Doctors Lounge - Gynecology Answers
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Forum Name: Obstetrics
|adtmommy - Fri Jan 16, 2009 8:17 pm|
I started my prenatal care late in my pregnancy due to some insurance issues and was unsure of my last menstrual period or the time that I actually conceived my baby. I visited a hospital E.R near my home for pain that is not my normal hospital or the hospital that I am going to be delivering at before I started seeing my OB and they gave me an ultrasound and told me that I was 27 weeks. I had an ultrasound yesterday at the hospital that I now receive prenatal care for and they confirmed the dates and told me that I was 35 weeks and 1 day and that they agreed with the dates of the original ultrasound. When I went to visit my doctor for my normal checkup today he wanted to do an amnio scentesis to make sure that the ultrasounds were correct and that my baby wasn't going to be premature at the time of my delivery. I have had two previous c-sections and I've seen a specialist who told me that it was impossible to have a normal vaginal delivery, and also had to be induced for both of my deliveries. I wasn't comfortable with having the amnio and denied the treatment. The doctor told me that since I wasn't going to have the amnio at 49 weeks they would not schedule my s-section and I would have to wait until I went into labor, or wait until I was 42 weeks for them to deliver my baby. Will I even go into labor naturally since my body did not go into labor with my other two children? He told me that the risks of going into labor on my own and not having the amnio were bleeding and my uterus possibly rupturing but also told me that it was a low risk of about 1%. No matter how low the risk is it's very scary for me and I'm now really nervous about this whole thing and wondering if I'm making the wrong decision by choosing not to have the amnio to make sure the babies lungs are developed. However I have talked to other doctors who have told me that the amnio was dangerous at this time in my pregnancy, though my doctor denies that. Do all hospitals not schedule you for a c-section if you deny having the amnio because the baby could possibly be premature and make you wait 42 weeks or is this just something my doctor and the hospital I'm delivering at do? Also will waiting 42 weeks be dangerous for me or my baby because of size or any other complications that could occur? Though they fear my baby could be premature I have been reassured by the ultrasound techs that the baby is indeed 35 weeks. Why isn't this enough for them. I'm so confused...Any advise is appreciated. Thank you.
|Debbie Miller, RN - Sat Jan 17, 2009 9:20 pm|
Most hospitals and obstetricians feel comfortable scheduling a planned repeat c-section at 39 completed weeks. There are risks of going past your due date so if there is confirmation of dates by ultrasound it is usually very safe to go ahead at 39+ weeks without waiting to 42 weeks.
If you are not comfortable with the care you are receiving you can always change providers, even at a late date in the pregnancy. It is important for you to have confidence in your doctor. If he/she does not explain well the reason they believe waiting is needed, this may be reason enough. Amnio does come with risks so you should not be made to feel guilty about this decision.
|beebopalooza - Sat Jan 17, 2009 11:46 pm|
I have had 4 children 3 natural and one c section. Yes you can have a vaginal delivery after c-section!!!
Secondly, since you declined the amnio the DR only has a clue as to how far along you are
for liability reasons he IS NOT willing to deliver your baby without KNOWING 100% how far along you are.
The purpose of the amnio was to determine the maturity of your babys lungs. this would assure the dr that your baby was physically ready to be born or if your baby needed more time in utero
I completly understand your drs refusal to deliver because he is looking out for the best interests of your child and for liabilty issues.
No offense but the risks of amnio are not that high at your gestation and they are far less than the complications of delivering a premature infant
I think your dr is 100% correct and you really need to understand the big picture here THE HEALTH OF YOUR CHILD
|Debbie Miller, RN - Sun Jan 18, 2009 11:05 am|
This guest is correct that it is important the baby not be delivered prematurely, a possibility when dates are not accurate and ultrasound does have a two week window of error. This is the reason you should not be induced prior to 39 completed weeks at the earliest unless there are medical risks involved. Usually that assures the baby has completed at least 37 weeks' gestation even at the outside limits of dating error. Of course there could always be additional factors here that your doctor is aware of and perhaps has not shared with you. This is why communication between doctor and patient is essential.
