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]

The reason counselling is suggested when mothers request Cesareans for non-medical reasons is there is no other situation when having surgery for non-medical issues is considered acceptable.

Its considered 'acceptable'. The NICE guidance also says they don't know if it actually works though, since there is no research on the subject. It is entirely possible that it could in fact be detrimental to a woman's health as there is proven research in other areas that suggests that certain types of counselling can make problems worse or that counselling is poor in quality because of who is doing the counselling. Certainly because there are very few, counsellors trained in this particular area there is a huge question mark as to whether counsellors that people are being referred actually have the skills and the knowledge to be able to deal with the issue.

In addition to this, I do know of two interesting studies from Sweden. One drew the conclusion that counselling of women who had high levels of anxiety and had been selected for it (but hadn't necessarily asked for an ELCS) after counselling about their anxiety over childbirth, were then in fact MORE LIKELY to have an ELCS in part as this wasn't an option that they had considered before. The other was a study about fear and birth outcomes; this study concluded that even after counselling, women with severe levels of anxiety were significantly more likely to have adverse outcomes from a VB if they choose that (much higher rates of instrumental and EMCS) and were much, much more likely to have an ELCS than the control group.

So I personally DO have very serious questions about the validity of counselling and NICE thought it was something worth also commenting on, though they did recommend counselling in the absence of data (I also note that they did not specify what type of counselling either, again because they haven't a scooby doo what works).

Counselling in way it is explained in the guidance doesn't necessarily even mean 'counselling' - its not entirely clear or explicit. It also could be interpreted, (and it is by some doctors) as being as basic as merely counselling the patient on the risks involved in the patients' individual circumstances and nothing more.

This does leave this issue of counselling as one that is somewhat contentious. People have jumped on it as 'being the solution' when actually it is nothing of the kind and there just isn't any evidence to actually support its use.

[Sioda]

Em, boob jobs? Nose jobs? Liposuction? Facelifts? Laser eye surgery? And I didn't see Jordan being packed off to have her ishoos sorted out on a therapists couch before going under the knife.

[Ushy]

redplastic you say having surgery for non medical issues is not normally considered acceptable but Sioda is right.

AND there is no guarantee that a planned vaginal birth won't turn into a medical emergency. If you plan a vaginal birth you might have a spontaneous uncomplicated birth but particularly if you are older or the baby is large or it's your first baby, you have a high possibility of it ending in an instrumental delivery, an EMCS or if you are really unlucky a failed forceps followed by EMCS.

So requesting a caesarean is not a psychological problem, it is a decision and it is extraordinarily misogynist that the NHS attempts to deprive women of the opportunity of making an informed choice - particularly as it is the choice a lot of very informed doctors make for themselves.

[Jessepinkman]

I have to say the 'as long as you are both alive' comes from me having my son, nothing else mattered to me apart from that he was alive. I wasn't ripped to shreds or anything, but it was the only thing that mattered to me.

Sorry if it caused offence.

[Jessepinkman]

And I may have misread, or only read what I wanted to, but I think the op says that going into to hospitals gives her stress. Why have a procedure that keeps you in hospital longer then?

[RedToothBrush]

Why have a procedure that keeps you in hospital longer then?

You are looking only at time in hospital associated with the actual birth. And yes its true that length of stay in hospital is longer for an ELCS than a VB (but its shorter than an EMCS).

And the real length of time you end up in hospital as a result of childbirth is more like how long is a piece of string. Truthfully because you don't know how your birth is going to go, you don't know until after the birth how much it is going to involve hospital visits AFTER THE FACT. If you do end up with a complicated birth (of any kind from any method of delivery), it could involve numerous visits to hospitals some time after birth from any resulting birth injuries.

If you happen to be in a group that is more at risk from birth injuries then considering it as a possibility and whether you can cope with that, in a worse case scenario, is a valid consideration.

[cakebaby]

So, working through my thought processes, I think it's the fear of the unknown that is an issue for me.

