VBAC and 42 weeks? - Mothering Forums

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#1 of 38 Old 08-14-2008, 05:51 PM - Thread Starter
 
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A little backstory, my son is 8mo. I planned a homebirth but when I went to 43 weeks my homebirth midwives weren't comfortable with me staying pregnant anymore and, after trying EVERY natural induction method, we went to the hospital for some pit. I labored with ruptured membranes for 26 hours, pit for 14 hours, and after everyone and her mother had their hand in my vagina, and the baby was still LOT and -2 station, and I was exhausted, we did a C-section. Discovered during the section that there was a true knot in my baby's cord. I believe with the stop-and-start labor, and his abject refusal to decend into my pelvis, that he was trying to tell me that he wasn't safe to be born vaginally, despite the CNM that assisted with my C/S saying "oh, but there's lots of length here!" Seriously, that woman was not okay with me being at peace with my decision, and her little comment has made me doubt the entire thing.

Anyways, my favorite CNM from my practice and I had a pap smear today, and I brought up the next pregnancy, which we're not planning to try for until my son is 2. I told her I thought I would go overdue again, and that even though I was again going to plan a homebirth, that I wanted to know what my options were if I was a 10-month mama. She said that the docs in her practice would not "allow" me the option of a VBAC if I went over 42 weeks. She said that she's really not very conservative (which is true, she's very earthy, which is why I like her), but that she strongly felt that my safety and the safety of my baby would be in jeopardy if I went past 42 weeks with a scarred uterus.

What's the research? Point me in a direction. I want to have some facts in my lap before there's another baby there. I've done some cursory searching, but I figured that y'all would have the most breadth of knowledge about this.

Thanks ladies!

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#2 of 38 Old 08-14-2008, 10:48 PM
 
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Well, I began having similar discussions with my doctor when my VBAC went almost to 42 weeks (my daughter was 12 days late). Never once did he mention the previous c-section as a reason why he didn't want me to go past 42 weeks. He began quoting some statistic that shows a dramatic increase in babies that die in week 43 and after. Now, I don't have any sort of evidence to back up his claim. I know, however, that many doctors don't want VBAC moms to go overdue because they don't want the baby to get too big and put additional strain on the scar.

Maybe if you have your membranes stripped every week or something after 37 weeks you'll have better luck with delivering earlier.
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#3 of 38 Old 08-15-2008, 02:37 AM
 
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Sadly the 10 month mama pages (& the whole birthlove site) have disappeared, but I did find this http://www.joyousbirth.info/forums/s...ad.php?t=15699

Leilah McKraken had a previous cesarean (or possibly more than one) and went on to vbac her other babies, who were all 43+ weeks, if I remember correctly.

I'll see if I can find you anything else later.

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#4 of 38 Old 08-15-2008, 02:46 AM
 
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From that thread, a link to the way back machine & the 10 month mama page
http://web.archive.org/web/200608130...onth_mama.html

mom to all boys B: 08/01ribboncesarean.gif,  C: 07/05 uc.jpg, N: 03/09 uc.jpg, M: 01/12 uc.jpg and far too many lost onesintactlact.gifsaynovax.gif

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#5 of 38 Old 08-15-2008, 09:50 AM
 
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The midwife I talked with when we were ttc said that at 42 weeks she would start having me go for bpp's and nst's to check baby and placenta and as long as everything looked healthy she would let me go as long as it took. I had bpp's and nst's with my cbac baby and even at 41 weeks my placenta was a grade 1! That is consistant with a 2nd trimester placenta and baby always looked great, of course I had an OB then who told me that my baby and I would die if I went any further... Oh to know then what I do now. I think some of us are just meant to carry longer than others!

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#6 of 38 Old 08-15-2008, 11:31 AM - Thread Starter
 
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Originally Posted by Devaskyla View Post
Sadly the 10 month mama pages (& the whole birthlove site) have disappeared, but I did find this http://www.joyousbirth.info/forums/s...ad.php?t=15699

Leilah McKraken had a previous cesarean (or possibly more than one) and went on to vbac her other babies, who were all 43+ weeks, if I remember correctly.

