Why is there so much judgement directed at c sections?

[DanceLikeTheWind]

I honestly don't want to start another endless VB v/s CS debate. I am just eager to read any insight that people may have on this topic- Why are other women so judgemental towards women who opt for c sections, whether elective primary c sections or repeat c sections?

There are several reasons why I will opt for a c section: a prior (minor) uterine prolapse, anxiety issues, and a family history of erb's palsy and incontinence.
I have faced nothing but judgement, ridicule and even hatred from other women :(:(

I am well aware that this is a major surgery with a longer recovery. I'm well aware it shouldn't be done prior to 39 weeks (unless of course I go into spontaneous labour). I'm well aware of the increased risk of complications in future pregnancies, however I don't plan on more than two babies.
I'm also aware of the risk of staph infection.

However, by opting for a c section I'm reducing my chances of developing
incontinence and prolapse. I have a zero chance of suffering an obstetric fistula, a third or fourth degree tear and perineal trauma.
My baby will be at a reduced risk of cerebral palsy, erb's palsy, brachial plexus nerve injuries and trauma caused by a possible assisted birth.

I'm not hard-selling c sections here, just pointing out that there are some benefits to a c section as well.
Why then do people only focus on the negatives? And why are the varied risks of a VB ignored simply because it's 'natural'?

I assumed people were talking about private electives with absolutely no medical reasons OR the new guidelines that may come in suggesting a choice. I'm arguing against the choice.

I see your point about the metaphor but this it's a pretty unique scenario! I guess HCPs should take more time to talk about risks and look at those risks in the context of the person but in the absence of time to do this, they have to make a purely clinical decision which a lay woman is not in a position to make.

As long as HCP professionals are talking about the risks of ALL types of birth. At the moment, the script is something like this:

"VB is king, nothing is better, CS is for emergencies only. Epidurals are bad, bad, bad and unnecessary unless you're weak-minded and not prepared, our bodies are built to do this, don't worry about anything (no mentioned of the risks of assisted delivery, or tearing, or damage to baby)

"CS's are bad, it means you failed to give birth normally, we won't give you one even if it's 50/50 that you need it as our stats for CS are high enough already, thanks very much. And don't tell us how you're feeling, we're the professionals, we'll tell you when there's something wrong. You need to calm down."

No-one EVER mentioned the risks of VB, including assisted delivery, or tearing, or damage to baby. All of which happenend to me.

Good grief that's terrible, I hope you are doing alright now.

They covered all of that stuff at our NHS ante-natal classes, were really up front about tearing, CS stats and pain-relief, and they passed around the epidural set up, ventouse and forceps so that we went in prepared for how it might go and what the options would be at each point. (I had an induction then EMCS in the end). Looks like I have been naive to think they provide the same for everyone, the lack of consistency is shocking!

Thank you NICEyNice for your incredibly well-informed and thoughtful posts.

It helps me to make sense of my own thoughts about childbirth... I am 36wks with a breech baby. I'd initially wanted to go to my local MLU and have a 'home from home' experience. I now want an ELCS and don't want the baby to be turned by a doctor in an ECV, or to vaginally birth him (a midwife actually said that everyone would be really impressed if I did it - I have no interest in being a hero ).

The 2 options seem like opposite extremes, but because I have suffered from panic attacks and anxiety in the past I just want to avoid a scary situation where I'm out of control. ELCS now seems like my best option.

I'm really struggling to verbalise why I want it to my DH far less the consultant. It's just the worst thing as a woman - anxiety = flaky, fear of birth trauma = not a 'real' woman.

I've had two EMCS's, first at 34wks, second as a failed VBAC. I don't view c-sections as the easy option. I was absolutely terrified during both operations, like I was at the total mercy of the surgeons knife, which of course I was. The first c-section went very smoothly as the consultant and anaesthetist were highly experienced ( I was staff at the hospital so knew of them), but I was still terrified of something going wrong as I had severe PET.

The second section was performed by a reg who was good but the anaesthetist was rubbish. The epidural he sited during labour didn't work at all, he then wanted to top it up for the section which, not surprisingly, only worked down one side. He did all the cold spray test but I could still feel it on one leg, he seemed pissed off like I was lying! I was afraid they'd do the op whilst I could still feel everything! I requested a spinal which took 30mins for him to site, all the while having regular contractions as I was 6cm. I was pleading with the midwife to get them to GA me as I was so sick of it all

As for incontinence, I don't think csections save you from this entirely. I feel being pregnant with a largish baby (8lb) has give me mild continence problems as I don't always know when I need a wee, nerve damage? It doesn't bother me now but may get worse if I have another baby.

