NICE consultation on draft quality standards for Caesarean section - what are your thoughts/experiences ?

(87 Posts)
MylinhMumsnet (MNHQ) Mon 21-Jan-13 12:29:55

Hello,

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.

Thanks,
MNHQ

JumpHerWho Mon 21-Jan-13 12:54:17

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!

HandbagCrab Mon 21-Jan-13 13:28:05

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?

1944girl Mon 21-Jan-13 13:37:08

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?










0

Ragwort Mon 21-Jan-13 13:38:34

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' hmm 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 grin.

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 smile.

poppy283 Mon 21-Jan-13 13:53:43

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.

oldebaglady Mon 21-Jan-13 13:56:28

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!

MolotovCocktail Mon 21-Jan-13 14:28:16

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.

LexiesGirl Mon 21-Jan-13 14:33:40

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.

TheSamling Mon 21-Jan-13 14:33:49

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!

MolotovCocktail Mon 21-Jan-13 15:03:39

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.

Oodsigma Mon 21-Jan-13 15:12:40

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.

oldebaglady Mon 21-Jan-13 15:42:44

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 hmm when actually your flow is better with biological nurturing! and I had the nappies to prove it!

YouBrokeMySmoulder Mon 21-Jan-13 16:24:35

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.

motherofvikings Mon 21-Jan-13 16:29:46

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. shock 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! smile However I still had to stay in over 48h. I was springing about within a week and normal by 3. smile
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! shock

Ariel24 Mon 21-Jan-13 16:46:16

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.

turkeyboots Mon 21-Jan-13 18:14:40

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.

TheToadLessTravelled Mon 21-Jan-13 18:15:42

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? confused

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?

firstbabyhelp Mon 21-Jan-13 19:32:46

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.

Oodsigma Mon 21-Jan-13 20:08:34

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.

Meglet Mon 21-Jan-13 20:32:58

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

LexiesGirl Mon 21-Jan-13 20:51:19

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 sad

Oodsigma Mon 21-Jan-13 21:05:03

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).

AlexanderS Mon 21-Jan-13 21:42:57

What about not just vaginal births after c-section but home births? I've heard, though I don't know if this is true, that there is only one NHS midwife locally is who willing to attend a home VBAC. If she is not on duty women here wanting a home VBAC don't get one.

I had my DS by EMCS, and it's left me feeling like, should I have another DC, I want either a home birth with no medical intervention at all or I want to cut to the chase and have an ELCS. What I don't want is another exhausting 31-hour labour, being subjected to increasingly frightening interventions, that ends in a c-section anyway.

I also had terrible postnatal care. I lost a lot of blood during delivery but didn't have a blood transfusion. The first time the midwives made me get up for a shower I felt terrible. I told them I didn't feel ready to get up but they forced me to anyway. They left me sitting on a chair in the shower where I promptly fainted. Where I came round I was lying on the floor with four or five midwives standing over me. I asked them to help me up but they refused for "health and safety reasons". So I had to pull myself up slowly and painfully using the shower chair. It took me about 25 minutes. That was just the start. They refused to help me out of bed but gave me no aids to help me get up myself. It took me ages to get up when my DP wasn't there to help me. To avoid having to get up at night I hid some vomit bowls from the bathroom in my bedside cabinet thinking I could use them as bedpans and get my DP to empty them when he came in. Nobody had told me I'd be, well, pissing like a horse whilst my body got rid of all the excess fluid it'd acquired during my pregnancy, so it didn't work and I wet the bed and had to ring the bell. The maternity care assistant who came looked at me like I was something on the bottom of her shoe, and of course she wouldn't help me up either, she just stood there and watched me struggle to get up out of a bed soaked in my own piss. I got an average of about two hours sleep a night whilst I was in hospital (I was there for 4 nights). There was my DS crying but also the lights, the noise, the woman in the bed next to me's baby crying, the woman in the bed next to me using her mobile all hours of the day and night, being woken up at 6am for my medication...The whole experience was thoroughly miserable. If I'd have had major abdominal surgery for any other reason I could have looked forward to a few days with my feet up and lots of support but you have a Caesarean and you are expected to leap out of bed straight after. I now work in a hospital on a medical ward and there whilst patients are expected to mobilise after surgery it is also understood that they need time to recover. They are treated much more kindly.

