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jelc

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questions about cervical effacement
« on: December 22, 2009 at 10:45 PM »
I saw the OB today and realized after seeing him that I have more questions than answers and I don't see him again until next week.  If any of you can help me out with your knowledge, it would be much appreciated.

So the story is this.  I'm 32 weeks along, have a 3 year old who was delivered by c-section due to being breech (so have no previous experience with the whole labour/delivery deal).  I have been having braxton hicks contractions for a long time through this pregnancy - maybe as early as 17 or 18 weeks, I'm not really sure, and they are MUCH more noticeable/uncomfortable than they were with my son - not to mention they started much earlier.  Mostly they have not been a problem, though sometimes it seems like they get started with the simplest of things, like walking up a flight of stairs.  Then, last week, I woke up at about 1am with braxton hicks - not painful exactly, but uncomfortable.  They went on for about 3 hours until I finally got up and moved around a bit, had something to eat/drink.  I had been hoping by staying in bed, still, they would stop.  I called the OB's office the next morning and they gave me an appt (for today) and instructions about going to the hospital if I had any concerns before today.  In the interim, I had another round of BH contractions lasting about 3 hours during the daytime/evening at which point I went to the Labour and Delivery unit (yesterday).  Again, they were not really painful, but certainly uncomfortable.  Of course they strapped up the monitors and made me lay still (I had already tried laying down for a bit at home which slowed down the contractions, but did not stop them) and as things would go, the contractions stopped.  The nurses used this to point out that I probably just needed to slow down a bit more and that will fix the problem (ok, good point).  Anyhow, after waiting another 3 hours w/o seeing a dr/resident/ob, I left the hospital, as I had an appt at the OB's office today anyhow and I agreed to return if the BH's started again.

Saw the OB today, who initially suggested it was no big deal, but he checked my cervix.  He then said that my cervix was quite thin, but not dilated. He indicated that he wants to check again in a week and that it may mean nothing, though he is not prepared to return my care to my family doctor until after next week, presuming everything is ok.  He did not tell me how effaced, and I didn't know enough to ask.  I am also not clear enough on the anatomy to understand how you can have 'quite a thin' cervix and not be dilated.  He did not make any recommendations regarding activity, though I can make some guesses about that myself as I'd obviously like our little guy to stay put as long as possible.  The OB also told me that at 32 weeks, they probably wouldn't try to stop labor if it started, which surprised me and I wondered if anyone else has been told something similar.  Now I realize that 32 weeks is much better than 30 weeks or even earlier that some of you are facing, but I also know that every additional day/week  that baby stays put is better too...  he stated that b/c the medications had their own side effects, that after 32 weeks, the con's outweigh the pro's around stopping labour.  He did not suggest anything relative to treatment, prevention etc. except to return to him in a week (and to go back to the hosp if concerned or other symptoms indicated premature labor).

Any experiences or answers to my above questions would be greatly appreciated.  I have reduced activity of my own accord, but am still planning to work.  Will do whatever makes sense if I'm having prolonged BH contractions (ie get up if I'm sleeping, lay down if I'm active, go home sick if needed).  Any suggestions about other things I should ask about or do would be appreciated.  I really like my family doctor and have an appt with her on the same day as the OB.  She's very experienced and willing to deliver a vbac, and I trust her judgment, so I feel I could get more info from her too.  Of course, being Christmas week does not make it easier to get appt's or info... Thanks in advance!

Trying not to be tooo worried.

Angela

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Re: questions about cervical effacement
« Reply #1 on: December 24, 2009 at 10:51 AM »
Hi, jelc!

I'm sure you love that all this is happening right before Christmas! Sheesh. You're doing the right thing by taking it as easy as you can, and you're right that every day counts. One doctor at the practice I went to said they don't stop labor after 34 weeks because NICU outcomes are "generally positive" at that point. Personally, I'm glad my individual doctor said, "No, let's do what we can to get you to 37 weeks." The March of Dimes also supports the 37-week goal.

