being 'allowed' to go beyond 40 weeks

Hi everyone,

I was wondering if any current or past VBACers could help me out with some questions, please:

I had my first appointment yesterday at the hospital, and I had my son with me, who was playing up, so I was too distracted to think ask this at the time.

Anyway, I'm a VBA(1)C patient, (my son was born via emercency c-section after FTP.) and the midwife I saw said that because I was a VBAC patient they wouldn't "allow me to go beyond 40 weeks", which I assume means they
would want to book me in an induction if I didn't go into labour naturally by the time I got to 40 weeks.

I have never heard of this before... is/was this the policy at your hospital?

In your experience, does this mean that basically my only chance of giving birth completely naturally is if I essentially went into labour early?

Do you think that if everything is going well throughout the pregnancy they would
let me go a few days to a week over the 40 week mark, to give me a bit more of a chance to go into labour naturally?

Finally, I am terrified of the idea of having an induction, especially given my VBAC status. (I want to research it more, but would almost rather another c-section ) Does anyone know what the risk of uterine rupture is for pregnancies that are 40 - 42 weeks, versus the risk of uterine rupture
for induced labours? If so, could you please point me in the direction of some studies?

Any thoughts would be very much appreciated

Amanda

Hi Amanda. When i had to see the OB at the hospital they told me something similar, although they phrased it that I might choose to have a c/s if I didn't go into labour before 40wks.

It is just ridiculous really. My DD was 12 days overdue and I don't expect this one to be here before my due date. They can not make you do anything. I will not be letting them induce me or do anything before 42wks. Have you got a Doula?? Might be worth a look for that extra support.

Induction for VBAC women increases the chance of rupture a lot! So it's pretty crazy that they would rather induce you and definitely increase the chances of rupture than be patient and wait for labour to happen naturally at the right time.

Sorry I don't have time to find the research atm but there are lots of studies you can find about how risky induction is for VBAC. Good luck!

My VBAC attempt was at 10 days post dates & I had been booked in to have my waters broken at 12 days post dates. I was told that legally they had to start inducing (or something) at 12 days over & noone is "allowed" to go further than that VBAC or otherwise. In the next sentence this midwife told me that some people just don't show up for their induction or s hedged c/section & the hospital can't exactly go to your house & drag you there ;)

You are likely to be in for a fight if you want to be left to go over your dates. I knew my due date exactly (bub was IVF) but they hospital changed to a later date because of ultrasound dates, so I went with that for the hospital appointments because it gave me more time. The hospital says DD was a week late, but she was definitely 10 days past my due date. If you can work things that way it's a big advantage IMO.

As for induction, you can actually be induced for a VBAC labour, it's just done differently. You have a few options...

If everything is favorable you can have your waters broken. The problem though is that you are then on the clock to get contractions started.

Either with AROM or without you can have a catheter induction, which is where a valor catheter is inserted into your cervix & "blown up" to dilate you to around 4cm which hopefully gets things started. If you're already dilating this won't help & there's no guarantee it will start contractions either.

The last option is a very gentle oxytocin induction. This is the normal drip induction but done very gently at the lowest possible dose for a short period of time. As with regular inductions it means your waters are broken at the same time the drip is started, so again you're on the click. Also there us the chance that the low dose won't be enough to start things going & after a c/section it's not safe to use a regular dose & increase it.

At the end of the day it has to be what you're comfortable with.

Good luck!

As sarah said, they can't force you to go in after dates and I would make it clear that you do not intend to be induced until x days after a due date.

I am lucky in that the ob I saw at my hospital is happy for me to choose the time when I consider it's enough. Basically when I get to my due date I am going to work out how much longer I will wait for (at the moment thinking 10 days or even 2 weeks) and let them know. If I hit this date without any sign of labour commencing, I will go in for an internal. If the cervix is favourable then I will have AROM as an induction method. No other induction will be used, so if I'm not favourable at that time, I need to be prepared that it will be a c-section at that time.

I would discuss this approach with your hospital. Be firm and say this is what you need. It seems ridiculous that they should expect the baby to come early.

Will be back later on my lappy, on my phone but my hospital wanted me to book in at 9 days over. I refused and got to 14 days attempting my vbac but my stubborn boy wasn't coming out so no it's not dangerous and I would say that you can say YOU won't "let" them force you to go earlier. I told the ob who wanted to book my cs in at 9 days that she could go ahead and book but I wouldn't be there.

My hospital went with my OB's preferences. I was "allowed" to get to 10 days post dates and then he would talk about options. I don't think he really pressured me early on because DS was 3 weeks early so he didn't expect me to get to 40 weeks at all. I made it to 38w4d.

A fe other things now I am home and can read properly! Not sure what hospital you are going to? Im in Melbourne too and went to the Mercy in Heidelberg and they don't induce for VBAC's so if they are saying 40 weeks it could mean they want to book a c/s at that point. You can question why that would be the case if everything up to that point is going ok? I had monitoring every 2 days after 6 days overdue for my own and their reassurance. Unless they are willing to "gently" induce then yes they are basically saying you need to go into labour before that time which is ridiculous and there are no vbac indicators for rupture after 40 weeks.

