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.
Trying to stick to the original questions in MNHQ's post, but a lot of the points actually overlap quite a bit so this is the best way in which I can express this:
1) There is nothing in the framework about for women who have a severe anxiety about childbirth and want an ELCS before they become pregnant for the first time or after a previous birth.
If the aim is to try and help women overcome anxieties, then only taking action once a woman has become pregnant adds to the stress of the experience. Baring in mind that one of the reasons that NICE changed the CS guidelines was to recognise the fact that small scale studies had shown that women with tokophobia had, in extreme cases, terminated their pregnancy.
The emphasis is solely on women once they are pregnant, which perhaps means the success rate of any counselling is likely to be much lower and ineffective as it is a race against the clock.
It also leaves a number of women in a state where they are putting off pregnancy and anxious about the process before it even starts, as they are not formally recognised in any guidance. It is wrong that women have to make such an enormous leap of faith before they are considered important enough to be considered.
The only thing in the guidance that comes close to this, is where women Draft Quality Statement 8: Debriefing where women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies.
There is nothing for women who have had a difficult or traumatic VB delivery, and may want similar help and advice.
2) Encourage of much clearer separation of Planned CS from EMCS in all planning and commissioning of services.
The two are still being widely lumped together as they are the same procedure, however, the risks and psychological impact on woman are hugely difference.
This is particularly true in the way that risks are being presented to women in a biased way.
When rates of CS are talked about, the number is almost always presented in a single figure - as was the case in the intro that Mumsnet posted to this very NICE consultation. Its very unhelpful as the issues surrounding both can be quite different. It is distorting things in a way that is quite alarming. EMCS are made to look safer and ELCS are made to look more dangerous. This is not helpful in the decision making process.
In using a single figure it is affecting planning, particularly in a climate which is hostile to 'expensive CS' as there are political moves to try and reduce this single figure, rather than to look the two as similar but different issues and on medical grounds alone.
3) Encouraging all HCP to make publicly available clear procedures and policies about what happens if you want/request a CS or a VBAC before you see a midwife or consultant.
There is no way of finding out the procedure for going about getting a VBAC or ELCS until you are in the system and this means you are very dependant on the individual HCPs you encounter. This means from the word go, women are going into things relatively blind. Making the system transparent and encouraging the promotion of services in some way so that women do not feel that they will have to 'go into battle' in order to be listened to. Many women seem to feel that the decision is immediately out of their hands.
By making policies more open before women even see a consultant or midwife, empowers women to be more able to go and find out information before a meeting and be able to ask the right questions.
Obviously each woman is on a case by case basis, but certainly there must be generalised things that could be put forward so the majority of women have a better idea about whether they are a good candidate for a VBAC or an ELCS.
For example better use of the hospital websites could make a huge difference to this and could be relatively inexpensive.
4) Better publishing of data would be hugely helpful.
Presently you can chose hospitals on the basis of what facilities they have, but data on method of birth is still quite primitive. Again this is hindering care, with many people, including HCPs having inaccurate perceptions of birth.
Data to show VBAC success rates would be hugely helpful - however, this also needs to be countered with a measure of patient satisfaction with involvement in the decision making process, in the same way that is suggested for maternal request in the Draft Quality statement 1. Rates alone are not reflective of success and should not be treated so.
Also there is nothing to breakdown rates for why ELCS are being done. This should be encouraged, particularly making clear distinctions about ELCS on the basis of mental health reasons, rather than 'maternal request' would be a massive step forward.
The term "Rates of planned CS in women in women where there were no indications for a CS" is somewhat misleading, misunderstood and frustrating in this regard. Its a fuzzy term that makes it an easy target for cuts.
More detailed rates about VBACs and ELCS are important to women to understand that both are available for their individual circumstances.
This is also hugely important to gain greater understanding of why ELCS rates in particular still seem to be increasing (I believe EMCS rates are more stable) in order to tackle issues, rather than be bogged down in politics that are being dominated by the tabloid press and to the detriment of women.
This is also true of EMCS but perhaps to a lesser extent. Women need to feel confident that hospitals are not practising in an overly defensive or being overly adverse to performing CS in certain areas.
