UK hospital challenges caesarean targets

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.

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Does a caesarean affect the way we bond with our babies?

It is often reported in the media that having a caesarean affects a mother’s ability to bond with her baby.

However, what is frequently missed in such statements is that research actually suggests it is the circumstances around the birth not the caesarean itself which can lead to problems. In fact planned caesareans have a better psychological outcome for women than instrumental vaginal births and unplanned caesareans.

It seems where bonding is affected, negative thoughts and feelings about the birth itself, rather than the practicalities of the caesarean, play a significant role. The following issues are thought to be particularly influencial:

It is important to understand that increased levels of stress may delay milk coming in, for some women and that for some this can have a knock on affect on how they perceive their bond developing, but for many there is no impact at all.

What is very clear is ANY birth perceived by mum to be traumatic can produce such an outcome.

It is simply not true that it will be impossible to look after your baby after a caesarean. You will be encouraged to pick up your baby and carry them as soon as you are out of bed (and you are expected to be up and walking within 12 hours of a caesarean). Unless you or baby are ill there is no reason why your baby cannot be in your arms or next to you for the whole period prior to getting out of bed. Discomfort from little kicking feet over the incision area can be easily managed by resting baby on a small pillow when breastfeeding (sitting or lying) and this does not prevent skin-to-skin contact. Proactive, positive support from midwives should mean that your experience of your baby in the hours following surgery should be no different from that of any other mother.

Such sweeping statements from health care professionals and the media lead to misunderstandings and cause women to fear caesareans, setting them up for difficulties post-operatively. It is such unnecessary negativity and fear mongering that contributed to my desire to write Caesarean Birth: A positive approach to preparation and recovery. I wanted to improve women’s understanding of caesarean birth so it is more likely to be viewed purely as another way baby arrives and not something to be feared. Unfortunately antenatal education rarely talks about caesarean birth in anything like a balanced and informative manner so many women go into their birth knowing next to nothing about caesareans.

Ways to improve your bonding experience:

  • Skin-to-skin contact as soon as possible, in theatre if you and baby are both well enough (put your gown on backwards before you go in so it opens at the front)
  • Focusing on feeding, with full eye contact and skin-to-skin contact ensures valuable one to one time with your baby is protected
  • Re-visit your birth and where necessary, seek support in coming to terms with any negatives thoughts about the birth itself
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Ideal gap between caesareans – new research

A new study by Soroka University indicates that there may be reasons, other than risk of scar rupture, why a longer interval between caesarean births is ideal. Up to now recommendations have suggested that a gap of 15-18 months or more be planned to reduce the likelihood of scar rupture during subsequent pregnancies. However Kessous et al discovered during their review of 3176 births between 1988 and 2010 that in fact scar rupture was no more likely in any of their groupings (less than 12 months, 13-18 months and more than 18 months gaps).

However they did find an increased likelihood of premature birth in the group of women who had a second caesarean within 12 months of the first. This risk was 12%  whereas those who waited longer had only a 5% risk.

Premature birth has significant implications for baby in particular. Low birth weight and the immaturity of baby’s lungs are just two of the complications that can occur and the earlier the baby arrives the more likley they will need assistance in a SCU (Special Care Unit).

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No connection between caesarean delivery and obesity in later life

In the past studies have suggested there may be a link between being born by caesarean section and being obese in later life. The hypothesis is that caesarean babies may not be exposed to useful bacteria during birth causing weight problems in later life

This latest study from Mamun et al  finds no such connection. The study carried out an assessment of all mothers and their babies born between 1981-3 in a Brisbane hospital. Researchers found that on reaching 21 years of age, 21.5% of all the babies were over weight (12.4% obese). However there was no relationship between this group and the manner in which they were delivered.

This is an important study for women. The guilt felt by some women when their planned vaginal birth concludes with a caesarean delivery can be profound. The reasons for their feelings of guilt are varied, but the on-going impact of a caesarean delivery on the health of their child is one that is sometimes reported after the fact. This study could go a long way to reducing such fears and guilt.

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Urinary Incontinence guideline issued

NICE have issued an update to the Urinary Incontinence guideline. “Since the publication of the 2006 guideline, new methods of managing urinary incontinence have become available on the NHS…Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. While rarely life-threatening, incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and carers of women with UI may be profound, and the resource implications for the health service considerable.”

