Finally! No caesarean rate targets in England

NHS England have finally admitted that the idea of an ideal caesarean rate is absurd. In fact, they have gone so far as to admit it is potentially “unsafe and clinically inappropriate”. No doubt influenced in no small part by the inquiry into the excessive number of baby deaths at Shrewsbury and Telford hospital NHS trusts. (Note – Shrewsbury NHS trust had one of the highest rates of vaginal delivery in the country during the review period!)

The letter from Jacqueline Dunkley-Bent NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity directs:

“all maternity services to stop using total caesarean section rates as a means of performance management…We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases.”

In response RCOG (Royal College of Obstetricians and Gynaecologists), said:

“We welcome this clarification from NHS England. These targets are not appropriate in individual circumstances. Both vaginal and caesarean births carry certain benefits and risks, which should be discussed with women as they choose how they wish to give birth.”

Along with other birth groups, we have been campaigning for this change for years and are very relieved such unnecessary, unethical targets have been removed.

Vaginal birth and caesarean delivery both have benefits as well as risks for mum and baby. NICE guidelines have made it clear since 2011 that it is reasonable for women to make an informed choice in either direction. However, target rates imposed by NHS England have made it very difficult for women to make use of this change to the guidance. Some hospitals sticking rigidly to the targets, others ignoring them and being penalised.

Fundamentally, we should be able to trust our Doctors to have our best interests at heart when making decisions about the progress of our pregnancy. Targets based on economics and hosptial policies has never put the women first and we welcome the NHS’ recognition of their mistake.

This letter means a mother’s right to make an informed choice for one mode over the other is now more possible. That doesn’t mean it will always be straightforward. Some practitioners stil believe “normal” (vaginal) is best and will strongly encourage you away from a caesarean. However with the hospitals no longer pressured by unrealistic targets women are in a much stronger position to argue their case. This does mean being able to demonstrate clear reasons for your choice is still very important. Knowing what is a necessary route to delivery versus just a suggestion is paramount. Caesarean Birth: A positive approach to preparation and recovery, covers everything you need to know to put your case forward effectively.

What are my options after a caesarean birth?

This is quite a common question. Unfortunately, the answer is not straightforward.

Hospital policies continue to influence things both overtly in terms of whether there are written (or unspoken) caesarean targets, but also more subtly through common practises such as induction guidelines / tolerance for the length of 2nd stage labour etc.

It is possible to avoid automatically having another caesarean, always assuming of course the reason for the first caesarean is not likely to recur in each pregnancy. Hospitals are being increasingly encouraged to support VBACs (Vaginal Births After Caesarean) and NICE guidelines state that:

“Women have the right to choose VBAC… Therefore, this model would support a woman being able to choose her preferred mode of birth in consultation with the healthcare professionals responsible for her care.” NICE guideline

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

For those women preferring another caesarean this will, in many cases, be dependent upon the opinion or policy of those responsible your care. Some hospitals do not encourage a planned 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 a later pregnancy.

“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. From Chapter 3 of Caesarean Birth: A positive approach to preparation and recovery.

For example: Where a caesarean request is being refused you have the right to a second opinion.

“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

There is a lot of detail in Caesarean Birth: A positive approach to preparation and recovery about ways to manage these discussions, whether your aim is to avoid or indeed plan a caesarean. Either way, there are quite a lot of things you can do to help you case.

Why prepare for the possibility of caesarean birth?

Like it or not, whatever your birth plan says, the fact is a third of UK births will be caesareans. As I have worked with practitioners and women preparing for birth over the years, it has become very apparent that fear and stigma can still be very much a part of caesarean experience for many. Unfortunately, in being unprepared for a caesarean outcome, when it happens some women in their sleep deprived, stressed and postnatal hormonal state, are unable to rationalise the experience describing it as “disappointing” or worse “highly traumatic”.

Understandably, many women take their adventure into motherhood very seriously, attending antenatal classes, buying book after book or, if neither of these, at least talking to family and friends about their options. Sadly in many cases despite the best of intentions many can remain quite in the dark about caesarean birth, inadvertently taking on board the negative opinions and media hype surrounding this mode of birth. And while some practitioners do try to talk about caesareans in a positive way, women often reflect they found it difficult to find the positive messages and that preparation advice was typically woefully insufficient.

