Tests during pregnancy typically look for diabetic and obesity indicators but this research suggests that there is a group of women outside of these indicators who may also be at risk of complications.

Preparing for the possibility of medical intervention should, in my opinion, be a formal part of everyone’s antenatal education as we never truly know what is going to happen on the day. These result emphasise the fact that there is yet another group of women for whom this is essential – unfortunately at present most of them do not know that they fall into this category.

Feeling in control is a key component in retrospectively perceiving an event as positive. If we felt out of control, that things were just done to us without our consent or without a feeling that we participated in the decision-making, we are significantly more likely to view that event negatively.

This is never more true than during birth where things can quickly change and our feeling of control disappear in a breath. I believe it is essential that women are armed with as much information going into birth as they feel they can cope with. It is great therefore to be able to tell you about another book aiming to support women in just that…

‘Choosing Cesarean’ by Magnus Murphy MD and Pauline McDonagh Hull

It focuses on caeasrean birth as the title suggests but does not set out to advocate caesarean birth for all women. Instead it simply proposes that it is legitimate for women to make an informed choice in favour of a planned caesarean even where there is no medical need. They argue that all vaginal births are essentially a ‘trial of labour’ (traditionally this term has been used only in relation to VBAC) and that being prepared for a variety of outcomes is essential. They believe that information and understanding options is key to decision-making and key to coping if the plan needs to change.

“Women are being sold the natural approach as though it is something tangible they can have-just as long as they follow advice, prepare for the big day, and avoid any unnecessary medical interventions that might derail this most desirable outcome. But no matter how good the birth preparation and no matter how ideal the birth setting, doctors and midwives are still only able to optimize women’s chances of spontaneous vaginal birth-not predict or guarantee them. An injection of realism wouldn’t go amiss sometimes.”

BERNSTEIN, MATALON-GRAZI and ROSENN wanted to investigate why it was that so many women were choosing to undergo a repeat caesarean rather than a ‘trial of labour’ also known as a VBAC (Vaginal Birth After Caesarean).

They found that “When patients perceived their providers as having a preference for ERCS [repeat caesarean], very few chose TOLAC [VBAC] whereas the majority chose TOLAC if this was their provider’s preference.”

Even though the sample size was relatively small (155 women and 3/4 were educated to degree level and over the age of 30) the trend was very clear. Practitioner opinion still heavily influenced the decision the woman then went on to make. Interestingly when the woman was not aware of the practitioner expressing any particular preference the split of who chose what was exactly 50:50.

More alarming perhaps is that researchers found that regardless of which birth mode the woman chose she had a woefully inadequate level of knowledge about both the benefits and the risks of her preferred choice.

The multi-choice questionnaire assessed the woman’s level of understanding of the mode of birth they were to undergo and despite the fact that they had all received prenatal care and counselling they were unable to accurately answer such questions as:

• If I were to try for a trial of vaginal labor, my overall chances of success are…
• If I try for a vaginal delivery (VBAC), the risk that my uterus will rupture (opening of the uterine scar) is…
• The reason for my previous cesarean section is an important factor in determining my chances of a successful vaginal delivery…

ACOG (American College of Obstetricians and Gynecologists) clearly define informed consent and this study reveals that women are not being given the level of unbiased, informative material they require in order to be able to genuinely make an informed decision.

As researcher point out “Informed consent, is defined as a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care and has become a mainstay of contemporary medical practice. It is viewed by many as a collaborative process between physician and patient intended to facilitate the patient’s autonomy in the process of ongoing choices. Our respondents showed insufficiencies in the area of comprehension, a major tenet of informed consent. They lacked awareness and understanding of their situation and possibilities. From our data, it appears that provider bias may affect the opinion of some patients, with undue influence on patient’s voluntary decision making.”

This is where knowing just that little bit more about birth ‘complications’ (not that ‘failure to progress’ is a complication) and rights versus hospital policies can make all the difference to whether or not you have the birth you hope for, assuming of course you are simply progressing slower than expected.

Incredibly studies from the 1950s which suggested that cervix dilation was a linear process (dilation = 1.2cm per hour) are still being referred to as ‘normal’ progress today. New research from Ohio State University suggests not only that the progress if not linear but that they have found a way to more accurately access labour progress for first time mothers. The tool, a partographer, “is a printed graph on which a clinician can plot cervical dilation and the baby’s descent to determine whether labor is progressing normally or if intervention might be needed.”

The researchers predict that “if their partograph were adopted widely in the United States, dystocia diagnoses would be limited to only the slowest 10 percent of first-stage labors; oxytocin interventions would drop by more than 50 percent; and cesarean sections performed because of dystocia would decrease by more than 50 percent.”

According to researchers at the University of Liverpool approximately 60% of diabetic women (including those who develop diabetes during pregnancy) will be unable to complete labour naturally and will require a caesarean.

Until now the reason for this has not been fully understood. Researchers have found “that contractions in women who had the disease were not as strong as those in non-diabetic women…Calcium levels in the uterus should rise to allow the muscle to contract effectively. Researchers found, however, that in women with diabetes, calcium levels are significantly reduced. “ University press release

While the result itself is useful in understanding why this is happening to so many of the 35,000 women that have diabetes during pregnancy every year, the implications for the management of diabetic labours is perhaps even more significant.

Researchers found that when uterine tissue of diabetic women was treated with oxytocin (a drug often used to assist labours that are experiencing difficulties) it was found that contractions “failed to reach the same levels of contractility as in non-diabetic women.” While more research is on-going, this finding does suggest that advice to women as they plan their birth ought to consider caesarean birth as a prophylactic option and more specifically for those wishing to attempt labour that the door is left open to switching to a caesarean during labour earlier such that they can have a caesarean before real signs of distress result in ‘critical’ surgical intervention.

