Stressful process to have ELCS after EMCS

[DancingHat]

I'm 27 weeks pregnant and had an emergency c section for my DD after lots of different interventions including epidural, augmentation, ventouse. Despite the fairly drawn out labour I am happy with the outcome of the c section and I recovered well. I'm now jumping through hoops trying to get an elective c section rather than a VBAC because I don't want all the long drawn out labour process which ended up in a CS anyway. I'd rather have a postive birthing experience this time as it will be my last. Except because there's no clinical reason I'm having to have multiple psychologist appointments to get one and quite frankly the one I saw for the first appointment made me feel attacked and was totally unsympathetic. I've had hyperemesis since 6 weeks and continue to take medication. I've not had the smoothest of pregnancies so far and despite feeling slightly better now I do still feel sick and all this battling is making me feel negatively about the rest of the pregnancy. At least with my Dd and the sickness there I didn't have all this battling to do. My next appointment is next week and I've been tasked with looking at the risks, which I had already done but didn't have all the facts and figures at my fingertips when she was challenging me. I have a research background so am able to interpret journal or academic articles.

My first question is does anyone have any links to research findings I could read to prepare myself with sufficient facts and figures of the ELCS vs VBAC risks please? I've looked at NICE guidelines, NHS and RCOG so far. The second is does anyone have any advice as to how I can articulate my position in such a way that I can put an end to this stressful battle and enjoy the last few weeks of my pregancy as much as possible? Thank you for your help.

You shouldn't need to provide research around the relative risks for ELCS vs. VBAC. Fact is, you want an ELCS and NICE guidelines say they cannot deny you. If the consultant you say will not sign one off, then they must pass you onto one of their colleagues who will.

I'm sorry you're having to go through this. I was expecting a fight to get an ELCS after a third degree tear, and was pretty surprised to get the green light with no arguing.

Following NICE guidelines, they have to do what you want, don't they?
I was induced, and then after 3 days of nothing happening I refused all else and asked for a section and got it.
I'm sure they have to.
I think id just literally keep saying 'I've researched the pros and cons of all birth options and have decided that a ELCS is the right choice for me and my baby.'
I'm pretty sure they can't refuse you.
Sorry I'm no help with the facts and figures though.

www.nice.org.uk/guidance/cg132

Look under "Key priorities for implementation"

Maternal request for CS

When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. [new 2011]

For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [new 2011]

An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS. [new 2011]

That sounds so patronising, send the wee woman to a psychologist because she doesn't know her mind enough to know what is best for her and her body.

Fact is, you want an ELCS and NICE guidelines say they cannot deny you. If the consultant you say will not sign one off, then they must pass you onto one of their colleagues who will.

Unfortunately what seaoflove says is not true. You have no right to an ELCS as NICE are only guidelines that do not have to be followed. However you have a right to appropriate care and you do have the right to make free and informed decisions about your own care.

More important than the above NICE guidelines on maternal request are the NICE guidelines that relate to VBAC/ELCS.

1.8 Pregnancy and childbirth after CS

1.8.1 When advising about the mode of birth after a previous CS consider:
•maternal preferences and priorities
•the risks and benefits of repeat CS
•the risks and benefits of planned vaginal birth after CS, including the risk of unplanned CS.

1.8.2 Inform women who have had up to and including four CS that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth and that the risk of uterine rupture, although higher for planned vaginal birth, is rare.

1.8.3 Offer women planning a vaginal birth who have had a previous CS:
•electronic fetal monitoring during labour
•care during labour in a unit where there is immediate access to CS and on-site blood transfusion services.

1.8.4 During induction of labour, women who have had a previous CS should be monitored closely, with access to electronic fetal monitoring and with immediate access to CS, because they are at increased risk of uterine rupture

1.8.5 Pregnant women with both previous CS and a previous vaginal birth should be informed that they have an increased likelihood of achieving a vaginal birth than women who have had a previous CS but no previous vaginal birth.

Let me stress the VERY FIRST piece of guidance there relating to childbirth after a previous CS - that maternal preferences and priorities should be taken into consideration.

The fact that they are spending you for psychologist appointments to get one when you have already had a CS is totally against this as its not respecting your wishes and could potentially be regarded as coercive.

It is NOT the same as having no medical reason for an ELCS. The increased risk of uterine rupture is something that you should be allowed to make informed decisions about.

