Elective c-sec - best to wait til labour naturally starts?

[Posey01]

Hi all - I've got a 'date' booked in for my elective c-section as baby is breech...the date is a few weeks ahead of 'my' dates (scan dates I feel are at leasy week out.) Is it best to wait for natural labour to start or just go in on the date i'm told? Thanks :)

Its best to talk to the consultant about why you feel your dates are accurate and why theirs are wrong rather than asking a bunch of people on the internet about a medical issue such as this.

We are not privy to the information that has led them to believe you are x number of week and to suggest you wait for natural labour under those circumstances would be wrong.

I think the issue here is more that you do not want an ELCS and are trying to somehow avoid it. Again I would suggest you discuss those concerns with your consultant and whether there are other option available to you.

A c section when you're not contracting us, I understand, far more straightforward than one when you are contracting.
Why would you not go in on the date you're booked in for?

You go in for your c-section on the date they've given you.

They book you in a couple of weeks ahead of your due date because they don't want you to go into labour.

Having a labour before a section is better for baby (breathing wise) but there are risks and your planned section then becomes an emergency. They should be booking your section after 39 weeks which reduces risks of breathing difficulties for baby but if you go into labour before then you ring and go straight in. I had an ELCS last time for breech and am booked again this time if the little blighter doesn't turn! I would prefer to labour before hand but the risks of that outweigh any potential benefits for me (mainly as baby is.footling and wouldn't want a vaginal birth which you risk going into labour).
Discuss the practicalities with your consultant.

Thanks Lumpy...But yes it's because I'm concerned baby won't be 'ready' by 39 weeks (as potentially they can go on for a few more weeks can't they) but I guess the risks outweigh that really.

Thanks for all your advice-much appreciated- it's good to hear others experiences.

Seems like you have two separate issues here OP? The first is whose dates are right and whether, if their are wrong, that might cause problems. The second is whether EMCS (which is the name for a section performed after labour has started) would be preferable to ELCS.

Nobody here can tell you which date is right, but in terms of whether it's better to wait until labour naturally starts, the answer is not really. The breathing stuff is somewhat hypothetical anyway, there are some people who think some experience of labour is better for the baby but the actual evidence for this is rather patchy. The 39 week stuff is true though, so if your dates would put you significantly earlier than this at the suggested section date I agree with previous posters that you need to raise it. In general, ELCS is safer than EMCS. With an ELCS, the team can take their time. They're not having to worry about contractions, the baby being imminent or the possibility of you delivering vaginally despite whatever contraindications there were to make a section be recommended in the first place. It can be scheduled at the safest and best staffed time. And the recovery is generally acknowledged to be easier with an elective. I had a very emergency EMCS and it was tough. You're recovering from both labour and abdominal surgery. Not a road you want to go down unless you have to.

I don't think 39 weeks is even considered perm is it?

Mine were 5 weeks early by CS. They were teeny tiny, but they're a couple of strapping teens now.

Perm = prem

No, term is 37 weeks. I believe the likelihood of breathing problems is a little higher before 39 weeks though, which is why ELCSs are scheduled at 39 weeks when possible. Obviously sometimes it needs to happen earlier, and plenty of babies are born at term but before 39 weeks and are just fine.

How different are your EDDs then?

I had my due date put forward by a week. I then had the ELCS scheduled for 39 weeks (according to "their" date; the scan date) and was worried as by "my" dates I'd only be 38 weeks.

He was totally fine, and big! Full term is from 37 weeks, so I doubt you have anything to worry about - unless you want to negotiate closer to 40 weeks? I was desperate to get the kid out of me by 39 weeks anyway

It's definitely not better to wait until you go into labour, because an elective section is way more relaxed than an emergency section. And with a breech baby, you don't want to be taken by surprise by a fast labour and find yourself in a real emergency.

DD (my third) was booked in for a ELCS after two EMCS with my DSs. I went into labour at 37 weeks so she ended up being an EMCS too. Things moved very quickly because they didn't want to let everything get too far on. DD was absolutely fine but they clearly didn't want me to labour naturally.

Actually, the 'breathing stuff' isn't hypothetical at all. Babies born by section are less like to have breathing difficulties if the mother has laboured - the thinking being that the labour triggers a surge in surfactant aiding lung maturation. The risks are reduced if section scheduled after 39 weeks (mothers should receive steroids if elective prior to this to aid lung maturation).

Can you link some evidence? I've heard it postulated, but nothing else. For the bit about ELCS babies being more likely to have breathing difficulties, not the 39 week stuff which is pretty standard.

That should've said ELCS babies being more likely to have breathing difficulties than EMCS babies above.

