AIBU to have try for a natural birth after 4c sections?

[ClareBear2019]

I've just found out that I'm pregnant with DC #4. My previous 3 DC were all c sections, the 1st emergency, the next 2 elective. I want to try for a natural birth this time, as I know c sections get progressively more risky the more you have. DH says I'm being ridiculous and says a c section is the safest option. I see both options as having risks, so why not take the least damaging one?
AIBU for wanting to at least try for a natural birth? WWYD?

Better* off

I also had an emergency followed by two electives (I wanted natural but they were worried the scar would rupture).

I didn't get a choice with number 4, she was elective as well.

...and 11 years on, she is sat next to me on the sofa...

Risks? Bladder and bowel injuries ,adhesions, placenta problems if it attaches to the scar tissue, infertility

bowel and Bladder injuries can occur with vaginal births through severe tears, with resultant incontinence, so it's a risk with any birth. If the placenta was going to attach to scar tissue it would already have done so. Infertility would certainly occur if you tried for VB and the uterus ruptured.

Up to you entirely, and I hope you make a decision which is right for you.

The c-section isn't the bit that is risk (so to speak). It's the fact your uterus is scarred.

This scarring increases the risk of uterine rupture during pregnancy amongst other risk.

During birth a contracting uterus is far more of a risk than another c-section.

These risks are higher the more scarring there is. Which is why VBAC usually are only done after one and it's usually advised that a woman once she has had two sections only has one more pregnancy.

These numbers are the lowest number in terms of risk (in other words the highest numbers a doctor can say is low risk.)

It absolutely depends on the scarring on your uterus. Some woman after three are high risk. I've known of a woman who had 12 sections (this is usually believe me).

I can appreciate it's scary. But for you and your baby another section is the safer option.

I’ve had four sections. All fine. After my last one the Ob did say my uterus was getting thinner but she didn’t rule out more if I had wanted them.

Personally I wouldn’t risk a vbac. I think the risk is greater than having a repeat section.

i had 6 cs the first was emergency, and the last had longer recovery, but i was fortunate i had good surgeons and no long term complications, last was 18 years ago. but not for everyone.

I had a 4th c section almost 5 months ago. My last c section before that was over 8 years before.

My doctors were terrified I might go into labour naturally at the slightest sign of labour I was told to rush to the hospital. They said under no circumstances should I have a VBAC, after 3 previous c sections.

In the end my waters broke and so my 4th c section happened very quickly.
I had some adhesions this time around- some stickiness between my uterus and urinary tract I think. No serious complications, just took surgeon a little bit longer to see me back up!
I was told no more c sections, as in no more babies.
I was very nervous before this 4th c section and so relieved everything was fine. So relieved that I won’t risk anymore.

It’s possible to have a successful vaginal delivery after 3 caesars. I would read through the Obs and Gynae guidelines on vbac to see where the medical advice is coming from.

The most important factor is why you had your first Caesar - how far you dilated (if at all) and where / when things stalled is an indication of how successful your vbac is likely to be.

Assuming failure to progress, no previous vaginal deliveries, closed cervix, age under 40, healthy BMI, your chance of a successful vbac is around 49%. This would increase if your cervix was showing signs of being ready for labour, and decrease with higher age and bmi (but you have previously said you’re in your 30s and healthy weight).

So you can look at your choices as:

1. Elective Caesar. Removes the risk of uterine rupture in labour, but further increases uterine scarring which may affect your ability to have more babies safely. Nobody will stop you becoming pregnant, but the thinner your lower segment, the riskier subsequent pregnancies are for both you and the baby. Your surgeon can give you an indication of what your uterus looks like during the Caesar.

1. Attempt at vbac. This has a 50/50 chance of being successful if no augmentation (that’s the hormone drip). Not many places would consider trying to stimulate a previously scarred uterus, but you’d likely be offered gel/pessaries/membrane rupture to get things going. You need continual monitoring and IV access in place. Epidurals are an option for pain relief but need to be carefully monitored as increased pain is one of the first signs of rupture.

This has two outcomes. Success - yay. You were in the 49% group, and your chances of future successful vbacs are improved. Your risk of rupture each time doesn’t go though.

Or failure. This can be for a variety of reasons (minimal or no progress, fetal distress, concern over potential rupture). In this case you end up with a Caesar in labour, which carries more risks for you and the baby and of the three options is the worst outcome. There is a higher risk of blood loss requiring transfusion, or hysterectomy in worst case scenario. If you need a Caesar because of uterine rupture you risk losing the baby, a hysterectomy and dying yourself (again, worst case scenario).

It’s a frequency gamble as to which group you would fall into with the vbac choice. The best outcome is a successful vaginal delivery, whereas the worst outcome is an attempt at vbac resulting in emergency Caesar. This is why elective Caesar is recommended as the outcome is known.

If your main concern is the ability to have more children then elective Caesar is likely (but not guaranteed) to be a better option. Vbac has a 50/50 chance that you will end up with a Caesar anyway, with more risks to you and the baby including the risk of hysterectomy.

This is a conversation you need to have with your obstetrician. Read up on things first (but don’t try and tell them their job, it puts their backs up). If you still really want a vbac then I would suggest that you plan a Caesar date for 39+ weeks but on the understanding that if you start to labour naturally they will examine you and see if they think it’s safe to see how the labour progresses. If you don’t go into spontaneous labour by your Caesar date then I’d take the elective.

