Is my logic correct in ELCS vs. vaginal birth?

[EvelynSalt]

I'm due to give birth this year and whereas I've just always assumed I'd go for a vaginal birth, I'm leaning towards ELCS. I'd love your opinions on whether my logic is sound or flawed, as I'm really struggling to know what the right decision is.

With such chaos and backlogs in the NHS at the moment, staff shortages, increasing COVID rates etc. my thinking is that ELCS would be a safer option as it's more medicalised than natural birth.

Normally I wouldn't necessarily feel that's a positive, but I'm really scared of having a complication through a vaginal birth which then isn't treated properly afterwards. I haven't had great experience with OBGYN here in that a lot seems to be brushed under the carpet as "just one of those things women have to deal with". If you've had good experiences with after care from tearing, incontinence etc please correct me...I'm so confused at the moment!

Many women experience more issues establishing bf post section - it is thought to be to do with how the hormonal cascade is promoted (or not)

Having a spinal anaesthesia comes with the risk of someone pushing a needle into the space by your spinal chord. Epidural headaches can persist for months.

Catheter related utis are one of the most frequent and problematic hospital-acquired infections. These can be antibiotic resistant.

These are all risks that have to be weighed up. In many cases the risk is outweighed by the benefits. But it's not a no risk situation and shouldn't be advertised as such.

Statistically breastfeeding is adversely impacted by having a CS versus a VB according to peer reviewed research. If you look into it eg Google scholar some reviews you'll see there are lots of factors involved but that's the population level stats. Doesn't mean it's impossible by any means but might make it trickier than otherwise would have been for you to get off to the best start.

Just a few further thoughts based in the points people have raised:

• I had one consultant and one midwife throughout for both, but did occasionally see a different midwife. My consultant couldn't do the second birth because she was on holiday.

• i arrived at 7+8 am and babies were born at 10+11. I waited in a comfy side room where my husband was given cups of tea (with my permission as I couldn't have any 😂)

• I pushed my own pram out of the hospital, got up to deal with baby fine after the first 2 nights (could for the second night but was slow) and was walking round the shops by day 3.

• meeting up with nct friends I'd had my baby towards the end/ ie most recent birth, and was better recovered and more mobile than most of those who'd had vaginal births a couple of weeks before me. Recovery was an absolute doddle.

I had to have a CS but was happier it ended up like that personally. Yes I had tummy pain issues, lifting first night, but overall I was happy not to have any issues down below.
I did try VB but was blessed with a doctor who knew when to call a halt to that.

@mishmased oh that’s awful, poor you.
I think I got a sip of water at some point. I just never envisioned that logistical part of the process ahead of time, and it never came up at any appointments so and wanted OP to be aware that the experience in its entirety is not quite like in the movies 🤣

Hmm that's difficult. I had a very straightforward VB and was absolutely back to almost normal a few hours later. Was really keen to go home and rest but remember waiting for the staff to check on dd before we got signed out. If I had another and could choose this 'perfect' VB I would. Saying that staff shortages meant no pain relief was easily available and it was very very painful. But I'd do it again on the basis that I was up and walking enjoying baby hours after the birth.

You can't really predict these things I don't think though.

Some women tear up to their anus, destroy their sfincter and are left with fecal incontinence.

Not wanting to roll the dice on that possibility is an entirely valid choice.

So is not wanting to roll the dice on being torn apart by forceps delivery, chronic pain, a fucked up sexual life, prolapse, PTSD.

Gimme the major surgery any day...

my understanding is that you are far more likely to have some kind of complication or long term negative effect from VB but the magnitude of those issues are generally considered low, not life-changingly awful in the majority of cases. complications in an ELCS are a lot rarer on average but when they do happen they are a lot more likely to be very serious. so there's no right answer and there's no safe option. it's a similar kind of choice to whether you spend £2 on a raffle ticket in a school fair where you might have a 10% chance of winning something worth £20 or spending it on a lottery scratch card where you have a 0.00001% chance of winning £2,000,000. neither is wrong, they are both a gamble (though the different levels of risk are a lot closer together in your choice).

but I do remember reading once that a higher proportion of obgyn professionals who give birth choose ELCS as compared to the general population.

Ideally you’ll go into labour naturally and have a good vb. If it comes to induction I’d just prefer a c section. But then you have to be lucky to be granted an ELCS at that late stage. So I’d just plump for section now and then hopefully you’ll go into labour and they can cancel the CS.

My induction was waaaaay too fast, very damaging. I know many people whose inductions have lasted 4 or 5 days then ended up in a section anyway. I’ve had 2 c sections and they were good!

by the way, chances are whatever birth you have you will end up totally fine, one way or another.

*Some women tear up to their anus, destroy their sfincter and are left with fecal incontinence.

Not wanting to roll the dice on that possibility is an entirely valid choice.*

This was me, and it absolutely was a reason for my two C-sections, medically advised.

If the OPs concern is an overstretched NHS then a vaginal birth is the way to go. With both mine I was discharged from my delivery room. I only had an overnight stay with my first because he was born at 9:30pm and by the time all the checks / stitches were done it was 11pm. They weren't going to send us home at that time and they weren't too busy (bonus of having a January baby).

It is also possible to have a vaginal birth and have no issues. I tore, but it was fine and no where near as bad as I thought. I expected terrible pain from tearing, but it didn't hurt any more than crowning and not tearing.

I have no issues with my pelvic floor. I birthed two babies over 9lbs as well.

I was lucky, low risk pregnancies and I'm fit and well.

If OP is low risk and wants to reduce time in hospital, vaginal birth all the way.

