ELCS vs VB?

[Rollersara]

So, I have a neurological condition which is relatively rare in women of child-bearing age. I'm now 33 weeks pg and over the past few months I've seen a host of specialists from neurologists to obstretic consultants. So far there has been no conclusive advice on birthing methods.

I've got an appointment with a consultant at 36 weeks, when we will "decide" on what will happen (I'm aware it's unlikely that it will go exactly according to plan anyway!). I'm just a bit worried I'm going to get railroaded into something I don't really want. I don't expect advice from strangers on t'internet about how to give birth, but what questions should I be asking? What do I need to think about before this appointment?

Last time I saw this consultant I did ask about recovery times and she said it would be about the same for VB as ELCS, which concerned me as I'd always been told CS was much longer...

That sounds very odd to me - ELCS is major abdominal surgery. It usually requires a MUCH longer recovery time than VB, given that it requires that all the layers of skin, fat, and muscle, plus your uterus be sliced through in order to extract the bub - and then sewn back up again to heal. The comparison between truly elective c-sects (ie those which are given for so-called 'social' reasons) and VBs have generally found that c-sect carries a 4-times greater risk of death than VB for the mother and the baby, for the simple fact that it is major surgery with all the risks that are associated with that. The healing time associated with c-sect is usually up to about 6 weeks (much like with any other major abdominal surgery) whereby you shouldn't lift anything heavier than your bub, drive a car, or do any physical exercise (including housework) more strenuous than a very slow and gentle walk. Obviously some women recover more quickly from ELCS than others, and more slowly from VBs than others - but the recovery times can't really be compared. Most women who have VBs (without, say, epidurals or other anaesthesia) are able to be up and walking around immediately after their VB. Although women who have CSs are encouraged to get up and walking around quickly, it's usually at least 12 - 24 hours before they can sit up in bed let alone walk around.

Please don't get me wrong - I'm not trying to scare you away from C-sect or to make out like they're evil or something. They're not, they're truly life-saving surgeries for both mums and babies when used under the right circumstances. I guess the problem is that they're sometimes not used under the right circumstances and this can be very dangerous.

Without knowing anything about your diagnosis, though, it's hard to comment (and I daresay even if I did know more about your diagnosis, it would be hard for me to comment as I don't have a medical degree).

I guess the kinds of questions I would be asking are:

-What are the risks associated with a VB? A ELSC?
What are the risks inherent with having an anaesthetic combined with your diagnosis?
What makes it riskier for you with your diagnosis to birth vaginally than for women without your diagnosis?
Is there any reason why a trial of labour couldn't be given?
If an ELCS is to be given, can you go into labour first (so as to ensure that the baby is truly ready to be born - ultrasounds can be up to 2 weeks out in some instances, meaning that some 'term' ie 37 weekers are actually premature at 35 weeks).

And I guess if you're intending to breastfeed your baby and an ELCS is given, then ensuring that you get immediate skin-to-skin contact in the operating theatre, that your baby isn't separated from you when you're in recovery, that you have the opportunity to initiate breastfeeding within the first hour after your bub's birth etc - all of the evidence-based practices that are so rarely practised!

My modest opinion is that if there's any chance that your neurological condition might get worse or complicate a VB or even remotely increase the risk to you or your baby then it's just not worth it. Go for ECS.
Most people I know have made an exceptionally quick recovery from CS where it's been elective. I can't say the same for VB which can go very smoothly (and then recovery is probably quicker than with any CS) or be very taxing on both mum and baby. I, for one, would rather have had an ECS than my first delivery which was highly traumatic and left me with a weak pelvic floor and took months to recover from.
I would ask one simple question: what is the safest option for me and my baby? And then just go with that one.
Good luck!

Do you have a preference for mode of delivery?

You should be able to ask as many questions as you need at the 36 week appointment to satisfy yourself that you are comfortable with whatever the final decision is.

Have you had a look at the scientific literature around people giving birth with your condition to see what is usually the best option?

I think recovery really varies. I had an elcs 16 days ago and feel great. I walked around with the catheter a few hours after delivery and felt pretty normal walking within a few days. In my previous vb recovery was fairly similar because I had forceps and an episiotomy-that scar actually gave me a lot more pain and hassle than this one.
Anyway, I am now a massive fan of elcs. There are risks but don't succumb to the horror stories, they happen with vb too.

