Anne Rogers wrote:
I chatted with a friend on Sunday and it's brought a lot of worries back
to the surface. I think she feels a that I'm a bit too relaxed about
just seeing how things go and really fears that I may injure myself
during birth.

I've basically been working on the principle that I'll get warning and
can take appropriate action, but I realise this may be partially flawed.
After my first birth, my pelvis and hips were very unstable for a few
days, which nearly resulted in some interesting falls and whilst I was
in hospital I was basically confined to bed as I couldn't safely get
anyway.

This will be a third birth, not a first birth, my ligaments and muscles
will be in a different state to how they were then. Also that birth was
not of a physically normal baby, IUGR meant his fontanelles were
significantly enlarged, which probably meant an awful lot more head
molding than average occurred.

All of which means I'm back in the groove of worrying that perhaps 3rd
baby, plus the injuries of 2nd time around, plus a normal baby
(hopefully), could turn out to be too much, even if I am feeling tip top
in the run up to the birth!

But unfortunately it seems like that is an unanswerable question and
I've really no idea how to approach resolving that.

Well, you've got a few different choices available:

1) Prioritize a non-emergent c-section (in other words, ideally
decide before labor if you'll need a c-section). If this is
your priority, then you have the least chance of a homebirth
or a vaginal birth. On the other hand, you maximize the chance
that if you do have a c-section, you'll be able to plan it
how you want it, and planned c-sections are slightly less
risky than unplanned c-sections.

2) Prioritize a vaginal birth (and/or homebirth). In this case,
you go ahead with the homebirth until and unless something
materializes to suggest that it's not the best option. This
maximizes your chance of a vaginal birth or homebirth, but
also maximizes the chance that a c-section, if needed, will
be an emergent c-section. It also leaves you wondering and
worrying about how things might go.

3) Try to balance the two. This might mean something like
attempting a vaginal birth, but with a very well planned
out c-section option. It might mean giving up the homebirth,
which might result in lowering the chances of a successful
vaginal birth or increasing the chances of a vaginal birth
with injuries, depending on the care providers and their
skill with potentially tricky vaginal births. On the other
hand, your backup plan is somewhat more robust.

Do you have a good idea what the worst case scenario is with a
vaginal birth? Is it likely that trouble will announce itself
in advance (i.e., if you are about to do damage, will you know
in time to switch to plan B, or do you only know after the
damage has been done)? If you can't know with relative
certainty that damage is about to happen, can you know that
if all indicators stay within certain limits that damage is
*unlikely*? What are the relevant indicators?

I think what you need to think through with your care providers
is what the indicators and thresholds might be, and what their
predictive power is.

Personally, I would never go lightly into a c-section. I think
the downsides are more numerous than many will admit. I have
a friend right now whose grandson is going through some medical
difficulties that may have long term consequences that I highly
suspect to have been related to birth injuries due to a possibly
unnecessary c-section, though no one comes close to admitting
that. (Of course, I don't know for sure, but I do believe I
smell a fish....) So, my natural inclination is to work hard
to give a chance at a low intervention vaginal birth. That
said, there are definitely times when the planned c-section is,
on balance, the lower risk choice. I think the key discriminating
factors a

1) Worst case scenarios (on either side)
2) Quality of information available on which to make decisions
3) Availability of information on which to make decisions
(before labor, during labor)

You'll never have all the information you'd like, and the
information you have will never be as accurate or predictive
as you'd like, but you take what you can get, evaluate it as
critically as you can, and then go with your informed gut
instinct.

Best wishes,
Ericka