Can I be forced into having a VBAC? Writing appeal letter now, need advice please...

[sunnysunnyshine]

I had an EMCS with dc1 after failure to progress and fetal distress. It was v traumatic and I suffered from PTSD. I was told by a midwife directly afterwards that if I wanted more children I would be allowed an ELCS.

However, after deciding that I'm absolutely certain that an ELCS is the way for me, at my last meeting with a consultant I was told that they'd decided that I won't be booked in for a section. I've been told to appeal if I don't agree with this.

I'm absolutely terrified. I'm already 31 weeks so panicking about time...

I'm writing my appeal letter now, but wondered if anybody had experienced this and successfully appealed and got their ELCS??

I didn't realise they could force you into a vbac?

Neither did I. In fact i have just come back from an emergency midwife appt where we discussed this very thing.

Why did the cons say that you wouldnt be granted a ELCS - what were their reasons? As you have already had an EMCS through FTP and then suffered with PTSD afterwards i would have thought that they were very good grounds for wanting an ELCS. Anecdoteally I know of people who have had them for much less.

I havent been in the situation of needing to appeal but I would write down all your concerns, also include that you have researched the risks of an ELCS - PPH, infection etc also that you know the risks involved in a VBAC - uterine rupture, poss EMCS and that having considered all of that you believe that an ELCS is the way forward. that way you can show them that you are making an informed choice and you have really thought about it.

From reading on here i think you can also go to PALS to gain advice if you are not happy with the decisions made by your hospital, NICE also have guidelines for childbirth. Might be worth a read?

And FWIW my MW just told me that even if I commit to a VBAC, if i suddenly have a 'wobble' nearer the time I can go back for review. I know that a consultant ultimately has to sign off surgery but in your circumstances 'forcing' you into a VBAC just seems cruel.

This sounds awful. When they tell you to appeal, who to? Who are you sending a letter to?

You need to arm yourself with NICE guidelines and demand to see another consultant asap.

I am really surprised to hear this as I too had EMCS with first for same reasons and that coupled with a history of very difficult births in my family was enough for consultant to sign off ELCS this time. Sister and SIL also got ELCS signed off for previous difficult births. Maybe you just have a very unreasonable cons. I thought the guidelines about ELCS changed last year so that as long as the mother was aware of the risks of a c section and esp if had a previous one then a cons could now authorise this rather than previously being the case that there had to be a risk to either the mother or child. Worth checking this before writing the letter as this is just what I recall from seeing something on news last year. Maybe get your gp to do a supporting letter as well if you were treated for PTSD.

The NICE guidelines have changed. The trouble is that though. They are 'guidelines' not something that any hospital HAS to follow. They can choose to follow different policies if they want. In the run up to the new guidelines being finalised some hospitals did pin their colours to the mast and say that they would not be following the guidelines and allowing ELCS to any woman who wanted a CS to have one in an effort to force their CS rate down.

This was very badly reported in the press at the time and has led to a lot of women believing they now have a 'right' to an ELCS. This is very sadly not true and yes they can in theory 'force' you to have a VBAC.

HOWEVER, I've seen several examples of this happening to other posters on MN and in every case to date that I've seen where the poster has been really distressed by an initial refusal to have a CS, they have managed to get one on appeal. You do need to be forceful and kick up a fuss if they are putting obstacles in your way but it definitely seems to be possible. The thing seems to be to fully arm yourself with knowledge and have your partner or another relative go with you to back you up.

The biggest thing you have got going for you is, if you have been given a formal diagnosis of PTSD. The new NICE guidelines are very clear about women who have anxiety about VB deliveries having a legitimate reason to request a CS. Read these and use this as a backbone to your argument, demonstrate you fully understand the risks and that you realise it is not 'an easy option'.

So don't loose faith and try not to get yourself too upset about it all. It seems some hospitals are being very difficult. And in some cases, its just individual consultants who are just being arses. Its very much a postcode lottery unfortunately.

Good luck.

I echo much of what the last poster said. I would ask your mw to refer to you a different consultant or a even a different hospital within the patch/trust if that applies to your area. I just did the same thing and have had a completely different experience with this new consultant.

I also got given some good advice to prepare your bullet points of your concerns /fears /reasons (physical and/or mental/emotional) and demonstrate the negative impact you think it might have on you/your family/your life/your mental health etc. Put it across in a straightforward way and ask the question "given these factors, would you consider doing an ELCS?"

If you can take a letter from your midwife or get to see a consultant midwife beforehand to discuss your case, that would help too. They may offer counselling support, which is not mandatory, but can be helpful in showing willing. They don't have to report back to the consultant as it's confidential.

