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

But the NHS is supposed to be providing evidence based care, and the evidence is not supportive of your view that planned c/s provides optimal outcomes for healthy women. In any case, this is a moot point as the NICE guidelines don't require a woman to provide independent evidence of this type, only to state that they wish to have a c/s.

I think you missed a whole load of points I made about whether women are even going to have subsequent pregnancies...

I think you have missed a whole load of points that NICE made when they made the decision to say that women should be allowed a CS on request. You know evidence based stuff.

Including evidence that birth can led to trauma; hence why many women who have given birth before are asking for a CS in the first place.

Once again, I'll repeat myself as you clearly missed the point that it doesn't have to be just about preventing physical injuries; it can also be able mental ones - even in women who have no history at all of such problems.

To be perfectly honest though Minifingers, I think you have made up your mind and don't wish to listen or have an open minded discussion about why a small number of specific groups may be more inclined to ask for a CS, even if they are generally labelled as low risk.

You are conveniently, continuing to miss out the key point about medicine needing to be individualised and tailored to each and every person with their full input and consideration of their feelings and priorities rather than generalised and imposed.

That is the debate. If failure to offer an on demand C section for a second birth after a first difficult birth - is that good from an NHS resources point of view given the fewer children born in England the better and our lack of money as a nation?

Anyway as I said above just go to a different hospital or follow the doctors' advice to feign some kind of mental problem.

"you have missed a whole load of points that NICE made when they made the decision to say that women should be allowed a CS on request. You know evidence based stuff".

So what does this mea?n: "In any case, this is a moot point as the NICE guidelines don't require a woman to provide independent evidence of this type, only to state that they wish to have a c/s." I'll tell you - it says that NICE guidelines are that planned c/s should be consented to if it's a woman's preference. That's it.

Including evidence that birth can led to trauma; hence why many women who have given birth before are asking for a CS in the first place.

"To be perfectly honest though Minifingers, I think you have made up your mind"

Yes - I have made up my mind. I have said good luck to the OP's sister in obtaining a planned c/s on the NHS as this is her preferred mode of birth. If you read my earlier post you will see that I have said this. Wishing her luck with this doesn't necessitate agreeing that planned c/s is the safest mode of birth for low risk mothers.

"You are conveniently, continuing to miss out the key point about medicine needing to be individualised and tailored to each and every person with their full input and consideration of their feelings and priorities rather than generalised and imposed."

Of course it should be. But we are talking about the NHS where there is a requirement to secure the best health outcomes for the largest number of people for the money that is available. This applies in relation to maternity care too. This is the case now and will increasingly be the case in the future. Hence I would recommend the OP's sister do what I did when I couldn't get the type of maternity care I wanted from the NHS: I paid for it myself. I had to borrow the money to do so and it took me years to pay off. But then it took me years to pay off my car loan, and I did that too. Obviously my birth was much more important than my car....... I can't get my head around well-paid professional people with access to funds to pay for private maternity care working themselves into a state of despair over this issue on principle because they don't feel they should have to put their hands in their pockets. The OP's sister should try to work the system as suggested by Xenia, and if this doesn't work, pay herself. Job done.

I would second Ushy to say that the way to get exemption to the policy is to put all concerns formally (in writing & sent recorded delivery) to the consultant, hospital risk manager, supervisor of midwives and chief exec of the hospital, with a copy to your MP.

Do let us know how your sister gets on

Just also wanted to say brava! to Red - I agree!

I think the point is that women shouldn't have to cast aspersions on their own mental health in order to be able to make choices about what happens to their bodies - they should be trusted to make the right decision for themselves and their babies. For most, that will be a planned vaginal birth, and for a few it will be an ELCS.

And, they should be able to get this care on the NHS. Otherwise, it is grossly unfair to women who aren't able to pay for private maternity care, and therefore don't have the "luxury" of choice. So I'm glad that women who may be able to pay privately are instead putting pressure on NHS hospitals to allow them to exercise choice, because it makes it easier for the rest of us to do the same, including women who have no choice but to use NHS services.

Mini- a caesarean costs less than £85 more than a natural birth taking into account short and long term costs - this is based on NICE calculations and is quoted in their guidance.

However, NICE does not take into account litigation and planned caesarean never ever gives rise to brain damage claims. These amount to over a billion in the last ten years. If you factor this in, a caesarean is no dearer than a natural birth and may actually be marginally cheaper.

The cost arguments against planned caesarean are baseless.

I agree Ushy and floating the back stop argument about cost (ie: all other arguments are exhausted or defeated) is nothing short of divisive as a result.

However I had mistakenly thought the NICE guidance didn't take account of the long term cost of VBs which effectively come out of budgets other than maternity (mental health/colo-rectal/urology are the major areas that spring to mind).

The cost argument is the one thrown out when all else fails...

Woman is capable and educated enough to make her own decision. Check.
Woman is in an acceptable risk group to be considered to have a valid argument. Check.
Woman has successfully argued the case that on balance her decision isn't selfish and might well be in the best interest of her child as well as her. Check

Best to throw out the guilt trip that they are depriving other women of their care and we can't possibly afford to treat their request with the respect it deserves.

Except of course, the evidence that NICE gives, is that this is bullshit and categorically states that ELCS should not be refused on the grounds of cost alone.

NICE, that organisation that has been widely slammed for stopping the use of certain drugs and procedures on the grounds of cost.

Its frustrating and boring as hell.

I agree, all the more frustrating when other women are arguing against it. I strongly feel everyone should pull together to fight for women to get the birth of their choice be it home birth, water birth, VB with epidural, CS or anything else.

If we're campaigning for people to have their treatment of choice regardless of cost then we should surely focus on more urgent matters like getting lifesaving cancer drugs and treatments made available regardless of cost or where you live.

"NICE, that organisation that has been widely slammed for stopping the use of certain drugs and procedures on the grounds of cost.

Its frustrating and boring as hell."

What planet are you on? There is a finite amount of money to be spent on the NHS and someone has to prioritise how it is spent. At what cost elective sections for anyone who wants them? NICU wards and equipment? Cancer drugs? Reconstructive plastic surgery for burns victims?

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.

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.

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.

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.

I'm pleased she had a successful delivery!

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.

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.

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.

ooops missed update!!

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.

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.

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.

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

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.