JumpHerWho Mon 21-Jan-13 21:56:19

sad just lost a really long post, detailing each horrible part of my post natal experience.

Not typing it again, but there are and will be many, many posts saying the same thing.

It's major surgery, start treating women who've had it with a bit of care.

And healthcare assistants in my experience are about as much use as a random in the street when it comes to breastfeeding support, but will try anyway, even the male ones. And won't call a midwife if you ask them to.

PPT Mon 21-Jan-13 22:00:55

Agree with what AlexanderS has written- I cannot understand why a woman, who has had major abdominal surgery, is expected to jump out of bed, less than 12 hours later and given pitiful pain relief.

For me too... Breast feeding was very difficult to establish, because even though my son would latch on in front of mw's none of them would take the time (doubt they had it) to actually sit through a feed. He'd drop off the boob 2 minutes later.

I was incredibly sore, and cried a lot. I felt I was treated like a bit of a hindrance despite having had a crash caesarean with pre-eclampsia and triple cord wrap round ds's neck.

I had no debrief about wound cleanliness or future pregnancies.

Would like to see an increase in private rooms available for c-section patients (they are in for longer and need to rest to recover... Again, it's MAJOR surgery)- but not have to pay for them through a fee.

Ariel24 Mon 21-Jan-13 22:10:56

AlexanderS I'm so so sorry you had such an awful experience, what you went through is appalling. I felt my postnatal care was lacking but only due to such severe staff shortages, the midwives were all lovely though and did the best they could in the circumstances. The midwives and care assistants you had the misfortune to meet sound absolutely vile. Your comment just hit the nail on the head for me as well, that with any other major abdominal surgery you'd be encouraged to rest and be looked after but after a c/s it's totally different.

Meglet Mon 21-Jan-13 22:31:21

I'm with AlexanderS, not exactly the same things happened to me, but the lack of care was the same. The feeling of being totally alone (but in the noisy PN ward from hell) after a major op and caring for a newborn was terrifying sad. I remember crying on the bed with 2 day old DS telling him I'd get us out of there as soon as I could sad.

I did choose to have a birth debrief after my EMCS when DS was 12 months old. All very straightforward, running through why it went tits up (broken cervix which we didn't realise was broken) and was told by the midwife to never attempt natural birth again. The midwife also apologised for the dire PN care and said it was pretty bad in most cases, they'd put money into ante-natal but not into the PN care. So it's not just the new mothers who think it's shit, some of the staff are in despair over it too.

As did the gynea nurse booking me in for my hysterectomy, and it wasn't a subtle rant, she said it was disgusting how post-natal CS women were treated and I was not going to be expected to move for at least 48hrs post hysterectomy. I was off paracetamol 5 days after that op (and only took morphine the first day), far far less than the pain-killer fest I had after my cs's.

And what is so bloody awful, is that my EMCS was 6yrs ago and I am still upset about the PN care.

What I will say is that I can't fault the ante-natal midwifes, consultants and theatre staff in either of my sections (emergency and planned). They were bloomin wonderful.

JumpHerWho Mon 21-Jan-13 23:21:17

<high-fives Alexander and Meglet>

Nodding at so much of what you both write Alexander as Meglet. I too had

I'm actually quite traumatised by it, this thread is triggering so many feelings. I can't be literate about it because it hurts so much to think back to how uncaring the staff were and how little help I had. I too passed out in the shower, following huge blood loss and no transfusion. I failed to breastfeed, despite huge pressure there was no support and no understanding of how much pain I was in, the bf counsellor said to DH 'does she actually really want to breastfeed?' because I was crying out in pain every time DS latched on, of course I bloody did, it makes your uterus contract and it had been cut open merely hours beforehand, and paracetamol wasn't quite cutting it strangely enough hmm

looby72 Mon 21-Jan-13 23:32:59

I'm 7 weeks post c section, required due to previous pelvic floor repairs in 2008 and 2009, following a total mis managed vaginal delivery. Prolonged 2nd stage, neglect of medical staff etc etc.

