Flexible private consultant at Chelsea & Westminster

[EPfds]

Hello,
I’m pregnant with my third and am trying to find a private consultant at Chelsea and Westminster hospital.
I’m considering attempting a VBAC but have some red lines that I would need the delivering consultant to respect in labour - which are:

• no IV/cannula unless it’s an emergency, I don’t want to labour with a painful cannula in my hand and never needed them before but was previously forced to have them.
• I’d probably still want an epidural, again, without cannula unless it’s absolutely necessary
• Absolutely no instrumental delivery or episiotomy, if things don’t work out on their own I want a c section.

I have PTSD from previous births because I was never listened to and already lost a child to an extremely premature birth at 24 weeks, as my entire pregnancy and delivery was horribly mismanaged. Subsequent elective c section was better but I again hated having no agency and feeling coerced into multiple unnecessary things, constant takings of blood for unnecessary tests and so on.

If anyone can recommend a consultant who believes in maternal agency during birth and would respect the above, I’d be very grateful.

I'm so sorry you've been through so much, especially the loss of your child. I don't have personal experience with this hospital so can't give an opinion on consultants, so my reply might not be helpful but didn't want to ignore.
Did you ever access a debrief after your births? Might be something to consider if not. What might seem like unnecessary bloods may have had an explanation behind it, it would be unusual to take blood for no reason. Someone going through all of your notes with you could shed some light.
Did you have a cannula in a very uncomfortable location maybe? As a Midwife I've never met an anaesthetist happy to give an epidural without a cannula. A side effect to epidurals is that your BP can drop quickly so you need IV access and IV fluids ongoing for that reason. That would not be possible for your obstetrician to ok even if you found someone supportive of your other wishes. I hope you get some more helpful responses than mine but just wanted to offer what I could.

From an anaesthetist... you will need to explore anaesthetic consultants as well as obstetricians. There (hopefully) aren't many anaesthetists who would agree to site an epidural without IV access secured (however, they should be able to explain why IV access is part of the package so you can make an informed decision re. whether to proceed).

@Lavenderandlemons thank you. Re previous tests - I know that in the run up to, before and after my ELCS the hospital insisted on literally dozens of blood tests that were entirely unnecessary. They just wanted to charge us for them. They even got a cardiologist consultant in who harassed me for hours after the section to have additional tests to “rule out” that I had a cardiac arrest during the surgery, which was ludicrous, there were zero signs that I had and ofc I did not. Basically, when I was under NHS care nobody tested me for anything ever and so tragedy struck. Once private, every test under the sun was forced onto me to bill me for it.

Regarding the cannulas - yes, sadly I’m aware that they are forced on women on maternity wards, but they should not be a requirement for an epidural. They can obviously be given ad hoc when required rather than in a blanket approach without indication. I never needed an IV for fluids, but was given medication through it without consent in the past and would never agree to a cannula again unless in an emergency.

I’m so sorry for your loss! Two words of warning from experience. I had an epidural and a spinal and did not have any issues. I then had another spinal with my latest section, my blood pressure tanked and I felt really awful until I was given medication to bring it back up through the (already sited) cannula. If they’d had to try to cannulate me then it would have been horrendous. I felt bad enough waiting for the medication to start to work as it was. That also applies in a proper emergency - you do not want the team to waste precious minutes trying to site a cannula, which can take even longer to do if they can’t find a good vein etc

The second point: I was also determined that I would not consent to an instrumental delivery or episiotomy in my first (vaginal) birth. In the end my daughter’s heart rate went wrong when she was so low down in the birth canal that a section would have been risky for both of us - they would have had to push her back up to do the section. So I consented to forceps. What no one explained to me in advance - and I wish they had - is that in a vaginal birth there are no guarantees that you won’t need an instrumental delivery. The only way to guarantee that is an ELCS - which is what I had for my subsequent two children.

Very best of luck, and hope it all goes smoothly. I had all my children at C&W but it was NHS, so sadly I can’t make a consultant recommendation.

