New guidance to reduce epidurals and a target rate of 20% for C-Sections

Actually, if I ever had any more children (ain't gonna happen!) I would quite happily be knocked out just before my due date then woken up and presented with a baby. Even before giving birth the first time i had no desire to experience it, just wanted it over with!

well rosabud, when i felt everything in my first delivery, more things went wrong and there was a lot of intervention needed. I couldn't move or hardly breathe because of the pain.

I agree that it may have helped for me to walk around for example but i literally couldn't move. And this was my so called "natural" birth. My second birth where i couldn't feel anything went more smoothly and easily, and no interventions (apart from the epidural i suppose!) So my experience is the exact opposite to yours. And just as valid. Yet hospitals are more geared to helping women have a more "natural" experience even when, as in my case, this isn't the best way for me to give birth.

Obviously this is only my experience and everyone is different. Which is exactly why women should have more choice when it comes to pain relief and interventions.

It didn't help me knowing that there was a birthing ball available, or a pool, or I could walk about if needed. What would have helped me would be knowing that alongside these things, more medicalised pain relief was available.I would happily give birth in an American hospital. To know that I could have an epidural whenever i wanted it? Wonderful!

Nature doesn't know best or always work. With first labour I wanted to be active, I got to 6cm without even a paracetamol. I walked around using gas and air for four hours having contractions every minute, I had the urge to kneel and push. I was still only 6cm. My body got it wrong. Being in hospital does not bother me one bit and being encouraged to have a home birth would have made me very uneasy. Everyone is different and we need to ensure women are able to access the birth they want/need whether that be at home or at hospital.

Rosabud if I had naturally been having the type of labour you describe in your second parragraph I wouldn't have had any pain relief, and I don't actually know anyone who had pain relief and was having the type of birth you describe there either. Most people give natural a go first then, only when its NOT working out how you describe to they choose interventions. My body wasn't allowing me to do what my body was telling me to do.. and like most women who chose to move on to more medical pain relief I DID try things like TENS, Birth pool etc first. What you describe there is what I thought would happen, what I thought my body would do, but it didn't, not that time anyway! It might next time it might not, I hope it will and will plan for that but I also don't want to be forced to continue down that route if it is NOT working naturally and believe I should have that choice

your post reads like you think there are a lot of women walking in saying "hook me up" at the first contraction so that they never even TRY to see what their body will do with the pain, but I don't think that's the case for most women who do end up choosing interventions, its not about avoiding all pain - I'm actually surprised that a woman who has given birth would say that about other women! there is no "no pain at all" route anyway? what is it? epidural isn't no pain whatsoever, CS CERTAINLY isn't, do you really think that many people choose have these painful and risky interventions because they think it will fulfill their right to feel no pain whatsoever?

Yes, childbirth is a natural process, but so is tooth decay, menstrual cramps or developing kidney stones.

Having read all of that feel very undecided about it! My eldest is 15, my youngest 7 so my experiences are probably out of date but I was in the "natural birth" camp, mainly as I was terrified of hospitals/ doctors etc. Won't bore you with my actual experiences but I felt that there was far too much pressure to have medical interventions.

Re the argument over pain relief. The thing with child-birth is that it is a natural process so your body is in charge and telling you what to do, eg you will know when you ought to be walking around, when it's time to squat/lay down/hang from the ceiling etc and the contractions control your urge to push and all that. So if you have blocked out all those instincts with pain relief then, surely, there is more chance of things going wrong and intervention then being needed? So there is a reason why you are supposed to feel everything, which means the pain too, in childbirth. BUT there are lots of natural ways to cope with that pain, the most important must be feeling happy in your environment. A medical environment where movements and other comforts may be restricted is therefore not the best place to be in for giving birth.

From that logic, I do agree with the feminists that have said that choosing which medicalised version of birth a woman would like is not a choice at all, that the whole debate is wrong in the first place. I do sympathise with the women who feel they have the right not to feel any pain at all, but I think there must be better ways to deal with that reluctance than to say, OK have lots of medical intervention.

"I can't understand why the pessaries can't be put in at home so at least the women can have early labour in comfortable surroundings perhaps with occasional community midwife visits?"

increased risk of something - placental abruption i think? i had an argument with a registrar who wanted to book me in to be induced at 7 days over as that was what suited the hospital. when i refused i was lectured on how this was a totally natural process, no different to spontaneous labour, just a helping hand, etc and when i asked why i couldn't have pessaries inserted then go home he had to admit that actually there were increased risks...

i ended up going in to be induced at 12 days over, had to have a senior nurse administer pessaries each time because no engagement meant an increased chance of the cord prolapsing, started to contract but ended up needing syntocin which meant i had to be monitored, if i moved the monitor lost trace so i insisted on having an epidural as there's no way i could cope with the pain while lying at an awkward angle, didn't progress at all for 8 hours then went from 3cm to 10cm in an hour, baby in distress, failed forceps, emergency CS with 2 litres of blood loss.

it was STILL a better experience than first time round ;) and if i was ever PG again i would insist on a scheduled CS due to the combination of my previous obstetric complications. the CS i ended up with was probably unavoidable as DS was stuck due to really broad shoulders, so it wasn't really a cascade of intervention situation.

i don't think targets have any place in determining care for an individual patient and while i can see why they are created i think they are far too "one-size-fits-all". i also loathe the fact that the reporting of this focuses on the choices women make when IMO most women who end up with a caesarian feel that they had no real choice but to opt for that.

