Refused El LSCS at Chelsea & West - advice please.

[DevonLulu]

My wonderful sister, who is currently 22+5 with first baby has a rational and coherent evidence based reason for requesting an Elective LSCS. Both she and her husband are doctors, and she is making an informed decision which she has painstakingly researched prior to coming to her decision.

She met with her consultant yesterday, who was exemplary in his professionalism, listened to her case and engaged in empathetic and highly respectful discussion with her and her husband. He stated that her evidence was correct, her reasons level headed and rational and that in her case, he agreed with her decision. He would in principle like to support her decision, but in practice, there is a blanket ban on C&W performing Elective LSCS for maternal request.

I do not wish to go into her reasoning for asking, but needless to say, she does not fall into the C&W criteria for El LSCS. He is aware of the NICE guidance, but C&W choose to ignore the guidance.

She has been referred to the Perinatal Mental Health Team, but she is neither Depressed, Anxious nor in need of mental health support. Her argument is rational and evidence based and this fact can not be changed. She is willing to attend but not willing to lie or make up anxiety that does not exist.

Has anyone else been in a similar situation. She is going to write to the Obstetrics department, the Chief Exec and PALS. She will comply with the perinatal Mental heath assessment and her consultant has agreed to see her 10 days after the assessment to re-evaluate the situation.

Does anyone know what else she can do? She feels so strongly about this, not to mention let down be her profession.

Many thanks in advance

[RedToothBrush]

Brilliant news amandine. Hope all goes well.

[amandine07]

Doodle1983
Good luck with your efforts & whatever you decide eventually, the most important thing is being taken seriously & having your fears taken on board and explored thoroughly.
My fingers are crossed for you!

[amandine07]

It's awful that it has to be this way, especially when being refused a CS can cause such psychological anguish & distress.

I was surprised at how smooth the process was and could see that the initial consultant put all the motions in place to get referrals & appointments in place v quickly.

Also he reassured that if I were to go into labour prior to 39 weeks the CS would most definitely be done- I knew this would be the case, but it was still a concern of mine.

The threads here on MN have been so helpful, this has allowed me to relax and really enjoy the last few weeks of my pregnancy- thank you to everyone!
Especially LittleRedToothbrush

[amandine07]

...posted too soon!
Have had nothing but positivity from my local trust- they did all the necessary things, took me seriously, absolutely no fobbing off.

CS now booked for when I am 39 weeks
It felt like such a weight had been lifted from my shoulders!

Initially the baby was breech, then flipped- I was a bit gutted about this...I know it's usually the othe way around, women are desperate to get breech to turn!

Although during my last scan last week, baby was breech again...was hoping this would be my indication for a CS!

I the end I pushed through for a as on maternal request- had to see 2 consultants- who were nothing but lovely, understanding & ready to explore my reasoning.
Plus they referred me to a psychiatrist who was equally professional and we had some totally frank discussion about my fears.

I should add, have never had any contact with mental health services. It felt like a formality though- I was questioned intently by all clinicians I spoke with, however, it seems that luckily my local trust does NOT have a blanket ban on maternal request CS.

The h

[amandine07]

DevonLuLu
Thank you for replying...congratulations to you as auntie and your sister!

I am so pleased that she got the outcome that she so desperately wanted- it's just an awful shame that her local trust had to make it so difficult for her!

Sounds like she had to seek out another trust who did take he concerns seriously & were prepared to do the necessary referrals in a timely fashion.

My experiences so far have been nothing but utterly positive, th

[RedToothBrush]

Trusts also have a duty of care to patients though. If their actions are effectively pushing 'a problem' elsewhere causing considerable stress and anxiety in the process and into another Trust's budget, then they are failing that patient and they aren't taking that duty seriously.

Even if they are under constraints within their budget, if the decisions they are making have serious consequences to patients they are liable for that. There is a case to be made about rights of access to appropriate care that have the potential to, ultimately, if someone choose to fight it, bring a legal case against the Trusts doing that if the issue is recognised by others as being detrimental to patient care. The fact that NICE have said quite clearly that they believe that refusing access to an ELCS could cause psychological damage, only adds weight to the argument.

At this moment in time, I do think that there are a number of Trust's taking the gamble that no one will challenge them in this way. Until someone does and has the finances behind them to do so, they'll get away with it too unfortunately. But then we've seen that be something that has been repeated throughout the NHS for a number of years and the culture does seem to be 'don't take responsibility for something if you can possibly help it'.

