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.”

Indeed 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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Caesarean Birth: A Positive Approach to Preparation and Recovery – A table of contents

For those interested in seeing more detail about the content and structure of my book – the following is the table of contents from the 2nd Edition – available on Amazon and from various other on-line bookstores.

Foreword……………………………………………………………………………… 5

Introduction………………………………………………………………………….. 7

  • 1 Caesareans explained………………………………………….. 11
  • 2 Why prepare for a caesarean birth?………………………….. 19
  • 3 I would prefer a caesarean…………………………………….. 27
  • 4 I do not want a caesarean……………………………………… 37
  • 5 How can I make the most of my caesarean?……………….. 55
  • 6 How can I improve my recovery?…………………………….. 75
  • 7 I am the birth partner, what can I do?……………………… 113
  • A The caesarean procedure……………………………………. 139
  • B Why do caesareans happen?………………………………… 151
  • C The benefits and risks of caesarean and vaginal birth….. 165
  • D Clinical definitions of difficult reactions………………….. 191
  • E Birth guide template………………………………………….. 195
  • F Questions to ask your practitioners………………………… 199

Glossary…………………………………………………………………………….. 203

Other resources…………………………………………………………………… 209

Acknowledgements………………………………………………………………. 217

References…………………………………………………………………………. 221

Index………………………………………………………………………………… 247

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Where can I get advice?

Hospitals remain under pressure to reduce their caesarean rate – despite recommendations to Inspectors to refrain from judging hospitals in this way. And where there are no targets in place, women can still face opposition from individual care givers.

This is why BirthRights – a UK information and advice centre – offer the option for 1:1 advice via their website.

They firmly believe in a woman’s right to an informed choice.

“Women have a right to make choices about the circumstances in which they give birth. This simple but powerful principle was established by the European Court of Human Rights in Ternovszky v Hungary (2010) under the right to private life in Article 8 of the European Convention which encompasses rights to physical autonomy and integrity. Article 8 is a ‘qualified right’ and so limitations on the right are permitted. The Ternovszky case concerned the right to give birth at home, but the principle applies equally to all choices that women make about childbirth. The decision represents a profound challenge to medical authority: if women have a legal right to make a choice, any limitation on that right must be justified. The decision-maker, whether a hospital or a doctor or midwife, must give proportionate reasons for their decision based on the individual circumstances of the woman and their reasons can be tested in court before a judge.”

To ask them a question click here.

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Why Do We Fear a Caesarean Birth?

Australian Birth site, Natural Parent Magazine, recently posted one of my articles. It is great to see more and more birth sites willing to talk about the possibility of a caesarean delivery. Knowledge is power!

“In reality a caesarean is an extraordinary addition to the tools available to those who help us with our births and it should be respected for the advantages if can bring to those who need it.”

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What if I have to have a caearean?

Australian Birth site, BubHub, recently posted one of my articles. It is great to see more and more birth sites willing to talk about the possibility of a caesarean delivery. Knowledge is power.

“With knowledge, a caesarean can be a really powerful experience. One we can remember positively even if it was not the way we thought our birth would pan out…”

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Caesarean targets for hospitals

For years hospitals have been asked to record data about caesarean births. The results of a Freedom of Information request revealed that the way in which this information was recorded varied significantly from one hospital to another.

For example:

  • Inconsistency in criteria used for recording whether a caesarean delivery was emergency or planned
  • Inconsistency in criteria for recording a delivery as a maternal request or performed as a result of an obstetricians recommendation

It is easy to see that in reality reports about current rates face an impossible task – the truth is hard to discern. Despite this many hospitals faithfully report their figures and face judgement for their caesarean rates – some praised for low rates, some criticised for rates that are considered ‘too high’.

In fact the WHO retracted their recommendation for an ideal caesarean rate back in 2009 because there was insufficient evidence to define one.