[stands up and applauds @hicdraconis]

OP ask for a debrief about your last birth specifically to enquire how things looked “down there”.

(And when I say “down there” I mean around your uterus and lower abdominal cavity)

My NCT anti natal teacher had a vbac water birth after 3 c sections. See if you can get any help/advice from your local NCT.

whereas the worst outcome is an attempt at vbac resulting in emergency Caesar.

That's not the worst outcome. Worst outcome would be neither the Op nor baby living to tell the tale.

I’m going to assume your tummy is a bit wreaked from the surgeries. Putting the risk of rupturing 3 incisions aside, why the hell would you want to mangle your vagina too?

My tummy actually looks fine, asides from the scar you'd never know I've had 3 children. I think I'm going to go with the elective though, it seems to be the best option, rather than risking an emergency section which will do more damage.

At my hospital you wouldn't be allowed to try naturally, it's too risky. I had an EMCS with DD1, then was asked before my DD2 was delivered by planned section how many children we planned as they said I had to start going natural if I wanted more than 3 children. We know we only want 2/3 children. I'm afraid you have limited your number of children by already having 3 sections.

@Scottishgirl85 it’s not a question of being allowed or not, unless the UK laws on consent have changed since I left. You can’t be forced to undergo surgery if you don’t consent to it. You can be strongly advised to have a section but ultimately if you are pregnant for a 4th time after 3 caesars you cannot be forced into an elective if you don’t want one.

And after 4 caesars they can’t physically prevent you from becoming pregnant a 5th, or 6th time. Again, they can strongly recommend against it, but they can’t tie your tubes if you haven’t consented.

The consultant seemed rude and abrupt.

You have been advised of some quite serious risks by an person very experienced in their field who has your and your child's health at the forefront of his mind and you want to go against it.
This isn't some trump trying to spoil the party, you asked a valid question and I understand why, you have been given sound advice but for some reason have felt the need to ignore those and ask Mumsnet.

Please take his advice have a C-section. I understand it's not want you want but there are good reasons why.

Just a note on a pp. this isn't about being forced into surgery this is about making a good decision based on medical advice despite it not being what you prefer to do.
You are able to choose, yes, but you need to choose wisely not just on a want or whim.

I agree with Ilovecolinjackson
The consultant probably got a little irritated with what he feels the OP has as a romantic ideal when he has the knowledge and experience to know that it isn't a wise decision. He probably also got irritated that the OP wants to put herself at further risk by expanding her family when she will alreaady have (hopefully) 4 healthy children.

In the grand scheme of things does it really matter how the baby comes out as long as both mum and baby are healthy?

Hi, op. I also want another vbac after 2 c-sections. My last c-section was very traumatic, so I would like to avoid another c-section. Last time, I had a beautiful birth plan, but ds3 had a different plan and needed to come out asap.

I have informed myself of the risks of both methods of births. For me, I think a vbac would be better for me. I will take any advice obstetrician give me but I want to be listened to and make a birth plan again with an obstetrician. It is ok to ask questions and why is a c-section better for you as an individual compared to the general public. It is ok to ask for tailored advice to you and your body.

Doctors are very knowledgeable but they can't see the future. So it is up to you to assess the risks and decide which risks you are willing to live with. Taking advice from an experienced doctor should help. Some hospital have vbac clinics, that you can ask to attend. I'm only 9 weeks now but this time the midwife said, she won't be able to refer me there but an obstetrician can. I didn't attend it last time as it happened the day after I gave birth. Last time I even had an extra appointment with a vbac midwife. Try doing that, she gave me my hospital statistics on successful vbac and she explained what my hospital normally does. Different doctors are more risk adverse than other doctors, so it also depends on who will be working, the shift on the day.

I’ve had four c sections. Last time I was strongly recommended having another one but ultimately it was my choice.

My advice would be to remember that your body typically does the same thing time and time again in labour so as your first section was because you didn’t progress, that is very likely to happen again.

I would also get another midwife as one who has even suggested being induced after three sections should be struck off! Going into spontaneous labour before 38 weeks is not a problem either especially since the act of doing so is better for the baby’s lungs (natural equivalent of steroids) but, as above you are likely to find that you don’t progress anyway so not getting to hospital in time is extremely unlikely.

The consultant was being very unprofessional and rude. You can report him if you like and ask to see someone else. You don't need judgement, but for someone to give you information on what they think is best for you (if you asked for their opinion). Otherwise they are there to present you with facts so you could make an informed choice.

Your risk of a uterine rupture goes up significantly if you try a vaginal birth after 2 c-sections. I imagine in your case it would be unacceptably high. The mw might tell you otherwise as they won’t necessarily know the facts - but you really need to push for a consultant referral.

@AllFourOfThem what made you think the midwife should be struck off. Is is because the risks to you seems to high? For some people the risks of vbac is acceptable to them.

You would be monitored and have a very low threshold for an emergency c-section. Why not let women who want to try, to attempt it? It is cheaper after all. The risks with uterine rupture is very small but if it happens it can be catastrophic. There are bigger risks, that I personally worry more about with vbac. That is the honest truth. I learnt from last c-section that yes, even a planned c-section can be tramatic. My emergency c-section was 100% better. Which is going against the grain of most people experience.