VBAC/ELCS meeting - how do I get the ELCS approved?

[UntamedShrew]

My reasons for wanting one, after much umming and ahing, are not really 'medical' reasons at all, therefore I fear the consultant may poo-poo them and force me to go for a VBAC. I had a ELCS before as it was twins.

This time last year they would have pushed me into a ELCS but the hospital is now facing big cuts and they are quite open about the need to save money. I can sympathise but only to a point!

For info my reasons are (just so you can see how easy many of these would be to refute) :

• Great birth experience last time, calm and wonderful, and don't really want the delivery of my children to be so drastically different
• I recovered very well after the last ELCS
• Easier to plan for vs. arranging short notice childcare when I go into labour in middle of night - twins and parents live 4 hours away +
• I like knowing what to expect, fear of the unknown is definitely an issue for me
• think it would end up being a EMCS after all which would be harder to recover from, potentially
• I already have a scar there, why have problems in another body area?
• I have complete faith in the surgeons and consultants at this London hospital but the MWs are very patchy. Postnatally I had a dreadful experience and I would be very scared to put myself and my baby in the hands of such uncaring women, should I have the misfortune to meet the same ones again!
• My mum had great births with her children incidentally, totally natural and no stitches - But urinary incontinence for 8 years is not really something I would want to inherit if I can possibly avoid it...

Can anyone help me with any other things I should say that might swing things towards an approved ELCS?
If not I think I would be OK (ie eventually get me head around) a compromise that says I will not be induced chemically so get booked in for 41+ weeks.

Thanks for reading, any help and advice would be much appreciated.

hiya, well although your hospital have a clear VBAC policy, its not usually cast in stone and if you feel that strongly then they will probably give you one. Just go in with the argument of previous CS, scar etc. I would avoid any points along the lines of 'its convenient' - that will just wind them up. As for the midwives, you would probably find they are great in labour and you should get one-to-one care when labour is established. Postnatal care is always the poor relative in any hospital, its not the midwives personally, its the awful system they work in that stretches them far too thin so they cant give proper care and believe me, they want to offer good care postnatally but often 2-3 midwives to 30 women, do the sums, it doesnt work and thats why most women remember their postnatal care as awful. Be careful on the incontinence issue, general feeling is that in later life mode of delivery has no bearing on pelvic floor/urinary incontinence - its pregnancy that buggers you up! Agree about postponing ELCS until 41 weeks and declining IOL. IOL will almost certainly reduce your chance of a VBAC so if you get to that stage have the CS, and I'm sure they will go along with that. Also have a think about what you would do if you decide on ELCS and go in to labour before the date (39 weeks). If you turn up in the middle of the night doing really well in labour, do you really want to go for a CS? Good luck with your meeting and your decision. Ang

Thank you Ang

Sorry didn't mean to offend any MWs, just the ones I met were brutal, and my antenatal care was consultant-led so I just didn't get to meet many others. I could see they were stretched to breaking point but calling me a 'lazy bitch' when I said I didn't want to carry a bucket of sterilising solution to the sink myself seemed a bit extreme! I have met the VBAC midwife though and she was lovely, I do think if I went into labour pre-41 weeks and had her on my side I'd go for it...

Hi,

Thought I'd reply as I've just had a consultant appointment this morning. Sorry for long post!

I had a previous EMCS due to failure to progress and fetal distress, and I want an ELCS this time. Definitely!

I went to the hospital feeling very un-optimistic given that the midwife at my 12 week scan pretty much said that I'd only get an ELCS if the baby was breech, plus they booked me in to a VBAC meeting with another midwife.

Sitting in the waiting room today I was reading all of the notices on the wall and spotted a lovely shiny new one dated July 2011 called 'Elective Caesarian and VBAC Policy' This basically said that if the hospital thought a VBAC was possible then tough, they wouldn't do an elective caesarian as it was policy not to do one just on maternal request.

I actually felt pretty calm after that as I'd already mentioned changing hospital to my community midwife and she was happy to do that for me.

Anyway, I went in to see the doctor (there was a midwife there too). I explained what happened last time although they were a bit lost as they'd not been able to get my notes from the other hospital where DD was born. They advised me to go to the VBAC appointment because that would explain both sides of the argument to me and I could then make an informed choice, hopefully with the support of the midwife from the VBAC clinic.

My husband did say 'so if we go to this and we still are determined to have an ELCS, you'll let us?' The answer seemed to be yes. However this does seem to go against their new policy so I am still confused.