However, following pelvic floor repairs, was not allowed to get out of bed for 48 hours! Comparing to a section, no electric bed and advised to get up and out of bed asap, with no assistance or advice on what to expect. To say you had just had major surgery, there was little assistance with the baby, on one occassion the baby nearly choking following some vomiting, because i could not move quick enough to lift him. Needless to say I chose to keep him on the bed with me, just easier!

I was discharged home on day 3, and have to say it was the best thing. Poor nutrition, limited support, having to constantly ask for appropriate analdesia and not getting any rest due to noise and regime of a ward with lights on at daybreak etc...not remotely relaxing.

Midwifes back home, equally as disappointing and varying in there warmth and level of care. Post natal care pretty rubbish, however cannot fault actual theatre staff, medical team carrying out the op or recovery staff, very understanding, even facilitating skin to skin contact.

1944girl Mon 21-Jan-13 23:36:32

firstbabyhelp

I am with you about the GA and it's effects.I never saw either of my sons until they were two days old but in those days that was normal procedure.Today, when a CS under GA is rare more consideration should be given to mothers feelings who have experienced this.I never had any trouble bonding with either of mine but when I come to think of it my first sight of either of them was that they were wrapped up like parcels and could of been anyone's baby.
PPT

Wtatedhen I had my CSs I had a single room both times and so did every other CS mother in the hospital I was in.It was all on the NHS, no charge at all.Sometimes you were moved into a bay if your room was needed for anothlready ser CS or ill patient but that only happened if you were due to go home within the next two days.As I have already stated; What has happened.

1944girl Mon 21-Jan-13 23:40:09

Sorry about the typos.The laptop I am using has a ''jumping'' curser.
I am not having a senior moment.

debtherat Tue 22-Jan-13 00:55:10

Quality of post op care is appalling - lack of fluids, no access to buzzer to call staff, no support with b/f - luckily my EMCS was 2nd baby so knew what to do but positioning with drip and major stomach wound (and massive depletion of energy that goes with GA) was still tough. First time mums after ECMS trying to breastfeed not supported - lots of crying mums and babies - mums still in shock. My humiliation was being told to get myself to toilet now (after 1 bed pan ) and 16 hours after surgery and getting up I bled profusely over the floor, lost my sanitary towel as not attached properly by night staff. And all the time the desperate pull back to the baby who needs to be loved/looked after more than you need to recover. I had one of the most vivid experiences of my life leaving the hospital after 3 days...I came out into a cool February evening, sun just setting, sliver of a moon and one star and I just wept at the joy of being alive still - I told my DH that if I could I would have knelt and kissed the ground. I am eternally grateful to the surgeons who saved me and my son.

LoopsInHoops Tue 22-Jan-13 05:59:24

I felt horrifically bullied into trying for a VBAC, after a stillbirth and premature birth b c-section. I stood my ground and was scheduled an ELCS, but went into labour early. For 2 days of latent phases labour I asked and pleaded to have a c-section, but they were insistent on a VBAC, despite my wishes and very real fear. Eventually, after the support of some wonderful MNers who are midwives, I got the courage to demand to see a consultant, who examined me and discovered bleeding, so I had to have an EMCS.

After the trauma of my first c-section, when I delivered a still born twin and a 32 week live twin, the resulting PTSD meant that I needed extra care. I requested to see a specialist midwife (again, thanks to advice from MN) who helped me put measures into place to make things easier. Seemingly. I had requested a very low level of a tranquiliser before the surgery, as the simple thought of it (even now) makes me cry and want to throw up.

Just before my 2nd c-section, with the above in mind, the anaesthetist came to see me to persuade me not to have the tranquiliser. I was exhausted and frightened, not having slept for 2 days, and being told I was bleeding and needed EMCS, I relented and allowed them to forgo the tranquiliser.
The part that I was/am afraid of is the spinal needle, not the surgery itself. I explained this, and the anaestheist seemed sympathetic and assured em that I wouldn't see the needle and that part would be quick and pain-free.

After multiple attempts to insert the needle, resulting in A LOT of pain and bruising all up my spine, the junior (why? why me? surely it makes sense in this case not to use your junior on me?) gave up and called for help, so the consultant anaesthetist ended up inserting the spinal properly. I still am very cross about this.

