2nd baby, 1st ended up EMCS. Now they are insisting on vbac. I know this has been done before but please help...

[maydaychild]

Im asking for a friend. She hates hospitals with good reason as she once woke during an anaesthetic. This is a known cause of PTSD.
So
1st labour horrendous. Ended badly with EMCS after about 3 days labour and inducement.

2nd preg 16w. At booking in she was told she had pre eclampsia last time. General don't worry you'll be booked in with ELCS.

She had an appointment with doc today who said she has to vbac. She requested to see consultant who agreed. Vbac

She is petrified. It has taken a long time to face pregnancy again (5yrs).

What does she need to say. Isn't there a specialist midwife she needs to get onside?

All help and hints gratefully received

Could she write to the supervisor of midwives or head of midwifery asking for support in getting the birth of her choice because of the PTSD etc? I think it's awful for her to feel dismissed in this way .

im quite shocked...i was automatically offered after an emcs a ecs..even talked out trying for a vbac!

I thought that they weren't allowed to refuse nowadays?

Tanfastic me too!
She has put on a brave face but this is unnecessary stress.
Superviser of midwives... Thats the one! Thank you

Is that who she would talk through feeling of previous traumatic labour with as well?

They certainly should be able to do that with her. Some hospitals have specially trained midwives that do birth debriefing too.

Thank you!

She could also quote the 2011 NICE guideline:

"Maternal request for CS

*When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.

*For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.

*An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS. "

I was in exactly the same situation as your friend - all through 2nd pregnancy I had exactly same conditions as 1st (ie me-small, baby huge & back-to-back which ended as emcs) and additionally had excess fluid too. I had lots of scans and hospital appts but only ever saw registrars who insisted on vbac. Finally saw the actual consultant at 37.5 weeks and was booked in for elcs 3 days later. Please get your friend to follow the advice given here (wish I'd followed it myself!). I got what I wanted/needed in the end but wouldn't wish 20 weeks of worry on anyone

Top notch pesto!
Just perfect

Glad you understand smog!

VBAC is cheaper than repeat c/s in the short term but has worst outcomes overall.

Below is what the NICE guideline says and might be ammo for your friend's case - translated it means that NICE sets a value of £20,000 -30000 on a 'Quality Life Year' or QALY and although VBAC is a bit cheaper in the short term, it has worse outcomes than repeat c/s so c/s is considered to be 'cost effective.' Women should therefore be offered a choice particularly as planned vaginal births have higher long term costs - perineal repair, incontinence, psychological trauma.

So basically, the consultant is saying that it is ok to deny a repeat c/s to save £307 despite VBAC having worse outcomes and this being contrary to what NICE recommends. (The one caveat is that women who plan huge families should be advised to avoid multiple caesareans which really are risky so VBAC really is better for them).

"The base case result suggests that the birth cost of a planned VBAC is £307 cheaper than a planned caesarean section. However, the base case also suggests that planned caesarean has a higher QALY and the corresponding ICER of £24,141 indicates that planned caesarean can be considered borderline cost-effective relative to VBAC using the NICE advisory threshold of £20,000 to £30,000 per QALY, especially given the level of uncertainty surrounding long-term downstream costs and QALYs. This model suggests that either VBAC or a planned caesarean section can still be supported on cost-effectiveness grounds for a woman's 2nd birth.
VBAC as a non-intervention is the woman's right should she so choose but on the other hand any additional costs of a planned caesarean section are relatively small and can plausibly be justified in terms of additional benefit. Therefore, this model would support women being able to choose their preferred mode of birth in consultation with the health care professionals responsible for her care.

Your friend ought to think about a formal complaint to the Chair of the Health Trust.

Good luck to your friend. I am having the same issue, it is very frustrating.

Hope we both end up with healthy babies, however they end up arriving in the end.

Just to add the Nice Guidelines are just that guidelines, the hospitals are entitled to ignore them in favour of their own policies. As mothers-to-be, we have the right to request an ELCS but they are free to ignore our requests, unless medically required in their opinion. (Opinions can change. i.e. last pregnancy CS was essential, this time VBAC is, go figure)

If your friend becomes overdue, she could refuse inducement in favour of a ELCS but if she goes into labour on time or early, no idea what she can do.

Is she close enough to a different hospital to change where she is booked into? Could she request an appointent with a different consultant for a second opinion?

I still think the SoM/HoM is the place to start, in writing.

Quote mental health and keep quoting it. The NICE guidelines are guidelines and can be ignored however they do enshrine into clinical practice the notion that mental health is directly related to a request for a ELCS and that a previous birth trauma is a very real and serious thing that should be considered when dealing with requests. If she has been diagnosed or can be diagnosed with PTSD even better.

Get her armed with the document. Know it backwards, forwards and upside down and quote it at health professionals. Any that will listen - a friendly midwife, a consultant, anyone. Get the issue flagged up. The thing is, that if she goes in, crying and fully prepared it makes it very difficult for them to refuse a request - if she is forced to have a VBAC and she keep making it very clear that she is distressed and unhappy with this and ANYTHING goes wrong or leaves her with mental health issues resulting from this, they are leaving themselves wide open to litigation.

Regardless she needs to get extra support from her midwives to reassure her about various things (and the NICE guidelines are not about encouraging ELCS they are about giving the assurance of having one whilst also trying to do as much as possible to allay fears and help women feel more confident about a VB and change their mind about an ELCS if they feel supported and able enough).

I wouldn't say that getting an ELCS is the ultimate goal here. Its about her getting the correct support so emotionally she feels able to face childbirth in which ever way she feels most able to.

Also worth checking out www.electivecesarean.com there a bunch of stuff there about asserting women's choice.

thank you allwrong
Sadly, we live in greater london and they closed our local hospital. So much for patient choice, she chose two hospitals and was refused access to them. Instead, being forced to give birth at a third and unwanted hospital. However, this is because she believed she would be having an ELCS. Her preferred choice doesn't accept ELCS (wtf?)
Maybe if they force the VBAC she can choose the other preferred hospital and then begin fighting again for an ELCS.

I think she is being a victim of budget cutting here.

If the suggested avenues don't work, she could try contacting AIMS.

I can't imagine how stressful this must be for her

She is not being a victim of budget cutting. She is being a victim of ignorance.

The Head of the NHS Alliance came out and spouted a load of crap about the WHO target on c-sections which was outdated and he got pulled up on it, when the draft of the NICE guidance came out. WHO now say that any woman who needs a c-section should get one. Unfortunately he's not alone in being backward on his knowledge of this.

The NHS seem to remain in a time warp which is still committed to targets on c-sections which is completely the wrong approach. For example I've seen kelland forceps have been pushed by some as a way of 'keeping c-sections down'. Sadly public opinion on ELCS driven by the wholly inaccurate and abhorrent pushing of "too posh to push" by the media - something that does not exist is not helping. It is not forcing decision makers to look at and get more up to date information and research on birth fear (tokophobia) and its financial and mental health effects.

They need to focus on better care and stopping fear in the first place. Secondary tokophobia as a result of a previous traumatic birth is entirely preventable and is happening because of poor practice methods.

Sorry to make this a political issue, but your friend needs to know the real reasons behind this, if she really wants to fight this. Don't be phobed off by the budget excuse. Its not true and the NICE guidance actually backs this up too.

I know Pauline Hull at electivecesarean was trying to get information on which hospitals in particular were not following the NICE guidance in order to put pressure on them to change their policy. Naming and shaming is the way to do this. Your friend should not be being put through unnecessary stress because hospitals refuse to take on board the throughly researched guidance.