bipolar and want an elective CS - any advice on persuading midwives etc to agree?

[NannyTutorAtLarge]

It's very early days but I've just discovered I'm pregnant with my first baby. Hooray! Very happy, but have a few misgivings around the birth and was hoping to get some insight from you lovely lot.

Basically I'm bipolar, so my history is littered with episodes of severe depression and psychosis. Been stable for the last year as a result of finally seeking help, getting the right drugs, giving up the booze and exercising. Best decision I ever made - have been able to retrain in a career I've always aspired to and will allow us to travel (something my partner and I always wanted to do with a young'un). I've been able to write again, which had totally fallen by the wayside, and my relationship has also benefitted no end.

Clearly what I absolutely do not want to do is put all the above in jeopardy. I get incredibly anxious thinking about a vaginal birth and am also obviously a prime candidate for post natal depression. So I would like an elective caeserian. I've read about so many different experiences securing this and was wondering if anyone who'd been in a similar situation might be able to offer advice re: talking/persuading midwives/consultants to agree to one.

Many thanks in advance!

Bypass the midwives. Go to your GP, have a long talk about how well you are and your concerns. Ask for referral to a consultant now not months down the line. Read the NICE guidelines and frame your concerns with reference to them.

Firstly, congratulations - on working so hard to be well, and on your pregnancy!

Who is looking after you on the mental health side of things? Your consultant or CMH nurse? I'd talk to them first off. They are most likely to have had experience of women with bipolar disorders being/getting pregnant and how to successfully maintain treatment during pregnancy. This can't be unknown!! They might also be a good sounding board for you to think through the different birth options available to you. I say that last bit not to be patronising - but if you have your psychiatric consultant/CMH nurse on board with your decision and your reasoning behind it, then you will have a stronger argument for ELCS if you come up against an obstetric consultant who is unfamiliar with bipolar disorders, tends to be in favour of VB and for those reasons thinks you are 'just another anxious woman'. If you have a good relationship with your GP and s/he is actively involved in your treatment, this would be another good person to talk to.

Although the decision for ELCS is not a MWs to make, you may find that the one you are assigned is helpful and sympathetic, so might still be worth mentioning your situation - see how you feel about her when you meet her. In any case, you need to mention your history of bipolar disorder at your first MW appointment and request that your pregnancy and delivery is at the very least managed on a shared-care basis (i.e. shared between MW and consultants). Although I'm assuming that you are on medication (?) and for this reason I assume that you'd be marked down for at least shared-care if not consultant-led care anyway. Also, as nodust says, get a referral to an obstetric consultant ASAP - you'd do this through your MW at your first appointment.

If you feel you are getting nowhere with the MW/obstetric side of things, you are perfectly entitled to switch hospitals. Your mental health team might know of a maternity unit that deals appropriately and sensitively with women who have bipolar disorders. So if you haven't chosen a hospital yet, it might be a good idea to chat to them first and see if they have any suggestions.
Might be worth posting this in mental health too.

Really wish you luck! XX

There is a thread here, an old one, which might contain info that is useful/relevant to you - I will try and find it now....

But as a first response - without trying to judge or sway you in any way! I'd say that you need to be aware that what YOU might feel is a reason for a CS might not be a reason for anyone in the medical profession to agree. For example - if there is firm evidence that PND among bipolar mothers is reduced when they have a planned CS rather than a VB, then fine. But if that's just your view of your situation, it won't carry any weight. I say that not to be miserable but because part of the whole conversation about planned CS with hcps is about proving you have read up on your subject, you know the relative risks and benefits as far as you can know them, and are 'talking their language'. IYSWIM. Also known as 'making an informed decision', to be fair.

I think cardamomginger's advice to get support (in all ways) from the mental health care professionals you must have been dealing with. It sounds like you may have found them very helpful, and as if having a good mental health support network in place anyway might be a very good idea.

I'll try and find that thread now.

www.mumsnet.com/Talk/childbirth/954334-Anyone-asked-for-ELCS-for-first-baby

I don't think fruitybreas's opinion was helpful.

First of all, congratulations on your pregnancy and maintaining stability for a whole year! :)

I was BPD when I was younger and thought I was a shoe-in for PND, 2 babies later and not a whiff of it! Surprised? You could've knocked me down with a feather!

For me it transpired I needed 2 cs for physical reasons, but psychological ones are equally valid. Tokophobia (or fear of vb) is a recognised syndrome.

No decent consultant on earth will wish to cause someone with mh problems additional mental trauma by forcing them to birth vaginally.

I'd talk to your GP and also your psych team about referrals and in the case of the psych team them contacting your consultant directly.

My consultant wanted me to consider a VBAC and asked me to look at RCOG which I did and their own guidelines backed up my valid reasons for elcs. It's not that they want to say no, but I think sometimes with budget issues they want you to be able to articulate why you're not a good candidate for vb.

Don't let the hippy lentil-weavers try and dissuade you with talk of lavender fields and hypnotherapy. Kudos to you for getting on top of your mental health and battling your demons - now is not the time to let someone tell you what you're feeling is invalid.

Again, massive congratulations!

Fwiw, taking the RCOG guidelines and blending it with information from that hospital I was able to show that I only had a 30% chance of a vbac and that there was no way of knowing how much damage would be done.

As it turned out I had a complicated elcs which would've been a difficult labour followed by emcs.

My 50 year old midwife told me afterwards "good call" saying she'd never seen such abdominal trauma. A couple of young mw's implied I'd been too posh to push.

