High rates of intervention?

[LorlieS]

The C-Section rate is 40-something percent in my local NHS Trust. This seems remarkably high when considering labour and birth are in essence natural processes? Why might it be? What are rates like nationally I wonder?

I've had 8 pregnancies and 3 births. First birth - hospital induction (in hindsight should have declined). Second birth - "normal" delivery in hospital. Third birth (decade after second!) - "normal" delivery at home with no intervention (no internal exams, natural delivery of placenta etc) with an Independent Midwife.

I'm also curious about them telling you they were breaking your waters as they needed the room and so wanted to rush you on OP. Did they actually say those words to you or are you just imagining that's why? Breaking your waters by no means leads to a super fast delivery of a baby!

The massive increase in induction of labour is a contributing factor in increased section rates. I strongly believe women aren't counselled properly when it comes to IOL.

Secondly, all these women who have a section first time found are more likely to have an ELCS for subsequent deliveries.

Finally midwives and obstetricians are becoming deskilled. For example, ELCS for breech presentations. Between 3-4% of babies are breech at term, yet very few professionals are not confident to deliver them vaginally. We're supposed to be experts, but shy away from this very common variation of normal. 3-4% is quite a lot and it's shameful that we have deskilled so much to the point it has impacted women's choice.

It's a scandal, we're butchering women and traumatising them in the process.

@ilostmyhearttoastarshiptrouper They believe it was due to the trauma which caused his system to "convert." Highly jaundiced for 7 days which caused hearing problem.

@ilostmyhearttoastarshiptrouper The student midwife told me that. I was in the TV lounge waiting for my husband to collect me 45 mins after delivering. Baby was jaundiced at that point but nobody recognised it.

@callainblue I totally agree. I stupidly agreed to an induction at 10 days over with first son. I absolutely was not counselled properly.
Refused for second son (overdue again) and again with third baby when waters partially went 48 hours before contractions started.

May I ask what the clinical picture was when you had your cord prolapse? Were you already in hospital?

@callainblue Please may I ask your occupation as you refer to "we"?

May I ask what the clinical picture was when you had your cord prolapse? Were you already in hospital?

I was thankfully yes. As previously stated, had I not been, my baby wouldn't have survived.

Another factor in increasing c-section rates is that there are more women having babies now who themselves have had significant medical issues which couldn't have been cured in the past. I'm one of them - I've had several rounds of major abdominal surgery, the first at 10 days old, as a result of which I live a near- normal life. However had I been even 5 years older, the chance of ever being well enough to consider pregnancy would have been very low. While my condition isn't common (1/5000 births), there are plenty of others alive now who wouldn't have been if they'd been born a generation earlier.

I was able to get pregnant, but needed a c-section (DD was transverse, probably due to the aforementioned abdominal surgery).

Midwife.

I understand people have worries about homebirth, that's why it's not for everyone.

The birthplace study tells us that for low risk women who have had at least one previous normal delivery, homebirth is just as safe, if not safer.

Obstetricians and high risk delivery suites are fabulous and can be life savjng when needed, but if everything in your pregnancy and previous deliveries has been normal and you haven't been meddled with during labour, you're just as safe, if not safer at home. You can agree or disagree, but that's what the research tells us.

I've seen 5 cord prolapses in my career, they've all been caused during or shortly after artificial rupture of membranes. I've seen countless PPH's, the vast majority have been due to long inductions, episiotomies. I've seen many a nasty shoulder dystocia, mostly inductions with epidurals. I'm not saying that obstetric emergencies don't happen at home, but they most certainly don't happen as frequently.

Most people don't understand home birth or the nature of true physiological birth, these emergencies very rarely happen at home, hence the findings in the birth place study.

The section rate is a worry that we discuss between colleagues all the time. Ours is currently 42%, way over the 10-15% recommended by WHO.

After many a shift of emergency after emergency, trip to theatre after trip to theatre, it raises the question 'what the hell are we doing to these women!?' 'Why can't women have babies vaginally anymore?' It's been a really noticeable shift over the course of my career.

For women who are truly fully informed and choose an induction or ELCS then I'm all for it. As with anything in the world of midwifery, knowledge is power, and informed decision making is key.