And while the NICE guidelines are not mandatory for PCTs, ask the consultant midwife and/or PALS to confirm what their policy is on following them - usually you'll find that they will, so long as you don't talk in terms of 'rights' or 'entitlements'.

IHTH

Put it in writing that you are absolutely decided you want an ELCS. Don't be wishy washy. Don't give them any room to say you are happy to wait to make a decision. Give reasons why you believe this is better for you and for the baby (past experience, Nice guidelines, etc.) Ask them to give reasons for denying this wish. And last but not least, remind them that if you are forced to have a VBAC any resulting consequences will be a result of their actions and not yours.

These are strong words. But they will get someone's attention.

Where are you? Can you change hospitals? Some are more friendly to a section than others. If you are in London, I would recommend QC or C and W. I had a section at each. QC was better, but C and W was not bad.

I have 3 kids, one crash section, followed by two electives. Was def the right choice for me.

IME with things like this as soon as you kick up a fuss they back down. I would recommend seeing your MW and getting her to help you with the appeal (assuming she's sympathetic). I would be confident you'll get your ELCS. What the consultant is hoping for is that you'll go home with your tail between your legs and that she/he will have done their bit to bring down CS rates in the hospital. Once you appeal they won't be able to justify the decision, especially seeing as you had PTSD.

It's shit that you have to face this stress when you're pregnant, and it makes me so annoyed that they're putting you through this for nothing. Bastards.

My first baby was a very traumatic crash section under GA and the most hideous thing that has ever happened to me.

2nd baby the cons refused me an elective.

So I booked a homebirth. I was not willing to have a vbac at that hospital. Anyhow, failed to progress so went in and had a CS, no surprise. Both babies were malpositioned and TBH I think I have a shit pelvis.

IIRC if they decline you a CS you can insist they refer you to a colleague who will do it basically.

I went for the other option because I didn't mind too much whether I had vbac or CS, I just wasn't going to have a VB in that unit. 2nd CS was MUCH nicer though, they wanted to break my waters and give me an epidural and I just kept repeating, no I do not consent to that. Take me to theatre for a section. Eventually they did, he was stuck and bloods showed he was getting compromised. I knew, I fucking knew he wasn't coming out but they were so set on keeping their section rate down...

Thank you for all the replies!

As far at the appeal goes I'm not even sure how it works. I had 2 meetings with a different consultant - a more understanding and supportive lady, who said that if they said no at the deciding meeting which was with 4 consultants, I could appeal. She didn't seem to think I would need to though.

At my my follow up appt - with an absolute arsehole of a man who was v dismissive and patronising - I was hoping/expecting to be told I could have an ELCS.
But he said that it would be less risky for me to try for a vbac but I would be carefully monitored and if I was not progressing, after 8 hours in established labour I could have an EMCS. No help to me as I didn't even progress to more than about 3 bloody cm over the 2 days anyway! So in theory the same thing could happen.

I'm embarrassed to say I ended up storming out as the consultant wasn't listening to me and was just repeating that a cs is very risky and it would be safer for me to at least try for a vbac. He said an appeal would take ages and I had to go back to my gp but wouldn't really tell me any more so I just left.

I saw a GP at my surgery straight afterwards who said he could understand why I would want an ELCS and would support me, but didn't know how the appeal process worked either. Nice guy but clueless.

I'm a bit worried about the PSTD diagnosis as I have a history of depression and when I went to the doctors and got referred I don't think I specified that it was purely down to my birth experience. It may be on my notes as general depression/stress/anxiety. However, the counsellor should have my notes from my first session which was talking about my extreme anxiety of horrible vivid accidents happening to ds, which was a direct result of my birth experience.

I don't know if the CBT would have helped as after the initial 2 sessions my brother was killed and the counsellor agreed that the cbt was best put on hold as I was obviously consumed by my grief. I still am to a certain extent as it was only just over a year ago, which is making this whole situation even more difficult to deal with. I really don't need this now.

I'm seeing my MW on Friday to discuss the appeal and hopefully she will know what I need to do. And hopefully back me.

I'm willing to travel to a different hospital if necessary - would this be possible then? Do I just approach another hospital?

See what your MW says, she might have come up against this before.

What that second consultant was saying makes no sense - how is it better to arse about for 8 hours then go for an EMCS? Surely a planned section is far better, particularly considering the stress an attemped VBAC is likely to cause you? It seriously pisses me off the way they just dismiss the psychological element of situations like this, as though your stress and worry now and when you're in labour mean nothing. On balance an ELCS seems infinitely safer and more sensible but of course as he couldn't give a shit about your mental state he's just looking purely at the physical side of things. But, even then, I thought a VBAC was pretty risky, not actually safer than a CS at all? Could be wrong there though.

