Thinking of asking my doc for more weeks - update at end [Archive]

KBecks

09-16-2008, 01:44 PM

OK, I have planned c/s deliveries due to a large incision from prior fibroid removal. The general routine is to have a lung maturity amnio test at 36 weeks, and if it shows mature, then deliver right away, if not, wait a week or more (both boys were born at 37 weeks).

Talking to my pp doula and the pediatrician, early means more difficulty feeding and greater likelihood of jaundice (both boys had).

I understand my OB is about minimizing risk. I am wondering about negotiating with him on going to maybe 38 weeks or just a little longer.

I have never been in labor. I have had some contract-y feelings but not often, no big deal.

Does anyone have access to statistics on when labor usually starts? I'd just like to know what the chances of going into labor at 36 weeks vs. 37, 38, 39, etc. Maybe we could let the baby stay in a little longer -- I know most pregnant moms are uncomfortable at the end, but I'd ask for more time if I can do so and I understand the differences week to week.

Thanks!!

maestramommy

09-16-2008, 02:05 PM

What are the consequences of going into labor, then having a c/s? I guess if I had my druthers 38 weeks is a lot better than 36, but Arwyn was born at 39 weeks and she still had jaundice. Although that may be due partly to our ethnicity.

ZeeBaby

09-16-2008, 02:19 PM

I had a cs at 38 weeks because of prior myomectomy as well, I was scheduled for 39 weeks, but I was having NSTs to monitor the baby and they noticed my fluids were low. Maybe you can request extending the time via NST's and biophysical scans

SnuggleBuggles

09-16-2008, 02:34 PM

I agree- what are the concerns if you do go into labor? If the risks are not that high then I would personally stretch out the pregnancy as long as healthy for you and baby (even past 40 weeks). 39 weeks makes a decent time to schedule. You can feel pretty good that baby is full term and you'll probably not have gone in to labor yet. Even if you go into labor it usually isn't a problem to do the c-section in early labor.

There is a study about "near term babies" (35-37 weeks) and the variety of health problems they can face. Since EDDs can be off by 2 weeks (even with certain dates we don't know for sure whether, if left alone, baby would come at 42, 40 or 38 weeks) baby could only be 35 weeks mature at 37 weeks, for example.
..." The research team examined records of infants born at Massachusetts General Hospital over a three-year period. They randomly selected groups of full-term (37 or more weeks) and near-term newborns for whom adequate information was available and who had no major health issues at birth, ending up with 95 full-term and 90 near-term infants. In addition to reviewing their charts for problems that developed during the infants' hospital stay, they also analyzed the costs incurred.
The near-term infants had significantly greater risk than did full-term infants of being diagnosed with many clinical problems - including jaundice, hypoglycemia (low blood sugar), respiratory distress, the need for intravenous feeding, and difficulty maintaining body temperature. They were also more likely to have multiple problems; 18 of the near-term infants had six or more diagnoses, a situation found in none of the full-term babies."...
http://www.mgh.harvard.edu/news/releases/080204wang.html

I used to have a link that charted when most babies are due in relation to their EDD but I can't seem to find it. As you can imagine it was a pretty good bell curve with the peak around 4 90% of babies will be born by 42 weeks, I know that one from the ACOG book. :)

GL! I say if it is safe for you to let baby cook a bit longer that would be the way to go. I like my babies big, sturdy and ready for the wrold. And, I have to admit, I like them in there a bit longer so I can have some "me" time before newborn baby world kicks in!

Beth

lilycat88

09-16-2008, 02:41 PM

I was a planned early c-section as well due to my OB not wanting me to go into labor. Different reason than you, though. I have a double uterus, double cervix, vaginal septum. They had no idea what would happen IF I did go into labor. I never had any contractions to my knowledge. We did a lung maturity amnio at 37 weeks and delivered that day. I never left the hospital. If I ever have another one, I am going to push for at least another week. DD was big at 8 lbs. but had feeding difficulty, jaundice that required readmission at 11 days old, breathing issues that required several hours of observation in the NICU and she still has asthma and respiratory issues. I understand my OBs concern but I feel more educated now about the potential risks of a near preemie and would push a little harder for more time.
Jamelin

egoldber

09-16-2008, 02:52 PM

The idea is that since you have prior uterine surgery you are at higher risk for rupture with labor, any labor. And since some ruptures are spontaneous, but tend to happen after 38 weeks.

