All about EFM - a letter to my doctor

Dear Dr ....

Thank you for seeing me last week. I think we both know that I was disappointed in how our conversation progressed. As I didn’t feel particularly able to put my case effectively on the day I thought I would write to you about my concerns.

As I said to you, I am very keen to avoid a c-section with this baby. The reasons are:

• Recovery time (I have three other children to look after)
• The risks of abdominal surgery are not to be taken lightly for mother or baby
• Bonding with the baby will be better after a VBAC
• The knowledge that if VBAC is successful, it gives a better outcome in so many ways for both mother and baby
• From experience, the whole thing is not a pleasant procedure.

I am extremely motivated to do everything in my power to labour successfully and deliver vaginally. Having said that, as with life in general, obviously there are things that are in fact, out of my power, and as a sensible person, I know that I need to be flexible and accepting of things that may not go the way I intend.

Like someone who drives a car (and takes a risk of death or injury every time they do) however, I will take every care to both have a good ride and get everyone to the destination safely, as far as I am able.

So, to the issues.

Uterine Rupture

As you stated, it’s well known that uterine rupture and dehiscence pose a risk to VBAC mothers. The commonly accepted risk is 1 in 200 or 0.5%.

I enclose an article that goes more into the specifics of various risk factors. According to this article, the risk of uterine rupture for me is brought lower by the fact that I have had four years between births, and I have had two previous vaginal deliveries.

I am also aware that the risk of having to have an emergency c-section for other acute conditions such as fetal distress, cord prolapsed or antepartum haemorrhage in any woman giving birth is approximately 2.7% - many more times as high as the risk of uterine rupture with a trial of labour, according to ECPC (Effective Care in Pregnancy and Childbirth, eds Enkin, Keirse, Renfrew and Neilsen).

Monitoring

Because of the risk of uterine rupture, continuous monitoring appears to be standard for VBAC, as fetal heartrate can be one indicator of rupture or dehiscence. I understand this and applaud the motive of care.

From what you said, I understand that you require continuous electronic fetal monitoring for your VBAC patients. However, my argument is that EFM has not necessarily been shown to be more effective than intermittent auscultation, which is what I am proposing for my labour.

I enclose an article from the New York Times which says that a study by Donna Stroup and Herbert Peterson, published in the journal of Obstetrics and Gynecology (86 [4Pt1]: 613-20, 1995 Oct), found that ‘electronic monitoring was not measurably better in spotting distress and indicating that intervention was necessary than the traditional practice of intermittent auscultation’.  In fact, ‘electronic monitoring was associated with a higher rate of Caesarean deliveries which increases surgical risks to mothers.’

In a study by Kaiser, published in the Journal of Fla Med Assoc 78:3037, it was found that ‘randomised clinical trials of the past 10 years have compared electronic monitoring to routine periodic auscultation and have consistently failed to demonstrate a statistically significant difference in either the perinatal mortality rate or the outcome of high risk pregnancies’.

A study by Prentice and Lind in 1987, published in The Lancet 8572:1375-7 found that ‘of the ...trials... none suggested any major advantage of continuous fetal heart monitoring over intermittent surveillance in terms of neonatal mortality, morbidity, cord blood PH values or the five minute Apgar score. The rates of C-section and forceps delivery were higher in the continuously monitored group.’

And in a study by Sandmire in 1990, published in Obst Gyn 76:1130-4, it was found that, ‘after reviewing several research studies, the American College of Obstetricians and Gynecologists concluded that EFM and intermittent auscultation are equivalent methods for intrapartum assessment.’

It is true that intermittent auscultation may be a problem in a busy labour ward, where there may not be the staff to patient ratio needed for such monitoring. In this case, I can understand how a machine may be more reliable than a person. However, attending my birth will be F...., an experienced mid-wife, currently employed at ......   She will be there from start to finish and will monitor me by Doppler every fifteen minutes, before, during and after a contraction.

I am also willing to hook up to the EFM every hour or so for 15 minute periods of continuous monitoring. If ...... hospital had a telemetry monitor, I would be more than happy to use that as well. If you know where to get hold of one, I am willing to rent it for the period.

