Women are too posh to push!

Incredibly some women are accused of this to their face, while others are guilt tripped by  the media. In fact, the figures used to support such an accusation are very misleading. In the majority of sources, figures actually incorporate all maternally requested caesareans including those which follow recommendations from the mother’s practitioner, i.e. when medical situations or clinician experience indicates that a caesarean might be the safer method delivery.

Where the media talk about unnecessary caesareans, factors such as increased age of first time mothers; practitioner’s desire to reduce operative vaginal deliveries; an increase in the overall incidence of fetal monitoring and a fear of litigation are frequently ignored or conveniently overlooked.

Even if all these factors are taken into account, the figure describing women choosing a caesarean in the absence of a medical need still invariably includes women making the choice because of tokophobia (fear of childbirth), previous traumatic birth experiences or trauma arising from sexual abuse, and others making a positive, informed, prophylactic choice.

And if all of that is not enough. The figures are unable to take account of the discrepancy in the coding of births which can occur between hospitals and the financial and policy decisions made by individual hospitals, as a result of which ‘apparent’ rates of intervention can vary significantly. For example, my second caesarean was coded as an emergency by my hosptial, despite the fact it was a planned casearean, simply because I happened to go into labour before the planned CS date – there was no emergency, it simply wasn’t at the time scheduled, which of course helped make their elective numbers look that bit lower.

At the end of the day, very few women make such an important decision without good reason and such a slur is not only disrespectful but dismisses the complexity of the decision-making the majority have gone through.

Family centred caesareans – the ‘natural’ caesarean 10 years on

Many women will experience a caesarean delivery (for example 1 in 4 births in the UK and Spain, 1 in 3 in the US, 1 in 2 in Turkey, 1 in 5 in France).

Some of these caesareans will be emergencies, some will be planned. For those which are planned – whether for medical reasons or not – there are adjustments that can be made to the birth plan which can make for a more ‘natural’ experience.

The idea of ‘natural’ caesareans was first discussed over a decade ago by Senior Midwife Jenny Smith (at Queen Charlotte’s and Chelsea Hospital in London) and her colleagues Professor Nicholas Fisk, (Consultant Obstetrician) and Dr Felicity Plaat (Consultant Anaesthetist).

This form of birth is now more commonly referred to as a ‘family centred’ caesarean primarily because there has been quite a bit of push back over the use of the word ‘natural’ by those who believe the fact of the caesarean makes the experience anything but, and who were concerned the use of ‘natural’ might drive an increase in requests for caesarean delivery. (Incidentally, this increase has not materialised – in the UK at least). However, according to those who coined the phrase, the term was simply meant to convey the idea that the process incorporates a number of procedures which aim to optimize the birth experience for women having caesareans section [by] putting women at the centre of care”.

The primary idea behind a ‘family centred’ caesarean is to slow down the surgical process and allow Mum and birth partner to participate in and/or witness as many aspects of the birth as possible. It also allows for additional environmental decisions to be made by the family rather than the surgical team.

The possibility of a ‘family centred’ caesarean is entirely dependent upon the way in which your pregnancy has progressed to date, any risk factors associated with your pregnancy and the experience and willingness of the clinicians providing your care.

So what is different about a ‘family centred’ caesarean?

In no particular order:

  • Slower delivery, also known as ‘walking the baby out’
  • Skin-to-skin as soon as possible – even while still in surgery – you will be asked to bring an appropriate top
  • Lowering of the screen (after initial incision and baby’s head has emerged). Some hospitals will offer a clear screen instead
  • Delayed delivery – extends compression while baby’s body is still in the womb to facilitate liquid expulsion from lungs
  • Favourite music playing during surgery
  • Favourite pillow
  • APGAR tests conducted, vit k injection, attaching of labels etc. within sight (weighing is postponed till transfer to recovery room)
  • Dimming periphery lights during delivery
  • Delayed clamping and cutting of the cord. Birth partner may shorten or trim the cord (but not the initial clamp and cut)
  • Saving the placenta

As Jenni Smith says “It is about the mother. After the incision is made, the curtain is removed and the mother is able to see her little baby wriggle out. It is a special moment that is missed otherwise…The baby remains in the abdomen for up to four minutes and the mother can look at it, see its little face and eyes, and when it wriggles out it is the parents that first determine the sex.”