They probably think I've lost the plot a little as I ended up in tears talking about DD's birth, so perhaps they think I need counselling and then if I still feel too traumatised they'd go with the ELCS?! I certainly hope so, but I know I'll be worrying about it for the next 17 weeks as they won't make a final decision until 36 weeks, which I think is pretty standard.

This probably doesn't help you that much - but it does go to show as other posts on here do, that it really depends on the hospital and the doctor that you see. The doctor and midwife today were realy nice and sympathetic, but I may well see one at my next appointment who isn't.

Good luck!

Ooh good luck to you too - it all sounds quite confusing. I went to the VBAC appointment which was more of a group session than I'd expected (10 mums) and left feeling quite open minded, like I say the VBAC midwife was lovely.

However since then I've had too many horror stories from friends (I know, I know) but most of all just thought about it (A LOT) and all the above reasons seem more compelling than the risks she talked about.

36 weeks does seem late to get a final decision though, so maybe we should try to prepare for a VBAC just in case..?

Hello. I'm booked in for ELCS next week (!!) after having EMCS with DD2, 2 years ago. I was certain that I wanted ELCS before I spoke with the registrar (have not seen a consultant, specialist reg has been great though). I found that speaking about my reasons with my GP and one to one with the supervisor of midwives (and my friend's mum, who is an obstetrician) really helped me to get my thoughts together before making my 'arguement' at my (I think) 16 week appointment. As it turns out, I didn't have to argue my corner at all. Registrar listened to my reasons, was pleased I knew what I was talking about and said I could have a section. TBH, whatever the hospital 'policy' I think it is very hard for them to refuse a repeat section if you are clear about your reasons and unhappy with the risks associated with VBAC. You can always ask to change consultant if you feel you are not being listened to and although I dont' really like the idea of holding doctors to ranson, my obstetrician friend (working in highly litigious Hong Kong) did suggest that a conversation about legal liability in the even of the 'procedure' going wrong may be useful.

I would ignore the arguement that pregnancy is the cause of later life incontinence rather than giving birth. Apparently a distinction is made between pelvic floor disfunction (caused by pregnancy) and pelvic floor damage (caused by birth). I had a fantastic pelvic floor all through pregnancy and it was giving birth that has knackered it. Have you looked at the NICE guidelines?

I am having an ELCS on Friday due to third/fourth (it isn't very clear which it actually was) tear. As it happens the baby is also breech but the ELCS decision was made before it was established that she is firmly breech and won't turn now.

I expected to have to "fight" a bit but in the event at the meeting with doctor at 36 weeks I didn't have to fight at all - she outlined why VB is preferable, I agreed it is preferable in circumstances where they can guarantee I won't be pushing for nearly three hours like last time or that I won't tear again and end up incontinent, but as they can't I would rather have the certainties of an ELCS. I did also, very nicely and politely, point out that if I was refused a C section and suffered complications to myself or the baby as the result of a VB or attempted VB I would sue. And that I am a solicitor.

And that was it really. I agreed to be open to attempting VB if I went into labour before ELCS date and if the baby was head down and if labour was progressing very nicely and quickly, but so far that hasn't happened.

Good luck. I am at Kings in London and recently had my discussion (midwives and consultants all agreed before but never formally set it in stone before 35 weeks) the other week for ELCS.

Had an ELCS abroad for my first (breech) Ob Gyn recommended not going for VBAC as my surgery for Asherman's (interuterine adhesions caused by rough D&C) meant the rupture risk was higher.

I was nervous I'd be pushed towards VBAC but apart from one consultant, who rather poo-poohed my Asian ob/gyn's reasons for a repeat section "Oh, they all say that in Singapore...." it was all consensual, adult and I felt listened to.

I would recommend reading and printing and taking with you the NICE guidelines and what the RCOG says about VBAC.

My reasons were:

Rupture risk. Small, but when it goes wrong, it is grave

I cannot be induced with prostaglandins and given I am being watched for blood pressure and may have to be induced, I'd rather not be induced manually.

The Asherman's having thinned my endometrium. I don't have my notes but it's an uncertainty I can live without

I would need close monitoring and protocols are set for the various phases. This makes doing things 'my way' and increasing my chances of a straightforward and active labour much lower.

I don't think facing a 30 percent chance of an EMCS after possibly labouring for a long time are good odds. I wouldn't bet on them. Since I don't have an emotional investment in vaginal birth I don't feel these odds are worth it for me.