When I consider this against the background facts of my age (40 at edd), 1st child, I'm likely to be induced and as associated, well documented correlation with instrument delivery and emcs, I'm still reaching the conclusion that elcs in MY case could be the way to go.

I suppose that a 'medical reason' is defined as breech position or an existing diagnosed condition that mum has. Shame it's not extended to preventing trauma to mum or baby, physical or psychological, when on the balance of probabilities, it is more likely that not to be the end result. Particularly when this is backed up by their own statistics.

I had no idea this post would attract so many responses and I thank you all, it's turning out to be far more interesting and enlightening than I could have imagined!

[LaVolcan]

You don't know how an ELCS would affect you either, so it's still something of an unknown.

You can say no to induction. Don't forget it's an offer, even if it's usually couched in language as 'you've got to do...' or 'we'll book you in for induction at..' If it got to that stage and they do offer induction you could ask them why they consider it necessary? You could opt for monitoring instead.

[janey1234]

Yes you can say no to induction, but once you're past 35, and indeed 40, the risks associated with going over term to the baby increase significantly. Placentas tend to deteriorate more quickly than they do in under 35's and the risk of stillbirth is more than double. This is the reason I wouldn't want to wait and go over term, let alone go over by over a week and then refuse induction.

[ByTheWay1]

do remember though that you can deliver early - I was booked in for a "probable breech" CS at 3 weeks before due date ( DD1 was breech and 2 weeks early) but DD2 decided to turn and come a month early and was a VBAC instead - in the middle of the night....

so no guarantees you get to the ELCS anyhow.... PLEASE - all of you with ELCS plans - be prepared for the fact that a VB may have to happen - or it can be something of a shock!

[LaVolcan]

I take her point about being worried about stillbirth, but I felt it was still worth a reminder that treatment is offered, and IMO should be tailored to the individual, and not just because that's the hospital protocol.

[Phineyj]

I had my first baby recently at 40 by EMCS, having done everything I could to avoid it including using an independent midwife. However, I must say the CS was straightforward and I have recovered quickly, with none of the damage friends have had from vaginal birth. Mind you I had to be very assertive once transfererred to hospital as they wanted to mess about with ventouse etc first. 4 out of 8 of the women in my NCT group had EMCS including me. All are aged mid thirties to 40. Nearly all were induced -- I think I was the only one 'allowed' to wait for labour to start by itself.

CS is MUCH more common than you'd think looking at NHS literature, it's just they like you not to opt for it directly for the reasons other posters have explained.

If you want an ELCS you need to find a sympathetic consultant and keep on at them. Consider taking someone else with you to the appointments if you think you might get upset and fail to make your case clearly. Although crying can be helpful sometimes!

As regards the antenatal care, you are unlikely to get the sort of support you are after unless you pay for it (independent midwife). GPs can be helpful in finding your way through the maze. You need to start thinking of the NHS as a sort of factory; even if individuals can be nice and helpful you rarely see the same one twice. If money is tight start building your support network, educate your partner if you have one, join NCT etc.

Knowledge is power!

[LaVolcan]

cakebaby talks about 'likely to be induced' and the point I was trying to make was, which is backed up by Phineyj is that she can say 'no thanks'. That could be part of her plan - if they think this baby ought to come out now, then go straight for CS and no messing with induction/ventouse etc.

[cakebaby]

Yes, Janey is right to point out stillbirth rate increasing in someone my age. It has been another of my considerations, but got lost between brain & keyboard.

LaVolcan also rightly points out that I can refuse certain interventions. I seem to be able to refuse or state a negative preference over many things, but not able to make a positive choice over others. Certainly feels like I'm being backed into a corner!

The thing is that the data indicates I could very likely end up being wheeled off for an emcs after a struggle by my 'aged' body, causing god knows what trauma to DC & me. I know elcs is not an easy option but if cs a likely outcome, is it not preferable for an el rather than am em? The data certainly suggests it is, but the professionals seem to be in cost cutting denial. If the short term costs are so similar, as NICE suggest, isn't it a shame we can't just pay the difference! (I know it's not that simple!)

