Would you / have you book(ed) ELCS? Why?

[throughthesunroof]

I'm sure just like everyone else - I'd love an uncomplicated, intervention-free, vaginal birth for DC#1, but the odds are less than even.

Very afraid of damage from episiotomy/tear and worried my wishes for an EMCS will be ignored in the moment because we give a vaginal birth-centre based delivery a go and end up needing interventions. Even if that results in EMCS, if the 'damage is done' it's too late.

1 in 3 new mums in my local trust deliver by Caesarean, 2/3 EMCS and 1/3 ELCS.

Given these odds, and my concerns, would you book ELCS and leave it at that? Or give it a go? Book a growth scan privately to see what measurements look like? Or is it irrelevant - are my dimensions (small in every direction) more important?

Especially any obstetricians / gynaecologists / friends and relatives of the same - I hear a lot of people say "my mate / SIL / DB etc is an obstetrician / surgeon / doctor etc and had all their kids by ELCS" - is this true?

I'm not ignorant of the realities of surgery vs vaginal delivery, risks to this and subsequent pregnancies / deliveries (although most of what I've read seems to overstate these risks), implications for recovery and establishment of breastfeeding etc - but my own body is high on my list of priorities. Hope that doesn't cause offence; I realise it sounds selfish and princessy.

Grateful for thoughts, thanks in advance.

Well you might end up with a tear or episiotomy from a vaginal birth/instrumental delivery but equally you might have complications from a CS so it’s hard to predict.

I am a doctor and I opted for vaginal birth, I had a lovely labour and got to 5cm at home and then to fully dilated in the birthing pool on gas and air but my son was the wrong way round and so I ended up having forceps and had an episiotomy AND a third degree tear. I’m not going to lie, it was pretty sore for the first 4-5 days but it has all healed beautifully and I’ve not had any problems with continence. If I could turn back time and do it again I still wouldn’t have an elective CS. I wouldn’t have wanted to miss out on the experience that I had even though it didn’t end the way I wanted.

It’s also not true that doctors all have elective sections - I think it’s about 30% that do and it tends to be more the non-obstetricians, particularly GPs, that do. I know an obstetrician that had three home births. I did three years of obs and gynae before switching to my current specialty so I was definitely in a good position to make the decision!

Well all you will get is women describing what they did, I had two elcs but I’ve no way of knowing what vaginal deliveries would have been like for me - as I’d suffered from issues in that area for years I expected a delivery to be very painful. I have always found smear tests painful for example. What concerned me more was the aftermath of tearing rather than the labour itself. My sections were great, I don’t have any feelings of missing out on something or indeed failing (I had dc against the odds so felt it was a success to get there at all).

I am thinking about ELCS. This is my 2nd child and my first birth ended in an EMCS for reasons that are unlikely to reoccure. But once you have an c section a vaginal birth does carry more risks. I was very ill after my EMCS (spesis) and looking after a new born while recovering from major abdominal surgery is not easy.

To be fair I didn’t find the surgery a difficulty when it came to looking after a newborn (it was just the looking after the newborn part that was hard!) but it was harder when it was a newborn and an older child. You didn’t do mug active stuff for the first few weeks anyway (sitting down feeding mostly) and by the time I wanted out of the house my wound was healed. (I don’t mean I didn’t leave the house at all - just driving/getting the bus type journeys I left till 6 weeks)

I had an ELCS and loved it. But I can’t compare it to an EMCs and those depend so much on the circumstances prior to it. I also had a vaginal birth previously with my stillborn son. While traumatic, physically that was fine - I recovered sooner than the ELCS, had some minor stitches and didn’t have an epidural (there was no time after we found out there was no heartbeat late in labour).

My tuppence?
Go into birth with confidence and faith that your medical team will have your best interests at heart. If you don’t have that faith (and I didn’t actually the first time around but kept being told it was because I was being a precious first time mum and I need to just suck it up) then change hospitals or ask for an ELCS or whatever is going to make you comfortable.

If it is only the anxiety around giving birth then try hypnobirthing and trust that loads and loads of women have simple vaginal births.

