Terrified they may 'make' me have VBAC.

[Paula1]

My second child is due 29/12/02, first was born by c-section at 38 weeks due to being breech. I have got an appointment in 2 weeks to talk to the consultant (who is new, so the midwives haven't really got a feeling yet for what she is like about these things). I have decided beyond all doubt that I want a second C-section (I know this won't suit everyone), does anyone have any idea of how likely it is/any good things that I can say to the consultant to ensure that 'I get my own way'?? The things I am scared of are that: I've never been in labour, so my body will treat it as a first, and everything will be really slow, my baby is due just after Christmas, what happens if I go into labour and need an emergency C-section during the Christmas holidays and there are only junior staff there? The thought of an emergency c-section fills me with horror. I also don't think I have got the right attitude of mind to face the hurdle that I believe VBAC would entail. Please don't all condem me, I'm really not 'too posh to push', just don't want to go through all the trying to fail and end up with my worst case scenario (emergency CS). Also, if the Consultant won't agree - what other options do I have, can I change Consultants? (and anyway, would one overrule another?) Go private - and if so where?

Agree with you both Lindy and MABS. C/sections are life savers when the benefits outweigh the risks of vaginal deliveries. They are a problem when they themselves are the risk factor to a mother and baby's health. Here we go again

Hi. I was just wondering if the doctors advise you to have an epidural if you are trying a vaginal delivery after a previous c-section? If so, when do they put this in place, straight away? or like normal once dilated so far?
I am unsure whether to opt for an elective c-section in my next pregnancy, or whether to give VBAC a go. I have always wanted three children, like my husband. How many c-sections are "allowed"?

Aloha, I meant to say that my friends who are having 2nd Csections were breech 1st time around (like me), not this time - this time they are just requesting cs and being allowed it (unlike me)!! Aimeesmum, my consultant told me that the the more c-sections you have the more chance you have of a post partum haemorrage, although, she told me that for a 2nd baby the risk is the same whether you have VBAC or a repeat caesarean

I seemed to have missed a few postings earlier on from Marina and Enid. There is a bit of confusion there about the 'lie' of the baby.
Enid - the lie of your baby was longitudinal ( the baby's body was vertical) but the 'position' was transverse. There is no reason to think that next time round you will need a C/S because your body will labour more efficiently having done it before. I looked after a friend of mine in labour who had the same type of delivery 1st time round after an 18 hour labour. Baby boy was 10lb 12oz. Next time she had a 4 hour labour and normal delivery of a girl, 8lb 9oz. IME most women who have had a forcep delivery 1st time round manage to deliver themselves next time. There are of course other reasons which may make an assisted delivery necessary, but if all is well Enid, you should be fine.

Marina - with your baby the 'lie' was transverse which means the baby's body was lying horizontally and cannot be delivered vaginally. This can happen is there is excess fluid in the womb or can happen where a woman has had many pregnancies and the tone of the uterus is poor. Hopefully this next baby will be able to maintain a longitudinal lie and you will be able to have a VBAC.

The latest research does suggest that all breech babies should be delivered by C/S as the safest option. It is advised though that a skilled attempt should be made to turn the baby to cephalic ( head down) to avoid caesarean delivery.

The epidural option regarding attempt at VBAC has differing views. My experience is that women who are mobile labour more effectively. Unless a woman expresses a desire to be mobile then women are usually advised that continuous monitoring is required when labouring after a previous C/S. This can make labour more painful and often women will opt for epidural. Epidurals can increase the need for forceps or C/S if they are inserted prior to labour being established i.e. cervix at least 3cm dilated. There has been a previous thread discussing this issue.
If there is an epidural in place it can be topped up for a C/section if that is required. Some people believe that is an advantage for VBAC.
Personally I think it is better to see how labour progresses without an epidural first. If a second C/S is decided to be the best way to deliver the baby then a spinal anaesthetic can be quickly inserted in theatre. It actually has a better effect than an epidural.

In our unit if a woman requests to be mobile or even use the pool then that request is 'allowed' unless there is a good reason that it is inadvisable. The baby is then monitored intermittently. To me that is the best option when attemping a VBAC.

