vbac v cs birth options meeting help!!!!!

[tiggersreturn]

I have type 1 diabetes which makes me naturally high risk. With ds (now 4) I was induced at 38+6 because that was the policy for diabetics in the hospital, he was OP and I ended up with an EMCS 21 hours later for failure to progress at 8cm. Not pleasant and I was keen to avoid this happening again. So I switched to another hospital in the next pg which allowed diabetics to go to 40 wks instead of 39 knowing that after a cs I couldn't be induced and thinking an extra week would give more of a chance of it happening naturally. I miscarried, that hospital handled just about everything to do with me very badly and then I was unable to conceive for 2 years so when it miraculously happened I went back to the hospital I had ds at on the grounds that I knew the system and was under them for both diabetes and fertility anyway.

2 weeks later I discovered I was expecting twins which thankfully turned out to be DCDA so the lower risk variety.

All my appointments up to about 22 weeks had obs telling me that I would be having an ELCS that they would not advise anything but a cs and not even to consider anything else. Suddenly at 22 weeks the obs in that appt asked me if I'd like to deliver vaginally and I said that would be nice and he said well if no. 1 is head down at the right time it might be possible. The next one who was a consultant said the same. However during this period I suddenly realised that although it would be very nice to be walking around after giving birth and not flat out on pain killers for 6 weeks (I had a bad recovery) all I really wanted was 2 healthy babies and preferably a vaguely competent mother to look after them and that whatever would do this in that order is the best option.

This week's obs told me that I needed to have a birth options meeting to discuss birth plan and pretty much that I would have to have a vbac because that is now government policy because of cost cutting. My response was pretty much as above (ie I want 2 healthy babies and a healthy mother) and that what I'm concerned about is managing a vbac with dt1 and a crash section with dt2. Her response was "well you'd have to be in hospital a long time with a cs". I pointed out that I'd have to be in hospital longer with a crash section than an ELCS and anyway I know I have to be in for a minimum of 24 hours to check the babies' blood sugars.

So having now got a meeting booked to discuss options (clever obs managed to book it for a date after she'd said the babies would have to be delivered as she got the month of due date wrong by 2 months!) I'd like some advice on what to say to make sure I get the best possible outcome.

My thoughts so far are:

If I were to go into labour naturally (under no circumstances am I agreeing to any form of induction except ERM at min of 8cm if had slowed down massively - last time they went naturally pretty early on and the pain got much worse as a result)

1. I'd need confirmation of what would happen if dt1 is OC but dt2 is breech or transverse as I understand that there are difficulties in turning a baby if you have a scarred uterus

1. I'd need absolute written confirmation that I can move around freely during CFM (mw in AN class said I could last time but mw in labour ward refused)

1. Advice on when is the best point to have an epidural in given that it can slow down labour and because of previouse cs no sintocin could be used to counteract this effect

1. How long I'd have to deliver dt2 if I did succeed with dt1 and the chances of this happening.

1. No instrumental delivery.

I know on the guidelines I'm a really bad candidate for vbac. I had a cs for failure to progress, no previous vaginal birth, type 1 diabetes and now twins. Although in theory it would be lovely to not have a cs and have a perfect water birth type thing I know that will never happen so I just need to make sure that this is the best possible experience for all of us and principally the babies. So any birth plan would be aimed at trying to make sure that if I did vbac it wouldn't end in major damage to me or another exhausting and traumatic emcs.

Does anyone have any suggestions on how to handle this meeting?

I would start by asking them what the percentages for successful vaginal delivery of twins is in the hospital. Then what proportion of those are VBACs (I don't think they will be able to tell you this). Ask them what the risk of death or damage to the second twin is of a vaginal birth.

Ask them how they will turn the second twin if he/she is non-cephalic (if they can't do an ECV due to risk of rupture, they may want to try to try in a different way or to deliver as breech - approximately 30% of breech second twins turn during labour btw). How many members of staff have experience in doing this? Will there always be someone there who has the experience?

What are their rates of instrumental delivery for twins and for VBACs?

With my twins, the hospital would have insisted on epidural and theatre delivery because of the risk of EMCS being required really quickly - does your hospital have any similar policies or will they count this as a conventional VBAC?

