Book review of 2nd edition

I came across a lovely review of my 2nd edition the other day. Thank you Helen Mary Labao Barrameda for taking the time to share your thoughts.

This is a very good resource book for Caesarean. I wish I read this during my first C-section. It contains a lot of useful and practical tips especially on the post-operation side of things. The author is also very sensitive and inclusive of various nuances like LGBT couple births and paternal postnatal depression (I did not even know that it exists before reading this book). I am glad to have read this; it stands a good chance of improving my C-section experience.”

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Once a caesarean, always a caesarean?

This is a fear many women experience following an emergency caesarean. No surprise really, an emergency caesarean is never planned, and some women find the experience highly traumatic, making it one they want to avoid ever going through again.

This is where being informed comes in.

In many cases a previous caesarean does not need to mean your next birth also has to be a caesarean.

Being informing about your rights is an important step in influencing such outcomes, but there are other factors to consider, namely:

  • The reason for your last caesarean – occasionally there are medical conditions or previous birth complications which are likely to recur, and which mean a repeat caesarean is a safer delivery method
  • How your current pregnancy is progressing – there may well be different circumstances this time round which indicate a repeat caesarean may still be a safer prospect
  • When is a recommendation for a repeat caesarean just that – a recommendation? Knowing the difference between recommendation and necessity means you can negotiate more effectively. For example, contrary to popular belief, your baby presenting in a breech position does not have to mean caesarean delivery

All that said, you may well want to choose a caesarean next time round for a whole host of valid reasons. Assuming this choice is based on solid information and the progress of this next pregnancy doesn’t dictate otherwise, there should be no reason why you should not be able to plan a repeat caesarean. Easier said than done of course, multiple barriers may well be put in your way. Here again, knowledge is power. Make sure you have clear reasons for your request and fight your corner.

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What are the caesarean rates in my country?

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. 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.

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Women are too posh to push!

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.

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Family centred caesareans – the ‘natural’ caesarean 10 years on

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.”

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Cascade of Intervention…

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.”

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Is there a link between depression and unplanned caesareans?

According to recent studies it seems women having an unplanned caesarean are 15% more likely to experience depression postnatally.

This probably isn’t a big surprise to some readers, but it is rather depressing.

Back in 2008, J Lally identified a woman’s expectations of her birth as highly significant. She recommended the setting and management of expectations be viewed as a key factor in helping ensure women interpret their birth positively.

Yet 11 years on, studies are still saying the same thing, but birth education has changed little. Women continue to be bombarded with strong messages about natural birth, avoiding drugs, avoiding caesareans, avoiding the difficult ‘What if…’ conversations.

For many women, the less medical intervention the better, but not only is this not the preferred route for some women, but also the likelihood of achieving a totally natural birth is actually lower than most think. Many women have no idea about rates of intervention and what the can do about them.

In the UK, some form of medical intervention – be that drugs, instruments or surgery will be involved in 50% of births (NHS Information Centre 2008) and 61% of births will involve anaesthetic (2014/15 NHS figures). And in 2017, the Birth Dignity survey in Australia revealed over a quarter of women surveyed did not achieve the birth they wanted.

It is unfortunately the case that some educators and practitioners make decisions for women about what they should and should not be told ‘in case we frighten them’. The result is that many, many women plan a particular type of birth for themselves with little, to no understanding of:

  • the likelihood of achieving it
  • alternatives to it which might become necessary
  • ideas for ways to transition between preferences as the birth progresses
  • coping techniques for interventions
  • detailed plans for caesarean delivery

Understandably, for some women then, any deviation from their birth plan can come as a tremendous shock and carries the potential for huge emotional damage. A US survey in 2011 recorded rates of PTSD in mothers of between 1.7 – 9% which can have a significant impact not only on family life and bonding with the baby but also on subsequent family planning.

Women are often just not prepared for the alternative possible outcomes of their birth plan and can struggle to manage them as a result. As an example see cascade of intervention.

This recent study, by Dr Valentina Tonei from the Department of Economics at the University of York recommends the ongoing needs of women for mental health support should be factored in to birth costs. Realising that 15% of women are likely to be depressed after their birth as a direct result of the mis-match between expectation and the experience of an unplanned caesarean (never mind other forms of intervention) suggests this has “important implications for public health policy, with new mothers who give birth this way in need of increased support…While the financial costs associated with this surgical procedure are well recognized, there has been less focus on the hidden health costs borne by mothers and their families. ” Dr Valentina Tonei

I would go a step further and say that the hidden costs of caesarean and vaginal birth are conveniently ignored in funding and planning circles:

  • An unplanned caesarean is a hidden cost of vaginal birth attempt
  • Pelvic floor surgery is a hidden cost of vaginal birth
  • Mental health support is a hidden cost of any birth that does not match a woman’s expectations

It is great that yet another study is highlighting the link between birth experience and mental health, but studies are not enough. Many women go into their birth believing they are in control of their plan, but nature is simply not that predictable even in second and third pregnancies. Women need to know that plans are great, but they are not a guarantee and alternatives need to be considered and planned for. Antenatal education must change. But so too must the funding of maternity services, which need to take account of this additional mental health cost to some women.