Sorry in advance for this very long response. I've just been thinking about this a lot and would love for all of my research to help someone else! :) I'd be happy to email papers if anyone is interested and can't access them.

I think considering ELCS is not selfish at all, or at least, not in a bad way. Your health is extremely important to your quality of life, and being ill and depressed from your birth injuries is not going to help your baby in the slightest. Besides, instrumental birth and EMCS carry much higher risks to the baby as well as to you.

My main considerations, if it helps at all, are:

• At my age (32) almost half of planned vaginal births in the UK end in either forceps/vaccuum birth (22.5%) or EMCS (25.7%) (Li et al., 2014)
• Both of these carry dramatically higher risk to both mother and baby as compared to ELCS, for example perineal injury (e.g.Pergaliotis et al., 2014; Landy et al., 2014; McPherson et al., 2014) and neonatal brain damage (Badawi et al., 1998; Towner et al., 1999)
• Severe tears are immediately diagnosed in about 6% of vaginal births, and this rate goes up by 5-6 times after instrumental birth (Gurol-Urganci et al., 2013; Pergaliotis et al., 2014; Landy et al., 2014). However, many tears go undiagnosed (and untreated) as evidenced by an ultrasound study that found anal sphincter defects in 80% of forceps deliveries (Sultan et al., 2013). Fecal incontinence symptoms affect about 40% of women overall (Dudding et al., 2008; Pollack et al., 2004), with 50% of those having permanent damage (Sundquist, 2012; Pollack et al., 2004).

As you say, the NHS information severely underestimates the risks of vaginal births and overestimates the risks of ELCS, to the point that some of the statements are flat out contradicting their own referenced sources. Largely this is because they conflate ELCS with EMCS and compare the combined risks to an uncomplicated vaginal birth. If you haven't already, reading the full NICE guidelines (www.nice.org.uk/guidance/cg132 /evidence/full-guideline-pdf-184810861) is very informative. This actually has a table that compares planned vaginal births (including those ending in forceps/EMCS) to planned CS, which is the relevant comparison to make before you know the outcome of the birth.

As for the claim that many obstetricians choose ELCS for their own births, the evidence is slightly disputed but there have been several studies showing that this is indeed the case. The most well-known study (Al-Mufti et al., 1996) found that 31% of female obstetricians in London requested ELCS.

Hope this helps at all. Please don't let anyone tell you that you are 'being princessy'! Only you can weigh up the risks and benefits to you and your baby.

I think it depends on how so many factors like how many children you want in total, your own set of unique risk factors and your own set of preferences and risks you are happier to take in childbirth.

I would do lots of research on statistics. Also consider things like going overdue and being recommended induction- the induction stats can often be even worse for emcs/instrumental deliveries so you may be happy having a spontaneous VB but an ELCS rather than induced birth .

Largely this is because they conflate ELCS with EMCS and compare the combined risks to an uncomplicated vaginal birth.

This winds me up so much! Women choosing to have an ELCS completely avoid EMCS so persuading women against choosing ELCS with those statistics is just utter madness. It is those attempting VB who need to pay attention to emcs stats. Why did they think it’s a good idea to put the information together like that? Makes no sense at all and is dangerously misleading.

The most well-known study (Al-Mufti et al., 1996) found that 31% of female obstetricians in London requested ELCS.

In other words the majority (69%) opted for vaginal birth.

True, but I think the crucial point is that the percentage is much higher than in the general population. Of course for many women, including obstetricians, the benefits of VB outweigh the risks (often faster recovery, a more natural experience, option of home birth, visible scar, etc).

