Delivery options with endometriosis - vaginal or csection?

[squashie34]

Hello,

I'm currently 30 weeks pregnant (have stage 4 endo and had 6 laparoscopies) just wondered if any ladies with endo can share their stories on how they gave birth?

I'm consultant led and at our last appointment I mentioned about a csection due to having severe bowel pain when opening (sorry if tmi) which is the pulling on my bowel adhesions from baby getting bigger, and the consultant said that a vaginal birth (with epidural) would be the safest method due to the likelihood of scar tissue present in my abdomen which would make a csection harder. Then there's also the risk of the endo then forming in csection scar in the future.

I've done a lot of reading however that states research has suggested women with endo are twice as likely to have an EMCS when attempting a vaginal birth, so id really like to avoid an emergency section where time would be of the essence especially if they think scar tissue would be harder to navigate- id rather they do that in a planned section where at least they have lots of time to get baby out.

Just looking for stories of either delivery of any ladies with endo and how it went for them? Not seeing the consultant again until 36 weeks so quite a while and near to the end! Thanks

[RyvitaBrevis]

Watching this post with interest. I'm in a somewhat similar position, except I will likely have to have a section for a different medical indication. From my reading, my understanding was that endo increases the chances of cesarean but specifically because of its relationship with other risk factors leading to a section such as placenta previa, gestational diabetes, small for gestational age, etc. If you don't have any of those risk factors, what is the evidence around increased risk of an EMCS -- not sure it can be untangled? And studies based on American data, or data in other countries with a higher rate of emergency C-sections, may not be accurate here. Personally, my preference would be to have a vaginal birth in order to reduce the chance of complications with a subsequent pregnancy/pregnancies. But I do appreciate why you're concerned about the existing scar tissue.

[HelloViroids]

Also following - 30 weeks with deep infiltrating endo, low placenta and GD. Was told by expert consultant in field that a C section on me given the level and location of my scarring would be difficult, and was also told by midwife friend that c section like to make future health and any pregnancies harder, as more scarring - before this conception I was told I needed intense surgery to get pregnant and they don’t know how I conceived spontaneously So am hoping to try for vaginal, although I know that placenta and GD issues make it less likely...

[squashie34]

@HelloViroids you sound like a very similar endo case to me- I have deep infiltrating endo and had significant surgery in May last year to remove endo from my bladder, bowel, ligaments, ovaries and womb, although the consultant is pretty sure I also have adenomyosis (endo inside the womb) which obviously can't be confirmed without a hysterectomy. His words to me were' when you've had your kids come back to me and we will whip it all out' 😂 so I anticipate like you the scar tissue locations would be right exactly where they need to cut for c section. I also naturally fell pregnant which was a huge happy surprise!

I guess I'm lucky as my low placenta has now moved and no GD - so your decision may be taken from your hands? I do however have cholestatis which means induction at 37-38 weeks, another risk factor for instrumental assistance/emergency csection.

My worry is, if the vaginal birth ends up in emergency csection (as the studies suggest higher odds for endo ladies) surely that's more risky as there is a huge time element to it than having a planned ELCS. I guess I just always thought with my bowel issues (and the idea you have to push through your bottom) that a csection would be the best option, but like you I don't want to end up suffering much more in later life! Not sure what to push for the best

[agteacht]

I don't have endo so can't help in that regard but just thought I'd come t having had an EMCS in December.

Really it was fine. A bit scary at the time of course because it was unexpected, but recovery was very manageable. I actually feel lucky that I only have a scar to deal with when I hear some stories of tearing friends have experienced through vaginal birth.

If I have a second child, which I hope I will, I will definitely opt for ELCS. I have no real desire to experience labour again!

[Sadie789]

Please don’t be discouraged from having a c section if you’re in any doubt about how a vaginal delivery will go.

It’s quite irresponsible for a midwife to tell you that a csection will give you future health and pregnancy problems when that simply isn’t true. A vaginal delivery, or a half and half situation could easily leave you with residual health issues.

I’ve had an EMCS and ELCS both were fine. No recovery issues or residual problems.