PN care not great either time. The first time, I was very fortunate to be in a separate room for bereaved mothers. This was fantastic, but unfortunately not geared up to bereaved mothers with live babied. DTD2 was in NICU, and I was expressing milk. I had to ring the bell and wait for the pump, then ring again for it to be taken away and sterilised. After a few days (bearing in mind DD was tiny and in NICU, also bear in mind this was my first pregnancy and all happened 2 months early so I wasn't prepared) my pump attachment came back with milk on. I didn't know I was upposed to be washing it before sterilisation. So tiny 4lb DD in an incubator in NICU had been tube fed dirty milk. sad

Sanitary protection - this isn't something you can do yourself to begin with, so health assistants shouldn't really complain if being asked to help with this.

And water! Those piddly little glasses every few hours are not enough. Jugs should be freely available and replenished often.

Yes to not enough painkillers. First time this was fine, not second. Yes to being expected to be up and showering after a few hours. I also passed out in the shower. Awful and unnecessary. Food trolley - no-one to get food even for those who had just had surgery, other patients post-op expected to serve themselves and the others.

LoopsInHoops Tue 22-Jan-13 06:01:56

Oh, and KEEP THE BOUNTY VULTURES AWAY FROM PATIENTS!

BasicallySFB Tue 22-Jan-13 07:25:59

One EMCS.

Postnatal care MUST be covered in depth. I've had x 9 abdominal surgeries - with my EMcS, after 8 hours when epidural had worn off and the 10mg morphine I was given in theatre was long gone, I was given 2 paracetamol, and told 'youre a mother now, not a patient'. On the second day, at 20 hours post section, I was told to get out of bed to take DS to the feeding room (no feeding in bed) and left bleeding in a chair.

There's NO other major surgery that would lead to such horrific post op care. It felt like I was being punished for a 40 hour failed early induction.

TheSamling Tue 22-Jan-13 08:04:55

Jesus, the disparity of care received between women on this thread is crazy!
I'm so sorry for those of you who have had some frankly negligent and inadequate care. I'm sure if a study of birth experience and incidences of PND was undertaken the NHS would see a real case for throwing some money and time at this problem. This doesn't just effect the women involved, but they tiny babies and the start they get in life, which in turn effects their whole lives.

Gatorade Tue 22-Jan-13 08:54:22

I think this is a difficult one as those so are so terribly unlucky to have received poor care will always be more vocal than others. Clearly nobody should ever receive awful care, but I don't personally believe this is typical.

I had an EMCS due to cord prolapse with my DD, the after care was amazing. I had to talk the midwives into removing my catheter so I could get properly up and about 8 hours after surgery (for me this was the right decision, I healed very well with no significant pain despite the surgeon describing my wound as 'large as we had to slash and grab'). I was happily walking around the ward with DD within 18 hours of the surgery.

Different people heal differently, have different pain thresholds and emotionally cope with situations differently.

In terms of the actual framework which is set out in the linked document (pre care directed) my recent experience (I am pregnant with DC2) is that most of it appears to already be in place where I am. Despite having wanted a 'natural' birth with DD I am terrified of the same this time around and the midwife I have spoken to has said that an elective will not be a problem and the views I have received have been balanced and not heavy on the risks of a c section only.

LoopsInHoops Tue 22-Jan-13 08:58:14

They let you walk around the ward with a baby?

And no feeding in beds is utterly bonkers. What a stupid rule!

Gatorade Tue 22-Jan-13 08:58:25

Also, I think a debrief post EMCS is very important for emotional well being and to help to not fear a future pregnancy. My consultant was fantastic in this respect and took time to explain what had gone wrong and the likely reasons why before I had even left hospital (I think it helped that I was at a relatively small hospital and was well known to the consultant following a 20 week loss in my first pregnancy)

Gatorade Tue 22-Jan-13 09:00:00

Loops Yes, I walked to the communal room and to the bathroom with DD as I didn't want to leave her, I wouldn't have done this any earlier or if I experienced any pain or numbness.

LoopsInHoops Tue 22-Jan-13 09:19:58

No-one (apart from staff) is allowed to walk anywhere with the babies at the hospital I had DCs. You have to wheel them in those fishtank cots.

cleanandclothed Tue 22-Jan-13 09:24:12

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.

