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

[VinegarDrinker]

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

Point 1. untrue that the NCT course did not cover Csection
Could you make it clear that the NCT class Kirstie attended did discuss CSection in the following lesson as Belinda Phipps made clear and that other interventions such as forceps had been mentioned. Kirstie attended the class and judged the content of the whole course on one eighth of it. Perhaps she would be entitled to say we were biased if she had attended all of it.

Point 2 - safety of c section
There are risks attached to Csections. They are a major operation with the associated risks attached to that. Recovery takes up to six weeks. Would you recommend that someone went to have a stomach operation on the same day that they came home from hospital with their new baby ? If you want a summary of the risks go and have a look at the National Sentenial Audit 2000 on CSections.

In some ways you can say the pain of birth in a csection is taken from the day of birth to the days of the post birth recovery with a csection. it is painful and hard to pick even your baby in the first 24 hours or so. Whereas with vaginal birth even with a small tear you are back on your feet, driving and able to pick up your baby straight away in most cases

C sections are great life savers for mum and baby but not to be taken lightly.

This is why consultants will encourage vaginal births to help preserve the health of mum and baby not to save money.

Point 3

Finally what I don't get is why people who are scared of tearing in vaginal birth then volunteer instead to have their stomach"torn" open in stead for their baby to be born?

Point 3

Finally what I don't get is why people who are scared of tearing in vaginal birth then volunteer instead to have their stomach"torn" open in stead for their baby to be born?

I have never met anyone who has chosen a c-section because they are worried about tearing with a vaginal birth with the exception of women who have had a birth injury that has caused significant and lasting problems. I expect there is probably someone who thinks like that but they must be a tiny minority.

I get annoyed with the rhetoric that suggests women cannot labour - I find that unhelpful, untrue and couched in patriarchy. I also find the suggestion that a planned c-section is to be avoided at all costs sits at odds with evidenced based decision making. Both come from the same idea of women being homogenous and unable to make good decisions which just isn't true.

I meet a lot of women who have just had babies.

BFing so can't type a long reply, but the long post above (sorry, can't remember poster's name) is absolutely classic of the false comparisons made between VB and CS.

Why is it commonplace to compare the worst case scenario of CS complications with the best of VB? Just a cursory glance through the "raggedy bits" threads give a tiny taste of how common it is to have severe and long-lasting trauma due to VB (not all of which are assisted deliveries). Whilst hundreds of MNers who have had straightforward elective CSs wouldn't recognise the description of CS recovery given above.

Now obviously MN is no scientific study, but the oversimplified "CS bad/VB good" argument is just so lazy, divisive and inaccurate.

In my experience (and those of my friends), midwives are unwilling to intervene in a birth unless necessary. This usually results in a natural birth, but in some cases - like mine - women are left to labour for too long. I have a severe prolapse because of this. My consultant admits I was left too long and the prolapse is the result. Now I am having a c section for my next baby and then I will need surgery to fix the prolapse.

And my friends who had c sections recovered more quickly than I did. And they do not have lasting damage like I do.

I know I am just talking anecdotally, but it does annoy me when cs is presented as negative and vb positive.

Redtoothbrush - where is the evidence that denying access to planned c/s for healthy women results in poorer outcomes for birth?

As for 'forcing' hospitals to offer greatly increased access to surgical birth without increasing midwife numbers and consultant cover - yup, great idea. If you actually want to see more maternal deaths.

sigh

If you really want me to start pulling studies out, I will, but you'll have to give me a couple of days to do that as I've got a lot on at the moment.

Its frustrating that you feel the need to ask, because NICE didn't update the guidelines to allow ELCS with the cavet about if a woman still isn't happy after being offered support that she should be referred to someone who will perform a CS.

It is the guidelines, and its available elsewhere. But hey ho... its not something you consider important or a problem therefore they shouldn't do it. Speaks volumes.

"If you really want me to start pulling studies out, I will"

Yes please.

I've not seen any large scale ones done on healthy women with no medical need of c/s.

I'm referring to studies on women without a diagnosis of tokophobia by the way. Women with a diagnosis of tokophobia are entitled to a c/s on medical grounds.

"its not something you consider important or a problem therefore they shouldn't do it. Speaks volumes."

That's a bit childish isn't it? Where have I argued that it's 'not important' that women have birth choices? My posts have just pointed out that there is a rationale for rationing c/s on non-medical grounds which is based on concerns about how current resources are use.

Whenever this subject comes up those posters who beat the drum for a large increase in the numbers of c/s on demand for healthy women refuse to acknowledge the very fundamental, crucial issue of midwife and consultant shortages, and the worrying increase in the numbers of women with complex and threatening conditions being cared for in maternity units.

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.

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.

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.

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.

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.

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?

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.

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.

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.

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'.

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.

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.

"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.

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.

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.