Why do medics argue for VB over CS?

[EmeraldIsle81]

Just reading so many threads where medical teams really argue with patients to do vaginal birth over Caesarean section when the patient wants a CS. Can anyone tell us why that is?

The uncertainty of vb, the risk of distress and damage to baby if vb doesn't go well, damage to mother, length of time in delivery, pain management. Midwives having to go to find a specialist if complications arise.

I just don't understand why all of that is so preferable to a patient wanting a CS where everything is prepped, planned, no surprises, quick procedure with the right people there in the room just in case, recovery is monitored and managed.

Thanks all!

Ive had emcs and elcs. In emcs I lost 1.8l of blood. In elcs I lost 2.5l blood, baby needed resuscitation for 10 minutes and we were in HDU after. I cant imagine it was cheap for the nhs and certainly wasnt pleasant. I'll never do it again!

Cross post with scar...interesting we are both still having scar issues more than 10 years on!

Aargh....puppy not scar

I think what is obvious is there is such a range of experiences - women who have found their ELCS to be a great experience with a good recovery, and those who haven’t recovered fully 10 years on. Likewise women who have a really positive VB, but an awful section recovery.

You just can’t generalise.

My last pregnancy was very high risk. I assumed I’d be strongly advised to have a CS. To my surprise, the consultant told me a VB was safer.

I assumed she meant safer for me so asked about the baby. But she said a VB was safer for ^both of us*.

Obviously, in individual cases circumstances might make a CS the better option, but in general a VB is safer.

Umm - based on researched peer reviewed scientific studies? Love MN but you're a bit nuts if you use MN as 'evidence'

Someone asked about microbiome seeding, it sounds much more complicted than it is. In a microbiome seeding, a woman who is having an elective or semi-elective cesarean (there is normally not much time during an emergency CS) has a small sterile swab inserted in her vagina before the CS. The swab is removed at the time the IDC (urinary catheter) is inserted in theatre and kept in a clean recipient (a urine pottle, for instance). Once the baby is born, the designated person (it can be the midwife or the dad) takes the swab and rubs it on the baby's mouth, face and body, hence "seeding" the baby with their mother's vaginal microbes.

It is still a relatively new technique, but preliminary studies have shown babies born by CS and "seeded" like this have a much more normal skin and gut microbiome, without any negative effects, compared to babies born by CS and not "seeded".

There aren’t many circumstances where surgery is the first option offered for treatment. It’s great we can do it but any surgery traumatises the body and carries risks that just wouldn’t be there otherwise.

VB of course carries it’s own risks but generally speaking they’re quite low compared to surgery. Also consider pregnancy affects your immune system and depletes your resources; it’s not ideal circumstances for recovery especially when you factor in care of a newborn.

I believe that there should be a choice and the opportunity for serious discussion with medics but that doesn’t change facts. One set of risks may be more palatable than the other to different people.

mclover

Is that aimed at me?

Aurynne please et me put this to you. DS was born 25 years ago. Labour was a continuous wall of pain - he was posterior. Midwife thought the pain I was in was funny for stage of labour. Ha ha your kess than 1/2 a cm God knows how you will cope later after I'd been violently sick. She then administered pethidine- told me she was doing it to help me. My permission was not sought. This was on a public ward. Labour got under way when I was taken to a labour suite and had privacy. The epidural helped.

Close to the birth DS's heartbeat fell three times. The first two times the midwife hauled up the belt and said it was the belt. The third time DH opened the door abmnd thankfully demanded a Dr.

The head midwife arrived and the button was pressed. I was hauled onto a birthing stool. The Dr arrived, ds was being strangled by the cord. The cord was cut with baby inside the vaginal canal. The Dr got ready the forceps and told me to have one more push. I pushed with all my might bursting a blood vessel in my eye and ds was born. Bright blue and needed to be resuscitated. It took quite a while and the tension was palpable. I had one small tear.

You would think that was great wouldn't you. Thankfully DS was fine and suffered no lasting damage. I however have needed significant pelvic floor physio re my bladder to maintain continence. In the last two or three years I have developed daecal incontinence due to that birth, managed with physio so far. Fortunately my clinical care relating to these things has been high quality and honest because I can afford to pay for private care.

So in summary a midwife who didn't know her arse from her elbow at a major London teaching hospital - certainly she didnt recognise the baby was posterior.

May I respectfully suggest that your assessment does not take into account all risk factors and their impact later on. I shall need surgery in the next five years - does that not also come with risks? I can also assure you that the care I have had and will have will not be available on the NHS.

I note you are a midwife rather than a qualified obstetrician. My next births were obstetrician led albeit vaginal and the quality if care when overseen by a senior doctor bore no comparison to the shit show that represented DS1's birth.

Why in this day and age are women not scanned in early labour so informed decisions may be taken if the pisition of the baby is sub-optimal. DS bearly died, I suffered long term damage. Both coukd easily have been avoided and I believe would have been avoided had I been reviewed by an obstetrician in early labour.

Apologies for typos.

@OhTheRoses, as I have explained before, in cases where the mother or baby's life are at risk, or the risks of side effects are higher than the risks of a CS, then a CS is absolutely the right thing to do.

I do not understand why the mismanagement of your labour and birth would negate any of the things discussed on this thread? Without having been personally there, and by your description, it does sound that your labour could have been managed much better. You were subjected to interventions without asking for your consent. A baby being posterior in itself is no obstacle for a vaginal birth, however, it does sound like they took you and your baby to extremes of suffering that could have been avoided. But there is no way that, before you started labouring, anyone would have known that you would be in that situation.

