For those campaigning for or considering an ELCS

[BeeBread]

The National Institute for Health and Clinical Excellence are due to publish in November a new clinical guideline in relation to caesarian section. On Monday they released a pre-publication (ie nearly final) draft - links are here.

The previous (2004) guideline stated that "An individual clinician has the right to decline a request for CS in the absence of an identifiable reason."

However, it looks as though the 2011 update will recommend this approach:

"For all women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS."

So it looks as though our hospitals should soon become more respectful of women's wishes in this area.

I'm not advocating too-posh-to-push ELCSs (if such a thing really exists ) or suggesting that a CS is generally a better approach.

I'm in a position of trying to educate myself about the risks/benefits of CS in the face of a uterine prolapse (read: saggy fanjo). I found the guideline a brilliant summary of those risks and it read much more impartially than the advice I had been given by the hospital. It's very long but an important read if you feel that ELCS is an option for you.

Bee, I'm also investigating ELCS for DC2s birth, as I have a rectocele from DS, and thats very good to know! Although I think I'm siding on attempting a VB as apparently birth wont make it much worse than it will already be after carrying a baby for 9 months...!
Are you preg now? I'm only 10weeks at the mo, but extremely uncomfortable already... :(

Hi Beyond, I'm currently 22 weeks. Weeks 9-14ish were the worst for me, in terms of my prolapse and pressure, but since then my uterus has lifted and my cervix is sky high for the first time in ages. Should stay like this until birth, fingers crossed. Hopefully that works for you too!

I was also told that after one vaginal delivery the chances of the prolapse worsening would be the same second time around regardless of whether I went for CS or another vaginal birth, but the advice was so loaded with anti-CS messages that I didn't feel as though I had impartial advice on the subject.

I'm due to see the consultant on Friday when I'm going to discuss it further and with the benefit of more reading - I was pretty unprepared last time and felt a bit steam-rollered.

Thank you, that is the single most reassuring thing I've ever read on MN
Been away for a week and got back and really wanted to get close to DH, then got myself all upset cause it was so uncomfortable. Fingers crossed it will only be for a few more weeks then, I can cope with that!!

I've been booked under consultant care because of it but yet to see one, no idea when I will either as everything was relatively "normal" with DS. The thing that worries me about an ELCS is the chance of being laid up for weeks, with an 18m old to look after too. Though I have no idea either how fucked up my nether regions would be if I had another VB, I guess I could easily be laid up either way!!

I hope to god that if these guidelines result in a sudden and significant increase in our already exceptionally high rate of c/s the government is ready to increase the number of midwives and the amount of theatre space and staff just as quickly to keep pace. Otherwise we're going to see women and babies dying. And it won't be those women booked for elc. It'll be the mums having vaginal births who'll be left labouring alone in increasing numbers and those women needing emergency cs.

Why on earth should these guidelines result in "a sudden and significant increase in our already exceptionally high rate of c/s"? The vast majority of women still think a VB is preferable, don't they?

As someone who had a CS for their 1st DC on mental health grounds, THANK GOD that option was available to me, despite the vague NICE guidelines, and widely varying hospital policy. These new guidelines are much clearer, and might well stop some of the women having to go through the awful anxiety that I had when I got pregnant.

All these guidelines say is that after discussion and the offer of support, including counselling/therapy, a woman is still adamant that she wants a caesarian, then she should have one.

Who on earth would advocate that after being informed of the risks, offered counselling/therapy where appropriate, a woman who desperately wants a caesarian should be forced to give birth vaginally against her will?

These guidelines are MUCH more informative and balanced in terms of CS risk than previously. For a start, they distinguish to a much greater degree between EMERGENCY CS and PLANNED CS. It's insane that those stats have lumped in together, as if outcomes were similar across both. If nothing else, it will help women to make a much better informed decision about their birth, and frankly, that's exactly what we need.

There were about 20 people present when DS was born, only about 10 are needed for a CS apparently...
So if I opt for a CS, it will be safe in the knowledge that LESS women or babies will die.

That's great news, especially for me who is very anxious about the possibilty of being refused one second time round after an EMCS last time - even though i'm not pregnant (yet!). Thanks for posting.

Yes - women having ELCS's posting here are often warned that if there is an emergency CS, then that will take priority, rightly, and they will be bumped down the list.

So the idea that women and babies needing EMERGENCY cs's will die because of this tidal wave of women hogging all the CS slots with their planned CS's is just utter nonsense. Theatre slots simply do not work in that way. Emergencies always take precedence.

And frankly, the amount of MW care you get during a CS is minimal, in terms of time and attendance. Mine was there for most of my 45 minute operation, and briefly returned at some point to fill in a form about breastfeeding. So I had about an hours' worth of her time? I hadn't thought before how great it was that my CS freed up a MW to attend to other mothers....