Throw this book at them. You do not need to 'prove' anything. She is asking you to provide information on risks? Is this correct? That means that the option of an ELCS under these circumstances would not be accessible to someone with literacy issues of some kind. That is not acceptable (and you should make the point as part of your argument if that is the case). It is HER job to prove this kind of detail and discuss them in an impartial and informative way. Its NOT your job to go out and find them. She can advise you, what she thinks is the less risky, but she should not bully you down a certain path.

Make the point that you feel like they are trying to coerce you with this procedure which does not follow NICE guidelines and that you are feeling pressured into something that you are not happy about and this is causing you unnecessary anxiety and stress which is not conducive to happy and healthy pregnancy.

If she still is 'challenging you', say that you find her manner aggressive and again stress the point about feeling that you are being pressured in a way you are uncomfortable with and want to see someone else.

The reason they are doing this, is NOTHING to do with risks or indeed your well being and everything to do with their targets and wanting to keep their CS rate down and have a high VBAC rate. It might be worth saying that you feel they are putting policy and targets ahead of your feelings and well being.

Be firm. Be confident. Be assertive.

Write it all down before you go into the appointment. Hand it to the consultant and request it goes into your notes. This means you a) don't forget anything b) makes it very difficult for them to argue against you c) makes sure everything is on record and potentially makes them accountable.

You are well within your rights to have an ELCS and an ELCS after an EMCS is generally regarded as a legitimate medical reason for both physical and mental health reasons which is recognised by NICE (which is supported by the RCOG and RCM etc).

Good luck. x

Wow thanks everyone You're echoing exactly thoughts thank you. I found the NICE guidelines with the 'maternal preferences and priorities' as the number one bullet piling and felt so angry that that wasn't being considered.

I have felt patronised and bullied and I'm concerned that this progress will make me feel more negative about the pregnancy than I already do. I was crying when I left the appointment and I think she ended it very badly simply because we were overrunning.

She left me feeling like I had everything to prove and I kept saying 'I don't feel I'm being listened to'. It is to do with my particular trust's rates and I know this because I am familiar with the data. I'm definitely going to write a one page summary of my feelings and conclusions from the research. According to NICE if after the discussion I still want a CS I should get one. I feel angry that I have to have another appointment, jump through another hoop, spend more NHS money on a process which I have decided is a waste of time. I agree that a less research literate person would be screwed. It's almost like she's challenging me to an intellectual debate because I offered up my research background saying I'd done my research. But because I didn't have the facts and figures she dismissed my interpretation of them. I said when I'm sick I struggle to make logical decisions but I'm now back at work and making a dozen a day. She actually said 'do you think you're being logical here?' And I said "yes because what I'm telling you now is what I decided when I wasn't pregnant and sick and I'm just echoing what my thoughts were then". I made a plan before I went through this again and I'm so angry I'm not being taken seriously.

Sorry for ludicrous typos. Ipad!!!!

I had a somewhat rubbish EMCS and then a definitely better ELCS. I was expecting an argument but my consultant and midwives were very supportive. I think they wanted me to listen to all the VBAC stuff but were otherwise happy for me to make up my own mind. I'm so sorry you're having to fight so hard. After an EMCS there are pros and cons to both types of delivery so they should be putting your wishes first as the deciding factor.

Christ almighty, this person really wants to have an intellectual battle with you, don't they? Sounds like they aren't accustomed to dealing with such a well-informed person. Sounds totally unprofessional to me.

She actually said 'do you think you're being logical here?'

At a psychologist appointment she said that? Really? Wow!

It doesn't matter if you are being completely illogical. Or indeed irrational! In fact you might want an ELCS precisely because you are illogical and mentally can't cope with the process of a VB. And you can be irrational and logical at the same time too, because your irrationality may make it logical to not put yourself through uncertainty of a VBAC. It gives you the time to work through your illogical thoughts in a logical way and you are fully aware of that by the sound of it especially since you had a plan. Surely she should be working to make a plan that you feel comfortable and confident in regardless of the method of delivery?

Having a psychologist appointment with regard to having an ELCS should be an optional thing rather than a compulsory one. (Note NICE's wording about being offered, rather that should have). It should NOT be a condition of having an ELCS in feeling like a 'test' that you have to pass to prove your sanity (or indeed lack of).

Oh and in case I hadn't mentioned psychological reasons ARE a clinical reason to have an ELCS. Mental health is a health reason. The clue is in the word 'health' in case you have to point this out to her.

