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NICE recommend all women should be able to have a cs

999 replies

LoveBeingAWitch · 29/10/2011 22:59

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.

OP posts:
StarlightMcKenzie · 01/11/2011 14:01

juule You may well have been asked but most woman think that it is in their best interest to accept. When actually sometimes this can interfere with her coping strategies and increase her adrenaline levels.

I think it is fairly safe to suggest that most women don't know that a)they can refuse and b)this is not going to lead to any negative outcome for her or her baby (except where there might be a medical concern, where the mw should be able to explain why she particularly wants to see).

'How does someone who has only just met you know whether you want them to stay or go at that point? How can they stay if the services are overstretched? If you are under their care how can they leave you alone if they have protocols to follow?'

Juule, these are my points exactly. The system doesn't allow for optimal VBs.

StarlightMcKenzie · 01/11/2011 14:03

There is no NEED to induce a woman who is overdue ONLY. Being overdue CAN cause other issues for which an induction MAY be indicated, but being overdue on it's own does not.

MrsJRT · 01/11/2011 14:04

Maybe I work in a completely alien place to the kind of hospitals where many here have given birth, certainly on delivery suite we have doctors there all the time, for high risk women they are kept abreast of developments during labour, they will often ask for updates, include them on a ward round at handover and generally be involved in the care. For those high risk women (or those women who become high risk during labour) I as a midwife do very little other than carry out the wishes of the doctors who are responsible for her overall plan of care. To say that 'midwives refused to give me a section' or 'midwives ignored the fact I wasn't supposed to have a prolonged labour' etc etc is completely at odds with every experience I have ever had as an NHS employee. Midwives have very little autonomy once a woman steps outside the realms of normal. I'm not trying to belittle anyones experience or cast aspersions on what happened to them but is it a case of perspective? Midwives are the most visible presence on a delivery suite and therefore they get apportioned the blame when in reality it is more likely the doctor who has made the plan and the midwife is merely carrying it out? Doctors appear when theings are going tits up and 'save the day'.

juuule · 01/11/2011 14:04

"The system doesn't allow for optimal VBs."

I agree with that.

StarlightMcKenzie · 01/11/2011 14:08

MrsJRT It was a doctor (SHO in fact) that blasted ds out with fundal pressure. It was the MW's that covered it up and denied that they saw it happen and failed to put it in my notes.

I don't understand why, but there must be a very complex relationship thing going on between the doctors and midwives and NOT in the interests of the women.

MrsJRT · 01/11/2011 14:12

SM and that was wrong but it's not like that everywhere. I obviously just work in an enlightened unit as I genuinely don't recognise a lot of the stuff posted on the childbirth boards here. Thats not to say I don' believe it goes on but I suppose I just find it hard to comprehend as it is so far away from my point of reference.

screamingbohemian · 01/11/2011 14:29

MrsJRT your hospital definitely sounds a lot nicer than the one I was in Smile

It's true I don't know what went on behind the scenes. All I know is the midwives (and one junior doctor actually) were very dismissive of my concerns and my notes, and very reluctant to let me speak to the senior consultant on duty. As I said, I was told beforehand that I should not have a prolonged labour. To then be left in a long labour, with no explanation for why they thought my consultant was wrong, was worrying. I would have thought, if they were really operating under another doctor's orders, they would have said, Oh actually, Dr X thinks abc is the best course of action. Instead they said things like, Well you know, sometimes labour just takes a long time.

But thank you for your insight because I'm realising now that of course I don't know what was really going on outside my room. Hmm.

starlight you said flat out that failure to progress is really failure to conform to schedule. If what you mean is sometimes, then add sometimes, it takes 2 seconds. You may think it's obvious but given that you also think giving birth is like having a poo, I don't really want to assume anything about what you think.

StarlightMcKenzie · 01/11/2011 14:37

I meant often.

StarlightMcKenzie · 01/11/2011 14:39

Having a poo uses similar reflexes. Muscles tighten to keep things in and relax to let things out. In order to relax those muscles, the mother has to be relaxed and uninhibited.

screamingbohemian · 01/11/2011 14:43

I see. And poos usually weigh 10 pounds, do they? Induce frequent and painful abdominal contractions that might, oh I don't know, interfere a tiny bit with relaxation?

It's a ridiculous comparison. Honestly.

StarlightMcKenzie · 01/11/2011 14:48

The muscle process is the same, if not the experience or outcome. I'm sorry if you don't like the comparison but it is the only one we have, except of course weeing, where our muscles also have to relax to let something out which is hard to do whilst being prodded, talked to or observed.

working9while5 · 01/11/2011 14:48

I think communication on wards can be poor from what I read on here. Throughout my labour, people kept coming in to look at the trace and stood over it muttering darkly things like "ooh, that is a bit suspicious" and making me move about. I wasn't really in a position to talk it over with them, but I feel that they could have explained things to dh who was a bit concerned by this. Then I started pushing at 11 and 2 hours later, having really been told nothing was going awry, there was this frenzy and I was signing a form with the doctor being terribly irritable with me for crying with the fright of it and saying things like "well it's to avoid death". I really do wonder, even now, what the hell went on in my labour. Why did I need those Kielland's forceps etc. I know they say not to debrief women automatically now but no one really explained that I could request it and I was like most new mothers a bit dazed and bedazzled by having a newborn. It seemed strange to me that there wasn't more explanation of the process.