I faced the same dilemma with Amy. With my history, we were going to do the amnio at 36 weeks and then deliver, but we ended up delivering at 34 weeks because of I was having strong contractions that could not be controlled with meds.

All that is to say....does your OB have risks and studies that he/she is consulting or is that just "what they do". Do you have a high risk OB/peri or just a regular OB? The reason I ask is that IME peris are actually more likely to give weight to research and balancing risks rather than doing anything at all costs to avoid any risk.

If I were in your shoes and were not having any signs of labor or contractions, I would be comfortable going to 37/38 weeks. Anything before 37 weeks is consdired pre-term and the babies are much more likely to experience jaundice, slow to eat, etc. I did exclusively breastfeed Amy, but I had to work VERY hard at it and be 100% committed to it. I had my MIL come and take care of Sarah, so my only "job" for the first several weeks was pumping for her and feeding her until we got her to the breast full time. If I could have I would have done what I could to get her to 37/38 weeks.

KBecks

09-16-2008, 03:29 PM

All that is to say....does your OB have risks and studies that he/she is consulting or is that just "what they do". Do you have a high risk OB/peri or just a regular OB? The reason I ask is that IME peris are actually more likely to give weight to research and balancing risks rather than doing anything at all costs to avoid any risk.

If I were in your shoes and were not having any signs of labor or contractions, I would be comfortable going to 37/38 weeks. Anything before 37 weeks is consdired pre-term and the babies are much more likely to experience jaundice, slow to eat, etc.

I have a regular OB and I believe he is up to speed with research. I think he will be open to negotiation and certainly discussion about waiting longer. My "pre-op" appointment is Thursday, so I can talk to him then about it.

I'm not sure if I have had contractions or not. I don't really know what a contraction feels like. I have had some "woah" kind of twangs here and there, but it's occasional and they are isolated, not repetitive. I didn't have those feelings with either of the boys so I'm guessing they may be contractions or Braxton Hicks? I don't know. A friend said that anything that felt like stretching muscles was a contraction but I thought that was just my abdomen stretching as the baby grew and grew (earlier on).

I am kind of lucky that both boys did well when they arrived at 37 weeks although Alek had more of a hard time BF (which could also be due to a slight tongue tie) and John was better. Both boys were circed and I felt that was a setback to our breastfeeding, we are not circing this baby. Alek had to go to warmers after birth for a little while to get his temp up. Both had jaundice but no lights or special treatment (lots of doc visits to check bili in the first week or two). Both boys ended up being supplemeted with formula from early on.

I think if I can wait until 37-38-39 weeks with relative safety and have better odds of avoiding jaundice and feeding difficulty that would be awesome.

What is NST? Nevermind, I've got Google!

egoldber

09-16-2008, 03:34 PM

NST = non stress test

Basically they hook you up to monitors and get a 20-30 minutes tracing on baby's heart rate. They are checking to make sure baby is not under any sort of stress which can be an indicator of problems.

I would tell your OB what you prefer and see what he says.

annasmom

09-16-2008, 04:06 PM

From what I have gathered in my own experience, everyone is different. It really depends on the condition of your uterus.

If your OB did your previous deliveries, perhaps he will have a good idea about your scarring already. However, looking at a uterus at a c-section won't tell an OB how THAT incision will scar & heal.

I too have to deliver at 36 weeks. When I was pregnant with my ds#2, I was able to push off delivery for a few days merely because of a scheduling issue (my dd was starting school and I didn't want to miss it). So I delivered at just shy of 37 weeks. After that delivery however, my OB was very insistent that he would not let me go past 36 weeks for another delivery - but that was based on his assessment of my uterus, my scarring.