Obstetric anaesthetist here - I don’t know any of my colleagues who would agree to doing an epidural without a cannula in situ, I certainly wouldn’t and it is in our guidelines and those of every hospital I can find that we would not put an epidural without a cannula. The risks of doing so are just too high and there are extremely good reasons why you need a cannula for an epidural as others have explained.

OP would you be willing to forgo the epidural?

I attempted vbac (in NHS hospital) and went against guidelines as chose the MLU. I said no to constant monitoring and no to canulation of both or either hands as I found it painful and distracting previously. It was done very tightly.

it meant in labour I was able to feel comfortable and more animal like (on all fours) no pain relief. I got to 9cm before an unlucky event meant a c section but I do believe all my choices of being less ‘medically bothered’ helped me get to 9cm easily

I think if nobody will give me an epidural without a cannula, then I will attempt to labour without an epidural, and if the pain gets too bad go straight to section. I will not labour with a cannula in my hand under any circumstances. I doubt that I'd manage without an epidural, I don't believe in having severe pain in childbirth. So another section it most likely will be.

Was there anything that helped you get to 9cm pain-wise?

Thanks for sharing. I know that they tell you that there is no way to guarantee not having an instrumental delivery in vaginal birth, but that's simply not true.
Instrumental delivery obviously fails often and then they have to do the section regardless how far along the 2nd stage is. They can therefore skip straight to C section and will have to do so if the mother denies consent for instrumental. It's just that they often don't want to because it's faster to quickly shred the mother with forceps. Forceps are banned in many hospitals in Europe, and their use is extremely rare almost everywhere in the world. The UK has an abnormal and unprofessional obsession with a frequent use of forceps.

There are also other ways to mitigate risks before it gets to that point in delivery - I personally would always skip straight to section if my baby was posterior or otherwise poorly positioned, or if there were early signs of my own exhaustion or fetal distress. Induction, especially if progressing slowly, is another sign that things are just not going optimally. Basically I'd always try to opt for an early pivot to section rather than press ahead with a vaginal delivery in suboptimal circumstances.

Yes! A tens machine helped me get to 9cm without epidural. Really helped.

btw are you okay with cannula in hand for c section? Pretty sure I had to have that for all my c sections

That is true, I could have insisted on a section when we found the baby was back to back. I’m sure they would have done it - though I did go to 10cm very quickly and there was no indication that anything was amiss with her position before that.

And yes, of course you can have a section at any stage - the question is, how risky is it for the baby especially (but also for the mother) vs an instrumental delivery. They were prepared to give me the section, and in fact I was fully prepped for it in theatre in case instrumental delivery failed. But they had to explain the risks, and I made my decision based on that.

Incidentally, I originally only consented to ventouse, which failed. I had said absolutely not to forceps, until the doctor said she was pretty confident she could get her out in just one gentle tug- which she did. I was getting very anxious about the baby by that point, and wanted her out ASAP. I then went on to have a suspected placental abruption, so I’m very glad I did make that choice.

Also - ventouse isn’t particularly great. Two people had to hold me back on the operating table while they were trying to pull her out with the ventouse. And the doctor confirmed my 3B tear had already been caused by the ventouse, before the forceps.

They can obviously be given ad hoc when required rather than in a blanket approach without indication

The problem is, if there is an untoward issue caused by the epidural, there may be limited time to get one in. That’s why they are standard with epidurals as you need open venous access, otherwise it’s negligent. There are many instances where seconds count, and you can’t waste time stuffing around putting one in once it gets to that. You will be extremely hard pressed to find an anaesthetist who would do this (and frankly I’d be perplexed if anyone agreed and wouldn’t want them treating me!).

Ah interesting, Tens seems to be a marmite type thing, I've either heard from women who swore on them or from those for whom it did nothing. Worth a shot I suppose!

A cannula is required for any surgery, I'd have to accept that. But for me it's one thing to lie around with a cannula in my hand for one hour or so while under total spinal anaethetic, and quite another to have one in distracting me while I have to endure contraction after contraction and try to concentrate on giving birth. I hated it so much in labour, it just felt counterproductive and intrusive, I'll never do that again.

