meeting with head midwife for birth choices after c-section - help with questions

[blackteaplease]

I had an EMCS first time as dd was a missed breech and my waters had gone with meconium in them by the time anyone realised.

I have a meeting next week to discuss my options for this time round and am compiling a list of questions to ask, can anyone add anything? I am starting to worry about what is the right decision to make and feel that a list of questions should help.

Here goes:

1. Is there a reason why dd was breech?
2. How likely am I to have a breech baby again?
3. Can I have an ECV if I have had a c-section previously?
4. If not, or if it fails, can I consider VBAC for a breech baby?
5. What are the risks of VBAC?
6. What monitoring will I need?
7. Can I be in MLU or consider homebirth?
8. DD was 40+12, how likely will it be that I go overdue again?
9. Will i be induced if I go over?

10. Are the risks different for ELCS and EMCS after VBAC failure? 11. If I did opt for another c-section when would I get it?

Have I missed anything important?

This is quite a common scenario and most people go on to have a successful VBAC. Your questions are fine. Most MLU do not do VBAC because of strict admission criteria but its worth asking. Home birth is also a possibility but some units are more relaxed about VBACs at home than others. What you need to remember is there is standard management, ie consultant unit, continuous CTG and then there are variations based on a clear understanding of risks and benefits and your own preferences. No management can be imposed on you. You are most likely to have the best birth in a situation that makes you feel most safe and relaxed. Only you have a good understanding of what that would look like.

Thanks Mayhew, I don't even have to make the decion for ages yet as I am only 17 weeks but for some reason I was awake for two hours last night worrying about this.

I thought that getting the answers to the above questions would enable me to weigh up the risks against my preferences and make an informed decision. Rather than opting for c-section as it appeals to my ordered and tidy nature. I don't think thats really a valid reason for a repeat section.

Im in same position though further along. My hospital will not 'allow' me to be in MLU and 'insist' on continuous monitoring although of course, officially, the mother decides. Other factors may become apparent at your anomaly scan eg placenta praevia or excess scar tissue from your section which influence your final decision.

Also, do give yourself time to mull your options. I was told that as time goes by, you often gain more clarity about what feels right for you. My consultant midwife told me that at 32 weeks approx your body produces a hormone which makes you feel more confident about delivery and what you want to happen. Mother natures way of helping you cope! This has happened to me and at 28 weeks I suddenly feel very different to how I did at 17. Hope that helps.

Thanks Loveis, I fully expect to be making up my mind up to the point where I am forced to decide. I have no idea why this is bothering me so much now, I think it's just the fear of the unknown at present.

My consultant was very sympathetic to me not wanting an induction so we've agreed that I'll aim for VBAC if I go into spontaneous labour but will have ELCS otherwise. As I was 12 days over last time, I feel that if it does happen naturally, it's meant to be.

loveisagirlnameddaisy do you mind me asking what you reasons are for not wanting to be induced (is it because of the increased risk of uterine rupture or something else)? Will you have ELCS at point of EDD? I ask because I'm considering a vbac myself.

I was told you can't have an an ECV after a c-section due to increased risk (presumably of scar tearing?). I didn't really care cos I wanted a 2nd c-section in any case but one of my twins was breech and it was made v clear that attempting to turn her wasn't an option at that hospital if I'd wanted to try vbac.

All I will say is if you wanted a homebirth (I think it's point 6) then it's up to you, they can refuse entry to the MLU but not refuse a homebirth - so don't 'ask if you can have one' as its your choice!

I wasn't sure about the ec v and is only 50% success chance anyway.

I meant is it an option or too risky? I'm not sure about a homebirth .

Sorry for short replies, I am on my phone

It's an option simply because it's your decision, not theirs. High risk women plan homebirths, including VBAC at home, but I doubt any MW would or could advise one for anyone other than a low risk woman, although you'd find that if you went for one, you would be appropriately supported. I think asking about MLU is reasonable as they can yay or nay that.

Don't know if this list of the cold hard facts from validated sources helps, blackteaplease but here goes

This is the RCOG's link on the detailed risks and benefits of VBAC versus repeat c section www.rcog.org.uk/files/rcog-corp/GTG4511022011.pdf

EMCS carries much higher risk than elective csection. VBAC carries higher risk of rupture and neonatal death than c section (although the risks are small).

There is a very much smaller and very tiny increased mortality risk to the mother for c-section (about 1 in 20,000 ). There is slightly more maternal morbidity with VBAC - mainly the rupture risk and haemorrhage and most of the risk is for unsuccessful VBAC. (NICE and RCOG)

A rather odd fact is that epidural INCREADES your chance of successful VBAC (RCOG)

The problem with home birth and VBAC is the incredibly rare risk that you suffer uterine rupture - don't want to be morbid but if that happens it is blue lights and fingers crossed for both of you - not just the baby. There is a certain amount of seriously dodgy and misleading information about this on the net - risks of 1% or 0.5% are not small risks if the outcome is potentially a fatality.

VBAC is safe but you need to be somewhere where there are emergency facilities on hand - as Flisspaps says it is still your choice so if you wanted homebirth you could demand it but it does not change the risk that is a real one.

So based on that, I reckon the choice you have made is totally sensible!

One question you might want to ask is your actual chance of having a successful VBAC. This varies a lot depending on whether you have had a successful previous vaginal birth and some other factors.

Good luck

Thanks ushy. That's the kind of.info i am hoping to get out of my meeting. Actual facts and risks that I can then weigh up to help me decide. The mlu is next to the labour ward so that cuts down risk if i do go for vbac.

joymaker I had a failed induction last time and found the whole experience pretty horrid. They tried a ventouse (not forceps - I don't know why) and really messed around with my DD's head. I do not want to put me or another child through that again. My DD was a large baby with a very large head which was awkwardly positioned and that was the reason given for the failed delivery.

The consultant seemed sympathetic to not being induced because of the likelihood of intervention (as inductions increase the chance of this happening) and both scenarios are less than ideal when there is previous scar tissue to consider. I've been told my every HCP I've seen that they are far less willing to hang around and wait with a VBAC because of uterine rupture.

In the end, we agreed I would have sweeps from 38 weeks to see if spontaneous labour started and if not, an ELCS on my EDD. I think the consultant would have liked me to wait until I was a week overdue, but in the end it was my decision and he totally respected that. I'm happy with what's been agreed.

Also, they heavily recommended continuous monitoring which I am not keen on as it means being limited to which positions you can be in - I firmly believe this contributed to the poor position of DD's head as I was flat on my back the whole time during that labour (epidural given as on synto and way too painful without). Given that we are a big-headed family (in the literal sense, I think the chance of being in exactly the same position again if I labour naturally, are high).

Yes, I could refuse continuous monitoring but my DD had rapid decels which contributed to the ventouse and EMCS so I wouldn't want to take the risk of anything being missed this time around.

loveisagirlnameddaisy- thanks for your reply. I wondered if your reasons were much different to mine and they're not although I didn't have a bad time being induced it just didn't work for me the last time.

I'm not keen on continuous monitoring either if it means restrictions to moving around (so long as all is well)...I will only be fine with it if they have one which is able to go into the birthing pool with me

Joymaker, apparaently such things do exist. My friend recently had her midwife meeting for birth choices and was told that our local hospital have invested in waterproof monitoring equipment.

I had to have the belt on for an hour or so before they realised dd was breech and it was the most annoying thing, every time I moved it slipped down and they lost the trace. Not sure how I would cope with that throughout labour.

Yes, you can be monitored in water if they have waterproof monitors. Not all hospitals do, mine have 2 but I've been told they're often out for repair so not to rely on one being available. Same goes for pool of course.