-TamIam, that's what I'd thought re: recovery time which has left me slightly at her recommendations. Sorry if I'm being dim but are you saying I can wait for labour to start and still have an ELCS?

It would technically be an emergency CS at that point (because of how they are defined), but unless you had a very quick labour it should be possible (that is what happens if people who are booked for CS go into labour early). It would mean that your baby was 'fully cooked' and ready to be born. I have had both, and the baby who was born when ready was much easier to look after, feed etc than the one who was an elective CS.

I am not sure that the recovery time from an ELCS is necessarily as described- I had one 5 days ago and feel completely fine now. Was up and walking after 6 hours and very little pain relief. I still need to be careful, But personally, having had VB and CS, the recovery times have been pretty similar so far.

Thanks for all the replies BTW, just been out so unable to answer! Ok catsareevil, that's what I had thought. I genuinely don't know what I'd prefer, other than whatever is safest for me and baby, and as far as I can tell the scientific literature is very limited on this one. Also, people talk about recovery in relation to walking - I find walking very difficult anyway and usually use a wheelchair, so I don't know how that affects recovery time either, and I have muscle spasms in my abdomen that may or may not be affected by either birth method!

I found that the ceasarians were bad for back pain afterwards, and my abdominal muscles took a long time to improve, but I dont know if that is relevent to your condition.
I found myself relying a lot on my arms after the CS, eg to pull myself up the bed, so that I could avoid putting strain on my back and adomen.

Thanks cats, I will ask about that. Generally I have very good upper body strength because I do use my arms a lot. Also what you said about whether the baby is ready or not. The other thing is I think a VB is likely to be very medicalised, i.e. induction, early epidural, forceps/Ventouse and episiotemy anyway and I don't know how that would affect recovery compared to ELCS, thanks goodnightmoon for your experience. I will ask if that's what the consultant meant, that the recovery times would be similar because a VB for me would mean a lot of intervention.

Thanks all, it's given me a lot to think / ask about!

www.rcog.org.uk/womens-health/clinical-guidance/birth-after-previous-caesarean-information-you

This gives you key facts from the appropriate professional body.

I was also in a situation where, due to a medical condition, my options were: induced labour, drips, epidural, continuous monitoring, high risk of assisted delivery/emcs - or elcs.

I went for the elcs. I can't say what is right for you, but I will say that comparing recovery time for cs and vb is difficult as it very much depends on the vb - I recovered more quickly than some friends who had difficult assisted deliveries, and more slowly than friends who had four hour labours, no tearing, etc.

All in all, the first two days after a cs are difficult but then it got better quickly for me and I felt fine by two weeks after. Some insurance companies will allow you to drive much sooner than six weeks as well.

I think I made the right decision for myself and my baby, and will be having another elcs next year (risks of a vbac would be higher than normal for me anyway).

Thanks kickingking, I am starting to think that might be the way forward for me. Driving might be an issue as I doubt I'll be able to push my wheelchair myself but there won't be much I have to go out for!

My experience of the type of medicalised VB you describe resulted in a longer recovery than friends' CS. I think you should ask about complication rates comparing medicalised VBs and ELCS. Also if you spend time in a wheelchair then it might be worth thinking about where scarring will be and how comfortable sitting down will be.

I probably should have said that my medical condition is type 1 diabetes, and aside from that, I am fit and active and did a lot of walking right up to a few weeks before the baby was born (when his head engaged and I could hardly walk for waddling!) so that probably helped with a quick recovery.

breathes, very good point about complication rates and possible scarring. Until recently I was pretty fit too with regular swimming and yoga so I'm hoping that will help!

When I was looking at risks for different birth options about a year ago they come out like this (from least risky to most risky):
uncomplicated VB
ELCS
EMCS
complicated VB, e.g. assisted delivery forceps, etc.

Personally I went for an ELCS as I thought the risks to the baby with a compicated VB were not worth it.

My recovery was perfectly fine, I was walking within a day, up and about as normal within a week, driving was not a problem and I was riding by 7 weeks. I have had a friend take 5 months to recover from an episiostomy so every option carries risks.

From what you say your situation is quite individual so it may be that only your consultant can really help. Best of luck which ever option you go for.