Completely agree with this. I haven't had a C-section but have been on post natal wards with women who have and who were given v little help. Last time, a women who still had a catheter in, compression stockings and who had been told not to get out of bed, was left for ages while she buzzed for help to clean her baby and get some sanitary protection. She asked everyone who came and lots basically said 'not my job' then the midwife came and said, in front of her to the assistant 'we have to do her she is just going to keep buzzing until we do'. She was then told that her DH should be in during all visiting hours to help (might be nice to be told beforehand, and what about lone parents) and the baby was swaddled by the midwife so the mother could pick it up out of the cot, despite guidance being given in the hospital not to swaddle.

A C-section is a distinct possibility for me with DC3 (2 3rd degree tears) and I am really horrified by the thought of the post-natal care.

elizaregina Tue 22-Jan-13 10:25:53

1) NO CONSIstency of atttitudes to women asking for ELC. Widley different expereinces on here some women even with severe physical probs from past labours have been written off and denied.

There needs to be a strict unity across the board and not down to the consultants preference - personal ideas or stats watching.

For me - I saw someone who is part of birth trauma association. I was granted one at 20 weeks ish which was a huge relief. Inspite of my previous labour being so called " text book" - 6 hours established - 24 mins pushing - one small tear.

My consultant took the holistic approach - and saw me as a human with a brain and emotions as well as a pair of hips and a good birthing pelivis!

2) all care up to the op including the op was fantastic.

3) care in recovery was fantastic - no problems with milk - its the placenta removal that stimulates milk - baby came out screaming from the get go no lung problems ( at 38 weeks).

4) overall good care on the ward in terms of caring people and constant attention and people came very qucikly when buzzer was used.

HOWEVER - all adivce was given on personal preference by each CA or MW. Every single time i was told something different.

I was also told by the ONE horrid MW to get moving and turn on my side - but with no guidance - I pulled something as I did a big twist.

So need guidance on how to move after a section - get in and out of bed - move in the bed which is very soft and makes moving even more hard.

6) remind all staff and keep them plugged into being caring to people who have had major ops! We are thier clients, you wouldnt be horrifcally rude to someone you are serviing in a pub for no reason and expect to keep your job.

7) wound care- moving advice when you get back on the ward please, not a leaflet weeks later given by HV.

Other than that - the care and staff numbers etc were fantastic. They just needed to be consitent. One lady said I could have oral morphine in between other drugs - another said no etc etc...

8) Have some ward ettitcute advice somewhere for people to read - ie, your baby cries at night - we expect that you cant help it - but you CAN lower your own voice and keep noise to a minimum. Dont have a mobile convo at 2am speaking at normal volume! Ask all visitors to wash and gel hands when coming onto the ward.

9) Allow husbands at least the first night in private rooms to help care for the baby and partner. Make this clear.

Whilst the care I had for my EMCS and subsequent CS was fine, it is certainly the after-care I found to be horrendous. I agree with another poster who said GP's are dismissive of any health problems afterwards. They are very much it's part of having a baby so put up with it, stop moaning etc.

Another huge thing for me was lack of help with establishing breast-feeding. Especially with DS1. I hadn't had a baby before, I hadn't expected to end up with an EMCS and I didn't know my milk wasn't going to come through until DS1 was 5 days old. As a result when I was struggling to latch him on comfortably/properly as it is, he was starving because my milk wasn't there. I also got a nasty internal infection and got a fever. It took me 3 years to get pregnant again and I think it was psychosomatic because I was scared after my first experience.

Oh, also, I was in agony for the half hour journey home in the car. My SiL who went to a different hospital was given morphine and told to put a cushion over her tummy and she was fine. It is all so inconsistent.

Mercedes519 Tue 22-Jan-13 13:22:18

Well I'm pleased to say my PN care was great - midwives who helped me with DD, supported feeding her every time I tried and discharged me after 3 days ready to go home.

However before that...

Women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies

This didn't happen.

Pregnant women who have had a previous CS are given the option to attempt a vaginal birth

Being given a LEAFLET at about 28 weeks with No. 2 about VBAC is not how you give an option. There was no further discussion until 38 weeks! I was not happy about not knowing how I was going to give birth - I had loads of questions about things like length of labour, the impact on my SPD, the risk of rupture becase I had done research. They were brushed aside as being something 'we'll talk about later'.

