NICE recommend all women should be able to have a cs

[LoveBeingAWitch]

Just seen tomorrow's front page of the Sunday times saying that NICE are saying cd has become such a safe op that every woman should be able to have one if that's what they want. Im quite surprised by this.

Having had two cses, the main reason I wouldn't have a third child is because I don't want a third

Cses are not enjoyable experiences. I'm not sure why anyone would chose to have one. And doctors who are NOT obstetricians, overwhelmingly chose to give birth vaginally because they see quicker recovery time etc.

i think that is such a good point to make bytheway1 and bugster. it may seem the easier, more controllable option, but it can lead to complications.

I wa stold the brathing risks for the child only relate to the time just following the birth and the first few days, I've not heard anything about being more prone to chest infections after that, or allergies.

My SIL went through hell giving birth first time resulting in an emergency CS. Depsite the under-lying medical conditiion which caused the hell remaining the case, they were still putting pressure on her to VBAC the next time, causing her totally unecessary stress.

I hated my labour (DD was 9lbs 6) and was quite traumatised by it but I'm not an operations fan and would go for a VB again now I'm pregnant with DC2.

More choice is definitely welcome -especially with second and subesquent pregnancies when people have their own evidence base informing their feelings. Plus I imagine SOME of the extra £800 might be offset against healthy mothers/ less PND etc which is surely a factor if you force people to have a VB when they dread it.

OK RISKS AS DETAILED IN NICE REPORT.

This is different to what I thought it would be actually...

RECOMMENDATION
Discuss the risks and benefits of CS and vaginal birth with the woman (see box A and recommendation 118), taking into account her circumstances, concerns, priorities and plans for future pregnancies (including the risks of placental problems with multiple CS).

Risks for babies:
VB better for:
NICU admission
13.9% planned cs 6.3% vaginal (inc unplanned cs)

No difference:
^Hypoxic-Ischemic Encephalopathy (CNS depression, seizures, pH < 7)
Intracranial haemorrhage Neonatal respiratory morbidity (intermittent positive pressure ventilation, transient tachypnoea, endotracheal tube insertion, pneumonia)^

Conflicting findings from studies:
Neonatal mortality
Apgar score at 5 mins < 7

On risks for mothers
Planned CS better for:
Perineal and abdominal pain during birth
median score 1 CS median score median score 7.3 vaginal

Perineal and abdominal pain 3 days postpartum
median score 4.5 CS median score 5.2 vaginal

Injury to vagina
0% CS 0.56% vaginal

Early postpartum haemorrhage
1.1% CS 6.0% vaginal
3.9% CS 6.2% vaginal (two studies)

Obstetric shock
0.006% CS 0.018% vaginal

Vaginal better for:
Length of hospital stay
3.2days CS 2.6days vaginal
3.96days CS 2.56 days vaginal

Hysterectomy due to post- partum haemorrhage
0.03% CS 0.01% Vaginal

Cardiac arrest
0.19% CS 0.03% Vaginal

No difference for:
Perineal and abdominal pain 4 months postpartum
Injury to bladder/ureter
Injury to cervix
Iatrogenic surgical injury
Pulmonary embolism
Wound infection
Intraoperative trauma
Uterine rupture
Assisted ventilation or intubation
Acute renal failure

Conflicting evidence for:
Maternal death
Deep vein thrombosis
Blood transfusion
Infection ? wound and postpartum
Hysterectomy
Anaesthetic complications

RESEARCH RECOMMENDATION
What are the medium- to long-term risks and benefits to women and their babies of planned CS compared with planned vaginal birth?
The main focus would be the outcomes in women which could be measured at 1 year (medium term) and 5-10 years (long term). These outcomes could include:
urinary dysfunction gastrointestinal dysfunction dyspareunia breastfeeding psychological health.
Infant outcomes could include medical problems, especially ongoing respiratory and neurological problems.

areyoutheregoditsmemargaret: Several of us have listed why we wanted one. I'll repeat myself. I have trouble getting and staying pregnant, and wanted the option which represented lowest risk for my baby, which was ELCS.
Does that explain?

Why do some people not respect others choices. You don't have to understand others choices to respect them.

Funny thing this... women in this thread who have electives on request... might not be tocophobic but definitely all expressing some sort of fear or anxiety here, whether it be for themselves or baby. Quite a few common patterns (btw fertility issues or miscarriages have been identified in Sweden as being more likely in women who request c-sections...)

