to think elective repeat caesarian is a valid choice?

[schmee]

I'm currently pregnant with DC3 and would like to have a repeat c-section. I had a planned c-section last time as had twins, one of whom was breach. I haven't seen the consultant yet, so I don't know if I'll be allowed one on the NHS but I hope so.

I remember last time round people saying "oooh I don't blame you if you're having twins" when I said I was booked into for a section. I really don't understand what "blame" has to do with it, particularly as the decision was made to safeguard the health of my twins. This time round if I say my preference is for a repeat c-section the response is even worse, with people from frenemies to strangers feeling able to question my choice and try to get me to reconsider. WHY?

I wondered if people here think repeat c-section is a valid choice. And whether anyone's mind about planned sections had been changed by watching One Born last night which showed what a calm and baby-focussed scenario a scheduled section can be.

I've never had a vaginal birth or even been into labour which is I think one of the factors that will be taken into account, along with my age, weight etc., as well as the size of the baby which I am expecting to be large (my twins were very large if you take into account their length of gestation and the fact they were twins).

The kidney analogy doesn't really work for me - obviously no-one is going to remove a healthy kidney on the principle of "do no harm". C-section v natural birth is always going to be a case of weighing up risks and potential harm. In my case, certainly last time, the potential harm of VB definitely outweighed the risks to me of the CS.

arsebiskits "VBACS can be more dangerous for mother and baby actually" - this is true. The infant mortality rate for VBAC is ten times higher than for repeat CS.

Its an absolutely valid choice- i have had several friends who had emc for first baby and were persuaded to try for vaginal delivery second time round- in all cases all it did was increase worry and stress for them and they ended up having c sections in the end anyway.

if you want to have a c section then just state this clearly, if that is what you want i cant imaging a consultant arguing against it.

I had a repeat c-section for DD2. DD1 was an emergency one (foetal distress, failure to progress etc...). Long story.

I didn't want the same experience with DD2 so when given the option of a planned section, I went for it and it was lovely knowing that it was sorted.

No-one else's business.

Having a VBAC, whilst possible is generally more risky following a c-s due to the risk of uterine rupture. Your consultant should look at the scar and talk to you about how you feel about either a VBAC or natural. They might want you to have a section to reduce the risk of rupture.

I was only allowed to push for half an hour when I had a VBAC and it was only the fact that the ventouse worked that I didn't have to have an ECS.

When discussing which birth to have with consultant, he was very open with me, telling me the risks of both and telling me it was my decision. He did say he thought I should have a section but it was up to me and they would support me trying.

Again - off topic - but Im amazed at the number of women who were 'made' to lie on the bed as they were monitored by CTG.
you do not have to 'lie on the bed'.
The leads are long enough for you to sit on a birthing ball or stand at the side of the bed and have a little pace arounbd. A birthing ball is fantastic for getting baby in a good position.
The unit may even have telemetry monitoring whereby you can run around like a lunatic if you so wish.

Dont be scared of asking/doing. Just because the CTG is put on while you are on the bed, it doenst mean you have to stay there.
Likewise for a VE, get up out of bed afterwards - dont just lie there.

YADNBU - did exactly the same with my DS2 - I found my first caesarian such a positive experience that I wanted to repeat it! I know that the stats say VB is safer, BUT I always wonder whether that's a bit skewed because C-secs are often done in emergencies, with multiple births, with older mums etc. The only slightly nerve-racking thing second time around was knowing exactly when he'd be born - I was far more nervous than with DS1 who was a 3 weeks early surprise! Good luck and do what you feel is right for you - you're the one having this baby.

OP, I'm in much the same situation as you.

First pg was twins and I had a ELCS because of pre-eclampsia at 35wks. Consultant said there was no point going for induction as it would fail and I would have ended up with a CS anyway. Despite it being major abdominal surgery (as some people keep banging on about) I found that the recovery from CS was very easy. I had other issues which kept me in hospital for longer (mainly blood pressure) but I would have been discharged 2 days after CS if that hadn't been the case. No problems lifting the babies or walking, I could have driven much earlier than I did but had help so didn't feel the need to drive before 6 weeks.

