Category: csections commentary

Understanding the caesarean rate in your country, and specifically in the hospital where you are going to give birth, is really useful when devising your birth plans.

Like it or not, the preferences and beliefs of those assisting with your birth are going to play a part in the advice you are given as your vaginal birth progresses.

Planning a vaginal birth, is just that – a plan – it is not a guarantee. So knowing a bit more about the conditions under which you may need to negotiate is going to be an important factor in the outcome and knowing the rates plays a part in this.

Let’s take the UK as an example. The caesarean rate has been 1 in 4 for years. In 2018 it climbed slightly – getting nearer to 1 in 3. However, if you look at the rates for individual hospitals in 2016, some were 1 in 3, others 1 in 5. So if you are hoping to avoid a caesarean and your hospital has a rate of 1 n 3 rate, you might want to know what it is that makes it different from one with a 1 in 5 rate. This knowledge is just as important if you are hoping to plan one.

Playing a large part in these differences are the policies and preferences of the clinicians and the hosptials they work in. You might be able to get a bit of an idea by asking the PALs (Patient Advice and Liason Service) team at your hospital for any information about the caesarean policy (non-medical electives may be strongly discouraged for example), any limits placed on the duration of 2nd stage labour and the VBAC policy etc. They may or may not show you this. So also talking to local antenatal support groups and other mothers who have already given birth in your hospital might give you a bit more information.

Unfortunately, despite an acknowledgement by the World Health Organisation that there is “no empirical evidence for an optimum percentage” for caesarean deliveries, some hospitals are still directing staff to drive down their caesarean rate. While this is often claimed to be for medical reasons, it is in no small part also a cost cutting exercise. Don’t get me started on the problems with this – suffice to say material used to support this claim are hugely problematic because they generally group all caesareans together and then compare their cost with natural, drug free births. The two are not comparable – an emergency caesarean does not have the same costs as a planned caesarean, and a medicalised vaginal birth is not the same cost as a natural birth. In fact the cost of a medicalised vaginal birth and an emergency caesarean are almost the same and only around 50% of planned vaginal births are entirely natural (NHS Information Centre 2008). Enough said.

Anyway, it is worth trying to at least work out what you are facing at your hospital as you make your plans. In particular, understanding what constitutes a recommendation versus a necessity when being asked to go ‘off plan’ and then having your opinion backed up with solid information will help you negotiate.

Incredibly some women are accused of this to their face, while others are guilt tripped by  the media. In fact, the figures used to support such an accusation are very misleading. In the majority of sources, figures actually incorporate all maternally requested caesareans including those which follow recommendations from the mother’s practitioner, i.e. when medical situations or clinician experience indicates that a caesarean might be the safer method delivery.

Where the media talk about unnecessary caesareans, factors such as increased age of first time mothers; practitioner’s desire to reduce operative vaginal deliveries; an increase in the overall incidence of fetal monitoring and a fear of litigation are frequently ignored or conveniently overlooked.

Even if all these factors are taken into account, the figure describing women choosing a caesarean in the absence of a medical need still invariably includes women making the choice because of tokophobia (fear of childbirth), previous traumatic birth experiences or trauma arising from sexual abuse, and others making a positive, informed, prophylactic choice.

And if all of that is not enough. The figures are unable to take account of the discrepancy in the coding of births which can occur between hospitals and the financial and policy decisions made by individual hospitals, as a result of which ‘apparent’ rates of intervention can vary significantly. For example, my second caesarean was coded as an emergency by my hosptial, despite the fact it was a planned casearean, simply because I happened to go into labour before the planned CS date – there was no emergency, it simply wasn’t at the time scheduled, which of course helped make their elective numbers look that bit lower.

At the end of the day, very few women make such an important decision without good reason and such a slur is not only disrespectful but dismisses the complexity of the decision-making the majority have gone through.

Many women will experience a caesarean delivery (for example 1 in 4 births in the UK and Spain, 1 in 3 in the US, 1 in 2 in Turkey, 1 in 5 in France).

Some of these caesareans will be emergencies, some will be planned. For those which are planned – whether for medical reasons or not – there are adjustments that can be made to the birth plan which can make for a more ‘natural’ experience.

The idea of ‘natural’ caesareans was first discussed over a decade ago by Senior Midwife Jenny Smith (at Queen Charlotte’s and Chelsea Hospital in London) and her colleagues Professor Nicholas Fisk, (Consultant Obstetrician) and Dr Felicity Plaat (Consultant Anaesthetist).