Lol, I knew that was coming
If I was at work I could access medical journals in a minute and obtain off colleagues...but alas I am on mat leave ane can only rely on a quick Google scholar search ( I just Googled surfactant deficient lung disease elective section) which obviously doesn't have the same scope and most I can only read abstracts

www.bmj.com/content/336/7635/85
www.sciencedirect.com/science/article/pii/S0095510808000213

www.sciencedirect.com/science/article/pii/S0146000506001029

www.sciencedirect.com/science/article/pii/S0002937805007179

www.sciencedirect.com/science/article/pii/S0002937806006077

Effort very much appreciated anyway!

I saw the first one when having a look myself, but it's a comparison between babies delivered by ELCS and those who were intended to be delivered vaginally, ie that were born by VB and EMCS. Obviously can only see the extract, but that's not the same thing as a comparison between ELCS and EMCS. Wasn't able to view the second, abstract of the third doesn't mention EMCS at all. Fourth does, but without being able to read it I'm unwilling to assume they eg controlled for gestation: the average gestation for ELCS is likely to be earlier than with EMCS, for obvious reasons. Fifth is again about planned vaginal delivery and therefore is including babies born vaginally: indeed they presumably make up the majority of the cohort.

So while I'm impressed by your research skills in straitened circumstances, none of these are really proving the assertion. The appropriate comparison here would be between ELCS at 39 weeks and EMCS. Because OP is choosing between ELCS and EMCS, babies who were born vaginally aren't relevant to her situation.

Yeah, I don't know why I included the last! Well, we will have to agree to disagree as I have seen better research and anecdotally see it in practice (not just the 39+ weekers who have transient tachypnoea of the newborn due to lack of effective fluid clearance but ones who need surfactant replacement due to surfactant deficient lung disease) - albeit the risk of breathing difficulties is low after 39 weeks but they are still there. However, like I originally stated, the risks of emcs of a breech baby (especially with my footling!) do not outweigh the potential small benefits of awaiting spontaneous labour.

Good luck OP!

Thisnis the full nice guideline with little charts on expected % of RDS depending on gestation for planned sections.

www.nice.org.uk/guidance/cg132/evidence/full-guideline-184810861

The reference list suggests no 282 provides the evidence for this but I can't access that journal.

282. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995;102:101–6.

.

Thanks Simon. I can't access it either. Am I right in thinking, though, that nothing so far posted has been an explicit comparison of babies born by ELCS and by EMCS, at same gestation?

Actually when you are looking at the risks here, you need to talk about the potential risk of the baby arriving breech too.

You need to consider the risk of breathing difficulties at pre 39 weeks, the risk of breathing difficulties at post 39 weeks verses the risks associated with a breech VB delivery.

The fact is that ELCS are usually recommended over and above a breech VB delivery. A CS once labour has started is not recommended. Why is this?

I would suggest that whilst there may be a risk associated with breathing, its a) still very minimal b) usually very manageable if it does happen c) the risks associated with a breech birth are higher d) there is a risk that if you wait until spontaneous labour starts there are other risks e) if you want for spontaneous labour and are not already in hospital there are additional risks.

If waiting for spontaneous labour and then performing an CS was preferable, I suspect that this would be offered and women admitted to hospital for observation - as is the case in some other conditions - rather than merely performing an ELCS.

As a rule, ELCS are generally regarded as safe for babies, although there is the possibility of complications of breathing difficulties.

There are also other things to consider here. Due to most breech births being ELCS these days there are few hospitals with staff who are experienced and adequately trained to deal with an undiagnosed breech birth which also increases risks.

I think it is alarmist to be showing all these studies about ELCS v EMCS without looking hard at why ELCS are recommended in the case of breech births and considering what could go wrong if you did want for spontaneous labour based on evidence from studies which compare outcomes between ELCS and EMCS.

Remember though studies will be comparing studies for women having ELCS for lots of reasons which will include the majority of breech births whilst the women having EMCS will be having complications which may include undiagnosed breech births (the reason why its undiagnosed is relevant) and will rarely include women attempting a breech birth as this is now extremely rare.

This will mean that the studies will carry a bias which might not necessarily reflect risks accurately for the purpose we are talking about in this thread.

It does go back to my points above about what risks are largest and most problematic rather than looking at breathing in isolation.

Also, that BJOG article cited above that people can't access is from 1995, which is ancient history. The fact that there are no newer studies to cite, so systemic reviews, suggests that the demand for that research just isn't out there, i.e. it's not a pressing concern for modern obstetrics.

*NO systematic reviews

Jizzy, I don't think you will find any research that compares el lscs babies to em lscs babies and even if you did I would wonder what worth it would have.

Yes you could group same gestation babies together but what you can't calculate is how much stress the emergency section babies have been put under by labour, how much of their reserves they've used up and if they're suffering from a certain degree of hypoxia, whether they've been in acidosis.