[littlemrssleepy]

Chapter 2 of thisexplains in simple terms how finances work in the NHS - although PCTs have now been dissolved and their replacements are Clinical Commissioning Groups (CCGs).

[littlemrssleepy]

Toothbrush. Yes. But that needs to be taken up with the commisioners not with the hospital trust. As a general rule, a hospital can't carry out treatment if it knows it isn't going to get paid for that treatment - it will end up in financial dire straits.

[Doodle1983]

I agree! And to say that drs need to practice delivering twins naturally would not have my backing either !!!

[RedToothBrush]

Except NICE actually recommend that ALL women should be allowed access to an ELCS EVEN IF THERE IS NO MEDICAL INDICATION, because refusing to do one potentially has psychological implications, even if the woman concerned does not have a history of mental health issues.

Everyone seems to be neglecting this aspect of the guidance, quite conveniently because this backs up their ingrained views about CS and women who choose to have them.

The reality is there are women out there who simply due to their age are in a situation when their statistical chances of ending up with a CS is not far off the flip of a coin. Their chances of having a VB without intervention are even lower. Yet they are not allowed to choose the risks; they HAVE to go for a planned VB with all the associated risks for a instrumental vb or an EMCS.

It doesn't make sense to deny women the choice as in any other medical situation where surgical intervention might be a possibility they would be given options. This is the problem and we REALLY need to get away from the idea that its not a legitimate and acceptable request to make.

[littlemrssleepy]

there is a blanket ban on C&W performing Elective LSCS for maternal request.
This is the issue. It's not completley clear from the op, but this line suggests that the reasons, whilst rationale, are based solely on maternal request than any medical reason. I don't know of any Nhs hospital (I was a business mgr for a maternity unit) that would give an elcs based solely on maternal request for one simple reason - their commissioner will have stipulated this and will not pay them for the treatment if it goes ahead. There has to be a medical or psychological reason. Hence why some trusts will try and get round it by referring to psych.

[sj73]

I had C section at C and W. I had twins and chronic SPD and even then, they were really pushy about me having a vaginal birth. The consultant was extremely sniffy and said that it was because of people like myself that trained doctors missed out on the opportunity to learn to deliver twins naturally. I had to do a lot of begging and until they agreed.

I eventually developed pre emclampsia and even then they made a last minute attempt persuade me to them deliver naturally.

Grrrrr.

[Doodle1983]

I am also in a similar position and have been referred to the perinatal mental health unit. Who have refused to see me due to my mental health issues not being sever enough. Fine with me but am currently in talks with my consultant as to whether an ELCS is the way for me. Am meeting a midwife at the hospital with a keen interest in mental health issues just after Xmas to talk though my anxieties. I'm still undecided which is the best option for us but want to feel like I will be given a choice. Fingers crossed x

[RedToothBrush]

Then does that just reflect the demographic of the hospital rather than what the hospital was doing was wrong?

Given that, as you are saying, that there was a significant number of doctors and doctors wives, then you can probably conclude a couple of things from that;

a) they were likely to be above average in education
b) had been given medical advice to say that an ELCS was as safe as a VB (or indeed in their case, perhaps a better option)
c) that they were probably more likely to be older
d) more liable to have smaller families

simply on the basis of the above being a fair reflection of who doctors are and who they marry and what type of lifestyle they have. Not to mention that Chelsea and Westminster... well you hardly have to be an expert to know who can afford to live in the general catchment area for the hospital.

Numerous studies have shown that if you are better educated and more middle class you are more likely to get access to better general healthcare regardless of where you live, simply because you can argue the case better and know of more options. Its one of the reasons that different groups have different life expectancies.

NICE have said that all women who want an ELCS should get access to one regardless of reasoning. They did so on the basis that the risks of a planned ELCS and a planned VB were comparable and the long term costs were comparable.

If anything, you can argue the medical case for an ELCS for first time mothers over 35 on the basis of their chances of having an intervention free VB too. That potentially fits the demographic pretty well.

In terms of funding and reducing CS rates there are two major problems. Hospitals are in part graded on what their CS rate is. The logic behind this, I can not fathom at all and is totally out of keeping with NICE's advice and WHO's current advice.

However given that when the NICE advice was updated in 2011 the head of the NHS at the time was still quoting that WHO recommended a CS rate of about 15% I think we can see where the problem lies. This rate was declared obsolete in 2009 by WHO, who said there was no evidence to support a recommended rate. But we still have the NHS trying to push down rates. I can understand the logic of wanting reduce EMCS due to the risk involved. I can understand trying to prevent defensive practise where women have CS when they don't want one. But in terms of wanted ELCS there isn't a lot to support reducing it, if the women involved are making educated and informed decisions about it.

