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PPROM at 20 wks...stat C/S at 25 wks, suggestions?

Last post 01-05-2011 8:13 PM by jessica_anne010. 15 replies.
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  • 12-30-2010 10:03 PM

    PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    I once was a midwives apprentice..
    Was present at 6 of my siblings births..
    My husband and I were planning on a home water birth for our first child but things went pretty much the opposite of what I had always planned and dreamed...

    I will try to keep this condensed, but now that Eleonora is nearly 2 and doing amazingly well we are talking about another pregnancy in the next months and would love to hear any thoughts and suggestions from you ladies!

    Due to presumed Endometriosis shortly after marriage (I had many symptoms but was not medically diagnosed), we decided to be open to a baby sooner than planned. I conceived right away (I was practicing fertility awareness so was pretty sure when I ovulated within a day or two).

    At 9 weeks due to severe, severe abdominal pain we went to the ER to rule out an ectopic pregnancy - via ultrasound everything looked good.
    At 17 weeks, one afternoon/evening I had what felt like lower abdominal cramps and a lower backache - my midwife suggested I take a bath and go to bed early. Felt pretty fine the next day.
    My bag of waters broke at 20 weeks with alot of bright red blood. Immediately layed in bed and drank lots, praying and crying. Had an ultrasound around 21 1/2 weeks - partial placenta previa - no funneling but cervix showed a little shorter than desired, baby looked good. Stayed pretty much laying down in bed all the time from 20-25 weeks. Had another "bleeding episode" at 22 weeks and then again at 24 weeks. Began to realize that the sensations I was feeling must be contractions -started taking 3 herbal tinctures hoping to calm my uterus which worked for a few days. At 24 weeks 6 days another bleeding. Went to the ER. Ultrasound and exam (no checking of cervix) revealed nothing new. Was going to be monitored for 24-48 hrs. then sent back home on bedrest. (I was having conx.every 5-20 minutes but the monitor was unable to pick them up). While my husband was home gathering some things for the night I started to bleed a lot - what followed were the scariest minutes of my life. I was rushed to the OR and put under general anesthesia, Eleonora was born at 25 weeks 0 days - crying (so I read on the report) weighing 1 lb 5 oz via a classical midline incision on my uterus. I was told it was a complete previa. My daughter spent 15 weeks in the NICU.

    The above is brief but I wanted to give some background for my following questions:

    -I was and have continued to eat extremely well and have done some cleansing after I stopped pumping at 13 months.
    What are your nutritional suggestions for wanting to have as healthy a pregnancy as possible after what I have gone through? I have read a lot about the Dr. Brewer diet and the work of Dr. Weston Price and plan on following their advice. Especially 100-120 grms protein and 2800 calories a day.

    -My feeling is that all of my troubles stemmed from the previa -which I believe may have been caused by a less than desirable uterine invironment due the Endomitriosis. Do you think this is possible? I know it is also a possiblity that my cervix was an issue but due to the Previa I had no internal exams (except at the 9 wk ER visit - the Resident said it was a bit more open then expected for this being my 1st pregnancy (like a finger tip he said) but what he described is exactly what I always felt even before pregnancy so it didn't concern us).

    -Can a complete previa precipitate a PPROM - or does PPROM more likely stem from preterm labor, IC, or other reasons?

    -I know statistically I have a higher chance of having another Previa, preterm labor, etc..but this doesn't mean I will and want to do all I can physically, emotionally and spiritually to prepare for a healthy pregnancy, birth (I plan on a VBAC but that is the subject for another post) and precious baby.

    -----does anyone have suggestions/ thoughts/ ideas for me??

    It will be so appreciated!
    Blessings,
    Sarah




  • 12-31-2010 3:16 PM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    bump

    Susan
    Moderator

    I get up every morning determined to both change the world and have one hell of a good time. Sometimes this makes planning my day difficult. --E.B. White
  • 12-31-2010 7:46 PM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    what does "bump" mean?

  • 01-01-2011 7:22 AM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    It's  like a cyber nudge and it pushes the discussion to the top of the list by giving it a "reply".  I wanted to make sure midwives saw this and that it didn't get "buried" under other discussions.