Why don't you use their bias against them? They think you're an hysterical hormonal pregnant woman? Well then: have a panic attack about the prospect of a vbac, shudder into tears as you describe how you're traumatised by your first birth, cry on the shoulder of the psychologist about how you can't face the risks of labour to your baby (not all of this literally obviously, I'm not an actress and I imagine you aren't either).

But stop being logical, just tell them you're terrified. The NHS allow elective c-sections. Psychological factors are most likely to get you what you want.

No, it shouldn't be this way. The system is cash-strapped and fails us as a result.

She really said that.

Unprofessional and unsupportive are definitely words I will be using in the next session. I wonder what she's trying to achieve? I agree to a VBAC under duress and I birth vaginally. Big deal! I will still feel wrung out by the process, not listened to, unsupported, coerced is a good way a PP described it as. And far more likely to suffer with PTSD or PND. I'm trying to safeguard myself against negative feelings I know I'm capable of and the last thing I want to do is resent the baby for causing it. I fully blame the health professionals for how I'm feeling.

She did ask me if I felt traumatised or suffered flashbacks from the birth and I'm not an idiot I knew what she was getting at. But I told the truth and said no because of all the steps I've actively taken to come to terms with it. I have debriefed with a senior midwife. I have retold the story many times to normalise it. I have researched how to do things differently next time. I've taken control of a potentially traumatic situation and actively dealt with it. And I'm being punished for my rationalisation of it all! I agree if I wail about how I can't cope with attempting a VBAC I will tick the 'psychological' health reason for a ELCS. And it pisses me off I have to play the system to that degree. When this is over I'm contacting PALS to feedback on what I can only describe as an appalling process. I feel the VBAC appointment midwife coerced me into a psychologist appointment when I said I didn't think there was any point.

What I'm hearing from all of you is despite her demands of logical reasoned reasons from me actually my preferences, regardless of their grounding in logic, should come first. Thank you for making me feel listened to. You've really made me feel better about my point of view

I agree if I wail about how I can't cope with attempting a VBAC I will tick the 'psychological' health reason for a ELCS

That is essentially what I had to do. I went in armed with RCOG guidelines that set out the risks of a vaginal birth, my point being I didn't want to take ANY risks with my pelvic floor and my continence. All completely dismissed by the consultant. As soon as I said I also felt unable to go through labour again, from a psychological POV, he said fine: ELCS for mental health reasons.

I won't lie, I was pissed off that the risks to my physical health carried no weight next to the mental health reasons, but ultimately I don't care because at least I was allowed an ELCS.

It sounds like you've been too honest DancingHat. You have dealt with the trauma too well!

And yes, screw logic (what has logic got to do with it anyway?). This is your body, your baby, your birth. Your preference takes precedence over all of this.

Woahhhh where abouts are you in the UK? I am absolutely shocked! I had an EMCS with my first, was asked how I wanted to give birth with my second at the booking appointment and said I wanted an ELCS. 'That's fine' they said, 'we'll get you an appointment with a consultant so you understand the pros and cons of both' Did that, 5 minute conversation? No problems at all, booking the date of the CS on the 1st April. Everyone supportive and friendly and encouraging. I'm in Glasgow, Scotland.

The way you are being treated is shocking! Have you looked into the complaints procedure, you should also demand to see a different consultant. You should not put up with this!

You need to say that you feel like you are being penalised for developing your own coping strategy without the need for their intervention.

My circumstances are different (1st baby, history of anxiety, saw specialist consultant prior to getting pregnant to avoid this issue, hospital which had a good understanding of the issue and followed the guidance well) but one of the things I did stress at the very start of the process was the actually process itself was something that was causing me considerable anxiety and I was as worried about that as the actual birth. They took this on board and made sure a plan was made to resolve getting a CS booked with as little stress as possible. Their attitude was that doing this was a way to build a relationship with me, and in doing so, if I later felt I wanted to change my mind I was able to do this without feeling pressured in any way. I was also offered and did refuse counselling despite being encouraged to have it which they didn't like particularly. However they were extremely supportive and did actively notice that I calmed down and regained trust in them after my CS was booked. The CS itself was my coping strategy and did help me. It won't be the case for everyone but it certainly was the right way for me.

Your last post was very good in expressing how you feel and is highly relevant to your care. I would recommend putting it down into any argument you make. The trust you have with your caregivers is EXTREMELY important and that requires a good relationship which respects your feelings and opinions - even if they don't agree with them.