One woman once wrote to me:

“I was actually on the table and surgery had started when it occurred to me to ask what the difference was between an epidural and a spinal anaesthetic,¦I should have known and it was too late to participate in any discussion.”

In the UK nearly 1 in 3 births are caesarean, and over 1 in 3 in the US with similar rates in many countries. Yet all too often the two phrases heard in connection are:

“major surgery” and

“it will affect your ability to bond with your baby”

While both can have an element of truth to them (for some women), the tone in which they are typically delivered and the total absence of any explanation, support or clarification makes them two of the most irresponsible phrases used in antenatal discussions.

That said it is becoming more acceptable to ask questions and a quick Google search will produce websites talking about how to improve your caesarean experience. But incredibly in 2021, the number of books which treat caesarean delivery as a valid and incredibly positive birth experience can still be counted on one hand.

I wrote the first edition of Caesarean Birth: A positive approach to preparation and recovery to redress this imbalance back in 2011 and it has since gone to a second edition (2018). As a complete caesarean ‘manual’ it covers:

  • Why one might be suggested
  • Why we should prepare
  • How to make the most of a caesarean (preparation and recovery guidance)
  • A detailed risk / benefit comparison with vaginal delivery
  • Implications for future births
  • A description of procedure itself and crucially how women can participate in and influence that process

The book blows apart the myths we hear about caesareans and women have reported feeling more confident and able to make informed decisions about their births as a result. Crucially it gives lots of ideas on how to prepare for and express preferences about the experience, radically improving the chances of perceiving it positively should a caesarean become necessary.

For example, knowing to ask to put your gown on backwards (opening at the front) prior to surgery means, assuming there is no emergency, you can easily hold your baby skin-to-skin and possibly even breastfeed while still in theatre. Such a seemingly simple thing is so incredibly important to so many and is actually totally achievable in many caesareans.

Asking questions and being better informed places us in a far stronger position to negotiate and actively manage the direction and experience of our birth whether it is a vaginal or a caesarean outcome, why leave out knowledge of a whole birth experience and risk being disappointed or traumatised unnecessarily.

“I am so glad I read this book before my birth. I didn’t intend having a caesarean but when it happened I wasn’t at all frightened and I fed ‘S’ in the recovery room. This book thoroughly demystified caesarean birth for me.” Vicki (35)

Why did I chose a caesarean?

At 38 weeks our 2nd child decided she had had enough fun bouncing around in my belly and now wanted to bounce around outside. I had a caesarean scheduled for the following week (6 days before the due date) so I was a little surprised to feel my first labour pains. So surprised in fact I didn’t really believe it was labour. perhaps not surprising given I had been in hospital the previous week with a “false labour”, and this felt very similar. I dozed through the night and at 6am thought – Humm this no longer feels “false” to me.

By the time I went to hospital at 7:30am, contractions were every 3 minutes and excruciating, but only 1cm dilated!

After a very successful planned caesarean with our first daughter, we chose the same route for our second.  On my notes it said I was electing and so when the consultant checked on me at 9am, it was agreed I could go straight in. The most daunting thing I have found with both caesareans is actually the preparation. I have a horror of needles and the IV in the back of my hand is, for me, the most dreaded part of the whole experience. Our baby was born within 5-minutes of surgery beginning. They held her up to me before cutting the cord and then whisked her away for a quick check. Within what felt like seconds she was back and being placed on my chest for me to cuddle. It was a little difficult with the tubes and the screen but lovely to have her in my arms almost immediately. The whole experience was very relaxed and friendly. At one point after Celia had been lifted clear the pain management needed some adjusting and the drugs were bumped up a notch, but other than that it was a very stress-free birth.

We were back on the ward in an hour. It was rather uncomfortable getting in and out of bed that first day and when walking round I was bent slightly like an old lady, but within 2 days I was back on my feet and ready to go home. I highly recommend peppermint tea and prunes; I was taking both from the moment I got back onto the ward making toilet trips relatively stress free. All in all, a wonderful birth experience once again. I’m glad I had my husband around to help with lifting our eldest (2 years) once home. It has ensured that the scar wasn’t strained, and I had no trouble at all with healing, sailing through my 6-week check.

So why did I have a planned caesarean on both occasions?

Within my group of friends, I joined the baby club quite late. And while we were happy with the decision, it did mean we had a little too much time to listen to friends’ birth stories. It was only as I sat down one day and did the maths that I realised 7/13 friends had had caesareans and only one of these was planned.