Are you scheduled for nst's at the end of your pregnancy?? I would talk to your OB - he/she might be open to letting you go longer as long as everything is proceeding well.

Good luck!

KBecks

09-16-2008, 04:14 PM

I'm not scheduled for NSTs, just the lung maturity ultrasound/amnio which is scheduled for next week Tuesday, and they would deliver that night but I think I'm going to tell my OB that I'd like to cancel that and wait until at least the following week. I wonder if at the ultrasound they'll get a better idea of gestational age? We weren't paying attention to the conception date and last menstrual period so those dates could be a little fuzzy.

I've had a good relationship with my OB and he's been my doc for years, he did the fibroid surgeries and he's said at my last appointment that my uterus seems to be doing well after all the surgery/deliveries.

I've been feeling very well, just those occasional twangs and feeling heavy in the abdomen and tired legs at the end of the day but I think that's all very normal. I'll want to ask about how it would work if we wait and then I'd assume if I had contractions I'd call him and possibly go to the emergency room -- not the greatest Plan B, but it doesn't seem to me very likely that I can't make it to 38 weeks safely. (On the other hand, I don't want to take on a lot of risk of rupture.) It will be interesting to hear what he has to say about it.

annasmom

09-16-2008, 04:24 PM

SnuggleBuggles

09-16-2008, 04:27 PM

By the 3rd trimester the accuracy of u/s dating is pretty bad. They probably wouldn't use it.

Beth

egoldber

09-16-2008, 04:27 PM

I wonder if at the ultrasound they'll get a better idea of gestational age? We weren't paying attention to the conception date and last menstrual period so those dates could be a little fuzzy

Did you have an ultrasound in the first trimester? Ultrasounds done in the first 10 weeks are far more accurate for dating than later ultrasound.

jk3

09-16-2008, 04:35 PM

I would not want to take the risk and would opt to deliver at 37 weeks. My 2 were delivered at 35 and 38 weeks and were perfectly healthy with no issues though I know this can vary.

ZeeBaby

09-16-2008, 04:40 PM

I would definitely suggest you at least discuss NSTs and biophysicals with your doc. Of course your doc will know best since he knows your history, but you want to at least try to see what other options are available to you. I did a lot of research before delivering my baby, based on my history of previous fibroids and the surgery. I discussed all the options with my doc and I think we came to reasonable resolution. Here are some info links:

http://www.americanpregnancy.org/prenataltesting/non-stresstest.html

http://www.bchealthguide.org/kbase/topic/medtest/tw9854/descrip.htm

KBecks

09-16-2008, 04:57 PM

I would call your OB right away and schedule a time to talk to him about this asap. My concern is that the longer you wait, they less likely they will want to cancel the amnio simply because of scheduling issues.

And, your plan B isn't really all that bad when you think about it. If you went into labor right now, your OB has probably told you that you will need to go to the ER and have an immediate c-section, right? So it isn't too different from your plan B right now. That is how it went with me at least - I was told that I may NOT go into labor (how I could stop it, I just don't know, lol) and that I was to go immediately to the ER if I did.

I was thinking I could do the amnio anyway, but just reschedule the surgery (which is tentative based on the amnio test results.) We can still find out how the lungs are developing, but if they show mature, we'd just wait anyway as if they didn't test mature. We waited an extra week with both boys because the test results were close, but not high enough. There was never a big deal about waiting a week. I don't see why delaying the amnio would be necessary? (I'm looking forward to the ultrasound part!)

I'm seeing my OB Thursday for a measure and to talk about the surgery, so just two days!

I think if I were to go into labor now, I'd call the OB office and then probably meet whichever of their docs is "on call" at the hospital? I think that's how it works -- I really don't know -- we haven't talked about that in a long time and so I need a refresher on what to do and how that all works out. Hopefully we won't need it but it's good to be prepared!

KBecks

09-16-2008, 04:59 PM

Did you have an ultrasound in the first trimester? Ultrasounds done in the first 10 weeks are far more accurate for dating than later ultrasound.