Is a family centred caesarean safe?

Reports are very good “Since publication of our paper there have been no reports of complications associated with the technique. In fact, a recent study from Germany found improved breastfeeding rates, and significantly better patient experience compared to the traditional technique, with no increase in complications.”

In an ideal world a caesarean should not be planned prior to week 39 and, in the UK at least, caesareans tend to be during this week unless there is a medical reason indicating that it should be sooner.

Research does show that by week 39 a baby’s lungs are sufficiently mature to cope well with delivery. Anything prior to 39 weeks increases the possibility of respiratory problems. That said where there are medical reasons making it essential for baby to be delivered prior to 39 weeks then a planned caesarean (where all the facilities and resources needed to make this as safe as possible are ready and waiting) is considered by many practitioners as preferable to inducing labour.

What is really important during the decision-making process is the accuracy of the dating of your pregnancy, if you are unsure then you should request a re-assessment.

Cascade of Intervention…

There is an important phenomenon all women should be aware of – the Cascade of Intervention.

This phenomenon is well recognised in the medical community and in relation to maternity services describes the idea that there can be unintended consequences to medical interventions.

Example 1:

Induction (chemical and mechanical) and the use of fetal heart monitors typically go hand in hand. Someone women do go beyond their due date and induction does become a necessary conversation. However, the use of continuous fetal heart monitoring, often paired with induction, reduces a woman’s mobility significantly, increasing dramatically the amount of time a she will spend lying on her back. This can have a notable knock on effect on her ability to labour effectively, setting off a chain of events that may result in failure to progress, ultimately increasing the likelihood of further interventions being needed.

Knowing the potential of this effect means women can investigate alternatives:

  • Continuing to do nothing (for a safe period of time), labour may still commence naturally
  • Request mobile monitoring, this is offered as a matter of course in some places, but certainly not everywhere. Being mobile reduces the impact of immobility, which in turn has the potential to interrupt a cascade of intervention

Example 2:

Some women want to use patient-controlled epidural as their form of pain management. This can work really well for some but some hospitals combine its use with the use of fetal monitoring. The potential for a cascade of intervention is therefore also present in this instance too as once again the woman can spend long periods of time immobile as the fetal monitor is used (albeit intermittently), setting off a chain of events that may result in failure to progress, ultimately increasing the likelihood of further interventions being needed.

Knowing that a diagnosis of failure to progress can, if unchallenged result in a caesarean means it is very important women understand:

  • What really constitutes a failure to progress and when intervention is truly necessary
  • The Cascade of Intervention phenomenon and which interventions can exacerbate the situation

A great source of information is the Childbirth Connection website.

“The best way to limit a cascade of intervention is to become informed, get all of your questions answered, and put plans in place in advance that will help avoid potentially harmful interventions.”

Is there a link between depression and unplanned caesareans?

According to recent studies it seems women having an unplanned caesarean are 15% more likely to experience depression postnatally.

This probably isn’t a big surprise to some readers, but it is rather depressing.

Back in 2008, J Lally identified a woman’s expectations of her birth as highly significant. She recommended the setting and management of expectations be viewed as a key factor in helping ensure women interpret their birth positively.

Yet 11 years on, studies are still saying the same thing, but birth education has changed little. Women continue to be bombarded with strong messages about natural birth, avoiding drugs, avoiding caesareans, avoiding the difficult ‘What if…’ conversations.

