went to 4th degree tear surgeon today for consult (urogynie) - Mothering Forums

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#1 of 44 Old 07-22-2005, 04:38 PM - Thread Starter
 
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Well, I am sure a lot of you know my story and what I am STILL agonizing over. I went to see the surgeon who repaired my 4th degree laceration after transport from my last homebirth. The baby was shoulder dystocia aand 10 1/2 pounds. Here is what he had to say.

He examined me. My perineum should actually be reconstructed once I am done with babies, which he advised I be. He said that I should consider my tubes being tied, which I will never do. Anyway,I have a very thin small perineum, but that isn't as concerning as the thin muscle in between the vaginal and rectal opening. I function fine right now, although he feels that things should be reconstructed better. He did what he could at that time of the birth. He was saying that if the baby is larger than 9 pounds that I should no way consider a vaginal birth due to my situation, it would be a real possibility that I will be fecal incontinent because of the thin muscle at the rectum. If they were to induce around 37 weeks, with a 7 pound baby , he thought I might be able to pull it off. I would be worried that my baby boy would not be ready though?And what if the ultrasound isn't right? What about shoulder dystocia and smaller babies in weight?

What do you think?
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#2 of 44 Old 07-22-2005, 04:48 PM
 
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So many variables. Honestly I take anything a surgeon says with a grain of salt- especially when he's suggesting surgery. I really think in your case though you need to listen to whatever that small quiet voice inside of you is saying. You've done a lot of research. You've considered all the variables. When you're in the dark in bed or in the shower alone, what feels like the right choice? Take some time for yourself- go on a walk in the woods or on the beach and see what your heart and gut say. I think this is one of those times that you have as much wisdom within yourself as all the doctors in the world.

good luck

-Angela
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#3 of 44 Old 07-22-2005, 05:09 PM
 
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Well, its hard. I mean given the choice between a v-birth at 37 weeks and a C-birth at term (not scheduling the C-birth, but waiting til labor starts) I think I *might* go with the C-birth at term. That way I would know for sure that the baby was ready to be born. I can totally understand your fears of fecal incontinance, as it would be a lifetime affliction for you. And not a fun one at that!

It's tough. I'll be thinking about you, mama and the decisions you need to make here soon.

Jenn, perpetually tired mom to DS(9): DD(4.5): DD(2) :
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#4 of 44 Old 07-22-2005, 05:38 PM
 
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First, I want to say that not all surgeons are bad, evil or that if they suggest surgery they are wrong. Thank God for surgeons for those of us who need them. They are trained, skilled professionals.

As to the OP problem, I would opt for the csection. I've said this in another thread and I have followed several of your other threads. I just wouldn't take the risk with a vaginal birth, and I do see your long term problems from having a vaginal birth, worse than that of a scheduled csection.

Kim
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#5 of 44 Old 07-22-2005, 05:56 PM - Thread Starter
 
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What if the baby is smaller though, would you still do the c section? A c section is not without risks, but neither is my vaginal birth.

I do find it a little risky to induce at 37 weeks, not really knowing if babyBOY is ready or not, posing a whole new set of problems. I like the the advice to try to hear my inner voice on this , or maybe just let this unravel into what is meant to be.
This surgeon is absolutely excellent and I did need him, so I am thankful for him. I would never do another homebirth, not that I wouldn't LOVE to be able to, but in my situation I need to be where I can get help. I had to transport to the hospital in Chicago rush hour , took 2 hours to get there, and my baby was not with me, nor did I know how long it would be until we were reunited. It was awful. I wouldn't want a repeat of that.

OH..he did say that he wouldn't want me having 6 sections, so hopefully I wasn't planning an extra large family..he said 4 was enough..can you believe that? LOL

Thank you all.
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#6 of 44 Old 07-22-2005, 06:04 PM
 
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See? that's why I hate drs. What if you wanted 6 more.... (just sayin.... ) I do think that the answer is within you on this one. It is complicated enough that I don't think there is a clear cut "right" answer. I'm a HUGE homebirth person. Think that ~70% of births should be at home (and insurance shouldn't pay for it otherwise... ) BUT you're in a complicated situation. I don't think anyone but you can decide what's right here. Really listen to what your intuition tells you. Throw out all the little- but he said, but she said, voices. They will just distract you. Pray or meditate on it if that's your thing. I have a lot of faith in that inner voice in all of us.