MrsJRT · 01/11/2011 15:06

I completely agree with you 9while5, things are not explained clearly enough and it's something we need to get better at doing. We offer a birth reflections service to all women no matter the mode of delivery, often at the time women are so grateful they and the baby are healthy that they don't think to ask questions, it is usually only a bit further down the line or as they contemplate further children that issues surrounding the delivery become pertinent.

Just reread that and it sounds like I am putting the onus on women to ask questions, it's not, we should be explaining why we are asking permisission to do all of these things, fact of the matter is we need consent for everything, that episiotomy? You needed to agree it, those forceps? You could have refused, the continuous fetal monitoring? Your choice (I use the royal you there).

screamingbohemian · 01/11/2011 15:19

That's interesting. I wasn't given a choice on fetal monitoring. The closest I got was 'if you don't want the monitor we'll have to send you home', which I really didn't want as I was in excruciating pain.

I'm also told I gave consent for my epidural but damned if I remember it!

By the time a woman needs forceps or an episiotomy she's often not in any fit state to consider pros and cons and give informed consent. Is there any way this could be done earlier, before things get really bad?

MrsJRT · 01/11/2011 15:38

And I wonder why we have such a bad rep if that is the kind of shite we are peddling to women. It's absolutely your choice. It is your body, we have no right to inflict anything on you that you have not only consented to but understood the implications of beforehand. I agree that sometimes, women are frightened, in pain and don't necessarily take in all that is said to them, it doesn't excuse the lack of consent, it really doesn't, ok so it might not be a full 10 minute conversation on ins/outs, pros and cons but there is never an excuse for us doing anything without some form of consent, more than that, to do so is assault. I've stopped a doctor from cutting an epis once as I reminded her that the woman had no idea what she was about to do, the doctor wasn't happy but she'd have been less happy if the woman took her to court for assault. Which is what it would have been.

working9while5 · 01/11/2011 16:01

I think this is my issue re: the Kielland's forceps etc. I did sign consent but as far as I knew it was for general forceps/CS. It really wasn't even vaguely made clear to me that Kielland's were more risky... and then there is the aftercare. I nearly passed out a week after birth when I had the dreaded consipation. No one had really prepared me for this, even though because of the Kielland's, I obviously had quite a lot of stitching and quite far back. In fact, no one told me about the Kielland's delivery until I went to the GP wondering why I was in so much pain 7+ weeks after delivery to be told it was "quite common" with these deliveries and could take 8-9 months before I felt right again. Which was about right. It seems a bit negligent to not inform a woman of these things. Which is I suppose why there is so little trust sometimes. I didn't feel I was communicated with appropriately and so I am more afraid of my next birth than I was of my first, because now I am afraid that things will happen that I don't understand or consent to that will have negative consequences. So a CS seems "cleaner" and more predictable...

quietlyafraid · 01/11/2011 16:22

I think we are hitting on something I feel strongly about. Trust.

There seems to be a lack of it.

I don't trust midwives or doctors.

But those guidelines are good for me as they give me trust that i will be listened to, if all else fails.

I think there is a lot of other women who it will restore faith to too. It then means that doctors/midwives should start take note of it all.

I'm sure if this does become reality someone will come along and start actually asking why women are choosing major surgery. It some ways its a sorry way to get this attention, but I think its one that will end up with the necessarily research and realisation on paper of some of the biggest issues in maternity at the moment. (I'm a pragmatist).

Questions being asked...

Thats better for pro-VB and pro-CS...

iggly2 · 01/11/2011 16:45

I post the relevant without biased. Wink

In women who underwent counselling, fear of childbirth was associated with a three to six times higher rate of elective caesarean sections but not with higher rates of emergency caesarean section or negative childbirth experience.

But they may have had fear of childbirth but this was not associated with a higher rate of negative childbirth experience. Personally I think that is good. Number one is healthy mum and baby, number 2 want is a non negative feeling (at least for meSmile).

Very negative feelings without counselling were not associated with an increased caesarean section rate but were associated with a negative birth experience. Sad...... No counselling may link to bad feelings.

iggly2 · 01/11/2011 16:57

Before you accuse me of biased the first 2 studies are same cohort it is to get more background.

fruitybread · 01/11/2011 16:58

While we're talking about 'trust' -

There seem to be quite a few posters here who simply don't trust other women to make their own, well informed decisions. How patronising, incredibly backward and depressing.

I hope every woman gets, or gets a damn good stab at, the birth they want. Whether or not it's the birth I want is irrelevant.

screamingbohemian · 01/11/2011 16:59

I agree trust is a major issue.

