Maternal choice ELCS in Cornwall?

[jamtomorrow1]

Hello all,

Does anyone have any experience of trying to get a maternal choice ELCS for reasons of (massive, crippling) anxiety in Cornwall? I was pregnant last year (very sadly MC at 10wks) and had no problems speaking to my midwife and being referred to a consultant with every indication that all would be fine, but that was in Essex and we are now on the move! I know that historically the Cornwall NHS Trust have refused CS without a clinical indication but presumably (hopefully!!) they have had to revise this approach in the light of the NICE guidance on CS.

Does anyone have any recent experience?

Thanks very much

I can't tell you whether they will allow you an ELCS but I can tell you that it does have specialist perinatal mental health support services although not completely up to the recommended standard. Which might not sound great but many places have no specialist services at all. (Essex is rated as having none).

That suggests it should be positive. Please bare in mind that anxiety is a mental health issue so IS potentially a clinical indication for an ELCS. The difference between maternal request ELCS and a request for an ELCS on the grounds of anxiety is a misconception that I frequently see talked about on MN and indeed by HCP. Few requests are for anything but anxiety or health concerns but the media would have you believe differently and this has influenced popular beliefs. The clue is in the health bit of mental health and can be a legitimate clinical indication for an ELCS as you rightly point out are in the NICE guidelines.

I find this ignorance particularly frustrating as I had an ELCS on mental health grounds (different part of the country) but my notes state maternal request because the way the NHS records ELCS is outdated. However it was repeatedly said to me that my ELCS was clinically indicated and was defined as a 'need' rather than a 'want'.

Depending on where you are, and whether you do face any problems you might want to be aware that Devon is rated one of the best places in the country for specialist perinatal mental health services. You do not have to give birth in Cornwall if you choose not to. Many women are not aware that they can do this. Hopefully you won't need to travel as Cornwall will be able to support you.

You have your previous medical history as support for you too. Your notes state that you have discussed the possibility of an ELCS and been referred previously, which should help your case.

Good luck!

Hi jam
I'm in the same situation as you I'm waiting to see my consultant to ask for an elective c section as well I had a still born daughter in October and I'm petrified of giving birth again my midwife doesn't think there will be a problem I also have the the start of spd again
Good luck pm me is you want xxx

Thanks very much guys. We are TTC and I'm not (necessarily) even pregnant yet and I'm already so worried about this that I seem to have done nothing but Google 'Cornwall ELCS' recently! RedToothbrush, thanks for your advice - you are quite right, I hadn't really thought about it like that. Very useful to know about Devon too. whohasnickedmyvodka, good luck and let me know how you get on!

Oh, don't necessarily feel you have to wait until you conceive to raise the issue. When you get a new GP see them about it stressing how worried you are and try and get wheels in motion. I did this and got an ELCS agreed in principle before getting pregnant. This is very unusual (it can be very hard to get referred prior to being pregnant and you may get bounced by the GP) but it is possible depending on your circumstances. Again it goes on your notes that its causing you anxiety, so doesn't count against you.

Hi

I'm afraid I can't comment on Cornwall, but I'm in the same situation as a couple of you and wanted to add my voice to the thread. I had a fairly traumatic miscarriage at 11.5 weeks in October (taken to a&e, fetus stuck in my cervix & removed manually by doctor/nurse, hemorrhage, emergency ERPC in middle of night). I got pregnant again a month later and had issues with bleeding and thinking I was going to miscarry again for the first 12 weeks. I'm now 28 weeks and the pregnancy is fine and healthy, but I'm struggling with bad anxiety problems. I seem to have been traumatised by the experience of my miscarriage - something about being out of control, the hemorrhaging, being afraid I was going to die before I went to theatre. It's causing me to start crying, sweating etc when I think about giving birth as I'm so afraid of something going wrong and I just want the baby here safely. I'm scared to be in another emergency situation. Anyway, I mentioned my anxieties to my midwife at my 22 week appointment, of course the tears came etc. I didn't even have to mention elective section - she did and said it might be the best option for me & it's ok if I want that and not to feel embarrassed. She made an appointment for me with the consultant at 32 weeks to discuss but has said that it's my decision and they won't stop me having the section if I want it. I wasn't expecting them to be so reasonable if I'm honest. Hopefully Cornwall will be the same.