Ok I think they are setting you up to fail in all honesty.
With such a (not clinically indicated or evidence based) time limit imposed, the chances of you labouring peacefully and successfully are slim and risk of emcs or other intervention high. With increased risks to your mental health. If you want to PM me I am happy to help you draft a kick ass letter.I have worked in NHS as well as used their services

I think you have a very strong case for an elective, don't let them bully you.

It is technically better apparently for you to labour then have a 'non-emergency' caesarean, which is effectively what your consultant is offering you, even though he sounds like a total arse!, rather than go for an elective section straight off the bat. (Sorry - what kind of phrase is that lol?).

The labour is good for you, the baby, the hormones? Is it something you would consider? Your consultant is giving the option of you a CS if it goes on too long or if it obstructed in any way? According to Michel Odent, a French dude who is known for trying to help birthing women, this is the second option to a straightforward, simple birth, because you are still loyal to the process iyswim, you just get the baby out a different door (confused).

Peanutdream you said "It is technically better apparently for you to labour then have a 'non-emergency' caesarean, which is effectively what your consultant is offering you, even though he sounds like a total arse!, rather than go for an elective section straight off the bat. (Sorry - what kind of phrase is that lol?)."

Two things.

a) The OP has made a decision. She is clearly an intelligent woman and wants a repeat CS.
b) NICE analysed the risk of VBAC versus repeat CS and VBAC has slightly poorer 'QLYs' i.e. overall slightly poorer outcomes. Elective (non-emergency caesarean) has much much lower risks than emergency caesareans.

OP, you are dealing with a shower of incompetent idiots at the hospital who wouldn't know good practice if it smacked them in the face.

Suggest you write a letter to the chief executive of the trust - copy to the local paper - pointing out how the hospital ignores NICE guidance and tries to force women to make choices that put them and their baby at higher risk just because it cannot manage its budget. (The only reason they want you to have a VBAC is that it is marginally cheaper in the short term. )

I'm sorry ..they are evil, uncaring mysogynists.

Very best of luck

www.birthrights.org.uk/

Contact this organisation. There are people there who can help you put an end to this sort of unreasonable bullying. An appeal process is ridiculous for this sort of situation! Its as if you were asking for cosmetic surgery?.

Labouring and then having a section can be a very risky strategy because once the baby's head engages fully and enters the birth canal, then they either pull him/her back or they tell you it's too late and you better push. That is not a place I would like to risk being.

Anyone I know who has has an emegency and a planned (including me) says the planned section is a completely different and far superior experience.

I would bypass the midwife and get to another hospital / consultant. She may be on your side, but I'm not sure how much decision power she has. What you need is a hospital/consultant who can support you.

Hi Ushy in response to point a) omg absolutely, OPs state of being not remotely in question, and I wish her the very best of luck getting what she needs.

As for point b) according to the RCOG green paper update for VBACs, the risks/outcomes are not as black and white as you put it. It depends on your starting point i.e. who you are, who your baby is - boy or girl, how big your baby is, risk factors for various risks of vbac e.g scar rupture, risk factors for c-sections eg obesity, what you are happy to risk eg difficulties breastfeeding vs pelvic floor issues, what births you have had before the list goes on and on and on! It's worth having a look to make your own personal decision based on what exactly you are prepared to risk.

Just to clarify, I think Monsieur Odent's point is that it should be easy to tell (if the midwife/doctor is paying attention) whether there is an obstruction or not by how its going, and at any sign of dodgy goings on a c-section should be done without hesitation. In which case, the baby/mother gets the benefit of having the labour to kick off all the hormones etc...

Anyway, I just wanted to share some info as I know how hard dealing with our current system is. Good Luck OP! Hope u get your CS x

Peanut sorry, I reread my post after I clicked send and it seemed as though I was criticising you. I am sorry about that it wasn't intended - I shall try to read my posts back properly.

What I was getting at is that NICE looks at the overall risks and benefits of a procedure and rates in on a so called QALY scale. So if you add up all the risks and benefits, the average women and baby have a very slightly better outcome if they have a repeat caesarean. (There isn't much difference though but it marginally favours repeat c/s).

But you are right, there are individual factors that make VBAC more or less safe. However, the OP has only had a previous emergency c/s so she is in the higher risk group for not having a successful VBAC. Plus she doesn't want one.

I just think it is scandalous that she should be encountering mindless opposition from health care professionals particularly when national guidance says this should NOT be happening.

