Can you be refused a repeat c-section?

[notalreadyinuse]

I've seen other threads about this, but I'm not sure what the definitive answer is. Can you be refused a repeat section and forced to VBAC against your wishes?

Please don't anyone try to extol the virtues of VBAC in responses - I know some people are very pro, but I'm not.

[maxbear]

notalreadyinuse, I know you didn't want people to mention vbacs but how can you expect people not to share their own experiences in a national forum.

Also many women who might be expecting to have one will be completely freaked out about the figures that keeps being banded about about how they are more likely to have a ruptured uterus if they vbac. There are risks to both, for most women neither of these things will happen. [busmile]

Anyway to answer your original question yes they can refuse you an elective section, you can't force them to do unnecessary major surgery on you.

However in most cases, if you go in and are obviously informed, talk about being concerned about ruptured uterus, it is very likely that they would let you have one. Hope you have a good section [bugrin]

[KarenHL]

I had a real problem getting an ELCS (despite prev EMCS).
My cons refused to talk about possibility of CS, would only talk about VBAC. He told me there was no point in referring me to another cons, as they would only agree with him.
My baby was breech, due to medical probs he wasn't expected to survive a natural labour and (due to same probs) his abdomen was apx 18 inches (circumference). I had PGP too (which I am still seeing the physio for, 4 months after baby's arrival). If I didn't have a phobia of labour before, I do now!
Eventually (wk 38), I was referred to another cons who did agree to an ELCS.

If I were you, I'd ask for a second opinion - and sooner, rather than later.

[VivaLeBeaver]

Notalreadyinuse - as far as I'm aware the research shows that VBACS are safer than another section. I'm not saying this to extol the virtue of a VBAC at all.

Its just that I think you will have more chance of winning a consultant over if you go in with the facts. If you go in and see another section is safer they will just say that it isn't and try and sterr you down the VBAC route. If you say that you know that Drs consider VBACS to be safer but you have weighed up the pros and cons and that on balance you would prefer to take the bigger risk of operation complication/post=op infection/complications in any future pregnancies rather than the statistically smaller risk (but could be argued more likely to be catastrophic if it did happen) of a uterine rupture. I think if you talk about it from that point of view you will have more chance of getting what you want rather than saying that VBACS are more dangerous which the Dr will most likely just disagree with you.

Sorry, hope that makes sense and that you realise I'm posting it to be helpful and not to try and convince you that VBACS are better - not my intention.

[kiwidreamer]

I had an EMCS with my first baby, 17 days over due / pre eclampsia / meconium / failure to progress. When I went to see the consultant's lackie at 16 wks with DC2 and was told choice was utterly and totally mine, hospital would support me either which way. I wasn't totally sure what I wanted so was told to come back at 36 wks to give them my decision. So off I went to 36 wk appt to tell the consultant that i'd deliberated all the pros n cons and decided I really wanted an Elective, consultant lackie number2 tells me that hospital policy has changed since my 16 wk appt and because I do not have any medical indicators this pregnancy I'd have to get permission from the proper consultant - I cried as I was so shocked, felt like the rug had been pulled out from under me. The following week my husband and I go along to the consultant armed to state my case and book my ELCS. Yeah. Didn't happen. Consultant apologised but stated that the hospital had changed and would not perform ELCS without a medical indicator, basically there was no wriggle room, it wasn't even an option for me anymore. So with 3 wks til due date I really was upset and struggling to get my head around my enforced VBAC, feeling a bit better now and have met with the consulting MW at Hosp and thankfully have been able to compromise on a few things like CFM etc. So there you go, it is possible that you can be denied an ELCS even if you've had an EMCS but you do what you gotta do I guess and keep your eye on the prize :-)

[nunnie]

I had an EMCS with my 2nd, and a failed 3rd stage with my 1st. I am pregnant again and was planning on being firm and wanting a ELCS. When I attended my appointment, there wasn't that I could pick up on any obvious pressure to have a VBAC, but I have come away planning one instead. This was mainly based on my own circumstances and previous history, and the fact that I progress from stage 1 to 2 very very quickly and if like last time I arrive pushing and progressing well, they will not perform a CS and also they won't do them here till 39wks, and my previous 2 were early my 2nd 4 weeks early, so even if I get a date I possibly wouldn't make it. These factors made me realise that even being firm about and ELCS I would still have these worries and decided it was easier to plan and prepare myself for a VBAC. The Consultant did say the quicker the labour the less chance of rupture it is long labours that have the greater risk apparently, which set my mind at slight ease. I also have the added worry that I have been stupid and fallen pregnant 11 weeks post EMCS so my scar healing time is quite short to say the least.

