Woman's Hour Childbirth special on now - with Kirstie Allsop

[VinegarDrinker]

Not sure if this is being discussed on any other threads?

[LaVolcan]

But midwives don't do caesarean sections, la volcan

Did I say they did? I was commenting on Cameron reneging on a promise to improve staffing of maternity units. As far as I am aware he didn't make any promises to improve consultant cover, but that is also a problem in some units, where it would be best to avoid an EMCS in the evening or at the weekend.

[Ushy]

But midwives don't do caesarean sections, la volcan

Whether elective caesareans are better for the mother depends on what she wants. Red is right - coercing people will never result in better outcomes and women are regularly coerced into vaginal births they do not want. (Read the thread about the Mner blowing her £13000 life savings on private care to avoid another vaginal birth).

However, caesareans pose fewer serious risks for babies ; Slightly more minor respiratory distress with electives but much less serious morbidity and mortality. There was a good study that actually quantified the risks here:

www.ncbi.nlm.nih.gov/pubmed/17011400

What is wrong with a woman wanting to choose the safest mode of delivery for her baby? Why should it not be her choice?

Resources don't come into it. The difference between caesarean and vaginal - taking into account the long term costs was estimated by NICE as only £84.00 BUT that excludes litigation costs. Since you almost never get brain damage or cerebral palsy caused by elective caesarean, the legal claims more than wipe out that small difference.

So basically, we should just be letting women make their own choice once they understand the risks of both modes of delivery.

[LaVolcan]

RedToothBrush: You should be addressing your complaints to your MP for a starter, but maybe you have done?
Or join a pressure group to support the NHS.

Remember that Cameron promised 3000 more midwives
blogs.channel4.com/factcheck/painful-contractions-cameron-breaks-his-promise-on-midwives - a promise which he has quietly reneged on since becoming PM.

[Minifingers]

Red - you need to learn the difference between the words 'explaining' and 'justifying'.

The NHS is in a state of financial crisis, and this is set to continue.

Even a change of government won't make a difference in terms of future priorities for the NHS.

[RedToothBrush]

Sorry, but anyone who justifies coercion should get that treatment.

You can not cut corners in care without it doing damage and harming people. The idea that you can is utterly absurd. And the truth is you end up paying for it elsewhere further down the line anyway. You don't get something cheaper because you cut corners. The greatest efficiency saving is to treat properly in the first fucking place.

If we can not afford things, then thats what should people should be told. They should not be coerced into anything. The idea that we should coercise because of cost is an appalling thing to suggest and say that we should be happy with.

At least that way it creates a situation of transparency and people can actually then be held accountable for, rather than this things of lying and saying this is the best treatment for you, you just have to wise up and agree to it and consent to something you are not at all happy with. This attitude of coercision destroys all confidence and trust in the system that you will be able to make an informed choice that is in your best interests and properly considers your needs.

If you don't actually get that, and you work in healthcare, then we really are already so fucked that the NHS is beyond all repair anyway. We might as well all sling women under the bus along with the elderly and save some precious money that way. Afterall its in their best interest to save their pain and dignity later one.

[Minifingers]

And I'm wondering what YOU are doing about the situation?

Are you part of any activist groups arguing for a massive increase in funding for the NHS?

[Minifingers]

Redtoothbrush - I would LOVE for the NHS to be given enough money so we could all have optimal care. But you know what? IT'S NOT GOING TO HAPPEN.

In fact not only is it not going to happen, but there is going to be more and more rationing - it's inevitable as we have an ageing population affected by very high levels of obesity, and a huge host of sophisticated and expensive new treatments for cancers and complex conditions which the public will expect the NHS to provide.

There will be more and more 'trimming' of services.

Please don't think by saying this I'm in favour of it. I'm frightened for the future of healthcare in the UK.

[LaVolcan]

That's very harsh RedToothBrush - trying to lay the blame for the problems of the NHS at minifingers door.

No one was saying coercion was good and I doubt if anyone thinks it.

I think that anyone who wants to deviate from the standard package that their hospital offers runs the risk of meeting with some sort of 'coercion'.

[RedToothBrush]

And you are saying coercision is good? And making excuses for it on the basis of cost?

Utterly appalling. Lets let old people sit in their shit because we can't manage our resources. We are a wealthy nation. We CAN afford this.

Stop justifying the unjustifable.