To further clarify the indications for repeat c-section vs VBAC (Vaginal birth after Cesarean), this guest is correct that spontaneous vaginal birth is possible and with little risk even after repeat cesareans, especially since you have given birth this way in the past. However, getting a doctor and hospital to agree to this is another issue sometimes. While many support a decision to do a trial of labor, often with the requirement that the labor is spontaneous; not induced, a few years ago ACOG (American College of Obstetrics and Gynecology) issued a statement that has resulted in a huge decline in VBAC births and increase in repeat C-sections, bringing the U.S. to an all-time surgical delivery high.
Their guidelines indicated that a repeat c-section after c-section should be the standard unless the facility is equipped with a surgeon immediately available along with anesthesia and facilities should a cesarean be needed. They further recommended against VBAC following more than one cesarean birth. The result is that most smaller facilities refused VBACs even among mothers who have previously had a successful VBAC. They defined "immediate" as having a doctor and anesthesiologist on site throughout the woman's labor; not just on call. Since many smaller facilities with limited numbers of deliveries do not have that luxury, they created policy prohibiting VBACs in their facilities.
This is believed to be primarily due to liability issues. The risks of surgical delivery are less likely to result in legal recourse than the risks that MIGHT be associated with a VBAC, the primary concern being a very slight increased risk of the serious complication of uterine rupture in the latter - something that even occurs in women who have never had a cesarean. Surgical complications are less likely to be blamed on the doctor or facility whereas attorneys may claim they might have prevented complications resulting from a VBAC, had the decision been made to do a repeat C-section. I am not saying this is right; just that this is what motivates in today's U.S. liability-conscious medical world.
Rumor has it that ACOG will likely revise their statement in 2010 in response to the fallout from the previous statement which appears to be an overreaction to potential risks with little regard for benefits of VBAC and risks of repeat cesarean, especially as it relates to future deliveries, should the parents desire a larger family. In the future we may see another decline in cesarean rates as more women are allowed to delivery naturally.
But, other factors come into play as well when parents want to be in control of when their baby is born to accommodate schedules (theirs, their family's, the doctor's). They are often afraid of labor and delivery and even choose cesarean because they are more comfortable with it because they feel more in control, even though recovery is much more difficult, painful and with potential complications. People these days are not patient to let nature take its course and there is also an increased risk for babies who truly are post-dates. Optimal delivery of an infant is 39-40 weeks completed gestation. When a woman is 38 uncomfortable weeks pregnant and the doctor tells her s/he can deliver next week on Tuesday (for example) if it is by cesarean, or she can wait and see if she goes into labor spontaneously, risking a delivery up to three weeks later by her doctor's associate because her doctor may not be on call or available, the decision tends to go in favor of the repeat. Ethical issues are at play because it can be in the physician's best interest (and even the facility) from a financial, scheduling/time perspective to do a cesarean.
The amnio is one way for the doctor to feel confident that they are not jumping the gun and if a repeat is the only delivery method available to her (either because of doctor, hospital policy or personal health history, baby position, etc.). Though very small, there are some risks with the amnio and if this is the only way her doctor will do the earlier cesarean, he is being cautious about potential preterm delivery and her only alternative is to wait it out, get further clarification, or find a doctor she can feel more confident with. If a baby were to be stillborn or the baby were to aspirate meconium because the delivery was delayed to 42 weeks, this too would be a tragedy. It's always a judgment call which is difficult since we have no guarantees in this.
It is truly my hope that the revised ACOG guidelines will help this cause but in the meantime we have to work within the limitations we have and not knowing the policies of this woman's delivering facility, I could not advise otherwise.
I hope this clarifies the situation a bit. Good luck.
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