I really wasn't worried about things when I fell pregnant, but after 7 months of questionable antenatal care, I was extremely worried.

If we are adding to our list of desired research Smile I'd like to see if there's a correlation between satisfactory antenatal care and planned method of birth.

fruitybread · 01/11/2011 17:25

quietlyafraid, I could write reams on the strange, hostile and irrational attitudes I've encountered towards C sections.

Let's start with the whole 'it's not an easy option' attitude - which often goes hand in hand with the completely contradictory accusation that women who have C sections have somehow 'got away' with an easy birth. Then there's the (moral) idea that birth and babies are something which need to be physically hard won - so by 'opting out', you're something less of a mother. Quite where that leaves adoptive parents, I don't know... and those who have epidurals or pethidine, or gas and air, even. I think there's a lingering religious inheritance influencing that school of thought, even if religion and its influence on women's roles isn't explicit.

Then I think there's the whole 'if I've been through it, YOU don't get to opt out' attitude. Very difficult to unpick, this one - you get women who have had very tough VBs, whose anger and sadness about it gets buried in obsessing about other women's birth choices. You typically hear the contradictory 'CS's are very hard/CS's are a cop out' speeches from these women. Often too, they really need to believe that no matter how bad their VB experience was, a CS would have been worse. They won't hear anything to the contrary, because it's too devastating for them. I try very hard to be sensitive to other people - but if asked directly, I will describe my CS as a wonderful experience. Because it was. That's the truth of MY experience. It's astonishing how often that is met with outright disbelief, or hostility that amounts to an accusation of lying.

All of these moral judgements get messily bound up with a bit of fact, a bit of hearsay, a bit of personal emotion which you'd be hard pushed ever to get to the bottom of... And what you get is vicious coercive nonsense.

The NICE revised guidelines are to be welcomed because they do at least attempt to make decisions based on available research and fact. So women cab be WELL INFORMED and able to make a CHOICE.

quietlyafraid · 01/11/2011 18:50

iggy2
Glad you have looked at some of the research on this. Do you start to see where I am coming from on this? Its NOT just about giving everyone an elective - its about providing a proper care pathway that doesn't exist at the moment. The NICE guidelines is very clear in that. The counselling part is a hugely important element. The NICE people have very obviously been looking at all these studies

Some reading for you, sorry I don't really know how to correctly reference these. The first one is worth a read in greater detail even though its a small study - it was one of the first on the subject and lays a lot of groundwork for subsequent studies. In terms of the quality of the studies, I wouldn't like to comment too much - they seem consistant with other studies on the same subject though. I do feel they aren't as strong as they should be and hope we do get better stuff in the future:

Tokophobia: an unreasoning dread of childbirth. A series of 26 cases - 2000
Hofberg K, Brockington I.
Queen Elizabeth Psychiatric Hospital, Birmingham
AIMS:
To classify tokophobia for the first time in the medical literature.
METHOD:
Twenty-six women noted to have an unreasoning dread of childbirth were interviewed by the same psychiatrist, who was not the treating doctor. A qualitative analysis of these psychiatric interviews was performed.
RESULTS:
Phobic avoidance of pregnancy may date from adolescence (primary tokophobia), be secondary to a traumatic delivery (secondary tokophobia) or be a symptom of prenatal depression (tokophobia as a symptom of depression). Pregnant women with tokophobia who were refused their choice of delivery method suffered higher rates of psychological morbidity than those who achieved their desired delivery method.
CONCLUSIONS:
Tokophobia is a specific and harrowing condition that needs acknowledging. Close liaison between the obstetrician and the psychiatrist in order to assess the balance between surgical and psychiatric morbidity is imperative with tokophobia

Obstetric outcome for women who received individualized treatment for fear of childbirth during pregnancy
GUNILLA SYDSJÖ, ADAM SYDSJÖ, CHRISTINA GUNNERVIK, MARIE BLADH, ANN JOSEFSSON
10 OCT 2011
onlinelibrary.wiley.com/doi/10.1111/j.1600-0412.2011.01242.x/pdf
Objective: To compare obstetric outcomes for women with fear of childbirth who received counseling during pregnancy with women without fear of childbirth.
Design: Descriptive, retrospective case-control study. Setting: University hospital, Linköping, Sweden.
Sample: 353 women who were referred to a unit for psychosocial obstetrics and gynecology because of fear of childbirth constituted the index group and 579 women without fear of childbirth formed a reference group.
Methods: Data were collected from standardized antenatal and delivery records. Main outcome measures: Delivery data.
Results: Elective cesarean sections (CS) were more frequent in the index group (p

quietlyafraid · 01/11/2011 19:00

fruitybread I seem to be getting a fairly good idea of what you already know!

WidowWadman · 01/11/2011 19:02

My opinion on maternal request ELCS is the same as on abortion - if you don't like them, then don't have one.