why the drive to reduce cs rates in nhs trusts?

[cakebaby]

Hello ladies
Long time shadow dweller, after 12 week scan its definitely a real baby and not just cake, so I've ventured into the light.
l'm 39 & have had to delay pregnancy for a number of reasons, one of them being a total horror of all things birth related. I have no idea where this has come from & cannot rationalise it. I hate hospitals & have to visit them fairly regularly for work. I get light headed, sweaty, spots before eyes, the works. I suspect this is related to my mothers slow death in hospital when I was in my teens.

At my booking in appt the MW briefly mentioned the b word & gave some options like hospital, birthing unit, home birth, completely ignoring elcs. My pack from the MW with hospital leaflet also completely ignores elcs but states they are proud to be reducing the cs rate. She laughed off talk of an elcs as if I was bonkers and gave the old line 'women have been giving birth for millions of years.... body designed for it' blah...
This was not a great start for me, in one sentence she has compounded my suspicion I will not be in control of my body and what happens to me when it comes to birth, that I won't be listened to or have any say in things. This is not just about requesting an elcs, but about being treated with respect & being listened to.

So, why are NHS trusts so keen to reduce the number of cs, to the point of seemingly aggressively campaigning against them or at least cheerfully ignoring the possibility of one?
Sorry for long post, this is causing me increasing anxiety already.

[RedToothBrush]

When doctors have Godlike status and its proven to be fallible then of course it creates problems. Medicine is pretty much trial and error based on observation. Every patient to a greater or lesser degree is a guinea pig depending on the extent of research that has been done in that particular area. Patients don't respond the same way to virtually anything. They respond in similar ways but not the same. Medicine is still very primitive in a way and we have an expectation that it knows and understands far more than it actually does. Which means that prescribed policies at completely at odds with this reality and it ties the hands of HCPs. Patients could really do with knowing this a little better tbh.

[trustissues75]

bamboozled - with regard the age of the placenta there appears to be a relatively quick and easy way to see how it's doing and tis rate of calcification and that's through ultrasound.

I do understand tht your DH must get very frustrated at times but he also needs to realise that if the NHS actually helped to educate women properly instead of giving them what basically boils down to a list at their booking appoint of what they "can and can't do" then there may be more trust and faith. \there are plenty of women out there who are quite happy to go along with whatever the Dr/midwife says and never question anything - I personally think this is a highly dangerous things to do. If you look at various NHS web-pages there are suggestions that the patient should play and active, informed role in their treatment - and yet that doesn't seem to apply to women who are pregnant/in labour unless you are very lucky to come across a hospital and staff who are a bit less mainstream - or that's my experience anyway.

For those women that want to think for themselves, this lack of information, use of words/phrasing that automatically implies there is to be no discussion, and lists of what they can and cant do gives us the impression that we're almost expected not to question...for me, during my first pregnancy, that meant I had almost zero trust

[LaVolcan]

He's probably as much a victim of the production line system as everyone else. IMO we need to get back to a human scale as far as health care is concerned.

[bamboozled]

His communication skills are great. He spends all day talking to women, terrified women, women in pain and exhausted women. No one wants the consultant in the room in what is meant to be a straightforward delivery. His presence there means that things have changed, the stakes are raised and it is his job to take the fear, absorb as much of the stress as possible, and turn it into a situation with a good outcome. It's just that there are a certain percentage of people who will not listen to advice. It's pretty hard to not tear your hair out when you are trying to save someone's life, have explained in great detail why the procedure is necessary and still people say, but I wrote on my birth plan I didn't want any intervention. In what way is this different to people who drive into rivers because their sat nav told them to turn left, even though they can see the water in front of them..? His aim is to have a reasonable dialogue, but don't ignore medical advice and then blame it on the drs when the outcome is poor.

[MmeThenardier]

As to the OP. I'm not sure... Something to do with saving money probably. Although you only have to look at the amount working cost the NHS to realise its probably a false economy.

Personally I'm in favour of supporting women in whatever they want be that Home birth, instant epidural or elective caesarean.

I don't like the suggestion that these things are 'too expensive'. There is always money available in this country for certain things, there's no excuse for poor maternity care.

Also it brings us back to this idea that women ought to feel pain (cos they always have) and shouldn't be given a choice. As has been said before on similar threads, people aren't refused pain relief post surgery why should they be on the labour ward.

[RedToothBrush]

La Volcan, I think its possibly more to do with this idea of mentality too. Its so strongly ingrained and presented throughout the process. All the stuff about how to avoid a CS being down to what you do and within your control. People don't want to believe that it isn't the case as it opens them up to this idea of 'failure' which is the opposite of all the positive thinking and determination they've been taught is so essential. Look at responses to threads like these that talk in ridiculous terms in that manner and are completely blinkered to women who have had a bad experience. Its a weird form of denial.

I do also think its down to trust in a huge part too though.

Obviously these feelings have been created by this idea that CS are widely being carried out when they aren't necessary.