I would also echo WilsonWilsonWilson in saying you should definitely consider looking at making a complaint as their duty of care is to support you, not make you feel worse about things. This is precisely why the NICE guidelines are being worded the way they are.

Bit of background for you to reflect on:
The NICE guidelines regarding maternal request actually state that there is no recommended treatment for women suffering from birth trauma because no research has been done in the area. In fact they do say that some psychological support currently could be harmful to some women based on what we do know because its not specialised and because of the lack of research into the specific needs of pregnant women.

I also know a little of the history of the change to the guidelines; they were changed because NICE recognised that diagnosing trauma was an incredibly subjective subject and was leaving some women in a situation where their case was not being taken seriously for some reason. Women outwardly behave and react in very different ways, so trying to work out who 'really' needs a CS and who doesn't is virtually impossible. Some will be calmer and appear more in control than others but won't have any less need. Having developed a coping strategy like you could be exactly one of those examples. NICE expanded the guidelines to state that ALL women should be allowed to have an ELCS on request because of the psychological danger of not recognising this and putting women in a position where they are effectively forced to have a VB against their wishes.

I really hope you get the choice you want.
Strangely I kind of had the reverse.I desperately wanted a vbac after emcs,and did go for it,but ended up with elcs.
I really believe that they turned to the c section way too readily,and I was denied quute safe and sensible choices in pursuing my vbac.
I wish I'd been better informed at the time.
Knowledge is your best tool in asserting choice imo.

So sorry you are having to fight for this. I had to also. I had two awful deliveries with first two dc, the second of which was an emcs. I had to fight all the way for an elcs for dc3. Stand your ground. It's not like you are asking for a section as you can't be bothered going through labour.

Good luck.

I'm shocked at the hoops they're making you jump through. I know they always advocate a VBAC if safe and that most trusts are under pressure to reduce cs rates, but this takes the piss.

I'm having an elcs in a couple of weeks after a previous emcs. I expected a battle to get it but they have been very supportive. I told them I had thought about it long and hard and had made the decision on what I felt was right for me physically and mentally.

someone weaker would crumble under that sort of scrutiny.

Maybe try contacting PALs

Just to give you hope - I had a similar experience requesting an ELCS for my first child. My reasons were based on my understanding of pros and cons of vaginal vs CS (no mental health aspect). I had to really fight and was refused the section on a number of occasions. I didn't have to see a psychologist but did have to explain my reasons repeatedly to various people through the process and was frequently spoken to in a condescending, dismissive and pretty aggressive way at times. I stuck to my guns though because (thank goodness) I knew about the NICE guidelines, so why I was told "no" I said "Ok, so I assume you will now refer me elsewhere."

Ultimately, my section was approved without referral and I didn't have to feign mental health issues. Unfortunately it seems necessary to jump through some flaming hoops. It shouldn't be this way of course.

Are you in the UK? This sounds like the last thing you need whilst pregnant. I had no problem at all with my plan for an El-CS, attended the VBAC clinic, but no pressure at all. I don't know how much is to do with the small age gap that I shall be having but that was only mentioned as a minor point by the consultant.
Sorry haven't read all the replies in detail but I think you are using the right guidelines. I wonder if you could go to a sensible GP and discuss to see if you could be referred to another consultant, or even another unit if that is at all possible. And PALS is not a bad idea. Good luck, please keep us posted on the outcome.

Thanks again to everyone for your support. I'm in England and the more I read your responses and talk to people the more I realise this process is not OK, not normal procedure and not something I should be preoccupied by when I'm still trying to manage my sickness.

It sounds strange but speaking to a psychologist friend of mine made me question whether I actually have to go to this next appointment or not. It's of no benefit to me and the more I think about it the more worried, anxious, stressed etc I get. That can't be what the process is trying to achieve. I'm going to phone my midwife tomorrow (who hasn't been involved in any of these related appointments) and ask her if I have to go and if not, what the consequences will be, and if I can still have a c-section. The best option is to not go and just attend the next consultant appointment next week and explain how traumatic this battle has felt and if I'm required to engage in this process then it's going to end up doing more harm than good. I know it sounds strange that it only just occurred to me I don't have to go but I've been so preoccupied with gathering facts to support my case I've forgotten that ultimately my preference is paramount, no matter what she might say next week. My friend was able to explain the techniques she thought the psychologist was using and how my interpretation of them suggests their application was having the opposite effect to the intended. So instead of scheduling another appointment to try again she should have just accepted what I was saying.

