39 Week "Limit"-Discouraged

[MaddieMay]

I am currently entering my second trimester with baby #2. I am being seen by a provider at my local small hospital. My provider is VBAC supportive; however, the small hospital bans VBACs. The hospital (minus their VBAC policy) is amazing for labor/delivery and post partum care.

The plan is to have a VBAC at a major hospital approximately 45 minutes away. However, I found out at an appointment today that the hospital won't "allow" a VBAC attempt past 39 weeks. I'd really rather not birth there, but I will so I can have a VBAC.

The doctor's recommendation is that if I don't have the baby by 39 weeks, I schedule a c-section for shortly after (before 40 weeks). I think that plan is nuts and I think it is crap.

Homebirth with a midwife is not an option.
UC is an option, but it's not my first choice for VBAC.
I have no problem laboring at home for as long as possible.
I have low platelet count.
I have access to prenatal massage and chiro.

They will induce at 39 weeks if I want to attempt a VBAC, but I feel like that idea sets me up for failure. What I don't want to happen is that I wind up with a c-section at the big hospital. Been there, done that.

Help me think rationally. I don't want to focus on all the time limits, but at the same time I want to have a logical plan in place.

[AustinMom]

You actually have a few options

1)Send the smaller hospital a copy of ACOGs new VBAC http://www.acog.org/from_home/public...07-21-10-1.cfm and it clearly states that VBAC should be allowed at smaller hospitals, as it's the moms choice for the added 'risk' of not having access to an immediate CS. If they are open to that, birth there. This may also help: http://www.ican-online.org/vbac/My-H...-Allowing-VBAC

2)Ask your Dr. where in the ACOG guidelines it states that VBAC has to take place before 39 weeks, and where in the guideline sit states that induction is a safer route to go than waiting for labor. Here is an article from ICAN that can help you with that conversation http://www.ican-online.org/pregnancy/induction-labor

3)Never schedule a CS with your Dr. By LAW your Dr. cannot deny you care after 37 weeks here is another link with lots of info that may help you: http://www.ican-online.org/vbac/your...-banned-vbac-q So tell them (after your 37 week apt. so they can't fire you) that you are not doing the induction and will schedule a CS/or induction at 43 weeks or later. Or just don't schedule one.

4)You can UC, I don't know much much about it, as I haven't really looked into it personally, but I'm sure there are a lot of other moms here with tons of info if you do decide to simply find out more info on that.

5)Stay at home, labor as long as possible and then go to hospital. You definitely want to have atleast a Doula for ANY option you choose as she will help you out IMMENSELY. Maybe a Montrice or apprentice MW can come to your house to check dilation and such to leave at the very latest possible to the hospital. This would be a later choice for me, as I do know of OB Dr. here at once arriving at the hospital, a VBAC mom was pushing and the Dr. actually pushed the baby BACK up in the birth canal and did a CS. So for me, that wouldn't be the option I would choose in my location, but I don't know what your hospitals are like, but it sounds as if they are not too far from this.

Find your local ICAN CHAPTER!!!!! Call the leader and they will help you through all of this process, and they know local apprentice MWs, Doulas, OBs, hopsitals, etc all of which info will be of great help to you locally.

Much Love!

[kltroy]

Another option: is there another local hospital around? Believe it or not, many women simply "show up" at a hospital - whichever place is nearest to them - in labor and have their babies. It may or may not be the hospital where they received prenatal care and where their dr is affiliated. It annoys the staff there (they have no record of you) and you will likely be treated as GBS positive unless you can provide some documentation that you are not, but you may have better luck having your baby someplace else, where they don't know you.

I would try talking to your Dr. first, though. Sounds like this person is not very supportive of VBAC, but sometimes "policies" are more flexible than they make them out to be.

Specifically, I would show your Dr. the new guidelines. They say "Although chances of success may be lower in more advanced gestations, gestational age of greater than 40 weeks alone should not preclude TOLAC." Later, they say, "Induced labor is less likely to result in VBAC than
spontaneous labor (44, 47, 92, 99). There is some evidence
that this is the case regardless of whether the cervix
is favorable or unfavorable, although an unfavorable
cervix decreases the chance of success to the greatest
extent (91, 100, 101). These factors may affect patient
and health care provider decisions as they consider
the risks and benefits of TOLAC associated with labor
induction."

I think maybe the best approach is to simply *bring* a copy of the article to your next appointment and have an open discussion on what sort of approach you'd like to take, given the information presented there. Have sections marked in both your copy and the copy you leave with your doctor so that you can refer to them easily.

[MaddieMay]

Thanks for all of the really helpful suggestions! I should clarify that I'm seeing two OBs-the small hospital OB (who I really like and will do most of my prenatal care with) and the big hospital OB (who is an okay person, just the policies stink).

I think I will bring the new VBAC guidelines to my next small hospital appointment. Their reasoning is that their anesthesiologist staff is only on call after hours, so not at the hospital 24/7. I'm wondering if we could come to a compromise.

