Try to have a consultation with Sara Paterson-Brown at Queen Charlotte's. Here's an article co-written by her:
Focus'The safest method of birth is by caesarean'
Share 12 reddit this Nicholas Fisk and Sara Paterson Brown
The Observer, Sunday 2 May 2004 Article history
Obstetricians spend much of their time exploring reasons why women ask for caesarean births. Sometimes we feel like a recording, going over and over the same pros and cons surrounding the delivery of their child.
But now the National Institute for Clinical Excellence (Nice) wants us to dissuade women from such requests. Its reasons are straightforward: a short-term cost saving of £11 million and a political view that maternal choice is fine, as long as it is towards' natural childbirth.
Women, not their doctors, make the choices about family planning, antenatal testing, where to give birth and whether to breastfeed. So why not how to give birth? The Nice edict is that maternal request is not an indication for caesarean delivery. Yet more than half of UK obstetricians regard vaginal delivery as more dangerous for the baby.
Women will scarcely be reassured that the Nice 'expert' committee of 16 was chaired by a GP, contained only two obstetricians and was subject to heavy pressure from Department of Health bureaucrats. Recommendations were by majority amid considerable dissent, and the report was rushed out after a staggering 1,400 critical responses.
The Government's target is the 22 per cent caesarean rate, and in particular the 9,000 operations done solely at the mother's request. Rates have risen due to a combination of the improving risk/benefit ratio compared to vaginal birth, and anthropomorphic pressures. Women reproduce later in life, have an average of only 1.7 children, and both they and their babies are getting bigger, resulting in more problems in childbirth. Vaginal birth damages the pelvic floor of many women, and may lead to serious problems in the baby. This is set against the background of society's aversion to risk, and the relative safety of modern caesareans.
Some requests are ill-founded; most are not. Nice wants us to offer women 'cognitive behavioural therapy', yet research shows this has no effect on a woman's decision.
What most women want is information. As was evident at last Thursday's meeting to launch the report, much of the information provided has been selectively interpreted. Nice misquoted risks for planned caesarean versus attempting vaginal delivery (it used higher risk figures of all caesareans compared to the lower risk figures of successful vaginal delivery). Everyone accepts that the best evidence comes from random studies, where treatments are allocated by the toss of a coin. However, in childbirth such studies are few and far between, so it is misleading to equate lack of evidence with lack of risk.
Apart from inbred bulldogs which all need caesareans, mankind is the only species in which the baby's head almost entirely occupies the mother's pelvis and needs to rotate through 90 degrees to come out. Virtually every muscle, nerve and tissue in the mother's pelvis is stretched around the baby's head.
Little wonder that 10-25 per cent develop problems. The most common is leaking urine when laughing or coughing, but a few women develop incontinence of wind or faeces. These 'women's troubles' were not such a problem in the past but women today are less prepared to tolerate the inconvenience and stigma of incontinence. Already 11 per cent of women undergo a vaginal repair operation to correct bladder weakness or prolapse of the womb.
The risks to the baby of attempting labour are much smaller than those to the mother, but potentially more serious. One in 1,800 babies die during labour. About the same number have fits after birth as a result of oxygen shortage, although only a third to a fifth of these develop long-term problems, such as cerebral palsy. Cerebral palsy has other causes, but planned caesarean reduces the chance of the baby suffering oxygen shortage at birth by more than 80 per cent. The greatest risk is the chance of the baby dying inside the womb while the mother awaits the onset of natural labour. Adding these up, the overall risk of death or damage to the baby of vaginal birth is maybe more than one in 500, yet a survey has shown that the average pregnant woman would want a caesarean to prevent a risk of one in 4,000. Ninety-two per cent of women say they want to be delivered by the method that is safest for their baby, and most obstetricians believe this is by caesarean. The risks to the baby of vaginal delivery are arguably greater than of activities society outlaws as dangerous - such as drink-driving or riding a motor bike without a helmet.
Women need to understand the downside, which includes wound pain and slower recovery. The chance of a blood clot and other rare but serious complications seems increased, although this is higher after an emergency operation in labour. Death from a modern elective caesarean in a fit healthy woman is so unusual that the risk can only be guessed at being in the region of one in 100,000 - less than a tenth of that from a road accident. Caesarean in a first pregnancy is likely to be followed by caesarean in a second - especially if for maternal request. The major drawback of repeated caesareans is the limitation to family size. The small increase in the chance of the placenta implanting over the cervix or getting stuck over the scar in a future pregnancy can result in serious bleeding and even hysterectomy.
This is why a requested caesarean is mainly an issue for older women having their first baby. It is the first labour that is most likely to be prolonged, difficult or end in a forceps or vacuum delivery, all risks for pelvic floor damage. And it makes more sense when there is a greater chance of complications in labour, such as with twins, or where labour needs to be induced with a first baby.
Vaginal delivery can be an immensely satisfying experience, as can an elective caesarean. Both can go wrong. Consumer choice, a central theme in pregnancy care, is already too entrenched in the labour ward for a return to paternalistic directives. The 'too posh to push' jibe belittles a genuine, well-considered choice for many women.
Nicholas Fisk is professor of obstetrics at Imperial College, London. Sara Paterson Brown is a consultant obstetrician at Queen Charlotte's Hospital, London