I'm now 23wks pg and although I have the option of having a VBAC, I have already asked for a ELCS, for the following reasons:

1. Like the OP, I've never had a contraction. If I go for a VBAC this will be like going through 1st time labour for me. Because of previous CS, I will have to labour in hospital, attached to monitors. I will not be able to have a water birth, or use the midwife-led unit. I am more likely to end up needing instrumental delivery or having an EMCS with all the recovery that entails. (In reality, I would refuse forceps anyway).

2. Because of previous CS, I can't be induced, so the risk of me going 10 days overdue and then needing a CS anyway are reasonably high. Waiting makes it much harder to plan childcare/help after the birth as I have no family anywhere near.

3. The one thing that birth programmes don't tell you about is that vaginal births can cause lots of damage to your fanjo leading to long term problems, and even simple tears can take a few weeks to heal. Every single person I know IRL who has had a VBAC has said that they wished they had had a ELCS because their recovery from the VBAC has either been worse or no better. I have no desire to have stitches in two places.

4. The risk of having a scar rupture, whilst small, is enough for me to justify the risk of abdominal surgery. The consequences of scar rupture are pretty catastrophic both for me and the baby.

5. The vast majority of female gynae/obstetricians choose to have their children by CS. They have seen the damage that "natural" childbirth can do. Generally speaking, its midwifes who push for the VBAC. However, they are generally not seeing the complicated/difficult cases as they are dealt with by consultants.

I know our hospital allows you the choice if you have had a previous CS. I have heard stories on here from people who have been told that they have to have a VBAC when they wanted an ELCS. I think the hospital should support you in whatever you wish to do. Although I have strong reasons for wanting a ELCS, I am sort of hoping that this baby turns out to be breech so that I don't have to explain myself every time....

My first was an em cs the second elective. I didn't feel an sense of satisfaction after the elective section, I felt as if i wasn't a proper woman somehow. I felt like I'd copped out with the elective one.
I went on have 4 vbacs. Personally I got an enormous sense of achievement giving birth naturally. It was a feeling that could not be replicated with a section They were a million times better for me than having sections.
You know it's all well and good saying how you give birth isn't important. It is for many many women, it matters whether they can give birth naturally.
I hate it when I see it dismissed as not mattering that much, maybe for some it doesn't but for others it does, it matters a lot.

My first one was EMCS and was seriously talked into a second because of my high BP and the risk of rupture. Do what you feel is right for you. Good luck

loueytb3
5) The vast majority of female gynae/obstetricians choose to have their children by CS. They have seen the damage that "natural" childbirth can do. Generally speaking, its midwifes who push for the VBAC. However, they are generally not seeing the complicated/difficult cases as they are dealt with by consultants.

I have great difficulty with this statement. A midwife absolutely deals with the high risk cases, every single day. It is a midwife who is in theatre with you when you have your baby by Elective/Emergency section. It is the midwife who alerts the registrar to impending problems during pregnancy/birth. Every midwife has a very real idea of things that can go wrong. I'd say it is obstetricians/gynae docs who have the skewed view of childbirth. We see every side of it, good and bad. They don't get called to a normal delivery, they don't hear from the women who have no problems. They just come round when the shit hits the fan.

I'm not sure where you are all getting the idea that CS are nicer for the baby from. Some CS babies are born with wicked forceps marks.

Really interesting thread. Has made me think very hard about this subject.

My personal view - speaking as someone who elected and had a fab home birth - is that, given the risks of CS and VB are not dissimilar (still believe many of the more 'minor' risks of VB are understated, especially mental trauma) and the costs not totally disproportionate (ten million is peanuts for example in the context of the NHS budget), all women should be able to choose the birth they think is best for them. Yes, it should be an informed choice - but information should be provided about the risks of all forms of birth. Ultimately, though, pregnant women are adults and if they make an informed choice for a C-section, I think they should be entitled to it. Only a woman knows, for example, whether she is likely to cope with the mental trauma from loss of control associated with interventions in VB (or whether she would rather avoid that risk entirely). Or whether, given the lack of midwife support in many hospitals, she would be better off with a CS than trying to labour alone, unsupported.

Actually, I don't think women will be signing up for elective C-sections in their masses - especially so, if the NHS offered proper one on one midwife care - but if they think, on an informed basis, that it is best for them, so be it.

