Category: csections commentary

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.”

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.

Antenatal advice may ‘perpetuate C-section myths’

With over half of UK births involving intervention, I believe women need to know more about their options so they can assess the risks for themselves and play an active role in the direction of their labour. Unfortunately some antenatal education classes shy away from this difficult subject leaving women in the dark about these important interventions. I highlighted this point for a BBC article.

“All too often the risks of vaginal birth are significantly downplayed while caesareans are portrayed as an intervention to avoid wherever possible, with those planning a Caesarean labelled selfish or “too posh to push”.”

“Unfortunately the majority of women still understand so little about C-sections that it should come as no surprise to find that many find their experience, if they have one, extremely traumatic, so severe in fact that some go on to develop post-traumatic stress disorder, while those who want or need to plan a Caesarean are left totally unaware of the opportunities for making their birth feel special and personal.”

While not all classes have such glaring omissions it remains the case that the quality of antenatal education is quite variable and “Unfortunately the toxic combination of out of date or inadequate information and biased advice means that women will continue to face their birth with huge gaps in their knowledge leading to unnecessary trauma.”

Maternal requests should be supported within the NHS

NICE have issued (subject to typo corrections) the new version of the Caesarean Section Guideline. There have been a number of significant steps forward in this version. In particular the following:

  • “Recommendation 38: For all women requesting a CS, 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.” pg 12
  • “Recommendation 39: An obstetrican has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.” pg 12
  • NICE “agreed that it is important that women are presented with evidence based information in order that they are able to make an informed decision. The reported benefits and harms can then be discussed with each individual woman to help her make decisions based on the relative trade off between the two modes of birth interpreted in light of her own circumstances.” pg 63
  • NICE “agreed that when discussing the risks and benefits outlined in the table, the healthcare professional and woman also need to consider the woman‟s individual circumstances which affect the risks associated with vaginal birth and CS such as previous abdominal or pelvic surgery, impaired mobility from pelvic girdle pain, or care of other children. It is also important to discuss the number of future babies that the woman and her partner are planning as some risks such as placenta praevia increase with an increasing number of CS.” pg 63