Yes, birth is often unpredictable of course as well as poorly monitored and managed, ending up at 10cm without anyone having figured out that the baby is poorly positioned is sadly fairly common I'm sure. I'm going private to have a higher chance of someone actually carrying out these checks in good time, and to check again on my request.

I can see why someone would opt for instrumental in certain circumstances and in sounds like you may have made the right call there - I just personally have decided that I would not. I've come to this conclusion after I I found out that various countries eg Germany have completely abandoned the use of forceps for instance, and after I read multiple studies showing that stats supposedly proving how safe instrumental delivery is often conveniently leave out maternal anal sphincter and prolapse injuries in their morbidity assessments. Maternal trauma is basically disregarded by many doctors who are keen to perform instrumental deliveries.

This study here was very illuminagting as well as shocking: pmc.ncbi.nlm.nih.gov/articles/PMC10585424/
While c-sections are ofc not without risks, it showed that "operative vaginal deliveries are associated with high rates of severe maternal and neonatal trauma", and that especially the risk of neonatal trauma is increased enormously if forceps are used after a failed ventouse attempt. It says: "Adjusted rates of
severe neonatal trauma are fourfold higher for operative vaginal
deliveries than for caesarean deliveries."

They'd never tell you that in the moment, of course! It just appears that ventouse and particularly forceps are significantly less "safe" than they are routinely presented to be.

And especially for people using the NHS - it's been reported again and again over the years that NHS registrar doctors often receive poor training for instrumental deliveries, esp forceps, and are often performing them without adequate experience unsupervised, frequently causing the type of injury you have sustained. All scandalous. I'm glad you and your baby are ok!

I'm just trying to think through the process here:

You could labour naturally, refusing cannulation and/or epidural. However, if you then have to change approach and switch to C-section, the first thing they'll do is cannulate and get the epidural in. Only it will be a lot harder to do at that stage because it'll probably be an emergency situation that forces you to switch to C-section. As approaches go, this just feels risky.

Also, you need to be aware that there are situations where VBAC progresses to such a point that C-section is no longer an option (i.e. baby is quite far down the birth canal already). Refusing forceps/ventouse at that point is pretty impossible, as there's no real alternative - do you want them to push the baby back up for a section?

I wonder whether the best approach for you would be to find a doctor with whom you build a relationship over a period of time so that you can develop trust in them; you can ask them to do their best to avoid interventions, but at the end of the day, you can't plan for every situation.

You could also consider hiring a doula to act as your advocate while you are in labour. Have you thought about that?

I agree that my best bet is definitely to find a doctor I can trust, but I also need one who is onboard philosophocally with certain things that are not up for debate. Nobody can plan a birth ofc, but women do have a choice in certain areas. While it's impossible to rule out c-section without risking calamity, opting to have a caesarian instead of attempting instrumental vag delivery is always a choice - I know that several leading consultants in London are basically completely against forceps deliveries and always want to do c-sections instead. Unfortunately I don't know whether there is one with this mindset at C&W. To answer your Q, I would indeed want for the baby to be pushed up the birth canal again instead of instrumental, doctors do this all the time.

I don't think it's likely at all though that I personally will be in a situation where the baby is very low in the birth canal and intervention is needed - simply because the chances that I'll let labour run for this long before requesting a section is very low. Statistically at my age alone (late 30s) very few women even go into labour naturally it seems - I'd refuse induction also as hormonal drip isn't allowed due to previous c-section and I don't want any manual internal procedures, no sweeps, rods, balloon etc.
In the absence of proper pain relief - I'll probs give tens etc a go but don't think it's likely this will be my rescue - I can't see myself labouring until the end without requesting a section.

I think there's a v v small chance that I'll have a 'fairy tale' delivery that happens on its own in a shortish amount of time - spontaneous onset of labour, perfectly positioned baby, ability to stay mobile, steady progression, no fetal distress, basically no interventions.