    Susan
    Moderator

    I get up every morning determined to both change the world and have one hell of a good time. Sometimes this makes planning my day difficult. --E.B. White
  • 01-01-2011 11:43 AM In reply to

    • midwifea
    • Top 10 Contributor
    • Joined on 02-12-2009
    • Kailua Kona, HI
    • Posts 475

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Sarah,

    You are so right when you say that even though you are at risk for another placenta previa it does not have to happen again.  Doing all you can now to arrive at and maintain optimum health of body, mind and uterus is probably the only control you will have over the situation.  That and positive visualization/prayer/meditation. 

    One question, and I am sure it was covered in your care, was there uterine or amniotic fluid infection?  That could have been a contributing cause to the PPROM.

    Also, is the endometriosis still a factor?

    I am glad you and Eleonora survived and are healthy today.  What a scary time. 

    Just so you know and I am sure other midwives will chime in here too;  I have served a mama who had a history very, very similar to yours including a classic, midline CS, but she had 2 previous fetal demise, at 25 weeks and 30 weeks, and she did go on to have a beautiful, term homebirth.  It can happen Sarah.  I don't think you'll be given a chance at it within the western medicine world, though.  For now eat well, ask the soul of your next child to choose a trouble free pregnancy and birth for you both, trust your body and be grateful for the experience and wisdom it has given you.

    One more thing, biolfavanoids can help grow a strong bag of waters.  Make sure your diet is rich in this.  Here in Hawaii I tell mamas to eat lilikoi (passion fruit) to grow a strong sack.

    Blessings,
    April
    moderator

    "The Voice

    There is a voice inside of you
    That whispers all day long,
    "I feel this is right for me,
    I know that this is wrong."
    No teacher, preacher, parent, friend
    Or wise man can decide
    What's right for you--just listen to
    The voice that speaks inside."
    — Shel Silverstein
  • 01-01-2011 2:02 PM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    I so appreciate you taking the time to respond to my post, it means alot to me.

    In answer to your questions; we do not know of any uterine or amniotic fluid infection before the PPROM (when/how would this have been discovered?) - all that I know is that on the placenta pathology report (after the C/S) it says " placenta...showing marked acute chorioamnionitis with acute  funisitis. There are also meconium-laden macrophages present" - can you explain to me what this means?

    Thankfully I have no symptoms of Endometriosis anymore.

    Thank you for sharing about the mama you served, it gives me hope. While I realize it will be very, very hard to find an OB willing for me to give birth naturally - I will not give up looking and hoping for this , as we will not be comfortable with a planned homebirth.

    I will take your advice to heart and am learning to be grateful for what we have gone through.

    Blessings,

    Sarah

     

     

  • 01-02-2011 7:20 AM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    "Acute chorioamnionitis" means that the there was infection of the fetal membranes and from the other parts of that sentence, it sounds like the umblilical cord and the amniotic fluid were infected also. "Funis" refers to the cord; "-itis" refers to infection. To put it really, really simply, macrophages are white blood cells that are like scavengers within the body. They surround and then "eat" infection.  (The name literally translates into "big eaters".)  Meconium is the first ***  that a baby makes.  It's greenish black to light brown, it's got a really tarry consistency (difficult to get off your skin or your clothing, for example).  Babies will poop this out for the first 3-4 days after birth.  However, it can be a sign of the baby being stressed or "in distress" if the baby poops while still inside the mother.

    Basically what that report said was that there was a sudden onset of infection which invaded the baby's environment and the placenta.  Infection is a common cause of babies being born early and of the waters being released earlier in the pregnancy than "normal".  Most of the time the waters aren't released (some people say "break") until late in labor for a term infant (37+ wks by medical standards), or sometimes right as labor starts.  There are all definitely all kinds of scenarios but that's the textbook version.  Waters releasing early *can* signal that there is infection going on--sort of a heads up to the care provider.

    Since you are not comfortable with an out of hospital experience, would you be comfortable with a certified nurse midwife in the hospital?

     

    How silly!  I wrote the word f e c e s and this program puts all stars in it's place.  It will accept "poop" however!

    Susan
    Moderator

    I get up every morning determined to both change the world and have one hell of a good time. Sometimes this makes planning my day difficult. --E.B. White
  • 01-02-2011 10:17 AM In reply to

    • midwifea
    • Top 10 Contributor
    • Joined on 02-12-2009
    • Kailua Kona, HI
    • Posts 475

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Sarah,

    Susan has answered beautifully about uterine/AF infection.  That was probably the underlying cause of Eleonora's preterm birth.  Placenta previa can cause bleeding but often babies get to term/near term with a previa.

