Questions to ask at VBAC midwife appointment

[CorBlimeyTrousers]

Firstly - sorry for length!

Background:
When I was pregnant with my son I was diagnosed with gestational diabetes quite late at 34 weeks after sugar was picked up in my urine at 32 weeks. I really wanted a natural birth (we attended hypnobirthing classes) but I realised intervention was now more likely. I managed the diabetes with diet but I'm not sure they'd have put me on medication that late anyway. I had growth scans at 36 and 38 weeks. At the 38 week scan the sonographer raised concerns about the baby's growth (the baby hadn't grown much since the 36 week scan) and placental blood flow. She told me 'not to leave the hospital' and that I had to see my consultant. I was terrified. The consultant advised coming in that night to start induction. Long story short, the induction didn't work (at all - no dilation so I couldn't go on the drip or waters broken) and there were some very scary times when the baby's heart rate dropped and I thought I was going to have an emergency c-section in the middle of the night without my husband there (midwife rang the bell, loads of people ran into the room, etc). After sleepless 3 nights they told me they couldn't carry on with the induction. After one doctor suggested a 'break' for 24 hours and start again and I burst into tears, another doctor suggested a caesarean and I gratefully accepted. After a horrible induction experience the caesarean was a very calm and positive experience. My experience on the postnatal ward was not great, breastfeeding went 'wrong' but my recovery from the caesarean itself was fine. I was later diagnosed with PND and the early months with my son were difficult. In all that I look back on the caesarean itself as being a positive experience.

I am now pregnant with our second child. Our son will be 5 when the baby is due and I will be 40. The big age gap is due to secondary infertility and we eventually conceived through IVF using an egg donor. I have GD again in this pregnancy but it was diagnosed much earlier and I am so far (31 weeks) managing well with diet.

I've long thought I wanted to have another caesarean. I have expressed this to midwives and consultants. They have all delayed any decision and I am booked for a VBAC midwife appointment this Wednesday (32 weeks). It has been suggested that I can have a caesarean if I want but I am nervous that it will be made difficult. There is no way, NO way I would ever consent to an induction. When I saw an obstetrician she said 'wouldn't it be better if you went into labour naturally' and that they will let women with diet-controlled diabetes go 1 week overdue. This obstetrician also told me that the 'placental bloodflow' concern with my son actually meant they were concerned about 'placental insufficiency'. No one had ever told me that before. It links to what a friend who is a paediatrician told me - that diabetes can cause the placenta to fail earlier than normal which is why they don't like women with diabetes to go overdue. She told me this when she didn't know I was pregnant. This has increased my fear of going overdue and the baby being harmed - I don't think I could bear to go overdue.

I want a caesarean because I would feel very very anxious going full term with this baby based on what happened last time and what I have been told about placental insufficiency and diabetes. I can't bear to think what might have happened with our son if that scan hadn't identified concerns. The caesarean is a known quality whereas vaginal birth would be a totally new and unknown. I could get a good night's sleep before a planned caesarean (which I didn't have last time) and go into hospital feeling prepared. Although a lovely natural birth may be the ideal, no-one can guarantee me that: I believe a planned caesarean is better than either a instrumental delivery or an emergency caesarean, either one of which I could easily end up with if I try for a VBAC. I won't agree to an induction under any circumstances as it was so awful last time.

Sorry for writing so much!

I assume I should tell the midwife everything I've written above about my reasons. I haven't totally ruled out trying for a VBAC (although probably am 90% sure) and I do want to listen to her. What I'd like advice on is what questions to ask. I was thinking:

After what happened last time - what is the likelihood of a vaginal birth without instruments; what is the likelihood of a vaginal birth with forceps/ventouse; what is the likelihood of an emergency caesarean?

What are the advantages for mother and baby of a vaginal birth over caesarean?

What are the advantages for mother and baby of a planned caesarean over emergency caesarean?

What else should I ask?

I'd also be interested in anyone who's had a similar experience to me and your thoughts.

Thank you. And well done for reading this far!

[Molotov]

In your situation OP, I think I would be insistent upon a repeat CS (elective repeat cesarean section or ERCS) unless I knew we wanted another baby. The risks that CS carry increase with each subsequent CS, so this needs to be taken into consideration.

You have a medical reason for a ERCS (you've had one before) and you have MH issues to do with labour in the form of your anxiety. VBAC carries a small risk of uterine rupture; a risk which no-one can force you to take. Have confidence to insist upon ERCS if this is what you want.

I think your questions are fine, but your MW won't be able to answer the liklihood of the need for assisted delivery. She will be able to offer statistical data, and she'll be able to offer statistical data about CS. Please bear in mind that the data about CS is skewed as EMCS rates get mixed together with ELCS rates; reasons for first and subsequent sections are not clarified (I.e. maternal and/or fetal issues).