Despite this, UK hospitals have continued to be scrutinised and judged according to their rates. Loaded statements by official bodies and the press have pushed many hospitals into defining, formally or otherwise, ideal targets for themselves. Stories of women requesting caesareans and being refused are all too common and maternity litigation claims in the UK are now thought to run to billions every year. The personal cost to families of these arbitrary targets can be shown to result in: loss of life, life altering injuries as well as obvious psychological distress.”

Now, finally as the Sunday Times reports “Inspectors have been ordered to stop judging maternity units on their caesarean rates after the care watchdog accepted that it had sent the wrong message on normal birth.”

Heidi Smoult, deputy chief inspector of hospitals – commenting on the report by P Hull which led to this directive – stated that “medical intervention, while important “should never be at the expense of a woman’s or baby’s health.”

The Sundays Times speaking to Alison Wright, of the Royal College of Obstetricians and Gynaecologists, recorded the view that: “The need for a medical intervention can vary dramatically across services and regions, depending on the local demographics and the health needs of women. Therefore, we believe the approach should be more nuanced than promoting a particular maternity indicator, such as a caesarean birth rate.”

A step in the right direction. However, if you are trying to investigate your own birthing options, whether that is to have or avoid a caesarean be aware that internal politics within your hospital may be an additional factor to consider. Despite this new recommendation, it is worth finding out whether your hospital still refers to target levels for caesarean births.

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Clinical Director NHS England says – stop focusing on CS rates!

For too long, healthcare providers have been concentrating on optimum caesarean rates, this despite the fact that nearly 10 years ago the World Health Organisation retracted their recommendations as there was “no empirical evidence for an optimum percentage”.

Now the Clinical Director for NHS England – Matthew Jolly – joined the fight by stating that caesarean rates should not have targets set as these can lead to “all sorts of unfortunate consequences.”

Attempting to artificially driving down the caesarean rate is dangerous. Over half the litigation costs in the NHS are still in obstetrics many of which relate to birth outcomes which could have been avoided if a woman’s concerns or wishes had been respected.

  • 47% of maternity units set target rates
  • 50%+ are graded on whether they encourage natural births

Cost is the major factor driving these targets and where cost is considered above a mother and/or baby’s safety, bad decision are going to be made and bad advice is going to be given to mothers.

NICE guidelines clearly state women should be able to make an informed choice about how they give birth. But targets like these are reducing options and we are regularly contacted by women at their wits end, wanting to know how they can challenge the advice given by their carers which they believe to be compromised.

But, is the tide turning? We are working with the Care Quality Commission to understand more about women’s caesarean experience, feeding into the development of this year’s Care survey. Watch this space to see whether such statements are actually reflecting a change in the behaviour of our Trusts.

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Caesarean Birth: A positive approach – goes to 2nd Edition

The 2nd edition of Caesarean Birth: A positive approach to preparation and recovery is now published and available globally via Amazon.

The update came about because conversations with many women in the 7 years since this book was first published reveals little has changed in terms of a woman’s experience of a caesarean or the extent to which it is included in antenatal education and the need for up-to-date information is as vital as ever.

That said, once a caesarean is agreed, ideas about how to improve the experience are being more readily accepted by some practitioners and the ‘natural caesarean’ approach is now more commonly discussed. However, the barriers faced by women wanting to discuss their options in the first instance are still many. Hospitals and individual practitioners, driven by economics and/or professional bias, continue to make things difficult for some women wanting more say their birth options.

Despite the World Health Organisation’s retraction of their recommended target levels (retracted in 2009), which clarified that the “optimum rate is unknown”, hospitals continue to be threatened with unachievable targets and women labelled ‘too posh to push, are blamed for driving the caesarean rate up.

This update:

  • Adds new research
  • Updates facts and figures pertinent to both caesarean and vaginal birth
  • Adds learning from women and birth partners who have shared their experiences with the author
  • Highlights the needs and issues of same sex birth partners – in this last case the needs of this group are frequently over looked and while much of their experience of birth is the same as for male birth partners, research suggests that these co-parents actually have a significant number of additional emotional factors to deal with and the impact of this is only just beginning to be researched and understood
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