For many women, the less medical intervention the better, but not only is this not the preferred route for some women, but also the likelihood of achieving a totally natural birth is actually lower than most think. Many women have no idea about rates of intervention and what the can do about them.

In the UK, some form of medical intervention - be that drugs, instruments or surgery will be involved in 50% of births (NHS Information Centre 2008) and 61% of births will involve anaesthetic (2014/15 NHS figures). And in 2017, the Birth Dignity survey in Australia revealed over a quarter of women surveyed did not achieve the birth they wanted.

It is unfortunately the case that some educators and practitioners make decisions for women about what they should and should not be told ‘in case we frighten them’. The result is that many, many women plan a particular type of birth for themselves with little, to no understanding of:

  • the likelihood of achieving it
  • alternatives to it which might become necessary
  • ideas for ways to transition between preferences as the birth progresses
  • coping techniques for interventions
  • detailed plans for caesarean delivery

Understandably, for some women then, any deviation from their birth plan can come as a tremendous shock and carries the potential for huge emotional damage. A US survey in 2011 recorded rates of PTSD in mothers of between 1.7 – 9% which can have a significant impact not only on family life and bonding with the baby but also on subsequent family planning.

Women are often just not prepared for the alternative possible outcomes of their birth plan and can struggle to manage them as a result. As an example see cascade of intervention.

This recent study, by Dr Valentina Tonei from the Department of Economics at the University of York recommends the ongoing needs of women for mental health support should be factored in to birth costs. Realising that 15% of women are likely to be depressed after their birth as a direct result of the mis-match between expectation and the experience of an unplanned caesarean (never mind other forms of intervention) suggests this has “important implications for public health policy, with new mothers who give birth this way in need of increased support…While the financial costs associated with this surgical procedure are well recognized, there has been less focus on the hidden health costs borne by mothers and their families. ” Dr Valentina Tonei

I would go a step further and say that the hidden costs of caesarean and vaginal birth are conveniently ignored in funding and planning circles:

  • An unplanned caesarean is a hidden cost of vaginal birth attempt
  • Pelvic floor surgery is a hidden cost of vaginal birth
  • Mental health support is a hidden cost of any birth that does not match a woman’s expectations

It is great that yet another study is highlighting the link between birth experience and mental health, but studies are not enough. Many women go into their birth believing they are in control of their plan, but nature is simply not that predictable even in second and third pregnancies. Women need to know that plans are great, but they are not a guarantee and alternatives need to be considered and planned for. Antenatal education must change. But so too must the funding of maternity services, which need to take account of this additional mental health cost to some women.

“Only seven percent (7%) of women suffering with mental health problems during or after pregnancy are refereed to specialist care.” RCOG Maternal Mental Health – Women’s Voices report.

So, what could this mean?

There lots of things we can do to help ourselves manage our birth experience, somethings are readily talked about:

  • Accupressure
  • Massage
  • Visualisation
  • Breathing techniques
  • Writing a birth plan

But what is unpopular, yet which really needs to be added to this list is:

  • Information about rates of intervention
  • Ideas for ways to transition between preferences as ones birth progresses
  • Coping techniques for interventions
  • Detailed plans for caesarean delivery
  • Practical coping techniques for births which have involved some form of medical intervention

Educating women about such things does not for a minute mean we should accept interventions are going to happen as a matter of course – there are definitely situations where an intervention may be suggested but is not definitely needed. The Cascade of Intervention is definitely an effect and something women need to know about.

But we need to stop being paranoid about scaring women, we need to help them make better plans, help them manage their expectations and enable them to make informed decisions before and during their births in order to mitigate some of the mental health impact of births that change direction.

Dr Tonei said: “Unplanned caesareans may have a particularly negative psychological impact on mothers because they are unexpected, usually mentally and physically stressful and associated with a loss of control and unmatched expectations.” So, let’s help women understand caesareans, demystify them, talk about them in positive terms and most importantly help women to plan for their possibility so that, should them become necessary, they are ready and not afraid.