electivecesarean.com speaks out

Yesterday NICE issued their Quality Standard for Caesarean Section.

Contrary to media reporting NICE statements regarding maternal request caesareans are NOT new. They published a guideline for caesarean section back in 2011. In this they recommended that women requesting a caesarean be offered documented discussion about the benefits and risks of all birth options and clarified that if a woman continued to prefer a caesarean they should be supported in achieving this.

Once again the media has  jumped on the emotive labelling of women ‘too posh to push’ blaming them for this rise in caesarean rates. NICE does not believe this group of women are responsible for the rise and conclude that “Many of the factors contributing to CS rates are often poorly understood.” And as Mcdonagh points out currently hospitals do not categorise births accurately. We have no way of knowing the actual number of maternal requests (where there are NO medical reasons for it) and unfortunately the new Quality Standard does not require hospitals to improve upon their reporting in this regard.

In actual fact, over the 30 year period in which caesarean rates have risen from 9% to 25% “rates of infant deaths have decreased significantly. The neonatal mortality rate fell by 62%, from 7.7 deaths per 1,000 live births in 1980 to 2.9 in 2010, and the perinatal mortality rate (which includes stillbirths) fell by 44% from 13.3 deaths per 1,000 total births in 1980 to 7.4 in 2010 (and in October 1992, the legal definition of a stillbirth was changed to include deaths after 24 completed weeks of gestation or more, instead of after 28 completed weeks of gestation or more; therefore improvements in perinatal mortality outcomes may be even greater.)” McDonagh

The popular press rarely report this issue accurately. NICE are absolutely right to continue to recommend that balanced discussion be documented. It is critial the imbalance is tackled to ensure women can make informed decisions.

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Caesarean NICE Quality Standard issued

Today NICE issued their Quality Standard in support of their Caesarean Section NICE guideline (issued 18 months ago). This Quality Standard serves to qualify key quality statements which should actually already have been put into practise by NHS hospitals over the last 18months.

Csections.org in conjunction with elective cesarean.com surveyed all NHS hospitals in England and Wales last year to determine the extent to which specific aspects of the guideline were being implemented. In particular we wanted to know how hospitals planned to deal with women who requested a caesarean when there was no medical need. We were very disappointed to discover that a significant proportion had not only failed to implement a policy but that they were actively banning all maternal request caesareans! At csections.org we find that actually many women face an incredible battle to plan a caesarean where there is no medical need and most fail to gain agreement.

Today’s Quality Standard purely serves to highlight that NICE stands by its recommendation from 18 months ago and continues to strongly advocate that women should have access to balanced information, they should be able to request a caesarean and if, following documented discussion they still wish to proceed down this route they should be actively supported in doing so.

Statement 2 Pregnant women who request a caesarean section (when there is no clinical indication) have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth…The discussion should include the reasons for the request and ensure that the woman has accurate information (including written information) about the relative risks and benefits associated with different modes of birth.” The guideline itself then says “…but if, after this, the woman still prefers a caesarean this should be granted.”

Hospitals are ignoring this advice.

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Practitioners ignoring clear medical evidence from their NICE guidelines

RCOGs latest report looking at practises and outcomes across the UK has found that some hospitals have been carrying out planned caesareans prior to 39 weeks when there is no clear medical reason to do so.

39 weeks has been defined (by NICE) as the preferred time to perform a planned caesarean (where there are no medical reason why it should be carried out earlier). This is because at 39 weeks the lungs are sufficiently mature to be able to cope with birth and the risk of breathing difficulties is no longer statistically significantly different to that of vaginal birth at the same stage. In addition, delaying beyond 40 weeks means that mum is more likely to go into labour prior to the caesarean and this increases (very slighlty) the difficulties associated with performing a caesarean on a womb that is contracting. (See also When is it safe to schedule a caesarean?)

Much of the data used to generate the report has been taken from caesareans carried out AFTER the NICE guidelines were issued in 2011, so it does beg the question – why do some practitioners continue to ignore clear medical evidence as captured by the NICE guidelines. Some practitioners/hospitals continue to pick and mix those elements which suit their purposes. Hence why we see some hospitals performing caeareans prior to 39 weeks and others banning planned caesareans entirely. Is it any wonder women have no idea who to trust and what to believe.

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Special requests when planning a caesarean

With any request  you make about how a planned caesarean proceeds it is worth discussing these well in advance. Some requests can be accommodated, others cannot but the hospital may be able to suggest alternatives for you.