Or, in the absence of any of the above, I'll pivot - likely v early - to another planned section. I just don't believe in vaginal birth that is forced. I was hoping to give VBAC a proper shot with an epidural, but if I must have a cannula to have an epidural VBAC is now a remote possibility. I also don't think it would be a problem to fit a cannula spontaneously. Proper emergency sections are nearly always the result of a poorly managed first stage/prolonged second stage in suboptimal circumstances.

The only thing I really worry about is having a section at full dilation - it makes cervical bleeding/injury more likely and increases the risk of future preterm birth. But it's still preferable to me than instrumental delivery, so I just have to accept this risk I guess.

In short - no idea what's going to happen, but I know I won't allow some procedures to be done to me regardless of the circumstances. Not being coerced into anything under false pretenses or dubious clinical practices is basically my primary hope for this birth.

You've done so much research and you are really well versed in lots of statistics and risks versus benefits. But I just felt I couldn't pass by without commenting on your wish to have baby pushed back up the birth canal. Disimpaction is a risky and complicated manoeuvre, and is avoided wherever possible in any scenario I've ever encountered or heard of. Many obstetricians will not perform this willingly. The only scenario you've perhaps not considered is one where labour progresses quickly and everything is well, with the fetal head low in the birth canal, and a sustained fetal bradycardia occurs. Delivery is not imminent, time is not on your side for a c section due to the brady and the only viable option without risking further compromise of the baby is an instrumental delivery. From reading all of your posts and your wishes, which are your every right of course, it sounds like an elective section would suit you best. I think there are too many variables with vaginal delivery to align with your preferences.

I am not a doctor, however, I was thinking would a planned elective c-section be less stressful?

would indeed want for the baby to be pushed up the birth canal again instead of instrumental, doctors do this all the time.

they don’t do it all the time at all. Because 99.9% of the time in such a situation they’d do an instrumental. I’ve only seen a baby be pushed back up the birth canal about 2 or 3 times and one of those times the baby died due to a tentorial tear caused by being pushed back up.

if you want to avoid an instrumental vs baby needing to be pushed back up situation I would recommend being as active (and ideally) upright as possible in Labour. Like a previous anaesthetist has said i can’t imagine anyone would site an epidural without a cannula so you’d be best off investigating other methods of pain relief, hypnobirthing, pool birth, etc as well as Tens machine which you’ve mentioned. Pool birth according to the evidence is better pain relief than TENS which I believe the Nice guidelines say is only recommended for latent stage of labour, saying that I’ve seen Tens work for some women for much longer but you obviously can’t use it in the pool. They will want you to be in a ctg but obviously can’t make you, some ctgs are waterproof so could still work in the pool.

Thank you for the kind words. We are both well thank you, and I have since had two more children by elective C section - both great experiences. I wonder if that might be a good choice for you too given your red lines (which you are more than entitled to have).

I don’t think my delivery was mismanaged. I was given an epidural very very early on, as I requested - at less than 1cm, because I wasn’t coping. I was scanned pretty much as soon as there were indications of issues (which so happened to be very late on, because I went from 1cm to 10cm
in 3-4 hours). I was given the choice of C section and the choice to decline instruments. I chose not to take the C section, because some of the risks of pushing the baby up were simply unacceptable to me. The risk of oxygen deprivation, and brain damage, for example, even if relatively small is a red line for me. That risk is a fact, and I wasn’t lied to about it. I am eternally grateful to the doctors who took me to theatre when they did and got my daughter out before she was affected by the likely placental abruption/ massive haemorrhage.

I do agree that forceps are pretty vicious, and avoided in many countries. The use of ventouse is rising though instead, and that’s pretty brutal too. My tear was the result of ventouse, and a friend of mine also had a 3b tear with successful ventouse (no forceps).