How women are being judged when it comes to method of birth is an important aspect that is being woefully neglected. This hopefully would help to address some of those issues.
What a wonderful post, RedToothBrush
I had an emcs nearly 7 yrs ago. The surgery itself was fine (well as fine as it can be) but afterwards was very diificult.
I had a spinal which wore off after 2 hours and I was in a lot of pain
I was left on a ward with other mums who had just given birth and had their babies with them - my dd had been whisked off to scbu. I was given no time or support by the midwives.
In the morning a hca came in and told me I had to get out of bed I did as I was told and nearly passed out with the pain, it was horrific like someone was holding a red hot iron on my stomach. They then decided maybe I did need some morphine.
My catheter was removed too soon and I went into retention which I'm sure added to the pain as I couldn't pee.
I think most of the problems I had come down to not enough staff and not enough understanding about what having a emcs is like.
I was pleased when in November 2011 NICE said c/s should be elective. I spoke about wanting one with DC2, but midwife discouraged it. He was born 2 days before this guidance came out. I think midwives' training needs to be changed so they accept some women like me may ask for a c/s and that it is a valid birth choice. Currently, in my experience, a vaginal birth is seen as the only valid choice, with c/s used only when necessary. Yes c/s costs more, but gastric banding and other procedures do too, but they are still offered as a choice. Midwives also seem reluctant to give pain relief- I asked for an epidural and all I had was co-codamol and gas and air. There is a pain ladder for childbirth, so why won't they give it when women ask? Their holistic approach to "natural childbirth" trumps mothers' choices/ wishes/ birth plans.
Women should be offered an informed choice about birth options, with pros and cons of all options discussed properly.
Midwives now train as midwives - not nurses - so how can they care for people who have had surgery with no nursing qualifications?
Exactly littlepicnic, what's needed is for epidurals, elcs, etc, to been seen as valid choices that women have the right to make.
And for women to be well informed enough to make them.
Offering support from a specialist psychologist where tokophobia is present or PTSD following a previous birth.
Surely post op care for a c-section patient should be part of midwifery training?
Whilst post - natal seems poor post c/s, it is also poor generally.
careergirl that's a very good (if worrying) point.
Definitely need a debrief. The surgeon made a couple of comments during my EMCS and I've not had them explained. At the time you're too overwhelmed to ask.
I also second careergirlabout present midwifery training.
I trained as a midwife in the late 60s immedietly after I qualified as a nurse.I n those days nearly everyone who did midwifery training was a qualified nurse so you already had experience of nursing post operative patients and were aware of their needs.I believe the present midwifery training does include a period of nursing ''general'' patients eg non maternity patients suffering from medical and surgical conditions, if the student is not already a qualified nurse.Is this period long enough though?.
Yes, agree a debrief is necessary. I had a relatively uncomplicated ELCS but the OB mentioned during the CS a couple of things that could impact upon future births or other situations. He said my blood was slow to clot: I haven't had this explained to me, so I don't know how significant this may or may not be relating to my general health.
I had a huge swelling for weeks after the CS as I'd had a haematoma where I'd been tilted to the right during the birth, and it's where the blood had pooled. I've had experiences of haematomas in the past, too, so - yep, a debrief would have been good.
I would like to second many of the excellent comments made above by RedToothBrush, especially in relation to the current problem of discussing CS as a 'general' birth type. Different CS types have different risks associated with them, and it is often not properly recognised that most emergency CS are in fact an outcome of a planned VD and should therefore be factored into the risks of planning a VD. The NICE guideline update in 2011 began to address this, but more organisations and documents throughout the NHS urgently need to do the same (i.e. focus on comparing birth PLANS, not simply the eventual outcomes).
I also agree with what RedToothBrush says about women who have anxiety about birth prior to becoming pregnant; they should be offered support too.
Finally, I would add the comment that we need to move away from measuring outcomes in terms of mode of delivery rates. The WHO says there is no known optimum CS rate (planned or emergency) and the Dept. of Health says that it does not set targets for CS, and yet we know for a fact that many hospitals are delivering maternity care under pressure of reducing or maintaining their current CS rates. Health outcomes and patient satisfaction matter far more than percentage rates.
