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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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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