Put simply we have a situation, where the funding and policy of the NHS is out of step and we instead have the rule of ignorant bigotry that wants to keep women in their place and is happy to enforce their will over women and cause an enormous amount of distress alone the way.

TBH, I was well aware of many of the reasons why C&W has such a high CS rate. I just think its a real shame that every 'observation' or journalistic reporting of this has never really reflected the full reality, and carefully neglects half the story. Instead it just sets the tone for ELCS on maternal request being just for 'posh middle classes who are too lazy/weak to go through labour' and when they get them, says its unacceptable and 'we must do something to stop it' which is appalling. Just by adding the cavet that you are not being judgmental does not mean you get off the hook because you are still not telling the whole story and trying to examine why these women are making this choice.

[mayhew]

I worked as an agency midwife at C&W in 2005. I was amazed at the number of el CS on request which would not have been agreed anywhere else i'd worked. About half the mothers were either doctors or partners of doctors. They were coming from all over as well.

Not a judgement, just an observation. It certainly gave them a high cs rate.

[Nah67]

I think the refusal for elcs is now to do with funding and hospital consultants are being pressurised to reduced them. Considering C&C section rate for last year it is not surprising. As the couple are both doctors they will get what they want, us minions will have to fight much harder for it.

[MyDarlingClementine]

ooops missed update!!

[MyDarlingClementine]

Wasnt there something on the radio about the highest budget of all birth related stuff went to compensation from labour?

Anyway op, as evern you have some amazing advice from Ushy and Redtoothbrush.

[cjdamoo]

Id move anyway I had my 4th at Chelsea and Westminster and it was a hideous experiance. I was bullied into an early induction (37 weeks)as My last baby was on the large side (delivered naturally with no problems i should add). There was blood all over the floor on the ward beside my bed, Then when the induction wasnt going to plan and Id had no sleep for 3 days I had to fight against a section despite baby showing no signs of distress. Staffing issues meant My miswife was looking after 3 women and only just made the birth. Despite an epidural I left 3 hours post partum.

[RedToothBrush]

Well I guess Chelsea and Westminster has had success at reducing its CS rate then... by passing on its responsibilities and shoving the perceived 'problem' somewhere else.

Of course this doesn't show up in their stats and just proves the need for NICE guidelines to be implemented everywhere. (Not forgetting of course that hospitals are still rated and funded in part based on their CS rate).

Appalling behaviour, serious figure fudging and a total disrespect for women.

Glad it all turned out ok in the end for your sister, though the stress and anxiety that the C&W has caused is still completely unacceptable.

[snoozysleeper]

I'm pleased she had a successful delivery!

[DevonLulu]

amandine07 - update

My sister delivered a beautiful baby girl at 39 weeks by El LSCS at another London Hospital having got nowhere with C&W. Having accepted the need to see the perinatal psychiatric team, no appointment was forthcoming in a timely fashion, private care was not financially an option (despite the presumed income level assumed given her profession) and the anxiety, frustration and disappointment which resulted from not being listened to became too much for her. Completely understandably.

Both she and the baby are doing brilliantly, and ably supported by her wonderful husband, she did get the outcome that she wanted in the end. Thank you.

I agree, this thread has been extremely interesting and I am grateful for the input from everyone. I wish you luck with your pregnancy and hope that you experience positivity from the obstetric services.

[amandine07]

Shameless Bump

DevonLuLu
I know that this thread is from 6 months ago & imagine that your sister has probably already given birth...was very interested to know whether she got the ELCS in the end...?

I am in a very similar situation (& profession) to her.
This thread has had a lot of interesting replies.

The only thing that's made me laugh out loud is the assumption somehow that all doctors are "extremely well paid" and therefore could easily stump up the cash for a private ELCS!

That's a debate for another thread entirely...this whole VB vs CS debate should not simply boil down to cost, that is way too simplistic.

DevonLuLu
I really hope that your sister got the outcome that she wanted in the end.

[RedToothBrush]

I'm on the planet that says that NICE isn't shy of saying we can't afford lots of treatment, but says ELCS are one we can afford and shouldn't refuse on the grounds of cost

HTH.

[Porka]

Go back to GP and ask for referral to another hospital. Queen Charlotte's were fine about doing mine, though that was quite a few years ago now.