Q. Hi, I`m 20 weeks pregnant with my second baby (first was delivered by Elective LSCS for breech at 38 weeks). I want a VBAC for my second baby but don`t want to be restricted to the bed. I`ve been told that I have to be continuously monitored so will have to be bed bound or at least stay sitting in a chair! I understand that this is due to the small risk of scar rupture. Is there any way that I can stand, walk, pace during labour as I don`t want to stay still? Also is intermittent monitoring completely out of the question? Thank you!

A. In the past, once you had given birth by caesarean section it was virtually inevitable that any subsequent births you went on to have would also be by caesarean. This was because the placement of the cut/incision meant there was a risk of the womb (uterus) tearing during labour (this is called ‘uterine rupture'). However, a change in the place where this cut is made (called an LSCS - lower segment caesarean section) means that this risk has been reduced; in fact, research shows that vaginal birth after caesarean (VBAC) is safe for the majority of women who have had a previous LSCS. It is also more likely to be successful where the reason for your previous caesarean was because your baby was in the breech position.

However, despite the reduction in risk, there still remains a chance that the scar from your previous caesarean section could tear open during labour. This is because the scar tissue is not able to contract as well as the rest of the uterine muscle. If the scar does tear open there is a risk of heavy bleeding (haemorrhage) which can be life-threatening for you and your baby. One of the earliest indications that this might be happening is an abnormal alteration in the baby's heartbeat; it is for this reason that your obstetrician and midwife are advising that you have continuous electronic monitoring of your baby's heartbeat during labour. This form of monitoring means that your baby's well-being can be checked at all times during labour and if there are any signs that your baby or your uterus are not coping with labour these can be acted upon immediately. Other signs which can indicate that your scar is tearing include pain that lasts between contractions, vaginal bleeding and irregular contractions - your midwife and doctor will also be monitoring carefully for these.

The advice you have been given by your midwife or doctor is because they are following their professional guidelines about the care you and your baby should receive in labour to reduce the risks associated with the signs and symptoms mentioned above. Therefore, I appreciate your concerns about possibly having to be confined to a bed during labour, and while continuous fetal monitoring does not necessarily equate with having to be restricted to the delivery bed, unfortunately, walking around is not really feasible. This is because the baby heart monitors are mains rather than battery-operated, so cannot be pushed around. The value of electronic fetal heart monitoring is that it accurately records the baby's heart rate as a paper printout on the heart monitor (fetal cardiotocograph). This then illustrates where quite subtle differences are occurring and these are easier to detect and more reliable with regard to what they might mean than observations taken less frequently. However, providing it is possible to frequently pick up your baby's heartbeat, it may be possible to compromise. As it is quite early in your pregnancy, you do have time to discuss your preferences with your midwife or consultant and it might be possible for you to have a more flexible approach to this monitoring, especially in the early stages of labour. This could include using a hand-held monitor which would mean you could sit in a rocking chair, walk about or adopt various positions that can make it easier to cope with your labour contractions. You will need to ask your local maternity unit if this is a possibility as these are special machines and not all units have them.

There are other options, such as holding the ‘transducer' in place - this is the part of the monitor that is strapped to your abdomen and picks up your baby's heartbeat, and is something your partner can get involved with. Birth partners can often feel helpless watching a woman in labour, so this is an aspect of your care that they can be part of alongside general supervision and support from your midwife. This means that you are better able to concentrate on breathing through your contractions and changing position, while your partner holds the monitor in place.

As suggested earlier, it would be a good idea to speak with your midwife and/or doctor about your wishes for your labour and birth, as these can be documented in your birth plan. Where circumstances alter during labour, which might mean that it is not possible to meet all of your requests, the midwife/doctor caring for you should explain the reasons why this is the case. I would also recommend that you look at MIDIRS Informed Choice leaflets, Listening to your baby's heartbeat during labour, and Caesarean section and subsequent births at www.choicesforbirth.org

Best regards

Vicky