A few weeks back now, I had a new OB patient (G5P3013) that was a transfer of care from a physician who she said, "did not listen" and would not allow her to VBAC. Since our hospital is one of the few hospitals in the state that VBACs and has midwives, she decided to switch to our care. Upon taking her history, though, things just did not seem right. She could not recall much about her first 2 vaginal births and focused solely on her last birth which was a cesarean section. She was dismissive of medical history questions and kept interjecting her horror stories about her previous obstetrician. Her children were also the most unruly children I have ever experienced in an exam room. The patient had no control over them and they screamed, physically fought and clamoured up and down the walls and on anything else they could climb in the tiny 8x10 exam room. Ten minutes into our visit, I had a raging headache. I left the room to retrieve the US machine and conveyed my misgivings of the patient and her history to my preceptor. I also warned her about the screaming, but there was no need. She heard them from down the hallway. We both re-entered the room, US machine trailing us.
The appointment ends with the patient thanking my preceptor saying, "You are a wonderful doctor. I am so glad I switched." To which my preceptor corrected her yet again explaining that she was a Nurse Midwife. Ignoring my midwife, she then said, "And your assistant is wonderful too." Ha!
We were not sure what would become of her. We left the consultation taxed, harried, overwhelmed and not even sure if we even wanted her to remain our patient.
Today, a month later, her medical records came in from her previous physician. Lo' and behold, she has had not one, but three c-sections! We were shocked. What if we had never received her records? What if we had helped her to VBAC? The possibilities of what could have gone wrong are both unsettling and frightening!
I have a friend who VBAC'd after 2 c-sections & I am thankful she found a doctor willing to take her on a patient & so is she (there were not many that would do it). She had a wonderful VBAC.
ReplyDeleteThis patient has had 3 c-sections, not 2. And the problem lies in that she did not disclose this. Statistics show that risk of uterine rupture is increased with prostaglandin use in VBACs and you have to take special care with the use of pitocin if you use it. Without knowing her history, we could have caused her risk for uterine rupture to triple or quadruple. Primary VBACs are of course done at our facility, but since there are not firm stats on VBAMCs, those patients need to be taken on a case by case basis (why did they have a c/s?, how long since last c/s?, etc.) to weigh risk vs. benefit. And the patient needs to have informed consent, knowing the risks vs benefits, prior to her decision and delivery. Without disclosing truthfully her past OB history, there was no way to be able to give her informed consent.
ReplyDeleteI can understand the importance of disclosing information but I'm sure she was worried (& rightly so) that she would never have a chance to have a vaginal birth. Wouldn't you abstain from using pitocin at all in a VBAC? I would think that is the safest bet for VBACs & really the best option for most natural child births.
ReplyDeleteNo, pitocin can be used with VBACs and is sometimes needed to get labor started or if it has stalled. Prostaglandins are not used with VBAC candidates due to increased risk of uterine rupture. There are definitely times when pitocin has to be used as not all labors go to plan. I am not sure what this patient's agenda was, and I am not sure if there is anyone in the practice that will do a VAMC. We shall see what happens...
ReplyDeleteI know it is used w/ some VBACs, but should it be? I think in nearly all births it should not be used (as I believe nearly all births would be "normal" if left alone). In the very rare case of a labor that needs help, maybe I could see the risk being worthwhile. But with studies showing that rupture chances increase with the use of oxytocin makes me think that it should only be used in rare circumstances where the baby's life is as risk if it is not born soon.
ReplyDeletePitocin has been proved considerably safe via research to be used judiciously and with care in primary VBACs. In theory, it would be wonderful if no pitocin was ever needed, but in reality it is needed, even with natural births. Oxytocin, the hormone our own body makes, is sometimes not produced or not produced in large enough quantities to begin or complete labor. Often there are women whose water releases and they never have contractions or those who get to a 4 or a 6 and cannot progress on their own. Pitocin, the synthetic form of oxytocin, is then advantageous to those labors who would otherwise end in c-section. Pitocin can be used wisely and gently - giving someone just a whiff of pitocin to get their labor started or help them continue their labor. Using pitocin though in VBAMC is more dangerous as their risk for uterine rupture increases 2-16 fold (http://emedicine.medscape.com/article/275854-overview#aw2aab6b5) over those with only one previous c-section. With a primary c/s their rates of uterine rupture with spontaneous trial of labor (TOL) is 1 per 225, augmented TOL with pitocin 1 per 144, induced TOL with pitocin 1 per 125. Prostaglandins increase it to 1 per 63. With VBAMC their rates go up - spontaneous TOL 1 per 131, induced 1 per 54, and prostaglandin use 1 per 19. So, it is a big jump. And if we had not found out this information on this patient and then her labor stalled out or her water released and we used pitocin on her not knowing she had had 3 previous c-sections, it could have been quite a dangerous scenario for both the practitioner and the patient. I would never want a patient to die or their child to die under my care. I am not sure I would be able to live with that.