I'll let you know what my midwife says but I can honestly say your support on here has made a real difference to how I feel about my decision. She was making me feel so weak and stupid, like I didn't know what I was doing. But you've made me see that whatever my choice I should have felt supported.

It's true, you don't have to go

It honestly sounds like this psychologist has been on a massive power trip: finding you unusually well informed and seeing you as a challenge she must win. Well, sod that. The psychologist actually has no say in whether you get the ELCS or not. It's the obstetrician's call.

Good luck, and remember you ARE the one with the power here. You have been made to feel utterly powerless and browbeaten (again, TOTALLY unprofessional on the paychologist's part) but, as you now know, your preference is important.

I've read a lot of threads like this and I've read a lot of research on fear of childbirth and there are a lot of reoccurring themes.

The key one is that women who request an ELCS usually do so with the need to be in control or regain control being a dominate factor in that.

So I do find your psychologists response here seems to be both completely at odds with that and lack an understanding of the common things at the heart of a desire to have an ELCS.

If you have a supportive psychologist with an understanding of the problem they are better placed to help you through the process. By this I mean, working through your reasons for an ELCS - not the pros and cons of an ELCS; not necessarily going back over the grounds of your last experience in detail, but exploring where you felt like it went 'wrong' for you and giving you the opportunity to say with the benefit of hindsight, what in ideal world could the hospital have done differently to help you cope with the same situation better; exploring ways in which help you feel more in control. Done well, it can help women feel confident enough to change their minds about a vb because they trust staff, feel that if the same situations arose they would be treated differently and would have better coping skills. I choose the hospital I did on the basis of the fact they had a record of never refusing an ELCS but had success in offering options to women in order to allow them to regain control who changed their minds about an ELCS of their own free (eg: early epidurals, good relationships with staff, being allowed to talk to labour ward staff before, trial of labour but with clear agree guidelines about how long its allowed to progress before going to CS, clear discussions about consent, limiting examinations amongst others). I take it, nothing like this has been talked about?

I think noting your desire and need for information and how you process it is important as its a key part of you and what you do on a day to day basis and a massive insight into who you are as a person and the way you think. It should be a positive thing, not turned into a negative one as it seems to be. Everything should be about helping to frame things in a positive rather than a negative one. She is perhaps trying to do this by getting you to find out more, but its coming across as a challenge rather than her going through things with her as an equal.

One thing I did over the years of dealing with my problem was to force myself to make a scientific research based case for the other side. The purpose of this was because I'm aware that you tend to have a bias when you look at research, so deliberately trying to find stuff to prove the other side of the coin was good for me as it removed emotion from how I felt, it forced me to re-examine the evidence I had to support my case and it made me look at different options than I perhaps otherwise would have considered.

Goodness RedToothBrush that's a scarily accurate précis of everything I've been thinking!

I have approached this in the way I approach everything and having my approach questioned sort of questions everything I base all my decisions on. It's true I think she's trying to make me research both sides equally but in a clumsy way. I too have said if an ELCS has complications then I will bear the responsibility. If a VBAC under duress does I will blame the health professionals for the rest of my life. The risks to me are higher but lower for the baby in my circumstances (as I see it; by no means is that going to be true in every case) so I'd rather play it safe for her but take the responsibility for the outcome.

I did get the impression she was dismissive of my reasons and I was another too posh to push case. When I said I pushed for 2 hours for no discernable progress she raised her eyebrows.

What pisses me off is if ELCS wasn't an option I wouldn't have got pregnant. Pregnancy for me is quite frankly an endurance test battling the nausea, pelvic girdle pain, chronic heartburn and other joys I know come later (carpal tunnel and whole lower body itching) so to labour again after a 9 month laborious process would not have been something I felt able to manage. I feel conned now there's no going back that the information I based getting pregnant on was flawed. I believed if I had another arduous pregnancy I would be allowed a positive birth. For me that means an ELCS.

I haven't heard back from my midwife today but will keep trying so I can cancel the appointment once and for all. Thanks again so much everyone for sharing your thoughts.

Dancing, write it all down.

I think that one of the problems with the process is the fact you go into appointments with a clear head but get 'ambushed' by the pressure or unexpected challenges (whether it be with the consultant, psychologist or midwife). You then come out and spend hours and days beating yourself up for not saying x, y or z because you forgot it.

All these thing about how you feel and coped is important and relevant.

I personally found the realisation that whilst I was unusual as a patient, that I was perhaps quite typical for a woman with this type of problem and as such felt reassured by it.