Consideration needs to be given that even though you are having a second baby, if you've had a CS the first time you are MORE worried about natural birth - all the anxieties of the unknown plus the worries left over from the first time.

There should be an informed discussion early on in the pregnancy about options (i.e. more than one), risks and how the conversation will progress. Then throughout they should remember it is your first labour so you WILL need the level of information of a first time mother.

poppy283 Tue 22-Jan-13 15:41:54

To add to my earlier comment:

I asked a hv after dc1 was born if I would be offered an elcs next time, she said yes. I asked my midwife at booking appointment when pg with dc2, she also said yes, no one will stand in your way.

So at my appointment, scheduled for 36weeks, I did not expect the consultant to be surprised that I wanted an elcs, or did I expect her to attempt to persuade me otherwise.

If I'd known I was going to have a battle on my hands to choose what happens to my body, I would have brought someone with me, and ome armed with nice guidelines etc.

So sorry to read others have had such shocking pn care, mine was mostly excellent both times.

RedToothBrush Tue 22-Jan-13 16:46:23

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.

MolotovCocktail Tue 22-Jan-13 17:13:06

What a wonderful post, RedToothBrush

girliefriend Tue 22-Jan-13 19:14:38

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 sad

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.

LittlePicnic Tue 22-Jan-13 19:35:36

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.

careergirl Tue 22-Jan-13 20:23:41

Midwives now train as midwives - not nurses - so how can they care for people who have had surgery with no nursing qualifications?

poppy283 Tue 22-Jan-13 20:27:40

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.

LittlePicnic Tue 22-Jan-13 20:48:45

Offering support from a specialist psychologist where tokophobia is present or PTSD following a previous birth.

Oodsigma Tue 22-Jan-13 20:48:45

Surely post op care for a c-section patient should be part of midwifery training?

LittlePicnic Tue 22-Jan-13 20:50:48

Whilst post - natal seems poor post c/s, it is also poor generally.

Meglet Tue 22-Jan-13 20:51:37

careergirl that's a very good (if worrying) point.

salcz Tue 22-Jan-13 21:24:39

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.

1944girl Tue 22-Jan-13 22:32:22

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?.

MolotovCocktail Wed 23-Jan-13 09:36:09

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.

PMHull Wed 23-Jan-13 09:54:41

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.

Cantbelieveitsnotbutter Wed 23-Jan-13 10:35:12

Ok,
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.

MolotovCocktail Wed 23-Jan-13 11:02:56

And it is incredibly important to distinguish between ELCS and EMCS.

LikeSilver Wed 23-Jan-13 11:22:38

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?

Andcake Wed 23-Jan-13 12:42:34

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!

JumpHerWho Wed 23-Jan-13 12:44:45

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 hmm )

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 grin 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.

JumpHerWho Wed 23-Jan-13 12:52:25

Andcake - what do you mean, aftercare would be better if women didn't have a CS 'for the wrong reasons' ? hmm 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.

NellyBluth Wed 23-Jan-13 14:11:55

Andcare - and what would constitute a 'wrong' reason?!

coldinthesun Wed 23-Jan-13 15:43:45

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.

MolotovCocktail Wed 23-Jan-13 15:48:12

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.

MolotovCocktail Wed 23-Jan-13 16:00:50

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.

coldinthesun Wed 23-Jan-13 17:13:49

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.

sorry i'm returning to this to contextualise why i went on about my VB - it is relevant because it was the circumstances of my labour, treatment and care that meant that if i ever did have another child i would want to have an elected caesarean. if first VBs were more often untraumatic and included good care during and after the birth less people would be wanting to avoid them the second time around.

also want to second the point that a VB doesn't necessarily mean easy BF established -if as i was you end up with a spinal block in theatre to repair the damage done to you in the process and you are then left on a delivery ward for hours and hours unable to breastfeed because you are paralysed but receiving no help whatsoever you are worse off than if you had a cs and were prioritised a place in HD or went straight to a maternity ward.