ReplyDeleteI just don't see how pitocin is needed in any significant number of births when home births don't use it at all. Sure, there are transfers to hospitals but most home birth midwives have less than a 10% transfer rate & even in a transfer, pitocin isn't necessarily used. So to me that says that in a healthy pregnancy & an unmedicated labor/delivery, 90%+ of women can go w/o pitocin & still deliver their baby w/o problems.
ReplyDeleteThis is one synopsis I found recently-
"Oxytocin (Pitocin) is widely used, so it is not surprising that this uterine stimulant has been administered in a majority of ruptures. One center found that oxytocin had been given in 77 percent of their ruptures and was typically used to stimulate labor in women with a prolonged latent phase. Misuse of oxytocin carries significant risks in any mother, and this risk may be increased during VBAC, especially at high infusion rates. ACOG guidelines and other authors indicate that oxytocin use during VBAC is acceptable. Induction of labor, regardless of the method used, is increasingly recognized as a risk factor for uterine rupture. Recent VBAC studies have shown three to five times more ruptures among induced mothers compared with those having spontaneous onset of labor." (Toppenberg, 2002)
Homebirth midwives DO use pitocin. They give it as an injection or have the patient inhale it. If you have someone that has released their water and is not contracting, you cannot allow them to become infected. Sure, it is advisable to try other things to stimulate labor, but sometimes those natural methods do not work and you have to use pitocin. It is not a horrible thing to administer if used judiciously and with caution. I have seen the midwives in Germany and the Netherlands use it and have talked to a local homebirth midwife who has used it in her births as well. I do agree that it can be misused (and often is), but it can also be used beneficially for the patient and fetus when labor does not commence on its own, labor stalls or water releases without labor beginning and natural methods do not stimulate labor. In the end though this patient is being released from care. She refuses a 4th c/s and there is not a provider who will agree to do a VBAMC.
ReplyDeleteMaybe home birth CNM midwives use it but non-CNM midwives do not, at least not the ones I have met & the ones I have used. I'm sure there is a need for it (just as there is a need for C-sections) but it should be used rarely for someone wanting a natural labor & especially w/ a vbac (imo). I really truly believe one intervention leads to another & it is a slippery slope when you start down that path. But you know I'm a no intervention kinda girl so I'm sure this isn't a surprise. :)
ReplyDeleteNo matter what your situation is, what kind of birth you're hoping for, etc, it is VITALLY important to be honest with your health care professional about your history, especially in a situation like this where both mama and baby could be at risk if the uterus were to rupture. Just because you want a vaginal birth, that doesn't justify putting your life and the life of your baby at risk. This lady needs a wake-up call. Kudos to you, Laura, for doing your research.
ReplyDeleteI am not sure on this Leslie but I think non-CNM midwives CANNOT use it because it is a Rx and they cannot write prescriptions. They do not have prescribing authority like CNMs do. It is true that aggressive interventions can lead quickly to a c/s, but most CNMs use pitocin very cautiously. Typically with a MD the RN will go up on the pitocin 2 drops every 15-20 minutes until the patient is complete. They are often confined to a bed and then end up getting an epidural because they cannot move to relieve the pain and the pitocin induced contractions are no longer mimicking normal labor. However, with CNMs, the go up by 1 or 2 drops every 30 minutes or more and stop when the mother is having a good contraction pattern, and most importantly, they are able to ambulate with pitocin. I even saw the other day pitocin being given up to 8 drops and then reduced and stopped once the mother's own oxytocin kicked in and labor then continued on its own from there. I definitely think minimal to no intervention is best policy, but sometimes interventions are needed to prevent poor outcomes or c-section.
ReplyDeleteThanks Alyson. You are right - it is far better to be safe than sorry. We just had a patient who had had 2 c-sections present for her 3rd yesterday. When they opened up the abdominal cavity they found the placenta had infiltrated through the uterine wall into the bladder and surrounding tissues. She had to have an emergency hysterectomy and lost well over 10,000 mLs of blood and had to have a massive blood transfusion. She is now in the ICU. She had no signs or symptoms and it was not seen on ultrasound. Had she tried to VBAC, she might not not be alive today. It is very important to always weight benefits against risk.