Being newly pregnant, this seemed dauntingly bad odds to me. I couldn’t even blame it on my friends being in a specific health authority, they were dotted around the UK. I knew recent national statistics indicated that 1 in 4 women have caesareans. It was this information, coupled with my friends’ rather graphic narratives of emergency caesareans as well as ‘normal’ birth stories which made me start looking at my birth options in more detail.

I started on the web and at that time (2004), it was apparent there was a lot of information about caesareans, most of which quite negative and lots of positive hype about natural birth. Positive aspects of caesarean birth proved particularly hard to find but given the odds I thought I better keep digging.

At this point I thought talking to medical personnel might be more useful. It became obvious that, in terms of physical and mental recovery, elective and emergency caesareans were two very different things and actually 1/3 female obstetricians planned a caesarean over a vaginal delivery. On top of this, the mental approach to the birth itself could play a significant part in determining the speed of recovery.

To cut a long story short, after all the reading and talking, I opted for a caesarean in the absence of any medical need.

My husband and I were surprised and a little hurt by the negative reactions this decision provoked from a variety of people. But we were perfectly happy with our decision and able to justify it.

I am pleased to say both my birth experiences were every bit as rewarding as those described in typical ‘natural’ birth stories we’ve all heard.  Oh, and I was awake the whole time; I saw my babies born and turn pink; I started breastfeeding in the recovery room; I was walking within 20 hours; there was no sign of the baby blues and on both occasions I was behaving ‘normally’ within the week, well as normally as a sleep deprived new mother can.

Interestingly in my NCT group of 8 from my first birth, only 1 managed a totally natural birth. The remaining 6, who had all planned natural births, were all medically assisted in one way or another, 4 ending up with emergency caesareans.

Here’s how you can improve your caesarean experience?

The following is simply a list of all the things you can do before, during and after a caesarean birth to help improve both your experience and your recovery. This is worth thinking about even if you are planning a vaginal birth, as, in many countries, a quarter of births end in caesarean delivery (planned or otherwise).

Before:

  • Maintain a healthy diet and exercise regime
  • Accept the anti-nausea meds offered prior to surgery
  • Be aware you do not need sedatives prior to surgery and have the right to refuse them (I am referring to sedatives, NOT anaesthetic)
  • Remain hydrated, only stopping liquid intake 2 hours prior to surgery

During:

  • A dedicated team member to keep you and your partner up to date and answer any questions
  • A doula (as well as birth partner) permitted in theatre if you have been working with one in the lead up to birth
  • Surgical gown on backwards (so it opens at the front) to enable skin-to-skin time in theatre if desired
  • Delayed cord clamping unless in an emergency situation
  • Baby passed straight to you unless medical attention is required. Weighing, cleaning etc. can be delayed
  • Skin closure with stitches, not staples (unless staples are medically necessary)
  • Appropriate pain relief regime begun immediately
  • Pressure shoes or stockings applied

After:

  • Encouraged to eat and drink within 2 hours, particularly peppermint to aid with gas (no fizzy drinks)
  • Immediate breastfeeding support if breastfeeding is the intention
  • Catheter removal as soon as possible, no later than 12 hours (unless specific medical reasons require it remain in place)
  • Pressure stockings remain in place for duration of hospital stay
  • Supported to walk the same day as surgery
  • Keep on top of the pain medication regime – once you fall behind by an hour or more it can be difficult to build back up to an effective level
  • Accept all the help you are offered; you can always say no thank you later

Once at home:

  • Take it easy. Baby and you come first, not a guest’s cup of tea – let them make it and ask them to unload the washing machine while they are at it. Your on-going pain meds can mask signs that you might be over-doing it, so pay close attention
  • Avoid touching the surgical site, but use clean hands if you really need to
  • Keep an eye on the surgical site for early signs of infection
  • Consider continuing to wear the pressure stockings for an extra few days
  • Do not be tempted to resume exercise too soon, listen to your body – twinges reveal you may be over-doing it. With care you can begin very gentle exercise prior to 6-week wellness check (I am talking a gentle walk, I am definitely not suggesting situps, nor even a short jog etc.)

Some of these ideas are from an excellent article on ChildbirthU

And much more detail can be found in Caesarean Birth: A Positive Approach to Preparation and Recovery.