[Jadegkeaney]

Interested in this topic. I too have stage 4 endometriosis, deep infiltrating endo in my bowels..I need a bowel resection at some point they think 6 months after I have baby. I am 17+6 now. I am consultant led and my gynae believes aswell as my consultant that I should be able to deliver naturally. I am scared with the pain it will cause as baby comes lower down onto my bowels. But also dont want a c sec if I can help it. I mentioned to consultant I was considering hypnobirthing but she was somewhat sceptical I think shes expecting me to have more pain then the average woman.. so if I feel I need a epidural then sod it I'll take it and think it will calm now down which is key I guess. Endo does shrink with pregnancy and they said my bowel endo would be much smaller.. still very stressful and just wish i was normal. please let us know how you get on regardless and hopefully some women can let us know how they got in with their endo births x

[Anaesthetist83]

Hi,

Similar dilemma but for Crohn’s rather than endometriosis.

I’ve never had abdominal surgery, so state of adhesions is unknown.

My big fear is a bad tear which will affect future continence (which can already be close to problematic during a flare up of disease).

The way I see it as someone who through work has been involved in a lot of sections...

A “normal vaginal birth” is your “gold standard” -
But is a retrospective thing. 1/3 will end up with a section, a similar number an instrumental and even those who deliver unassisted, a good number will have a tear/episiotomy. So not many will avoid some degree of pelvic floor issue.

An emergency section carries with it uncertainty -
Operator - whilst someone who can do a section, they may be less experienced and Sod’s law says it will be the middle of the night. Time to carefully divide the tissue planes is reduced if there is fetal compromise so there is a greater risk of bowel/bladder injury than with an elective.

However there is no disputing that an elective section is a major abdominal procedure and potentially an unnecessary one - and may cause future problems in terms of adhesions.

But there are other advantages including the ability to plan for it (though could still labour early). Not having laboured for hours before getting to the point of section. Recovery generally better from elective then emergency. Providing all goes well, I think you could be home quicker than if need an induction.... which in these times of coronavirus is relevant.

So all in all, I’m planning an elective section. If I go into spontaneous labour beforehand, I may give it a go but would request a section at the slightest hint of poor progression.

(Disclaimer - being medical is difficult when it comes to making these decisions as knowledge and experience of dealing with the abnormal can’t be forgotten.... and I don’t see the lovely, normal deliveries so experience skewed towards the problematic)

[squashie34]

@Anaesthetist83 I could have pretty much written your post myself, that is totally how I feel- if it's quite likely a normal vagina birth in a first birth (especially an inducted one) ends in some form of intervention and a high % of those who need intervention involves EMCS then surely that's more of a risk as like you said there's a time pressure involved to get little one out , could be any surgeon on call and yes definitely middle of the night job 😅 surely with an ELCS they can book you in for a time in which a surgeon with experience for that medical issue is available and there's plenty of time to work through the scar tissue etc. I'm also worried as with obstetric cholestatis there comes with it an increased risk of still birth so I will have that hanging over my head whilst in labour too.

I really would like a section for all those reasons you've mentioned about being able to control any problems that arise and I have honestly read so much about all the risks involved etc so it isn't just a decision made lightly. However, it's my consultant who says that it's safer for a vagina delivery with epidural and about the risks of adhesions etc with a csection, so how can I push myself for an ELCS if he's against it, surely they will just say no 🙁

@Jadegkeaney my endo pains in general have got much better in pregnancy (used to have them down my legs and my groin and it was agony) however now that she's bigger my bowel issues have been intensified and it's getting worse the more it's pulling on the adhesions. Opening my bowels gives me awful pain and it's for this reason (pushing is essentially like pushing a big poo I've heard 😅 and the scar tissue on my bladder the consultant said that the labour would be much more painful so he recommends an epidural straight away!

[HelloViroids]

@Jadegkeaney like OP I’ve also found my endo has got better during pregnancy - consultant described it as “sleeping” due to the hormonal shifts and so far haven’t found opening my bowels too bad (certainly no worse than prepreganncy). Ive already made my peace with possibility of an epidural, will try hypno/gas and air etc, but I guess we are all experienced enough on this thread to know the importance of pain management and what our tolerances are!
In terms of weighing up attempted vaginal delivery but risk of EMCS vs. ELCS for future scarring, continence, pregnancies etc - I don’t really know what to do. I also need to see what they say at my scan in 5 weeks.

[HelloViroids]

@Sadie789 do you have endometriosis? The potential c section “damage” afterwards can be different for those of us who have a lot of internal scarring already. My uterus is fused to my bowel all the way up one side, and parts are described as “obliterated with adhesions”

[TenThousandSpoons0]

Following also - very interesting topic, I don’t know if there is a right answer but you should definitely feel listened to - and if you decide that you would prefer a CS for all the above, well informed reasons, then your consultant should support you in that.