Examples of things you may want to request (there are lots of others and I discuss many more in my book):

  • Partner present during set up (e.g. insertion of anaesthesia needles etc.) – This is permitted in some hospitals but unfortunately tends to be down to the practicalities of the size of the room. If you are to be fully ‘prepped’ in the actual theatre (and not everyone is) there should be sufficient space for your partner
  • Delayed cord clamping – Delaying for 2 minutes is thought to enable valuable oxygen and nutrients (e.g. iron) to continue to reach your baby until breathing has been properly established, (also reducing the risk of anaemia). This is an on-going debate but if you have a particular view, state your preference in advance as it can be quite difficult to gain agreement for this
  • Skin to skin contact ASAP – Unless there is a medical emergency which has led to your caesarean there is absolutely no reason why you should not be able to hold your baby within seconds of her being born. Many hospitals prefer to have a quick check of her condition but if this is a straightforward planned caesarean with no complications predicted then there is no reason why you shouldn’t ask to hold her immediately. You can actually go one step further and hold her skin-to-skin if you make sure your gown is free of the screen prior to surgery commencing. Indeed it is possible to attempt breastfeeding in theatre but you really do need to agree this in advance as your gown will need to go on backwards (e.g. open at the front) and your partner will need to be next to you to assist you in holding and positioning (you are flat on your back and it will be quite tricky to hold her safely). Breastfeeding in theatre is not common practise and you will need the support and encouragement of the team and prior agreement for it. Women have reported that they were refused the option of turning their gown around being told it would “compromise the sterile field”. I have checked this with medical professionals and there is absolutely no truth in this – the screen protects the sterile field not your gown
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Urinary Incontinence more likely following vaginal birth

A recent study looking at the likelihood of experiencing urinary incontinence in later life found that the likelihood is far greater following a single vaginal birth than following a single caesarean birth. The study questioned 6148 women and found that the prevalence of urinary incontinence trebled (10.1%) after a vaginal birth compared to caesarean (3.9%).

While the most significant risk factor for symptomatic prolapse was vaginal birth Maria Gyhagen (co-author of the paper) also pointed out that “There are many factors affecting urinary incontinence but obesity and ageing as well as obstetric trauma during childbirth are known to be three of the most important risk factors.”

So what does this mean in terms of birth planning?

While it is certainly an important finding it is just one more piece of information to take into account when evaluating the risks and benefits of both modes of birth. Alone, this increased risk of urinary incontinence should not be a reason to jump at choosing an caesarean birth. There are many other factors to consider and your own circumstances with regards your current (or planned) pregnancy should be taken into account before making any decision either way.

My book Caesarean Birth: A positive approach to preparation and recovery talks a lot about the benefits and risks of both modes of delivery and provides up to date research and statistics which you may wish to use to inform your debate with your practitioners.

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Repeat caesarean or VBAC?

There has been a lot of coverage in the media over the last few years quoting research looking at the comparative safety of a repeat caesarean versus a vaginal birth after caesarean (VBAC).

The findings are invariably such that the research can be used both by protagonists wanting to reduce the caesarean rate and those wanting to promote the validity of repeat caesarean birth (particularly maternal request CS). In other words it is still very much a matter of personal opinion.

What is clear is that for women trying to make decisions about their birth plans the risks typcially being discussed (e.g. scar rupture, fetal death and haemorage) are, with either delivery mode, incredibly small.

While findings can be manipulated to make controvercial headlines all current research can really emphasise is that rather than making snap decisions one way or the other women need to evaluate the broader risks of both modes of birth in their specific situation and make their decision based on their preference once fully informed.

So revisiting pre-conceptions and assessing the quality of the information you are given is of paramount importance. For example: Hemorrhage risks are incredibly small (2.3% in planned VBAC and 0.8% in planned caesarean). Despite this some women, who would prefer a vaginal birth, rule out an attempt accepting a potentially ‘unnecessary caesarean’ because they have not been given the full facts. Conversely those women, for whom the risks associated with a planned caesarean feel more acceptable than the risks associated with a failed vaginal attempt, may not consider a prophylactic caesarean because they feel unable to challenge the popular opinion being pushed by the media and natural birth advocates that VBAC is better.

It is important that women feel empowered to make decisions, that they are involved in the decision making process and that they challenge the advice they are given. Afterall they are the ones that have to come to terms with the outcome.

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Caesareans, breastfeeding and gut bacteria

Once again the media have gone rather mad about a research paper without assessing the details of paper itself in an attempt to deliver sensational headlines about caesarean birth.

This paper actually describes gut bacteria in 24 infants at 4months of age but the media have rehashed old concerns about links with asthma.

