Category: csections commentary

At long last there is a trial of the pioneering proceedure commonly referred to as a ‘Natural Caesarean’. Jenny Smith a senior midwife at Queen Charlotte’s and Chelsea Hospital in London developed the idea 10 years ago. There are many annecdotal benefits to the procedure and women report a much better experience of caesarean birth if they have been able to give birth this way. It is hoped that a successful trial will lead to this process being rolled out across the NHS.

We discussed this wonderful technique a while ago and there is an excellent video describing the process.

“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.” Jenny Smith

The Royal College of Obstetricians and Gynaecologists (RCOG) have published a report into the ‘State of the Nation’ with regards Maternity Care. It makes for an interesting if somewhat alarming read. It seems that childbirth is falling fowl of the ‘Postcode Lottery’ that is affecting so many aspects of British life.

The report is very careful to point out that while the data quality of many of the hospitals require significant improvement, they have attempted to provide a status nonetheless.

“Some of the observed differences could be due to differences in the quality of the data submitted by trusts…over 10% of hospital trusts failed all data quality checks and [we call] for greater NHS trust engagement in ensuring that IT systems are fit for purpose.”

During our work on the 2011 NICE Guideline on Caesarean Section, csections.org and  other organisations made a case for accurate reporting on births. In particular on the importance of separating out emergency from planned caesareans and the underlying indicators leading to each birth.

Media coverage of the recent report suggests that too many women are having planned caesareans prior to 39 week gestation-even in the absence of medical need. Once again the damning ‘Too posh to push’ label rears its head. However this may not be an accurate reflection of the report, for the reasons highlighted above and until such reporting is reliably undertaken by ALL hospitals in the UK it is not possible to say with confidence what the real situation is.

NICE Guidelines are clear-delivery prior to 39 weeks should be avoided unless there is a clear medical reason for it. A baby’s lungs are less well developed prior to this time and are therefore at increased risk of complications.

WHAT DOES THIS REPORT REALLY TELL US?

That while we would like to trust our practitioners have our best interests at heart (and that of our baby), the presence of a ‘postcode lottery’ reveals that advice given to women may be biased by a combination of hospital policy and personal opinion. The hard truth is COST is a major factor in the type and level of care you might receive.

KNOW YOUR FACTS!

“We need to build bridges between midwives and doctors so we can all work together better for the best interests of the patient,” says Skinner. “At present we have a very short-term view. We make sure the baby is alive and then we leave, with little consideration for the long-term physical and emotional wellbeing of the mother.”

Anecdotally most women will know at least one friend who has required reconstructive surgery following their vaginal birth. In my case I have two friends who waited years before they had the courage to see their doctor in order to have serious issues fixed.

Why is it we don’t talk about it? Why do we seem to think that physical trauma is just all part and parcel of birth to be endured in secret?

Skinner is a co-author of a new piece of research looking into the psychological consequences of tramatic vaginal birth.

The women Skinner (an experienced midwife) interviewed were all low risk first time mothers. From a population of 850 births evaluated, 70 were identified as having major pelvic floor trauma (1 in 12) and 40 agreed to participate in the study. Of these some had given birth without intervention (14), some with ventouse assistance-vacuum (8) and some with forceps (18). Of these women 100% suffered ‘levator avulsion’ (where part or all of the pelvic floor muscles are pulled off the pubic bone on one or both sides – resulting in urinary incontinence and/or urterine and/or bladder prolapse) and 55% suffered major obsetric anal sphincter tears.

Co author University of Sydney’s Professor Dietz says “Only about 25 per cent of women get a non-traumatic normal vaginal delivery that did not do serious damage to their pelvic floor or their anal sphincter” and continues “The forceps rate has doubled in NSW over the last 10 years. At some hospitals quadrupled”.

Dietz suggests that in trying to reduce the caesarean rate, other forms of intervention are once again on the increase.

Once again the lack of balanced information is making it very difficult for women to make an informed choice about their mode of birth.