Their opinions really don't matter! I am happy with the choice I made and of course happy my experienced mw backed me up.

The vbac would've been pretty brutal physically and psychologically for me.

Alpinepony, I had a planned CS 2 years ago for my first child. For psychological reasons. For primary tokophobia. I too have a history of mental illness.

The point I was trying to make, without scaring the OP, was that in the UK, there are PLENTY of cases where consultants HAVE refused women who are desperate for a planned CS - both for first DCs and DCs born after awful, traumatic VBs.

I don't know what you think is unhelpful but in the UK, on the NHS, these things are a lottery. There are people who seem to have pretty much argued their way into a CS - others who have tried and tried and failed and been forced to have unwanted VBs.

I don't know what in my reply you found unhelpful - but when you say in your post "No decent consultant on earth will wish to cause someone with mh problems additional mental trauma by forcing them to birth vaginally" then I'm sorry - that does happen here. You only have to read posts this week, made on this board, to see examples of that. It shouldn't happen but it does.

Hey nanny, I am in your situ :)

I have Bipolar, (amongst other things...) and I will be having my elc a week tuesday. I have two children already and both born vaginally.

This time i was heavily medicated when i found out i was pregnant (had been told this was impossible so quite a shock but we are over the moon) I had to come off all meds as not compatible with baby.

I hadnt even been thinking about the birth as I had been trying to keep my head above water and each day as it comes iykwim, not been easy tbh.

The baby was breech, so had all the gumf about sections and ecv's etc, i decided to go for section.

Saw my psychiatrist who got my med plan in place for the day i deliver etc...then the little bugger flips back over...

I went into complete, and quite unpredicted, melt down with DH at the idea of it being another X amount of weeks...he called the consultant and explained i needed to get back on meds and wouldnt consider taking them whilst still pregnant.

The section was booked that day.

I know this isnt your situ exactly, but i found that the consultants seemed a little scared of my condition and treated me like a bomb about to go off.... I dont think i am that bad, but as its worked in my favour I am happy to roll with it tbh. I have found my anxiety about what will happen, how, when, why etc has really been far more manageable since i knew the section was a cert, and I have no fear at all of giving birth and have said that to the docs too!

I havent really bothered with my midwife much, i go straight to consultants at the hospital, the midwife here was a bit tick box and not really listening to my ishoos, unlike the consultant who seemed more than clued up about MH risks in pregnancy.

Talk to your Midwife. If you feel unheard then ask to be refered to the consultants. Good Luck

(sorry its so long )

Hi Nanny, in a similar situation to you. This is what I posted on a similar thread a few weeks ago, hope it helps. This is jus my experience though and I believe fruity is right in that it can be a total lottery on NHS. Wishing you lots of luck xx

I'm 21 weeks pregnant with my first baby, but for as long as I can remember I have been terrified of pregnancy and childbirth. I've also had depression as a teenager and believe the two are linked somehow. Despite my fear, me and my husband really wanted a family, and after having depression before, I weighed up that not having kids could cause me more upset and depression in later life. So we tried and I fell pregnant quickly.

I knew this would be difficult for me but I didn't realise just how difficult! I was a total mess before my booking app and hadn't felt so low since my teens. I was so worried that I would see the midwife and she wouldn't understand my fears and tell me not to be silly, at worst I was scared she would mock or make fun of me. I wont go into every reason now (as I would be here all day!) but I can only contemplate having my baby by c/s, due to being in control, knowing exactly what will happen etc. Anyway, I went along to the app and she was actually incredibly understanding, kind and compassionate. She recognised I have tokophobia immediately and referred me for CLC (she even picked a particular consultant who she thought would be sympathetic to me). She also suggested I see my GP, just to make him aware of my situation and he was also very kind, he did suggest an online course of CBT, not to 'cure' my fears or change how I feel about having a c/s, but just to help me and keep my depression at bay. I do need to spend some time looking into the CBT as admittedly I haven't done this yet, due to focusing on my consultant app etc.

Before my consultant app, I spent time writing down ALL of my fears and feelings, why I wanted a c/s etc. I wrote about 5 pages in the end, and at my midwife app before the app with consultant, she read through all of this and thought it explained my situation perfectly. I knew I wouldn't be able to cope with talking about it all with the consultant so I took what I had written with me. I had the appointment with him when I was 15 weeks. He read through everything, and then immediately agreed to my request for ELCS- he said he didn't see any point in trying to talk through my fears, as he thought it would only make me worse. He also agreed for the c/s to be done under general anaesthetic. After the app my consultant cc'd me in a letter he sent to my GP, letting him know my care plan and that my ELCS is booked for October. In the letter he wrote I was the worst case of tokophobia he had seen in 20 years of obstetrics so he must have taken me seriously!

One final thing, I think the consultant was able to agree to my request for ELCS so quickly because of everything I had written down. He said himself that it had been very helpful to read and he didn't think I would have been able to explain it all properly if I'd tried to just talk about it. I also really explained everything, my fear and phobia and the specifics of those, how it made me feel, how it affected my life and my husband as well, and about why I wanted a c/s. I also wrote that I knew about the risks etc of a c/s and I think they are more prepared to listen to requests if they know you are making an informed choice. I didn't even have to mention the updated NICE guidelines, I think they treated me so much as in individual.

Thanks everyone for all your comments, help and congratulations! Some really helpful points, will definitely write down all my fears etc. Thanks again!