If all is well I would definitely be telling them that you would like to go over the 40 weeks even if it means having to have scans to check placenta etc in that time. There is no significant increased risk of rupture over 40 weeks, however the risks are higher with induction

Here is an except taken from a site, listing quite a few studies.

I'd be very cautious about induction for a VBAC. It can be done safely if very conservatively monitored but should be avoided. In this case, routinely inducing for 41.5+ weeks would seem a tad premature. I would go for a biophysical profile first and get some confirmation of bub's condition way before deciding to induce. Here is some research that may interest you:

The risk of symptomatic uterine rupture does not increase for women awaiting spontaneous onset of labour after 40 weeks (in the absence of other risk factors) (Zelop et al. 2001). However a higher risk of UR is associated with induction after 40 weeks.

Zelop, CM, Shipp, TD, Cohen, A, Repke, JT, Lieberman,E. (2001).Trial Of Labor After 40 Weeks’ Gestation In Women With Prior Cesarean. Obstetrics & Gynecology 2001;97:391-393

“When comparing the women having a trial of labor, the 70 with uterine rupture more often had induced labor (24.29% compared with 13.92% in the nonrupture group; P = .013)”

Rageth, JC., Juzi, C, Grossenbacher, H., (1999). Delivery After Previous Cesarean: A Risk Evaluation. Obstetrics & Gynecology 1999;93:332-337

Oxytocin used before active labour increases the risk of uterine scar separation and the longer it is used the greater the risks.

Leung AS et al. Risk factors associated with uterine rupture during trial of labor after caesarean delivery: a case-control study. American Journal of Obstetrics and Gynecology 1993; 169(4):945-950.

Prostaglandin used to ripen cervix is also associated with higher risk of rupture.

Induction of Labour for vaginal birth after caesarean delivery. Committee on obstetric practice. The AmericanCollege of Obstetrics and Gynecologists, Washington DC. In International Journal of Gynacology and Obstetrics, 2002, Jun: 77(3): 303-4.

Good luck with it all and I would definitely be talking to your caregivers about your concerns and options. Remember yes they can bully you, scare you and lie to you (and they do) but you are brave and smart enough to research yourself and basically say NO to anything you are not comfortable with. xox

My vbac attempt i was "allowed" to go to 10 days over before 1. seeing if ARM was an option for induction or 2. booked in ceaser.

Lucky enough i was in labour before then...just. Not sure what i would have done if i havent of gone into labour myself.
Good luck

There is no increase in risk of rupture if you go overdue, there is no evidence that anything related to your previous c section goes wrong just because you got to your due date, big babies, ruptures, blah blah blah, they are medical myths that have entrenched themselves in medical practice. I birthed a 10 day overdue 10 pound baby after 2 c sections, I did heaps of research and knew my actual medical facts so well that I confronted doctors on nearly everything. In any pregnancy, things can go wrong at more than 2 weeks overdue, but this can be monitored. I birthed with the caseload program at sunshine, I had continuous care with 2 midwives the whole time, so we understood and trusted each others feelings on birthing, and both knew where the line would be drawn. Birthing with a known caregiver who you trust makes all the difference. Even if you go for a c section you can do it on your terms. When it comes to being allowed, my response was generally " how are you going to stop me" I made it very clear that I would not even consider a c section unless there was a medical problem. Just being overdue is not a medical problem. Most hospitals will not induce, most will put a limit on how many weeks and how long you can be in labour. THere is no medical evidence to support this being good medical practice, it has just become entrenched.
If you are interested in more specific statistics, I can go on about it, having done so much research myself. Basically, in the context of our medical practice, which is using a lower uterine incision, double sutering, not inducing or augmenting, the actual risk of "rupture" is 0.2%. It doesn't really change no matter how many you have had.
The medical definition of rupture includes anything from a small tear in some layers of the tissue (the scar goes through all layers of the uterus, stomach muscles - when we think rupture we imagine the whole thing ripping open from one side to the other) which is a non medical event, to the medically traumatic tearing of the whole thing. I can't remember what the breakdown was, how many of the 0.2% of women who experience rupture were medical events. From memory many of them where discovered after birth, when an ultrasound was down and small tears were discovered. A medical intervention is only justified when the risk involved outweighes the risk of not, many obs do a c section when there is no evidence that you are at risk, therefore they are subjecting you to potential harm for no good reason. I always asked for specifics, and for supporting evidence, which most obs didn't like. It is their opinion, not fact.
Anyway, good luck, I found this forum indispensable when I was working up to my VBA2C, ask away, obs are very good at undermining your confidence, so are people, as the attitudes are entrenched everywhere you go. Everyone knows everything and they all feel the need to put their two cents in.
Kate