Second CS or VBAC?

[2margarinesonthego]

Hi All,
My DD1 was planned CS due to being breech, and I initially decided to go for a VBAC for this baby (DD2). But now I'm having cold feet for lots of reasons I won't bore you with.

I wondered if anyone had any pros / cons of going for either option. I feel I don't get the full story from medical professionals, IYKWIM.

Many thanks :)

The first CS was for reasons not at all connected to your ability to give birth. You did not labour.

If you choose to labour, this time will be the first time as far as your womb is concerned. The likelihood of needing intervention would be the same as any first timer. Spontaneous labour is most likely to end in a straightforward birth. Not being admitted until labour is well established is very helpful.

The existing scar on your womb is a consideration but a minor one in terms of risk.

main areas of consideration
: are you fearful of giving birth vaginally? Lots of women are but manage to overcome this and are pleased they did. Would something like hypnobirthing be helpful?
:are you thinking of having more children? Although an individual cs, especially elective, is a pretty safe option, repeat cs after 2 does start to multiply complications and can lead to difficulty in conceiving.
: recovery time, with a toddler. This is very variable. Some women think elcs is easier than a first vaginal birth, others the opposite!
: is it an issue around birth timing? In my unit, some women book an el cs if they have not laboured by eg 41 weeks. This gives them some control.

I had EMCS with DS1 and wanted VBAC with DS2, went into labour spontaneously at 41+4, was 7cm dilated by time I got to hospital. All seemed to be going well, got to 10cm within a couple of hours. Membranes had to be ruptured by MW. Baby's head had not descended into pelvis and evidently was not going to! Ended up with another EMCS
12 days on I can honestly say I feel fine. Wish I'd gone for ELCS all along. I guess what I'm saying is go with your gut instinct, I wish I had!!

Good luck OP

I had planned a 2nd c-section right up until 36 weeks then wavered, then went with a VBAC. I spent the whole pregnancy ready every single scrap of information I could about it for & against.

In the end I went into labour 11 days overdue, the night before I was scheduled for waters breaking then a c-section if that didn't work. It was horrendously painful, ended up with forceps which hurt ds2 then a pph where I just avoided a transfusion to their surprise.

But even with all that I was happy with the birth I had because it was my decision. If there's a next time I feel I've done the natural birth and will be asking for a c-section quite happily!

There is so much information out there for and against that I think the way to feel the best about the method is the one you feel strongly about. If I'd felt I had to have a VBAC for external pressure issues I would've been really unhappy at the way things turned out.

I'd go for vbac with a very low threshold to proceed to CS (ie if any need for induction/ augmentation ). That was my plan with DS2. unfortunately he needed to be delivered early, and induction was not going to be safe for either of us. It is unlikely now that i will ever have a vb.

It seems generally that recovery from an elective or early emergency CS is often easier than a vb (other than very straightforward ones with minimal tearing). 2nd time round my recovery was fab. Driving after about 2 weeks, lifting my 3 year old after about a week.

If this is likely to be your last baby i would have a section. If you're planning more give a vbac a shot. I've had three sections and the third pregnancy was complicated due to the previous two sections. My third section was also tough going recovery wise and I've been advised not to have any more children.

This will DEFINITELY be my last baby.

Birth timing is a massive issue due to childcare; basically if I don't go into labour at 39 or 40 weeks then I will be labouring on my own... I'm sure lots of people have similar issues though so it seems somehow mercenary to be planning the type of birth around this.

I have had high BP all way along controlled with labetalol but it is now going up and I have other signs of PET (which I had with DD1 also)... Would this affect the actual labour?

I desperately want to avoid an emergency CS especially if I am alone which is likely.

Yes I'm fearful of a VB but then so is everyone I guess. I put off pregnancy til 34 because of this I would probably opt for a water birth if an ELCS wasn't on the table but am told it is unlikely as baby needs to be continuously monitored and there is only one wireless monitor.

Thanks all for your feedback it is really useful in my decision making.

I had a straightforward and intervention-free home VBAC in February and found it much less painful and much faster to recover from than the EMCS I had with my first baby. Is it really necessary to have continuous monitoring? I had to be upright and mobile in labour and for delivery - I couldn't have been on the bed. I would be put off by this if it was 100% required - but I would get more information about why it is necessary and ask them to consider whether intermittent monitoring would be just as good.

A good friend of mine also had a VBAC in February a week after me, and also had a positive experience although a very different birth - she had a hospital birth with induction and an epidural, but overall was happy that her wishes were listened to and she was consulted at every stage. She also found the physical recovery much faster and easier with this birth than after her section.

PS I second the idea of looking into Hypnobirthing - I found it brilliant.