I don't remember -- is that awful? I think I had one but it may have been at 12 weeks? I have photos in the baby book and I could go check the dates. But I think it was pretty early and they did set the edd at 10/23/08 or agree to it or whatever.

Ceepa

09-16-2008, 05:08 PM

Karen,

I was a repeat C. Near the end of pg I had two NSTs and a late U/S. I was scheduled at 39 weeks for the section on a Monday. All was looking well until in the middle of the night Saturday I started having regular contractions. Called my OB in the morning. At the hospital they hooked me up to monitor how regular/strong my contractions were. Because I was at 39 weeks and was planned to go for the next morning we just went ahead and did the section. So I was laboring for about 10 hours by the time I had the repeat C. The contractions were regular and close together but never reached an extremely painful level.

KBecks

09-16-2008, 05:09 PM

I want to say thanks everyone too, I love you for talking about this with me! It's awesome to be able to chat and I really appreciate it.

annasmom

09-16-2008, 05:27 PM

[QUOTE=KBecks]I was thinking I could do the amnio anyway, but just reschedule the surgery (which is tentative based on the amnio test results.) We can still find out how the lungs are developing, but if they show mature, we'd just wait anyway as if they didn't test mature. We waited an extra week with both boys because the test results were close, but not high enough. There was never a big deal about waiting a week. I don't see why delaying the amnio would be necessary? (I'm looking forward to the ultrasound part!)

I don't remember, but would you need the amnio if you delivered at 37 weeks?? Of course it would do you a world of good to know that the baby's lungs were mature, but I honestly don't remember when they stop doing the amnio for lung maturity.

LBW

09-16-2008, 06:23 PM

I've never had a c-section, so I have nothing to contribute. :)

I do, however, want to say that I'm amazed that you are due so soon - it seems like you only just posted that you were expecting! Good luck with everything!

mamicka

09-16-2008, 06:42 PM

I have nothing to add except that I think telling your doc you'd like to wait is fair.

I can't believe you will deliver so soon! Best of luck to you, Karen. I'll call you soon.

ThreeofUs

09-16-2008, 06:52 PM

I'm going in for my c-section next Wednesday, at 39 weeks gest, b/c my OB specifically wants to give the baby a lot of womb-time to gestate. (In fact, the practice pretty much refuses to do c's until after the 37 week mark.) Until then, I've been having NSTs and BPPs weekly.

On the NST, they want to see 4 periods of fetal heartrate 15 points above resting, with associated activity. On the BPP, they look for "practice" breathing, limb movements, body movements, and amniotic fluid volume. Taken together, these 5 points give a very good picture of how the baby is doing. So, if you wanted to stretch out your time, I'd suggest these to your doc to get you at least past the 37 week mark.

That said, I thought the take on incisions and ruptures was that even VBAC patients had very few ruptures from uterine scars. ITA about being conservative, but it takes quite a bit to rupture a well-healed incision - more, that is, than a few contractions. A good article is on obgyn net:
http://www.obgyn.net/displayarticle.asp?page=/pb/articles/uterine_scar_rup

Good luck with negotiating with your doc - and let us know!

SnuggleBuggles

09-16-2008, 08:06 PM

[quote=KBecks]I was thinking I could do the amnio anyway, but just reschedule the surgery (which is tentative based on the amnio test results.) We can still find out how the lungs are developing, but if they show mature, we'd just wait anyway as if they didn't test mature. We waited an extra week with both boys because the test results were close, but not high enough. There was never a big deal about waiting a week. I don't see why delaying the amnio would be necessary? (I'm looking forward to the ultrasound part!)

I don't remember, but would you need the amnio if you delivered at 37 weeks?? Of course it would do you a world of good to know that the baby's lungs were mature, but I honestly don't remember when they stop doing the amnio for lung maturity.

It varies by practice but, imo, the reponsible ones do it even at 37-38 weeks. Anything before that magic 39 week mark but definetly at 37 or early 38 we.