How do the NCT back up their mantra of 'cascade of intervention'? To me correlation does not imply causation in this case. There is no way of knowing what intervention would have/would not be necessary with/without induction, epidural etc do how can they state it as if it's medical fact.

If I had syntocin then epidural is that a cascade? I needed syntocin because I was 6cm dilated for over 4 hours and my contractions started to weaken. What was my alternative to this intervention? Surely most people who have the syntocin drip do so for a reason and most people I know who have got to the point of having syntocin will do anything to have their labour be over. If you have an 'easy' or straightforward labour then of course you won't need intervention epidural or not. The more I read about the NCT the more I dislike them.

(and before you say I should have refused induction - meconium stained waters without any signs of labour are not a situation where I thought it'd be in the interests of my child to hang about and wait and see)

Margery

"Women need to be better informed about the 'cascade of interventions' and make their own informed choices rather than being dictated to be doctors."

fucking cascade of intervention scaremongering makes me still angry. First time round I was so scared of the "cascade of intervention" that I refused any pain relief, even cocodamol when I already was in insane pain (thanks to the oxytocine drip). It was a lot of hard work for the midwife to convince me to give myself a break (in the shape of gas and air which did fuck all for me, and Meptid which was brilliant).

Yes, I ended up with a CS, but I doubt that it was the pain relief, which I agreed to way later than neccessary (nor was it the induction), which led to it, but just basically an unlucky draw.

I've given myself way too much grief and had too much unneccessary pain because of the "empowerement" promoted by the lentil weavers. I could have saved myself a lot of pain, if I hadn't been so paranoid.

Yes women should make informed choices, but misinformation doesn't only come from doctors.

And do you reallly think that there aren't any female OBs in 2012?!

I don't know a single doctor who does random c sections to fit his "golfing" schedule. I've only seen doctors who will refuse to perform c sections and literally force women to have vaginal births. Honestly, where are these so called c section loving doctors? I've only met the ones who will refuse to perform them unless someone is dying.

Margery

Most women know they can legally refuse anything. But do you really think it's that easy when you have bullying, patronising HCPs giving you 'advice'? It isn't always so simple.

And no birth CANNOT always be done without injury, whether it's surgical or vaginal. There are ways to minimise tearing, pain and discomfort but it cannot be avoided altogether.

NanBullen my midwife was saying the same, I was blacking out with the pain! I couldn't sit down as it was too painful so I was kneeling on a bed holding on to the side and blacking out as each contraction peaked. Luckily my husband could see how much I was losing control and stuck up for me. This was in January.

my first birth - no pain relief apart from g&a which only works for me unto a point. I asked repeatedly for an epidural but was told i didn't need one because i was dilating so well. the midwife seemed to miss the fact that because i was dilating so well i was in unbearable pain. in the end needed a ventouse as i found pushing so painful. then had retained placenta, still no pain relief even after being put back into labour and agony for 2 hours until it could be removed in surgery. This was my so called "natural" birth.

second birth - saw many consultants and the head midwife at addenbrookes hospital to try and get a cs. no luck. saw a counsellor at same hospital who said i had ptsd but still couldn't have a cs, as one bitch consultant said, i shouldn't just assume i could have a cs "on a whim" Had to involve the head midwife to try and ensure that i would be guaranteed an epidural, had to get her to sign off on my birth plan (like I'm a fucking child) to say that as soon as i was in active labour (4cms dilated according to her, 3cm according to me!) i could have an epidural.

Long story short (sorry!) I got the epidural and pushed dd out in 2 pushes because i had no pain Although not before the same bitch consultant came into the room saying the epi should be turned off so i could push better

Sorry this is soo long, but why, why, why did i have to go through so much pain in my first (apparently natural) birth and then have to fight so hard just to be sure i could get the pain relief i wanted in my second? this was only last year! Where were my choices?

I think all women should have the choice to give birth however they want (safely) and the option to change their mind whilst actually giving birth.

sorry about the long post, this just makes me so fucking angry!

This is what I meant by women being I'll informed- lots of women don't realise they can refuse inductions they don't want, refuse ecvs, etc

Women need to be better informed about the 'cascade of interventions' and make their own informed choices rather than being dictated to be doctors.

A lot of women don't want c sections but end up with them because they were forced into inductions that they didn't realise increased their risk of c section.

This is 'mass mutilation', as are unnecessary episiotomies and 4th degree tears. Birth can be done without injury.

The medicalisation of birth has benefitted men by increasing the job opportunities on OB which has mostly benefitted men. Not even to go into the logistics of births being timed to fit in with their golfing schedule.