I wish I had known that Boobostoo as I was induced which led to lots of intervention and an ELCS would have been a much better option.

I have had both a VB and an ELCS. I much prefered the VB, experienced wise - I felt eurphoric afterwards and was able to bond with baby very quickly, but then a month later I was back in hospital with retained placenta, and heavy blood loss which left me severely anemic for a long time, so in the end recovery was very long. I should add that my VB was not medicalised, I stayed at home until I was 10cm and then went to a midwife led birth unit. It just goes to show that even non intervention type births can result in crappy recoveries sometimes!

I hated the experience of the ELCS - felt very vulnerable and helpless while it was going on, but did recover quickly (for an ELCS) However, although my recovery was good, I couldnt push a (heavy) pram for ages, lift my toddler up or do a lot of walking for a good few weeks, wheras after the VB I could do these things fine after a few days (but then again, second degree tear made peeing and pooing horrible for a long while!) swings and roundabouts!

It definitely takes weeks to get your tummy muscle strength back - which you need for everything! and only days to recover from an uncomplicated VB, so I can only think that your doctor was talking about recovery time while in the hospital, not complete recovery. I left hospital 24 hours after the CS, but was in bed at home for another week.

Its a very hard decision, and there are possible risks on both sides, when I had to make my decision for the second birth, I asked lots of questions about breastfeeding/bonding/being with baby right after the birth, sometimes having a CS can mean there are different hospital procedures to be followed which may mean you dont get to be with your baby as soon as you would after a VB. If you are planning to breastfeed, let them know, and ask what support you will get.

You say that you use a wheelchair often, perhaps you should ask about how much you will be expected to walk upright and when while recovering, and see if you feel comfortable with the amount. You are asked to stand up straight quite soon (a few hours) after the operation, and then encouraged to walk around a lot, standing up as straight as you can (your instinct is to double over and walk with a stoop - or even better just stay lying in bed!) so as to stretch your tummy muscles and not let the scar form too tight. Apparently if you dont walk around much recovery takes longer.

congratulations on you pregnancy by the way

breatheslowly sorry you had an unpleasant experience! If you are interested in more details have a look on Google Scholar. There are quite a few recent studies that differentiate between EL and EM now that large numbers of women are option for EL in the US (around 25% although I don't remember the exact number so don't quote me!) and in China (around 40% again can't quite remember exactly). Previously the statistics conflated EL and EM which made EL appear riskier than it is.

Thanks MummyAbroad! I hadn't thought about needing to stand up, I can't do that at all at the moment and I already walk with a stoop already and I don't want it to get worse!

Given your reduced mobility if you do end up going for a section would it be worth asking to be referred for physio now so that they can assess your needs for the postnatal period?

Hello catsareevil, yes, I've already seen a physio and she's asked me to make another appointment when baby arrives. I wish I'd started this thread before I saw her last time as she'd probably have a view on a lot of the questions raised here!

Maybe make another appointment to see her before your bub arrives then?

Hi, I'm in a similar situation to you as I have a very rare neurological condition and am 39 weeks pregnant. My condition causes fatigue, weak muscles (particularly my core muscles, legs and hips) and I also have a weak diaphragm which causes breathing problems and I use a bipap machine to breathe at night. Despite this I have had a good pregnancy and coped much better than others thought I would. I have seen a number of specialists throughout my pregnancy, most of whom seem to have differing opinions about the birth. I have also spoken to a handful other women with my condition who have had VB or ELCS and it seems that there are a variety of experiences no different to the general population. I have really carefully thought about all my options and have decided to go for a VB with early epidural. I'm well aware that I may also need intervention (but not necessarily so), but I have been told my recovery from CS may be much more difficult and longer than for the average person. I'm still keeping an open mind though as nothing ever goes to plan. I have found my doctors very supportive and although my respiratory consultant would prefer a CS he is happy to go with a VB but with a low tolerence to having a CS if any probs and the option of me being transfered to their respiratory HDU if needed. As long as the baby it safe, thats the important thing, so just do whatever seems best for you. Keep asking questions and make sure your doctors and midwives are communicating, and as you get nearer the time it will be easier to decide. I'm trusting that my body will do what it's meant to do, and if it doesn't then the doctors will do what they are meant to do!