Got a cup of tea and read the document.
From what I can gather not really applicable for me as I was an emergency.
What I can comment is the appalling after care. Was put in a ward with lots of other women and their babies including three sets of twins. All night the babies would wake (as they do) each other up so literally no one got any sleep. When I tried to find somewhere to change my son outside the ward (so i didnt wake the others) got shouted back to do it in the ward and basically 'sod the others'. There was also no way of getting a bath or shower, as there was no one to look after baby. Consequently I discharged myself (to an empty house!) just to get some sleep for me and ds!! And a well needed shower!
There was one midwife the rest were hca's, no breast feeding help or even conversation at all. One hca was amazing though and really helped practically with the baby.
No debrief about why I needed the cs, to this day I don't know if the cause is a problem with me or just this birth. No idea if I'd need one again. But it would be very useful to know to make an informed decision.
Subsequently I had two midwife visits and then absolutely no contact from health visitors. I also had problems to do with the epidural, and 1 operation to correct problems with the original c section- which hasn't worked. But I had to fight with three gp's to get anyone to take it seriously.
And it is incredibly important to distinguish between ELCS and EMCS.
I had my dd (now 10 months old) by emcs. I would like to agree with the numerous posts highlighting post-natal care as hugely important.
I have never been offered a debrief, nor had I any idea that this was even an option until coming across the Birth Trauma website. I don't feel quite ready to do so - truth is I'm terrified that to do it I'll have to return to the hospital where I had my dd and I doubt I could even get myself through the door.
My emcs occurred after 74 hours of labour. I started out feeling all-powerful in the birthing pool at the midwifery centre. We were then blue-lighted to the hospital and my dignity and control were stripped away bit by bit. I was begging for an emcs by the end of it. In four days (five midwives, numerous other medical staff) nobody once asked to look at my birth plan. I spent my emcs vomiting as they failed to manage my blood pressure properly. I saw my dd for approximately two seconds before they whipped her away, my DH went with her but the midwife (the same one who had shouted at him for using the 'wrong' toilet on the delivery ward and for 'looking at confidential notes' - he had happened to sit down on a chair next to where she had been writing the notes - MY notes and he is my DH) would not allow him to dress her. It took an hour for me to be stitched up as I had lost a lot of blood (although I had no idea of this before my midwife home visit the week later) and my dd was an hour old before I got to hold her.
I asked the midwife for help to get dd to latch on - she is my first. The midwife told me that she needed to type up my notes and that would take priority, and she would help me afterwards. I tried by myself but couldn't get it right. My dd screamed for hours until finally at five hours old the midwife came over to help her latch. It is almost a year later and I am furious that my dd was left like this.
I was then transferred to the maternity ward - a nine bed ward of screaming babies. There was one midwifery assistant on the night shift who stands out in my mind purely for her kindness, and that's ridiculous, because there were plenty of staff on that ward who could have smiled at me or offered help. I saw no evidence of my particular ward being understaffed - the midwifery assistants were milling about quite often but the midwives seemed to all sit in the room behind the front desk unless called for anything which was then treated as an inconvenience.
Like a previous poster I was made to get out of bed within a few hours and had not had sanitary protection attached correctly so I bled on the floor and was looked at like something on a shoe. I was told where my buzzer was but couldn't reach it. It was extremely painful to stand and pick my dd up out of her cot but there was no help. I too wasn't told that my CS may have an effect on my milk production - my milk did not come in until day 5 and on day 4 I made the decision to top up my dd with formula as she as screaming and screaming in hunger and I couldn't help any other way. I was then made to feel like an idiot by a bf-ing 'counsellor' (nazi) for doing so. I'm pleased to say we continued to have a successful bf-ing relationship but this woman did not help in any way towards that.
A previous post struck me when it was commented that with any other major abdominal surgery people would be cared for and treated with kindness, expected to rest and so on. It's so true. Yes of course there is a baby who needs care but what is so wrong with helping new mums?