I had a VBAC after EmCS. I had pre-eclampsia the first time so was induced and it ended in the EmCS.
Because I hadn't experience any labour pains (had epidural straightaway to bring BP down, which it didn't) I was determined to have a VBAC. I wanted to know what labour was like. I spoke to the consultant midwife beforehand about the monitoring and requested that they only use a doppler. In the end I had to have the other thing but it was up to the midwife to keep it on me as I crouched next to the bed. I also insisted on no canula at the beginning which they did comply with.
Unfortunately after only having had gas and air, I ended up having a spinal to sew the third degree tear. I was so pleased to have given birth naturally although the recovery was worse that for the EmCS.
I am having an ELCS this time round. And if my BP was going up, I would deffo have an ELCS. I think your BP goes up in labour anyway - but i could be wrong.

All the best, i hope that your BP behaves itself.

I did enquire about a home birth (because my experience staying in hospital with DD1 was pretty awful, even though the ElCS itself went really well) and was told it wasn't possible at all. The VBAC consultant I have seen told me the baby has to be continuously monitored all the way through, and I will also have to have canula in in case it turns into an EmCS. She also told me some horror stories about what will happen if it turns into an EmCS.

I feel absolutely clueless tbh. I am definitely swaying towards an ElCS. I'm really not bothered about experiencing labour... I don't want to put the baby (or myself) at risk. The only bonding and BFing issue I had with DD1 was that my milk took a couple of days to come in properly but we got round it.

THere are so many pros and cons, it's hard to make a list. But my second emergency c sec (had planned for vbac) was a lot easier in terms of recovery than first one. It's so different from person to person, it's of no help at all to you...

Looking back I would have gone for planned c sec, but hindsight always comes too late!

Second emergency c sec was much easier for me. I knew what was going on and there was not so much emotional issues to deal with. I only laboured for 8 hours (it was 24 hours for previous emcs) and I was up on my feet very quickly. Breastfeeding went much better after second emcs. I had all the right things in my bag (ie LOTS of snacks and fruit juices!). It was a lot less stressful than first one.

I'm in the same position (although Induction/EMCS for first), and I'm going to have a frank conversation with the VBAC midwife in a few weeks as I'm not confident that I'm going to get the chance to have the birth I'd prefer if the consultant is involved (consultant was rubbish - explained nothing, didn't listen to my concerns, thrust a leaflet at me rather than answer questions etc).

IF the VBAC midwife says that it's likely that I can get what I want (no induction, no augmentation, mobile monitoring, no canula until I actually need it, minimal interference) then I'm happy to go for VBAC (with low bar for C-Section). If the consultant is going to be the one in charge, then no dice.

I don't want to spend my labour fighting to be left alone.

Oh, and despite having been induced for nearly 3 days, my EMCS was fine to recover from - on my feet and going to the toilet in the morning (had EMCS at 10:30pm), home 1.5 days later, and going on short walks within a week.

The EMCS itself was unpleasant, but I certainly wouldn't describe it as a horror story!

I planned to try VBAC after an emcs. Like spreadsheet I spent whole of 2nd and 3rd trimester researching it, had 3 appointments with consultant (so non committal and not that much help) Eventually agreed to try VBAC with quick intervention if it went wrong) .DC2 was 2 weeks late and they wouldn't induce due to previous placental abruption/ I didn't want a sweep as felt if baby wasn't ready why bother. Has an elcs at 42+3 weeks. DC2 was 10lbs and they said would never have descended through pelvis! Basically all that worrying and planning went out if the window! I'm expecting DC3. No probs conceiving and will be hacking an elcs this time. Whatever you decide, I know it's a hard decision (I wanted someone to just decide for me!) in the end what will be will be so try not to get too stressed. It ruined my pregnancy in a way. This time I can just relax (once i stop this hyperemesis malarky!) and think about meeting bubba rather than worrying about how I will meet him/ her!

The VBAC consultant I have seen told me the baby has to be continuously monitored all the way through, and I will also have to have canula in in case it turns into an EmCS. She also told me some horror stories about what will happen if it turns into an EmCS.

I don't think she can say 'have to be' and 'have to have' - treatment without consent is assault, as I understand it. You are still entitled to say no, even if they don't agree.

'Strongly advised' would be a better term, but that would require her to tell you why, and give a better answer that a tale of horror about what might go wrong, or 'protocol'.The hospital might be bound by protocols but the patient isn't.

LaVolcan - yes, in theory they're not supposed to speak like that, but in practise that's exactly how mine spoke too ('we will allow you to go to 41 weeks, then we will rupture your membranes and we will put you on a drip, you won't be allowed to do X') etc. No discussion, no explanation, very proscriptive (and ignoring my very firm, "No, you won't")

The VBAC midwife in contrast assured me that even if I was being continuously monitored with wired monitors then I wouldn't be nailed to the bed - that they knew that movement in labour was very important and that long wires, wheelie trollies and accommodating midwives

I had DS1 by CS due to breech position too. As CS go it was very straight forward and calm but going up stairs/pushing buggy was quite hard. Also didn't like taking lots of dugs which may have made BF'ing tricky initially. No real complaints though.

