NICE consultation on draft quality standards for Caesarean section - what are your thoughts/experiences
We've been asked by The Quality Standards Team to contribute to a National Institute for Clinical Excellence (NICE) consultation on the draft quality standard for Caesarean section (CS). The draft standard is made up of a set of measurable statements and the consultation asks for your thoughts on these statements.
The background information provided by the consultation states:
"Caesarean section (CS) rates have increased significantly in recent years. In the UK 20-25% of births are by CS, up from 9% in 1980. The draft standard focuses on improving the information available to women who may request or need a CS. The draft standard also focuses on reducing potential risks or complications for the woman and the baby."
The consultation is interested in hearing your views on nine draft quality statements, listed in the consultation document (pages 3 & 4). These range from ensuring pregnant women who request a CS discuss their choice with their maternity team, to involving a consultant obstetrician in the decision-making process, and to exploring procedural options when there complications arise during labour.
The questions asked by the consultation are:
1.Can you suggest any appropriate healthcare outcomes for each individual quality statement?
2.What important areas of care, if any, are not covered by the quality standard?
3.What, in your opinion, are the most important quality statements and why?
4.Are any of the proposed quality measures inappropriate and, if so, can you identify suitable alternatives?
Please post your thoughts on these questions and, of course, anything else you want to say on this thread. The consultation closes on 24 January 2013 at 5pm.
Post-natal care should be covered by any new guidelines.
The info and help before the op was fine, the op itself was wonderful, but from the recovery room onwards I was on my own.
It was the most horrendous experience and really ruined any chance of breastfeeding and bonding properly with my gorgeous newborn. I was in so much pain and it was only 'healthcare assistants' who came when I pressed my buzzer, I thought they were midwives and their advice and help varied from crap to downright damaging. I cried and cried, as did baby, and received no help. I was referred for 'enhanced postnatal support' by the midwife doing the release form 2 days later, which consisted of a couple of judgy and useless HVs turning up a few days later, by which time the damage had been done.
One to one midwife care for every woman postnatally until she leaves hospital. Not just helpful but essential.
Everything before the birth was professional, caring and great - I struggle to understand why postnatal care is not seen as important. It is the most important bit!
I had an emcs so I can't comment on many of the points as they are geared to elcs/ planned cs.
However, I absolutely agree post natal care is dire. I was ill, ds was suspected to be ill but I felt pressured into doing far more than I should have on less painkillers than I needed (dh had to keep asking for them otherwise I'd be forgotten). I would have loved a debrief as detailed in the guidelines, I had a very short consultation with a healthcare assistant who didn't know many things as she had just joined.
Nearly 14 months later I'm still not sure things are right but I find gps are dismissive of anything to do with gynaecology after childbirth, covering themselves with the catch all that things are just different after it. Proper follow up care with an expert would be brilliant, perhaps an out patient appointment?
I don't know if my opinion will be of any use here but here goes.
I gave birth to both of my children by EMCS the younger one is now 40years old.At that time, 1972 and 1969, the whole of your care from admission to discharge was excellent especially for post ceasarian mothers.I know that the CS rate was much lower then so there were fewer of us.CS mothers were in hospital post natally (sp) for 7-10 days so were more or less ''back on their feet'' by the time they got home.The care in hospital was very very good.Attention from qualified midwives who spent time with you, assisting with breast feeding and very careful attention to your wound.All sutures were removed before you went home and I can hardly remember any wound infections.
There were some aspects then which would be considered negative now, e.g. all CS done under GA which made you and baby very sleepy and groggy for first 24 hours, and you and baby were isolated from each other at first.Baby was in SCBU under observation for 24-48 hours.I did not see either of mine until two days old.You were taken straight to the ward from theatre-no recovery rooms.This was compromised though by excellent immediate post operative care, especially after GA.You did not leave the theatre until aneasthetist was satis fied you were breathing normally and able to answer to your name!.
I also trained as a midwife before having my children (mid 60s) so have had experience of the old days from both sides.
This care was all provided on NHS.People have to go private and pay exorbitant sums of money to get anything near this now.
What has happened?
