This approach makes no sense to me-can someone explain why this would be best

So a woman who is a member of a site I am very active on is pregnant and just posted a blog updated and I am very confused by it.

"Lets see. I am 38 weeks and 4 days today. WOW. I have been so frigign miserable lately. We have our induction date and time. Lucas should grace us with his presence Jan 7th. We have to be at L&D on the 6th at 10PM. I'm guessing so late, so that they can get everything started and let me labor all night since I will not be pushing or anything. It's a matter of time and how long it takes my body to push him out itself. It's so weird. I will be holding my son in less than a week."

Someone asked about not pushing and she responded with

"With my heart condition (congenital aortic stenosis) the pressure on my heart during actual pushing would be too dangerous. They are going to let me "Labor Down" which is basically what they did back in the 40s or whatnot. My body will do the work for me during the first stage of labor and most of the second stage. Once the baby is close enough to delivery, the doctor will either ease him out with his hands or if needed forceps or vacuum. The amount of blood volume loss during a c-section is more than vaginal plus the benefit of a quicker recovery and less risk of infection. So I will be very comfortable with a long range high dose epidural and they will tell me when he's out."

Does this make sense to anyone?
First, induction is much more intense on the body and baby, causing much stranger, longer and more intense contractions. And some of the side effects for mom are cardiac arrhythmia, premature ventricular contractions, hypertensive episodes as well as severe vomiting, all of which put a lot of pressure on the heart and make it work harder. If the condition is so bad that she can't push because of the strain to her heart, wouldn't letting natural labor take it's course be better for the heart(and for all the other normal reason too).

Secondly I have heard that it is very hard to labor down with pit, as it is not natural and being controlled by a pump. It seems like this could be very stressful on the baby.

Third, I understand that the epidural can help lower BP, but to have it up to the point were mom feels nothing seems like it will stall labor significantly. Also with the epidural mom wont be able to really use gravity to help get this baby low in the pelvis.

Maybe I am just crazy, and a little too obsessed with natural birth, but this sounds like a horrible plan and a recipe for very long, painful and traumatic birth with a ton of vaginal trauma and/or c-section.


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She will probably end up getting a c-section. Its ridiculous that they have scared her into this, I would have gotten a second opinion.
I'm guessing a section also, but you never know. I would be wary of inducing her, but I am with everyone:) The problem with letting her go natural, though, is more of a stress issue. If she is not willing to prepare herself for it, this can put a strain on the heart also. Fear, stress, etc. can all cause the blood to not flow as well to the uterus, it can also increase blood pressure. Laboring down would probably work great for her, but it would take longer and it depends on how patient the doctors are. If they are willing to wait 3-4 hours, it may work out fine and be less stressful for her, but if not then that's way I would say it might be a section.

My thoughts for this mom: I would work really hard on labor prep. Work to help her deal with the pain in a non-stressful/fearful way. I wouldn't induce unless neccessary. Then if it appears that the labor is affecting her heart(increase blood pressure, labor slowing down, baby not dealing with the contractions) get the epidural. For pushing I would encourage more normal pushing (not holding your breathe for 10 secs with glottis closed). With or without an epidural, I would encourage her to moan the baby down and push for shorter intervals, possibly even having her push every other push. I would put her in whatever position works best for her and baby. Of course, blood pressure would need to be monitored as well oxygen. If even gently pushing isn't working, I would just labor down, but be very patient with the time it takes. I would also see if she could do some grunty pushing at the end to try and avoid forceps.
Perhaps the induction is to ensure that she gets a dr who will allow her to labor down rather than an automatic c-sec?
My friend was recently induced for HBP. They gave her Cytotec to get her to efface & dialate and start contracting. Then when she was, they broke her water to get her body to pick up where the Cytotec left off. They did not begin to give her Pitocin until 12 hours later when she had not established a regular "strong" contraction pattern and had not dialated past 4cm.