"IN countries where the OB/Gyns are knife happy and like doing Caesarians, such as the US, the maternal death rate is sky high. Compare it to the maternal death rate in developed countries where vaginal birth is the norm and the outcomes are much better for women."
Sakura - what sort of alarmist nonsense is that? The US CS rate vs. UK CS rate is 33% against 24% - yet the maternal death rate is double. There are lots of theories, not least more teen mothers who are at higher risk of poor prenatal care and delivery problems.
Interestingly Italy has the lowest maternity death rate in the world, although the c-section rate is one of the highest globally.

merielandmatt, the new guidelines do not fully give a choice in the way a lot of people think they do though. Its misleading to suggest its a 'free choice' in the way people think it will be and I think it will lead to disappointment for some women who come across the reality. Its a choice UNDER GUIDANCE.

The guidelines actually state that:
When a woman requests a CS explore, discuss and record the specific reasons for the request.

If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth (see tables 4.5 and 4.6) and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and to ensure the woman has accurate information.

When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.

Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care.

For 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.

An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.

The reality is the guidelines encourage support and encourage trying to deal with anxiety. The encourage doctors to take a woman's opinion more seriously and to listen to women requesting a c-section and try and address issues resulting from that. It gives a clear right to a second opinion. A clear point is to ensure that 'a woman has accurate information'.

Remembering these are guidelines rather than rules, I think its reasonable to says that if a doctor feels a patient really doesn't have accurate information (eg, they don't feel they are capable of understanding risks and discussion put forward by the medical team), there would be room to perhaps not take the request forward. I think the guidelines are about women demonstrating that the fully understand the implication of the decision they are making as part of an ongoing consultation and forces doctors to more fully explain why they think a particular route is the best course of action rather than enforcing it on a woman. It makes them more accountable and women feel more in control and understanding of the advice they are being given.

Nursenic, that is interesting about the hypoglycemia, when ds was born the consultant on scbu asked if I had suffered from gestational diabetes, because ds was very bloated, I didn't know because my last few MW appointments had been cancelled (she was ill and then on holiday) and I hadn't done any urine samples. I was nil by mouth from midnight and had the section at 12.30 pm. My blood pressure is always low, and was very low in pregnancy, but this had been taken into account and drugs were given to help keep bp up, but they didn't seem to work as well as hoped. When I had dd2, i had had an epidural and passed out because my bp plummeted, so all this had been discussed, but it still all seemed to spiral out of control. WRT the pains in my chest, the drs said that I was having a panic attack, it felt like a heart attack!

I have so many questions about what happened, because I am desperate to know if there is a reason why my ds has the problems he has. Unfortunately the 'counselling' session only made me feel more uncomfortable, because there seemed to be a determination, to say everything was fine.

I just wish the whole thing would go away and stop gnawing at the back of my mind.

nice there is a difference between talking to the individual, looking at that individuals specific situation and needs and giving the choice to the individual.
Of course the first two should be done but once an accurate individual picture is built by the HCP, why should the mother have the power to over throw medicaly justified recommendations?

Thanks for the extra info niceynice it's really interesting. I agree with entropygirl on the choice

meriel I think you may be biased....

btw nice I understand that at the moment doctors have no power to intervene (and in the case of all other procedures where 'my body my choice' makes sense I have no problem with that) but where the life of someone with no ability to make a case/decision themselves is involved I feel that doctors should have the power to intervene.
As for Jehovas witnesses...again they have the right to refuse treatment of themselves but I cannot see any argument for them having the right to refuse treatment for anyone else, regardless of that persons age.
The sooner we get over the idea that babies/children are owned by their parents the better.

HugosGoatee, I'm keen not to influence anyone too much either way. I don't see arguments for homebirth that far away from arguments for ELCS. The same important factors pop up time and again for both. Its just how one woman deals with it compared to another. And that could just be down to personality.

I think theres merits for both, and down sides to both. Its the bit in the middle that I have greatest concerns for - namely women who go into it, blindly thinking that a doctor/midwife is going to do the best thing for them without a proper dialogue of risks for and against a VB or a CS - in the context of individual cases. I don't see how they can, unless they have a very good close one on one relationship with a patient (again merits for one to one midwives).

I think the point is to look at the information out there, and assess whats the biggest concern someone has and look at the best ways to solve that problem. The whole thing about discussing care with a midwife/doctor is a huge part of that, and I do think in many cases, 'with accurate' information people will changes minds.

The really interesting point NICE made was the need for research to look at what methods work best to help with anxieties - and included looking at CBT, counselling, one to one midwife care, and other birth options as part of an exploration for a request for a c-section. I think the NICE guidelines really add pressure for more money to be put into maternity and to create a debate about it.