Don't dismiss requests for a CS as being from women who are 'too posh to push' - after carefully considering my options, I asked for a ELCS - I was completely dismissed out of hand and told that a 'big' healthy woman like me would have no problems - I ended up with an EMCS - I didn't care but it must have cost the NHS much more money .
Having a CS can affect breast feeding and bonding, I only found this out thanks to Mumsnet - this should have been properly explained and when my DS was failing to put on weight it would have been nice if my DH hadn't had to almost make threats before my DS was 'allowed' to have a bottle.
Please be sensitive to the medical needs of the mother, I could have cried when I asked for some sanitary protection as I knew I was bleeding heavily, the
very young nursing assistant just put it at the end of the bed ........ I couldn't reach it. Yes, I know I should have just asked her, but I was incredibly weepy, (DS diagnosed with serious health problems after birth - nothing to do with the CS), dosed up with GA etc etc - a little kindness and thoughtfulness would have been nice.
This was all 12 years ago, no lasting problems for either my DS or I so we did have a happy ending, but hope comments may be useful .
I requested a cs after dc1 was born by emcs. The consultant was initially dismissive, then scheduled the op as close to my due date as she could. If I went into labour I was to try for a vbac.
I ended up with another emcs after 24 hours of back to back labour.
I never wanted a vbac, and I'd like that to be recognised as a valid choice.
A CS can be a good experience, I "enjoyed" mine, but women who have CSs should have choices like women who have vaginal births, for example delayed cord claming IS possible with an uncomplicated CS, at my local hospital vaginal birth women have this choice but CS women do not, also slower removal from the womb to "squeeze" the lungs and whether or not to have the screen down and delivery onto mothers skin etc... there's no choice! its all down to the particular consultant's way of doing it! All of the above are possible and reasonable if a CS is going to plan, and noone would deny a vaginal birth women those choices, but once you are having a CS you are having the kind of CS the consultant likes doing! Imagine the same attitude applied to vaginal births!
I had a very positive ELCS in April 2012 with my second baby.
I delivered my first baby vaginally in February 2009, but developed coccydynia as a direct result of the 2 hours it took to push her out.
Therefore, I requested an ELCS second time in order to prevent further damage to my spine. My consultant was initially very dismissive ofthe reasons why I wanted the CS. My impression was that he was
inclined for me to deliver vaginally again because the coccydynia might not recur; despite me informing him of my independent consultations with a physiotherapist an chiropractor - who both said that I was at a much higher risk of worsening the coccydynia.
The individual merits for me were only given as: 'you'll know your baby's birth day'. Then the demerits were things like: 'you could need a hysterectomy'. All very frightening. All true, of course, but not given in a balanced context.
In the end, due to the NICE November 2011 guidelines, I was offered the CS because I had informed myself of the risks. I'm emboldening the last statement because, had I not independently consulted the NICE guidelines and consulted other relevant HCPs, then the risks that applied to me had been given way out of context.
I was also told by the OB that CS is a "violent" mode of birth for the baby. I didn't say anything, but I did think 'it couldn't be more violent than my poor DD1 who was eventually suctioned out of me because I was literally too physically exhausted to push anymore.'
So, in conclusion, if I were to see a consultat obstetrician again to request a CS, I would like to hear a more balanced, personally contextualised account of the risks and benefits of ELCS and a planned vaginal birth.
Ultimately, I would like ELCS to be regarded as another legitimate birth option. There is still stigma attached to CS; mostly because of the damaging 'too posh to push' mantra that has become normative within out society. No, its not due to being too posh. This attitude must change somehow. Through unbiased, clear information, I think.
And for what it's worth, my ELCS was calm, peaceful and extremely positive. Not "violent" at all, as far as I am concerned.
I hope this helps.
My EMCS was the only 'enjoyable' part of my entire labour. The rest - before and after - was was pretty bloody useless.
Picking up on one point in the consultation document...
Women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies - I wasn't, and haven't been, offered any discussion about this. I am quite certain on my choices for a future pregancy, but this certainly wasn't part of my aftercare, and it would be useful if I was unsure what to do for another pregnancy.