No problem Ushy :) It is scandalous. The same RCOG paper has a list of things that are supposed to be discussed with women regarding the decision to have a VBAC or repeat c-section. They were not discussed with me by my consultant and I suspect think that is the same everywhere .

I only actually bought it up because there was some confusion as to why on earth any consultant would let a woman labour for eight hours first. There are reasons apparently, and in fact some women would rather labour if it has been agreed that in the case of any obstruction, a c-section (not necessarily an emergency one) be performed sharpish. I wondered if the OP might like another chance at labouring if she knew that she could have a section at the end if it wasn't working again.

It's worth knowing that u can say no to aspects of medical practice while accepting parts that you are happy to. It's something to do with not technically being a patient but a labouring woman.

Am so sorry to read this.My first child was born at 33 weeks and died 2 weeks later(vaginal delivery).7 years later when pregnant with ds1 I requested a section and was told to see how I go...ended up with Emergency section for failure to progress.Over 7 years later requested section for ds2 and had no problems and had elective.Ds2 was born in Republic of IRELAND.tHE OTHERS IN uK.

Thanks for all the supportive responses...

Will reply properly later on when have time. I'm seeing the midwife this afternoon, really hoping she'll be supportive but I've got a feeling she'll be pro vbac...

Best of luck...it is not on! You should have the choice.Please let us know how you get on.x

Hey, how did you get on? This happened to me in 2011.....I was promised a repeat c section and at 34 weeks the consultant started telling me this was impossible and not hospital policy. It was very traumatic and ruined the end of my pregnancy (even thought I got my c section in the end) so I can understand how you are feeling. NICE guidelines suggest that all women who request c section for any reason should be treated with respect and if after counseling are still not happy with a vaginal delivery their wishes should be respected. The evidence is that VBAC should be treated on a case by case basis as the pros and cons aren't clear cut. There is in fact mounting evidence that elective section for first and second pregnancies is an increasingly safe alternative (although obviously not without risks which should be explained), so it should in theory be getting harder for doctors to refuse. However there is a back lash against this attitude as many obstetricians and most midwives wish birth to be as non medicalised as possible, and as such there is lots of pressure to "get c section rates down". I am a doctor as well as a mother....sadly these decisions also involve funding.....PCTs don't automatically fund VBAC anymore (even though in the long run it is no more expensive for NHS once you consider conversion to emergency c section and pelvic floor damage associated with vaginal delivery) so your consultant has to apply for funding for each elective section he or she requests. However the fact that your GP will support you stands in your favour. I agree if you have not already done so going to PALS and quoting NICE guidelines as well as your GPs support is a good place to start. Also make it clear they did not in any way make it clear how an appeal process would work. State that this is to be your last pregnancy so benefits of VBAC to future pregnancies are not relevant in your case and as such it is not in your best medical interests in terms of mortality and morbidity for either you or your baby. If that doesn't work then threaten to report the hospital to the department of health and to the press for denying your autonomy and promoting a service that does not comply with current guidance without giving you clear explanation. Stories like this make my blood boil and make me embarrassed by my own profession. Good luck x

Your story sounds similar to mine op. So I will be watching this thread with interest. I am also requesting a ELCS but I am at the early stages of the process only having had my 12 week scan last week. I cannot go through what happened with dd again and know the risks involved in a ELCS, I am fully informed but very upset already at the fact that I am being treated like I am on a conveyor belt rather than as an individual..but I know it is going to be a fight. Can I ask which hospital you are at? I cannot believe they put women through unnecessary stress and upset following traumatic experiences though I know they have to have a process. I feel it is just unnecessarily cruel.

I apologise for not reading all posts in full but I felt I had to post.
An ELCS is safer than an EMCS in every single case, always.
An ELCS is the safest mode of birth for the baby and marginally more risky for the mother than a straightforward VB, but the risk of an EMCS is very much higher for both.
If your community midwife is sympathetic or you can get your GP to get his arse in gear, simply be asked to be referred somewhere else.
You should not have to fight on this.
This is about money and C-section rates (the targets for which have been withdrawn by the World Health Organisation as outdated and irrelevant) and not what is best for you.

Contact the Birth Trauma Association, they are extremely experienced and very knowledgable. I am sure they will help with the appeal.
Get the NICE guidance and quote it, get a statement from your counsellor and your GP in support and your midwife.
This should make them back down because the worst case scenario for them and for you, is that they insist on a VBAC against your express and documented wishes and then something goes wrong. The hospital would be absolutely vilified in the courts and I should think the consultant would have a case to answer to the GMC as well.

This drives me mad. Women are supposed to have choice in labour and childbirth.