I've really looked in detail at the risks, pros and cons of vaginal vrs section birth. If someone could guarantee me a straightforward vaginal birth without emergency situations/interventions then i'd take that option. But they can't. I do believe that the controlled environment of a planned section would be the best option for my current mental health. I'm satisfied that, if section performed after 39 weeks, the additional risk of baby having breathing problems is only slightly higher than vaginal birth - and I think it's worth the trade-off of reducing the other risks I'm concerned about with vag birth, such as baby getting stuck, cord round his neck, oxygen deprivation, distress etc. I'm already mid-30s so not planning more than one more child after this anyway.

My problem is that I'm afraid of making this decision myself. I'm afraid I make the wrong decision and I'm also afraid of being judged by others, family included, for having a maternal request section. I do think, as someone above said, that mental health can be an indication as well as physical reasons. Midwife has also offered me option if seeing maternity psychologist and I want to do this as would ideally like a professional to confirm that this option would be better for my mental health.

Anyway, I hope you get on ok and get a referral. I just wanted to add my story as it's good to connect with others having same issues.

Notamumyet81 I was very worried about being judged by others. In the end I did explain to a few close friends who surprised me with their response. It gave me confidence to be more honest about it in time. I think it helps to stress when you do so that this is a medical issue recognised by NICE and the guidelines were changed because it was acknowledged that Daily Mail Style influences rather than sound research were having a greater impact on decision makers and this was harming women. NICE state that an ELCS is not necessarily more expensive if you include long term costs such as mental health related complication or physical complications that could result from refusing an ELCS and that cost should never be used as a sole reason for refusing an ELCS. Which considering this is from an agency that often does not recommend drugs because it doesn't deem them as cost effective its quite telling.

In terms of helping me give confidence in my own decision making, I did a lot of reading up on alternative options. It came down to breaking my anxiety up into lots of chunks - I wrote EVERYTHING down. The concept of eating the elephant bit by bit rather than trying to swallow it whole. It was about seeing how each individual fear fitted into the scenarios of a planned VB and the most likely complications and a planned CS and the most likely complications. It was about working out which situations you might be able to cope with, if you had the right support, communication and planning and which were the ones that bothered you the most and you thought you'd struggle most with, even with help.

It came down to if I had a VB and things when wrong or if I had a CS and things went wrong, which would leave me most regretting my decision. Everything else was very much secondary to that. It helped me be at peace with my decision.

I was also grateful that I was aware that my hospital had a track record of supporting women by granting an ELCS but also did this in combination with trying to build a relationship with the woman concerned and also offering counselling. They had many who requested an ELCS later feel confident enough to go for a vb without feeling pressured and were happy with that decision retrospectively. Whilst I decided to go ahead with an ELCS and didn't waiver from that, I did find it reassuring that they were happy to listen and offer alternatives and guidance to those who had more doubts and not assume that once you had an ELCS booked that the decision was final and that was it, in terms of how they supported you.

I personally don't think that merely just giving you an ELCS is enough - you need the additional support. For me that additional support wasn't about counselling or CBT either which women often feel pressured into (I turned down the option). Its about tailoring care to individual needs, providing options and potential solutions in certain circumstances instead of feeling out of control and at the mercy of events.

I want to do this as would ideally like a professional to confirm that this option would be better for my mental health.

Just a point on this. I doubt you'll get anyone able to answer this definitively. The NICE guidelines say that little research has been done into what alternatives can be offered and just how much benefit an ELCS actually is. The issue is more that refusing an ELCS is damaging as this has a psychological impact. The evidence is that women do best when their expectations of birth match closely with the birth they have rather than the method of birth itself. Hence why ELCS are often promoted because the variables are fewer not because they are better for anxiety. For anxious women pushed down the ELCS route this might not be the best solution though and may have consequence in its own right.

It should be about trying to manage various situations and scenarios - which is why I say you need to really understand your fears yourself. No one can tell you how you'll cope better than you. There isn't a one size fits all solutions and I do feel at times that the NHS and woman are both looking for this. A robust birth plan that's is individualised and given a lot of time to certain scenarios and taken seriously as being important by staff is probably the best thing IME regardless of how you actually give birth for this reason.

Thanks for your detailed response Redtoothbrush, it's obv you've thought about these issues a lot.