LaVolcan I was induced with DC2 due to hind water leak, luckily this was done by breaking my forewaters due to already being dilated but before I was examined at no point was I told what would/could happen and how long it could take. I spent 12 hours on a ward waiting for a bed in a delivery room and another woman on there who had had a pessary had to spend those 12 hours contracting on a ward with only paracetamol and the company of 4 other women and their partners. What an awful experience for her. I think the whole area of overdue induction needs looking at whether that be monitoring beyond 42 weeks, ELCS or pessaries/drips for hormone induction. I can't understand why the pessaries can't be put in at home so at least the women can have early labour in comfortable surroundings perhaps with occasional community midwife visits?

In my experience midwives tell you the bare minimum which limits your control and ability to push for an alternative. Until MN id never known about monitoring beyond 42 weeks induction at term + 10 was given to me as this is what will happen. With DC2 he was also breech until 36 weeks, again being sent for ECV was told to me as 'this will happen' when in actual fact based on my own research I was going to refuse it and opt for ELCS and the possibility of a vaginal breech birth, whilst not for me was never mentioned.

Maybe women need more unbiased info way before 41 weeks when they're presented with scary facts and limited options?

I was warned, weighed up risk of waiting past 38 weeks, opted for induction, had EMCS after 39 hours... But I never had expections for anything other than a medical birth, and after 12 years of infertility I just wanted baby here safe, and they literally could have done whatever it took to get him here. That was my informed choice - and one I'm very happy with!

Your first paragraph expresses what I was thinking FrillyMilly. I know a couple of people myself who have had the same experience and it's one that I think precious few would choose. I hadn't the heart to ask them whether they were warned that it might take 50 hours and then lead to a CS anyway.

So why not start to question whether these inductions need to be offered? Does the baby need to be got out now, in which case why not offer a CS straight off? Otherwise, can it wait? How many women are offered expectant monitoring?

onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1998.tb10047.x/full

The risk of stillbirth increases gradually from 37 to 43 weeks of gestation from 0.7 per 1000 to 5.8 per 1000.

ukpmc.ac.uk/abstract/MED/1553174

www.ajog.org/article/S0002-9378(01)11435-3/abstract

the risk of perinatal mortality is lowest at 38 weeks of gestation.

I know several people who have had an emcs due to failed induction when overdue. All of them forced to labour for a long time before going to c section, all of them wishing they had been allowed a csection earlier and most of them opting for an elcs for subsequent births. I think ELCS should be offered as an alternative to induction instead of pessaries every 12 hours unless there's no delivery rooms, being left to contract on a ward, being allowed to labour for days, often needing a syntocin drip and intervention. What's natural about that? Surely the process also takes up a lot of resources?

If MLU are to become the default are they going to stop closing them? Our local one is only open if you request it, you have to phone when in labour for the midwives to meet you there. If anything happens its a 20 minute transfer to the CLU at another hospital. If you need to go on to a ward rather than be discharged its a transfer to the CLU. On the information I was given it stated that if your baby needed neo natal care then it would be 45 minutes before the neo natal team arrived in an ambulance from the CLU. I had both my babies at the CLU and I think I saw a consultant once, other than that my care was midwife led.

LaVolcan

The bigger the baby, the greater the risk for shoulder dystocia. Obviously, shoulder dystocia can occur even when the baby is small, but SD is definitely more common in babies weighing over 3kgs. You'll find plenty of research to back this. And needless to add, overdue babies are more likely to be bigger.

Furthermore I've read plenty of research papers that prove the risk of stillbirth increases after 41 weeks. There was even a recent study that showed how elective c sections at 39 weeks could actually prevent a certain number of stillbirths.

I don't see what we will achieve by figuring out how many women who are induced end up with c sections. What's the solution? To stop inducing women who are overdue? That comes with it's own set of risks. And as I said, not many women are happy to be pregnant endlessly- many want to be induced.

And many even gasp, shock want c sections.

I didn't know that shoulder dystocia was related to being overdue - I believe it's not even necessarily due to size. I don't know how much reliable information there is about stillbirth even? I know that stillbirth rates haven't significantly changed in recent years, so whatever we are doing now to prevent them doesn't seem particularly helpful.

No, not all would want to go to 43 weeks let alone 44 but as you say the key is choice and it should be informed choice. Not 'we will book you in for induction... you don't want a dead baby do you? ' kind of information.

I still think it would be useful to know how many inductions and for what reason, ended in instrumental/CS deliveries. I don't even know whether they keep such statistics.

LaVolcan

Not all women want to be the "44 weeks mommas" (a latest fad in the grand USA). Most are happy to be induced once they're 12 days or so past their due date as they realise the increased risk of stillbirth post 41 weeks and the increased risk of complications like shoulder dystocia with an overdue baby.

Again, they key here is choice.

40 odd years ago though women did campaign not to have routine episiotomies. First baby = episiotomy, second and later = episiotomy, why? Because you had one before.

Not that 4th degree tears are an improvement! A better standard of intrapartum care might help here.

I always wonder how many EMCSs, forceps & ventouse happen because of inductions? Especially for inductions where the reason is being overdue - which could be 10, 12, 14 days over your due date, depending on the policy of your hospital.