Beth

KBecks

09-16-2008, 09:25 PM

Ivy, thanks for the link and good luck!!! I think my incision is a classical, at least my scar on the outside runs from my belly button to my pubic bone. I'm not sure what the insides look like. :)

egoldber

09-16-2008, 09:26 PM

ITA about being conservative, but it takes quite a bit to rupture a well-healed incision - more, that is, than a few contractions.

Scars from a low transverse incision (as is typical in most c-sections) is low risk to rupture. (Alas, low risk, does not mean no risk....). However, scars in the upper part of the uterus are considered higher risk because they are in the part of the uterus that experiences the greatest force from contractions. And if they do rupture, these ruptures are in a very vascular area of the uterus and tend to be more serious than a typical rupture.

ThreeofUs

09-16-2008, 10:08 PM

Karen, m'dear, I wish you and your new little one the very best - whichever course you take. We should exchange phone numbers; we're going to be up at the same times over the next few months! ;)

Scars from a low transverse incision (as is typical in most c-sections) is low risk to rupture. (Alas, low risk, does not mean no risk....). However, scars in the upper part of the uterus are considered higher risk.
Certainly. And since Karen says her scar is classical, ITA she's at higher risk. (To be fair, this is in the link I posted.) I wasn't suggesting throwing caution to the wind; I'm saying that the risks are pretty low for what she wants to do. That is, go for a couple more weeks and then have a section - with plan B being run to the hospital if she starts to go into labor.

We're talking under 2% for a classical incision - though some small studies cite rates as high as 12% - with full trial of labor (TOL), not some contractions and then a section. I know some folks can't get pubmed, so here are a couple of available studies that would help with risk evaluation:
-Chauhan et al at http://www.greenjournal.org/cgi/content/full/100/5/946 for a good study
-Nahum at http://www.emedicine.com/med/topic3746.htm for full overview of current stats up to about 2005 with discussion.

egoldber

09-16-2008, 10:27 PM

I'm saying that the risks are pretty low for what she wants to do. That is, go for a couple more weeks and then have a section - with plan B being run to the hospital if she starts to go into labor.

I'm not disagreeing that it's low risk. Which is why I said if it were *me* I'd feel comfortable waiting. :)

My comments were meant more to illustrate that there are particular risks to scars from myomectomies that are not there for prior cesarean scars, namely that the location makes a rupure, unlikely as it is, more serious on average than when a cesarean scar ruptures. The women I have met on-line with fundal ruptures pretty much all had very negative experiences.

ThreeofUs

09-16-2008, 11:53 PM

My comments were meant more to illustrate that there are particular risks to scars from myomectomies that are not there for prior cesarean scars, namely that the location makes a rupure, unlikely as it is, more serious on average than when a cesarean scar ruptures. The women I have met on-line with fundal ruptures pretty much all had very negative experiences.

Ahhh, gotcha. I found the second (survey) study interesting because it had data on these scars, too.

sariana

09-17-2008, 12:08 AM

I think one of your questions was "What does labor feel like?" I actually can't answer that question very well, so here's my convoluted response to your post:

As the mother of a 32-weeker and a 36-weeker, I am all for extending a pregnancy as long as possible. But you do have to ask yourself: Do you trust your doctor? I imagine he is recommending what he thinks is best for you and your baby.

As for labor, with both of my children, I went to the hospital because I had bloody discharge, the first time at 29 1/2 weeks and the second time at almost 36 weeks. Both times I was having contractions 2 minutes apart. I felt NOTHING. With my first, they gave me meds to stop the contractions because it was so early. I got 2 1/2 more weeks, but my water broke at almost 32 weeks. Even then, I did not feel anything for several hours (but then WHOA--give me that epidural!). With my second, the baby was breech, so I had to have a c-section, not emergency, but urgent. I never got to the point that I felt any contractions. So not feeling anything is not necessarily a sign that labor is far away.