[RedToothBrush]

You can say no to induction. Don't forget it's an offer, even if it's usually couched in language as 'you've got to do...' or 'we'll book you in for induction at..'

See, in my personal situation, this is actually one thing that also adds to the fact of not wanting to go down that route, simply because I don't want to be having to argue the toss or be assertive at that stage. I don't want to have to deal with the emotional blackmail trip. If staff are doing that, they have already completely lost my confidence and I would be severely freaking out.

As for going into labour early. Yes it is also a risk, and that would be something I would want to make sure was discussed so that if that happened an ELCS would still an option ahead of schedule, unless in the extremely unlikely event that labour progressed very quickly (and given that first time mothers and in particular those over 35s tend to have longer labour, this is perhaps less of a worry than if you are younger; thats not to say it isn't a risk).

IMO should be tailored to the individual, and not just because that's the hospital protocol.

Well yes it should. But then there the reality is that a lot of hospitals are extremely difficult about being flexible with ANY hospital policy and induction dates or 'no maternal request' policies despite the NICE guidance do seem to particular sticking points. Basically cos they are fuckwits. Which leaves women having to use the system in whatever way they can.

If the system wasn't as rigid and wasn't so factory production line I rather suspect you would have some women also being a little more flexible in their approach too.

All this 'will not allow', 'you've got to' or none discussive "we'll book you" language are all things that remove control from women. And women want to feel as much in control, when and where they can. So it leads to a clash of that straight away.

[rainrainandmorerain]

This is entirely anecdotal - but I felt and feel I would be a fool to ignore it.

I was/am an older mum (39 with 1st dc) and I became very aware when ttc that almost without exception, the late 30s/early 40s mums I knew seemed to have very long and difficult labours, before mostly emcs's or very rough instrumental births with attendant damage.

For the women I knew under 30 having 1st time babies, they generally had an easier time of of (shorter labours, far fewer emcs's).

I don't think late 30s/early 40s is an optimal time to have a 1st dc, although that's sometimes the way life turns out. It seems reasonable for maternal age to be taken into account when thinking about birth. Other physical factors sometimes are (eg bmi). It's another consequence of 'one size fits all' care that concerns about age are brushed off.

[working9while5]

Okay, been there and done this... and then some.
I haunted these boards looking for information on the relative merits and demerits of each possible "option" but there are serious issues with this whole topic.

1. Your issue is primarily anxiety. It is not that a terrible birth is likely, nor is it likely you will lose control in labour etc. It is that you worry a terribly birth is likely and that you will lose control in labour.
   
   
2. Having said that, unfortunately there are increasing stories of women having suffered the things you fear which maintain and increase your anxiety. These are not in your head.
   
   
3. The NHS is notoriously poor at discussing this without having cost at the top of their considerations. ELCS is a preferred option for some women and it is not because they have "ishoos", it's because having weighed up all options and considered relative risks, they feel that the ones they are most comfortable with relate to ELCS. However on the NHS it will always be something you are dissuaded from pursuing and although there are valid reasons for not undergoing CS from a risk point of view, these will not be communicated objectively in a system which is struggling with cost reduction.
   
   
4. If you do decide to go down the NHS route for ELCS, be prepared to be told that you risk internal injury, your baby risks serious breathing difficulties, you may be left infertile etc. This will not help your anxiety. These "risks" were communicated to me again and again even though I didn't want an ELCS and never requested one. I simply wanted to consider options for induction. Unfortunately this "information" proved very unhelpful when my baby presented as breech up to 38 weeks and I had this swimming around in my head .
   
   
5. Be prepared that even "rational" anxieties about birth (e.g. fearing that you won't have 1:1 care in labour etc) will be perceived to be "irrational" and that when you are labelled "anxious" at least some professionals may change the way they treat you. They shouldn't, but some will sadly.
   