-Angela
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#7 of 44 Old 07-22-2005, 10:20 PM
 
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Quote:
Originally Posted by mommamiagal
What if the baby is smaller though, would you still do the c section? A c section is not without risks, but neither is my vaginal birth.

I do find it a little risky to induce at 37 weeks, not really knowing if babyBOY is ready or not, posing a whole new set of problems. I like the the advice to try to hear my inner voice on this , or maybe just let this unravel into what is meant to be.
This surgeon is absolutely excellent and I did need him, so I am thankful for him. I would never do another homebirth, not that I wouldn't LOVE to be able to, but in my situation I need to be where I can get help. I had to transport to the hospital in Chicago rush hour , took 2 hours to get there, and my baby was not with me, nor did I know how long it would be until we were reunited. It was awful. I wouldn't want a repeat of that.

OH..he did say that he wouldn't want me having 6 sections, so hopefully I wasn't planning an extra large family..he said 4 was enough..can you believe that? LOL

Thank you all.
Yes, even with a smaller baby and your two previous births I would go with the csection. Only because I know two moms who had SD babies, even with a smaller one.
I also wouldnt want to take a 37 weeker male fetus -- male babies are prone to more problems and he may have to stay in the nursery or need help breathing.
My OB is willing to do 5 csections and when I asked her why there was a limit of three in the past she told me. Everytime you open the abdominal cavity you risk more abdominal adhesions, its harder on your uterus each time -- not only is their scar tissue, but you risk having placental problems with the more you have, etc. (there is more) I think this is something to really think about. I feel comfortable having 3 or even 4 csections based on my OBs recommendation and my own research.
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#8 of 44 Old 07-22-2005, 11:21 PM
 
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I had a 3rd degree tear into my rectum. The ob stiched me up and told me to not keep problems with anal leakage to myself b/c it can be fixed. I thought nothing of this and that it would heal fine. I found myself having little accidents. I would squat down to be with the kids on the floor and opps a little poop would come out. Or, I would have problems b/c the consistency of the poop was on the softer side and so it was easier to loose some. Hope I am not grossing you out, but it sounds like this is an issue for you too. After almost of year of this and wondering when my body was going to heal I finally went to a colon/rectal surgeon out of sheer frustration. She said I would probably need surgery one day but that I should try Physical therapy first. I thought, yeah! I would rather do that then get cut. Did the doc you talk to say anything about this option? I went to a PT that actually had training in how to help woman after childbirth who had problems with urinary or fecal incont. and it has been amazing. There is this little thing she put in my rectum and told me to squeeze as hard as I could and it measured the strength of my muscles, well I squeezed a 4. 6 Weeks later I was up to a 7 out of a possible 10 and said most people can do a 8 or 9. The PT has also helped me strengthen my lower back and ab muscles. I stopped doing the exercises when things were so much better = no more accidents, no more having to change my underwear, etc... and within 3 weeks the problem slowy crept back in. So, I will always need to do them, but they are easy stuff. I hope my experience will give you some other avenue than surgery.
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#9 of 44 Old 07-22-2005, 11:58 PM
 
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Quote:
Originally Posted by Tyleah
I had a 3rd degree tear into my rectum. The ob stiched me up and told me to not keep problems with anal leakage to myself b/c it can be fixed. I thought nothing of this and that it would heal fine. I found myself having little accidents. I would squat down to be with the kids on the floor and opps a little poop would come out. Or, I would have problems b/c the consistency of the poop was on the softer side and so it was easier to loose some. Hope I am not grossing you out, but it sounds like this is an issue for you too. After almost of year of this and wondering when my body was going to heal I finally went to a colon/rectal surgeon out of sheer frustration. She said I would probably need surgery one day but that I should try Physical therapy first. I thought, yeah! I would rather do that then get cut. Did the doc you talk to say anything about this option? I went to a PT that actually had training in how to help woman after childbirth who had problems with urinary or fecal incont. and it has been amazing. There is this little thing she put in my rectum and told me to squeeze as hard as I could and it measured the strength of my muscles, well I squeezed a 4. 6 Weeks later I was up to a 7 out of a possible 10 and said most people can do a 8 or 9. The PT has also helped me strengthen my lower back and ab muscles. I stopped doing the exercises when things were so much better = no more accidents, no more having to change my underwear, etc... and within 3 weeks the problem slowy crept back in. So, I will always need to do them, but they are easy stuff. I hope my experience will give you some other avenue than surgery.