VB and CS are not disconnected because the realities women go through with the former can lead to electing the latter for their next birth or for some women even hearing about the the way you're treated for the former (being abandoned on labour wards, being sent home only to go into full on labour ten minutes later, having your legs stuffed in stirrups when you have spd and have specifically arranged that this should be done under no circumstances, etc etc etc) can lead women to want the controlled birth of an elective cs.

also having a bad vb experience with complications and then having no info as to why things went wrong, what the prognosis is for your future births etc can lead to a better safe than sorry attitude.

also realistically what the hell is wrong with a woman wanting a cs? this isn't a moral issue.

my future prognosis btw was that, 'it might be alright, or it might not' hmm most helpful.

also i had a totally bodged episiotomy repair and ended up back in hospital for a secondary repair that i was extremely lucky worked or it would have meant plastic surgery.

i honestly don't think i'd risk a vaginal birth again due to the ineptitude of my care and treatment with a VB.

JumpHerWho Wed 23-Jan-13 19:23:12

SaF - my ELCS was amazing and perfect, so calm and lovely. Peaceful, lovely caring anaesthetist and assistant, professional but sting atmosphere.

It's the post-natal bit that is awful.

elizaregina Wed 23-Jan-13 19:42:24

Its the removal of the placenta that stimulates milk, I too do not understand people saying the section affected milk.

Its only personal to me and my friends - but I had elc and my milk came in normally and Bf was all fine, and between friends its a total mix of who BF and who didnt it was all personal and not down to mode of delivery.

"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."

Absoluty its no one else business what people want or chose quite frankly, I cant belive the arrogqance of telling some one else to do with thier very own body! angry

JumpHerWho Wed 23-Jan-13 20:12:09

Eliza I struggled to breastfeed after my section and ultimately failed. Nothing to do with milk production and everything to do with the pain I was in, and when DS latched on my uterus contracted (as its meant to) which having been cut open hours earlier meant it hurt quite a bit... I received no help with positioning which would have helped - I was told to do it whilst slightly raised and I was in so much pain. It's disingenuous to say it doesn't affect bf, it clearly does. My milk came in on day 4 fwiw but I know this is similar to vaginal births. I was released after 2 nights having failed to establish bf, this is something I will always be upset about. The bf counsellor just didn't believe I was in pain, she kept saying 'what's wrong' when I was flinching and crying out, when I said it hurt, she didn't accept how much and that it might just make me unable to focus on the 10 pound weight lying on my open wound! All I wanted was for him to be taken off me! It was nothing to do with nipple pain, no problems with latch, and that's all she wanted to talk about. And I wanted constant skin to skin, which they wouldn't allow as I kept falling asleep and DH was kicked out at 9pm til the morning so I couldn't bf unless I rung the buzzer for a crappy hca to come and stand arms folded while I tried to hold DS comfortably.

poppy283 Thu 24-Jan-13 08:11:47

Andcake, how offensive. 'wrong reasons' indeed.

I absolutely echo the comments made by redtoothbrush and PMHull and would each that measuring by numbers of CS as outcomes is just arbitrary and has nothing to do with offering what women need.

Stats about CS need to be separated between EMCS and ELCS. And I'd go further to show, especially for first time mothers, where EMCS followed attempts at assisted delivery as this can be a big part of people's fear.

I'd also add how critical it is that any guidance, standards and midwife AND consultant training to be around equal importance on mental or physical reasons for ELCS and stipulate this in the wording of these documents with definitions that go beyond a simple 'tokophobia' as there are often complex sets of mental, emotional or physical factors affecting birth choices or fears.

The standards as currently written talk about timeframes for 'discussing' fears with members of the maternity team without specifying a timeframe for making a decision - which is just as crucial as when the discussion starts - it shouldn't be a long, drawn out process as this is likely to add to anxiety.

The working 'patient satisfaction with involvement in decision making - does not demonstrate actual shared decision making nor respects that it's ultimately the woman's body and bay - for the medics is just a job in the end...its not their life that's affected.

Patients and medics need to both be clearer on whether the 'offer' of mental health support is an offer or is obligatory and what effect/input it has (or not) to any ELCS request decision.

Steps shoud be taken to make sure that women having ELCSs are not viewed or treated negatively by staff and that wording on notes for ELCS is handled sensitively and in agreement with the women.

And care and understanding (the soft, communication skills) of the medica, especially consultant, should be an integral part of the ir re-training and these standards.