I'll see if I can find you anything else later.
I've seen the archived 10mo mama page, but I'm looking for empirical research. I know a mom who had a UBAC in her bathtub almost exactly a year after her C/S. However, my CNM and her "governing" OB are not going to be interested in my anecdotal stories, they will want research, or they're not going to listen to me. So I'm looking for published, peer-reviewed studies that clearly outline the risk/benefit scenario.

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Originally Posted by Sara268 View Post
The midwife I talked with when we were ttc said that at 42 weeks she would start having me go for bpp's and nst's to check baby and placenta and as long as everything looked healthy she would let me go as long as it took. I had bpp's and nst's with my cbac baby and even at 41 weeks my placenta was a grade 1! That is consistant with a 2nd trimester placenta and baby always looked great, of course I had an OB then who told me that my baby and I would die if I went any further... Oh to know then what I do now. I think some of us are just meant to carry longer than others!
The OB office I work through operates on the midwifery model, and they are more open to letting me do what I feel is the right thing in general. I want to have another appointment with my CNM to talk about some possible future scenarios (like, if I do go to the hospital, how I will be outright noncompliant with their clear-liquids only in labor policy), but I need some ammo first.

It's so easy to get outgunned by doctors and midwives. I'm a trained, unlicensed nurse, and I know my stuff about birth pretty cold. However, I still found myself suddenly worrying about placental integrity and amniotic fluid volume when I was face-to-face with the CNM and the OB. Once I left the office, I regained my sovereignty over my pregnancy, but in the office, I felt like I didn't really know anything. Just exactly how current was my research, anyways? Don't these women do this for a living? What the f*** do I know?

I'm more prepared for that vulnerable reaction to being pantsless on the exam table now, but I want to be armed with some statistical facts.

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#7 of 38 Old 08-15-2008, 07:35 PM
 
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Did you read the first link I posted? If you scroll down the thread, there were studies mentioned at the bottom of the very long second post.

mom to all boys B: 08/01ribboncesarean.gif,  C: 07/05 uc.jpg, N: 03/09 uc.jpg, M: 01/12 uc.jpg and far too many lost onesintactlact.gifsaynovax.gif

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#8 of 38 Old 08-15-2008, 10:13 PM - Thread Starter
 
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Originally Posted by Devaskyla View Post
Did you read the first link I posted? If you scroll down the thread, there were studies mentioned at the bottom of the very long second post.
I saw them, and they would be great if all I was looking for was postdates, but I'm looking specifically for postdates and VBAC. My practice was okay with me going postdates with my son, as long as I kept coming in for checks. However, my CNM said that for a VBAC, 42 weeks = RCS. Period. She said that the chance of rupture was too high, and played not only the dead baby card, but the dead mama card as well. I'm wondering if anyone has the numbers.

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#9 of 38 Old 08-16-2008, 05:20 PM
 
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No great answers for you mama, but my extremely experienced and conservative MW was not comfortable having homebirth after 42 wks. We were going to go to the hospital in the evening on the day of 42 wks. I gave birth at 41+6. I'm not so sure it was for increased risk for rupture, but more for placenta etc. Also, she thought I would have a better chance at going into the hospital and having a small dose of pit to try and get me going, as opposed to being after 42 wks. Either way, my placenta was very healthy looking and River was healthy as well. Wish I had some cold hard facts for you.

Emily, WOHM to Joshua (05) River (08) HBAC,  Rylee (09) HBAC and Levi (coming 8/11) planning another HBAC 

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#10 of 38 Old 08-16-2008, 06:28 PM
 
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http://www.birthtruth.org/fears.htm
http://www.ncbi.nlm.nih.gov/pubmed/12679819 (last sentence before conclusion)

Not having much luck with google scholar atm. Have you tried looking in the book Birth After Cesarean: The Medical Facts by By Dr. Bruce L. Flamm or in The Thinking Woman's Guide to find research that's related. I don't have either of them on hand, but I would think at least one would have something.

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#11 of 38 Old 08-17-2008, 12:00 AM
 
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Maybe you should try asking your cnm for cold hard facts on why she thinks it it so dangerous. I have never heard of VBAC and postdates together being more "high risk". And since you are having a hard time finding any info on it at all, it sounds like they don't have anything to base it on.
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#12 of 38 Old 08-17-2008, 01:19 AM
 
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Try this one:

http://www.aafp.org/online/en/home/c...ecs/tolac.html

It is a review of several VBAC studies with statistics, including maternal age and gestational age. And it is from the American Academy of Family Physicians, so it is a legitimate source. Not that a lot of the other aren't, but this may hold more weight with your doctors/midwives...