I had a cs due to my ds being breech. I hate being shoved into the elcs group as I would have preferred a vbac as I think in the majority of cases it is better for the baby. This was my view before the cs and i believe it more so now. Emergencies are different.
The cs itself was fine but as a planned cs we had problems with a sleepy baby and my milk coming. I had asked about possible bf problems at my pre assessment and got the usual no bf will be easy talk. Ds ended up loosing too much weight after birth and ended up having a prolonged stay in hospital fed through a tube. Bf then never really worked despite Attempts to exclusively pump.if it wasn't for my cs I believe I would not have had to give ds formula. Early in my pregnancy I had been offered an elcs as he was a bit of a miracle after years of infertility and mc. Can you imagine how awful I would feel now if I had made that choice and that had led to the ff!
To return more to the guidelines I think mw should be trained better in cs aftercare particularly bf, looking after ds when I couldn't move on the first night was horrendous and I felt v guilty calling the mw frequently. I wished DP could have been there to help pass me the baby etc. ds was the loudest on the ward taken into the mw bay as me buzzing and his crying was keeping everyone awake. I think my pain relief was good, I wanted to be up and about early to help me mend and to care for my longed for baby.
If it wasn't for women having cs for the wrong reasons maybe the attitude towards them and aftercare would be better!
Can I add another thing - not sure if this applies to vaginal births too though. Regarding communication between HCPs and pregnancy/birth notes.
I had a problem during pregnancy - it transpired I have a uterine septum, which meant my baby had limited space to turn. This resulted in my eventual ELCS.
I was advised during pregnancy by Kings (where I'd been referred to by antenatal team at my local hospital) to have another scan 3 months after giving birth to check the septum and its likelihood of affecting future fertility and pregnancies and whether I would need an operation to remove it. It needed to be at Kings as they have excellent specialised scanning equipment to get a proper look. (It was lucky I got a referral there during pregnancy as it goes, as I was twice misdiagnosed with something else during pregnancy, they only picked up on the septum at week 36 )
So 3 months after giving birth, I went to GP and explained this. No notes. None. Nowhere. I had to have about six useless scans and appointments with local consultants before they re-diagnosed it and sent me to Kings to get a proper scan and assessment, which took a couple more months. Every person I saw, I had to explain the condition to, and all the scan pics from my pregnancy seemed to have vanished!
Surely pregnancy and birth notes are a pretty fundamental part of a woman's physical health record, why are they not combined with notes at GP? It was such a waste of my time and NHS resources.
I understand my notes are kept at the hospital I have birth at - I was so shocked and traumatised in the first few weeks after having DS that I couldn't look at them, and the midwife who was to take them on the final home visit said it was best not to read them. I have no doubt there will be stuff about 'over-emotional' 'nervous first-timer' and stuff in there... I wish giving birth by CS was seen as the massive thing it is. Just because women do it and survive it doesn't make it pretty much the biggest physical deal you'll ever have to go through. It's like being hit by a bus, then immediately having to get up and drive the bus with no training or help.
I had something happen during the op too that I don't understand - the placenta I think got stuck to the septum I have in my uterus and they had to yank it pretty hard to get it out. The surgeon came up to my head end afterwards and explained what they had done, but I had been sick and was all over the place so can't remember a thing of what she said to me. I lost a lot of blood at that point, just under the amount for a transfusion to be necessary. I was sent home after two nights. Two! The most hellish two ever.
Andcake - what do you mean, aftercare would be better if women didn't have a CS 'for the wrong reasons' ? even if you are judgy, isn't it reasonable to expect NHS staff and planning not to make judgements?! Doesn't every birthing mother deserve to be treated with respect?
Fwiw when it became apparent I would need a ELCS, the midwives became noticeably less helpful and friendly - I had been planning a midwife led type birth, and didn't realise how little midwife help I would get if I had a CS. I barely saw one before during or crucially afterwards, whereas people I know who had a vaginal birth could expect to have a midwife with them for those first crucial hours.