“Only seven percent (7%) of women suffering with mental health problems during or after pregnancy are refereed to specialist care.” RCOG Maternal Mental Health – Women’s Voices report.

So, what could this mean?

There lots of things we can do to help ourselves manage our birth experience, somethings are readily talked about:

  • Accupressure
  • Massage
  • Visualisation
  • Breathing techniques
  • Writing a birth plan

But what is unpopular, yet which really needs to be added to this list is:

  • Information about rates of intervention
  • Ideas for ways to transition between preferences as ones birth progresses
  • Coping techniques for interventions
  • Detailed plans for caesarean delivery
  • Practical coping techniques for births which have involved some form of medical intervention

Educating women about such things does not for a minute mean we should accept interventions are going to happen as a matter of course – there are definitely situations where an intervention may be suggested but is not definitely needed. The Cascade of Intervention is definitely an effect and something women need to know about.

But we need to stop being paranoid about scaring women, we need to help them make better plans, help them manage their expectations and enable them to make informed decisions before and during their births in order to mitigate some of the mental health impact of births that change direction.

Dr Tonei said: “Unplanned caesareans may have a particularly negative psychological impact on mothers because they are unexpected, usually mentally and physically stressful and associated with a loss of control and unmatched expectations.” So, let’s help women understand caesareans, demystify them, talk about them in positive terms and most importantly help women to plan for their possibility so that, should them become necessary, they are ready and not afraid.

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Birth options after a previous caesarean…

There are a lot of people with a lot of opinions about which way a mother should birth after a previous caesarean. And I am not just referring to medical personnel. It is not uncommon to find men as well as women with strong views on which mode of birth is best – often with little or no medical information to back up their opinion.

It is natural, after a negative birth experience, to be tempted to assume the other birth mode is better, but this may not be the case (unless specific medical indicators suggest otherwise). Where this is the case it is very important we try to ensure our opinions are based in fact not just gut feel.

Unfortunately, with some medical personnel, personal preference will play a part in the advice given and hospital targets are known to impact advice in some facilities. Working out when this is the case is tricky. But unless there are specific medical indicators in the current pregnancy, or a specific outcome in your previous birth which indicates one birth mode over another it is actually far less clear cut than we are led to believe and very much more about our own person view on risks and benefits.

My book dedicates a full appendix (11 pages) to facts and figures about benefits and risks of vaginal and caesarean birth. There are a lot of statistics about medicine’s current understanding of likely outcomes based on numerous international studies. Using this it should be possible to form your own opinion about levels of risk, types of intervention you consider preferrable etc. For example: some women may, on reviewing data view the risks associated with instrumental interventions in a vaginal birth as more risky than a planned caesarean.

Whatever you choose, always remember that in absolute terms the risks of adverse outcomes with either birth mode are incredibly small. Indeed a recent study looking at birth data from over 70,000 births in Scotland between 2002 and 2015 states that:

While “Attempting vaginal birth was associated with an increased risk of the mother having serious birth and post-birth related problems compared to electing for another cesarean section…the absolute risk of complications were small for either type of delivery. Overall, just 1.8% of those attempting a vaginal birth and 0.8% of those having a planned cesarean experienced serious maternal complications.”

The 2019 NICE Intrapartum Care guideline reports on the review committee’s discussion of the evidence, finding “There was no strong evidence to suggest a difference in outcomes for the baby between a vaginal birth or a repeat caesarean section, and the committee felt that healthcare professionals should inform women about this to aid decisions about mode of birth.”

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Smartphone app. reduces hopsital stay after caesarean

A mobile phone app claims to improve the caesarean birth experience, reducing the average time a woman will stay in hospital after surgery from3.7 to 2.7 days.

The mobile phone app, trialled in the US by Dr Attila Kett at Saint Peter’s University Hospital, New Brunswick, found that using it for a period of weeks before and after surgery reduced the duration of women’s hospital stay. And early results suggest it may also positively impact upon “surgical site infections, urinary tract infections and patient satisfaction”. The study is ongoing.

“The app empowers women by putting them in control of their health care needs,” said Dr. Kett. By offering prompts about appointments, providing pre-surgery information to their palm and prompts about timely medication post operatively it is thought users feel more confident in the process and more likely to monitor their condition effectively.

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Ask questions…

It can be challenging to separate a truth from a half-truth or indeed an out and out lie in some media stories. I’m not talking about fake news here, but simple carelessness or personal bias. But when you think about this challenge in relation to women trying to make decisions regarding their birth, it is more than disconcerting, it is alarming.

