to whatever you want, but that it may not be worth picking a fight about this one up front. Just roll with it, ask for a telemetered system if possible, go to the hospital late, and you'll be fine.