Maybe they are going to try to do that w/this lady. Get the process started and hope her labor kicks in and the rest goes w/out needing anymore help. As for laboring down, I have heard that works for women that have strong epidurals but its usually most successful when women are in labor w/out Pitocin. I am w/you in thinking that pitocin induced contractions would be too stressful on mother & baby for the amount of time it will take to labor down.
This discussion makes me think about risk vs benefit for the baby. Assuming that this goes "as planned" and baby is born vaginally, are the side effects and exposure to pitocin and epidural the lesser of two evils? Or would it be healthier to have a cesarean, if only to bypass the heavy use of medication over a long period of time, and forfeit the benefits of moving down and out of the birth canal?


Also to clarify, if the mother who this discussion is referring to is reading this, I am NOT suggesting that you are making the wrong decision or trying to discredit your decision in ANY way.
Vaginal birth is always safer than cesarean even when induction is involved.
A cesarean is never healthier, the problem here is that she might not be aware of the risks she is going to face, somebody if not done yet, should tell her to wait and have a normal natural start in order to have less problems.
I hope this will help a little, or at least add to the discussion.

With congential aortic stenosis (CAS) some women are actually advised to NEVER get pregnant becasue it can be very dangerous/deadly for them. While we know most women have normal pregnancies a woman with a congential heart defect is HIGH RISK. So with that said unfortunately lots of things we want to see as we support the normalization of birth are not for her. She is HIGH RISK and needs to be followed as such. She has probably been seen by a cardiologist throughout her pregnancy and her risks are certainly high. It sounds like her heart disease is "mild" enough that she has had an uneventful pregnancy. Some women with same condition cant even complete pregnancy. Termination is sometimes recommended or they are induced waaaayyy before they reach term gestation.

The ultimate goal is a vaginal delivery with no valsava (pushing) efforts. There is also the goal of maintaining the heart rate and not allowing it to raise to unsafe levels. For a woman with a normal heart the changes in blood pressure and heart rate during labor and deliver are fine. For a woman with CAS these changes can literally be deadly. The early epidural will definitely come with its own risks but will minimize the risks of cardiac changes associated with labor that could be deadly for this patient.

So it sounds like the plan is to admit her. Give her an early epidural, allow her to "labor down" which is a good practice for all women with epidurals, CAS or not, and then help the baby out with her providing minimal to no pushing efforts. You CAN labor down with Pitocin. While pitocin has all sorts of other issues connected with it laboring down is not one of them. I know this may sound strange but for a woman with this issue it is the safest route. :-( While vomiting (a side effects of epidurals) can accur and do put stress on the heart it is not the same as labor. I am sure she has vomited at some point throughout her life. That is a different sort of heart stress when compared to second stage pushing.

Usually these women have gotten opinions from many folk inculding their life long cardiologist, general practitioner and they get early/prenatal anesthesia consults. There is a risk benefit discussion that should be had with all women concerning any intervention. While most women don't always get the information they need, we can only pray that she has had these discussions. She has spent a lifetime with this disease. And as a woman I am sure her cardiologist has had conversations with her repeatedly about pregnancy and the risks to her. That being said, lets pray she was well informed and has a wonderful outcome :-)
Nicole-I appreciate your response. I am just curious if you think that going without an epidural is a possibility at all. I mentioned before, that I would like to see if she could go without if she wanted and as long as everything was ok with her heart, but I have never seen this disease before. Is it likely that this won't be a possibility. Also, is pushing without the valsava efforts ok. Of course, without the epidural, it is harder to control this. I like to do it this way anyways with women, but again, I haven't see this disease before.

As a nurse, I would be curious about this for future reference. I love laboring down though. I wish more doctors would use this with women with epidurals.
Rachel, It is my understanding from the limited research that i have done that any bearing down aside from normal BMs can be dangerous. It has been a long time since I have personally cared for a patient with this condition but it doesnt seem like the plan of care has changed much. At the end of the day, get an epidural to decrease the work on the heart, labor down, no pushing and use a vacum to pull the baby out. :-((

I think the issue is it's hard to determine, with the extra work of pregnancy, which women have heart's that can handle the extra stress and which one's don't. Like you said without an epidural its pretty impossible to avoid bearing down when its time to birth.

I too love laboring down. I had a young girl once who labored down so far that her baby literally delivered with her simply laughing. :-) It was a funny!
What does laboring down mean?
What I understand is that laboring down is allowing your body to do all the pushing, with no bearing down. It takes longer, but is less stressful and usually avoids tearing or episiotomy.



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