You are the reason why healthcare is in the state its in. Because you are accepting it instead of saying this isn't acceptable. You allow those running the services to get away with it and carry on, rather than tackle the issues.

[Minifingers]

"to make the suggestion of coercing women is bad, in all things but healthcare"

Sadly we are all 'coerced' into choices we'd not usually make by a lack of funding in the NHS and across public services.

My elderly disabled FIL is bedridden and is currently being 'coerced' into staying in bed by a lack of funding for physiotherapy which would help him regain some of his mobility, for example.

Not offering surgical birth on demand across the NHS isn't misogynistic, really it isn't. It IS about the fact that hospitals can't safely accommodate higher levels of surgical birth than they are currently doing without an increase in funding. And it's hard to argue that any increase in funding should go towards expanding elective surgery for healthy women when women with complex health conditions (including tokophobia) are experiencing higher levels of mortality and severe morbidity because of a lack of consultant cover and postnatal care.

Women who have significant mental health problems relating to childbirth should already have access to surgical birth if this is what they need. If they are not being diagnosed and put on the right care pathway then this issue needs addressing, but that is not what's being discussed here is it?

[Minifingers]

Red toothbrush - I absolutely agree that women should have the choice of a planned c/s, just as they should have the choice to have gastric band surgery if they feel they need it for a decent quality of life. The question is whether this choice should be provided by the NHS where women and babies are already being put at risk because of an over-stretched surgical service and a lack of midwives.

[RedToothBrush]

VinegarDrinker Fri 16-Aug-13 05:41:54
I don't think it's helpful to conflate the issues of resource management (FWIW I'm not aware of a national Consultant shortage, the opposite if anything, though I've certainly come across units which are very understaffed from a midwifery POV) with the fundamental (feminist?) question of whether an individual woman should be able to make an informed choice about her mode of delivery.

Yes, all the things you have mentioned are hugely important, and reducing em CS rates is an admirable goal, but it is patronising in the extreme to assume that all women strive for a VB - even if they could be assured it would be complication-free.


BINGO!

As for coercion of women. Really?

Lets coerce women to stay home, do all the housework etc etc etc. Lets ignore the implications of coercing women who do not want to do what they are being coerced into doing...

Fuck that!

Am I living in some parallel dimension were it is unacceptable to make the suggestion of coercing women is bad, in all things but healthcare because of this utterly misguided and disgusting view that women are incapable of making an educated decision for themselves and someone else has to somehow tell them what to do.

I am utterly horrified by that comment and the implications of it.

[Minifingers]

"but it is patronising in the extreme to assume that all women strive for a VB"

I don't think I've implied that all women want a vaginal birth have I?

"FWIW I'm not aware of a national Consultant shortage"

here

"A shortage of obstetricians and gynaecologists is putting women and babies' health at risk, a report says.
The Royal College of Obstetricians and Gynaecologists called for another 1,000 consultants on top of the 1,500 working currently to provide a safe service."

"Why is it commonplace to compare the worst case scenario of CS complications with the best of VB?"

Well I don't think it is. All sensible people acknowledge that the very high rate of interventions in attempted vaginal deliveries in the UK results in the picture not being straightforward. But there is still no doubt at all of this: that the majority of vaginal deliveries to healthy women are NOT complicated by serious perineal damage, and result in shorter recovery times than for c/s. This is massively the case for healthy mums who are having a second and subsequent baby. Less so for first time mums who are more likely to have complications.

"The question is whether they should be forced to try for one, or allowed an informed choice."

That's a bit of a distorted way of looking at it. It's not the NHS which will force the mother to try for a normal birth. It's her own body! The question is whether the NHS should offer the option of an operative birth. For me this is the nub of the problem. Across the NHS there are many cases where people are not able to have their preferred pattern of care - not just in relation to surgery, but in relation to drug treatments and other therapies. For example, some very overweight people may feel very strongly that they need to have gastric band surgery in order to have an acceptable quality of life. But perhaps their trust is limiting this type of surgery to overweight people with diabetes, as there is a financial imperative to ration surgery and the commissioners of services in this particular trust feel that they need to focus on ensuring the best health outcomes for the largest number of patients, and in this instance it's offering a treatment which will reduce the likelihood of severe complications further down the line with diabetes. They are doing the same with c-sections for healthy women - rationing to get the best bang for their buck in obstetrics.