I was given the option though and have been told, I can change my mind at any point.

[WidowWadman]

When I went to request my ELCS (after previous section) I've discussed the RCOG and NICE guidelines with the consultant who was happy to grant me my choice as he could see that I had looked into the risks and benefits of both, and also, that I tried to gain my information not from some random website with an agenda.

My midwife told me that consultants in general prefer patients who made an informed choice, and I might have been sent away for another think with some reading material, if I hadn't shown that I looked into all eventualities.

My hospital seems to be quite pro VBAC by the way, but accepted my reasons.

[notalreadyinuse]

kiwidreamer - sending you lots of hugs and support. Very angry on your behalf but very hopeful for you too that you are getting the support you need. I really hope you will have an amazing VBAC after all. I think you're right - I need to get this sorted sooner rather than later as if I am going to be forced into an attempted vaginal birth (and possible emcs) against my will I need to get my head round it asap.

maxbear - tigerwhocametotea was incorrect in her facts so I was correcting her misinformation. I've no interest in scaring people against VBACs.

vivalebeaver - taking your comments entirely in the way they are intended, I really don't think I've seen any research that says a VBAC is safer, and I have read extensively about this. I think VBAC may be safer than an EMCS but not an ELCS... Please correct me if I'm wrong, because you are absolutely right, I don't want to be spouting incorrect information when I'm presenting my case.

[VivaLeBeaver]

As a midwife I hear consultants and registrars saying that VBACs are safer. Now counselling women about their options is not my area of expertise by a long run as I work on labour ward so people have generally made their mind up by the time I see them.

I believe NICE guidelines state that the risk of uterine rupture in a VBAC is o.35%. Drs will say that the overall risk in a section is greater than that - not just of haemmorhage, post surgery infection, DVT, neonatal respiratory depression but there is the risk to consider in future pregnancies - more likely to be a placenta previa, placenta accreta, etc. I really don't know what the risks of these are in terms of percentage - sorry.

Drs may also argue that uterine rupture is usually picked up very quickly due to good CTG interpretation and that you would be taken to theatre before anything tragic was to occur. However I think its very unreasonable to say that you don't want to run the risk, you'd rather have a calm elective section with lower risks than a more urgent emergency section. That you're aware your chance of having a successful vaginal birth is lower in a VBAC than a non VBAC.

There is no right or wrong decision here but I do think its important that your feelings are taken into consideration. Sadly I do know of at least one hospital trust where even the consultants are no longer allowed to grant a request for a repeat section - they're under strict instructions from the PCT (or whoever it is now) that maternal request repeat sections will not be funded under any circumstances.

[notalreadyinuse]

Thank you VivaleBeaver - that's a really well balanced post, and is helping me to frame my thoughts. This is a huge post and a bit of confessional as I'm trying to get all my real feelings about this down.

I am really worried about the placenta accreta thing as my placenta is covering my old cs scar, but when I asked the consultant she said it was rare... I'm actually terrified that if I did manage to give birth naturally I might be whipped off for surgery under GA after the birth as the accreta would only be discovered at third stage labour and I think that fear will stay with me through the birth. I think that's why the sonographer, registrar and a friend who is a consultant anaethatist (sps) have all suggested cs as the best option. This is my last pregnancy - DH prob having snip...

On the other figures - I looked them up, not to challenge you, but just to make sure I had them straight in my pregnant brain:

I think the risk for depression is higher for vaginal birth (10.8 pc v 10.1 pc acc. NICE so small difference but have seen larger difference elsewhere). This also includes, I believe, EMCS in CS figures. I think the risk of thromboembolism (is this the same as DVT?) is around 0.04% - it's higher for a cs but still very low. The risk of haemmorhage is lower for cs (0.5% v 0.7%). The risk of post surgery infection is higher, so you should be given prophilactic antibiotics.