If nothing changes and I pass the 39 week mark, my plan is to not schedule anything and simply show up at the small hospital ready to push. Easier said than done, I am sure. I do have access to an "underground" sort of person that could probably come to my home during labor and help me decide when to head in. Honestly, I think my small hospital OB would do the VBAC in that case because it was an "accident" and then he wouldn't get in trouble with hospital policy.

Leading up to that, I plan on getting myself as prepared as I can so that hopefully I don't have to use ANY back up plans!

[kltroy]

I would talk to your small local hospital OB (from the VBAC ban hosp) - as you suggest. The new guidelines specifically state "When resources for immediate
cesarean delivery are not available, the College recommends
that health care providers and patients
considering TOLAC discuss the hospital’s resources
and availability of obstetric, pediatric, anesthetic,
and operating room staffs. Respect for patient
autonomy supports that patients should be allowed
to accept increased levels of risk...After counseling, the ultimate decision to undergo
TOLAC or a repeat cesarean delivery should be
made by the patient in consultation with her health
care provider."

Seems to me this is a good opening for a discussion. While you will not likely change hospital policy immediately, the guidelines first and foremost suggest that YOU have the final say in your decision.

[Family4Christ]

This would be a later choice for me, as I do know of OB Dr. here at once arriving at the hospital, a VBAC mom was pushing and the Dr. actually pushed the baby BACK up in the birth canal and did a CS.

Wow. Just. Wow. Mom consented to this?

[AustinMom]

Originally Posted by Family4Christ

Wow. Just. Wow. Mom consented to this?

Yeah, I know, WOW, IMO, of what I know (having not pushed my baby out) if I was at the point of crowing, I would be able to be a very good advocate for myself at that point. I was a crappy self advocate after just laboring 27 hrs, I can't imagine laboring, pushing, getting to final stage of pushing, and then changing environments and dealing with 'we don't do VBAC here, you have to have a CS no matter what'.

I doubt the mom just sat back and said 'ok, what ever you think is best...' but I can understand not being a good fighter as well.

[Storm Bride]

Originally Posted by AustinMom

...I do know of OB Dr. here at once arriving at the hospital, a VBAC mom was pushing and the Dr. actually pushed the baby BACK up in the birth canal and did a CS...

I know I'm not an expert, but that seems like it would be awfully stressful for the uterus, and possibly even cause a rupture. One has to wonder what the hell someone is thinking, yk?

[AustinMom]

Originally Posted by Storm Bride

I know I'm not an expert, but that seems like it would be awfully stressful for the uterus, and possibly even cause a rupture. One has to wonder what the hell someone is thinking, yk?

Uh YEAH! That's exactly what I said, and what the attending Doula said. But as you may know, Doulas are on kinda a weird ground when it comes to hospital births. This is yet another reason why I feel more comfortable HBACing than VBACing in one our our local hospitals.

[onyxravnos]

my advice is 'just say no' they can't make you have a c/s and they can't deny you 'treatment' . it sucks that you have to but just put your foot down. Get a doula

[claudi81]

yeah thats full of............... to me, they would induce you which uppens the risc, but they will not let you wait till labor sets in on its own that is such a contradiction. My limit was 41 weeks not sure why, but if I have felt better bp wise I would have forgot the first scheduled c-section date or came up with a stomach bug or cold as an excuse...maybe thats what you can do if you choose to got with them anyways

I have known very few moms that go into labor before 39 weeks, but lots moms went past edd, so not sure what to tell you othere than your chances of having a VBAC by "their" plan and timeschedule seem to be discouraging to me anyways.....


wish you the best and send you a hug

[buckeyedoc]

I would show them the ACOG guidelines, refuse the 39 or 40 week guideline and show up at the hospital in labor and decline RCS. You have that right.

FWIW, my OB won't even start talking "postdates" with me until 42 weeks, and we would do conservative induction before RCS...

[tarama]

I agree with past posts that you should not agree to chemical induction, because of increased risk of rupture.

Also, my doc "bent" a few VBAC policies at the request of me and my doula and awesome L&D nurse, including intermittent monitoring instead of constant monitoring. Don't be afraid to ask your doc about how closely the policies must be followed, especially if you are completely healthy, baby is happy and your labor is going well.

If they want you to have your baby by 39 weeks because they are afraid it will be too big, then what's one more week? Half a pound at most. Certainly after you push out the head that won't mean a thing!

[MaddieMay]

Well, I had another appointment and came armed with research and knowledge. The good news is that they have pushed back their "deadline" to 41 weeks, so I can breathe a little bit easier.

The issue becomes what they think is best at 41 weeks. Both doctors (small hospital and large) think that it's better to schedule a c-section rather than induce, stating that the success rate is lower with induction (duh!).

Personally, if I haven't gone into labor by 41 weeks they can shove it for another week. I am not even going to entertain ideas about being overdue until I'm past 42 weeks. I am very good at stalling.

[buckeyedoc]

Originally Posted by MaddieMay

Both doctors (small hospital and large) think that it's better to schedule a c-section rather than induce, stating that the success rate is lower with induction (duh!).

So they want to schedule a C-section in order to avoid the chance of an induction leading to a C-section?