However, as poppy puts it, "I never wanted a vbac, and I'd like that to be recognised as a valid choice". This, definitely. It's only finding out recently from friends that cs's are allowed for the next baby that has reassured me, I didn't realise quite how scared I was by the thought I might be pushed in to a vbac. Though I am worried about all the hoops I will have to jump through, and that they might schedule it so close to my due date in the hope I will go in to labour on my own. I am terrified of natural labour now. I appreciate that women should see a professional to discuss their choices, but I think the tendency to try and override the mother's natural feelings on an elcs v vbac is terrible; if a mum is already scared of natural labour, why make her pregnancy even more stressful by continally pushing her towards something she doesn't want to do?
A few other things that cross my mind:
My baby was poorly, hence the emcs, and was rushed off to NICU. I didn't even get to see her, let alone hold her, which still plays on my mind even a year later (and is part of the reason why I don't want a vbac). Now of course I know that if my baby needed medical care immediately that is far more important than seeing or holding her. But I suspect everyone in that room knew she would be that poorly when she was born, and I just wish someone had told me that. I wish someone had explained it to me, so I wasn't sitting there a day or two later, once the drugs and shock had worn off, thinking - hang on, what happened there?
Also, I had no explanation or instruction of how to get out of bed, how to look after my wound, that sort of basic care. Like several other posters have said, the postnatal care was absolutely shocking. I don't think one-on-one midwife care is anywhere near achievable, but just the sight of a midwife or nurse would be help. The women in my hospital were just left in bed on the ward with the baby, and no nurse or midwife even popped in to see if everyone is alright. I can't even begin to imagine how the new mum's three hours out of a cs coped with a newborn baby.
The NHS currently seems very happy to stress that it is major surgery if you are trying to get an ELCS - but then very happy to ignore that you've just had major surgery when you are on the postnatal ward.
Lastly, if a mum has had a cs because the baby is ill and the baby is then taken to NICU/SCBU, please try not to put her on a main ward with other mums and babies wherever humanly possible. I know beds in private rooms or small wards might not be available, but is it so hard to just have a piece of paper that says 'move Ms X to a more private bed when one is free'? The first night on a shared ward with newborn babies crying and mums chatting was living hell for me. I ended up at the nurses station at midnight in hysterics because I hadn't slept for three days and my baby was poorly, and I was treated as if I was overreacting and a completely pain in the arse to them. Yet they finally admitted there was a bed free in a side ward for mums with babies in SCBU! I even saw they'd written in my notes for that night that I was 'over-emotional'. A little bloody compassion, please. I honestly don't think that any of the medical staff on our postnatal ward for 30-odd women had any interest whatsoever in babies or in acknowledging what the women had been through.
Reading some of these I feel very grateful to the lovely team at Hull mother and baby unit where I had my emcs. From the moment I arrived in the ambulance the situation was turned from a panicky, stressful mess into a calm, controlled, peaceful and very happy experience.
I got the pain relief I needed straight away, they listened to everything we wanted as soon as DS was born. DH was in the operating theatre, he got skin to skin contact with DS straight away, he got to cut the cord, DS was breastfed by me within minutes. The C'S itself was amazing, upbeat happy, almost celebratory atmosphere that totally set DH and I at ease and made it a very special time for us. (hmmm I wonder if some of that was the drugs, but DH said it was fab too!)
post natal care was FAR superior to my Vaginal Birth experience with DD, (which was shockingly crap) in fact te whole experience was much better than first time round.
The only thing I would have changed was having a room to myself, but that's being VERY picky as I was in a room of two, compared to 8 in York, so minimal disturbance.
I honestly don't think they could have done anything better for us. We went home happy, rested and looked after, it was the most amazing start in life for DS and they saved him and my life into the bargain. it was the care that every woman and her baby should have. My introduction to motherhood and nod could have been avoided with DD if the team at York had been Half as good tbh. It really makes a HUGE difference to get good care from a respectful and understanding tem!
TheSamling's post has reminded me: credit where credit is due. The antenatal and postnatal care, not to mention the team who delivered my baby at Birmingham Women's Hospital, were first class. I'd definitely choose there again for another pregnancy and birth.