It is entirely possible to make statements about the presence of the various bacteria from reliable tests conducted on the infants fecal matter and the paper should really have stopped there. However, it goes on to suggest links between caesarean birth and lower levels of breastfeeding and an increased likelihood of developing health problems in the long term (as a result of a lack of exposure to certain gut bacteria due to not having passed through the birth canal).

Aside from the media’s poor attempts at reporting on a very small, inconclusive study, I  take issue with the research paper itself:

  • No mention, or assessment of any environmental factors which can also easily influence gut bacteria level, other than use of antibiotics, (it looks purely at birthmode and breastfeeding patterns)
  • Only one assessment of gut bacteria levels are taken (at 4 months of age – no follow up to assess changes due to on-going development and exposure to new environmental factors – yet it is widely acknowledged that “gut profiles vary widely in the first year of life.”)
  • Sample size is laughable small (the total number of babies assessed – 24, of these only 6 were actually caesarean births) “A study of this size is too small to reliably detect any differences between natural and caesarean deliveries, and formula and breastfed babies, and even less so to detect any differences according to type of caesarean delivery (emergency vs. elective) or brand of infant formula, for example”

What is particularly disappointing is that the researchers feel comfortable making vague statements along the following lines “It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births” (which quite clearly shows even they cannot say their study provides conclusive evidence let alone how these bacteria levels relate to later health issues) and yet they are happy to produce a paper suggesting there is a link with caesarean birth specifically. Not only this but they take no account of the impact their statements may have on mothers who ‘need’ a caesarean to avoid serious outcomes. Nor dothey offer any information about how women can redress the bacteria imbalance. In otherwords they scare without offering any hint of a solution.

The NHS have been very quick to denounce the media’s scarmongering and suggest extreme caution when attempting to draw any conclusions from such a small study.

“The study does not provide any evidence that the mode of delivery or feeding pattern was the cause of the bacterial levels measured. Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life”

They go on…

“The researchers say that the development of bacteria in the gut in the early part of a person’s life is poorly understood. However, the design of this study means that it arguably adds little to that understanding. It only examined the gut bacteria of an extremely small sample of babies at one point in their life and can tell us little else about the causes of these bacterial levels, or how they related to longer-term health outcomes.”

And there is more…

“Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life.”

As for the media’s poor attempts at interpreting the paper, they have chosen to re-hash claims suggesting there are links with childhood asthma. This despite the majority of studies investigating such a link having been repeatedly shown to be inconclusive often omitting significant environmental factors, such as the presence of parental smoking.

Actually don’t get me started on the media…

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Survey – when is a caesarean required?

I have been investigating how far antenatal education is meeting the information needs of women with regards caesarean birth.

As part of this I have a quick question that should take no more than 2 minutes to answer (unless you decide to go hunting on the internet for the answers !-)

Click here to take survey

Thank you for helping.

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An increase in the UK rate of forceps deliveries

The forceps rate has doubled in the last few years, according to a recent report picked up by the Mail On-line (over 42,000 last year) but is that really a surprise given:

  • The suggestion in 2010 (from within the medical profession) that there be an increase in forceps use if the aim is to reduce the emergency caesarean rate
  • The increased focus on natural birth, seemingly at all costs
  • The drive to reduce the caesarean rate making it ever more difficult to plan a caesarean for border line cases

It would be useful to know how many of these forceps deliveries were performed on women who might actually have been better advised to plan a caesarean? Indeed some of them could well have been advised of this but were so afraid of this ‘unknown evil -the caesarean’ that they actually preferred to take their chances.

Caesareans are regarded as a “last resort, best avoided” and because women are still not given balanced information many will resist a caesarean when it might actually be the safer option for them and their baby. Some of these women will go on to require highly medicalised instrumental births, many of which are truly traumatic, (damaging them both emotionally and physically, not to mention the risks to baby).

Women’s preparation should not simply be driven by the current bias towards natural birth. They need more information across birth modes and their opinions should be respected. Crucially in order to form these opinions in the first place they need to be supported in the development of realistic birth expectations using balanced information. Sadly neither of these can be guaranteed in many antenatal publications and clinics and many women will continue to have traumatic births, some of which could have been better managed, and experienced far more positively, with a planned caesarean.

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NICE Caesarean Section Quality Statement Review

NICE (National Institute for Clinical Excellence) issued new Caesarean Section Guidelines back in 2011 and since then they have been going through the process of defining Quality Standards (QS) for some of the recommendations from that Guideline.

Csections.org are actively participating in this review process. We were disppointed with the  quality of the Draft document and have provided extensive feedback in the form of concrete recommendations for enhancements and qualifications. We hopes to see significant changes to the document when it is issued and will keep you posted.

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