Hope eveyone can follow my ramblings

Aimeesmum,
Forgot to add that although a maximum of 3 C/S was once advised, many women ignored this! Each C/S can be a bit trickier than the last due to scar tissue and adhesions etc. but I have seen a woman who had 6 sections. I have looked after a woman who had VBAC after 2 C/S but that was because she was very determined and had to change consultants to get her own way regarding labour.
In most cases 2 C/S usually means all subsequent deliveries are by elective C/S.

Mears - this is interesting. In Silent Knife they report a lot of cases of VBAC after 2 c-sections (in the US).The authors did their own survey of 105 VBAC and 24 of these were after 2 c-sections... 21 delivered vaginally. It depends on your desire, your determination and the competency and support of those around you during labour I suspect.

BTW Have you ever heard of GBS infection ???? Just wondering if this is something that we talk about in the UK (it is a "big" deal in other countries but I have never come accross it here)
Thanks

Pupuce, I agree with what you say about 2 previous C/S. I think there is not enough demand from women here to want to do VBAC and it all depends the reasons for previous C/S. Perhaps viewpoints will change if more evidence becomes available.

GBS - group B strep infection is as big a deal here but is not as agressively looked for here as in some parts of the US. Some areas there do vaginal and rectal swabs on ALL women.

In our hospital all women who have a history of ruptured membranes prior to labour have a vaginal swab obtained to detect primarily the presence of GBS. This is an organism that many women have that outwith pregnancy is harmless. However, if it is present during pregnancy, and there is a history of prolonged membrane rupture accompanied by a maternal temperature then the baby is at risk of GBS infection which can be fatal. Babies succumb very quickly if this infection takes hold. It can result in meningitis, sepicaemia etc.
If group B strep is detected on the swab or has been present in a previous pregnency then women are offered intravenous antibiotics 4 hourly throughout labour. There is no point treating the infection antenataly because it may recur and it is only a problem for babies when the waters break. When the infection is picked up then the woman is treated as a carrier for all pregnancies and treated for all labours.
If antibiotics are given 4 hours or more before delivery then the baby is protected. If not then the baby is swabbed and fluid from the stomach is sent for analysis. If the organism is found and the baby has a temp. or is preterm etc. then it is given intravenous antibiotics.

The UK support website is this

Mears, thanks for the explanation re transverse positions/lie. I was scanned urgently at 34 weeks because a student midwife thought I had too much fluid round the baby, but the people I saw felt that this was a false alarm. My notes indicate there wasn't an excessive amount of amniotic fluid at birth, but what you've said made me wonder. No-one raised that as a possible explanation as far as I remember.
I felt rather affronted when the consultant first put it to me that I might have a slack uterus ! We will see what happens this time. I was transverse, apparently - and my mum (complaining mightily by her own admission) managed to have my younger sis by very carefully monitored VBAC, back in the sixties. So there's a family precedent.
I can't tell you how good it is to have a midwife on Mumsnet who is so willing to answer questions and put our minds at rest. I really do appreciate the time you take to explain things!

Thanks Marina. I do enjoy helping out if I can

Just to second Marina's thanks to Mears. I have never really understood it all - my fault really as I always forget everything I'm supposed to ask my midwife (I remember it all as I get back to the car ) That has definitely made things a bit clearer in my foggy pg brain

Thanks Mears.
Wellmy Belgian cousin (due in 3 weeks) had GBS with her second and was on antibiotic as you described... and she is again infected... the reason I am looking into this is because she has been told she CANNOT have a bath ! She wants to labour in water and she isn't sure she will be allowed....
I have asked someone very very familiar about this and she told me that labouring in water should be OK (I didn'task about baths),she also told me that you can treat GBS as effectively with chlorhexidine (rather then antibiotics). I got this info from a VERY good source I'll send it to you via via.... IYKWIM

But thanks for letting me know the UK stand on this !

Mears, do you have any experience of the mobile epidural. I had a c-section for my ds, but am vaguely contemplating another baby (he sleeps now! I must be insane). I would tend to favour another c-section as it went so well last time (pain free delivery, quick recovery after two days of very limited mobility in hospital), but have thought about a mobile epidural as I absolutely hate the paralysed feeling of the epidural I had for my section (makes me feel totally claustrophobic, if anyone knows what I mean). I understood research showed that mobile epidurals lead to a much lower rate of intervention than conventional ones. I just couldn't/wouldn't face the pain of an unmedicated labour (wouldn't have my teeth out without anaesthetic and childbirth has to hurt a lot more, right?) and epidurals often lead to sections, I understand, so do you think I would be a candidate for a mobile epidural? I think St Thomas's does them. I would be very grateful for some expert thought here!

