Category: csections commentary

Some women seem to be taking matters into their own hands when attempting to address the issue of whether or not a caesarean birth places babies at a disadvantage in the development of their microbiome (the colonisation of their gut with health bacteria).

In recent years there has been a lot of talk in the press linking caesarean born children with a higher incidence of obesity or asthma. Such media scaremongering is not helpful for those mothers whose medical situation has meant a caesarean has been a necessity and whose recovery has already been hampered by emotional trauma.

A recent study looking specifically at birth mode and a baby’s microbiome found there to be no lasting difference even as early as 4-8 weeks after birth, particularly if they are also breastfed. Chu 2017

Similarly, while some studies suggest there is a moderate risk of obesity in children born by caesarean, most fail to acknowldge that maternal BMI during pregnancy as well as maternal and paternal BMI post birth are also found to have an noticeable effect. A study attempting to evaluate a collection of studies on this issue still only found moderate risk and could not rule out the above confounding variables. Li 2013

And on the issue of asthma, studies are also contradictory and inconclusive, at best finding either no link, Maitra 2004, or include significant additional factors such as prematurity, maternal asthma, allergic parents, being born with respiratory difficulties etc. rendering the results unreliable. Debley 2005, Roduit 2008, Smith 2004

Despite this, the media continue to propogate such stories, despite the fact that even the research papers themselves rarely say anything more concrete than for example: “It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births”.

Instead women are putting their babies at risk through inadvertent exposure to dangerous STIs including HIV, chlamydia, herpes and gonorrhoea.

Dr Patrick O’Brien, from the Royal College of Obstetricians and Gynaecologists states: there is “no robust evidence” that vaginal seeding actually has any health benefits to a baby. And a colleague leading the review of studies looking at vaginal seeding, Dr Tine Dalsgaard Clausen, Consultant obstetrician at Nordsjaellands Hospital, Denmark adds “Currently, there is no evidence to show that the potential long-term benefits of vaginal seeding outweigh the risks or costs associated,…it’s important that healthcare professionals promote other factors that are known to improve a baby’s colony of bacteria, such as early skin-to-skin contact, breastfeeding and a healthy diet.”

Until there is robust evidence that this technique is both safe and effective, parents could be well advised to evaluate the megre information presented in media stories and review current research for themselves.

In 2011 the UK National Institution for Clinical Excellence (NICE) recommended that women be allowed to make a request for a caesarean delivery, even in the absence of any recognised medical need. Despite this, a recent Freedom on Information request submitted by the Daily Mail found that:

• 21/91 hospitals do not offer maternal request caesareans
• In four hospitals where Maternal request was supported, bosses rejected requests on cost grounds
• Several hospitals insist on mental health counselling prior to giving agreement for a caesarean (this is unfortunately a recommendation in the 2011 NICE guideline – completely failing to recognise a whole group of women who have made an informed choice to request a caesarean)
• Only four hospitals offer Maternal Request caesareans even though their Clinical Commissioning Group do not fund it

Kim Thomas, of the Birth Trauma Association, says in response to the findings: “Women usually have very good reasons for requesting a planned caesarean. Often they’ve already had one traumatic birth and want a less frightening experience next time round. Denying these women their request is cruel, and goes against Nice guidelines.”

Similarly, campaigner Pauline Hull, said: “Women are increasingly choosing a caesarean birth because they’ve decided it’s safer for their baby and safer for them. The maternal landscape has changed. Women are older, heavier, and having fewer babies; babies are heavier.”

Incredibly, Trusts are still using cost as justification for these rejections and define policies to drive down their overall caesarean rate. Trust managers are failing to join the dots…

The costs associated with a straightforward, uncomplicated planned caesarean are actually less than many medicalised vaginal births. This is because unless a vaginal birth is totally straightforward and natural (i.e. not involving any form of medical intervention or pain relief and Mum and baby leave hospital the same day), the costs immediately begin to creep up. Over 50% of UK births involve some form of intervention (NHS Information Centre statistics). In the USA, 67% of births involve anaesthetic, 30% of women are induced and 13% have an episiotomy (Listening to Mothers – USA). You can see how the cost arguement immediately starts to fall apart.

As far back as 2003, studies revealed that just adding induction using pitocin “nullified any cost differences; if epidural anaesthesia was also used, total costs exceed the cost of elective caesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective caesarean delivery.” Bost 2003

“A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by caesarean section. With the balance in favour of benefit for the baby from delivery by caesarean section, it is now difficult to sustain the argument favouring vaginal delivery…A critical evaluation of costs indicates that there are probably few grounds for denying women their request for caesarean section for economic reasons”. Morrison 2003

And this is before you start looking at the cost to Trusts of longer term issues arising from vaginal birth. Studies reveal the long-term risk of stress urinary incontinence and pelvic organ prolapse surgery is significantly higher for women giving birth vaginally and of course there are significant costs associated with each repair work.

Come on hosptial pencil pushers – JOIN THE DOTS!

Flexibility is key!

You may have lots of ideas and preferences but they need to be just that – preferences.