Hmm... food for thought. Need more UK based research for sure.

Think there are definitely some statements about rocket science though I guess.

Its one thing to respect a person's choice to have a non medical c section, its another to expect Joe taxpayer to foot the bill. I think we need to think as a country how we fund the right for women to choose their birthing method.

It is not being hard hearted, but recongising that the NHS is not financially a bottomless pit.

And again;

"Add message | Report | Message poster Ephiny Mon 31-Oct-11 11:51:35
I thought the whole point was that they couldn't justify refusing maternal request CS on cost-effectiveness grounds, i.e. there was no strong evidence that this would significantly increase overall costs. That's what it says in the actual text of the recommendation, anyway."

Repeated again. It's NOT about cost. Which is why NICE say it's ok - it represents a cost effective option.

Just wondering how the cash strapped NHS is going to fund all these CSs.

Todays papers say they cost on average £800 more than a vaginal delivery.

Reeling, read the NICE guidelines. I shall repeat (again)

"Add message | Report | Message poster Ephiny Mon 31-Oct-11 11:51:35
I thought the whole point was that they couldn't justify refusing maternal request CS on cost-effectiveness grounds, i.e. there was no strong evidence that this would significantly increase overall costs. That's what it says in the actual text of the recommendation, anyway."

Repeated again. It's NOT about cost. Which is why NICE say it's ok - it represents a cost effective option.

Agree with reallytired. Unfortunately there aren't unlimited funds/resources on the NHS for everyone to choose. Yes there are clearly people that should be given the option or advised to go for a c-section but, in my opinion not everyone.

If all mothers-to-be are given the choice on the NHS then the c-section rate will increase significantly.

Beg your pardon.

"btw fertility issues or miscarriages have been identified in Sweden as being more likely in women who request c-sections..."

Sorry quietly, are you implying that the miscarriages or fertility issues are due to the cs request or have I read that wrong?

Because it would seem far more likely that they request a cs due to the miscarriage and fertility issues, as BagofHolly points out.

I'm sure you can't have meant to imply otherwise, surely?

Here's what it actually says (someone already posted this and more further up the thread, the full text is available online)

"The group noted that there was likely to be an increased resource use with CS due to the increased length of hospital stay. An economic model developed for this guideline suggested that planned vaginal birth was cost-effective compared to a maternal request CS. However, this finding was limited to outcomes that were reported in the included studies for the clinical review undertaken for this guideline (see section 4.2). A sensitivity analysis suggested that the inclusion of adverse outcomes not reported, such as urinary incontinence, could make the cost-effectiveness conclusion less certain. On balance this model does not provide strong evidence to refuse a woman's request for CS on cost-effectiveness grounds."

And again this is not going to be presented as an option to all pregnant women when they turn up for their first appointment, that's not at all how it's going to work!

Women who request cs are more likely to have had fertility problems or miscarriages in the past. Clearer?

How can it not be about cost? Mothers who have had c-sections require way more care than your average VB mother, therefore more resources will be needed thus putting the costs up. Also surely an obstetrician is paid more than a midwife...? A midwife can't perform a CS-section...

Maybe I'm missing something???

Montsi
Read the evidence

You're missing the bit that Ephiny just posted, about how that conclusion was reached - you have to take into account the correction of complications of VB which work out MORE expensive than ELCS.

The pre-publication draft is available here, for those who want to see what is, and isn't, actually being recommended.

I had CS and was out in 2 days and 1 follow up appointment I have 2 friends both VB who are still going to appointments for complications from natural birth 3 years on.

These are the sort of costs that the report is referring to

We are talking about planned C-Sections. So they take place during day and take about 30mins to perform.

Vaginal births take hours of a midwife's time, may still need an obstetrician if things start to go wrong and can take place 24 hrs a day. Costs include all emergency c-sections that arise out of a planned vaginal birth.

In terms of staffing, maybe not such a huge difference after all. I was mildly surprised by the length of time in hospital for both too (detailed above). I though there would be a bigger difference than there actually is.

on costs, there are also lots of women like myself who are basically prepped for a c-section but then the baby is coaxed out with forceps. The medical staff required and costs must be similar to a c-section, though the post-natal ward costs may be lower (earlier discharge).
I am one of the many to have needed later surgery too from the above scenario.
for that and other reasons I have been "granted" a c-section this time around.
I'm not wildly thrilled but I am reassured to know my bits won't be torn up further.