PTs are awesome and can help a woman do amazing things--amazing by a surgeon's measure, that is! My personal story in a nutshell is episiotomy stitched too tight with 1st birth and after 2nd birth feeling a saggy pelvic floor, surgery to correct childbirth-damaged pelvic floor would be required. I had a cool CMN who referred me to a PT, and guess what--I learned all sorts of things to remedy my problem, which involved muscle awareness, patience, and an increase in overall core body strength. (Just like Tyleah, who worked on her abs and back--yep, they're part of the crotch, LOL!)

I always think of my mother, who chose a hysterectomy with her pelvic floor lifting surgery, and I am convinced that she could have benfited with a little PT the way I have.

So my point is: seeing a PT worked for Tyleah, and indeed for me, for a differnt type of Ladies' Complaint. Good luck as you explore all your available options!
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#10 of 44 Old 07-23-2005, 10:50 AM - Thread Starter
 
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Yes, I had the PT option when I had my fourth degree. That option is still there for me if I need it, except I do not leak fecal matter, thankfully , so chose not to do it at that time.
A fourth degree is worse, well more complicated affected more of the rectum, than a 3rd because the 3rd tears into the anal sphincter the surface before the rectum, a 4th degree goes internally into the rectal mucousa. The problem with that is , if it were to tear again, because it has been repaired and is scar tissue now, it could be beyond PT because it is no longer native muscle. This is what I was told by a top Chicago pelvic floor surgeon. Also, when cutting and stitching numerous times, you could staart to damage nerve endings, and then have no control and feeling..I do not believe you can get that back ..am I wrong? I actually have a friend who has a friend that is a Pt who works with women 's problems such as this, this would be a good question for her..how many times could this happen before PT can't help anymore.
I have to see how big baby is by 37-38 weeks, and I think my gut is telling me to opt for the planned C section after that time frame . I just keep imagining myself playing with my kids and loosing control of bowel movements , or standing in a crowd socially and this happening..how devastating.
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#11 of 44 Old 07-23-2005, 12:31 PM
 
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When I had my section after 2 4th degrees & s.d. I was constantly amazed at how easy the incision was to care for. I had no complications with my incision so it was just a matter of taking some tape off, compared to sitting in a tub 3 times a day & spraying a spray bottle & taking stool softeners, praying that the stitches in my butt wouldn`t pop open.

The doctor told me of course its an easier incision, no poop is coming through it every day, way easier to heal & less chance of infection than an episiotomy. Of course, that`s just my experience, but I know planned sections have much lower chance of complications than emergency ones.

Married Catholic mami : to 5 boys, : 9 6 3 : 5 mo. 5/6/02-6/22/02 (HIE)
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#12 of 44 Old 07-23-2005, 12:54 PM
 
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Interesting idea- PT. I would not trust a sugeon's opinion on what PT would or wouldn't do. See what your PT friend says.

-Angela
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#13 of 44 Old 07-24-2005, 10:10 PM
 
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Quote:
Originally Posted by mommamiagal
Also, when cutting and stitching numerous times, you could staart to damage nerve endings, and then have no control and feeling..I do not believe you can get that back ..am I wrong?
One reason I lacked tone in my pelvic floor, according to my PT, was that there was a little nerve damage on one side. This means when my brain would say, "kegel", most of the muscles kegeled, but not the area that was damaged by the nerve getting super-stretched out during the birth. (A totally uncomplicated quick 2nd stage, BTW.)