    I think focusing on your next birth is too far ahead of the game.  You will have many battles to find some one to honor your choice for a yoni birth and that is stressful so instead make a concious conception and healthy pregnancy your goal. Your  birth will unfold from there.  Visualize baby and placenta growing and your placenta placed well away from your cervix and the scar on your uterus, visualize healthy, nourishing amniotic fluid for your baby.

     

     

    Blessings,
    April
    moderator

    "The Voice

    There is a voice inside of you
    That whispers all day long,
    "I feel this is right for me,
    I know that this is wrong."
    No teacher, preacher, parent, friend
    Or wise man can decide
    What's right for you--just listen to
    The voice that speaks inside."
    — Shel Silverstein
  • 01-02-2011 1:40 PM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Thank you for your explanations. So, this means that potentially I had an infection prior to 20 weeks causing the PPROM at 20 weeks - correct? Looking back the only other unusual symptom that I had was some vaginal discharge at 18/19weeks that was slightly colored (light green/yellow prehaps?) that also had a slight smell -but when I called the midwife about my concern she said it doesn't seem like something to be worried about.

    But my bag of waters did reseal (at least my ultrasounds at 23&25 weeks showed normal amount of water), so do you think it was a "sudden onset" infection as the report basically said - or do you think I may have had this infection for longer? I am so very thankful that Eleonora was born without an infection (her cultures came back negative a couple days after birth) - of course they started her immediatley on strong antibiotics and poor baby they tried but couldn't do a spinal tap (due to the presumed infection).

    As for a Certified Nurse Midwife, I definitely would be open to this! I do not look forward to having prenatal care with an OB and also being seen as "very high risk", and will miss having care from a homebirth midwife. Do you know of CNM's that would take someone with my history? Especially my classical scar?

    Have a blessed week,

    Sarah

     

  • 01-03-2011 6:41 AM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Sarah, you can only go by what the report said.  It's virtually impossible to know when the infection set in, how, and why.  However, it does jump out at me that you reported a colored vaginal discharge with an odor which sounds like it was unusual for you (we all know our own smells and how our body makes discharge and what's unusual for us).  It's my opinion--and I'm not saying your midwife was wrong or right--that any time a woman has a concern and it's worrying her, it should be checked out even if it turns out to be absolutely nothing, something very normal and "textbook".  At the very least, it puts the woman's mind at ease.

    Do you know what the incision is on your uterus?  If you don't have them already, you need your records to determine that.  This will determine if a vaginal birth could be safely attempted.  There is no one in my area, for example, who would risk a vaginal birth after a classical uterine incision.

    Susan
    Moderator

    I get up every morning determined to both change the world and have one hell of a good time. Sometimes this makes planning my day difficult. --E.B. White
  • 01-03-2011 10:49 AM In reply to

    • midwifea
    • Top 10 Contributor
    • Joined on 02-12-2009
    • Kailua Kona, HI
    • Posts 475

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

     

    Susan,

    this is from the original post.

     

    "I was rushed to the OR and put under general anesthesia, Eleonora was born at 25 weeks 0 days - crying (so I read on the report) weighing 1 lb 5 oz via a classical mid line incision on my uterus. I was told it was a complete previa. My daughter spent 15 weeks in the NICU."

     

    It doesn't hurt to ask again, how ever, that is why my posts have reflected an absolute that no western medicine practitioner will allow her even a trial of labor.  I do not know of a CNM who would take this, maybe for prenatal care only.

    Blessings,
    April
    moderator

    "The Voice

    There is a voice inside of you
    That whispers all day long,
    "I feel this is right for me,
    I know that this is wrong."
    No teacher, preacher, parent, friend
    Or wise man can decide
    What's right for you--just listen to
    The voice that speaks inside."
    — Shel Silverstein
  • 01-03-2011 11:30 AM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Sorry.  I missed/forgot the classical incision in the uterus. I replied and couldn't see the orignal post but I should have re-read it.  So sorry, Sarah. And April is correct in that no western/allopathic provider will attend a vbac with a classical uterine incision.

    Susan
    Moderator

    I get up every morning determined to both change the world and have one hell of a good time. Sometimes this makes planning my day difficult. --E.B. White
  • 01-03-2011 2:26 PM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?