Here to say after 2ELCS I would whole heartedly recommend another.

I liked the Planned birth time and any Complications dealt with as part of specialised surgery aftercare

@EvelynSalt I saw a ‘birth choices’ midwife so see if there’s one in your team - this was for my 2nd birth though so after a big tear. Not sure there’d be much to go off for a first timer but probably a good person to chat through the options and your own circumstances with.

Also yes I was consultant led twice and saw the same doc throughout pregnancy, alongside seeing the midwives. They didn’t do my sections though.

@MadZott the spinal needle is supposed to go in the cerebrospinal fluid (space around the cord) - that’s the difference between a spinal and epidural. The needle used for a spinal is much smaller than that used for an epidural though so the chance of a post-dural puncture headache is lower (PDPH occurs after about 1:250 spinals, vs about 1:100 of all epidurals).

An ELCS is more predictable and I wish I'd had one.

I had a 'standard vaginal delivery'. Three hellish days on postnatal as I was in too poor a condition to go home, huge problems establishing BFing despite loads of support in hospital (baby ended up readmitted seriously I'll with dehydration), in a lot of pain for weeks due to tears that took a long time to heal. My pelvic floor sustained long term damage as a result.

I've had an EMCS and then a VBAC with forceps. I would opt for the ELCS without question!

Also once the anaesthetic has worn off and catheter is out wouldn’t you be able to get everything you need.
All be it very very slowly.

Hahahahahahahahahahahahaha. If only it were so easy.

The catheter typically stays in for at least the first night. I spent 18 hours after my first section sitting in a pool of blood. After the surgery they had shoved a maternity towel between my legs but without pants to keep it in place, they might as well not have bothered. Even after the anaesthetic had worn off and I could move my legs, I was in so much abdominal pain I couldn't move apart from to reach my arms out to reach a water bottle. It took about a week before I could even turn over in bed or sit up without having to use both hands and arms to push myself up (no core strength as it had just been cut through of course). I had to position myself and someone else had to pass me the baby every time he needed a feed.

Second time around was slightly better because I knew what I was in for and I asked to get up and go to the bathroom once the anaesthetic had worn off (catheter in tow, but I wanted to freshen up) and it also gave them a chance to change the bed sheets.

Overall it was 'fine' and overall I don't have a prolapse, but I do have a tummy overhang. However, don't underestimate how bloody hard those first days are, and you can't even prioritise yourself and your recovery because you have a baby to deal with.

A c section is not to be chosen lightly.

My (uneducated) point being that no needles anywhere near my spine and no chance of a headache or worse is my preference.

Those risks seem quite high to me. I have previously known women floored by those headaches, and one who had to be readmitted and lie flat for really extended periods of time, with a newborn.

As I say, I'm not against intervention and would have taken anything. But to plan and choose to be more messed about with when your motivation is concern about resources, staffing, quality and availability of care...all seems counter intuitive to me.

I also found the midwives were incredibly biased - I stupidly assumed that if a CS was a better option for me midwives would suggest it (no one mentioned you could choose it for yourself) instead all I got was loads of pressure to have a home birth or use the midwife-led unit, neither of which I wanted.

I'd be a bit wary of having an honest discussion with one about birth options as they weren't giving out balanced information about risks or listening to my priorities.

@FoxtrotSkarloey but are you comparing your CS recovery to VB recovery?

With my "straightforward" water birth DC1, I was mobile straight after but sore AF from tears and stitches in my vulva. Walking put pressure on that area and was not without pain.

I'd also spent the best part of 3 days in labour so was incredibly sleep deprived and had to call DH to come in the middle of the night because I was hallucinating with sleep deprivation! Compare that to the ELCS where bub was latching on the boob 45 mins after they got me into theatre...

I've had both VB and ELCS and with both, the recovery is a challenge.

But the main thing is that - AFAIK - those maternity trusts with excessive maternal and neonatal deaths were due to MWs withholding CS births from women whose VB was going off the rails and needed surgery. EVERY SINGLE ONE.

So in the risk-benefit analysis, if staffing ratios are OPs concern, she and baby are almost certainly safer with a CS.

@WoolyMammoth55 No, no comparison. I was just responding to the comment 'wouldn't you just...' which I couldn't quote as it was already a reply to a quotation. It definitely isn't that easy. Even though overall I consider I had quite an easy time of it, some aspects were awful and depressing and I wouldn't choose to go through again.

Everyone has a different experience. Literally no two births are the same and you don't know beforehand what you will get, which is why it's such a hard decision for the OP.

Ok so positive story for NHS aftercare following a vaginal birth here.

I had a 3b tear during my son's birth as he came out at a funny angle (amplified I think by an old anal fissure) and was repaired in surgery with a spinal as anaesthetic.

The surgeon did an incredible job, I was seen by a consultant and a physiotherapist in the weeks that followed (this was during lockdown 2 in 2020) and I have absolutely no lasting problems. It's as if it never happened.

I feel like if there's no medical necessity for you to have a c-section then it's better to try for a vaginal birth.

Emily Oster's books are excellent re weighing up the evidence and how good the research is, as well as what it actually shows. She doesn't tell you what to do, just sets out what the research shows.

But bear in mind she's not in the U.K. so different hospital environments etc

I've had two vaginal births, both ventouse, both tore, stitched up with no issues. Third was an EMCS and recovery was fine, I didn't struggle with anything. I felt less pain that the vaginal births to be fair (after which I felt like a donkey had kicked me in the nether regions and every muscle ached from pushing). The only bit about the CS that I hated was the fucking overhang I've been left with that no amount of exercise or diet will budge.