"So the idea that women and babies needing EMERGENCY cs's will die because of this tidal wave of women hogging all the CS slots with their planned CS's is just utter nonsense."

Except I didn't say that. We all know that emc take priority when it comes to theatre space.

But if a woman having an elective is in theatre and is halfway through her op, then a woman needing a crash section will have to wait.

"Why on earth should these guidelines result in "a sudden and significant increase in our already exceptionally high rate of c/s"? The vast majority of women still think a VB is preferable, don't they?"

Even if it's only a 2% rise that will make a difference. Partly because of the ongoing issues then of repeat c/s.

I think there are a lot of women who've had poorly managed first labours, or poor experience of NHS antenatal care who, quite understandibly, like the idea of having a highly managed, scheduled delivery, which is what is on offer with c/s on demand, which - as far as I can see - is what the NICE guidelines are supporting.

C/S rates in almost all countries where women have the option of electing for a c/s are higher than ours. I can't see why ours wouldn't rise to match their, especially if women themselves are not having to shoulder the cost themselves.

Re: midwife numbers - overall women who have c/s usually have longer hospital stays than women having v/b and are more likely to be readmitted to hospital afterwards. This will put a strain on postnatal care, particularly in the community.

Anyway fruitybread - there's not need to be sniffy and unpleasant about it. There's no denying that at present maternity services are massively overstretched financially and in terms of staff numbers. There's general agreement that c/s are more costly for the NHS and put more of a strain on bed space and staff input. After all - many mums, yourself included probably, have said on this board that penny pinching is behind the current situation where women wanting a c/s are sometimes being obstructed.

"
So if I opt for a CS, it will be safe in the knowledge that LESS women or babies will die"

Beyond - come on, surely you can accept that vaginal birth is less costly to the NHS overall, even if your birth involved more than the usual number of health professionals?

Anyway - I'm all for more choice, as long as it's done within the context of providing safer care for all women and all babies.

Of course I can accept that a straightforward VB costs nothing compared to a CS, but surely women who want to opt for a CS are also generally more likely to not have a straightforward VB, even if its just because they are stressed out by it?

I'm not considering an ELCS for the hell of it, I wish I werent in the position that I had to consider it. I wish I could be (obviously within reason) "guaranteed" a relatively "normal" VB. I'd be happy if my labour went as it did with DS, even with assistance and a room full of doctors, it wasnt traumatic and it was only months later that I realised my problems weren't normal birth injuries that went away on their own.
Or I even wish that I had to have a CS so the decision is taken away from me and solely in the hands of the professionals. As it is, if I decide that I think a CS is safer for me and my DC, I may have to fight for it if one consultant disagrees, where another may agree. Under the new guidelines, it might not be so much of a fight?

Again, tittybangbang - you, and so many others, do not make any distinction between planned and emergency CS in terms of outcome.

The new NICE guidelines do, to a large degree, much greater than has been available to patients before, and thank god we can all be better informed.

As to your scenario where an emergency CS patient is waiting to go into theatre and a non emergency CS is taking place - I asked about this scenario when I was being prepped for my planned CS.

I was told that it can happen, it's very rare, but they have a strategy for coping with it, depending on the degree of emergency. Basically, straightforward CS's really don't take that long. By the time an emergency CS has been hastily anaesthetised and prepped, a planned one will be either postponed, or done and dusted.

Again, you could argue for a far fetched scenario where a woman labouring in hospital has no access to a MW, or a very long wait for one because they are understaffed thanks to a homebirth situation. [and I have seen posters on this board advocating just calling the hospital and demanding a MW to come to them when they go into labour at home - apparently there's a legal requirement that they come? I've no idea if that's true or not, but I've seen it said on these boards...]

None of which I would use to argue against anyone having a homebirth, btw.

And in terms of birth cost - I have always argued - we don't KNOW how much births costs. We are never given long term or holistic figures. Simply 'on the day' costs.

This is SO shortsighted. You can read many stories here from women who had nice cheap VBs, or instrumental births - who then returned to hospitals with infection, who needed reconstructive surgery, physio, counselling, etc etc. That never shows up as a 'birth cost', purely because another bit of the NHS foots the bill. And those costs can run into thousands of pounds for one individual.

Interestingly, in the NICE CS update, which can be found here - guidance.nice.org.uk/nicemedia/live/12156/56255/56255.pdf - there is a large section on cost, and cost analysis.

One section in the conclusion on page 220 reads as follows: - "This model suggests that the immediate birth costs are lower for planned vaginal delivery than they are for maternal request caesarean section. However, the model does not conclusively demonstrate the cost-effectiveness of one mode of birth over the other. Using the adverse outcomes data only included in the review produced for this guideline, planned vaginal birth does appear more cost-effective but its cost-effectiveness relative to maternal request caesarean section is likely to be reduced to some extent if adverse outcomes such as urinary incontinence are included within the model."