The following findings from the study make very depressing reading…

• Inadequate antenatal education (reported by 72.5% of respondants)
• No information from clinicians regarding the possibility of postnatal pelvic floor issues (reported by 90%)
• Conflicting advice before, during and after birth (reported by 87.5%)
• Partners traumatised by events (reported by 52.5%)
• Long term sexual dysfunction / relationship issues (reported by 67.5%)
• An absence of postnatal assessment of injuries (reported by 90%)
• Multiple symptoms of pelvic floor dysfunction causing lifestyle alteration (reported by 87.5%)
• Putting up with the symptoms quietly (reported by 90%)
• Symptoms of PTSD (Post Traumatic Stress Disporder) (reported by 67.5%)
• ‘Dismissive reactions from clinicians’ (reported by 65%)

Skinner and Dietz believe that physical and psychological birth trauma is a major public health issue with “forceps being the main risk factor. Only a small proportion of anal sphincter trauma us optimally repaired, and major levator trauma is rarely diagnosed and never repaired”.

If postnatally your pelvic floor exercises do not appear to be improving symptoms it may be you have suffered ‘levator avulsion’. A simple explanation of this tramua can be found here. Go to your GP and request further investigation and support – there are options.

An update to the Antenatal and Postnatal Mental Health Guideline has been issued and is catching up with the caesarean guideline in recognising that a fear of childbirth can be a major challenge to some women. The guideline now recommends that:

“For a woman with tokophobia (an extreme fear of childbirth), offer an opportunity to discuss her fears with a healthcare professional with expertise in providing perinatal mental health support in line with section 1.2.9 of the guideline on caesarean section (NICE guideline CG132).”

In a step towards joined up thinking this, in theory, means women should be able to discuss their fears of childbirth, increasing their likelihood of getting the support they need.

However automatically steering them away from a request caesarean in favour of vaginal birth should not be the focus of this support. Rather it should aim to help women develop the confidence to make informed decisions for themselves. Hopefully practitioner interpretation of the guidelines will recognise this. Of course specifying the term ‘tokophobia’ may give some the get out they want in order to turn away requests from women without the diagnosis. However, knowing about these two guidelines and what they really mean, prior to antenatal appointments, give women a new advantage.

Finally a UK hospital has had the sense to challenge targets handed down by others (in this case their Clinical Commissioning Group). The Royal Berkshire Hospital has been told that their current caesarean rate (27.1%) is too high and they must get it down to 23%. When asked whether it was cost driving this target the interim Medical Director Brian Reid said “That would be the driver.”

Unfortunately this target led approach to hospital care of pregnant women is typcial rather than unusual. Targets are a major factor driving policy and practise in many places. Where targets are based on cost cutting this can only mean that the health and safety of pregnant women and their unborn child cannot take top priority.

The NICE guidelines on Caesarean Section have clearly stated that:

• women wanting to request a caesarean where there is no medical need should engage in a detailed discussion with their practitioners. All the risks and benefits of both vaginal and caesarean birth should be fully discuss but if, after this, the woman still prefers a caesarean this should be granted
• women wanting to request a caesarean on the grounds of fear should be offered perinatal mental health support and if, following this, they continue to want a caesarean, this should be granted

So if more women are making an informed decision in favour of a caesarean birth (and it is not clear that this group of women can be ‘blamed’ for the continuing rise in the caesarean rate) then the targets need to reflect this need.

The target recommended by the World Health Organisation in 1985 is frequently quoted by policy makers and yet WHO retracted their target 4 years ago when the studies on which they had based it were found to be flawed. They have now stated: …there is “no empirical evidence for an optimum percentage”, an “optimum rate is unknown,” and world regions may now “set their own standards”. ‘Monitoring Emergency Obstetric Care: a handbook’

Despite this, official bodies continue to use such figures to beat their hospitals into submission by giving them unachievable targets, legitimising their requirements by quoting the old, unsubstantiated advice of WHO, when in reality the targets being handed down are based on cost cutting – putting the lives of mothers and babies at risk.

So if you are hoping to plan a caesarean, read the NICE guideline and arm yourself with the facts and references prior to discussing your ideas. Whether you are hoping to avoid a caesarean and need evidence as to why it is not necessary or you want to plan one and there is no clear medical reason for ir, you are likely to face a battle in order to make your choice about your body and your baby.