I wonder if you have an irritable uterus. That's the general term for a uterus that contracts with physical activity. For me, also starting at 17 weeks, just about anything caused my stomach to tighten into a contraction: going up or down stairs, standing up from a chair, bending over, reaching for something up high. I limited all of that kind of activity at 33 weeks with my daughter and 24 weeks with my son. An irritable uterus may or not be related to preterm labor (not enough research to know for sure). The only way to know if the contractions are causing the cervix to change is having the length of your cervix checked by transvaginal ultrasound. Please see this info here: www.keepemcookin.com/prevention.aspx and talk to you OB about it. Also, thinning occurs before shortening/dilating. Consider it a warning sign that we're lucky to get. With "normal" labor, the thinning and dilating happen pretty close together. With preterm labor, they can happen gradually...and then boom!

Another test to learn about is the fFN test, which predicts the likelihood of delivering in the next two weeks. (Info here: www.keepemcookin.com/prevention.aspx, about three-fourth the way down the page) You can have that done easily in the office next week. If you get a positive test result, then you and your doctor can determine if strict bed rest is needed.

Also, there are medications to limit your contractions. Procardia/nifedipene is a popular choice. There's info on that here toward the bottom of the page, under "Tocolytics": www.keepemcookin.com/prevention.aspx.

Let me know if you have any questions, or just want to chat! I could go on and on. For now, ask your OB about preventing preterm labor by checking the length of your cervix, taking an fFn test, and possibly taking an anti-contraction medication. Keep me posted, OK? How have your contractions been the last couple of days?

--Angela

« Last Edit: December 24, 2009 at 10:56 AM by Angela »

jelc

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Re: questions about cervical effacement
« Reply #2 on: December 24, 2009 at 12:28 PM »
Hi Angela - thanks so much for the reply.  I/We are trying not to be worried (ok, realistically I know my husband doesn't worry as much as I do!) especially as that is likely to be counter productive.  Contractions have been ok in the past few days - that is to say there have been no long episodes and I've been pretty careful to restrict activities that are not 'necessary' while still going about my work day for the most part.  I still have lots of BH's , but not that go on for hours.  Typically they are worse from mid afternoon through evening and into the nighttime and they seem to settle in the night (such that by the time I get up for the day, I really just want to stay in bed for a few more hours as I am finally sleeping comfortably!  Unfortunately the 3 year old isn't so keen on sleeping in! - maybe over the break when we are all at home!)

I will talk more to my Dr and my OB about the possibility of IU - I had seen their site before this one and had wondered as most of my friends are surprised with the frequency and how early my BH's started compared to them (I had some with my son, but mostly not noticable and certainly not so early).  The OB outright denied that I could have uterine contractions lasting 2 minutes ( I told him sometimes they are short and sometimes seem to last about 2 minutes or even more) saying that was impossible, so my best guess is he is not going to support the IU notion.  I do really like my family doctor though, she is very experienced and she delivers, so I'll talk to her more about it too.  She may be a bit wary of things now though, in terms of following my care, if there is a risk of preterm birth, and unfortunatly she does not have privledges in the hospital that the NICU is in - only at another hospital which has a special care nursery, but not the care we would need if we have a baby in the next month or so (here's hoping not).  In any case, I really like her and trust her judgement, so at least talking to her about the circumstances will be good.  Until then (same day as next ob appt)

I"m going to keep it pretty low key over the next while, which is a blessing of the holidays I guess!  We have also managed to coordinate something for care of our older child in the event we need to go to the hospital over the next few days, of course our regular back-ups are all away for the holidays - so that is a stress relief that we have something in place.  Fun times.  I'm hopeful all this planning will be for not, and we will see the 40 (or even 37 or 35 week mark!)  and I'll be glad to have additional appts next week.  I will most certainly ask about the fFN test, I don't know where you are located - I'm in Canada, and I've never heard of this test, so maybe we don't do it here.  I will also ask about the meds to stop contractions.  As an aside, another co-worker of mine has a daughter who is 34 weeks who is having some difficulties also and they told her they would stop her labor (and have given meds just this week) until at least 35 weeks - so who knows what would actually happen at the hospital - it would depend on the OB who saw me I guess.

Anyhow, again, thanks so much for the info.  Have a wonderful holiday season.