Women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies I have just signed the consent firms for CS4. They spent ages going over the risks but tbh I don't really have an option at 32 weeks! Information should ge given pre pregnancy.
Post natal care was v scant. They wouldn't let me get home early but weren't able to help me. I was also on crutches and with tubes in my arm I couldn't use them.
Also yes to having some choice over delivery & not being down to the cons.
oh and it would be helpful if the post natal staff both understood, and assisted with biological nurturing - for someone with an abdomen wound it's so much easier! unfortunately the (otherwise good) staff on the postnatal ward seemed to think that breast feeding didn't work without gravity (as if I'm some sort of milk jug! that needs to be poured!) and kept trying to make me sit up to feed in cradle or rugby position, or on my side, instead of reclined on my back. They told me the baby wouldn't be getting any milk that way when actually your flow is better with biological nurturing! and I had the nappies to prove it!
The vbac discusion is important but I think they have it the wrong way around. In my major London teaching hospital VBAC was the only considered option even though I had asked for a ELCS as the pregnancy had been difficult.
In the end I ended up with a EMCS and a rupture and a trip to intensive care.
I have since learnt that the rates for rupture for a long labour and intervention with vbac are higher than reported.
Women should be able to have an EMCS after an EMCS if they dont want to try for a VBAC.
The aim should be to try and prevent the first EMCS a woman has and not to push women into VBACs for the subsequent births.
I had an emcs in 2009 at southmead in Bristol. I was sent home 36h later! I had had major abdominal surgery, this was my first child and we were told we were going home. me and dh were stillin shock from the emcs so didn't question it at all. It took me a good 6 weeks before I could walk more than 10 mins before being exhausted! 24h extra in hospital would have made a massive difference in term of my recovery.
i believe all cs births should be able to stay in hospital for more than 48h if you wish!
I had an elcs in 2011 at southmead hospital. This time I was begging to get home and I felt fine! However I still had to stay in over 48h. I was springing about within a week and normal by 3.
but I did have to ask the orderlies (?) to move my food tray for me (from the end of the bed) as my spinal hadn't worn off. I was greeted with a massive huff! Some awareness of patients limited mobility for orderlies etc would be useful!
I agree that petients should talk to someone before their elcs BUT this shouldn't be an opportunity to make you vbac. This should be a discussion of the pros and cons of an elcs or vbac. However this depends on the individual HCP being open to all methods of birth.
Oh and someone should warn you that you may never get back the feeling where the incision was made. Noone mentioned it before my emcs or at my elcs! I have a very numb section!
I read this the best I could but bit frazzled looking after 3mo!
I just wanted to add my experience as feel it's quite relevant. I had a c/s in October due to extreme Tokophobia. So extreme in fact that my consultant said it was the worst case he had seen in over 20 years of obstetrics. So I totally agree with Ragwort's comment- please don't dismiss all women requesting c/s as being too posh to push. I was so upset and scared I really did contemplate aborting my much wanted baby, I was in hell really and shudder to think of what could have happened. I had a pretty horrible time when I was pregnant as I was so anxious but I had fabulous prenatal care from my midwife and consultant, he agreed to my request for c/s under GA immediately during my first appointment with him. He was fantastic and very understanding, I think the care I received should be the standard. The only thing I think he omitted to do was arrange an appointment with the consultant anaesthetist for me as on the day of my OP the anaesthetist wanted me to have an epidural rather than a GA due to risk etc, but he was still ok about me having the GA.
The care I had in hospital was so good, all the staff were so kind and compassionate. The only thing I would say is due to cuts and generally being understaffed there is nowhere near enough support with breastfeeding etc, especially at night. After a c/s I couldn't get out of bed to pick up DD to feed her or change her nappy, it would even have been better if my DH had been allowed to stay overnight. So yes, I definitely think postnatal care needs to be addressed.
The final thing I would add is that on my discharge summary, the reason given for my caesarean was ' maternal request', and I think this should have been recorded as ' Tokophobia'. It should be recorded as a medical indication for c/s in the same way a physical medical indication would be.
I haven't read document as on phone, so will come back. But I agree that it should cover post natal care. I have had two perfectly pleasant ELCS and one very horrid post natal experience. Second time round at least I knew what to expect, but neither time was given any info on pain management, or when epidural would wear off, or when catheter removed.
