In a message dated 26/11/1999 22:14:40 GMT Standard Time, 
[log in to unmask] writes:

> >I wonder what your views are on vaginal birth after caesarean after 2
>  >caesareans.  I am pregnant for a third time and I am dreading the thought
>  of
>  >having another caesarean.  My first caesarean was for fetal distress
>  >(passing meconium, dipping heart-rate etc).  My second was for failure to
>  >progress (I think it was just taking too long for everybody else).
>  >
>  >I feel now that they were both due in the most part to my absolute fear 
and
>  >terror of the birthing process and lack of attention by a midwife during
>  the
>  >labour process.
>  >
>  >I don't want to go to hospital as I feel that this was definitely part of
>  >the problem for me.  I am considering a home birth and wondered what the
>  >radical midwives thought of this idea.
>  

Hi Bernadette,

I am sorry to hear that you are so feeling so bad about your previous two 
caesarean sections and so apprehensive about this particular pregnancy and 
labour.  It is quite understandable and I wonder if these sorts of questions 
would not help you in asking for clarification from the midwives and the 
doctors you may see.

First of all, I would ask to review the previous two labours: what was the 
level of fetal distress?  what was the condition of the baby at birth?  how 
big was that child - normal weight or smaller than normal or rather large?  
how long were you in labour for that first baby?

There is a rising number of caesarean sections and there are differences 
between countries, maternity units and even obstetricians within the same 
unit, so it is possible that a caesarean section is one maternity unit would 
not be one in another.  However there are babies - and mothers - who greatly 
benefit from caesarean sections.  But it would be important to work out how 
threatened your first baby was.  If he was smaller than expected, this is a 
condition that may well happen again and since that is the result of a poor 
placental function, labour is potentially quite threatening for those babies. 
 

For the second baby, the essential questions must be how long you were in 
labour and how the uterus was behaving whilst you were in labour.  You should 
also ask what the condition of the uterus was at the time of the caesarean 
section.  The major danger of prolonged labour must be uterine rupture where 
there is a previous scar.  This potentially very serious problem is increased 
for this labour.  I would also like to know whether or not you had any 
evidence of infection after that delivery.

It is possible that the complications of both your previous labours were due 
to what you put as your absolute fear and terror of the birthing process, but 
that is by no means certain.  Whatever the truth of that, the reality is that 
you now present with a third pregnancy and two previous caesarean sections.  
It seems to me that you need to weigh up the risks of hospital delivery 
versus the risks of home delivery, for yourself, for your baby and for your 
family.

These seem to me to be the questions you need to answer before making a 
judgment:
- irrespective of where labour happens, 
    what are the risks of fetal distress?
    what are the risks of uterine rupture?
    what are the chances of a normal delivery?
- how much value would you give to a home birth?
    how much to a hospital birth?
- if you chose to labour at home
    what complications could arise,
    what are the risks to you and how likely are they to occur?
    what are the risks to your baby and how likely are they to occur?
    what increased risk would transport to hospital in an emergency bring?
- if complications arose at home
    what complications could arise (there may be some differences with home 
care),
    what are the risks to you and how likely are they to occur?
    what are the risks to your baby and how likely are they to occur?

At the end of the analysis, you will have to decide if the value of the 
outcome is worth the risks.  It is not possible to do by e-mail without 
having a very long and good look at what happened before.  I suggest that you 
should discuss this very amicably with your midwife and the medical team who 
may be looking after you.  Ask questions and demand exact answers - I mean 
numbers for probabilities.

Ask yourself some penetrating questions too.  If you decide to go for a home 
birth, the midwife will have no choice but to look after you, but her ability 
to monitor what is going on will be limited because of the home situation.  
If everything turns out to be fine, that is OK.  If however everything does 
not turn out to be OK and you have rejected to suggestion - that I am sure 
will be put to you - that you ought to deliver in hospital, you will be in a 
pretty weak legal position should you decide that you want to sue.  

It is possible to have a vaginal delivery after one or more caesarean 
sections, but there are risks attached.  Of course there are risks attached 
to everything we do, but in your case your risks for yourself and your baby 
are increased because of the past history.  You cannot take a wise decision 
without being able to calculate the risks and then deciding what level of 
risk you are prepared or not prepared to take.  You may need a lot more 
information than what you have for the moment.  Make an appointment with your 
midwife to arrange the highest possible level of consultation at the 
hospital.  Make known your views very clearly and make sure you understand 
also very clearly what they tell you.  Take pen and paper and write things 
down.  Then think very carefully and measure the risks you are prepared to 
take.

There are no right or wrong answers, there are only levels of risks that we 
are prepared or not prepared to take.

In any event, best wishes to you and your family.

Marianne Mead





%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%