@Anaesthetist83 the last part of your post made me chuckle a little bit - your username makes it obvious what sort of medical professional you are and of course you get a bit of a different view - you’re probably mainly called to see women who are desperate for an epidural, or in need of emergency delivery! I promise lovely and normal does happen, quite frequently!! Of course you’re right with all your reasoning but the numbers are a little better (about 20-25% CS total if you look at all births including electives; about 12-16% instrumental delivery rate; I’m not sure re tears). That’s not to argue with your choice - I’d probably choose CS too.

All the best w your decision OP - just go with what feels right to you.

[squashie34]

Thanks ladies, it's so nice to know that there's others out there who are also having this dilemma in light of the endo! Although I'm sorry for your long gynae journeys too.

Please all let me know what the advice is that you're given in future appointments about it - I've got 6 weeks until I meet the consultant again at 36 weeks so quite a bit to really think about it. I am leaning to try and push for an ELCS for all the reasons we've discussed - if I knew I was going to have a straight forward birth, or even if I know I was going to need epidural and then forceps for example, at least I would be prepared for that, I just can't help thinking it may be a car crash of intervention and then a rushed EMCS which is then riskier.

I guess the positive to having a csection is that between us we have probably had more than enough surgery to know exactly how the recovery will be 😅

[TeaAndCake30]

I have endometriosis (took 2 years to conceive but then fell pregnant unexpectedly when no longer trying!) and gave birth 5 months ago via EMCS. I had planned a vaginal delivery and water birth, but after 24 hours in labour, I had to go in for the EMCS, however this was because of the position of my son's head and not related to the endo. I'd have preferred to avoid a C-section because I was worried about the impact on the endo with the new scarring, however it was pretty straightforward and touch wood, I've had no problems since, but don't know how it will affect me in the future if we try to conceive another baby. I also found the recovery easier than recovering from a laparoscopy, which as you say is probably because we're used to it.

Best of luck with everything

[krispycreme]

It's a difficult decision and one where you'll never really know whether you did the right thing. For me a c section, that I had to have due to a breech baby, resulted in lots more nasty scar tissue that played even more ha I know with my periods afterwards plus major implications on future pregnancies. Obviously not everyone will end up like this. All I will say is that if you believe an ELCS to be the best option for you then you are 'allowed' one. Firmly ask your consultant for one, explaining you've read the risks etc. If they won't book you one then they need to hand you over to a consultant who will.

[Sadie789]

@HelloViroids yes I have endometriosis and I also have a large cervical fibroid and two “hanging” fibroids inside the uterus, all three issues were of concern but with my first pregnancy I was pushed and pushed to stay with a vaginal delivery.

In the end I went early and the consultant in charge at that moment decided on a section as soon as she looked at my notes.

There was a higher risk to me in having a section, more so than the fibroids, but it’s a managed risk.

The operation, delivery and recovery were straightforward with no issues, and same with the ELCS I went on to have with my second .

[Sadie789]

Should say more so from the fibroids

[squashie34]

@Sadie789 that's great to know that information, and can't believe one consultant pushed you to have a vagina delivery whilst another one straight away said a section was needed. Glad that they were straightforward too for you!

That's exactly what I think about yes there's risk but surely that's a much more managed risk in a planned section as this can be thought out and time taken- in an emergency section it's harder to manage as it's done so quickly and I really don't want to go into a vagina birth worrying if I need an EMCS it's going to be much higher risk as from what I understand they're normally very stressful situations anyway

[mouse1234567]

Hi,
I had a lap two years ago for endo. Took a long time to conceive and am now 37 weeks pregnant after 2nd round of IVF. Unfortunately baby is breech so I have the option to try to turn him with an ECV but feel quite uncomfortable with that option. I really hope it doesn’t make my endo worse having a section -I’m pleased to hear from some of you it didn’t seem to and that you did conceive after. I would love a second and I know IVF will be needed -I just hope the scar won’t make it even worse.

[SoloMummy]

Hi all,
OK I have endo and similar situation to the op @squashie34.
I gave birth nearly 6 years ago (where does the time go).
I suffer badly with my bladder and bowels. But was lucky after about 18-20 weeks the usual endo pain had subsided due to the whole hormone thing.
I was induced. Omg. Sorry I'm not trying to be one of those horror posters, and I genuinely have nothing else to compare it with as only have one child.
The pain of "contractions" was quite literally my endo bowel pain; the mw said she'd never seen anyone fly off the bed that way before! However, once a spinal block was in, it was fine.
It ended, as many inductions do, with forceps. I begged for a csec but was told in no uncertain terms that they were too wary of my scar tissue and the potential of issues for the scar tissue, plus potential this created for hysterectomy that they really would only do that as last resort; to help you gauge this, I had 12 medical professionals in the room at the time.
Now, what I will say is, take whatever Painkillers you can have. Recovery after wasn't straight forward, but I always get infections from catheters.