When I look at things rationally I'm sure I do know what is best for me. I've written a lot down and read everything I can about the subject and, even from a solely rational point of view (taking out my current emotional issues), I prefer the risks of an elective section over the unpredictability of a trial of labour. I've also looked at statistics for first time mothers of my age in my NHS trust (freedom of information) and can see that 30% end up with an emergency section, 26% with either ventouse or forceps. And that doesn't even take into account the numbers within the remaining 44% who experience birth trauma, serious tears, hemmorhage, damage to baby etc. So given those figures I don't think it's unreasonable for a woman to make an informed decision from the outset to go for the more 'known quantity' of an elective section, if that's what she feels more comfortable with. I think I might find it easier if it was more 'normal' to choose.

I've also looked at my personal risk of various options. Ideally I'd prefer to avoid surgery for anything, but this baby has to come out somehow. I don't have any complications that would make me high risk for surgery - I'm not overweight, diabetic, don't have high blood pressure etc. On the other hand my intuition tells me that I am at risk of experiencing a bad tear and/or another hemmorhage - (won't go into details but family history, experience of my miscarriage, previous colo-rectal problems requiring surgery).

I've also, like you said, considered how I would feel if thing went wrong in either route. I know rationally what I prefer.

No matter how many times I go through it all I come back to the same conclusion. The fact that I currently start crying even thinking about being in an emergency situation/my previous miscarriage cements that decision (though I know I'll need to deal with the anxiety issues either way, and I do intend to get help for this). What's holding me back from commiting to and owning this decision are two things - the first is irrational - I'm afraid that I make this decision & then end up in a rare situation like having a heart attack during the surgery, or an embolism or stroke and that it'll 'serve me right' for not just getting on with a 'normal' birth. However I try to rationalise this in that I could end up with an emcs & have a rare complication too. The other, like I said, is fear of judgement. I think THAT is why I want a professional to tell me that this is the least risky route for me - not because I think that they understand my fears or how i'll cope better than me - but because if the section was officially 'indicated' it would absolve me of some of the, I suppose guilt, that I feel for opting for this route. I don't believe that I 'should' feel guilt, but there you go, that's the result of current attitudes in society I guess - the daily mail effect.

Anyway, these are all issues I'll need to to try to deal with and come to some sort of peace with ASAP as the baby is coming one way or another. I'll defo make sure to push to see the maternity psychologist as I think it'll help me personally, given the issues surrounding my miscarriage.

I assume you have been happy with your choice of elcs Redtoothbrush?

I am happy and have had no regrets at all.

I found it the mental side of the surgery easier than I expected, but physically harder. The actual procedure left me feeling out of it for a few hours despite being textbook which I wasn't expecting. But mentally because I was well guided beforehand and this proved to keep me calmer than I thought I'd.

I did need a lot of support from DH afterward as I struggled to do anything for about two weeks.

Long term though, the good treatment has done a lot to restore faith and trust that I'd lost from previous experiences. Not solved them, but things are a lot better than they were.

You don't owe anyone an explanation of your delivery plans.

Just wanted to add that I'm also having my first baby by ELCS due to anxiety, and I have the same concerns- lots of guilt and fear of judgement, and also worried about the CS itself. But I still know it's the best option for me. I wish I could find someone locally who's been through the same thing, but it does me make me feel better to come on here and realise I'm not the only one.

Just to add another voice I had an ELCS for anxiety/other mental heal issues.

In my experience (not in Cornwall) all of the midwives I saw antenatally were fantastic, they listened, they supported, they referred and then they advocated.

Sadly, the consultant was not supportive. She was absolutely vile to me, and I can't type it all out now because the thought of the conversation (a year ago next week) still makes me cry. If I had more strength I would complain.

Despite being utterly rude and cruel to me she did sign off the ELCS- so quite what the point of her cruelty was I have no idea.

What helped me- having the senior MW with me to advocate and after the disastrous appointment I never went without DH again. He was very good at saying 'stop, I think that's unnecessary pressure' and similar when it was needed. I was only patronised when he wasn't with me.

Best of luck

Actual ELCS- definitely the best decision, 9MO DS is fabulous and anxiety pretty much gone

Thanks very much to everyone. This is all such useful advice that I am going to cut and paste bits of it into a sort of crib sheet for what I need to say to the midwife and consultant! It is so good to be able to talk to people who have been in the same situation.