@callainblue Great to hear from someone who clearly has knowledge in this field. You sound like my IM (whom I'm still friends with three years on). She was incredibly knowledgeable and supportive.
It was the small things as well I learned from her, like why did she use a Pinard to listen in to baby rather than a doppler? She told me to fill a sink with water and I soon understood why!

@callainblue I had a PPH with my first baby after a long labour (not induced and no other intervention). I had an episiotomy as that baby was large (as was the second with whom I experienced the cord prolapse). Are you saying that the PPH was likely caused by the episiotomy and that, had I had a home birth, this wouldn't have occurred?

There are different causes for a pph. An atonic uterus is the most common cause though bleeding from the epis will have contributed to some blood loss. So an atonic uterus is where I doesn’t contract like it should after the birth, this is more likely to occur after a long labour so it’s possible it’s the length of the labour which was a factor in the pph. Or it could just have been one of those things, sometimes women with short labour also have an atonic uterus.

As above, could have been the prolonged labour, could have been the epis. Hard to know.

If you'd had a homebirth you'd have been counselled that as it's your first baby there's a higher chance of transfer into hospital.

You had a prolonged labour, so you'd have been advised to transfer into hospital before delivery.

You also state you had a big baby on board, if this was known prior to birth through fundal height measurements and ultrasound scan, you'd have been deemed unsuitable for homebirth.

Sorry @ilostmyhearttoastarshiptrouper I meant to tag you!

The statistics for last month at the hospital I gave birth to my son in...

52.7% IOL. Wowser.

And 84 unplanned cesareans.

52.7% is their induction rate. The section rate is 42%.

It’s the high inductions which are causing the increase. 20 years ago induction rates were around 20%. The Reason for the higher induction rate is very likely caused by all the recent evidence in the last ten years or so saying you have to monitor for x and y in pregnancy and if you then find a problem you can’t just leave it.

A lot of inductions will be failed inductions or even if the woman gets into labour she doesn’t progress to 10cm, or an induced labour means she needs a ctg and then that means heart rate problems are more likely to be picked up and that means they are more likely to have a section.

You could also ask why continuous monitoring is used for non low risk labours because the evidence from a Cochrane Review suggests that it doesn’t improve mortality or morbidity but does increase the chance of a section.

And that Cochrane review questioning the effectiveness of continuous monitoring had no impact on maternity care at all. No change to practice. But anytime any evidence suggests a hint of more intervention everyone is all over it.

i remember not that long ago NICE in their draft guidelines wanted all BAME women induced at 37-39 weeks because the MBRRACE report had said there was a 4 fold increase in the chance of them dying in pregnancy/labour. For some reason NICE thought that increasing their intervention would solve that. Rather than looking at the actual causes which are more to do with systemic racism, language barriers, etc.

The Reason for the higher induction rate is very likely caused by all the recent evidence in the last ten years or so saying you have to monitor for x and y in pregnancy and if you then find a problem you can’t just leave it

Is that a bad thing??

The 1 water birth is also terrible, with evidence showing how good water can be for mum and baby

No, not if it’s bringing down still birth rate, rate of cerebral palsy, etc……which it seems to be doing.

The caveat I suppose is that if you find a problem in ten pregnancies and you intervene in those ten people. Maybe you save 6 lives and the other 4 would have been ok without intervention so theoretically you have intervened when you didn’t need to. However as things stand currently that’s the way things are. Maybe in the future with more research then the investigations will become more nuanced and doctors will know for sure which cases need intervention and which ones can be left.

So raised dopplers (blood flow though the cord) is a good example. So a baby is picked up as small for gestation on palpitation, confirmed by scan and the scan also shows raised dopplers. So the doctors know that a small baby with raised dopplers is increased risk for a stillbirth. There is a balancing act regarding early delivery vs prematurity but at some point it may well be decided the baby is safer out than in. You obviously can’t wait until the baby is minutes away from dying to make that decision (and you can’t tell that without 24/7 monitoring which is not realistic). And I guess doctors will quite rightly err on the side of caution. Some babies they induce or section at this point maybe they’d have been ok for another two weeks and gone into labour spontaneously, or maybe they’d have died two days later?

Yes, there’s a lot of anecdotal evidence that midwives don’t suggest waterbirths to women when they come to labour ward even if they’re “suitable”. I think pools are very under used.