I don't know what the answer is but I don't want to see high risk women dying while waiting to get into theatre because there has been a big increase in planned c/s with no consequent increase in surgical staffing. I don't want postnatal wards to be any worse places to be than they already are, and they will be if there is a significant increase in women having operative births. Because who are the women who get fucked over when resources are short? I can tell you (and I have seen this for myself in hospital) - it'll be the young ones, the poor ones, the ones who don't speak English and are unlikely to make a complaint. No - I don't believe in choice at any price - not if it ends up putting vulnerable women and babies at increased risk of neglect in hospital.

[CommanderShepard]

I think that's fair. There's still a question mark over whether I did have pre-eclampsia (one high BP reading only but consistent ++ on PCR test) and if it happened again I might question a little further but I definitely wouldn't have been happy with automatic induction at 40+x because of policy and wouldn't consent to a sweep in a month of Sundays.

[LaVolcan]

I wasn't thinking of inductions for pre-eclampsia, but more of the routine inductions because a date has been reached on the calendar 40 +10,12,14 depending on where you live. Personally I think 'we'll book you in for induction on....' could be seen as coercion, whereas, 'you are 40 + [some days], your choices are induction or monitoring, what do you think?' isn't.

[CommanderShepard]

I think coercion and inductions is right - I really didn't get given the option to refuse but on the other hand they'd just diagnosed me with pre-eclampsia and I was 40 weeks.

DD was EMCS following failed forceps and ventouse but I have to say, the recovery was fantastic and I was properly up and about before a friend whose daughter was born vaginally 4 weeks before mine.

Do I think the induction led to the EMCS? Absolutely. Do I wish I'd had a vaginal birth? Absolutely not (though I would go for a VBAC next time, all being well). I was fine and DD's APGARs were 10, 10, 10. She may not have been as healthy had I not had a c-section.

C-sections are not, in any way, an easy option but neither are they the work of the devil. DH wouldn't be alive if they didn't exist, for example. There's a balance and the NCT haven't achieved it yet, although we did have a c-section role play with playmobil in our class and that was tremendously helpful, complete with suggestions of how you can take some control.

Kirstie Allsopp, meanwhile, does no-one any favours. I've completely lost track of what she actually thinks other than 'DOWN WITH NCT'.

[LaVolcan]

But we don't coerce/force women to do other things that are good for their baby

I get the impression that a lot of coercion is going on e.g routine bookings for induction - justified on the grounds that they are only thinking of the baby.

[VinegarDrinker]

Some women, despite reassurance and support, still don't want to try for a VB. The question is whether they should be forced to try for one, or allowed an informed choice.

[VinegarDrinker]

I'd refute "much". Anyway, absolutely women who want a VB should be supported to have one (in the ways discussed upthread). But we don't coerce/force women to do other things that are good for their baby either before or after birth (eg losing weight or stopping smoking before TTC), we allow them the autonomy to make informed decisions and trust them to do so. And importantly, the fetus has no rights in law until born.

[Bowednotbroken]

In an ideal world, if everything else was equal, a vaginal birth is much better for the baby than a planned caesarean birth. The contractions stimulate the baby's central nervous system so that s/he is much readier to breathe, the squeezing through the vagina encourages some fluid from the top bit of the lungs and vaginal bacteria help to prep the baby for healthy living too. That is NOT to say that this means anyone planning a caesarean birth is clearly not caring about their baby - but surely it does mean that if there was anything that could be done to reassure women so they felt happy and confident to birth vaginally it should be tried at least?

[VinegarDrinker]

I don't think it's helpful to conflate the issues of resource management (FWIW I'm not aware of a national Consultant shortage, the opposite if anything, though I've certainly come across units which are very understaffed from a midwifery POV) with the fundamental (feminist?) question of whether an individual woman should be able to make an informed choice about her mode of delivery.

Yes, all the things you have mentioned are hugely important, and reducing em CS rates is an admirable goal, but it is patronising in the extreme to assume that all women strive for a VB - even if they could be assured it would be complication-free.

[Minifingers]

And by the way - I agree that if you take women in obstetric settings, them the sort of care in labour which leads to high levels of failure to progress, have high induction and augmentation rates, high rates of CEFM on low risk mothers, heavy use of opioids and routine use of epidural (both linked to higher incidence of fetal distress in labour) you ARE going to have very high rates of emergency c/s. In a system where this is the only alternative to a planned c/s, then outcomes are never going to look good for planned v/b. Of course not - because women having v/b's in these settings are getting sub-optimal care leading to very high rates of birth complications and emergency surgery.