Rightly or wrongly, news reports, blogs, TV dramas, each others’ birth stories are all absorbed and digested, feeding our perceptions of what is ‘normal’, what is best for the baby, what is safe and what is not etc.

As I researched my book it became disappointingly apparent that media reports frequently look only as far as the Abstract of a research paper, and then make broadbrush statements that fit their intended message. On reading the papers themselves it is in fact sometimes the case that the reporter has misrepresented or over emphasised the significance of the findings. Yet it is often these media stories, not the research papers, which form the basis of what many women believe to be true and on which we understandably base our own decisions.

Added to this, uptake of antenatal education is only around 60% and significantly lower for women that have already had one baby, (according to a UK Maternity Survey Report by the National Perinatal Epidemiology Unit, 2010). Important information doesn’t always get through, so questioning the truth of what we read elsewhere is important.

Personal bias, political or economic bias can all impact the truth of a report or blog and indeed the advice being given by health practitioners. Really it is only in reading around a subject – going to the original research papers, indeed more than one, that we can start to uncover the detail behind headlines. For example, often a research paper contains caveats – some of which can render a result interesting but very far from conclusive. Yet the media may report the results of that same research paper as beyond a shadow of a doubt – caveats rarely make it into an Abstract.

But a single research paper is a single viewpoint, a single investigation, a single set of conditions and single point in time. It is often possible to find papers that expand upon an idea or indeed completely contradict it – see below – and it is only in reading around, asking questions and questioning the agenda of the author, the researcher or the doctor that we can start to formulate our own position.

This all sounds very scary. How can we know that what we are hearing or reading is reliable. In reality we don’t, but by reading around an issue we stand a greater chance of knowing what questions to ask, it makes us more able to determine what is fact and what is a current best guess, what is a trend and what is plain persona, political or economic bias.

With a background in research I am used to reading research papers and statistics and I will never forget reading a published paper which claimed caesarean section caused obesity in children. It’s good headline fodder and no surprise has been covered time and again in the media. However, in this particular instance, on reading the full paper, I discovered the researchers failed to accommodate several important variables, in particular familial obesity. The presence of such a relevant, confounding variable renders the finding highly questionable. Being unable to rule out the impact of family patterns of behaviour with regards attitudes to food and eating habits makes it impossible to say with any degree of certainty that caesareans cause obesity.

An illustration of how media bandwagons often create more problems…

For quite some time, studies have been talking about the benefits of breastfeeding for babies born by caesarean. Research, suggesting composition of gut bacteria is subtly different according to whether the baby is born vaginally or by caesarean section, this study for example, typically finds caesarean babies breastfed for at least the first 4 weeks will demonstrate broadly similar gut bacteria to babies born vaginally by the time they are 8 weeks old (with implications for immunity systems). In other words, breastfeeding may mitigate the potential impact of a caesarean birth – with regards immunity. Naturally this has fed into the ‘breast is best’ campaign – no bad thing (assuming it is not used to guilt trip mothers about breastfeeding).

But media spin on such studies have on occasion also gone on to suggest – with regards immunity that caesarean born babies are at a significantly disadvantaged adding risks of obesity and asthma to the mix. All of which can understandbaly scare the pants off those women facing an unplanned or unwanted caesarean.

However, in 2017 yet another study, published in Nature Medicine, investigated levels of microbiota found in several locations around baby’s body and found that regardless of age at delivery ALL babies developed very similar levels of microbiota by the time they were 8 weeks old. Indeed by 6 weeks old the microbiota had expanded (and diversified) across ALL infants regardless of their mode of delivery.

The researchers said “We conclude that within the first 6 weeks of life, the infant microbiota undergoes substantial reorganization, which is primarily driven by body site and not by mode of delivery.”

In other words – the link between caesarean delivery and an increase in immune disorders is far from confirmed. Despite this, the media continue to generate emotive headlines, particularly when attempting to regurgitate old myths about the selfishness of women too posh to push, blaming caesareans for all sorts of childhood issues. As you might expect, in line with such scare mongering there has been an increase in the number of women asking about vaginal seeding when told they will need a caesarean delivery as a means of combating their worries about immunity complications. Ironically these women are asking for a procedure far less researched and far less understood than the caesarean itself.

As an aside – please note – the current stance of the UK’s NHS  is “vaginal seeding has unknown risks and is not recommended.”

While in the US ACOG state “At this time, vaginal seeding should not be performed outside the context of an institutional review board-approved research protocol until adequate data regarding the safety and benefit of the process become available.”

Such incomplete articles lead some women to actually consider adding procedures to their birth experience which are in fact far from proven and may actually prove to be harmful to their baby.

It is my intention with this post to draw attention to the challenges women face when trying to make informed decisions. Newspapers print the story that increase readership or reflect the bias of their readership and the onus really has to be on us to conduct our own investigations, asking lots of questions. Most articles name the study or author and with the Internet it is quite easy to get to the source to see what the researchers have actually said.

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