DS 2 - VBAC. Drip induced due to broken waters. Fast labor at only 4 hours. Straight forward otherwise. I was very frightened though (my first VB) and had relatively close monitoring. Very quick recovery though, much better then CS and I quietly felt a real sense of achievement.

DS 3/4 - VBAC. Both normal straight forward labors lasting about 4/5 hours oddly and using gas/air. Less monitoring, much less fearful and lots of fab birthing positions. Seemed really natural and instinctive. Easiest and least painful births. I wish all my births had been like this.

first child was cs because of breech position. dh nearly fainted when at first meeting with consultant after giving birth I was asking about vbac for next child!
decided on vbac for dd2. weighed up everything - healthy, didn't have narrow pelvis, family history of fairly easy deliveries (mum, sisters), didn't do too much reading up as I didn't want to get bogged down with too much information.
in the end laboured for about 4 hours, tore a bit but everything was fine. mid wife was fab though.

greenformica, that sounds interesting: my DC1 is still quite new and was emcs due to onset of labour and baby's position.
I'm desperate to actually give birth, so want a vbac next time, but have been told of the difficulties of vbac combined with induction (I would be induced due to pre-existing med. condition).

What happened with your DS2 and the induction? Were the drs. worried about inducing you? Was your scar ok? How long did you leave between pregnancies?

I haven't read all the replies but here is a brief synopsis of my history.

Horrid delivery with DC1.
DC2 - ELCS because of third/fourth degree tear from DC1's birth.

With my 3rd pregnancy, I went to see consultant who assumed I wanted another ELCS. I had been wavering but burst into tears at the thought of it. Said no thanks, hired a doula to make me feel brave and had a great VB on gas and air. 7 hours - 9lb 5.

DC4 had another VB - 4 hours. Gas and air. 10lb 14

I definitely recommend a doula. She helped me (and DH) approach it positively. I also felt confident that she wasn't anti CS and would talk me into having one if things got hairy.

If you're not bothered about experiencing labour, and you are worried about labouring on your own if you haven't had the baby by week 39-40, then what are your "for" reasons for a VBAC?

I had an ELCS after an EMCS and all was well for me and I was happy with my decision. I guess there is a tiny pang that I've never experienced a vaginal birth (I did experience labour/contractions/pushing etc but it ended in an EMCS) but that wasn't enough to make me want a VBAC after the EMCS. The recovery from the EMCS was fine but the ELCS was even better as I was far less tired and hungry than when I ended up having the EMCS.

Maybe have a chat with your consultant again and ask what the implications are if you do develop full PET.
I had an emcs for PET the first time and this time, have been told that if I develop PET again then I will need an elcs as they wouldn't induce me, due to previous section but if I labour naturally then I could have a vbac if I wanted, with low threshold for moving on to a section.
Not sure that much help, both options have pro and cons which in my mind almost cancel each other out, so part of me is just waiting to have the decision taken out of my hands.

I don't know if this helps. I dithered about VBAC and ELCS, saw three different registrars [consultants kept failing to show up] after having an EMCS for failure to progress. Eventually I contacted a family member who is a consultant obstetrician and got the following response:

Questions from me.
It's been indicated already to me by a registrar that notes from the first delivery re narrow pelvis/difficulty ascertaining dilation etc put my chances of a successful VBAC at 50:50 rather than 75%. My mind is nearly made up therefore to stick with the devil I know given those odds, rather than risk all the complications that a normal delivery brings or a repeat performance. I understand though that a failure to progress would be declared a lot earlier this time around if applicable.

My key concern is this - I am in my late 30's, while it is unlikely that we will go for a third child the risks of a 3rd C/S plus the recommended 2yr break between sections would pretty much rule it out entirely if I have a C/S now. A successful VBAC would possibly leave the option open if I were mad enough.
So the question is this - is a scheduled ELCS likely to result in less uterine damage (lower risk 3rd section) than an EMCS carried out on a contracting uterus for failure to progress? Or is it entirely irrelevant generally speaking? I appreciate that's entirely subject to the latter being a repeat scenario of my first C/S - no foetal or maternal distress and you have not seen my notes so I am asking for a theoretical response but I would appreciate your opinion.

