C-section being strongly suggested by obstetrician. Fair or overly cautious?

[Babynamelist]

I could really do with your thoughts please as I feel very mixed about this.

I'm currently just over 36 weeks' pregnant with DC2.
DC1 was born just over three years ago by EMCS due to failure to progress and the baby getting in distress (rapidly shifting heart rate). There was meconium in my waters when they broke anyway.
I am almost 40 (but not quite!).
I had a scan today and the baby is estimated to currently weigh 3.488kg (7lbs 11oz). There is a 20% margin of error so could be currently as low 2.79kg (6lbs 2oz) as or as high as 4.19kg (9lbs 3oz). Quite a range then!

The obstetrician has booked me in for another scan in a fortnight's time so we can look at the rate of growth and see how big the baby will be then. However, she strongly suggested that I should have a a sweep at 39 weeks, soon followed by an elective C-section if that doesn't work. They are worried about scar rupturing (even though no one has actually inspected my scar and my last c-section was over three years' ago).

I really want to go a more natural route because I will have a toddler to look after (as well as a newborn), want a quicker recovery time and (least importantly) live quite rurally now and will be very isolated at home during my recovery. Having said that, I don't have a 'romanticised' view on what a VBAC will be like. I understand there are unknowns and risks there too.

Do these reasons outweigh the doctor's concerns about possible scar rupturing? I know there is an approximately 70% chance of VBAC success and logic tells me this will decrease if the baby is large. Are they just being overly cautious and protecting themselves (and possibly me)? Or is there something in what they are saying?

Please help as I feel so unsettled by it all. I am usually a pragmatist and will go with the best option for me and my baby but I feel like I'm gently being rail-roaded down a route I wanted to avoid. Though I'm not expecting black and white answers, I'm trying to educate myself so I can make an informed choice.

[LibrariesGaveUsPower]

It sounds like your consultant is fairly anti v-bac generally. Did you try asking whether there are ever circumstances where she would be happy with VBAC at term?

[Gintonic]

I am in a fairly similar situation to you but only 24 weeks. My hospital are encouraging a VBAC. They think the risks are lower than for ELCS, but advised me that the risks are very low with either option. I have asked for a growth scan as my previous baby was quite big, I don't think they would have given it if I had not asked. Are there any other health issues that are making them keen on ELCS? If not I would seek a second opinion.

[WankerDeAsalWipe]

I am not a qualified obstetrician and can only offer my own experience.

I had an EMCS at term after 36 hour labour with a back to back baby (9lb 13oz) stuck solid and only ever for to 8cm dilated. I was 34.

13 months later I was due my 2nd baby, also expected to be large and sitting back to back. Obstretrician was inclined to leave me until I was due and to try for a normal birth. If not gone by them but to be booked in for a planned section for my due date. I was worried about the scar and obviously about the same thing happening in labour - my midwife fudged the dates a little helped by the fact that they only took bookings on one day a week and booked me in before due date.

During the Op the consultant said that the scar would never have held in labour - eek!

Anyway just wanted to say that a planned section is like night and day compared to an emergency one and I was up and about and out f hospital in 48 hours with a 13 month old and a newborn. So it may not be as bad as you think.

[Babynamelist]

Thanks so much for the speedy replies!

I've seen three different consultants at the hospital over the course of my pregnancy (one man and two women, if that makes any difference) and they have all been very cautious about VBAC and have recommended constant monitoring throughout, told me that I won't be able to use the midwife-led unit and have to get to the hospital as soon as my labour starts (rather than staying at home for a bit).

I'm OK about being on the labour ward but now we're getting closer to my due date I do feel like I'm being corralled in one direction. Prior to today they mentioned induction at 39 weeks due to scar rupturing risks but this has been discounted following the scan, due to the baby's potential size. No one has mentioned any other medical reason to me that could be an issue. In the interest of full disclosure I do have pelvic girdle pain but plenty of women give birth without this being an problem.

[Babynamelist]

Thank you for your positive story Wanker. It's good to hear this kind of stuff so I can make a decision - rather than being told what to do.

[hazelnutlatte]

I was given the choice of vbac or a elcs at 39 weeks. I chose the c section and I'm glad I did, as during the op the consultant told me that my scar was 'paper thin' and would have ruptured if I had gone into labour naturally. Scar rupture is a serious medical emergency and is a huge risk to the baby so I'm so relieved I didn't have to go through that. Obviously there are risks to c section too but if your consultant is concerned about scar rupture I would ask them what their reasons are that they consider you to be high risk. If you really are high risk then the safest thing would be to go with their recommendation.
I would also say that my elcs was a much better experience than my emcs - much calmer and I would say it was a positive birth experience when my emcs really wasn't!

[Mulligrubs]

They don't need to check your scar - they are talking about the internal scar on your uterus rupturing which is what is serious, not the external one on your skin. And it is a real risk.