[MmeThenardier]

I realise what you meant bamboozle. What I mean is that when the 'rules' vary across the town (and the example here is induction) and two consultants are giving out different information this may apply to other things.

Such as the intepretation of when an emcs becomes an emergency. In which case it is no wonder that women want to clarify that there really is a need for a procedure to be carried out. Whether that is induction or an emcs, forceps, episiotomy etc.

Trust is important too. Its so common to hear about unnecessary intervention. Who wouldn't want to establish they're aren't about to become a victim of this.

And honestly, if he's tearing his hair out over this regularly perhaps he needs to change his approach and start recognising that women expect to be communicated with. A medic (or similar) who regularly writes patients off as 'not compliant' or complains that they don't understand, needs to look at their own skills.

[LaVolcan]

it was over getting people's consent for emergency surgery, to save the life of the mother/child/both, because it is not written on the birth plan,.............but some people stick rigidly to what they have written, even when the facts are right in front of them, heart rate monitors etc...

I wonder if we are back to the issue of trust here? If you see a different person at each ante-natal visit and then go through two or three shifts of different staff in labour, none of whom you have met before, who might be contradicting each other, then could it be a question of not knowing who to believe? Then perhaps sticking (too) rigidly to the birth plan is your way of coping?

I don't know, I am just musing.

[lotsofcheese]

I think another factor to consider on the elcs v's trying for a vb is the availability of senior medical staff outwith 9-5 hours.

I'll be having a CS again this time & with a high risk pregnancy, would rather have an planned elcs performed by a consultant during working hours, with full medical support on site.

I will be declining ecv, induction etc as I do not wish to have an emcs performed by a junior member of staff. Or some inexperienced registrar making the decision should an emergency arise in a natural birth.

I won't go into my obstetric history in this thread, as it's not appropriate, but no amount of cbt, persuasion or discussion will change my history or make a vb any safer for me, physically or emotionally.

OP, I hope you manage to get your elcs. Insist on seeing a consultant (not any grade of staff lower than this) but expect that final decisions in any birth are not made till around 36 weeks.

[bamboozled]

Sorry, fat finger syndrome, it was over getting people's consent for emergency surgery, to save the life of the mother/child/both, because it is not written on the birth plan, when stats are dropping and outcomes are looking very poor. A piece of paper isn't going to change an outcome, but some people stick rigidly to what they have written, even when the facts are right in front of them, heart rate monitors etc... That is what I was referring to..

[RedToothBrush]

Why is it the case that inductions are done by the calendar and the policy of the hospital (which vary enormously from hospital to hospital) primarily.

And yet its ELCS - which are now no longer recommended before 39 weeks without clinical need - are vilified as 'fitting around the schedules' of either mothers or consultants.

We know the truth is both are routinely planned around staffing. Particularly since inductions are the default choice over monitoring.

Both have consequences if they are done too early or too late.

I think its relevant because, the value and social acceptability and clear double standards here are about control and what the hospital or doctors or whoever wants AHEAD of the interests of mother and child.

We have to be fitted into nice neat little boxes and behave.

[bamboozled]

Just to clarify, I didn't use the word fight over induction, it was over getting peo

[MmeThenardier]

Bamboozled why gamble at the end?

To answer your question because there is also a risk with induction, just as there is in going over.

So we have to decide which is the greater risk. Here we are routinely offered induction at +14, on the other side of town, the hospital routinely offers induction at +10.

So someone is wrong or has a different take on the data or a different agenda. This is one of the reasons that it is sometimes hard to trust medical professionals - when two are completely contradicting each other. Indeed often there is no 'correct' just an educated opinion based on many factors.

Women are perfectly entitled to expect good explanations and have their questions answered.

I have come across some arrogant, bullying Drs who don't seem to realise that part of their role is to communicate with their patient (the Mother of course). A 'fight' is an interesting use of language.

[bamboozled]

Sorry Working,, that was replying to LaVolcan. I'm not sure if I explained that properly either .
Also, Cakebaby, sorry, in no way is this meant to offend or upset you.

[bamboozled]

Yes, obviously, but the risk increases as the days past due date increases. The problem is that the camps are SO divided, those that don't want intervention generally don't want the medical stats either, 'it's my body, I know best' - and in fact are doing a huge disservice to the women that want to have the proper information before making up their minds. It just muddies the water. If we were told that the car seat we wanted to buy to bring our new born home in, was not guaranteed to save their lives in a crash, but that this other one definitely would, there's a rats chance in hell that we would buy the one with a speculative outcome.

[working9while5]

Oh and I was born by elcs (consultant about to go on holiday ) and have asthma but I don't blame my mother for it! Asthma can be a pain in the arse, but unless you are one of the very unlucky few for whom it is really disabling, it is that and nothing more (and yes, I've been in intensive care).

Redtoothbrush, dead right about theray needing to be a project "alongside" vs a "route to".