So with time, my nerve continued healing, and I've got full sensation & muscular control now.

Cutting and stitching, like with all surgeries, can and does snip nerve endings. How many c-section mamas do you know that have tingly scars? That's nerve damage. Or wisdom tooth extractions--very common for facial nerves to get bumped, dinged, or completely damaged.

Good point, Angela...ask the surgeon about sugery, and the PT about physcial therapy. No one doc/health care specialist can know all the options and treatments in all fields. The patient gets to learn all the options available from all the practitioners, and maker her choice from there.
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#14 of 44 Old 07-25-2005, 12:54 AM
 
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If the baby truly is only 7 lbs now it will only be about 7 1/4 at 38 weeks and 7 1/2 at 39 and 7 3/4 at 40 so what is the worry?
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#15 of 44 Old 07-25-2005, 08:40 AM
 
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Where are you getting that a baby only gains 1/4 of a lb a week at the end. I was under the impression that they gained at least 1/2 a lb in the last 4 weeks. Being that this woman's children were 10.5 lbs at term them based on your theory they would be 9.75 lbs at 37 weeks.

I would go for the c-section but this isnt my decision to make. I don't know what else to tell you.

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#16 of 44 Old 07-25-2005, 09:15 AM
 
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Hi, I don't know too much about your story but, I would:

Ask your PT friend many questions and I would opt for the c-section when labor starts on it's own. Is that still considered emergency? Also, did you have fast previous labors?

I would be too scared to schedule a cs without baby being ready.

I also think listening to that inner voice is very good advice...

Good luck, not very easy decisions all around.

Mama to 14yo, 9yo, 7yo, and babe born 9/2012
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#17 of 44 Old 07-25-2005, 10:26 AM
 
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Heavenly this is not from "theroy" and there are many factors but the researched info on medican weiight gain is 1/4 lb a week-- this was just discussed on a midwifery board I am on. Pamidwife has the info- my other computer that has that email is in the shop- so I can't give you where it is quoted from.

And yes if a woman is having a 10 lb baby at term which I am very familiar with at 36 weeks those babies are already big--

I would also say I have had 3 babies over 10 lbs each myself and one that was 9 lbs- my oldest was 10 lb 5 oz and was born on time - no dystocia but I did have a epis that extended- 3rd degree very bad repair job and it is amazing I did have sex enough to have another baby also purple instructed pushing #2 10 lbs 11 oz another hospital birth and epis with extension also messy repair my perineum was always short but now it was also messy with lumps and valleys something that would always get friction during sex and cause pain also wearing a pad would hurt -- spontaneous pushing that was interferd with because I was being moved from a bed to a gurney and I could feel that head but was also afraid my baby was going to fall on the floor- then from a gurney to a delivery table- ah the old days-- in any case he was out in 3 pushes with my body in a very confused state- I did and didn't want to push---
baby #3 homebirth 9 lb baby I tore a bit down old lines- only pushed spontaneously in a semi-hands and knees- born into my own hands
#4 12 lbs and no tearing born in a full squat-- all the old scar tissue was stretched and smoothed- I decided to really slow down and birth this kid in a way that I would protect my self as much as birth him- for about one instant I started to move into a hands and knees position but when I felt that body and shoulder drop and the pressure go off the perineum no way was I doing that I rocked back into a squat and moved my tissues around so that where there was slack I smoothed it around so it would loosen the tight places

for women who's contraction pattern at the end is 5 minutes apart then a head can be on the perineum for 5 minutes and often we can and do wait for rotation--- there are differences between slow shoulders and dystocia and I am not sure where you and your babies fit into this picture-- it sounds as if the 4th had something to do with technique but ? could not be sure-

can you get into a full flatfooted squat?
was your last baby posterior or chin(mentum) presentation?
the things I see -- moving you while pushing from the tub to the bed--- although I understand the concern I also wonder how this might have affected you was there anything that came to your mind a position or a feeling of what you wanted to do while pushing that you didn't do-- would you have put your hands on your rectum and guarded it or shifted your position? what were your thoughts while you started to push in the tub and when you were moved?
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#18 of 44 Old 07-25-2005, 10:48 AM - Thread Starter
 
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When I read your birth stories it empowers me to want to try the vaginal birth , just in case things are different this time, that's where my heart is BUT rationally thinking and knowing my personal situation and history it doesn't seem like the best educated decision when waying risks on both sides.

