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

Oh, and KEEP THE BOUNTY VULTURES AWAY FROM PATIENTS!

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. :(

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.

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.

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.

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

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 . 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 .

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.

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.

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.

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.

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.

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).

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

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

Re point 5- c-sections to be after 39+0. Our hospital only does planned sections once a week so my 'choice' is 38+6 or 39+6. There's a good chance I'll go into labour before 40 weeks and would then need an emergency c-section. So some consideration needs to be given to these factors.

I 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.

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?

on what planet can women elect to have a caesarean without discussing it with their maternity team?

i agree it is postnatal that need addressing too. i was stuck on a delivery ward for ten hours because no hcp was free to take out my catherta (sp) with a full spinal block from post birth episiotomy repair performed in theatre and a starving baby i couldn't breastfeed and no assistance. i should have been on high dependency unit but there was no room. things didn't improve when i finally got a ward.

can i also make the suggestion that in this century when a woman has had her vagina sliced open then stitched up she might be offered more than a paracetamol every 4 hrs for pain relief??

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.

I haven't read document as on phone, so will come back. But I agree that it should cover post natal care. I have had two perfectly pleasant ELCS and one very horrid post natal experience. Second time round at least I knew what to expect, but neither time was given any info on pain management, or when epidural would wear off, or when catheter removed.

Compared to the information and support I had before the section, the lack of post natal care was really noticable.

I read this the best I could but bit frazzled looking after 3mo!

I just wanted to add my experience as feel it's quite relevant. I had a c/s in October due to extreme Tokophobia. So extreme in fact that my consultant said it was the worst case he had seen in over 20 years of obstetrics. So I totally agree with Ragwort's comment- please don't dismiss all women requesting c/s as being too posh to push. I was so upset and scared I really did contemplate aborting my much wanted baby, I was in hell really and shudder to think of what could have happened. I had a pretty horrible time when I was pregnant as I was so anxious but I had fabulous prenatal care from my midwife and consultant, he agreed to my request for c/s under GA immediately during my first appointment with him. He was fantastic and very understanding, I think the care I received should be the standard. The only thing I think he omitted to do was arrange an appointment with the consultant anaesthetist for me as on the day of my OP the anaesthetist wanted me to have an epidural rather than a GA due to risk etc, but he was still ok about me having the GA.

The care I had in hospital was so good, all the staff were so kind and compassionate. The only thing I would say is due to cuts and generally being understaffed there is nowhere near enough support with breastfeeding etc, especially at night. After a c/s I couldn't get out of bed to pick up DD to feed her or change her nappy, it would even have been better if my DH had been allowed to stay overnight. So yes, I definitely think postnatal care needs to be addressed.

The final thing I would add is that on my discharge summary, the reason given for my caesarean was ' maternal request', and I think this should have been recorded as ' Tokophobia'. It should be recorded as a medical indication for c/s in the same way a physical medical indication would be.

I had an emcs in 2009 at southmead in Bristol. I was sent home 36h later! I had had major abdominal surgery, this was my first child and we were told we were going home. me and dh were stillin shock from the emcs so didn't question it at all. It took me a good 6 weeks before I could walk more than 10 mins before being exhausted! 24h extra in hospital would have made a massive difference in term of my recovery.

i believe all cs births should be able to stay in hospital for more than 48h if you wish!

I had an elcs in 2011 at southmead hospital. This time I was begging to get home and I felt fine! :) However I still had to stay in over 48h. I was springing about within a week and normal by 3. :)
but I did have to ask the orderlies (?) to move my food tray for me (from the end of the bed) as my spinal hadn't worn off. I was greeted with a massive huff! Some awareness of patients limited mobility for orderlies etc would be useful!

I agree that petients should talk to someone before their elcs BUT this shouldn't be an opportunity to make you vbac. This should be a discussion of the pros and cons of an elcs or vbac. However this depends on the individual HCP being open to all methods of birth.

Oh and someone should warn you that you may never get back the feeling where the incision was made. Noone mentioned it before my emcs or at my elcs! I have a very numb section!

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.

oh and it would be helpful if the post natal staff both understood, and assisted with biological nurturing - for someone with an abdomen wound it's so much easier! unfortunately the (otherwise good) staff on the postnatal ward seemed to think that breast feeding didn't work without gravity (as if I'm some sort of milk jug! that needs to be poured!) and kept trying to make me sit up to feed in cradle or rugby position, or on my side, instead of reclined on my back. They told me the baby wouldn't be getting any milk that way when actually your flow is better with biological nurturing! and I had the nappies to prove it!