“It is the attitude of mind that is the most important thing of all…to be able to go into labour [or indeed any type of birth or life situation] with the positive attitude ‘I am doing’ rather than ‘it is being done to me’.”

It is very important therefore that you know your rights. “Calmly discussing your options, knowing what can and cannot be insisted upon and the difference between a ‘required’ and ‘suggested’ caesarean, puts you in a strong negotiating position.” ‘Caesarean Birth: A positive approach to preparation and recovery’

Trying to avoid a caesarean:

For those wanting to avoid automatically having another caesarean this is increasingly possible, always assuming of course that the reason for the first caesarean is not likely to recur in each pregnancy. Hospitals are being actively encouraged to support VBACs and NICE guidelines state that “Women have the right to choose VBAC.” (pg 22)

Some hospitals offer special clinics aimed at encouraging just this. It is worth asking what is available at your hospital and local doctor surgery as these classes can provide lots of information and support about how to manage your pregnancy and labour such that you may increase your chances of achieving a vaginal birth.

If you continue having difficulty gaining agreement for a VBAC it is worth knowing that the NICE guidelines are very clear on this “For the process of seeking consent to be meaningful, refusal of treatment needs to be one of the patient’s options. Competent adults are entitled to refuse treatment even when the treatment would clearly benefit their health. Therefore a competent pregnant woman may refuse CS, even if this would be detrimental to herself or the fetus.” (pg 71 )

That said it is very important that you understand why a VBAC is not being supported this time round. Just a few examples of the reasons are: there may be genuine medical indicators meaning this is not the safest route for this pregnancy, the practitioner is less confident with VBACs (in which case you may want to consider alternative providers) or you are hearing a practitioners personal opinion coloured by fears of scar rupture rates. I dedicate a whole chapter in my caesarean book to the many things you can try in order to help influence your chances of avoiding another caesarean. In particular I address the mis-information often presented to women on scar rupture rates so that you can make an informed decision about the level of risk yourself.

Requesting a repeat caesarean

For those preferring to have another caesarean this will, in many cases, be dependent upon the opinion or policy of those responsible your care. Some hospitals do not permit maternal request caesareans, even after a previous one, if there is no medical need. (A previous caesarean no longer constitutes a ‘medical need’, unless as already mentioned, your first caesarean was for reasons which are likely to recur in this pregnancy). Where your request is being refused you will need to seek a second opinion and may even (if the opinion is a hospital policy rather than the personal opinion of the practitioner you are talking to) need to approach a different hospital.

The NICE guidelines are very clear on this:

“Recommendation 39: An obstetrician has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.” NICE guideline (pg 12)

However the guidelines are just that – ‘guidelines’. NHS hospitals are not required to follow them to the letter so you may find you are requesting a caesarean at a hospital where maternal requests, in the absence of any medical need, are indeed banned in which case you will need to seek an alternative place to deliver.

I talk in a lot more detail in my caesarean book about things to know if you want to avoid or indeed plan a caesarean. In both cases you may find significant barriers are put in your way, but there are quite a lot of things you can do to help you case.

• acceptance of informed choice as a valid indicator for maternal request caesareans (the document as it currently stands still makes this ambiguous, referring primarily to instances of tokophobia therefore failing to recognise the full spectrum of reasons why women may request a caesarean)
• clear statements about the scope of antenatal education in relation to caesarean birth (the document talks about the importance of education in relation to the risks and benefits of the procedure and improved understanding of the surgical procedure). The guideline does not address the absence of balanced antenatal education on all aspects of caesarean birth as a standard part of birth preparation
• allow women to gain early agreement for a planned caesarean, e.g. well before the current common practise of week 34. Women suffering from tokophobia or who have on-going medical indicators that suggest a caesarean delivery should be able to progress through their pregnancy without the additional stress of having to wait to see if their consultant will agree to a caesarean birth
• removal of the assumption that women who request a caesarean should be provided with support to ‘change their minds’. Some women wish to make an informed choice in favour of a planned caesarean after careful evaluation of the risks of caesarean versus vaginal birth
• clarification that a woman who has had a caesarean agreed but goes into labour prior to the surgery date, will have her planned caesarean upheld and conducted as soon as possible
• ECG wires be attached to the woman’s back rather than her chest to facilitate skin-to-skin contact and breastfeeding while in theatre (see Natural caesarean)
• post-operative debriefs are automatically offered to all women following their birth. This service is only offered sporadically across the country yet it is particularly important for women planning more family that they understand their caesarean birth and its implications for future pregnancies
• standardised reporting techniques such that types of caesarean and their reasons can be more clearly distinguished and risk/benefits rates more accurately allocated (that maternal request caesareans be specifically identified and separated from those planned caesareans where obstetric advice has ‘suggested’ a caesarean may be preferable

Some women experience difficulties because their scar is uncomfortable. Learning alternative breastfeeding positions can make feeding equally possible and just as rewarding as the more conventional positions.

While the cradle position works perfectly well for many women following a caesarean, side-lying puts you and your baby on your sides next to each other and your incision is less easily kicked. Bed-sharing makes it easier to get into position and respond more quickly to the feeding needs of your baby. In the football hold you sit up holding your baby to one side rather than across your body again protecting your incision. Lots of pillows can make this position very comfortable. It is easier for managing your baby’s latch as you have both arms free.

If you are experiencing difficulties talk to your health visitor, find out about local breastfeeding support groups and talk to other mums. Just one new idea from any one of these might be the thing that makes all the difference for you and your baby. Remember too, if breastfeeding is not working for you don’t beating yourself up, acknowledge that you have tried and switch to a bottle. It is far better that your baby has a confident, happy mum than one that is stressed out from pain or feelings of inadequacy.