Not blaming the overstretched midwives, but it needs to be recognised that they are a crucial part of the process regardless of birth type. In my case it went consultant - surgeon and anaesthetist - health care assistants. And the HCAs were beyond useless, lovely as some of them were.
Andcare - and what would constitute a 'wrong' reason?!
Andcake, attitudes like that are EXACTLY the ones that I was referring to in my post, when I said that there are HUGE misconceptions and myths about why women are having ELCS.
Thank you for illustrating the point, quite so well.
For the record, from what I have learned, mode of delivery doesn't necessarily have an impact upon BF. That is, BF isn't necessarily easier if you've had a VB and it isn't necessarily more difficult if you've had a CS.
A traumatic VB might mean difficulties with BF whereas an uncomplicated CS (so I guess I'm talking ELCS here) can lead to instant, uncomplicated BF.
Andcake I think it's important that you clarify precisely what you mean about your "women who have CS for the wrong reasons" comment. It's this attitude that we are desperately trying to move away from in order to make CS another birth choice.
Also, in correction of Andcake's post: an unassisted, planned vaginal delivery is the safest mode of delivery for baby, followed by an uncomplicated ELCS. Assisted deliveries (ventouse then forceps) are 3rd and 4th safest, then EMCS.
I'm being served by memory alone here. These statistics are available from either NICE or Caesarean Birth: a positive approach to preparation and recovery by Leigh East.
Molotov, those stats are right but also don't quite reveal the whole picture.
Technically you can only plan to have a VB or plan to have a ELCS. Therefore the risks associated with an assisted VB delivery and an EMCS are relevant to planning an unassisted planned vaginal delivery.
At which point, the differences in risk between the two are much closer together.
Of course, this is also influenced by other risks factors too. So if are over 35 you would be statistically significantly more likely to end up with an assisted birth or CS than an unassisted VB.
This illustrated just how flawed and how badly understood a lot of data that is out there actually is. Its useful to know that EMCS and assisted births are more dangerous, but it also needs to be put into the correct context.
There are far too many people out there, even in the profession, who are not properly grasping these concepts as it suits them to believe what they want to believe.
I personally would love to know the figures about ELCS done for mental health reasons, but I do not believe the data actually exists. It certainly isn't freely available in the public domain and what little there is still seems very, very limited indeed in my experience.
In fact in looking for this information, I've found it interesting that a couple of people have used the FOI Act to try and get this information.
This one for North Cumbria University Hospitals NHS Trust
And this one for Greater Glasgow NHS Board
Both are from the last twelve months. North Cumbria did provide figures, however Glasgow did not as they did not have the data themselves.
North Cumbria's response is interesting - there is no category (as far as I understand it, but its in medical terms so I could be wrong) for mental health. There are 14 deliveries that are simply labelled as "Delivery by elective caesarean section" which works out as about 4% of the total number of deliveries for the period. Its a very vague phrase and certainly isn't clear what it is referring to.
Back in 2003 The Select Committee on Health Fourth Report reported that:
86. According to the Centre for Family Research at the University of Cambridge, the RCOG and many others who provided written evidence for our inquiry, pregnant women want more information on the risks and benefits of caesarean section and wish to be involved in the decision-making process. A survey carried out between 1999 and 2002 by the Centre for Family Research at the University found that that maternal requests for caesareans were made mainly because of fears about the health of mother or baby. In their most extreme form, these fears constituted a phobia of giving birth (tokophobia), and a small number of seriously traumatised women may need surgery in order to avoid severe psychological problems.
So if Andcake, knows difference, I'd really like to know. Her views are just a mirror image of whats in the press and I personally find it an attitude that is very difficult to deal with.
If I felt I would be able to discuss this with friends, family or HCPs without judgment or feeling like I would be instantly dismissed as "Too Push to Push" I think I would feel very much more supported and it would be one less hurdle and anxiety to have to deal with.
This is getting slightly off the purpose of this thread, which is technically more about clinical practice, but I do think it is relevant to my earlier post and the way in which policy and care needs to go. I just find the whole thing very, very frustrating and I don't see any way to change this without making sure that more of the relevant data is firstly collected and secondly freely available to challenge these views.
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