Sounds like your babies came fast, within minutes of pushing?, mine on the other hand do not. I pushed for about 2-3 hours with my first, 1 hour with my second and about that long with my third. My contractions are always within minutes at that point, but I still can't get the baby out. It really is true shoulder dystocia with me.The head is not supposed to be fully born for that long.
Have you ever had your rectal mucuosa repaired? That might be the big difference between your healing and mine. I think you said 3rd degree tear, mine is a bit worse, so having that repaired again might not be such a good idea for me. That's the tough decision.
I believe that I have read the baby is gaining 1/2 pound a week in the last weeks, which I am sure mine does. I think my doctor will schedule another ultrasound to see where I am at right now . She is supposed to call today, because she spoke to my urogynecologist on Friday.. We'll see.
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#19 of 44 Old 07-25-2005, 11:21 AM
 
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Here is some information that a really great midwife/resource just gave in response to how much babies actually grow in the last month of pregnancy and beyond:

(contrary to what OBs tell us, it's not a pound a week - not even close! if that were the case, we'd all be spitting out HUGE babies!! Not to mention the notorious unreliability of ultrasound weight estimates...)

I’m looking at a chart right now in the back of Obstetrics (gabby, neibyl,
simpson).

It lists the birth weights of babies in the US by week of gestation.



The fiftieth percentile looks like this:

37 weeks = 3117

38 weeks= 3263

39th = 3400

40 weeks= 3495

41 weeks = 3527

42 wks = 3522

43 wks = 3505



So – it looks like a baby born at 40 weeks may average 273 gms more than a
baby at 37 weeks.

And a 40 weeks might average 232 gms more than a baby at 38 weeks

I always have to get my calculater out to do the gms to pounds conversion:
hang on.



273 gms is .619 pounds

232 gms is .51 pounds



So……. A 40 week baby averages about 2/3 of a pound heavier than a 37 week
baby.

And a 40 week baby averages about a half pound bigger than a 38 week baby.

And you can see from the charts that the rate of growth slows after 40 weeks
so that a 42 week baby is only a little larger than a 40 week baby.



Midwives used to tell women the old rule of thumb is that a baby will gain
about a quarter of a pound per week from about 37 weeks to term, and not a
whole lot afterwards.

And these numbers bear out the truth of it!



Ha! A POUND A WEEK!

What garbage!



Even in the old days they knew better than to use the argument of “Better
induce now, before the baby is too big next week”!

I remember reading DeLee from the 1930s saying that the rate of fetal growth
is so slow, that the only way induction to avoid macrosomia made sense was
if you induced many weeks early – like six weeks or more!

You could maybe make an argument that there would be enough “obstetrical
size” difference between a woman’s baby at 34 weeks compared to the expected
size at 40 weeks or more. But the difference in weight between 40 weeks and
42 is almost neglible.

When we consider the massive increase in cesarean with induced labors
compared to spontaneous labors, it makes even more sense to let labor begin
when it’s ready.



Ps – this chart comes from “a United States national reference for fetal
growth, Obstet Gynecol 87:163, 1996” Alexander, Humes, kaufman et al.




(Sorry it's not formatted properly!)
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#20 of 44 Old 07-25-2005, 12:41 PM - Thread Starter
 
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I guess the argument could go the other way then.
I was worried about my OB scheduling my c section a week earlier than my due date, according to the statistics of that particular source, I would have nothing to worry about from 39 to 40 weeks?
So if you have 10 pound babies when are they growing the most? According to most books right now at 33 weeks , my baby should only be around 4 pounds. If they only gain .25 pound a week , that would bring me up to maybe a 6-7 pound baby at term. I could handle that, no problem!!!I will pass this info on to my OB , makes for a great arguement.
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#21 of 44 Old 07-25-2005, 12:59 PM
 
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The problem scheduling early is going to be an early baby, not weight. Some big babies have breathing problems and nursing problems if they're kicked out too early. That would be my worry.