    April and Susan,

    I really am grateful for you taking the time to "listen" as I process all this. Yes, I know it is impossible to know when the infection set in - but to be honest you have been the first to mention that an infection -may- have been the cause of the PPROM, so it just makes me want to explore this thought. Do you know if there are more "common" types of infections that could precipitate PROM? Are there ways to test prenatally for example, BV? I will move on from exploring all the "what if's and why's" of what happened, but I still want to spend a little time thinking through all this.

    As for the my incision, I am sure it is a classical incision. I was told when we went to the ER if the baby were to be born this early it would be by classical, I was told on the way to surgery and after surgery more than once, and my operative report states it more than once as well. For the first year I did not even contemplate a VBAC believing the risks were extremely high. I have been doing alot of reading and research (mostly from medical journals and studies) and believe that my risk of rupture is 2% or less (in my opinion not alot higher than the 0.5% risk for low transverse or low verticle incision). A study from 2004 has the risk for "special scars" (classical, inverted T and J incisions) to be at 1.9%. I have researched (and continue to) many aspects of classical C/S and potential VBAC- interval time between deliveries, suture material used, double vs. single closure, induction/augmentation in VBAC TOL, drugs during labor, etc...

    I am a part of a "special scars" yahoo and facebook group which is a safe place to talk and share with others who are contemplating, planning or have had a VBAC after a special scar. A handful of Mama's have had VBAC's after more than one C/S plus having an inverted T incision. I have heard of 2 OBs who have been willing to take Mama's with special scars. Don't misunderstand me, I know that my chances for finding a willing and supportive OB are extremely small but I cannot let myself give up hope for a vaginal birth which I believe to be safer than an automatic repeat C/S. As long as my husband feels that we must be in the hospital (and at this point I don't disagree) for our next birth, my only option is to hope and pray (and search when the time comes) for a supportive OB. I know that no CNM in the hospital could take me.

     

    Thank you again for being willing to share with me,

    Sarah

     

  • 01-05-2011 9:38 AM In reply to

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Edited:  Crap, I had a lovely post that my laptop apparently ate.  Ok, let's see if I can remember what I typed the first time.

    Hello Ladies!  I am a relatively new student midwife, mom of 5 kids and the founder of the Special Scars Yahoo and Facebook groups.

    3 years ago, I had my first VBAC after an Inv T with two homebirth midwives at their free standing birth center.  Last May, I had my second VBAC in my bathroom with my husband and a doula friend.  Care providers that will assist or serve at a TOL after a Special Scar are very few and far between, but there are 3 OBs in the US that I know of and have heard rumors of others and there are some homebirth midwives out there too.

    Sarah - I'm sorry I didn't point out that chorioamnionitis was an infection to you earlier when you asked.  I've been off this last month.  I've been getting all the PROM info I can for you out of my books.  I hope to be posting it by the end of this week.  There are a variety of infections that can cause PROM.

    Talk to you all soon.  I hope this post actually posts!

    Jessica
    http://www.specialscars.org
  • 01-05-2011 5:19 PM In reply to

    • midwifea
    • Top 10 Contributor
    • Joined on 02-12-2009
    • Kailua Kona, HI
    • Posts 475

    Re: PPROM at 20 wks...stat C/S at 25 wks, suggestions?

    Aloha Jessica,

    and welcome to our boards.  You are right when you say there are only a handful of care providers willing to assist a woman with a special scar.  Great to know there is a yahoo group for this purpose.  I am also glad you were able to have a Ybac (yoni birth after cesarean).

    I have assisted two different women at home with their births after (1) a midline classical incision and (2) an inverted T incision and one Yba 4cs's, also 4 Yba2cs's and many ybac's.  So there is care out there for mamas.  I know many of my sister midwives who could say equal. 

    We are quietly working away attending one birth at a time.

     

    Sarah,

    with out having had cultures done it would be impossible to say exactly what infection you had with Eleonora's pregnancy  but infection that causes PPROM can range from BV to Listeria.  Being in the state of optimum physical, emotional and mental health will be your best ally for next pregnancy.

    Blessings,
    April
    moderator

    "The Voice

    There is a voice inside of you
    That whispers all day long,
    "I feel this is right for me,
    I know that this is wrong."
    No teacher, preacher, parent, friend
    Or wise man can decide
    What's right for you--just listen to
    The voice that speaks inside."
    — Shel Silverstein
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