Instrumental deliveries are associated with increased risk of bowel problems, urinary and anal incontinence. The amount of damage can be perceived as greater than a caesarean and certainly more than a straightforward vaginal birth,[i] affecting movement and causing significant pain during recovery. Ventouse seem to cause less damage and pain than forceps,[ii] with forceps particularly linked to increased incidence of pelvic floor issues. There is some suggestion that women should be counselled to consider a caesarean rather than forceps intervention when experiencing a birth that requires instrumental assistance[iii]

Bear in mind when assessing childbirth risks that while vaginal birth seems to increase the likelihood of pelvic floor problems, particularly where forceps are involved, it is not the only factor. Obesity, smoking, HRT and hysterectomies are also thought to be factors, as is the extra weight of pregnancy itself exerting pressure on these muscles. McDonagh Hull talks in more detail about this issue.

[i] S. Paterson-Brown, ‘Elective Caesarean Section: A Woman’s Right to Choose?’ Progress in Obstetrics and Gynaecology J Studd, Ed. (2000)14:202-15

[iii] S.A. Farrell, ‘Cesarean Section Versus Forceps Assisted Vaginal Birth: It’s Time to Include Pelvic Injury in the Risk–Benefit Equation’ CMAJ, 166/3 (2002)

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AIMs review Caesarean Birth: A positive approach to preparation and recovery

Chloe Bayfield an AIMS midwife recently reviewed Caesarean Birth: A positive approach to preparation and recovery.

“The book is easy to follow and explores almost every aspect of the thought processes you are likely to go through when making decisions about your birth…Using this chapter, [“How Can I Improve My Recovery”] along with Appendix A (“The caesarean procedure”), will go a long way towards preparing you for your operation.”

Thank you for your supportive words.

(AIMS -Association for Improvements in the Maternity Services objectives are: working towards normal birth, providing independent support and information about maternity choices, raising awareness of current research on childbirth and related issues.)

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Dads suffer during birth too!

Professor Marian Knight from Oxford University speaking about her new research reveals that “pregnancy complications…can have long-term effects on mental and physical health, as well as on family relationships.”

Of course Mum experiences the pain and worry of childbirth, but it would be incredibly naive to assume that it is a walk in the park for the partner. The birth partner (often the father to be) witnesses the person they love in pain and are powerless to stop it. Yes they may be given ideas of how to help during labour but they cannot stop the pain and they have to watch hour upon hour of it without any idea of when it will end or indeed how it will end … and those are just the straightforward births.

Add to this those practitioners who treat partners with impatience, indifference and/or a general lack of respect and you have individuals feeling totally inadequate and traumatised by the whole experience. For those suddenly excluded from theatre if an emergency arises requiring a caesarean (it is not uncommon for the partner to be left in the corridor alone with no news of mum and baby for considerable time periods) there is a particular risk of trauma and flashbacks.

When I interviewed dads for the book Caesarean Birth: A positive approach to preparation and recovery I repeatedly came across descriptions of events where they felt completely out of control, horrified and unprepared. Some described months of nightmares afterwards, others confessed they hoped not to have more children and still others revealed that they were relieved their wife had a caesarean. One father contacted me begging me to convince his wife to have a caesarean as he could not face a third natural birth.

It is wonderful that partners are encouraged to participate in birth but they too require support and understanding in order to remain effective during the birth and beyond.

While I believe that it is entirely reasonable for Mum to be focused inward during pregnancy and particularly birth this should not be to the total exclusion of the partner and their feelings.

In an ideal world antenatal education would encourage families to recognise the needs of everyone involved in the birth. For the sake of family relationships going forward it is crucial both parties are helped to recognise the long term effect on relationships where partners have been excluded, emasculated and traumatised. For these families far greater support is needed postnatally than is currently available.

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Odent – worth reading or not?

Michael Odent is releasing another book. When the Telegraph spoke with him last week about his latest ideas, for a few days I couldn’t think of how best to respond without ranting then a friend pointed me towards an excellent response. Take a look – enough said!

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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. in conjunction with elective 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 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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