I agree that you have to be honest w/ your care provider, I was just saying that I can see why maybe she was afraid to be as so many ppl turn town VBACs. And the whole, "better safe than sorry" argument is why America is in this whole C-section epidemic crisis we're in so I'm not convinced that is the best policy to take on the matter. Definitely not reckless abandon either...
ReplyDeleteI had a friend VBAC yesterday in a home birth after 2 c-sections & everything went really well. Another friend of mine VBA2C'd 2 years ago w/ Dr. Ryan & it went very smoothly (no pitocin used at all as she wanted no interventions). Sure you can't take these 2 examples to say that it is entirely safe... just as you can't take your recent csection to say that it is entirely not safe. It pretty much is a gamble but stats do suggest that overall it is low risk.
Yes, you are right, non-CNM that do home births cannot prescribe pitocin. I do believe that most carry pitocin to use in emergency situations if there is severe bleeding after birth but none use it to progress labor. They use natural methods to stimulate labor if needed (which I am totally for) and generally give moms a lot of time to deliver a baby rather than saying that the baby needs to arrive w/in a certain amount of time. And with a transfer rate of less than 10% for a good home birth midwife, it shows that pitocin is not needed in the majority of natural labors. (Of course when you get into the epidurals & such, you are looking at a whole different type of labor.)
I am not saying that pitocin has no place... of course we need it and other meds (and c-sectoins for that matter) for true emergencies but it is way over used. Our bodies are designed & meant for birth & should be trusted to be able to do it w/o help from synthetics unless it truly is an emergency. I really don't think it should be used, even in small amounts, if a woman's labor slows. Maybe her body needs a break & it is all in the natural progression of things.
And just to reiterate that our bodies will deliver babies safely, look at Ina May Gaskins and her work at the farm. She is a CPM (so she doesn't rx meds, so no pitocin) & her stats are amazing! She is a very well known & respected midwife, has written many books. She has kept excellent records on all their births. Her transfer rate is only 4.9%! So that means that 95.1% of their 2,028 births are w/o medical intervention.
http://www.inamay.com/?page_id=28
Now those are stats to aspire to!
I am just not convinced. I would not take this patient on in my practise. Maybe if I had had heaps of experience with VBACing and VBACing wtih 2 c-sections, but to have 3, I would be quite nervous. We just had a huge catastrophe at our hospital with a placenta percreta due to repeat c-sections and there was another patient who when they did her c-section the baby's fist was through the uterine wall. Those type of things make me quite nervous. I would definitely agree that primary VBACing is relatively safe, but multiple c-sections increase the risk because the tissue is thinner, more scare laden and less likely to stretch as well as it would pre-caesarean. I think we need to focus on reducing the c-sections instead of increasing risk by trying to deliver all multiple c-section patients. Not everyone is a candidate.
ReplyDeleteStats show the chance of uterine rupture increases with each repeat c-section. It is even risky to do a repeat c-section. There is higher risk on both counts.
It is difficult to compare hospital births with home births. They are like apples and oranges. At home, your midwife is with you the entire time - that is not the case in the hospital. The midwife may have more than one patient laboring at the same time. Additionally there are doctors in hospitals that will begin to question why the labor is not progressing and why are interventions not being used to aid in the progression. This does not happen at home births. They are free to take all the time they want. Lastly, hospitals are businesses. You cannot have someone occupying a room for 2-3 days watching and hoping they labor. Sure we use natural methods in the hospital as well and we educate our patients to stay home as long as possible but sometimes these methods do not start labor. I have seen women do nipple stim, have their membranes swept, take herbs, etc., but sometimes they just do not work. Especially with VBACs. Their body was never in labor before (typically) and so it takes a lot longer to start labor as they are considered a primary vaginal birth. Additionally, if water releases, you only have 24 hours to get that baby delivered before infection sets in - which is much more likely to do in a hospital.
I agree that pitocin is way over used, but it does have a place and there is a need for it for labor dystocia or for induction if the patient is post-dates and the fetus is not showing reassuring signs.