Answers

1. I would disagree your odds are 50%. If your next child was facing right way next time then your odds would be closer to 70/75% if you labour spontaneously. No one will know that until you labour so even if she was OP (back to back) before labour they often turn once labour starts. As doctors we are terrible at diagnosing narrow pelvises etc so I would ignore that comment. it is subjective and not helpful.
2. You are correct. if you laboured again you would be given usually upto 4 hours. if you hadn't progressed then usually a section would be done so no long delays like people often have with the first because of the risk of scar rupture (approx 1 in 250 but I believe its rarer than this because we tend to bail out early).
3. I wouldn't blame you for wanting an elective section. A first delivery like that is traumatic but the odds for a successful vaginal delivery would still be in your favour should you chose to wait and see.
4. No one will ever tell you 1/2/3/4/5 sections is safe but the reality is every day I operate on women with 1/2/3 and often 4 sections. They can be difficult (from my point of view) but the risk of a serious complication or bad outcome is very low. I would say less than 1% in women with 2/3 sections so to have upto 3 sections first of all is very common nowadays and generally quite safe.
5. a section is a section is a section so elective or emergency/ urgent would have no real difference from altering risks of a subsequent 3rd section. Emergency sections do carry with them increased blood loss etc but overall still I would say would are generally very safe.

6 Similarly the 2 year wait is an ideal and we see it broken the whole time without consequence. Section or no section if you ask doctors will probably say even if you have a vaginal delivery for number 2 you probably should wait but again we really don't know that ideal time. 6 months for sure but probably 1 year is ideal before trying again regardless of what the mode of delivery for number 2 is. I don't think a 2 year wait is based on very scientific evidence so I would be happy with 1. So overall I would reassure you, whatever you opt for is safe and I would opt for whatever you're comfortable doing. If a vaginal delivery is important to you then go for it. Odds of success are still in your favour. if the worry of a vaginal delivery is killing you then opt for elective section. Either option is generally the majority of the time very safe and an excellant outcome is what I would expect either way.

In the end I opted for the ELCS as it was the devil I knew and I wasn't too fussed abour experiencing natural labour. Waters broke early, had a fast labour and a VBAC with forceps delivery in the end. Some "minor 2nd degree tears". The recovery from my first EMCS was much faster so I wish I had been able to have my planned ELCS.

These are questions I prepared for my meetings.
VBAC

1. Pain management during VBAC ? are my pain mgmt. options more limited due to link between pain in scar area and rupture, or is monitoring a sufficient indicator should I require an epidural?
2. Among women who attempt a trial of labor after prior cesarean delivery, what is the vaginal delivery rate and the factors that influence it?
3. What are the short- and long-term benefits and harms to the mother of attempting a VBAC after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
4. What are the short- and long-term benefits and harms to the baby of maternal attempt at a VBAC after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
5. What are the non-medical factors that influence the patterns and utilization of VBAC after prior cesarean delivery?
6. Is continuous monitoring mandatory and if it is, or I prefer to have it, are their facilities to be monitored in a birthing pool at this hospital?
7. www.childbirth.org/section/VBAC.html
8. Should I plan for early hospitalisation ? ie if waters break or contractions start naturally to allow for monitoring. What is the general practise in this hospital? ELCS
9. Who will be my surgeon? Can I request the same surgeon as I had before? Are trainee surgeons allowed to carry out ELCS's? Presumably not allowed to carry out EMCS's?
10. What are the risks of repeat caesarians? What would be an optimum number of children to stop at in order to statistically avoid a high risk pregnancy eg: placenta previa, or post op complications eg: hysterectomy
11. My first CS was entirely complication free but what are the key maternal risks I should be aware of with an ELCS and at what rate do the incidences of these types of injuries rise with multiple caesarians. eg bowel injury, ICU admissions, post-operative ventilator use, cystotomy and more?
12. What are the key risks to the infant I should be aware of with an ELCS?
13. Under what circumstances are forceps used during a CS and am I at higher risk of this use as part of an ELCS if the baby has/has not descended?
14. Will my post op recovery period be longer with a second CS? Internally due to repeat surgery or shorter due to fewer drugs, lack of labour etc?
15. Will the incision be in the same spot or will I have two scars?
16. If I go into spontaneous labour, and there is no medical reason not to try for a VBAC, what are the decision criteria for recommending I progress to a CS? My BP or Fetal distress is an obvious one, is there a time period after which Failure to Progress status is conferred?

Really interesting to read all of this as I have been mulling over the very same question.

I think I am veering towards another ELCS (first one was because DD was breech), because, as someone said upthread it is the devil I know.

I also am thinking about my due date which is sometime around Christmas, and the effect that might have on my DD, who will be 3.9 and therefore really excited about her Christmas day. If I can't be there because I have gone into labour I would feel absolutely dreadful for her (and me!). But I don't know if that's too 'shallow' a reason to have asecond ELCS?