MylinhMumsnet (MNHQ) Thu 24-Jan-13 16:50:08

Hello

Thanks everyone for sharing your experiences and your thoughts on the consultation. It's clearly an issue of importance to mums and soon-to-be mums, and we're sure the people over at NICE will value all your contributions.
We've pooled your responses and sent over our response. We'll be sure to post the published findings from the consultation, so watch this space!

Thanks again
MNHQ

Rosduk Sun 27-Jan-13 08:01:27

I had an emcs 8 weeks ago. My little boy was born at 27 weeks and sadly we lost him 2 hours after he was born.
The experience I had of the hospital and staff at Hastings Conquest was fantastic. I had gone into hospital with reduced movements when I was 2 hours from Home visiting family. I had forgotten my pregnancy notes.
Within an hour of stepping into the hospital my son was born. Although the reason he needed to come out wasn't explained fully they did explain the urgency of the situation. As my partner was 2 hours away he wasnt there but the midwives etc in the theatre looked after me and made sure i was supported throughout until my mum arrived. I received a full debrief a few days later and a doctor went through our post mortum and funeral choices.

My recovery was difficult dealing with the grief and pain but every midwife was fantastic, drugs offered regularly - I didn't have to wait and I was constantly kept informed of where my son was even after he had died. The only thing I would say was for the first night I was kept (in a private room) on the labour ward so I could be checked regularly but I could hear other labouring mothers and their newborns, but was moved to the bereavement room on the 2nd day.

My aftercare was offered through either Hastings hospital or my local Royal Berks in Reading. They did their normal checks aswell as asking how we were doing emotionally.

I am now fighting with my local GP for councilling and the nerves regarding my next pregnancy (hopefully!) have kicked in. My partner and I want to try again ASAP and would like to know what support is in place, will I be monitored more and my birthing options next time round. My GP would not discuss this until we get pregnant. No risks have been discussed with me for future pregnancies and having being fobbed off by my GP (who congratulated me on my baby and asked where he was at my 6 week check!) I'm now not sure of my options. I am now changing surgeries.

Gatorade Thu 31-Jan-13 18:00:04

Rosduck I am so sorry to hear about the loss of your son. The lack of support from your GP is completely unacceptable.

I lost a baby around 20 weeks (which I appreciate is no where near as terrible as what you have experienced) and I found the best support I received was via my NHS trusts counselling midwife service, I was referred by a midwife.

If possible I would try to contact your local midwife team and ask for a referral. You basically see a midwife who is trained in bereavement counselling (my understanding is that all trusts should have at least one) and she will discuss your fears in relation to future pregnancy and refer you for appointments with any specialists (be it obstetrics or geneticists or similar) who you should see before you get pregnant again, or just to help to reassure you.

Good luck with everything and take care of yourself.

Pandasandmonkeys Sat 02-Feb-13 17:57:32

The after care following my cs was awful. I had a very difficult section - baby was stuck, retained placenta, I had some horrible brushing from being pulled and pushed around to get baby out. Once back on the ward I was given minimal pain relief, dh was constantly having to go and get help as I was in so much pain. Eventually, I was given morphine, dh we sent home and I was left to cope alone with a newborn. The morphine worked for the pain but made me feel very light headed and wobbly. No one came to check on me or help me with the baby. While desperately trying to breastfeed I blacked out/fainted and baby ended up on the floor. Had I been cared for properly this wouldn't have happened. Also, the policy of sending partners home is ridiculous. It's a time when you need 24hour support and the staff are unable to provide it.

Pandasandmonkeys Sat 02-Feb-13 18:09:35

The after care following my cs was awful. I had a very difficult section - baby was stuck, retained placenta, I had some horrible brushing from being pulled and pushed around to get baby out. Once back on the ward I was given minimal pain relief, dh was constantly having to go and get help as I was in so much pain. Eventually, I was given morphine, dh we sent home and I was left to cope alone with a newborn. The morphine worked for the pain but made me feel very light headed and wobbly. No one came to check on me or help me with the baby. While desperately trying to breastfeed I blacked out/fainted and baby ended up on the floor. Had I been cared for properly this wouldn't have happened. Also, the policy of sending partners home is ridiculous. It's a time when you need 24hour support and the staff are unable to provide it.

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