Author: admin

The ‘Good Patient’ phenomenon

The idea of the ‘Good Patient’ phenomenon may ring a few bells when you hear Birthwares’ description of how we sometimes interact with our health-carers:

“It presents with the need for the pregnant mama to please her caregivers. Often she will undertake medical tests and procedures without understanding the need for or the value of the information provided by the tests. She will attend prenatal appointments promptly and regularly, but will leave her list of burning questions, unasked, in her pocket, for fear of taking up the time of her busy caregiver. She will accept any intervention or treatment offered to her, with the implicit understanding that her caregivers know best.”

I know I have certainly done this time and again despite knowing that I have burning questions about things that are concerning me. Even with a list in my hand I have felt compelled to keep quiet because someone is frantically trying to keep on top of their own schedule. 

However it is crucial that we ask questions and do so even when we feel pressured to move on.  Each pregnancy is different and new questions will arise even if you have already had a baby. As Birthwares suggests “bring your list of questions. Lose the niceties about the weather and how hot it is. Rattle off your questions instead.” So whether you are planning a vaginal birth or a caesarean stand your ground and ask those questions. It can help to take someone with you to every antenatal appointment, even if you think you are just there to wee in a bottle, you never know what you are going to be told or what you might want to ask and a second pair of ears can mean less gets missed.

Maternal requests hits the headlines again

The maternal request debate has been in the headlines once again. This interest comes in the month when the National Institute of Clinical Excellence (NICE) will issue the latest version of their guideline on caesarean birth.

This latest review of caesarean research by NICE reveals that “In general, [caesarean section] is a safe operation, especially when performed as planned procedure.” NICE have extended the rights of women to request a caesarean birth on the grounds of tokophobia (fear of childbirth) to all women recommending “if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.” Clearly stating that “if an obstetrician feels a woman’s request for CS is not appropriate after the woman has received appropriate counselling and support, then s/he should be able to decline to support the women’s request. This does not over rule the woman’s rights to express a preference for a CS however, and in this instance the obstetrician should transfer care of the woman to an NHS obstetrician within the same unit who is happy to support her choice.”

Disappointingly there has once again been a rash of commentaries about the cost implications and selfishness of women making such a choice. Such commentaries continue to ignore the flawed data on which it is based as well as the fact that this tiny, tiny number of women who prefer to request a caesarean rather than attempt vaginal birth tyically have very good reasons for their request. For some the origin may be fear while for others it is an informed assessment of risk comparing vaginal and caesarean birth experiences and outcomes. But for a significant number the request is based upon an informed assessment of risk in relation to their own personal circumstances. An example of this latter group are those women falling into what could be considered the ‘grey’ area of clinical need. These women are often categorised as maternal request because, following discussion with their practitioners, they have been given a choice. Examples of ‘grey’ areas are breech, older mother, previous caesarean etc.

Radical childbirth – One doula’s perspective

A very interesting article in the F-word (written by doula – Amity Reed) discusses the extent to which our culture both reveres and fears childbirth and questions how this happened. Reed asks “How did we get to this place, where giving birth is something to be survived and suffered instead of something in which many women can find a sense of empowerment, accomplishment and joy?”

She believes “we are on the cusp of reclaiming birth as an awesomely powerful and completely normal event.” But what is really striking for me about this article is that Reed emphasises the importance of informed choice for everyone. “It does not mean only advocating for natural birth either, but informed choices, real choices and the autonomy that birthing women and their partners deserve, regardless of what kind of birth they choose or end up having.” This positive and balanced approach is crucial as we strive for greater levels of fairness and safety in our maternity service. “It means we hold women in such high esteem and reverence that we trust them to make sound decisions for themselves, their babies and their families.”

Amazon book review of ‘Caesarean Birth: A positive approach to preparation and recovery’

A lovely Amazon review for my caesarean book … thank you.

“As other reviews have pointed out, this book is a no-nonsense, practical and very informative guide which helps women to be prepared for caesarean as a possible outcome of any birth, and to make informed choices about the birth they want.

