Indítás úgy, hogy nincs beilleszkedve a baba. Nagy eséllyel császár lesz?

Az tény, hogy nem koraszülött. Ellenben egy 37 hetes meg egy 39 hetes magzat érettsége között baromi nagy különbségek vannak. Nem véletlen, hogy az olyan elektív császárokat, ahol nincs veszélyállapot, "csak" pl. medencevégű a magzat, a betöltött 39. hét után javasolja az összes guideline.

36+5 hetesen pedig a 3047 g az kalkulátortól függően 66-75 percentil, tehát még az LGA (korhoz képest nagyobb súly) fogalmát sem meríti ki, a macrosomiáét meg pláne nem. LGA esetén szintén nem javasolják egyébként a 39. hét előtti indítást.

Nyilván nem kell kivárni a 41 hetet, de a 37. igen is korai. Azért ilyen korban jóval gyakoribb a légzési elégtelenség, PIC-re kerülés stb.

A1 GDM with good glucose control — For patients who remain euglycemic with nutritional therapy and exercise alone (A1 GDM), we discuss the possibility of induction and the tradeoffs of induction at ≥39+0 weeks versus expectant management until 41+0 weeks. This relatively noninterventional approach is based on the favorable outcomes reported in a classic uncontrolled case series of 196 patients with class A diabetes managed this way [40]. Although clinical practice varies from institution to institution, the general consensus is that these patients should not be electively delivered before 39+0 weeks of gestation [71] or after 41+0 weeks. Timing of induction between 39+0 and 41+0 weeks is more controversial.

While a study using decision analysis found that fetal and neonatal mortality may be minimized by birth at 38 weeks of gestation, this mathematical model alone is insufficient for changing our clinical practice [72]. ACOG has opined that birth should not be planned before 39+0 weeks of gestation unless otherwise indicated and that expectant management up to 40+6 weeks is generally appropriate with antepartum testing [38].

A2 GDM and A1 GDM with suboptimal glucose control — For patients with GDM whose glucose levels are medically managed with insulin or oral antihyperglycemic medications (A2 GDM) and patients with A1 GDM with suboptimal glucose control, we suggest induction at 39+0 weeks of gestation based on data from a retrospective cohort study of patients with GDM suggesting that the infant mortality rate at 39+0 weeks (8.7 out of 10,000) was statistically lower than the risk of stillbirth plus infant mortality with expectant management over an additional week (15.2 out of 10,000) [43]. In addition, induction may reduce the risk of shoulder dystocia compared with later birth since birth weight should be less in the absence of ongoing growth in utero [63,64].

Early term birth (37+0 to 38+6 weeks) is not indicated in uncomplicated A2 GDM with well-controlled glucose levels as the risk of stillbirth is low while neonatal morbidity rates are increased at this gestational age [73]; however, if a concomitant medical condition (eg, hypertension) is present or glycemic control is suboptimal on pharmacotherapy, birth should be undertaken as clinically indicated prior to 39+0 weeks of gestation [63,64]. Fetal weight also needs to be considered. The risk of stillbirth appears to be increased among those who are LGA near and at term compared with those who are appropriate for gestational age (AGA). For example, a study of pregnancies complicated by GDM reported the absolute risks of stillbirth at 38 weeks in LGA and AGA fetuses were 21.5 and 4 per 10,000 pregnancies, respectively; and at 39 weeks 20.7 and 5.7 per 10,000 pregnancies, respectively [45]. Limitations of these data included the absence of information about glycemic control and about patients requiring medication versus those managed with nutritional therapy and exercise alone.

ACOG suggests birth at 39+0 to 39+6 weeks of gestation for patients with A2 GDM that is well controlled with medication [73]. However, guidance for patients with suboptimal glycemic control on pharmacologic therapy is less precise. They suggest birth at 37+0 to 38+6 weeks of gestation may be reasonable, but that birth prior to 37+0 weeks should only be initiated when more aggressive efforts to control blood glucose levels, such as hospitalization, have failed [38].

Route of birth — Estimated fetal weight is an important consideration in decision-making.

●Estimated fetal weight ≥4500 grams– Scheduled cesarean birth to avoid birth trauma is typically offered to patients at 39+0 weeks with GDM and estimated fetal weight ≥4500 grams. The fetal weight threshold at which scheduled cesarean birth should be performed to reduce the risk of birth trauma from shoulder dystocia is controversial. It has been estimated that in diabetic pregnancies with an estimated fetal weight of ≥4500 grams, 443 cesareans would need to be performed to prevent one permanent brachial plexus injury [74]. Whether this tradeoff justifies the increased risks of cesarean birth is unclear. The ACOG practice bulletin on GDM recommends discussing the risks and benefits of scheduled cesarean birth with patients with GDM and estimated fetal weight ≥4500 grams [38].

If a patient with GDM and estimated fetal weight ≥4500 grams decides to undergo a trial of labor, we follow labor progress closely and perform an instrument-assisted vaginal birth only if second-stage descent has progressed normally because forceps- or vacuum-assisted birth is associated with a higher risk of shoulder dystocia and brachial plexus injury, with the risk even higher with the use of vacuum as compared with forceps [75,76]. (See "Shoulder dystocia: Risk factors and planning birth of high-risk pregnancies", section on 'Planning birth in high-risk pregnancies'.)

●Estimated fetal weight <4500 grams — Cesarean birth is performed for standard obstetric indications.

Egyébként nyilván nem gyakorin kell erről tanácsot kérni, de ha magad sem vagy biztos a dologban, akkor minimum egy beszélgetés az orvosoddal, esetleg egy második szakvélemény kérdése beleférhetne. Szerintem.

Én pozitív élményt írnék. Kórelőzmény miatt a betöltött 40. héten indított szülésem volt. Véralvadási zavar miatt csak oxitocinos indítás jöhetett szóba. Reggel kilenc körül kaptam az első adagot, teljesen zárt külső és belső méhszájjal, baba teljesen fent. A szülésznő már reggel közölte, hogy szerinte császár lesz. Délután kettőkor többszöri próbálkozás után sikerül egy hosszú ujjú dokinak burkot repeszteni, a többiek nem értek el. Kaptam edát, azt mondták segít elsimítani a méhszájat. A fajasok is burokrepesztés után indultak. Este fél nyolc után néhány tolásra megszületett a gyermekem.

Szerintem is nagyon korai az akkori indítás.