This form of birth is now more commonly referred to as a ‘family centred’ caesarean primarily because there has been quite a bit of push back over the use of the word ‘natural’ by those who believe the fact of the caesarean makes the experience anything but, and who were concerned the use of ‘natural’ might drive an increase in requests for caesarean delivery. (Incidentally, this increase has not materialised – in the UK at least). However, according to those who coined the phrase, the term was simply meant to convey the idea that the process incorporates a number of procedures which aim to “optimize the birth experience for women having caesareans section [by] putting women at the centre of care”.

The primary idea behind a ‘family centred’ caesarean is to slow down the surgical process and allow Mum and birth partner to participate in and/or witness as many aspects of the birth as possible. It also allows for additional environmental decisions to be made by the family rather than the surgical team.

The possibility of a ‘family centred’ caesarean is entirely dependent upon the way in which your pregnancy has progressed to date, any risk factors associated with your pregnancy and the experience and willingness of the clinicians providing your care.

So what is different about a ‘family centred’ caesarean?

In no particular order:

• Slower delivery, also known as ‘walking the baby out’
• Skin-to-skin as soon as possible – even while still in surgery – you will be asked to bring an appropriate top
• Lowering of the screen (after initial incision and baby’s head has emerged). Some hospitals will offer a clear screen instead
• Delayed delivery – extends compression while baby’s body is still in the womb to facilitate liquid expulsion from lungs
• Favourite music playing during surgery
• Favourite pillow
• APGAR tests conducted, vit k injection, attaching of labels etc. within sight (weighing is postponed till transfer to recovery room)
• Dimming periphery lights during delivery
• Delayed clamping and cutting of the cord. Birth partner may shorten or trim the cord (but not the initial clamp and cut)
• Saving the placenta

As Jenni Smith says “It is about the mother. After the incision is made, the curtain is removed and the mother is able to see her little baby wriggle out. It is a special moment that is missed otherwise…The baby remains in the abdomen for up to four minutes and the mother can look at it, see its little face and eyes, and when it wriggles out it is the parents that first determine the sex.”

Is a family centred caesarean safe?

Reports are very good “Since publication of our paper there have been no reports of complications associated with the technique. In fact, a recent study from Germany found improved breastfeeding rates, and significantly better patient experience compared to the traditional technique, with no increase in complications.”

In an ideal world a caesarean should not be planned prior to week 39 and, in the UK at least, caesareans tend to be during this week unless there is a medical reason indicating that it should be sooner.

Research does show that by week 39 a baby’s lungs are sufficiently mature to cope well with delivery. Anything prior to 39 weeks increases the possibility of respiratory problems. That said where there are medical reasons making it essential for baby to be delivered prior to 39 weeks then a planned caesarean (where all the facilities and resources needed to make this as safe as possible are ready and waiting) is considered by many practitioners as preferable to inducing labour.

What is really important during the decision-making process is the accuracy of the dating of your pregnancy, if you are unsure then you should request a re-assessment.

There is an important phenomenon all women should be aware of – the Cascade of Intervention.

This phenomenon is well recognised in the medical community and in relation to maternity services describes the idea that there can be unintended consequences to medical interventions.

Example 1:

Induction (chemical and mechanical) and the use of fetal heart monitors typically go hand in hand. Someone women do go beyond their due date and induction does become a necessary conversation. However, the use of continuous fetal heart monitoring, often paired with induction, reduces a woman’s mobility significantly, increasing dramatically the amount of time a she will spend lying on her back. This can have a notable knock on effect on her ability to labour effectively, setting off a chain of events that may result in failure to progress, ultimately increasing the likelihood of further interventions being needed.

Knowing the potential of this effect means women can investigate alternatives:

• Continuing to do nothing (for a safe period of time), labour may still commence naturally
• Request mobile monitoring, this is offered as a matter of course in some places, but certainly not everywhere. Being mobile reduces the impact of immobility, which in turn has the potential to interrupt a cascade of intervention

Example 2:

Some women want to use patient-controlled epidural as their form of pain management. This can work really well for some but some hospitals combine its use with the use of fetal monitoring. The potential for a cascade of intervention is therefore also present in this instance too as once again the woman can spend long periods of time immobile as the fetal monitor is used (albeit intermittently), setting off a chain of events that may result in failure to progress, ultimately increasing the likelihood of further interventions being needed.

Knowing that a diagnosis of failure to progress can, if unchallenged result in a caesarean means it is very important women understand:

• What really constitutes a failure to progress and when intervention is truly necessary
• The Cascade of Intervention phenomenon and which interventions can exacerbate the situation

A great source of information is the Childbirth Connection website.

“The best way to limit a cascade of intervention is to become informed, get all of your questions answered, and put plans in place in advance that will help avoid potentially harmful interventions.”