Anyway - they have recommended ELCS for you. It is only a recommendation though, it is totally your choice and if you want to really go for a VBAC then you need to speak to your doctors again. They can push you in whichever direction but it is ultimately down to you. There are risks with VBAC and ELCS as you know, so either way you'll be facing risks of complications.

[Babynamelist]

Mulligrubs thanks for the explanation about the scar. That makes sense and I'm slightly ashamed of myself that I hadn't considered that before!

I just kind of feel that it's all 'six of one, half a dozen of the other' at the moment with no clear risk statistics that are tailored to me to help me make a firm decision.

[IssyStark]

It's difficult.

I had a level 3 emergency C-section for ds1 for much the same reasons as you, plus he was back-to-back, never engaged (turned out the cord was wrapped around his tummy so he would have had to spin around a lot to be able to drop down), waters with meconium, no progress (never got past 2cm) after over 24hours labour, plus was 40+14 when waters went.

I was going to VBAC for ds2 five years later when I was 40 years and 5 months old. I got to 8cm when labour stalled as he was still back-to-back. His heart-rate was all over the place when I eventually went into theatre. As they were stitching me up, the Registrar was discussing why she called it as a level 2 with the SHO who was assisting. Apparently we could wait half an hour rather than need a crash section (level 1, usually under a general) however we couldn't wait 3 hours (unlike the situation with ds1) without serious risk to the baby. The SHO characterised it as a level2+.

I didn't find recovery too bad at all. I was up within 12 hours, home after 1 night. I was able to sit comfortably which might not have been the case had I had a vbac and torn. My scar took a bit longer to heal than the previous time but I think that was my own fault because I stupidly picked up my hefty 5yo a week post partum (up to that point it was healing well!!)

It is a real toughie. I would have loved to have pushed one out, but at the end of the day a healthy baby and healthy mum are more important.

[LibrariesGaveUsPower]

I think what you need to understand is whether there is something in your personal risk profile making them worry. Or whether this team is generally anti them. In which case other hospitals may be saying very different. Then you can assess better what you want to do.

Vbacs obviously have risks. But people take different views as a baseline. Bit like induction.

[Babynamelist]

Thanks for all your helpful thoughts and suggestions. What questions do you think I should be asking them when I go back to the hospital in a fortnight's time?

[Topsy34]

I dont get why they are insisting on c section.....

Vbac are more an more common and although yes there is a risk the scar will rupture...what is that risk? How many women a year that they see has a ruptured scar?

The estimated weight is daft, its a huge margin either way! My mw predicted ds would be 10lb 5oz....he was born a day after his due date at 7lb 15oz.

I would be asking:

• rate if vbac at the hospital
  
• rate of vbac that they over see (per consultant)
  
• what are the actual risks - not generalised risk
  
• if you went ahead with vbac, would they insist on continued monitring through labour
  
• in the scan you just had, where did the baby fall on the percentile chart
  
• what are the risks to the baby
  
• how would they make an incision if you went ahead with c section (new scar, old scar)
  
• if they cut the old scar, woukd it increase healing time, how would the scar tissue heal

[perfectlybroken]

I had similar advice and cOmpromised by going for vbac but on a consultant rather than midwifery led ward. Chance of scar rupture is miniscule but if it happens you need help fast.

[Babynamelist]

Those are great questions Topsy. Thank you. The baby is currently on the 91st centime so it'll be interesting to see how that changes.

Am feeling a bit more philosophical about it all today. Am of the opinion that they're not going to encourage a c-section without good reason - they just need to give me the reason/s so I can make an informed decision relevant to me and my baby, not just some banal generalities.

[Roomba]

It's your decision, OP. However if it were me, I would be inclined to listen to the consultant. She may have read things in your previous hospital notes that you are unaware of - I know that when I got hold of mine and read through them there was a lot of info there that I'd had no idea about at the time. Plus she will be experienced in examining women and having a decent hunch what the outcomes will be (if that makes sense?).

I would still ask the questions suggested though, as it may be that she is just more cautious than an 'average' obstetrician. Maybe ask what her c-section rates are compared to the NHS/hospital average? That may not tell you much either though as if higher, it may just be that she deals regularly with the more complex cases which come with a higher risk of c-section births.

As someone else mentioned above, the 'scar' she referred to is the internal scar on your uterus, not the external one you can see yourself. She is very likely to have examined this by ultrasound I would have thought.

I opted for a second c-section despite a fair amount of pressure from my midwife to go for a VBAC. Even wondered if I was mad, as my first section was horrendous and I had a slow painful recovery. The quoted risk of it being about 70% likely (in my case) that this would end in a c-section or assisted birth with forceps etc. was just far, far too high for me personally. I was not going to put myself through a trial of labour for a 30% chance of 'succeeding' to do something that would be agonising anyway.