Although there are endless pregnancy guides available, most seem to mention caesarean birth only in passing and more than a few imply that caesarean is a drastic intervention to be avoided at almost any cost. However, as the author points out, there is no clear evidence that the overall risks for women planning small families are higher [than vaginal births]. Inexplicably, sufficient caesarean information is omitted from many antenatal classes despite the fact that many women will end up having the procedure. This lack of preparedness in itself is likely to contribute to a negative experience of caesarean birth.

It’s important to stress that that book does not promote planned caesarean over vaginal birth but rather aims to give women detailed information which enables them to consider the full range of choices for their birth, and to be prepared for the possibility of a caesarean even if they would prefer to attempt a natural birth. The author is scrupulously balanced and factual, backing up information given with detailed references. After reading it you will feel in a much better position to have an informed discussion with your medical advisers about your choices in your particular pregnancy circumstances.

One useful aspect of the book is that it distinguishes between planned and emergency caesareans. Statistics for straightforward planned caesareans are often lumped in with those for emergency caesareans performed after an attempted vaginal birth that has, by definition, encountered complications (hence the need for the caesarean). Unsurprisingly, outcomes for caesareans seem to be misleadingly bad when apples and oranges are compared in this confusing way. The author points out the difficulty of disentangling the negative outcomes often associated with caesareans from the condition or complications which lead to an emergency caesarean taking place.

This book is for those who suspect they are not getting the full picture from those with a natural birth agenda, and want clear, factual information in order to make a rational decision about the birth of their baby.”

Leigh East talks to BBC Coventry – Antenatal education may let women down

Following my article for the BBC I was interviewed by BBC Coventry for a debate on whether antenatal education prepares women effectively for caesarean birth.

I was asked why I thought women need to know more about caesareans “Women need to know there are risks with it [caesarean birth], but they also need to know that there are ways to make their birth more managable. They go into birth expecting one experience and some women come out with a completely different experience and they are, naturally, traumatised by this…But if they are told they can breastfeed in theatre, if they are told that they can hold their baby within minutes of her being born, if they are told that they can be the one to work out whether it is a little boy or little girl, (all the sorts of things that women consider important with a vaginal birth) and that they can also do these with a caesarean this can make MASSIVE difference to the way in which women perceive their birth.”

Unfortunately some antenatal classes spend little time discussing caesarean birth. Women may get a bit of information about epidurals and perhaps how many people are in the room but sometimes it is little more than this. While I am aware that not all antenatal classes brush over caesarean birth so lightly I found during my research for Caesarean Birth: A positive approach to preparation and recovery, from the interviews with countless women and indeed in my own experiences of antenatal classes that a significant number do.

So when I was asked why I thought women are told so little my response was “unfortunately it is a scary message, 1 in 4 women will have a caesarean, 50% of women giving birth in this country [UK] will experience some form of intervention, be that epidural, forceps delivery or caesarean etc. These figures are scary and a scary message to give to women when they are pregnant.”

Despite this I believe that women do need to know even very basic facts about caesareans. For example, the majority of the women I have spoken to on this subject over the last 6 years believe that a breech baby automatically requires a caesarean. This is not true and if a woman wishes to plan a vaginal birth she can do so assuming there are no medical complications identified with her birth. However the reality is that women are “up against the personal opinion of the practitioners, which sometimes doesn’t take account of the opinion of the woman. For example, if you have a breech baby there is actually no reason why, if the woman wants to deliver vaginally, she shouldn’t (assuming there are no other complications). However women are not told this because some practitioners think it is safer for mother and baby if the baby is delivered by caesarean. So then it is down to whether the woman understands this…this is where education is important, if women understand this, they know they have options and can make more informed decisions.”

A seemingly simple point can have significant ramifications for both mother and baby as well as her subsequent family planning. But to simply tell women that they can refuse a caesarean if their baby is breech is also insufficient. The number of breech babies delivered by caesarean in recent years has led, some say, to a de-skilling of some midwives in this regard. Before women are encouraged to go against a medical recommendation for a caesarean they should be encouraged to check the experience of their midwives with breech deliveries.