   
6. Whatever happens and whatever you "decide", there is a huge amount of uncertainty in birth. This is a huge and horrific realisation that most women come to through the process of giving birth. When you have been trying for a long time and/or have issues with loss and grief to resolve, birth can really bring these out. If you were sent for CBT about your desire for ELCS, they would almost definitely be telling you that you need to learn to "tolerate uncertainty". This may seem far too huge to grasp at this point in time when you are actually dealing with something that is precious and important to your life beyond anything else you have ever experienced.
   
   
7. I found this after birth and I wish, wish, wish I had found it before I ever approached the NHS about my anxieties and that I had had it during pregnancy
   
   
8. Finally, if you can, please try to avoid discussing this issue on boards like these. It nearly drove me mad with fear. Statistics about what anxiety does to labour etc were terrifying. By the time I gave birth I was in an absolutely acute state of ongoing anxiety that was crippling. I had a short labour and a beautiful waterbirth managed by very caring, person centred NHS midwives within a hospital setting. Is the plural of anecdote data? No... but similarly all the "evidence" about what is best for you is not based on study of YOU - your background factors, your personality, your anxiety. There is a Buddist saying which is "if there are two witnesses, trust the principal one". Basically you are the best judge of what is going to be right for you, the "experts" can share broad statistical probabilities which can help you come to a decision but only you will be able to work out a course of action.... and even then, your baby and circumstance will trump it.
   
   Good luck x

[RedToothBrush]

8) Finally, if you can, please try to avoid discussing this issue on boards like these.
It might distress some, but it might also HELP others. As you said, yourself everyone is different. Knowledge able and out there for those who choose to access it, is vital. It is your choice to get involved in discussions. If you know you are anxious, you probably know if looking at these boards is going to help or hinder you too. No one should be denied being able to discuss this if they feel it should help.

Personally I do feel that this is a subject that NEEDS to be discussed EVEN IF it upsets people, purely from the aspect of getting the message out there to people who can can the system rather than allow it to continue in the way that is; which isn't to benefit of ANY women who is experiencing anxiety.

If we avoid discussing the subject, we merely sweep it under the carpet and pretend it isn't happening and pretend that real concerns over real risks are not there and that they are very often being rose tinted a very deliberate way, which is hugely political rather than designed to actually help women.

If information was being passed on and discussed by the NHS in a way that was fair, transparent and consistant across the country, we probably wouldn't need threads like this. And for me, that perhaps is the greatest point of all.

Don't shoot the messager who delivers the message, shoot the one who creates the contents of the message.

[cakebaby]

Working, helpful post thank you, until the opening sentence of point 8. Forums like this are a great place to discuss such issues IMHO. No one HAS to engage with them and I imagine many ladies find them extremely useful. I'm glad you achieved the birth you wanted, let's hope all of us do!

[janey1234]

cakebaby - btw - wasn't trying to scare you by pointing out the stillbirth rates, as a 38 year old first time mother myself it's something I'm having to think about too, hence I'm pushing for elcs. If I could choose a VB with no lasting complications for me or the baby, that is of course what I'd choose. But I think the chances of that happening are less than they would have been 15 years ago...

[Phineyj]

One very helpful thing my independent midwife did re induction was to lend me two guides to induction, one for laypeople and one for professionals - the publisher was The Campaign for Birth - something like that. The guidance on induction and rates of stillbirth turned out to be much less clear cut than I'd thought.

Also the NHS method of estimating due dates seems very unreliable. I was given two different ones and they absolutely refused to take into account that I knew the date of conception (IVF)-- mad! So saying you are overdue and 'must' have an induction may not be based on proper data.

Remember you have to give informed consent to any procedure and that includes induction. You can choose monitoring instead.

Although my birth didn't go exactly to plan, I felt much better for knowing that I'd looked into the pros and cons thoroughly and could give informed consent.

Someone mentioned upthread about taking a private midwife into hospital -- unfortunately as they can't get insurance they can't look after you in hospital although they may be allowed there as a birth supporter.