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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Should antenatal education be answering basic caesarean questions?

YES!

On a daily basis I have emails from women with questions and worries. Many of which originate in stories and myths they have been told by friends, health practitioners or read in the media.

A classic one:

‘Will my arms be strapped down?’

The simple answer: NO

However, many women have heard that this is a possibility and some link it to the truth that the table will be on a slight tilt giving it seemingly more credibility. The table is on a tilt but the tilt so slight it is not necessary to restrain you in any.

The list of  myths is huge and the fear they generate considerable. Is it any wonder that some women are terribly afraid of this mode of birth and fight the thought of it even when it might be the safest means of delivery in their specific circumstances?

It is essential to cover caesarean related questions in a balanced, respectful manner and all women should have access to such an approach from those responsible for their antenatal care.

Other examples of typical myths I have been repeatedly contacted about are:

  • I will have to wait till I am back on the ward before I can see my baby (IT DEPENDS – Your baby can be delivered straight onto your chest for skin to skin contact if there are no medical complications. Where there are complications your baby may indeed be elsewhere, but then she is in the best place given her physical condition and you can be wheeled to her immediately if you too are well enough)
  • I will be able to see my insides (UNLIKELY – You will have to look very hard to see anything at all in the blur of the lights above you and there is a large screen between you and your abdomen in any case. Women who want to see their baby lifted from them need to ask to have the screen lowered in order to view anywhere close to the surgical area)
  • I’ll be cut right down the middle (UNLIKELY – Most caesarean scars are horizontal and in your bikini line, it is only in very specific circumstances where this might be necessary and you will be told in advance)
  • I won’t be able to breastfeed my baby (MYTH – Breastfeeding can be tricky however you give birth but a caesarean delivery does not make this more so unless you have needed a General anaesthetic in which case you may be drowsy for up to 24 hours after delivery)
  • I won’t be able to pick her up for days (MYTH – She is NOT too heavy for you to pick up it is more an issue of how quickly you can move in the first 24 hours. You may benefit from having her passed to you initially but you can now request basinets which attach to the side of your bed so even this is becoming a problem of the past)

Then there are more detailed questions:

  • Will I be awake?
  • What is the difference between a spinal and an epidural?
  • Can my partner be with me?
  • Will I have a vertical scar?

I am often asked such things by women who have already been told they need a caesarean and therefore should also have been told the answers in their case. I find it staggering that women are having to ask such things AFTER their appointments.

Educators should not wait to be asked, the information should be presented fairly and accurately. It is not respectful to assume that women do not want to know (many do) nor should it ever be assumed that women know what questions they should be asking in the first place.

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Recovering from a second caesarean birth

There is no clinical evidence which concludes that recovery is longer or more difficult after a second caesarean. That said, anedotally you will always find women who say this was the case for them. For some it may be the surgery itself causing physical difficulties second time round but in many cases it is actually the circumstances around the birth that create the difficulties. By this I mean not only the circumstances at home but also whether or not the second caesarean had been planned.

Please do not underestimate the disappointment and emotional trauma that can follow a failed VBAC attempt (Vaginal Birth After Caesarean). Some women view a vaginal birth not only as their preferred mode of birth but also as a way to expunge the memories of a previous emergency caesarean. So when a second vaginal birth attempt ends in caesarean some women can be left with a lot to deal with emotionally.

However having a young child already at home plays a very particular role too. The extent to which it is possible for you to ‘take it easy’ after  this caesarean can vary significantly depending on the age of siblings, how much help you have etc. A young child needs your time and attention and will be making physical demands, not just to be carried or lifted but they will naturally want to play with you and half the time that will mean on the floor. Getting up and down, trying to visit playgroups, do the nursery / school run as well as look after your new baby and run a home means that the circumstances in which you are trying to recover from this caesarean are really very different from the last.

So listen to your body – even quite small twinges should be viewed as your body’s way of telling you you’re doing too much. At the very least they may be telling you to change the way you are doing something or to do it more slowly. The way in which you approach this recovery is very important. You will need to plan even more than last time.

Something as simple as getting everything on one level e.g. the changing mats on your dining table for the first few weeks (then daily bring everything you and your baby need for the day downstairs) so you limit the number of times you go upstairs, manage your toddlers expectations before the birth – start them climbing onto your lap rather than you picking them up etc.  I talk about this in lots more detail in my book Caesarean Birth: A positive approach to preparation and recovery.

Speaking personally, I found recovery second time round to be no more difficult than after my first, if anything it was easier:

  • I knew what to expect and so did my immediate family
  • I didn’t fret about getting off the pain medication as fast as possible
  • I knew how to get out of bed and off the sofa without hurting myself
  • I had my ‘baby station’ set up downstairs
  • My toddler loved ‘helping’ (though I didn’t sell it to her as helping – she thought she was playing games seeing how many things she could fit in her trolley (the muslin, the remote, the telephone, the baby wipes) when all I actually might need was the baby wipes)

Put simply: Be prepared both physically and emotionally.

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