The RCM put out another statement about a shortage of midwives this week. Ideal timing of course...

They say the following on their website:
The document says these women should be told of the risks and discuss their request with a clinician, but their request cannot be denied.

This has led to speculation and fears that women who are able to have a vaginal birth, will push for a caesarean section.

But Cathy said that, with the support of midwives, few women will elect to have the procedure.

?Midwives need to be able to give time to women to really discuss what they want, and then be able to fully support and advise women towards this,? she said.

?One-to-one care in labour from a midwife a woman ideally knows and certainly trusts is particularly important.

?The RCM believes that if midwives are able to help women to understand what their choices mean for them and their baby and feel they will be supported in labour then very few women will want an elective CS.

?They will be making decisions from a fully informed position and from a position of trust in maternity services, not one based simply on hearsay.?

entropygirl, I think theres a difference between making a distinction between parents making a decision about a child that has been born and one that hasn't.

I've read various things about how, if you start to give 'rights' to unborn babies, then it opens up a huge minefield about human rights and the position a pregnant woman has in terms of the rest of society (in other words it puts her at the bottom of the pile, leaves her open to abuse and not on a equal footing with the rest of society and that she is just a vessel for carrying a baby).

NICE your posts have been informative, well-balanced, unbiased and really interesting to read. Thank you!

"One-to-one care in labour from a midwife a woman ideally knows and certainly trusts is particularly important"

I think this is an area that the NHS is particularly poor at. Anecdotally, many friends tell me how disappointing it is to have a complete lack of consistency during pregnancy care, and how frustrating it is to have to repeat your life story at each check up.

From my personal perspective, I didn't see one midwife more than once all the way through pregnancy and through labour. Everyone was a different face, and I never felt like an individual going through an important life event - I just felt like and item on a conveyor belt.

In fact, after my 44 hour labour, and 2 hour post-delivery surgery, they took my back to my room in the labour ward, and there was someone else in there, even with all my bags still on the chair!!!

hazey

If we can make sense of life events, then we can accept them and live better with them. I get the impression that what is 'gnawing at you' is the lack of explanation.

Trouble is, most healthcare organisations interpret requests for information, explanation and clarification as a prelude to legal action and so get defensive.

Sometimes there is no real explanation. However, your not being followed up for the appointments your midwife was away for is troubling and all too common.

Maybe you could ask for another meeting and make it clear in your request that you are not planning legal action?

Otherwise one of the support organisations for women who have traumatic memories of pregnancy/birth may help you.

Nowaynohow - I agree with everything you said in that post about continuity of care.

The thing that gets me in this debate is actually nothing to do with the births in either fashion. The reason it seems to me that management and this think tank like c-secs is simple; you can book em in and turn em over. IE you can work out exactly how many in one 24hr period you can do and critically, plan the financials to make it work.

Im finding it hard to swallow the arguements that either version of birth is simpler. Its simply easier to work the maths out if you can plan use of rooms and facilities for c-secs. Natural takes much longer and is usually more changeable in what happens. Thus maths and £ is much harder to keep track of.

Its just taking away from the story that midwifery is in dire straits and more £ time effort and training is required for what is one of the only two certainties in life. However the Co-op seem quite fine dealing with the other one......

nice that is a bloody good point you make about rights of unborn children versus rights of women. Good grief - what a minefield that discussion is...

I still think there may be historical baggage in that though. The idea that women need protecting from the consequences of being pregnant seems a bit stuck in the idea that they didnt get pregnant by conscious decision or that it was forced on them somehow. Now that women (at least in the UK) have free reign to make the decision to conceive and also the decision to terminate, I cant see any reason for them not having equal rights with the unborn child once the termination limit date has been passed?

Hmm I think its a very difficult one. What about instances where an ex-partner or current partner is pro-ELCS and challenges the woman on the unborn child's behalf because she is pro-VB for a breech baby for example? Or a man is adamant their baby should be born via VBAC even when a woman has a very traumatic delivery in the past and there may be non-clinical mental health reasons for an ELCS. In many situations, you could get one doctor to give you medical advice to go one way, and another to go the other in the other direction. There are so many examples of where women have challenged successfully advice about homebirth too - with the support of a midwife and have had no problems. Like I say, minefield...

Bare in mind how few maternal/infant deaths in childbirth you actually have in the UK. And the point is that the doctors give advice, and in the overwhelming majority of cases, in the end women will follow that advice if presented with a real case suggesting there is going to be a death. It would positively benefit so few babies, but would potentially negatively affect a lot more mothers.