I truly did find my c sections great though. I was NHS, and my first section was done by Melissa Damodaram (I don’t think she does private though), and the second by Tarek Al Shami - both excellent, and I had great recoveries. I was also seen by Mark Johnson and Roshni Patel in my pregnancies, and they were also great and very supportive.

it's worth reading the whole paper that's quoted above - even a quick skim read suggests some of the reasons that trauma is more common in Canada than in other parts of the world (which is what the gist of the article is, rather than 'all interventional's are bad').

re. 'pushing the baby back up' - it's not done frequently and it's very much worth looking up the risk factors and implications for impacted fetal head (which is frankly one of the most terrifying medical emergencies I've ever seen).

The need for a cannula before a spinal in theatre is independent of the need for a cannula for surgery. A routine part of spinal management is to prevent/manage the predictable sympathetic block (and the funky cardiovascular changes it causes) that you get with a spinal that's high enough to provide anaesthesia for a c-section. The same is true for epidurals although the degree of sympathetic block is usually (but not always) less, but as epidurals are very different techniques to spinals there are some other risks for which an immediate treatment must be available before starting. Siting a cannula in an emergency on labour ward is not always as easy as it sounds, particularly when it's being done in response to cardiovascular collapse, and reacting to a (possibly iatrogenic) emergency rather than anticipating the risk and preventing it would be negligent practice.

the problem with childbirth by any route really is that you really only know it's going to go smoothly after it did go smoothly.

@Lavenderandlemons and @MoominUnderWater - I’m aware that many doctors push for an instrumental delivery attempt when the head is low and time is of the essence. But it’s not the case that doing a c section in this scenario is extremely rare. It’s pretty common. Instrumental delivery attempts often fail, and then a section is performed. It’s why many instrumental deliveries happen in theatre.

I know that in the UK in particular, doctors often claim that a forceps delivery is necessary. But if entire countries no longer do them, they’re clearly never necessary. International stats show that in many countries instrumental delivery is v rare, which means in the UK they’re mostly performed for ideological, practical or fiscal reasons. Instrumental deliveries are ultimately always just an attempt to avoid a c section, and I’m fine with a c section. Experienced obstetric doctors will even be familiar with the freak scenario where they have to do a section after the head has been born already and the baby is truly stuck.

It’s pretty common I think that the head is not very well positioned in the birth canal, but if manual manoeuvring or position changes won’t help, I’d just want to skip the instrumental attempts and do a section.

I could of course also just have a planned section from the start. My previous ELCS was fine, and I may also decide to do this again, yes. But I did not enjoy the constant unwelcome interventions and hassling I described in my OP. Unfortunately one is basically a piece of meat during a section and fully at the mercy of a room full of strangers.

Some women do have births without unwelcome intervention, so why not give it a shot is my thinking. I’m pretty open minded re experimenting with midwifery techniques and positions and pain relief etc and I’m not fixated on a particular birth. I just don’t want an instrumental delivery and I think with proper one to one care this can be avoided.

re the suggestion of using a pool - my midwife at C&W has sadly said it’s not allowed for a VBAC as the baby needs constant monitoring. I’ve never heard of monitors that can be used in a pool, will ask about that!

I did read the whole paper. The findings regarding the substantially elevated risks for mother and baby in instrumental deliveries are applying universally, not just to Canada.
the study merely also highlights that Canada has a particularly poor record re injuries in instrumental births.

I’m not sure I understand what you wrote re cannulas. I’m just saying I would refuse a cannula during a VBAC attempt if all else looks normal. That’s surely pretty uncontroversial, even if hospitals prefer to place them on arrival.

Are private midwives still a thing or has their profession been killed off now? I think a private midwife would be really helpful here

That’s good to hear, and thanks very much for recommending these doctors, I’ll look into them.

Just to clarify - I’m not saying I think all births ending in instrumental deliveries are mismanaged. I just think births where an emergency arises that leads to frantic attempts to deliver with forceps are often mismanaged.

I can also see why someone would opt to attempt instrumental instead of a section, a section has its own risks. Some doctors are also much better at performing instrumental deliveries than others, some are specialised in complex operative vaginal delivery so that would give me more confidence in the procedure than an unsupervised registrar getting the forceps out at 3am because he wants to go home, which is so often what happens sadly.