Also, HCPs tend to promote the best-case VB against the worst-case CS.

Have you checked out the NICE website and looked for data on there? There's also the RCOG 'green top' guidelines (no.45, I think), which also has data for first and subsequent sections.

[FlumptyDumpty]

You have three very good reasons for choosing ELCS:

• previous placental insufficiency
  
• over 40, meaning going over 40 weeks implies increased risk of stillbirth (esp with previous placental problems) and being unable to have an induction following previous CS.
  
• MH issues following trauma last time (just as valid as any physical health issues).
  

My reading of the stats suggests that ELCS is safer than assisted delivery and EMCS.

Yes, you could have a 'normal' vaginal birth, but as you say, it can't be guaranteed. And would only have a chance of happening if you went into spontaneous labour before 40 weeks.

If you want an ELCS you will probably have to jump through the VBAC discussion hoop, but I really can't see how they can ultimately refuse a CS. You could make it clear you wouldn't consent to induction.

As a pp said, I would familiarize myself with stats and data, Nice guidelines and RCOG guidelines. The RCOG paper on VBAC makes it clear there is an increased risk of uterine rupture, though still small, and that VBAC may not be as safe as previously thought.

Make it very clear how the trauma of the first birth affected you. If you can show this while talking about it, so much the better. They need to take into account your whole wellbeing, not just the physical side of things, and how PND can affect the baby as well. Ultimately, you want the right decision for you in the round. And not one that is aimed at improving their CS stats or pandering to somebody else's ideology. They are not the ones who will live with the consequences of whatever you decide.

Good luck.

[TreadSoftlyOnMyDreams]

I posted some questions on this thread which I used to help me to prepare for my meeting and make a decision re VBAC. I hope they are of use.

www.mumsnet.com/Talk/childbirth/2408316-VBAC-or-C-Section-please-help-me-think-it-through

[Molotov]

I agree with flumpty in that from my reading, the 'safe' order for mode of delivery (for baby) goes from:

Safest to least safe:

1. Normal vaginal delivery
2. ELCS
3. Assissted vaginal delivery
4. EMCS

[CorBlimeyTrousers]

Thank you so much. That's all very helpful. I will look up those guidelines and read the other thread.

A couple of people in real life I've mentioned wanting a caesarean have expressed surprise that's what I'd choose so I was starting to wonder if I was missing something in my thinking.

[Molotov]

I think a lot of people react like that to CS - usually it is born from ignorance i.e. their experiences of birth have not made them question VB as the only possible option. Then there's the 'oh, it's major surgey!' thing and the horrendous 'too posh to push' nonsense.

Yes, it is major surgery but if an ELCS goes well (which statistically it should), it's all very controlled and predictable. Of course, you could have a sneeze birth, but you'll never know until you try. As the other pp here said, your age, placental problems as well as anxiety mean that, IMO, a CS would be the better option.

Just because you have a vaginal opening and can give birth, does not mean that you should. And, there is no easy way to give birth. You are just in the position now where you choose the risks you'd prefer to take.

Wishing you the very best

[FlumptyDumpty]

Completely agree with Molotov. I think attitudes to CS are often informed by silly media 'too posh to push' nonsense and outdated information. CS is much safer than it was when my mother was having children 40 years ago, for example, yet her attitude to it hasn't changed since then. Yes, it is major surgery, and shouldn't be chosen lightly, but it is a safe way to give birth, and the aftermath of vaginal birth can be just as bad, and sometimes worse.

As Molotov says, VB and CS both have risks and benefits, but they are different, and IMO you should have the right to choose which risks you feel more comfortable with, given your particular circumstances.

Oh, and I've found since getting pregnant that the world and his mother's aunt seem to think they are entitled to an opinion on my choices, be they food related, birth choices, how I will feed my baby and the size of my bump. I reckon the only way to deal with this is just to ignore the lot of it!

[CorBlimeyTrousers]

Thanks again.

Saw the VBAC midwife this morning. She asked what I wanted (caesarean) and then had a list of risks and benefits of VBAC vs caesarean that she went through and gave me a leaflet. She didn't try to persuade me. She said the decision would be for me to make with my consultant. She said it would be a joint decision. I queried what happens if my consultant and I have different views and she didn't really answer that - just said we would need to come to a joint decision.

So I will see the consultant on the 27 July, the day before I am 36 weeks. I'd like to have the decision made sooner than that but I'm really hoping the consultant will support what I want.

[TreadSoftlyOnMyDreams]

Hmm - you are 40, have GD, a prior C section, a history of PND and prior issues for growth scans at 36 & 39 weeks and a strong preference for an ELCS.
I don't think the consultant will argue at all for more than a second.