There seems to be more risk for post date babies, but the numbers aren't that much bigger. But at least it gives you some stats to start the conversation with!

Good Luck!
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#13 of 38 Old 08-17-2008, 02:07 AM
 
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I have no cold hard facts either but I like the idea of asking them to prove their point. Tell them you have been looking for the studies that show increased risk and just can't seem to find any.

Or...I don't know if I would do it or not but I know a mom who "remembered" her LMP a week or two later than it acutally was. Of course if you agree to the ultrasounds that wouldn't really work.
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#14 of 38 Old 08-17-2008, 02:38 AM
 
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http://209.85.173.104/search?q=cache...ient=firefox-a

They have a section saying post dates are not a contradiction. They just state your success rate slightly declines but that postdates doesnt change if your a VBAC or not.

http://www.cmbc.bc.ca/clinical_pract...sPregnancy.pdf

Just guidelines on postdates from BC College of Midwives.

Sorry trying to find more info on postdates and vbac but nothing on hand just the Sogc guidelines which is study based.
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#15 of 38 Old 08-18-2008, 10:33 AM
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hi mama.

just a note on going past the 40w mark... With my first vbac attempt, I went to 42w, and my glorious bradley-style labor ended in a c, and I had a beautiful and huge 10lb 3 oz babe. When I became pg 5 mos later (much to my surprise), I knew I wanted to try for a vba2c and I was petrified of going to 42w again as I knew there would be discussions of induction or a scheduled c and I was also afraid that those extra weeks would grow a bigger baby that i wouldn't be able to push out... My MW had to convince the chief o.b. at the hospital that it meant a lot to me to try for a vba2c, especially since the risks of another c with 3 other children at home were scary indeed... needless to say, DS arrived early! via vba2c at 38w and 8lbs 10 oz.

So all my fears about going to 42w again were in fact opposite of what happened - instead of going late, he came early, thankfully!

In terms of vbacs and going late, I don't have any medical info other than the normal 'going late' stuff after 42 weeks... not sure why a vbac would be any different than a regular birth going late. I'd want to find out why it's more risky for a vbac to go late than a non-vbac.

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#16 of 38 Old 08-25-2008, 03:37 PM
 
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Not research, but I heard this story today & thought of this thread.

A mama who had a cesarean with her first baby at 44 weeks for being 'overdue', had a home VBAC at 43 weeks for her second baby & home birth/hospital transport VBAC at *46* weeks for her third. The only reason for the transport was the midwives were a little freaked about her being 46 weeks. Baby was fine & healthy, only a few ounces more than her other 2.
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#17 of 38 Old 08-25-2008, 07:28 PM
 
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Quote:
I saw them, and they would be great if all I was looking for was postdates, but I'm looking specifically for postdates and VBAC. My practice was okay with me going postdates with my son, as long as I kept coming in for checks. However, my CNM said that for a VBAC, 42 weeks = RCS. Period. She said that the chance of rupture was too high, and played not only the dead baby card, but the dead mama card as well. I'm wondering if anyone has the numbers.
Hmmmm. I would ask for the specific studies they are using as validation for this time limit. Given the difficulty I've had finding anything applicable (I was a reference librarian at a major research university so I'm not exactly bad at this sort of searching ) I'd be surprised if they had much "peer-reviewed" literature on their side... more likely they're doing their own "anecdotal analysis".

However, here's what I've found so far while searching PubMed (bolding mine):
Obstet Gynecol. 2005 Oct;106(4):700-6.
Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation
Quote:
RESULTS: When the cohort was defined as 41 weeks or more of gestation, the risk of a failed VBAC was again significantly increased (35.4% compared with 24.3%, odds ratio 1.35, 95% confidence interval 1.20-1.53), but the risk of uterine rupture or overall morbidity was not increased. CONCLUSION: Women beyond 40 weeks of gestation can safely attempt VBAC, although the risk of VBAC failure is increased
J Reprod Med. 1999 Jul;44(7):606-10.
Safety and efficacy of attempted vaginal birth after cesarean beyond the estimated date of delivery.
Quote:
CONCLUSION: The patient and her family can be reassured that passing her due date does not alter the efficacy or safety of a trial of labor. No change in counseling is warranted simply due to the completion of 40 weeks' gestation.
Now, I did find studies that suggest a preterm c/s can lead to complications in a future pregnancy or birth (the incision wont necessarily be a lower transverse incision in a full term pregnancy if the c/s was done significantly preterm). And I found studies that showed Uterine Rupture risks were lower in mamas who had their vbac pre-term.