Best,
Jennifer

Angela

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Re: questions about cervical effacement
« Reply #3 on: December 28, 2009 at 09:01 PM »
Let me know your appointment goes this week!

jelc

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Re: questions about cervical effacement
« Reply #4 on: December 29, 2009 at 06:51 PM »
Hey Angela thanks for the note and the continued concern.  Kind of a frustrating day.  I decided to see both the OB and my family doc eventhough the OB said I needn't bother with my family doc.  He insisted I return to him b/c he had assessed cervix and he wanted to assess it again, not my family doc (who is very experienced; an excellent doctor) as it is a subjective assessment.  Anyhow, I saw my family doc this morning.  She was quite concerned about everything and also quite surprised he didn't do the fFN test last week, but suggested I ask for it this week.  She also raised the notion of not returning to work, reducing activity, but not bed rest, and we had a chance to talk about general considerations.  She concurred with the OB's statement that they wouldn't try to stop labour, though she was surprised he hadn't suggested a steroid shot, though she said now, at 33 weeks, they probably would think twice about giving it anyhow, as baby's lungs are pretty good and I am borderline for gestational diabetes (fun times this pregnancy) and I guess the shot can put you over the edge for the GD.  She also concurred with his request that I return to him for reassessment, saying that it is subjective to check a cervix, and best that it is done by the same person twice rather than two different people.  She also stated that she wouldn't assess my cervix so that he could do the fFN test and then he could check it against last weeks results.  Anyhow, great appt with her, I felt like I really could ask questions and could get some info.

This afternoon with the OB did not go as well.  First, I got there and there was a mistake in booking so I did not have an appt by their records.  They did fit me in though, so that was good, but it meant a pretty long wait (I have the appt written down in my book, so it was a mistake on their part, which happens, not really a big deal).  Then the OB had the resident see me first (w/o him present).  She outright declined my request for the fFN test and then proceed to ask me if I work in a medical setting because patients don't usually request specific tests.  She then pretty condescendingly told me that the fFN test was no more useful than manually checking the cervix over multiple visits and if I had a concern then I could simply go to the hospital(yeah, because that is very convenient).  Apparently reassurance for me is not a medically indicated concern.  Then she proceeded to check my cervix (if someone else was going to do it anyhow, I might as well have had my family doctor do it who is most certainly more experienced than the resident and who will likely be following my care anyhow - not to mention that my family doctor would have done the fFN test this morning b/f checking my cervix).  The resident then told me I was simply having run's of Braxton Hicks contractions and it was nothing to worry about - the fact that the contractions have become quite a bit more painful in the past few days was not a concern to her and she was quite condescending about the whole thing which really raised my ire.  Apparently educated and knowledgeable patients are not part of her experience thus far, as I'm pretty sure I could have figured out the whole BH thing without her 'educated' assistance.  Then the OB came in and stated that my cervix is unchanged from last week (by the subjective assessment of the resident) and told me that there was nothing they would probably do in any case except deliver, so it didn't really matter one way or another.  After all that, he stated that he wanted me to return to his office to be checked again next week, just to be sure.  Ay-ya-yi.  I was seriously pissed off at this point, especially b/c of the holidays, I can not return to my family doctor till next week (she's not in again) at which point they won't be able to do the fFN test (I'll be 34 weeks, presuming that I still have an inside baby, which I'm still hopeful of). 

Anyhow, I guess the good news is that things, presumably, are not radically different, however I work all the time with residents as a supervisor and know they can be VERY inexperienced, so my confidence about her comments is limited.  I don't know if I'll bother to return to the OB next week or not - I made the appt, but frankly would be happier to see my family doc.  If I do go, I will probably tell the nurse at the outset of the appointment that I do not consent to care by a Resident (they are supposed to ask first, but did not today, and often do not), which means that I'll probably piss off the OB, but at least will have second assessment of my cervix by the same person who assessed it the first time.  My next appt with my family doc is 2 weeks from now.

As an aside, I've had two episodes of extended BH contractions - both in the middle of the night.  One 3 hour session again, and one shorter (1hr) last night where the contractions had gone uncomfortable to painful and more intense.  I probably would not have waited 3 hours last night due to the difference in the contractions.  So I'll cross my fingers that baby stays inside for now, and wait and see.

Sorry for the long post - Thanks for 'listening' to my rant!  I'm sure things will turn out ok and however they are meant to in the end.

Cheers,
Jennifer

Angela

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Re: questions about cervical effacement
« Reply #5 on: December 29, 2009 at 08:37 PM »
Hi, Jennifer.
Thanks for the update. Wow! That visit with the resident sounds so frustrating! Since WHEN do patients not request specific tests? And the fFN test can predict with 99% accuracy if you will deliver in the next two weeks. Checking your cervix (while valuable) can't provide that type of specific information. Uhg. Well, that's good at least that she didn't find anything to worry about with the cervix check. I think you'll feel better about going back next week, to be on the safe side. My OB said she wouldn't do the steroid shots after 34 weeks, because at that point they don't provide additional help. She described it as "If you get the shots at 32 weeks, you've 'boosted' the lungs to 34 weeks, but they can't be advanced beyond that." Of course, that's just one OB's opinion. I haven't seen a specific study I can refer you too. Sorry!