Just a question: Did you get a steroid shot to help develop baby's lungs? I had one for both of mine, and neither DS (32 weeker) nor DD (breech 36 weeker) has had any breathing issues. It is my understanding that there are no known risks with getting the shot; for my second is was given only as a precaution and turned out to be unnecessary.

annasmom

09-17-2008, 07:20 AM

Just a question: Did you get a steroid shot to help develop baby's lungs? I had one for both of mine, and neither DS (32 weeker) nor DD (breech 36 weeker) has had any breathing issues. It is my understanding that there are no known risks with getting the shot; for my second is was given only as a precaution and turned out to be unnecessary.[/QUOTE]

Not Karen, and not sure if it would never be an option, but as recall, the steroid shots take 24 hours to start working, and the effects wear off after a bit (don't recall how long). I don't think an OB would give a steroid shot to someone with a scheduled c-section prior to the amnio. My OB told me ( at least last time) that if my amnio showed that the lungs were immature, and everything else was fine, we could just wait a bit. If something were wrong, than I guess the shots would come into play.

Karen - I hope you don't think I am highjacking your thread. This topic is really interesting to me, and I am going to be going through the same thing in a few short months!

o_mom

09-17-2008, 07:50 AM

Certainly. And since Karen says her scar is classical, ITA she's at higher risk. (To be fair, this is in the link I posted.)

To throw another wrench into things - she can only see the outside scar. Her doctor should know what the uterine scar is and it may or may not be classical. Along with the previous sugery scars, that is something that she should clarify with her doctor as it would make a big difference.

KBecks

09-17-2008, 07:55 AM

No, I like reading the discussion. So you can be in labor and not feel it at all? Wow. I guess that explains the need for monitoring, which I didn't quite understand. EATA: This would actually be a concern, as I'm a person who generally writes off minor aches and pains, etc., and would probably feel like - oh no, that's not labor!

I haven't had steroid shots, since the amnio/ultrasound showed both boys near mature for lungs at 36 weeks, we simply scheduled the delivery for the following week for the boys to have more natural time to develop. Both boys were born at 37 weeks and did well, except for some struggles with breastfeeding and both had jaundice (I guess mild jaundice but it was still stressful for me.) If the amnio came back really low for the lungs, then I think a steroid shot would be one of the things to look at.

Since my doc would wait until 37 weeks anyway if the lungs don't make the mature level, I think I my doc would be OK with waiting 1 extra week, and I think he will be open to going to 38 weeks... but I'm interested to know what he has to say about it and what he thinks of the condition of my scar and uterus.

For me, it was very stressful with both boys struggling to breastfeed and worrying about the jaundice, making multiple trips to the pediatrician. It sounds highly likely that we'll experience the same struggles if babe #3 is born at 36/37 weeks, which I can handle, but it would be nice if an we can do an extra week or maybe two safely and have a better chance of avoiding those issues. I felt that I didn't get to really enjoy the newborn phase with the boys, well, I was way too hyper and stressed about the feedings and the newborn care. It's one of my goals to try and relax about everything and just trust that it's all going to turn out OK, but it's not easy in the beginning!

ETA: I do trust my OB, and I think he'll respond with a good analysis of my situation, what options might be available, and the reasoning.

egoldber

09-17-2008, 09:07 AM

Steroid shots are seldom given after 35 weeks. There are risks to them and after 35 weeks the risk to benefit ratio is not considered favorable.

KBecks

09-18-2008, 04:54 PM

I met with my OB today and asked about additional weeks and he did not feel it's a good option at all. He described the size of my fibroid (I knew it was huge) and how it was imbedded into the wall of my uterus and said it would be playing with fire to wait longer. He basically indicated that structurally it was kind of a big deal. He feels we should deliver as soon as we know the lungs are ready -- so it could be as early as Tuesday depending on the test.

I forgot to ask my questions about when the average woman goes into labor (how many weeks) and what would happen if I started labor.... I should have thought to ask that, but he was very clear on not wanting to go longer once the lungs are developed. I feel OK with that in the end. I was surprised because I thought a week or two would be no big deal, but I trust his recommendation.

I cannot believe that we might have a baby on Tuesday though!!!