For example:
Am J Obstet Gynecol. 2006 Oct;195(4):1119-26.
The Maternal-Fetal Medicine Units Cesarean Registry: safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery.
Quote:
RESULTS: Rates of uterine rupture (0.34% vs 0.74%, P = .03) and dehiscence (0.26% vs 0.67%, P = .02) were lower in preterm compared with term TOL. After controlling for gestational age at delivery and race, neonatal outcomes such as Neonatal Intensive Care Unit (NICU) admission, intraventricular hemorrhage, sepsis, and ventilatory support were similar in both groups except for a higher rate of respiratory distress syndrome in those delivered after a TOL.
And there are many many studies that show VBAC success decreases with longer gestation, or with a bigger baby, or with an older mama, or with induction, etc. But these are generally not "huge" decreases in success and these studies don't suggest "increased risks" associated with a TOL... just a decrease in success. So it's possible your care provider has spun these studies together to justify their deadline. And it's possible they've been handed a deadline by their malpractice insurance provider. But as for studies specifically showing an increased risk of UR in a postdate vbac... I'm not finding them.

I'll keep looking though. And good luck! For what it's worth, my c/s happened at 42 weeks 3 days with no obvious signs of postdates while my vbac babe arrived just days past 40 weeks so you may not be a lifetime member of the 10 month mama club.

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#18 of 38 Old 08-25-2008, 07:57 PM
 
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I can't think of any reason a VBAC mom is in more danger going post date. There are studies showing placental breakdown post date and baby just not doing as well in some women, but that has nothing to do w/ a VBAC. Have you asked on ICAN? Maybe she was thinking going postdate would put you at a higher risk for ctxs that came and went often for a long time and maybe that would put too much pressure on the scar? I don't know, I would just ask what she's talking about. Evan was born at 38 wks looking postdate and w/ a placental abruption, so things can happen earlier too w/ placenta etc. Getting past a certain point just makes people more aware I think.

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AJ (5/03), Evan (12/04), Ilana (11/06), Olivia (2/09), and Unity (8/2012)

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#19 of 38 Old 08-27-2008, 08:25 PM
 
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Originally Posted by aylaanne View Post
A little backstory, my son is 8mo. I planned a homebirth but when I went to 43 weeks my homebirth midwives weren't comfortable with me staying pregnant anymore and, after trying EVERY natural induction method, we went to the hospital for some pit. I labored with ruptured membranes for 26 hours, pit for 14 hours, and after everyone and her mother had their hand in my vagina, and the baby was still LOT and -2 station, and I was exhausted, we did a C-section. Discovered during the section that there was a true knot in my baby's cord. I believe with the stop-and-start labor, and his abject refusal to decend into my pelvis, that he was trying to tell me that he wasn't safe to be born vaginally, despite the CNM that assisted with my C/S saying "oh, but there's lots of length here!"
I think you're on the right track, my DS wouldn't come down when I was induced at almost 43 wks and hammered with pit until the contractions were on top of each other. When they took him out, he also had a true knot, and it looked like it was pulled tight (they showed it to me--yikes!--and DH took a photo of it--double yikes!). Anyway, I agree that the baby knows not to come down in those circumstances.

I think the only way to know if you'll go post dates again is to have another baby and see what happens (but I bet you won't ).

I read somewhere either in a Sheila Kitzinger book or Henci Goer book that the 40 week gestation is pretty random (some doc a long time ago sort of pulled that number out of his a**). When I was post dates, I kept having to get BPPs every few days , and with each one they were quite surprised and pleased with how great my placenta looked.

I don't have the exact number in front of me, but if you want to VBAC and your biological clock isn't ticking down too much, you SHOULD wait until your DS is 2 b/c the chance of uterine rupture goes way down with 2 or more years between gestations (which may help keep the scalpel-happy docs off your back).