I'll give you an example. The other day we had a patient in labor that went into labor on her own but had a very dysfunctional contraction pattern. After 8 hours, she was not changed from a 4. She did everything possible, tried every position and got into the tub. Nothing changed. At 10 hours she was a 6. At 14 hours she was a 6. She decided to have her water released in hope this would prevent her from having to have pitocin and allow her to labor on her own and progress. At 16 hours she was a 7. At 18 hours she was still a 7 and we started pitocin. At 20 hours she was a 8 and said she could not take it anymore. She got an epidural. The pitocin was only on 6 units (a very slow pit to organise and strengthen her contractions, but not horribly high), but she just did not have any strength left. At 22 hours she was a 9 but pitocin had to be stopped because the baby was having difficulty. There was a discussion about a c-section. This is the last thing the parents wanted and they both cried, but they were so spent by this time they just did not know what to do. I asked them to try one last thing - to get on hands and knees. Four of us turned her over. At 24 hours she was complete and we had her start pushing (still intermittent issues with baby). At 25 hours she delivered. If we had not used pitocin, she was would have been sectioned at a 6 for labor dystocia. I will use pitocin, hands down, to prevent a c-section.
ReplyDeleteI am not sure what Ina May does and I would love to go study and learn from her at The Farm, but she does have the luxury to labor on as long as she wants at her farm or at home births. It is not the same in hospitals.
Well of course she couldn't take it any more, she was having pitocin (unnatural) contractions, no matter how low the dose, they were not her own bodies naturally produced contractions. And being at the hospital for such a long time, laboring out of her comfort zone is also not so great for progressing labor. Of course I know that some women are just not comfortable w/ home births but those that want a natural birth should labor at home for as long as possible. It is unfair that the hospital has time limits they put on moms & this practice has lead to many c-sections. Yes, pitocin use before a c-section is the better option but a time limit is deplorable. I totally understand the hospital dynamic & needing to get women in & out but if that practice doesn't change, I don't see how we can hope to drastically change the c-section rate. And for me, the fear of someone intervening in my labor & delivery was so great the 2nd time that I opted out of the hospital system all together. But for this mom you mentioned, the breaking of the water was the first step down the intervention road, next the pitocin, & third the epidural. Yes, it is good that she didn't have to have a csection but knowing how powerful experience my natural unmedicated births were, I feel sorry that she lost the chance to have the birth that she wanted. If she were at home, or in a place w/o arbitrary time limits, she could have had that natural birth that she set out to have. Labors can take days... that doesn't mean anything is wrong. And why on earth was she being checked every hour? Especially after her water was broken??? All these things lead us further & further away from how nature intended us to birth our babies. I hope that you do get a chance to work with home birth midwives & maybe even those that don't have the ability to prescribe pitocin or other meds so that you can learn about what other effective methods are used (I have no idea since both of my labors were allowed to progress as they did, even w/ Isabella being born 10 days past due). To study with Ina May would be an amazing experience, I'm sure!
ReplyDeleteLeslie - she was checked every 2-4 hours. Typically if people are making good progress on their own there are no checks and there are no interventions but she was having a very dysfunctional labor that was apparent by monitoring. It was her choice about the water being released. She wanted to try something but not pitocin at that point. She wanted the labor to improve. She was exhausted due to the long labor, not the pitocin. The pitocin was at such a small dose that it was only stimulating a coordinated contraction pattern to help her uterus push the baby down. It was not causing more pain and she attested to that. She did not want the epidural but without knowing when the end would come and being so exhausted, she requested it. We talked to her at every step of the way and never talked her into anything. My midwife allows for a very patient led birth experience and only intervenes when there is a life at risk, and even then she discusses all their options and allow the patient to make a choice. That is informed consent.
ReplyDeleteI know you had 2 really great births, but not all are like that. I am sure you can remember back to your first one with not knowing when it would end and wondering if you could continue to go on. She really did an amazing job for how long she was in labor. She actually stayed home the full night before in labor without sleep so when she delivered she had been up for 48 hours. She was mentally and physically spent. I am sure emotionally as well.
The hospital is a huge system that one person cannot change. You can affect change with your patients and in small ways, but you cannot go and re-write the whole book of protocols that you are governed by. Especially not if you want to keep your job. I think it is good to desire change and advocate for change, but you have to understand that hospitals take a long time to change (as well as ACOG and physicians). I wish you could see how it is in the hospital and to work as a CNM. It is not the same as a CPM and it is not the same as home births. I doubt it ever will be. Hospital births in Europe are also very different than home births. You cannot get the exact same type of experience in a hospital as you can at home. It just does not happen anywhere. I hope to find a balance between medicine and no interventions whatsoever no matter what. I think there is a happy medium where you can give the patients the births they want in most cases, but that you are equipped and wise to know when to intervene to prevent complications. We had 2 other patients during this time and both of the other 2 patients delivered without pitocin, without an epidural, without their water being released and without any interference. One of them had a doula, which I highly recommend. A midwife cannot be with you the entire time in a hospital, so it is definitely advantageous to every mom that wants a natural labor with support to hire a doula.
I thoroughly enjoyed reading all these comments!
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