If you only want to look at 'immediate' 'on the day' birth costs - go ahead. I don't think we should ignore the EFFECTS of birth on a mother, and what it might cost to deal with that further down the line. At the moment, 'adverse effects' of planned vaginal birth include increased long term urinary incontinence. There is a cost associated with treating that - and if you include that in 'how much does a birth cost', then planned VBs are less of a low cost saving than they appear right now.

No point having a go at me about that - that's what the NICE guidelines say.

And without being remotely sniffy or unpleasant - you oppose these revised guidelines, tittybangbang. So what do you think should happen to a woman who desperately wants a CS, who has been as well informed as she can be by HCPs about relative risks/benefits, and for whom counselling/therapy for fear of birth is not successful?

Tittybangbang I think an issue is that your concern/comment is directed at women who, on an individual level, are taking a difficult decision to have an ELCS and may be perfectly reasonable for making this request.

If the system needs to change, then so be it. Frankly I think it has been a long-time coming - the valid needs of many thousands of women for whom vaginal birth isn't an acceptable option have been dismissed for far too long. Just because this may have a price tag attached doesn't mean that it is bad news.

The economic argument isn't as straightforward as you make out. If you read the latest version of the NICE report you'll see that a CS is about £800 more expensive than a vaginal birth.

However, as the authors of the report state quite openly, this £800 takes no account of certain additional costs to the NHS of forcing women to have a vaginal delivery - for example, the costs of treatment of resulting mental health conditions, and pelvic floor/continence issues.

To give you an example, in my case, a further vaginal birth is likely to worsen my prolapsed uterus which means that I am likely to need lifelong treatment and quite possibly surgery at a later date. This would cost far more than the £800 difference. Not to mention the vast difference that it would make to my quality of life, for the rest of my life. So a CS may well save the NHS money, albeit in the medium/long term.

For a long time there has been a political and costs-driven agenda to reduce the number of CSs, using simple statements like "CSs are more expensive". However, the fact that NICE have reviewed their guidelines suggests that it is a much more sophisticated and finely balanced issue than that.

I believe that long term costs of birth injuries must be considered.

A friends Mum is shortly to have extensive surgery due to a forceps birth. They made enquiries as to how much this op would cost if she went privately and it was £11,000! Hardly cheap! And the physical and emotional trauma that this lady has suffered is beyond belief. The surgery is so major she will be in hospital for 5 to 7 days and months of recuperation. Fortunately she has managed to get an NHS appt for the op.

As a side note, I wish I'd known more about the risks of VB beforehand. Probably wouldnt have done anything different, but would have been nice to know exactly what could happen, I like to be informed. I understand that HCPs dont have to inform you, but would have thought it would have been in the pregnancy books in the "things that can go wrong" section, that already contain some darn unlikely problems.
OP, I've read through my books again this time, and cant find anything in them about pregnancy with an existing prolapse. Didnt even find much on the internet about it!! When I first looked into it, it made me feel I'm being a bit precious or even that theres something so wrong with me that noone on the whole internet has had a problem with it!! (luckily I've found more info since the initial search)

Beyond, have you seen prolapsehealth.com? It's really very informative.

I hadnt, I'll go and have a read now! Thanks!

Leaving the cost issue to one side for a moment. I certainly personally welcome these updated NICE guidelines. However I did read somewhere, perhaps a post on thus site, that hospitals don't absolutely have to follow these guidelines. They are what it says on the tin. Just guidelines. Has anyone else heard this?

And given that hospitals are still under pressure I assume to reduce c section figures I'm not overly optimistic about my hospital changing it's policy any time soon!

VBB, I think i've heard that too somewhere but i'm not sure if it was on here or somewhere else on the internet. I suppose only a midwife or a consultant can tell you the answer to that (any on here?!). I've heard that some hospitals have notices up in the waiting area stating their policy is no ELCS for maternal request but i'm not sure how accurate that is. I've probably been reading far too much and need to step away from Google.

Kblu-I know what you mean about googling too much! I have become obsessed with looking up policies. My hospital is one that has their vbac and no elcs on request policy stuck literally everywhere in the waiting room. And it only came into effect in July this year. Given by then everyone already knew what the NICE guidelines were going to be I can't see that it will make a difference to them at all.

Makes NICE look redundant then!!

I'd never heard of NICE guidelines until I started googling. I wonder if it makes any difference to whether your wish for an elcs is granted if you start quoting said guidelines at your consultant appointment? Or will this just make them think you're a bloody know it all and piss them off even further?

Kblu - when I started quoting NICE and RCOG guidelines at my consultant he was very happy to agree to my ELCS as I could show him that I've looked into risks and benefits of both options