Wishing you a 40-week gestation and a fabulous birth next time around!
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#20 of 38 Old 08-27-2008, 08:26 PM - Thread Starter
 
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Hmmmm. I would ask for the specific studies they are using as validation for this time limit. Given the difficulty I've had finding anything applicable (I was a reference librarian at a major research university so I'm not exactly bad at this sort of searching ) I'd be surprised if they had much "peer-reviewed" literature on their side... more likely they're doing their own "anecdotal analysis".
That's what I'm thinking, too. However, this CNM is not a fear-monger. She attended my induction and was absolutely fabulous. When it came to c-section time, I was the one who brought it up, and she spoke about it honestly and supportively to me, including making it clear that it wasn't required at the point where I was at.

I've been doing some searching on Ovid at work (I work at the hospital where I had my c/s because I was super impressed with the way they did my care) and I found some of the same studies you did. Here is what I also found:

Obestet Gynecol. 2001; 97: 391-3.
Trial of Labor After 40 Weeks' Gestation in Women With Prior Cesearean
Quote:
Conclusion: The risk of uterine rupture does not increase substantially after 40 weeks but is increased with induction of labor regardless of gestational age. Because spontaneous labor after 40 weeks is associated with a cesarean rate similar to that following induced labor before 40 weeks, awaiting spontaneous labor after 40 weeks does not decrease the likelihood of successful vaginal delivery.
That looks promising, indeed. But then I found this:

EJOG. 2006; 126: 68-71.
Is gestational age an independent variable affecting uterine scar rupture rates?
Quote:
Conclusion: The overall incidence of scar rupture and success of trial of scar after previous caesarean section in our population was similar to that quoted in the literature. Previous evidence has suggested that it is safe for these women to exceed 40 weeks gestation but our data do not support this.
And that made me a little sad.

I have more studies and I'm looking over them slowly. I still plan on having one or two meetings with both my CNM and my HBMWs to discuss risk/benefit scenarios. DH, to his infinite credit, is being fabulous and involved, and I trust him to take an objective look at this with me to let me know if I'm taking a risk just to have the emotional satisfaction of a vaginal birth at the expense of my or our future child's safety.

I will say, I'm so grateful for this community and I'll keep you all posted as this unfolds. I'm so glad I'm not on a clock yet, for sure. I'd hate to be doing this research while I was pregnant.

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#21 of 38 Old 08-27-2008, 08:29 PM
 
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Oh, I forgot to mention, when DS was born via c/s at almost 43 wks. gestation, his apgar scores were almost perfect!
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#22 of 38 Old 08-27-2008, 08:39 PM
 
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Originally Posted by crunchybelle View Post
Maybe you should try asking your cnm for cold hard facts on why she thinks it it so dangerous. I have never heard of VBAC and postdates together being more "high risk". And since you are having a hard time finding any info on it at all, it sounds like they don't have anything to base it on.
as a vba2cs, i think i have tried to research all there is out there and i have never seen any research on post dates w/ vbacs...i dont think it exists..and if it doesnt exist, its not fair for them to pull the card.
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#23 of 38 Old 09-04-2008, 01:43 AM
 
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Originally Posted by meatloafkend View Post
I know, however, that many doctors don't want VBAC moms to go overdue because they don't want the baby to get too big and put additional strain on the scar.
I don't have much to add except this peice of anecdotal information:
A friend of a friend gave birth at 41w+5 a few weeks ago and the doctor mentioned that babies lose weight in the days/weeks past 40weeks because thier fat stores start to deplete a bit. Maybe the doc was talking out his behind, but thought I'd throw that out there. Not something I've looked into myself!

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#24 of 38 Old 09-04-2008, 08:28 AM
 
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Next time Fudge your LMP a few days to give yourself some extra time

Jeana Christian momma to 4 sons Logan 18, Connor 15, Nathan 6, and bonus baby Jack 1
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#25 of 38 Old 09-04-2008, 11:40 AM
 
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I have to wonder if the "decreasing success rate" of VBAC after 40 weeks has more to do with unsupportive care providers than it does with the mother's body.