Compared to the information and support I had before the section, the lack of post natal care was really noticable.
I would like to see a full debrief before discharge included as part of standard procedure following emcs. I would like to know if the surgeon could determine why I after 2 hours pushing ds did not come out. This would enable me to make an educated decision about elcs vs vbac next time round.
on what planet can women elect to have a caesarean without discussing it with their maternity team?
i agree it is postnatal that need addressing too. i was stuck on a delivery ward for ten hours because no hcp was free to take out my catherta (sp) with a full spinal block from post birth episiotomy repair performed in theatre and a starving baby i couldn't breastfeed and no assistance. i should have been on high dependency unit but there was no room. things didn't improve when i finally got a ward.
can i also make the suggestion that in this century when a woman has had her vagina sliced open then stitched up she might be offered more than a paracetamol every 4 hrs for pain relief??
sorry that still baffles me - can you imagine if you sliced open a man's testicles, stitched them up, handed them a new born baby to care for and when they complained of pain you offered them a paracetamol?
I agree with the other posts about post surgical care. I had an emergency CS under and GA so can only comment on standards 8 and 9. Unfortunatley i did not have a positive expereince and week that followed my CS was awful. When I woke up my husband was holding our son and I was told by the nurse in the room with us that I had "better feed him". No further support was given to help me to do so. This remained the case for the following three days and I quickly dreaded trying to feed my son as I didn't know what to do and when I buzzed for help a midwife would come and quickly latch him on then leave, only for my baby to break his latch again often seconds later. The end result of this was that we failed to establish breast feeding, my son lost too much weight and was admitted to the neonatal unit for two horrible days. During his admission he was given formula feeds and stopped opening his mouth to latch on completely. (fortunately the breast feeding support in this unit was excellent, worlds apart from the maternity ward, and with their help my son and i managed to successfully learn to breastfeed by the time we went home).
The two issues which I don't think we're handled properly were:
1. (Related to QS8) The psychological impact of an ECS under GA - for the first few days I struggled to recognise my baby as my own - the one that I had carried for nine months, because I wasn't conscious for his birth and knew nothing about it. It would have been really helpful if someone had taken the time to tell me exactly what had happened while I was unconscious and to talk to me about how his method of delivery might affect our bonding. At no point, either in hospital or once I got home, did anyone ever talk to me about the emotional and psychological impact of this method of delivery. A suggested outcome for this standard would be that the woman is offered a dedicated appointment soon after birth with a midwife familiar or present at the proceudre which provides her with the opportunity to discuss the procedure and the potential effects on bonding, breast feeding, emotions etc.
2. (Related to QS9) Assistance with establishing breast feeding - I think extra structured support is essential for woman who have had a CS, with or without a GA, given the sedating effect of the drugs used during the procedure. A suggested outcome here would be a set amount of time/sessions allocated in the first few days for the woman to spend with a breast feeding specialist with the goal of establishing confidence in breast feeding.
Re point 5- c-sections to be after 39+0. Our hospital only does planned sections once a week so my 'choice' is 38+6 or 39+6. There's a good chance I'll go into labour before 40 weeks and would then need an emergency c-section. So some consideration needs to be given to these factors.
I'm going to come back and answer this properly tomorrow as I want to mull it over first. But I will say that IME post-natal CS care is shit.
'Getting on with it' did not make me heal faster or be a better mum, it left me in pain, sobbing in my hospital bed trying to shuffle out to pick up my howling newborn for the 3 days after my EMCS. It was better after my planned CS as I simply refused to move (even when the midwives said I could) and I buzzed them for everything, less pain and perfect bf from day one that time around
Just wanted to agree with what toad says about a debrief. Without a discussion quite near the birth about why an emcs was needed, it's difficult to make informed decisions, and that might be stopping some women from having further children.
It's very sad to hear about how many women feel they had practically no postnatal care and were just left to get on with it following major surgery
Lack of debrief means that women may get pg again and not realise how high risk they are ( just found out I had a PPH with dc3 and am 32 weeks with dc4).
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