“…have a plan A, have a plan B, go down to a plan G or K if you need to.” Elizabeth Duff (Senior Policy Advisor for the NCT)

In reality  no-one knows how things are really going to pan out on the day. Keeping preferences flexible ensures that the team looking after you have a good idea of the direction you hope your birth will go, but have the space to be able to suggest other things if it seems like the plan needs to change.

However, this is where your knowledge becomes most important.

For example: If you are hoping to avoid a caesarean, then it is useful to know that some hospitals place what can seem to be quite arbitrary timescales on 2nd stage labour. Knowing this you can ask very specific questions about your status before making a decision regarding drugs to speed up your labour.

Another example: If you know you want to hold your baby skin-to-skin while still in theatre, then it is important to specify this in your birth guide so your gown can be put on backwards and the screen positioned to make this possible. Both these things need to be agreed in advance. If it is your birth guide, the discussion cannot be forgotten.

Know your facts and if in doubt always ask more questions.

A google search will generate a list of lots websites discussing vaginal birth plans. Caesarean plans are a little more tricky to find, but not impossible and in ‘Caesarean Birth: A positive Approach to Preparation and Recovery’ there is a whole section dedicated to the issue of ‘Birth Guides’, including: possible content, structure and key things to think about.

FANTASTIC!

A well known TV star (Helen George) from Call the Midwife has revealed she made a positive, informed decision to have a caesarean in an NHS hospital, stating it should be a valid choice for any woman.

“Helen George called for a national conversation about C-sections, saying they can be a positive choice for women and should not be restricted to medical emergencies…I’m not against natural birth, I’m pro whatever you feel is right for you.” (Radio Times)

While George reveals that the impetus for an alternative to natural birth arose prior to pregnancy as a result of her exposure to negative birth stories and themes while working on ‘Call the Midwife’, she says she went on to balance the fear with “lots of research” and decided that “if [she] ever got pregnant, that’s what [she] would do”. (Radio Times)

We wish her and her family all the best for her adventure into motherhood.

The Royal College of Midwives (RCM) have announced they are ending their decade long campaign promoting ‘normal’ birth. ABOUT TIME TOO!

The campaign no doubt grew out of good intentions, in particular encouraging a return to more natural births. But as time has gone on, it has meant an increasingly unrealistic form of antenatal education has taken hold and become the norm. Incredibly with a caesarean rate of around 25% it is not unusual to attend UK antenatal classes which dismiss caesarean birth in a matter of minutes and which fail to talk about the implications of a ‘cascade of interventions’ and how to rationally manage this.

The RCMs change of heart has unfortunately come far too late for the many women who have had ‘normal’ birth promoted at the expense of informed guidance and whose expectations have been mis-managed to the extent they have experienced significant negative reactions to their birth. And let’s be clear about what this can mean:

• delayed bonding
• breastfeeding difficulties and early cessation of breastfeeding
• no further pregnancies (even opting to adopt)
• prophylactic caesareans
• etc.

While I do not dispute the lack of sufficient funding in recent years has led to the woeful situation maternity care finds itself in, (which no doubt contributes to the increase in medicalised births-for reasons of both expediency and cost-effectiveness), this is however the current reality (albeit unacceptable). Women need information at their fingertips relating to ALL modes of birth and ALL interventions if they are to stand any kind of chance of coping with and feeling in control of their birth.

For a long time now, those of us monitoring maternity care have taken issue with the use of the term ‘normal’ with its implication that anything other than a totally natural birth is therefore ‘abnormal’. Women hear a lot about vaginal birth and coping techniques and practically nothing about interventions and caesarean birth. This absence has left many women so poorly informed that expectations rarely match reality. No wonder then that the incidence of emotional trauma has been rising.

It is great that the rhetoric around birth will be removing reference to ‘normal’ birth. However, I take issue with the blame the RCM appear to be placing at the door of the women themselves. On the one hand saying they don’t want to “contribute to any sense that a woman has failed” but then adding “unfortunately that seems to be how some women feel.” They do not appear to acknowledge the role their campaign has played in encouraging midwives to emphasize one mode of birth over another to the extent that balanced information is almost impossible to come by in many UK classes, ostensibly setting women up to fail.

As the Guardian article points out “the campaign was criticized in an inquiry into the deaths of 16 babies and three mothers at Furness general hospital in Cumbria between 2004 and 2013.” and found that the campaign appeared to influence a group of midwives to such an extent as to contribute to “unsafe deliveries due to [the midwives’] desire to see the women give birth without medical interventions “at any cost”.”

At its most extreme the campaign appears to have contributed to the loss of life-though the RCM strongly deny this. But at the very least it is clear the campaign has actively encouraged women to write birth plans specifying little or no pain relief and to be distrustful of all interventions thereby failing to prepare them adequately for the current realities of birth in the UK.

This change in rhetoric is very welcome, but only time will tell whether those midwives who strongly emphasize natural birth will actually adapt to offer a more balanced, open-minded approach to education, birth planning and the support of birthing women.