Safe for baby, risk load is on me, which is fine by me.

If I could guarantee one on one midwife care and giving birth at a good time in a fully staffed hospital, I may have considered vbac. But that's not the reality of my hospital

My baby was safe, my recovery was fantastic with my first and so I am happy to repeat this. It meant enforced bedrest for a couple of days which helped breastfeeding as I just had her on my breast almost constantly (and ahem, still feeding her 2.75 year's later)

(Plus I don't see the point of knackering myself in two areas, but I would ever say this!)

What puts me off is 2 nights in a post-natal ward!

Good luck.

Oh, like Georgimama, I agreed ( and meant it) that if I go into labour spontaneously before 39 weeks and it all looks to be going well I shall continue.

I think that made me come across as sensible.

Strange thing is, when I had my first, I wanted a planned section (had been raped and have borderline tokophobia) but the Singaporean (those notorious scapel happy doctors) refused and then I got my head in a good place and was ready to give birth naturally, but she was frank breech.

Thank you all so much, this is really useful.

Otch I am also put off by a longer stay in the post natal ward, 2 nights would be a result after last time though! Your list of reasons was very helpful, thank you.

Breathe mentioned NICE guidelines - anyone know which are the latest ones? I tried google but the only ones that come up are 2004, surely there are more recent than that?

NICE guidelines - the 2004 ones are the most recent official ones.
However, they have another draft in progress which is also on their website, and due for official publication in November 2011 I think.

I had an ELCS on the NHS.
I had a meeting with a registrar who went through everything with me re c-section. I told her I would prefer to have the measured risk of elective c-section than the unpredictability of natural birth, which could easily end up in forceps, or emergency or even crash caesarean.
Adam Rosenthal, Clinical Research Fellow at St. Bartholomew's Hospital in London cited a study at Queen Charlotte's which suggested that women over 35 only have a 49 % chance of delivery without intervention anyway. So if you're over 35 and opt for natural delivery, you're more likely than not to end up with a medicalised delivery anyway!

I found this website very helpful indeed - www.csections.org

BTW it advises that if you get turned down by your consultant, you are entitled to a second opinion - but you must check what the hospital's policy is on non-medically indicated c-sections, because it would be pointless to have a second opinion given by the same hospital. They should refer you to another hospital who will do elective c-sections.

Here are some excellent articles. I printed them out and took them along to my meeting. BTW it was in the news the other day that there were 17 avoidable deaths in 18 months in London hospitals, due to poor care. I don't imagine any of them were elective c-secs....

www.guardian.co.uk/lifeandstyle/2010/dec/10/torn-apart-by-childbirth

"The safest method of birth is by Caesarean" www.guardian.co.uk/society/2004/may/02/health.politics1

www.guardian.co.uk/lifeandstyle/2010/nov/20/elective-caesarean-tokophobia-childbirth-phobia/print

www.independent.co.uk/life-style/health-and-families/health-news/british-maternity-wards-in-crisis-2261403.html#

www.thisislondon.co.uk/standard/article-23927143-family-of-girl-paralysed-at-birth-win-pound-400000-payout.do

www.thisislondon.co.uk/lifestyle/article-23913235-writing-brought-my-baby-to-life.do

Good luck!!!! xx

There is also a website that shows how many electives each hospital trust performs, some are above 10 percent, some below. You'd want to go for a hospital with a higher number. I'll try and find it.

I had a second elcs 18months ago, I think what swayed it for me was that I was prepared to give the vbac a go, but I said I would refuse an induction. I went 10 days over due, 2 sweeps failed to get things going so I was given my section. I think they were happy to do so because I had shown some willingness to even consider a vbac should things have started naturally (my first cs was because ds was footling breech so I hadn't gone in to labour with him at all)

So what's happened to 'No decision about me without me' that the government was spouting at the last election?

It drives me mad that people are being strong armed into making decisions that can actually lead to WORSE outcomes. (VBAC definitely has higher death rate for the baby, more brain damage and much much more uterine rupture - see the RCOG 'GreenTop'.)

What is wrong with the NHS? The lifetime costs of a brain damaged baby are enormous. And no, vaginal birth does not lead to quicker recovery. Only if you have an uncomplicated vaginal birth. Traumatic vaginal birth takes much much longer to recover from than an elective.

I think we should send these posts to the Minister for Health - what a complete disgrace ..

Btw - not suggesting that woman who CHOOSE VBAC should be talked out of it at all. Just that this is a personal issue and people should have choice.