Category: csections commentary

Sit any group of women down to talk about caesareans and you will hear all sorts of alarming ‘facts’. Common ones are:

• You will have to have a caesarean if your baby is breech
• You cannot pick up your baby or drive for 6 weeks
• Bonding with your baby will be severely affected
• Once you have had a caesarean, your next birth will have to be a caesarean too
• the list goes on and on

What is really alarming about these facts’ is not one of them need be true.

Hard as it may be to hear, antenatal education often does little to disabuse women of these misconceptions. Rather, it can perpetuate the idea that this important procedure is a last resort best avoided.

In reality, in addition to being lifesaving in an emergency context, caesareans have significant benefits in certain pre-labour situations where attempting a vaginal delivery carries greater risk for mother or baby. Add to these, those women who view a caesarean as preferable because of the unbearable fear and uncertainty they associate with vaginal birth (tokophobia) and there are a lot of women who can benefit from planning a caesarean delivery.

Unfortunately, many women still understand so little about caesareans it will perhaps be no surprise to hear some find their caesarean experience so traumatic they go on to develop post-traumatic stress disorder (PTSD). And those who do want (or need) to plan a caesarean are left totally unaware of the opportunities for making their birth feel special and personal.

Nearly one in three women in the UK will have a caesarean, with unplanned caesareans accounting for two thirds of these.[ii] They are a possible outcome of even the most straightforward pregnancy yet are barely touched on in many antenatal classes.

This reluctance to talk positively about caesareans has forced them to the periphery of antenatal education. Books and classes can be biased in favour of vaginal delivery making it impossible for women to have open, rational discussions with those responsible for their care. Most remain unaware of the huge benefits of preparing for the possibility of caesarean birth, either planned or emergency.

Helen Walsh, author of Go to Sleep,[iii] said of her antenatal classes:

“They did not prepare me for a caesarean outcome and perhaps more importantly, the implications of such an outcome. Had I known more I would have opted for an elective caesarean and I would not have endured such a traumatic birth experience [breech baby] which I firmly believe contributed if not triggered my descent into postnatal depression.”

It is well known that a woman’s preconceptions can affect her labour[iv] and realistic expectations are significant in determining both how she ultimately perceives her birth[v] [vi] [vii] and how she approaches her recovery.[viii] Yet women are still unable to get access to the information they need in order to develop a flexible approach to birth. All too often the risks of vaginal birth are downplayed while caesareans are portrayed as an intervention to avoid wherever possible, with those planning a caesarean labelled selfish or ‘too posh to push’. This systematic bias (intentional or otherwise) leaves women in the dark about what they face.

The likelihood of needing intervention (epidural, instruments, induction or caesarean) during vaginal birth is made light of, but actually effects a significant number of women – over half of UK women will experience some form of intervention[ix] yet many remain poorly equipped to negotiate their way through the experience.

The feelings of distress and loss of control that can become associated with such a birth can have a significant impact both physically and emotionally on mum and baby.[x] [xi] Women need to know more about their options so they can assess the risks for themselves. While some would prefer to leave things in the hands of their carers, many more would prefer to play an active role in decision-making. [xii] To achieve this they need realistic information about the experience they face. Women need to know the implications of the decisions they might be tempted to make, and they need to know their rights in this regard. In the case of caesareans: knowing how to prepare for the procedure; being aware of the opportunities open to them during surgery; learning alternative positions for breastfeeding and ways to improve recovery can all radically improve the experience for many women, even if the caesarean was not their original preference.

Fortunately, in the UK at least, the National Institute of Clinical Excellence (NICE) are addressing the issue of antenatal education, in relation to caesarean birth.[xiii] They agree:

“It is important that women are presented with evidence based information in order that they are able to make an informed decision…For all women requesting a caesarean, if after discussion and offer of support a vaginal birth is still not an acceptable option, offer a planned caesarean.”

This was a huge step forward back in 2011. Unfortunately, the reality is that the extent to which this guidance is followed is still very much in the hands of the individuals providing the care – their personal opinions (as well as hospital policy), consequently perspectives can vary widely.

The toxic combination of out of date or inadequate information and biased advice means women will continue to face their birth with huge gaps in their knowledge. Failing to inform women properly contributes significantly to the mismatch between their birth expectations and birth experience exposing many to unnecessary levels of trauma.