So in summary, I am not sure how your personal situation is relevant to this matter. You yourself state that your following births were vaginal births. You seem to have an issue with midwives as a result of very poor care you received by a midwife, however there is plenty of birth damage to mother and babies which happens under the care of obstetricians. There are good and bad midwives, good and bad obstetricians, and there are also situations which would have ended in disaster regardless whether the best professionals in the World had been present.

So your vase does not seem to be a case of VB vs. CS, but a mismanaged labour and birth which has left you traumatised and distrustful of midwives, which is understandable if not logical (had you had a different, more competent and respectful midwife, a lot of the trauma and physical harm could have been avoided).

Still, a healthy mother with a healthy baby is, statistically, much more likely to have better outcomes with a vaginal birth than with a CS.

Post surgical support is IMO one of the problems. If you have a hysterectomy then the assumption is that once you get home you will take it easy and rest up. Post CS you are expected to go home and just get on with things.

Again, problems are minimised. Wound infections must be more likely if the mother is being overlooked.

In general post surgical practice has changed. It does seem that even after major surgery and GA as soon as a patient can shuffle their feet into slippers then they are expected to go home. This is fine if there is proper support at home but if a mother is expected to go home and immediately pick up the reins of running the household, managing toddlers etc then there are going to be problems. It isnt rocket science to realise this is going to happen.

There needs to be more information given about the need for post surgical support. A mother leaving home post birth should feel empowered to demand support from the people around her. The people around her should be given the information to give her support.

In the Netherlands postnatal care (kraamzorg) is standard for the first 8-10 days post birth. This is to ensure mother and baby are recovering well from the birth.

*your case, not your vase

@cokehoke the daftest thing was when I had the tear/repair I WAS discharged with painkillers but after my c section, just "take regular paracetamol/ibuprofen"!

I think I also read that CS babies are also more likely to be obese, also due to the natural gut organisms they collect on their route to being born naturally but miss out of with a CS.

There's been a lot of theorising about this so I don't doubt you've read it, but theorising it all it is. There is some evidence that babies born by CS are more likely to be obese later on, but the difficulty is in ascertaining whether this is because of the CS or the things that led the CS to be needed/chosen. Particularly given that it's only in the last couple of decades that genuinely elective section with no medical indication that it's the better option has become popular: you don't have to be very old to have been born during the period when nobody would've chosen a CS if they didn't have to because it was so clearly less safe.

VB of course carries it’s own risks but generally speaking they’re quite low compared to surgery.

A) that's wrong because the picture is far more complex and B) attempted vaginal birth involves a risk of surgery. So even if it were correct that the risks of VB were clearly lower than those of surgery, it would still not be the appropriate way to frame the issue.

I can share my CS horror story if you want some evidence that not everyone on MN thinks they're positive experiences

@BoxedWine, there is plenty of research about CS and increased childhood obesity and a majority of them have found a correlation. Here are some examples I found in about 30 seconds of searching:

adc.bmj.com/content/97/7/610.short

www.nature.com/articles/ijo2012195

academic.oup.com/ajcn/article/93/6/1344/4597836

jamanetwork.com/journals/jamapediatrics/article-abstract/2548440

onlinelibrary.wiley.com/doi/full/10.1111/obr.12267

Of course it's about the money.

@Aurynne I think the point I was making was that the midwife should have known the baby was posterior and should have then provided better support and information.

In subsequent pregnancy, obstetrician led, whenever I asked a midwife a question the response was usually "I don't know" or notes were written inaccurately. DS2 was obs led because he had hypoplastic left heart syndrome and came at 27 weeks - sadly he didn't make it andvdied a few hours later after which I went into surgery to have some placenta removed. When I xame round a nurse in recovery told me to pull myself together because I wasn't the only patient there. I recall the tears coming as I went under.

With dd obstetric care all the way at a different hospital. I had a vaginal birth only because my obstetrician committed to my labour being managed by very very experienced midwives.

I had had a lot of miscarriages by that pg and even in that pg the midwife who booked me having just taken a medical history asked me if the baby was planned. That was the point when I insisted on obstetric led care so do forgive me if I have little time for the competencies, intellectual capacity and bedside manner of the average midwife.

My experiences taught me never ever to trust a midwife or nurse.

"There aren’t many circumstances where surgery is the first option offered for treatment. "

Yes. I've just had a tooth out with a general anaesthetic. I appreciate it was much more expensive for the NHS than with a local - 5 members of staff as opposed to 2, took longer, etc. I'd had to to through trying with a local first.

My apologies @Aurynne you said in your reply there was no way at the start of labour my difficulties could be predicted. There is and was then significant evidence to indicate that a posterior birth is often difficult and iften instrumental, far mire painful and more often than a more optimally positioned baby leading to CS. Proceeding to a vaginal birth should have been based on the facts and should have been discussed at the outset. In subsequent births I sought affirmation that all was well with cord and a portable scanner was used. Why is a portable scanner not used in every early labour?

Also important to remember that EMCS risks are risks of attempted VB.

Attempted VB equals possible emergency section. Planned section means no risk of emergency section.

@OhTheRoses sorry to hear about your experience but I can sadly confirm that this kind of thing is still going on at London teaching hospitals. I had a similar terrible forceps delivery with a baby I should never have been advised to deliver naturally. Just by sheer luck we are all okay. I also don't know why women aren't scanned.
I don't trust midwives in this system. Consultant led with my second, much happier with that.

How can you make an informed choice if you haven't been given lots of evidence about what the option means?

Friend had 3xEMCs that she was fine about followed by a planned CS that she found very traumatic. We aren't all the same, and all that.