And on the cost issue, given that it's not a totally disproportionate cost, when did pregnant women become so undeserving a part of the population???

Oh, and what about all the counselling and follow up repair operations etc that can follow a traumatic VB - are those factored into the figures, or just the 'in-patient' time immediately after birth?

schmee "The infant mortality rate for VBAC is ten times higher than for repeat CS"

Where did you get that information from?

ScroobiousPip

Excellent Post. Agree totally

Scroobious pip - good point about how we're measuring maternal morbidity. Studies measuring morbidity would take account of ongoing care - for example, follow up urogynaecology support for women who have very bad tears.

DrMcDreamy sorry I didn't mean to imply that MW don't see complicated cases during childbirth, more that they generally don't see the long-term aftermath eg if a mother needs further surgery as a result of a bad tear, continence issues etc. In addition, many women who have had a difficult birth before will bypass the midwifes next time round. I have rarely seen a MW in either pg and only then to check bp/urine. Most of my appts are with Drs. (Although I am high risk because of previous pre-e as well). Therefore they generally get the less complicated VBAC cases. There was certainly no MW in theatre with me when I had my ELCS so maybe they are also influenced by seeing more EMCS which are obviously done under lots of stress?? All of this means that the general feeling I have had from the MW's I have spoken to is that it is better to try for a VBAC.

Alimat1 - you can theoretically be off the bed on a bouncing ball while hooked up this happened in my first failed induction. The monitor kept slipping down, the leads weren't very long at all. Even though I had a mobile epidural it didn't work, had to be topped up and couldn't stand up.

For a potential VBAC they said they wanted to monitor me carefully and I would be as upright as possible on the bed .

arsebiskits you have some interesting ideas. None more so than the existence of "increased risk of rupture due to postnatal infection." This is a new one to me.

I've got that idea from the RCOG guidelines for birth after previous Caesarean. My consultant agreed. You might want to go and look them up

WidowWadman I am aware of the RCOG guidelines. No need to wink, it's not a secret.
Both they and the Cochrane systematic review make it abundantly clear that what evidence we have is weak and non-substantive. I questioned where you got the idea that postnatal infection causes uterine rupture, there is no evidence that it does. The small, retrospective, cohort study that the RCOG uses states maternal temperature of >38deg post c/s as a possible risk factor. It doesn't stratify according to closure technique,or any other variable, and there is no randomisation. Of all the links between VBAC and scar rupture/dehiscence (and they are rare enough)this has to be the most tenuous. Your consultant was happy for you to choose repeat c/s because it's 'easier' to manage an elective repeat c/s than to watch and wait for a VBAC.
Most consultant obstetricians are ok with women choosing repeat c/s. Most consultant obstetricians are ok with women choosing VBAC. The reason? There's not a lot of good quality evidence to support one over another, and the clinical scenario that leads to one being a better idea than the other is so individualised that it's difficult to have a blanket policy.

Anyway, how can maternal pyrexia/postnatal infection be a risk factor for VBAC? According to an earlier post, there is no risk of infection with c/s.

Not since the 80's anyway arsebiskits

arsebiskits the ten times higher infant mortality rate is from NICE. Louey - sounds like you are in a very similar situation to me! Good luck with your elcs.
ScroobiousPip - great post!

its your body your choice,

DrMcDreamy sorry I didn't mean to imply that MW don't see complicated cases during childbirth, more that they generally don't see the long-term aftermath eg if a mother needs further surgery as a result of a bad tear, continence issues etc. In addition, many women who have had a difficult birth before will bypass the midwifes next time round. I have rarely seen a MW in either pg and only then to check bp/urine. Most of my appts are with Drs. (Although I am high risk because of previous pre-e as well). Therefore they generally get the less complicated VBAC cases. There was certainly no MW in theatre with me when I had my ELCS so maybe they are also influenced by seeing more EMCS which are obviously done under lots of stress?? All of this means that the general feeling I have had from the MW's I have spoken to is that it is better to try for a VBAC.

wow - I am amazed there was no midwife in theatre with you. Who took the baby at section? Who did the paperwork?
And the midwife only tested your BP and urine.

I want to work at the hospital your delivered at.

We attend EVERY section - high risk, low risk, EM, EL - every single one of them.