[ii] J. Thomas, S. Paranjothy and Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. (London: RCOG Press, 2001)

[iii] H Walsh ‘Go to sleep’ (Canongate Books Ltd, 2011 ISBN:978-0857860057)

[iv] K. Hofberg, M. R. Ward, ‘Fear Of Pregnancy And Childbirth’ Postgraduate Medical Journal, 79 (2003) 505-510

[v] J. Lally, M. Murtagh, S. Macphail et al, ‘More in Hope Than Expectation: A Systematic Review of Women’s Expectations and Experience of Pain Relief in Labour’ BMC Medicine, (2008) 6:7doi:10.1186/1741-7015-6-7

[vi] C. Oblasser, The Faceless Caesarean (BoD, 2009)

[vii] C. Francome, W. Savage, H. Churchill et al, Caesarean Birth in Britain: A Book for Health Professionals and Parents (London, Middlesex University Press, 1993)

[viii] L East, Caesarean Birth: A positive approach to preparation and recovery, (Tiskimo 2011  ISBN: 978-0-9568480-0-0)

[ix] NHS, Latest Maternity Statistics Show How the Pattern of Giving Birth in England is Changing, (NHS Information Centre, 2008)

[x] J. Lally, M. Murtagh, S. Macphail et al, ‘More in Hope Than Expectation: A Systematic Review of Women’s Expectations and Experience of Pain Relief in Labour’ BMC Medicine, (2008) 6:7doi:10.1186/1741-7015-6-7

[xi] L East, Caesarean Birth: A positive approach to preparation and recovery, (Tiskimo 2011 –  ISBN: 978-0-9568480-0-0)

[xii] K.L. Ingold, author of ‘A phenomenological exploration of women’s experiences of giving birth in Leeds and discussion within the context of NHS maternity policy’ (Masters dissertation in Public Health, University of Leeds Academic Unit of Public Health, 2011)

[xiii] National Collaborating Centre for Women’s and Children’s Health, Caesarean Section Guideline, Draft (Commissioned by National Institute of Clinical Excellence, RCOG, 2011)

Which of the following circumstances necessitate a caesarean delivery over attempting a vaginal delivery?

1. The baby is in the breech position – presenting bottom down rather than head down
2. Mum is carrying twins – both twins are presenting head down
3. Mum has HIV – with a viral load of less than 400 copies per ml
4. Mum has had a caesarean previously
5. Mum’s labour is failing to progress
6. The baby is in the transverse position – lying across mum’s body

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Only No. 6. and even then, only after attempts to manipulate baby into a head down (or breech) position have not worked.

In all other instances, a caesarean may well be recommended, but it is not required.

That said, it is worth listening to the fine detail of why a caesarean may be being recommended. For example, over the last few decades the number of breech babies delivered vaginally at home has significantly decreased, so if your baby is breach and you are planning a home birth and your midwifery team are recommending a hospital birth, this could be because they feel less experienced in home breech births. Investigating the possibility of an experienced, independent midwife may mean this is still possible, or moving the birth to a birthing centre within your local hospital may help move towards a birth plan which supports both parties.

Similarly, twins do not have to be delivered vaginally, but where one twin is lying in a more complex position i.e. not head down, then a caesarean may be preferrable to mitigate against situations where cords become entangled or prolapse as the first twin is delivered.

At the end of the day, it is about being informed and checking you have all the facts. If you are at all unsure that the advice you are being given is the whole picture, it is your right (in the UK at least) to ask for a second opinion.

There are many myths about caesarean birth, and the popular press often perpetuate these to achieve sensational headlines.

It can also be the case that as women talk to each about birth experiences, incomplete or inaccurate information can be inadvertently passed on. One person’s negative experience can so easily paint this important procedure in a terrible, light.

It is so incredibly important to check information, ask questions and challenge responses before making a decision about the way in which you prefer to give birth. Taking on board second-hand information without questioning it, means some women face birth knowing next to nothing about caesarean birth. As a result they risk missing out on opportunities to make their experience a positive one.

• Did you know, putting your gown on backwards means you can try holding baby skin-to-skin during surgery?
• Did you know a breech position does not mean you must automatically have a caesarean delivery?

Caesarean Birth: A positive approach to preparation and recovery blows the myths out of the water. It also dedicates entire chapters to the preparation for and recovery from caesarean birth. There are even whole appendices on the risks and benefits of both vaginal and caesarean birth to help in your decisionmaking. All data has been reviewed by a team of midwives and obstetricians and we are confident the information is accurate and reflects the latest research.

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.

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 2^nd 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.