It turned out my gut feeling was right. The surgeon who performed my second c-section told me afterwards that the scar on my uterus had been very thin indeed and would have, in her opinion, ruptured during labour. She was very clear that any future births (not a chance now!) would have to be sections as uterine rupture is so dangerous and FAST.

[Babynamelist]

Just wanted to come back with an update.

I'm booked in for a c-section next week. I chatted with the hospital's senior obstetrician and explained my concerns. He was v sympathetic and really helped me weigh up the pros and cons. I even asked what he'd recommend his nearest and dearest women in his life. Due to a variety of factors involving the size of the baby (now in the 99th centile, having put on another 2lbs in the last 2 weeks!), my age, my failure to progress last time and risk of the previous scar rupturing it seems like a sensible decision. Not what I wanted but certainly the 'best' option given the circumstances.

Thanks to all of you who offered advice and their experiences. I feel as content as I can be with my decision now. Roll on next week so I can meet the newest addition (and definitely the last!) to the family.

[insanityscatching]

I had an ELCS for my second who was a footling breech after having a vaginal birth for my first. It was a trial of labour for my first because I'm small and obstetrician had concerns regarding size of my pelvis,
He recommended an ELCS for my third but I wanted a VBAC. I was 10 days over due date when my waters went but no contractions. Again he wanted ELCS not least because dd was bigger and back to back but agreed to give me half a dose of prostaglandin and I had to agree to an epidural in case of rupture. The half dose kick started the contractions and Dd delivered vaginally really easily.
My fourth was another VBAC went to hospital at 5cm dilated but agreed to an epidural at consultant's request.
My fifth was under a different consultant,was induced with a drip after waters broke and no contractions. No epidural this time as he didn't ask me to have one and dd again delivered easily.
I hated the ELCS and even though I had epidurals and drips I found the VBACs so much easier.

[AnnieLewis]

I just wanted to add my tuppence worth, especially as you are now booked for section, I've just had an elective section, day 6 today and honestly I feel fab! I had intervention vaginal deliveries first 2 dc (ventouse and forceps) and my recovery has been so much better with the section!

I was up and about very quickly, my milk came in fine (I was worried it would be slower/an issue) and it's honestly been a really positive experience!!

Good luck and have fun meeting your new family member!

[lulalalala]

I had an elcs this January (I'll be 40 at the end of the yr) and it was the best decision for me. I did have a 2 year old to look after as well, but it actually was fine and I felt a thousand times better as I wasn't as knackered!!!

I had an EMCS with my first due to failure to progress (only 1cm dilated). I had been induced and it had dragged on for days. I ended up having a 3 litre pph and a spell in HDU.

We all agreed I couldn't be induced as I was at high risk of pph, if I went for a VBAC it had to happen before 40 weeks as DD1 was 9lb4 and they didnt want DD2 getting too big. DD1 was born at 42+2 so it didn't look likely. ELCS was the best course of action.

[swisscheesetony]

With similar stats to yours I cross-referenced the RCOG guidelines with results from my hospital. It gave me just a 20% chance of a successful VBAC.

I pushed for the ELCS - turned out the right call as baby stuck in my pelvis and despite c-section was still pulled through my scar with ventouse. Midwife said she'd never in her 30 year career seen bruising like it. Labour would've been a total disaster and even had they kept trying I'd have been ripped to shreds with forceps.

Check the stats. No regrets here

[jaffajiffy]

Joining and marking place as I'm seeing the obstetrician on thur and will have the same queries. My first birth ended in an emcs due to "failure to progress" though it wasn't an emergency as such. I'm 41. Had DS at 39. My recovery was straightforward. I like the question "under what circumstances would you recommend a Vbac?" And will ask that on Thursday. I'm quite sure they will not have any, though, so I think I will threaten a home birth so they at least sign off on MLU if the baby comes early or on time. I'm happy to book elcs for the week following the due date. Really useful thread - thanks. I'll post again thurs.

[mrsmeerkat]

I had a similar experience on first pregnancy and had the option to go vbac or elcs and I went for the elcs and am glad I did.

It was much less traumatic than first time around and I personally was glad I didn't have all of the stress second time around.

I recovered quickly and didn't have much help/live out in the sticks and couldn't drive but relied online for grocery shop etc

[WLondonMum]

I think that having an ELCS sounds like the right decision. I had one not long ago and while I definitely believe it was the right decision for mine and baby's health, I had a surprisingly difficult discovery (unlike most people it seems) and needed a lot of help. Can you try and get some more help lined up for after the birth just in case you need it?

[Babynamelist]

Just a little update to thank you all for your thoughts. I had a gorgeous baby girl last week via c-section. Recovery has been hard (as anticipated) and she didn't weigh as much as feared but I now remain certain it was the right decision, given my circumstances. My husband is being fab while he's on his paternity leave and I'm in the process of organising help when he returns to work.