For me the logical response to this is not: well lets tell women that planned v/b is dangerous and give everyone the option of planned c/s instead. The response is to change the way maternity care is delivered in order to reduce the number of women experiencing complications in birth leading to emergency surgery. And luckily for us in our cash strapped NHS the patterns of care associated with lower rates of complications in labour namely giving birth outside of obstetric settings, also happen to be quite cheap.

[Minifingers]

Well lots of issues there, mostly stemming from women not being treated as individuals, and a lack of continuity of care. Many of these problems would be resolved with greater access to case loading midwifery care, which would empower women to obtain the births they want.

Re: rates of unplanned c/s - for healthy, low risk mothers this obviously varies hugely according to place of birth, age and parity. However,according to the Place of Birth study 2011, more than two thirds of healthy first time mums giving birth in low-tech settings (birth centres and home births) had normal births. When you look at both first time mums and mums having subsequent babies, over three quarters of healthy women who planned births in midwife led units had completely normal labours (ie, no episiotomy, no syntocinon, no forceps, no c/s etc)


Now do you, or do you not acknowledge the evidence that EMCS and operative VBs are worse for both mothers and babies in terms of outcomes than ELCS?

"Now do you, or do you not acknowledge the evidence that EMCS and operative VBs are worse for both mothers and babies in terms of outcomes than ELCS?"

Outcomes for ELCS are better for mothers than EMCS, not necessarily better for babies. Assisted deliveries it's difficult to make any sort of comparison as they cover a huge spectrum in terms of difficulty. Most women who have assisted deliveries in the UK have uncomplicated ventouse births and have no further problems following on. The majority of forceps births are low cavity and don't result in any ongoing problems . I'll grant that an uncomplicated EMCS is generally going to leave a mother and baby in much better shape than a complicated mid-cavity delivery involving rotational forceps, but then these are quite rare these days. And of course it also depends on whether you're willing to factor in complications in future pregnancies and births, which is always an issue with c/s for mothers who want more babies.

"The main problem being that there is still a situation where they haven't the slightly clue who is low risk and high risk until after the birth"

They know enough to identify a group of women who can plan a birth outside of an obstetric setting who can reasonably expect to have the majority chance of a normal delivery. They have been doing this for years and the outcomes for these women and their babies as a group are very good.

[RedToothBrush]

BTW, you might want to start with a WHO report on the subject of women opting for a CS without clinical need as an interesting debating point.

This is a very interesting critic of their finding which is incredibly telling.

Please note that straightstatistics.org are not a website which has a political line on being pro-CS or pro-VB. Its a site about getting to the bottom of what figures are showing and how they are being manipulated to show a desired outcome by those presenting the statistics.

[RedToothBrush]

Do you know how hard it is to get diagnosed as tokophobic...? Thats part of the point actually. A MASSIVE part. It was because there is so much disagreement about what constitutes an 'acceptable' level of anxiety. The NICE guidelines were written with this in mind because of the widespread inconsistances in care across the country in relation to this subject. I'm sure this has been stated explicitly in either the document or the press releases associated with it. I'll do my best to find it for you.

Sadly their aim to stop this has not progressed in any shape or form whatsoever. Especially since so many professionals refuse to even acknowledge its existence.

Good luck trying to get diagnosed if you have issues of this nature.

For women who are over 35 there are a great many hospitals that have rates of well over 30% ending up with a CS (thats a combination of EMCS and ELCS), about 30% ending up with an operative VB and only 30% achieving a birth without intervention of this nature. This is for all women and does not reflect the fact that first time mothers are even more likely to need intervention. I'll try and find this information sometimes for you too.

Now do you, or do you not acknowledge the evidence that EMCS and operative VBs are worse for both mothers and babies in terms of outcomes than ELCS?

So isn't that enough information alone to start asking questions about 'healthy' mothers? The main problem being that there is still a situation where they haven't the slightly clue who is low risk and high risk until after the birth. Nor do they have much of a clue why older women have a harder time really. Sure they are more likely to have other underlying medical conditions but that does not explain everything. As I've read so many times before "You are classed as low risk until you are classed as risk risk" and thats about as far as they have got in terms of identifying problems.

Perhaps however you'd like to do your own donkey work and read the NICE guidelines at length though instead of relying on me to regurgitate and repeat it back to you.