The reason I am arguing so strongly against continuous EFM using the belts is that I know that I cannot move around or stay active when I am hooked up to them. I have done this twice before, and both times I have ended up stuck on a bed in a painful position where active labour has been impossible. Studies show that CEFM slows down labour. From my experience, I believe it. If I am going to succeed in birthing vaginally, I need the opportunity to stay upright and active and being belted up to the monitor will not let me achieve that.

In any event, it seems illogical to me that when the risk of c-section for reasons like fetal distress and cord prolapse is much higher for mothers across the board, than the risk of uterine rupture, that VBAC mothers alone should be continuously monitored.

Induction and dates

Obviously, and in agreement with standard practice, I do not want to be induced into labour as most forms of induction increase the rate of uterine rupture.

However, I also don’t want my waters to be broken. An article entitled Intervention Management – the New Normal, by Melanie Jackson, published in Midwifery Matters, March 2009, puts it like this: Each intervention has iatrogenic side effects which often require management with an additional form of intervention; this sets up a process which is defined as ‘the cascade of intervention’.

Thus, I will do everything in my power to get my labour to start spontaneously.

However, I am very aware that none of my three births have begun spontaneously before 40 weeks, and I heard you being extremely definite about induction at 40 weeks maximum.

Your reason, it appeared to me, was because of the risk of stillbirth after 40 weeks because of my gestational diabetes.

I have attempted to do research on this, but the most information I have been able to come up with tells me that it is untreated diabetes that increases the stillbirth risk. My diabetes is very much treated and I am very motivated to keep my blood sugar levels low and my diet healthy. I will take insulin if it’s needed, but so far, things look good, according to my endocrinologist.

I understand that, approaching 40 weeks, the risk factors to look for include evidence of fetal distress and/or placental calcification which can be done through a non-stress test and ultrasound. I would be keen to read more studies on this topic, but it would seem that if all the test results were good, I could at least wait 7 to 10 more days before embarking on the induction or c-section route?

Macrosomia

Another issue is of course, the size of the baby.

I understood that you were telling me that even though I was keeping my GD under control, that wouldn’t necessarily have an effect on the baby’s size.

However, a study by Wechter et al, published in Am J Perinatol 1991 Mar;8(2):131-4 found that ‘the incidence of fetal macrosomia in gestational diabetes can be kept equal to that of the general population by a program of intensive dietary therapy and home glucose monitoring, with insulin being used only therapeutically, not prophylactically.’

If, however, the baby does grow to a macrosomic size, the question of management becomes important.

In an article published in American Family Physican, Jan 2001, Zamorski and Biggs argued that in a 1989 study macrosomic infants did not increase the risk of uterine rupture in VBAC mothers. They did find that the risk of shoulder dystocia was higher in diabetic mothers, but concluded that, ‘Macrosomia remains a common complication of pregnancy; its prediction is imperfect, and there are no reliable interventions to improve outcome in uncomplicated pregnancies. Elective caesarean section is seldom a suitable alternative, and elective induction of labour appears to increase rather than decrease the c-section rate. ...For almost all macrosomic pregnancies including diabetic mothers, previous deliveries with shoulder dystocia, or women considering VBACs, expectant management with vigilance for evidence of fetopelvic disproportion will have optimal results.’

You agreed with me that the size of the baby at this stage seems normal and certainly not above average. As long as this remains the case, and while placental function remains fine, I don’t see that an induction or c-section at 40 weeks is necessary. On my history, 41 weeks seems more reasonable.

I would be happy to go in for daily monitoring from 39 weeks if it is appropriate, and let the decisions be made from the results.

So, will you be my doctor?

I will be disappointed if you find yourself still unable to take me on as a patient. It’s true that I have some strong ideas about how I want this birth to go, but I’m not insensible of the risks, and I’m not a person who wants to harm herself or her baby.

Rather, I want to explore all the options that are open to me and find good compromises so that I can give this VBAC the best possible chance of success. I hope that you might find yourself able to support me in this.

With thanks for your time, CP