I'm also terrified of an EMCS as I know these can be awful and mine will be more complicated anyway due to low anterior placenta. I don't think I have a good chance of VBAC. It would be my first labour, I have an obese BMI, I'm advanced maternal age and the baby is 95 centile (with a 100 centile ac causing concern for shoulder dystocia) and I'm completely physically and emotionally unprepared (having never thought I'd go through a "natural birth").

Then there's the emotional issues which I know I need to start dealing with quickly if there's a possibility I may be forced to have a VBAC:

I'm terrified of birth trauma and have been all my life. To me vaginal birth is unnatural and disgusting - which I understand is wrong (and that is beautiful and empowering for many women), but feel at a really deep level.

When I had my boys my world fell apart completely and I felt utterly out of control. I lost all faith in medical professionals. The only thing that feels positive about the whole experience was the elcs itself and seeing my babies for the first time in that way. I had to draw on those few seconds over and over again to get through the first few months.

I also have struggled to come to terms with the effect of the first pregnancy on my body - my twins were huge and my abdomen is now deformed in my eyes. I haven't looked in a mirror at myself naked since the birth. My DH hasn't seen me naked and any intercourse is with me semi clothed with the lights off. If my vagina had been affected by the birth, I don't think we would have made it that far...

I'm going to phone the midwives tomorrow to ask to have an appointment with someone. I'm going to ask to have a different consultant, but also to see if I can be referred for counselling concurrently with the process of finding out whether I can get an elcs.

[fruitybread]

NICE guidelines on C Section from 2004 are here -

www.nice.org.uk/nicemedia/pdf/CG013quickrefguide.pdf

I think these are the most up to date. If not, I apologise. Guidelines for a VBAC are on page 4.

I'm surprised that consultants and midwives are simply saying VBACs are 'safer.' This seems a misleading generalisation in the light of specific risk factors. A quote from the NICE guidelines is below [I've added bold for emphasis]: -

"Women who want VBAC should be supported and:

? Be informed that uterine rupture is very rare but is increased with VBAC (about 1 per 10,000 repeat CS and 50 per 10,000 VBAC)
? Be informed that intrapartum infant death is rare (about 10 per 10,000 ? the same as the risk for women in their first pregnancy), but increased compared with planned repeat CS (about 1 per 10,000)"

The asolute risk of uterine rupture and infant death is very low. But the relative risk of both is greater for VBAC than it is for a planned repeat CS. I admit, I'm surprised by the increased risk of infant death for VBAC (I was aware of the risk of uterine rupture).

A CS may carry higher risks than a VBAC in other areas, and women may have strong personal reasons for choosing a VBAC. But in purely in terms of uterine rupture and infant death, a planned repeat C section is safer than a VBAC. According to NICE. And women are supposed to be informed of these risks while being supported in their decision. Not just told 'it's safer.'

[VivaLeBeaver]

I'm glad you've looked the stats up for the risks of a lscs. You can take these risks written down into a meeting with the consultant and show that you've done your research and considered everything. Will definetly be in your favour.

That and your emotional worries, plus the concerns about baby's size all seem really good reasons for you to have a section. Some people might say that counselling would help you be more positive about a vaginal birth/overcome your worries but from you say it seems a bit deep seated to me to be sorted out in a few months. How many weeks are you btw?

I think definetly insist on a meeting with a consultant to get a definitive answer now. If you're earlish on in your pregnancy don't let them fob you off saying that they'll see you again at 36weeks and make a decision then. Be quite clear that its affecting your emotional/mental health and you need a decision. Good luck.

[VivaLeBeaver]

Fruitybread - yes I don't think that true informed consent is something that health care professionals as a whole are too good on at times.

[fruitybread]

viva, indeed, and it's something I find very frustrating. Some isolated risk factors can have a great relevance for some patients, and not for others, depending on an individual's health.

To be fair, I know some patients get a bit overwhelmed by risk information, and just want a simple answer ('tell me what's Good and Bad' etc). I'm sure it can be a tricky line to walk for MWs/consultants.

I'm not suggesting this is you alreadyinuse, I can see you are concerned to get a detailed picture of risk. I really hope you get the birth you want, and given your circumstances, I'm sure you will.

FWIW, I think viva's advice here is good and realistic.