-Angela
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#22 of 44 Old 07-25-2005, 10:20 PM
 
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thank you Pam


this is why ultrasound info after 12 weeks gets to be iffy and starts being off more and more on estimation of age via size measurments-- because different growth/genetic patterns start expressing themselves- so by the time your baby is 36 weeks it has achieved some size already close to birth size.
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#23 of 44 Old 07-26-2005, 12:30 AM
 
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U/S information is poor at a late stage, the problem is it can go either way. I was told Molly was roughly 8.5 at 36 weeks--and I believed them as I was a 10 lber and my little brother was a 37 week 12 lber! My OB however told me she didn't feel like she was that big. She was born at 37 weeks due to pre-e and she was 6 lbs 4 oz--a long way off from her weight the week befoer of supposedly 8.5.
The main problem is that they can't know you're baby is a 7 lber by U/S, it could feasably anywhere from a 5 lber or a 9 lber.
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#24 of 44 Old 07-26-2005, 10:54 AM - Thread Starter
 
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Well, my hopes of a vaginal delivery are slowly dwindling..since U/s are so unreliable at a later stage. I wouldn't want to be told it was 7 pound , to find out it is a 10 pounder again , while stuck.

I see my Ob on Monday.
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#25 of 44 Old 07-26-2005, 01:00 PM
 
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Well, it sounds like your surgeon gave you the best surgical advise he could for you to take care of you. Coming from the infant side of the fence I will agree with the posters who recommend avoiding induction at 37weeks. If you decide on an intervention to help you prevent further injury I would vote on c/sec after 40 weeks or after labor has started. Especially if you don't deliver rapidly. There is time to get in and get a c/s. The only people who wouldn't agree with this are anesthesia folks who like you to not eat or drink anything, however they treat all pregnant women as if they have just eaten anyway due to slower gut motility.

Besides induction carries risk especially increased risk of cesarean which would have you with an early baby and a belly scar anyway. If you think you want an A/P repair later on then I would avoid further scar tissue especially if your muscles are already weak.
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#26 of 44 Old 07-26-2005, 02:34 PM
 
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another option if you are looking at definately having a c-section would be to labor until you are dilated well to help the baby be prepared to be born and to help you as well- hormones and a smaller segment of your uterus to be cut.
I have an aunt who had 6 c-sections although they were all repeat sections she labored with each. Especially since you are not considering this to be the end of your fertility-- the stats on rupture on VBAC do not just include risk in labor but pregnancy itself carries a risk of rupture--- getting a secton on a completely effaced and dilated lower segment is a much smaller amount of tissue than on a non-effaced or dialted uterus
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#27 of 44 Old 07-26-2005, 06:50 PM
 
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Originally Posted by mwherbs
getting a secton on a completely effaced and dilated lower segment is a much smaller amount of tissue than on a non-effaced or dialted uterus
How interesting! I did not know that--makes sense.
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#28 of 44 Old 07-26-2005, 06:59 PM
 
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getting a secton on a completely effaced and dilated lower segment is a much smaller amount of tissue than on a non-effaced or dialted uterus
I would love to see the documentation for this to add to my book of notes.

Thanks.
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#29 of 44 Old 07-26-2005, 08:18 PM
 
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Originally Posted by mwherbs
getting a secton on a completely effaced and dilated lower segment is a much smaller amount of tissue than on a non-effaced or dialted uterus
I would also love a reference for this. My first section was for PROM at 37 weeks and FTP. Had a failed induction, and I never effaced or dilated at all. In my (natural, noninduced) VBAC attempt, I had a UR. I am curious as to how the scar strength may have been affected by this.

New WOHM to DD8 and DD3
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#30 of 44 Old 07-27-2005, 02:25 PM - Thread Starter
 
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i thought that being effaced and dilated regarded the cervix, i didn't ralize that it also thinned the uterus? please send me the source.
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