I'm not sure if that's helpful?

Fwiw after, breastfeeding kept periods at bay until 10 months. I then went back on zoladex at about 14 months as was doubled over again.

[squashie34]

@SoloMummy that is a really helpful post thank you as it sounds so similar in regards to your endo sites! Your birth also seems to be how I visualised it would go exactly.. there's nothing worse than bowel endo pain either is there 😫 were they swift to give you the epidural after they saw how bad it was making your contractions?

How was the forceps delivery? (In total honesty!) I know you wouldn't be able to feel anything with the epidural in but was it all quite traumatic and did you tear badly/need an epistomy? I don't want to end up incontinent or with severe pelvic floor issues as tbh with having endo being intimate is tough enough as it is 🙁

That's pretty much what the consultant has said to me about a section that the risk of scar tissue and navigating it is difficult - I just wondered whether those risks are mitigated more in a planned section.

[SoloMummy]

The spinal - took a while as they had a backlog in the anaesthetist queue. Something I never realised could be a possibility tbh.
The forceps delivery isn't ideal. You're cut so that you don't tear unnecessarily. The stitching afterwards seemed to take ages, think. 45-60 minutes, but that could have felt worse because my lo was rushed out of the room for quite a while.

I can't comment on the whole post sex thing, as haven't dared venture down there. I'm sure you understand that reluctance. I don't know if that's compounded by a fear of the usual pain but also the loss of libido that zoladex causes.

Are the risks mitigated? Not really as I understand it as until they start to cut they really are going in blind and once they've cut regardless whether planned or due to prolonged labour, the amount of time they have is limited.

However, what I will say is that friends who had csecs, but no endo, may have been bed bound initially whereas I was up and about on the ward straight away, they were in a far better position than I was 3-6 weeks later with the infections, but arguably the catheter etc would have been required for csec too would have still been an issue but the other infections if it had been a planned csec wouldn't....

It's a really difficult one. And probably if I'm honest, I wouldn't want a rerun. But I think I'd still go for vaginal birth if there was ever a next time (there won't be!) Partly also fuelled by how do many mothers of csec babies I've known say that they struggled with bonding in the early days and those early hours and days memories to me are so special....so I'd suffer the forceps for that. But obviously I know loads don't have that issue too I'm sure....

[HelloViroids]

@squashie34 how are you feeling now? I’ve just started to have lower back/bowel pain, think he’s now putting pressure on the scar tissue (am 33 weeks...)

[squashie34]

@HelloViroids oh no, I'm so sorry to hear it's finally starting to bother you 🤦‍♀️ have you managed to take anything for it? I'm exactly the same- bowels are a 'hold on the bathroom walls' when having a BM jobby at the minute and dull backache. In the last week baby has dropped down slightly and now my bladder is really struggling- have that constant pain like when you've held in your wee for hours. Not sure if normal or scar tissue irritated.

Are you under consultant care? I can't remember- got my next appointment at 36 weeks so in a month.

How's everyone else doing?

[Cockodoodledoo]

I have endo and had one vaginal birth (induction, forceps, episiotomy etc) and two ELCS.

I didn't find any additional problems as such with either of the births at the time but now, 18m PP with number three I have been diagnosed with adenomyosis (if you thought periods couldn't get any worse than with endo you were wrong!) and am currently waiting to have an endometrial ablation (delayed due to Covid 19 elective surgery ban).

I had no idea it even existed as a thing until seeing the Gyno about the horrendous flooding periods I was having after #3 and although very poorly understood (like endo basically) one of the causes is understood to be likely to be a disturbance to the uterus lining during surgery (like a c section incision) which allows the endo cells to implant outside the uterus and into the muscle wall outside the uterus (sorry I'm on my phone so not as easy to search and look up the finer details). So if I had have known that was a risk I'm not sure I would have been so happy to jump at the ELCS.

I know that's not what you were asking OP but it's possibly something to ask about/ consider.

Good luck with the birth and rest of your pregnancy anyway

[Cockodoodledoo]

Sorry just seen this thread started a few weeks ago and there was just an update going on. Never mind me