I started CBT when ds2 was 4 weeks old, and have had it weekly (with some holiday breaks etc) until quite recently. I have four sessions left. In some ways, I don't think it actually would have been effective for me without the Mindfulness - because a lot of the "cognitive answer" was about tolerating uncertainty (no shit!) but how do you do that? As you eloquently put above, your experiences can bring fears that defy logic.

Mindfulness is more about meeting those fears and learning to see them as fear, and to sort of hold that fear if it makes sense? In the beginning mindfulness was very overwhelming because I sort of had this whooshing of anxiety/racing thoughts and just sitting them without needing to do something with it e.g. reason it/research it/find a solution to it. Mindfulness usually is an 8 week course, 2 hours a week and you are expected to practice 30mins to 45 mins a day. So probably potentially faster...? The two complemented eachoether well because the CBT helped me work out the sometimes weird and wonderful beliefs I had picked up about birth (even though I was post birth it was still useful to work out where the anxiety had come from!) and the Mindfulness helped me know I could manage my current fear differently without always needing to DO something e.g. read/research/solve the problem (which often made it worse).


I couldn't put a timescale on the CBT really, there were various moments where things clicked. One was where I started to realise just how terrified I was of the experience of being overwhelmed and in pain and of being judged for that. I was actually more afraid of being judged than of the pain or even being powerless, which I would never have guessed. Included in this was the fear of not being heard when I was in pain, but also that it would "wrong" to be in pain when others had things so much worse in life (good old Catholic upbringing there!). I had a lot of shame about that too. I also had this bizarre fear that if my baby died it would be my fault for not being thankful enough for being pregnant in the first place. Again, only got there through a lot of talking!

If I had to boil it down, therapy works because someone listens without judging. The quality of the therapy is going to be more about you feeling that your fears are heard and accepted rather than the method of it etc... though I think CBT probably appeals to people like us who are essentially very rational and sceptical of woo etc. Mindfulness seems (to me) to work by helping you realise that your fears are not you, and that you can feel afraid without being overwhelmed and distraught because of your fear? Does that many ANY sense? It's probably slightly different for everyone. Mindfulness is the sort of thing that is impossible to explain, you can only realise what it is when you try it out a bit.

I think dealing with the anxiety has been very freeing for me as a person and really you are right, that has nothing to do with the birth, though I would never have probably realised I was anxious without the birth iyswim. Would have described myself as laid back rather than a worrier, very rational etc etc... but everyone has some fears that hold them back I think, and it definitely has been great to begin to deal with it.

[LaVolcan]

I presume that there must be women who have suffered placental failure before the hospital's declared induction date occurs? This is really just a request that women are treated as individuals and given the proper information on which to make a decision.

[janey1234]

Exactly bamboozled - especially given that as maternal age increases, the placenta deteriorates more quickly - and the risk of stillbirth increases. Part of the reason I will be requesting an ELCS...

[bamboozled]

I think the problem with that is that a placenta doesn't have the capability to support a baby in-utero indefinitely... It will break down and then the baby will be compromised, and this is very difficult to monitor, hence the need for induction. Obviously there are women who have refused induction and gone +17 days etc, but there are also the women who have had terrible outcomes because of placental failure... It's not a risk worth taking in my opinion. If you've spent 40 plus weeks growing a baby, not eating blue cheese, not drinking, not taking ibuprofen etc, why gamble at the end..

[LaVolcan]

Obviously I am biased, because I live with one of these consultants who comes home tearing his hair out at the fight he has, before the EMCS, to actually do the EMCS.. But if people understood that emergency intervention is everyone's least preferable route of care, perhaps they would lay off the drs a bit.

I suppose it is a digression but as you say, I think the point does need to be made. I often wonder though, how many of these EMCSs relate to failed inductions? Which in turn makes me wonder how necessary was the induction? I sigh inwardly when I hear someone say that they 'had' to be induced, had a long labour and it ended up in an EMCS. I wonder how many of these inductions were really necessary or were dictated to by a date on the calendar, and whether the woman would have had a perfectly straightforward VB if left alone? So in a way this is back to choice and being listened to - rather than 'we book you in for induction at 40+ 10/12/14/whatever' it would be nice if the pros and cons were offered. Sheila Kitzinger once said words to the effect that the protocols are a good servant but a bad master, and I think this is a point worth remembering.

[RedToothBrush]

She's right. You shouldn't feel guilty for things you had no control over ultimately. They just 'happen'.

[ByTheWay1]

thank you trust... (that was a lovely thing to say.... )

[trustissues75]

Oh and bytheway - please don't beat yourself up over this, you really really don't know if the CS actually did give your one daughter problems - there are a lot of theories out there with allergies, it's realy not worth beating yourself up over - you're doing your best and that's all anyone can ask of you.

[RalucaV]

BytheWay,

me and my health are a perfect example of the opposite that this theory says. I was born by VB and I have multiple allergies verging on asthma (I am fighting not to develop it). I have had them since I was born the so called "natural" way. Every cold means weeks of sniffling and coughing.
My husband and my parents are the same way. I mean, isn't genetics rather then some germs from the birthing canal (that can be smeared on the baby after CS anyway)?