Will definitely be booking an elective for my next baby ( when it happens as ttc no 2) .
I had an awful time with baby number one, I was induced over 5 days, only ever getting to 1cm dilated. My body kept stopping and starting. This worries me that this may be the norm for me and I just don't dilate. Those 5 days were awful filled with dread and anxiety in the hospital ward as I didn't have a clue what was going on. No one explained anything to me. I originally went in with reduced movements at 37 weeks and they wanted to induce or do a c section. They didn't ask me what I would prefer and that's why I was induced.
On day 5 of being in and no progress they finally decided to perform the c section as baby was not happy and heartbeat had dipped. I was booked in for around 4pm and then went for one at 11 because of his heartbeat ( they didn't actually tell me this but I JUST KNEW , I could see it on the monitor and kept asking. I think they didn't tell me because I was such a mess of nerves and anxiety and it would have made it worse)

The c section for me was a brilliant experience. The team were great and made me feel so at ease. The recovery wasn't bad at all and all went pretty smoothly. The worst part was getting up for the first time but after that it was fine and I made quite a quick recovery. I had some really lovely nurses helping me out as I have chronic fatigue syndrome and was taking longer to feel ok and needed extra drugs lol!!

To be honest with you I don't know why I didn't demand a c section with baby one, due to the chronic fatigue and the fact I was terrified by vaginal birth , even thinking about it I feel panicked. It's something my midwife never spoke to me about.

I've learnt a lot from having baby number one that I need to be more assertive. And not just go with what I think the midwife thinks is beat because at the end of the day you know your body and you k ow how you feel. Midwives do a brilliant job but we know our bodies best.

Does that 31% include ALL elcs?

Yes I suppose the majority opt for a vaginal birth so it does seem to get a bit exaggerated (I’ve heard people say ‘nearly all’ drs go for a planned CS etc) but I still think it’s telling that the percentage is still much higher than the overall rate.

I’m a doctor (not an obstetrician) and had two planned sections. It’s the safest way to deliver (for the baby, not the mum). Both mine were ivf babies, difficult anxiety ridden pregnancies and to be honest I wanted some control over the situation. Both were lovely births and recovery was quick (I’m 3 weeks post section now and completely pain free, able to drive, look after 3 year old etc).

Simaler experience to @welshweasel here, very anxious pregnancy.

Multiple mcs and missed mcs. Scanned weekly. Consultant recommended Elcs as safest delivery for baby, so I went with that.

Recovery was absolutely fine.

I’m going to push for one if I get that far.
I’ll be 41, thisvwill be my only baby (currently nearly 10wks).

I want baby out quickly and safely, I am convinced I’ll end up with an EMCS anyway. I have the smallest pelvis, no hips and no desire to try. All the women in my family in recent memory have required EMCS, we are not designed to deliver babies.

Currently have high blood pressure so optimistic I might get one for medical reasons anyway.

I assume the 31% of female obstetricians is 31% of female obstetricians who were pregnant in that particular year, not 31% of all the female obstetricians there are? (Obviously if it were the latter that would suggest that virtually all female obstetricians chose ELCS!)

Either way, 31% requesting an elective section is still many many times higher than the rate of maternal request sections in the population at large. I think that the rate of maternal request sections in the population at large is under 5%.

I wonder how many obsestrians and other hospital based doctors have their babies later in life and therefore are more likely to have complications which mean ELCS would be a preferred delivery route?

I elected for a c section. First birth. I had severe pelvic girdle pain and was pretty much housebound... my baby was very large and I was extremely scared about the potential birthing experience given those two factors. My sister had an incredibly stressful vaginal birth a couple weeks earlier and this also contributed to my anxiety, she took about 9/10 weeks to recover.

My c section was fairly relaxed though my placenta was unknowingly low and my blood vessels didn’t close properly resulting in a large blood loss. This affected my colostrum production and I had a stressful few days not being able to feed my baby who lost a lot of weight. Had to top up with forumla which I really didn’t want to do and keep expressing to try and stimulate my milk production as baby lost a whole lb in a few days. Fast forward a few days and the pain was very manageable, my milk came through, stopped he forumla and my baby started building weight.

Overall I see it as a positive experience, I was up and about a lot sooner than I thought, baby is doing really well and it is quite nice not worrying about vaginal damage I have to say, scar is very neat and low down.

