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Friday, March 7, 2014
Meconium (a greenish substance that builds up in the bowels of a growing fetus and is sometimes released into the amniotic fluid) is a controversial topic in obstetrics. There is an increased risk of fetal infection when meconium is present. However, that does not change management of labor. Given that there is reassuring fetal status, the options are to manage labor in the usual fashion or perform amnioinfusion (circulating saline into the uterus). Amnioinfusiuon has not been shown to improve fetal outcome. The literature has shown benefit from suctioning the neonate's nose and mouth before the delivery of the body in these cases.
There used to be the feeling that "once a C-section, always a C-Section." The fear of allowing women who had C-sections in the past to labor was that the uterine scar would break open during labor. This is an uncommon occurrence. Assuming you had a transverse (side-to-side) uterine incision, the chance of having a rupture of the uterine scar is approximately 0.7% (7 per 1000). The overall chance that a woman with a prior C-section will be able to successfully deliver vaginally is high. This may be lower for an individual woman depending on specifics of the medical history. Ask your doctor if you are a candidate for VBAC (vaginal birth after Cesarean).
Preterm labor is defined as the onset of labor before 36 weeks of pregnancy. The signs of preterm labor are similar to normal labor, but may also be more subtle. The signs of preterm labor include uterine contractions or cramps, pink vaginal discharge, intermittent low back pains or a pressure feeling in the vagina.
Despite the great advancements in taking care of the premature baby, we have not been able to decrease the incidence of premature labor and delivery. It is an area of obstetrics that years of extensive research have not been able to perfect prevention or treatment. Your best course of action is good prenatal care from your obstetrician.
Treatment options would depend on how things went in your last pregnancy. Did you actually have preterm labor: regular uterine contractions and progressive cervical change? If preterm labor in your last pregnancy was brought on by a uterine septum, you can be comforted in that successive pregnancies tend to go longer as the septum is stretched with the previous pregnancy. An incompetent cervix can be managed by placing stitches in the cervix, possibly combined with bedrest.
The benefit of medication in the face of preterm labor is marginal. You could consider waiting to start medication until you definitely demonstrate preterm labor. Terbutaline is one of the medicines used to treat preterm labor as an outpatient. Other medicines such as nifedipine or indocin can be used to treat preterm labor as an outpatient.
Currently it is recommended that any woman with active herpes lesions in labor be delivered by c-section to reduce the risk of transmission to the baby. A c-section does not guarantee that herpes will not be transmitted to the infant. There is some evidence that antiviral therapy in the later part of pregnancy may decrease the outbreak rate and reduce the need for a c-section. As for the risks of the medication in pregnancy, no controlled studies in mothers have been done, but there appears to be no risk in observational studies. The difference is that in a controlled study two identical groups of women are given the drug or placebo and they are compared. Very few drugs are tested that way in pregnancy. Most are observational studies that look at a single group of women who were exposed, but no controlled placebo group is used for comparison. Many drugs in pregnancy are studied this way. If no obvious affects are seen, the recommendation is that these drugs be used if the benefit outweighs the risks.
Last Reviewed: May 28, 2002
Arthur T Ollendorff, MD
Associate Professor of Obstetrics and Gynecology
College of Medicine
University of Cincinnati