I still think its shaky ground to bring in issues of equal rights for an unborn child - even after termination limit date has been passed for that reason. The status quo might not be perfect, but it is the most workable and fair way of doing something imho. I think drawing a line in the sand at point of birth, ultimately is the best solution as so few women will actively endanger their child as it goes against instincts. When it comes down to it doctors should persuade not enforce.

Dancelikethewind - I totally agree with you in that there is a lot of negativity directed towards c-sections and in particular, ELCS. It's something that people have really strong views on and also get really angry about. A bit like how people get really het up about the FF v BFing, and vaccinations..

I think you must go with what you feel comfortable with and then block out all the negativiety.

I have had 2 c-sections, one was emergency and then the 2nd was elective. I wanted vaginal but my body doesn't go into labour it seems. Anyhow, I can say the elective CS was a really positive experience. It was calm, ordered and I felt very peaceful. The doctors and midwives were great. I have nothing negative to say about the experience so please don't listen to the negative comments. It is up to YOU only

I agree with you dead souls. There are so many issues regarding child birth, feeding, parenting, etc that will provoke such strong opposing views from people that you really have to make your own decisions with the support of your team and not feel that you have to justify them to anyone, easier said than done.
I had two vbs and they were fine thank god as the pregnancies were high risk, I was terrified before the first and was only to be given a short trial of labour, any problems and I was having a c-section straight away, had been prepped with epidural and spinal in advance. Thankfully it wasn't necessary as I was even more terrified of ending up in theatre! Definitely not what I would consider the easier option! The only downside is 3 yrs later my bladder still hasn't recovered and no hope for mprovement asno 3 due in may!

I was interested to read the link about women who fear childbirth having worse outcomes with VB. From my point of view I would disagree with entropygirl on the subject of there being one objective safer option for a particular woman with the HCP being in the best position to decide. Coming from a specialty where I regularly have to make decisions in my patients best interests against their will on the most fundamental things (such as the right to leave hospital or take treatment) I value choice highly and recognise autonomy as being important to hard outcomes. We try hard to achieve as much choice for patients even under these circumstances, for example offering them a choice of drug even if I'm taking away their choice to refuse treatment. They might not always pick the medication I might but the minor differences in efficacy and side effects pale against the benefits gained in terms satisfaction in treatment, trust in services and long term engagement - all of which then have an impact on their clinical outcome. And these are patients who lack capacity.

The study mentioned might be evidence that there are similar effects in obstetrics though I don't know much about obstetric literature. I've certainly seen women with psychiatric problems after their experiences with both VB and CS and one of the factors seems to be feeling out of control. I can't help but think that having a CS when you wanted a VB or vice versa might make a difference to psychiatric outcome in women who feel strongly one way or the other. Certainly I've seen some who had no inkling of the complication risk so were completely unprepared for what they then found a terrifying experience. As most women want a VB in the UK then usually the women I've seen have been hoping for a VB and ended up with a CS but there's no reason why it might not be the other way around.

Most importantly if you feel simply that it is babies outcome which is the priority - post natal depression in mum can also have a harmful effect on the baby, therefore maternal choice could logically have an impact on baby too. If some women decide to let the HCP decide, this is still them making a choice based on their personality, experience and knowledge and therefore is them exercising their autonomy but other women who make a different choice should still be respected. My reading of the evidence in NICE is that the differences in many risks for VB vs CS are slim which therefore increases the importance of maternal choice in my book.

Btw NoWayNoHow much of the evidence in the guidelines looks at 'intention to treat' rather than simply elective vs emergency. ie the outcomes if you are planning vb include the outcomes if you end up having an emergency CS. This is the correct way to do it as no one can plan on avoiding an emergency CS or complications! You want to know what is your risk of x,y or z if you plan VB vs if you plan CS regardless of what actually happens.

Rather waffly but hopefully that might make some sense!

ara I did say all along that the mental state of the patient is an important factor in deciding what the objective best option is and I can see that needing to be in control is one important factor that some, but not all, patients bring with them.

The definition of risk is probability of out come multiplied by severity of outcome.

In our current state of affairs the doctors know the first part of the equation but the patients know the second. ie. a doctor can quote the risk of incontinence but only the patient can tell you how much that will matter to them.

Some but not all patients will be able to absorb the probability aspect from doctors successfully and compute an accurate personalised risk factor and hence make the right decision for them (although I still feel the baby needs someone in their corner!). For these people patient choice is better than being treated as a statistic rather than a person. Those who cannot make this calculation are utterly failed by the system and left floundering. For them the decision may well be better made by the doctor.

My suggestion is that by proper communication with the patient the doctor should be able to extract all of the relevant information to deal accurately with the severity of outcome aspect and hence produce the optimum individual treatment consistently for all patients.