Ultimately no one can tell you best course of action as it’s so personal.... hope you end up with the delivery you want xxx

I will be electing for a c-section with DC2. My first birth was horrific. Recovering from a severe tear (patched up under GA), a PPH and sepsis was bloody hard work. I know recovery from c-section can also be difficult but I feel as though there's a bit of a myth that delivering "naturally" means you're up and about quite quickly. You definitely aren't if it all goes wrong! And my birth was anticipated to be low risk - I was in my twenties, healthy bmi, low risk pregnancy, no underlying health problems. So it can happen to anyone.

@Jackshouse that’s a good point. You would probably find the ELCS rate higher than average for women who are lawyers or women who earn six figures or who are educated to more than a degree level or something, probably representing that these women are just older more than anything else (also maybe able and prepared to fight their case a bit more strongly, which probably also applies to doctors).

The obstetricians study was a questionnaire sent to 282 obstetricians/consultants in London. Of those 282, 73% returned the questionnaire. Of the female participants that responded, 31% answered that they would choose ELCS in their own (hypothetical) future pregnancy.

I could have written this post word for word @throughthesunroof I don't think there is anyone who can help make this decision for you (if only there was a crystal ball to see how your birth would go!) but I hope hearing my experience will help.

I'm 30 weeks pregnant and have been suffering with bad anxiety about giving birth for the whole pregnancy. I'm perhaps unlucky that I have a few people close to me who has suffered with bad tears and long term consequences that the anxiety has taken all joy out of the pregnancy.

I'm lucky that my midwife has been great and really understanding - even though I end up in tears at every appointment! With her help, I've been to see the Consultant Midwife and am seeing the Obstetrician in a week to book in my ELCS. I've also been receiving counselling to help verbalise my fears and to try and reduce some of the anxiety.

I haven't decided 100% to go ahead with the ELCS but feel that having one booked will help give me the space to consider whether or not I feel able to consider a vaginal birth and associated risks.

The one thing all the professionals involved have reiterated to me is that mental health is just as an important consideration as physical health when it comes to booking an ELCS. It is not the 'easy way out', and there are risks to all methods of giving birth.

I wish you luck with your decision and hope that your midwife and trust are as understanding as they have been with me

I had an ELCS (breech baby) and then a VBAC so I’ve had experience of both. Broadly, both were fine and great experiences as I got to meet my babies! But I preferred the VBAC. I felt more in control, and the recovery was MUCH easier. I’m talking about a few days versus 6 weeks. And I had an episiotomy / forceps etc, it wasn’t pretty! No long term issues.

No one can answer for you as a vaginal birth is unpredictable, but remember the majority of women have these and the majority have no long term issues. I understand your worries but your body is going to change due to pregnancy and in the nicest way, you have to deal with that.

I am tokophobic and the only way I would give birth is an elective. If I can't get it on the NHS I will go private. Not only do I have the fear, I also know the facts as stated above by Hipstercat from doing my own extensive.

ALSO

"Either way, 31% requesting an elective section is still many many times higher than the rate of maternal request sections in the population at large. I think that the rate of maternal request sections in the population at large is under 5%."

• That is because MANY hospitals "don't allow" Maternal request despite the NICE guidelines - look at the recent research done by Birth Rights etc on this and the freedom of information requests they sent out to many trusts.

From my research, many women know this and push for it on mental health grounds (even if it's just a " maternal request" ). And it also seems to be standard with some trusts that if you make a maternal request you are sent along to see Perinatal Mental Health.

Impossible to say what will be best, isn't it. My biggest thing was to avoid forceps. I told the consultant that I will never consent to forceps. She said of course - except in an emergency she would use them. No thanks. I couldn't get the image out of my head of myself, lying on the bed screaming in agony after days of labour, while the doctor shoves forceps inside and rips the baby out, being mentally traumatised and incontinent forever - and knowing it I was my fault because I could have avoided it if I had just spoken up and insisted on a cs.

Of course that may not have happened. But I just couldn't take the risk.

In the end my bub was breech so I would have had one either way.

It was a really great experience. Very little pain, was able to do everything for baby, going for walks in a park after a few days, lifting the pram and driving after a week.