Aloha - I am afraid I do not have any experience of mobile epidurals - our unit does not do them. We trialled it a few years ago without much success. Don't know why we haven't done it again.
Although I have mentioned increased risk of assisted delivery with epiduals it is not such a problem when labour is well established i.e. that contractions are regular, at least 3 every 10 mins, moderate in strength and the cervix is dilated. Did you labour at all last time? If not you might be expecting labour to be more painful than it actually will be if you know what I mean. If you found C/S to be painfree you probably have a high pain threshold anyway. Just a thought

Pupuce - it tends to be the US that advises no baths. We do not discourage them and in fact, women can use the pool fpr pain relief if hey want. The only thing different is that in labour they have a cannula in their hand to allow the administration of the intravenous antibiotics 4 hourly in labour. They are not permanently connected to a drip.

Do not have experience of chlorhexidine treatment but I would not risk it. I have been searching for information to update our protocols for the midwifery unit and I have not seen any research info regarding it's use with GBS. That will be interesting.

Thanks Mears, it's so great to have you 'available' so to speak, as this kind of information is so hard to get elsewhere. I didn't labour at all last time (placenta praevia) so you might be right about less pain than I imagine (though some of the posts on here scare me witless!!), but could you tell me how much paralysis to expect with a normal epidural? I absolutely hate that 'dead' feeling and can't imagine having a baby feeling like that (though friends tell me they didn't care at all about it as they were just so happy that the pain had stopped...). All this is, of course, hypothetical as am not even pg.

Aloha - well I found labour painful but equally a friend of mine said she felt very little pain... when I didn't believe her I asked her MW... who said : absolutely - it was a breeze for her... so you never know !

Maybe your local MW (when you are pregnant again) can tell you if you could get a mobile epidural.

Mears- The GBS info is on its way... This is Belgium where they test for GBS (every woman!) and where you are not allowed a bath !!!!

Aloha - the paralysis feeling you describe sounds like a spinal anaesthetic rather than an epidural.
Local anaesthetic is injected a little bit deeper than an epidural so it works very quickly and is much more dense. You cannot raise your legs at all. This is the usual anaesthetic for elective caesareans.
When women already have epidurals in place and need a caesrean the epidural is 'topped up' with stronger strength of local anaesthetic to give a denser block than needed for labour.

During labour you should still be able to move your legs in bed but are unable to weight bear. You have quite a bit of mobility actually. The mobile epidurals you mentioned earlier are when women actually walk about with them. My understanding is that if they start to wear off they need topped up really quickly or the effect is lost.
In our unit there is a continuous infusion of weak local anaesthetic dripping in all the time through a pump after the epidural has been sited. Top ups are only given if there is breakthrough pain. As I said women can freely move their legs and reposition themselves in bed.
There is more to epidurals than meets the eye

Thank you Mears. Very clearly explained, as ever.

I had a epidural in place during labour..and had a top up every hour, so 12 in total. Well, I was given what was refered to as 'the good stuff' before I went for the c-section..and guess what..it didn't work! lol! They were quite shocked when they were testing me to see if it could work and I could still feel everything. So, they flipped me on my side and did a spinal block, which after a few mins worked fine, so I was totally numb!

Aloha, I had an epidural when my son was born and it was exactly as mears has described. I could reposition myself on the bed, wiggle my feet still, and draw my legs up for the final push at the end. I definitely didn't ever feel claustrophobic, although a friend of mine who had an epidural for a Ceasarean did have that feeling (the feeling seemed to even extend to her chest she said?). I went into my labour thinking that I might be able to cope all the way through without more than gas and air, but in the end opted for the epidural when, after 12 hours of labour, having been told I was 10cm dilated but with an anterior lip which should even out soon, was re-examined by a different, non-student midwife, and told I was only 5cm! That set me back a bit and at that point I went for the "big e". It was fantastic, totally transformed how I was feeling and my son was born 3 hours later with no further intervention.

Another quick update, they have agreed to my repeat c-section as requested, though not with good grace!! Anyway, it's all booked for 19th December

Glad to hear that you have been able to get agreement for the delivery you wanted. Now you can relax and enjoy the rest of your pregnancy.