SAHM to Declan (12/12/06) and Blythe (2/9/09)
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#26 of 38 Old 09-04-2008, 12:17 PM - Thread Starter
 
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Originally Posted by JBaxter View Post
Next time Fudge your LMP a few days to give yourself some extra time
I've thought about it, but I'm worried that might be shooting myself in the foot. If it really is riskier to stay pregnant for that long, I don't want my stubbornness to put me or my baby at risk, kwim? OTOH, I also don't want to then go early (though highly unlikely, still possible) and have my baby gone over with a fine-tooth comb because they think she's more premature than she is. I also don't like to lie, and prefer to keep everything as above-board as possible. Part of my meetings with my MWs (both hospital and home birth) will be to figure out how much fudging can be covered with a wink-wink-nudge-nudge, and how much would seriously ruin their trust in me.

And they need to trust me. I believe in being equal partners with my birth attendants, and that means that I need to trust them and they need to trust me. If I'm just going to do what I want and to hell with them, I might as well UC, and I'm not comfortable with that at this point. So it's important that the trust stay intact.

knit.gifWife to Ageek.gif since 7-7-2006, Mother to Mnocirc.gif since 11-23-2007ribboncesarean.gif, and N slinggirl.gifborn on 4-9-2010vbac.gif
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#27 of 38 Old 09-04-2008, 11:51 PM
 
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However, my CNM and her "governing" OB are not going to be interested in my anecdotal stories, they will want research, or they're not going to listen to me. So I'm looking for published, peer-reviewed studies that clearly outline the risk/benefit scenario.
The OB office I work through operates on the midwifery model, and they are more open to letting me do what I feel is the right thing in general. I want to have another appointment with my CNM to talk about some possible future scenarios (like, if I do go to the hospital, how I will be outright noncompliant with their clear-liquids only in labor policy), but I need some ammo first.
Given the kind of CNM she seems to be, I highly doubt you will have a VBAC under thier care, no matter how many studies you show them. Have a homebirth. It is the only way you will probably ever be able to have a "normal" labor and birth, and to give birth when you are ready, not when a professional tells you to be... i am glad the OBs office seems more relaxed, but they arent the ones who issue the paychecks, or cover insurance, I would bet...I have a feeling it is probably the hospital they are associated with who Really Calls the Shots....
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#28 of 38 Old 09-05-2008, 12:03 AM
 
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i guess im not getting this.

its almost as if the dr's dont have to "prove" what they are saying. if THEY say it, its golden and should be listened to. the patients are the ones who have to scramble and find the research proving what they are saying is not accurate.

so...if we cant prove them wrong, we have to accept what they say?

thats just not the way i accept my health care professionals providing care for me and my children. If they want to suggest something, or have a concern, they need to be able to back up what they are saying.
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#29 of 38 Old 09-05-2008, 07:21 AM
 
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I don't have much to add except this peice of anecdotal information:
A friend of a friend gave birth at 41w+5 a few weeks ago and the doctor mentioned that babies lose weight in the days/weeks past 40weeks because thier fat stores start to deplete a bit.
its because the placenta can potentially start to shut down in some women/pregnancies so the babe isnt getting as much nutrition, so they start to lose weight. same as anyone outside the womb. stop eating and your body will use up what youve already got, kwim? that happened to my oldest.

has absolutely nothing to do with a vbac, just going postdates.
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#30 of 38 Old 09-05-2008, 10:12 AM
 
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Given the kind of CNM she seems to be, I highly doubt you will have a VBAC under thier care, no matter how many studies you show them. Have a homebirth. It is the only way you will probably ever be able to have a "normal" labor and birth, and to give birth when you are ready, not when a professional tells you to be... i am glad the OBs office seems more relaxed, but they arent the ones who issue the paychecks, or cover insurance, I would bet...I have a feeling it is probably the hospital they are associated with who Really Calls the Shots....
I think this is a huge leap, and based on the evidence given you can't say that. It may be nicer if your OB/MW does everything the way you want without a question, but having protocols doesn't automatically mean they're going to pull the bait and switch.

On the other side of the table, I know someone whose OB was really not very supportive of VBAC. She was in an MFM practice and switching wasn't really an option. The peri was very cool, the regular OB was not. Well, that unsupportive OB caught her baby... or, rather, pulled him out with forceps. (Yes, he was really stuck, and my friend was totally exhausted and just couldn't push any more.)

DD 01/2007, DS 09/2011

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