If you do have another round of contractions that last more than an hour after lying down and having a glass of water, and they're coming closer than 10 minutes apart, it wouldn't hurt to call your doc, or even go straight to L&D. It's a hassle, but it is worth it. At least you'll get another opinion!

DrJenGunter

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Re: questions about cervical effacement
« Reply #6 on: January 03, 2010 at 04:16 AM »
You can have a thin cervix and not be dilated. Assessing the thinness of the cervix with a vaginal exam is not that accurate unless you are also dilated.

Steroids are recommended before 34 weeks if your risk of delivery is high. A fetal fibronectin test can help determine your risk but it doesn't tell you that you will deliver. A negative test is most helpful, because if it is negative then your chance of delivering in the next 7 days is less than 1%.

If you see the resident you can (and should if you have concerns) ask to see the attending if you have concerns. Make them explain why they think you do not need the steroids or the fetal fibronectin test. Most docs are happy to do a fetal fibronectin if the cervix is less than 3 cm (it doesn't help you with a longer cervix) because it can give everyone peace of mind if the test is negative. However, the test has to be done first, before anyone checks your cervix as stimulation from the exam or gel can mess up the results.

Hang in there.

Jen




jelc

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Re: questions about cervical effacement
« Reply #7 on: January 13, 2010 at 12:09 AM »
Hi all - thanks again for your replies.  I still have an 'inside' baby and am at 35 weeks today, so am happy about that.  I continue to have runs of BH contractions - at least a couple of times a week, most recently a couple of days ago, from midnight to 5:30am, which stopped, and so I guess are more of an annoyance than anything.  Though there were some cervical changes initially, the OB doesn't feel there continues to be significant changes from my appt a week ago.  I can't recall if I noted in the last post that I have been 'diagnosed' with an irritable uterus, no surprise there.   I did have another OB appt where I (1) refused to see the resident, and (2) discussed at somewhat more length the FFN test.  The OB still refused to do the test, stating that serial manual cervical checks give the same results.  I continue to disagree, based on several factors, not the least of which is that is is not all that convenient to come in to the OB's office repeatedly, and it takes 3 weeks to do 3 serial checks, where the ffn test could give pretty quick results.  In the end however, I was very nearly 34 weeks, so it was also refused based on the fact that I am too far along now for reliable testing, which is fair enough - no point in a test which is not informative.  I do think that at 32 weeks I would have very much appreciated the reassurance (especially as it was over the Christmas holidays) of the FFN but I'm not going to continue to to fret about that at this point (and I did make my point at the last appointment).  So, on the whole, I am happy with each additional day baby stays put, though I hope that I'm not here writing at 40 weeks and complaining that baby hasn't made an appearance!  I will also discuss with my family doc at an appointment this week if she is prepared to take back my care now that baby (as I understand it) will only need special care nursery and not NICU, maybe not anything now, or if she wants me to continue for a week or two more with the OB.  I have another OB appointment, but if my family doc is comfortable with taking my care (she is excellent and very experienced as well, obviously, she delivers) then I will probably return to her for the balance of my needs, as I really do not care much for the OB.  Presuming that baby stays put, our biggest 'issues' now are around hoping for a VBAC as our first son was breech and delivered by section.

Again, thanks for everyone's comments and support.

Jennifer

mktarrant

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Re: questions about cervical effacement
« Reply #8 on: January 13, 2010 at 02:58 PM »
I really hope you get your vbac. Some doctors dont know what to do when a patient actually stands up for themselves. I have found that the ICAN network has helped me tremendously in the pursuit of a vbac. Good luck!

jelc

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Re: questions about cervical effacement
« Reply #9 on: January 17, 2010 at 09:41 PM »
Thanks again for the response - really, we will be happy with healthy baby and healthy mom - we are nearly at 36 weeks now, which looks a WHOLE lot better than 32 weeks did.  I know many people on this site are worrying about much less than 32 weeks - our thoughts are with you.

Best.