On the monitoring - I know that due to the positioning of my twins, monitoring of twin no 1 was very difficult at routine check ups when sitting completely still. I'm not convinced they will let you be mobile.

I think the best thing to do is be clear in your own head what you want. Do you really want to try for a vaginal delivery? If you do, brilliant, but you need to flush out all the issues now. If not, you need to be clear in your head that asking you to VBAC twins is unacceptable and don't back down.

Thanks Schmee that's really helpful.

The problem is that I'm not entirely clear in my mind which is the best option and I think I need to figure that out before I get to the meeting.

Good luck with it - I'm sure you will come to the right conclusion. From my perspective I've never for a minute doubted that I made the right decision to have my twins by ELCS - although it was very, very hard in the first few days - but it's such a personal decision. Please bear in mind that the change of policy for hospitals re c section means that you may be encouraged towards VBAC even when the odds of success are low, so just have a think about how committed you are to giving it a go.

Congratulations on having twins BTW. It is wonderful.

Thanks Schmee. I've decided to wait until my next appt in 2 weeks and then insist on seeing the consultant obs and get him to explain why this is such a good idea given my history. Particularly when the RCOG guidelines say that VBAC is contraindicated for twins.........

I am really pro VBAC and natural birth -BUT I think personally for me VBAC for twins in your circumstances I wouldn't go for it - and if RCOG guidelines are against it I am suprised they are pushing it. sound like a MAJOR change of policy - are you sure the doctor read your notes properly

Yes - but she plainly admitted this was because they had to on costs grounds. Mind you she got my due date wrong by 2 months and scheduled the meeting initially for after babies will be born so not the brightest cookie in the jar......

My plan is as described below to see the consultant at my next appt in 2 weeks (I have a copy of the RCOG guidelines in my notes now ) and quite simply refuse if they can come up with no good medical reason for doing this. I'm also going to take support with me.

If they insist I attend this meeting I will start the discussion on the basis that I'm very pro-natural birth and would like a water birth in the birth centre. What are the chances of me having this? Zero because of type 1 diabetes let alone vbac and twins and therefore what you're offering me isn't "natural birth" it's a whole load of interventions which are more likely than not to end in a worse experience for me and potentially a deadly and harmful one for my babies than an ELCS. The more I think about it the less I want to even consider it.

The whole major change of policy thing has been quite upsetting and I really just want to know what's going to be happening now.

Thanks for your responses.

I think you've had some great advice. I just wanted to add, having had a failed VBAC, I realised afterwards that although they probably won't tell you, they are pretty keen to avoid giving you an epidural, because although there are other signs that the medical staff would probably pick up, if your scar ruptures you won't feel it. Mine did rupture, and I was able to tell them (I didn't know it had ruptured at the time, just that there was pain vaguely there). If I had had an epidural I wouldn't have known. If I could go back I would have an ELCS rather than an EMCS under GA as it ended up (baby DD is now 15 months and fine btw!).

Thanks Zoonose. Obs' other comment was "well you can have an epidural in the whole time"!

I've had 2 VBAC's now following an EMCS in 2006. The latest VBAC (Nov 2010) was induced by a drip. They decided they would try it as I wanted to try to avoid a CS. I started on only 6ml/hr and it was increased gradually (I only got to 12ml/hr as delivered within 45mins of drip starting !). There aren't any hard and fast rules about not being able to induce a previous CS. Good luck and enjoy your twins !

gforgiraffe - I thought the point about induction is it increases the rate of uterine rupture? Also I've been through an induced labour ending in an EMCS have really no desire at all to repeat the whole cascade of interventions scenario.

I think there is an increased rate of uterine rupture but the medical perspective in some areas seems to have changed from not doing things to avoid risk, to taking more risks in order to achieve VBAC.

Thanks for the support. Had appt with consultant today and csec is now booked for 38 weeks. Agreement was that if they come of own accord we'll see how it goes (which was my starting position). I then saw that he'd written in the notes if favourable ARM/unfavourable elcs. But I'm just going to keep emphasising the closer we get to 38 weeks that I am not accepting any form of induction whether ARM, gel or syntocin and if on the day they want to try any sort of VE I'll just refuse until they give me an ELCS (although will have to point out to them that either way I'm going to need to know in advance in order to manage insulin on the day). Dh is primed too.