[darleneconnor]

Maybe it's your bmi which is putting the consultant off a elcs. Tbh with your particular circs i cant see you not having an elcs.

[notalreadyinuse]

I'm 28 weeks which is when you see the consultant at my hospital. They said to make another appointment at 33/34 weeks, but I think I need to see a new consultant now. I think I am allowed to ask for that...

I left the meeting last Thursday with the consultant in a very, very bad way and have been waking up crying at 4 in the morning, etc since.

Today I had really bad Braxton Hicks solidly for three hours which my DH thinks is caused by the anxiety (I had it checked out and is ok). I've been finding it quite hard to keep it together. I don't think I realised about the emotional side as I didn't think I was going to have to face up to it.

I usually try to avoid talking about that side of things as I don't want to be a primadonna, but I think I need to.

Thank you all for your support and advice. It makes a huge difference to me.

[VivaLeBeaver]

You are definetly allowed to ask to see another consultant. Hopefully your m/w can suggest one who may be more sympathetic (or scapel happy).

[ElfOnTheTopShelf]

I am pg with my second, had my first by section 5 1/2 years ago.
Midwife and consultant at the hospital all fine with me having a "try" at VBAC, the only thing they wont do is induce me should I go overdue because that can increase the risk of rupture because (and I'm really paraphrasing here!) the body isn't ready to be in labour and there is no build up in the contractions. I had assumed it would be the "had one, so have another section" route, but that doesn't seem to be the case. Midwife actually said she'd support a home birth should I want one, but that was a bit too risky for my liking!

[maxbear]

notalreadyinuse, I sympathise with your situation and I really hope that you get your section, I would be very surprised if you didn't. Definately ask for a second opinion if you don't. Thing is it wouldn't only be maternal request, as there are several other factors that altogether might well make it a better option for you. let us know what happens

[mrsravelstein]

seems to be a huge variation from one consultant/hospital to another.

when i was preg with 2nd child in 2008, i wanted a vbac and consultant was totally anti and lectured me at length about how risky it was over an elective (i ended up with another emergency section, as it turned out).

when i was preg with 3rd child in 2010, i wanted an elec section, and the same consultant, who remembered me from last time, said the guidelines had just been changed and that he now strongly recommended a vbac not an elective section. (however he did give me one, but had to lecture me at length about the risks first!)

[VivaLeBeaver]

Yes, guidelines/research have recently changed to say that a vbac afetr 2 sections is no more risky than a vbac after one. Not all hospitals/doctors have caught up with this yet and I still hear consultants saying to women after their second section "this means that if there is a next time you will definely have to have a planned section".

[WidowWadman]

Vivalabeaver - but isn't that in direct contradiction to the RCOG guidelines which state that it looks like VBAC is not as safe as previously assumed?

[VivaLeBeaver]

WidowWadman - what contraindicates the RCOG guidelines, what I've just said or what I said the Drs are saying?

I don't think what I said contraindicates the RCOG guidelines as as far as I understand them the guidelines say that VBAC is not considered as safe as previously thought but is still thought of as a safe option. The guidelines don't say that VBAC is less safe than a LSCS otherwise I really do think guidelines would have changed in this country to discourage VBACS when in reality it seems to have gone the other way. Big difference between less safe than previously thought and not safe.

[WidowWadman]

Ah - I see what you mean. I've always read it as "less safe than ELCS", but that might have been just me.

[VivaLeBeaver]

No its definetly not to be interpreted as vbacs been less safe than a lscs. Just that its less safe than they thought maybe 8 or 9 years ago, but still considered safe and promoted generally as a safer option.

But as this thread has shown its not really a black and white issue and there are many factors that can make vbacs less safe for an individual or less likely to be successful. Plus the important factor of mental health as well as physical health.

[LaraCameron]

You definitely can have a repeat. I read the NICEguidelines and they clearly say that the second time onwards maternal preference must be taken into account.
If they refuse, just say you would like it in writing that they take full responsibility for anything going wrong. A friend did this and it worked. Also say that you will not give any official consent for vbac.

They will want you to have a vbac because it is cheaper for them.
In america only 3% doctors actually approve of vbac and in India and China it isnt allowed.
Im sure the doctors there have a reason to think that way.
Im quite sure the main reason it is encouraged here is to cut costs.
So just be very firm.