Referred to Perinatal MH team because I've requested an ELCS

[MinisterforCheekyFuckery]

I'm 37 weeks with baby no2.
For background, baby no1 was born after a three day labour with a failed epidural. Although baby was small (2nd centile) I sustained a 2nd degree tear.

Baby no 2 by contrast is big, measuring above the 90th centile and has been consistently for the duration of pregnancy. Have had regular growth scans and the sonographers keep mentioning how big his head is and making jokes like "I can tell you what he weighs but it might make you cry!" and "you're quite petite aren't you? Good luck with this one!". Every time I've seen a Consultant/Registrar (roughly every 3 weeks, different doctor every time) I've expressed concerns about whether I will physically be able to push such a big baby out safely, the increased risk of shoulder dystocia associated with babies above the 90th centile, risk of instrumental delivery or EMCS etc and been told "it's too early to think about the birth yet, we'll make a plan nearer the time".

Today I saw yet another new Doctor who told me we needed to make a decision about "the timing and mode of birth". She offered to induce me at 38 weeks due to babies size which I declined as everything I've read suggests induction is actually riskier for lager babies. I explained that having read about the potential problems women experience delivering big babies, particularly my concern about shoulder dystocia and my wish to avoid forceps I believe an ELCS is the safest way for me to give birth. She agreed and said she was happy to book me in for an ELCS at 39 weeks as this is the safest time to perform the op but just needed to run it by her consultant "as a formality".

She came back about five minutes later looking very sheepish and said that actually the consultant did not feel that baby's size was a valid reason for an ELCS (although they would still be happy for me to have a 38 week induction for this reason) and that if I wanted to request an ELCS I would need to be assessed by a consultant from the Perinatal Mental Health team. I told her I didn't understand this as there's nothing wrong with my mental health- I'm requesting an ELCS because having researched the risks and benefits of both vaginal and a cesarean births with larger babies, I believe this method is the safest. She told me that, despite her having previously said she would be happy to get it booked, there was no way I could have an ELCs without the Perinatal MH specialist "agreeing that I have a good reason", even though my reasoning is nothing to do with MH!

This doesn't make sense to me. Mental health services are so notoriously overstretched but they're happy for a specialist to take the time to assess me even though there are no concerns about my MH whatsoever! I'm also concerned that as I won't see this person until next week when I'm 38 weeks, even if they agree I am 'deserving' of an ELCS it will be too late to book one for 39 weeks.

I'm just so frustrated that I've been asking to have this discussion with various doctors for weeks and been told it's "too early" to talk about it and now it all feels very stressful that I'm having to jump through all these hoops at the last minute.

Anyone else have any experience of this?

No but raging on your behalf. Woman knows what she wants to do with her own body =
Mental health issue

I hope someone can be along soon to advise. BTW I had ELCS for reasons of big baby and other issues and I had to fight but I got what I wanted.

In some areas the perinatal MH team do all the birth options counselling as they have additional counselling training as well as being midwives. All maternal request sections go through birth choices (wrong but common).

rightreckoner that's exactly how it felt ...I can't possibly be expressing an informed opinion, I have to prove that I know my own mind.

Over thank you, I wasn't aware this was standard practice. If a woman requests an ELCS for MH reasons then I can completely see why that referral would be necessary but it just seems like a waste of an assessment when my reasons are nothing to do with MH.

Unfortunately i think the delaying tactic is pretty common when it comes to maternal request ELCS and I can't help but believe they do this intentionally so you feel rushed and panicked and are therefore less likely to follow through on your request. I know this sounds incredibly cynical but that is my experience of the process.

I was also offered an induction instead of an ELCS even though the research I read suggested that this was the absolute worst thing if I wanted to avoid an assisted birth/EMCS It would honestly seem like they are so desperate to shut down requests for csections that they will offer risky inductions which is incredibly ethically dubious.

Stick to your guns and jump through their hoops. The system is stinks but you aren't in a position to change it at the moment.

Also I think that as they are sticking to the line of argument that a C-section isn't medically necessary then you may find that your C-section will have to be granted on mental health grounds. It's ridiculous as even if you can prove that you are making your decision based on statistics and thoroughly researched facts, they will still imply that you can't possibly reasonably disagree with their professional opinion.

Also I think that as they are sticking to the line of argument that a C-section isn't medically necessary then you may find that your C-section will have to be granted on mental health grounds

Well, if that's the case I've got no hope. My MH is fine and I'm not going to pretend that it isn't in order to get a C-section as that would be completely immoral.

If the consultant thought you were anxious about childbirth, that could have triggered the referral to the mental health team according to NICE guidelines. It doesn't mean you have to pretend you have mental health problems in order to get an ELCS.

It will help to have the NICE guidelines off by heart though...

1.2.9 Maternal request for CS
1.2.9.1 When a woman requests a CS explore, discuss and record the specific reasons for the request. [new 2011]
1.2.9.2 If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth and record that this discussion has taken place (see box A). Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and ensure the woman has accurate information. [new 2011]
1.2.9.3 When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. [new 2011]
1.2.9.4 Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care. [new 2011]
1.2.9.5 For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [new 2011]
1.2.9.6 An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS. [new 2011]

@MinisterforCheekyFuckery
Well, if that's the case I've got no hope. My MH is fine and I'm not going to pretend that it isn't in order to get a C-section as that would be completely immoral.
I'm not saying that you have to pretend you have mental health issues, but from my (limited) experience they like to pretend that anyone that takes a different view of the risks and therefore preferable mode of delivery than them is doing so because of anxiety rather than rationale judgement. I went down the route of memorising statistics, guidelines and recommendations and tried to prove that opting for a C-section was a valid, sensible decision, but ultimately they would only concede on the basis that it would affect my MH if I was denied the mode of delivery that I was adamant was safest.

It sounds like an extra check for financial reasons. So the people in charge of the cash have decided that they can’t just fund every ELCS, so they put in an extra gatekeeping layer.

So you turn up, say what you’be said above, they sign off as ‘anxious about complications from induction’; that ticks the MH box and hey presto you’re allowed it. They’ve done their gatekeeping and have demonstrated that, you get your ELCS.

Or it could be the above but instead of cash being the driving factor it’s because they’ve been criticised for the EMCS rate or something.

You won’t be having a formal MH assessment & it’s not about diagnosing a condition - it will be about some form of controlling access to ELCS and detailing/recording that.

Criticised for the ELCS rate I mean

Thank you all. This has been helpful as nothing was really explained at the appointment in terms of why I need to see this person and on what basis they will make the decision.

I do find it bizarre that every time I've tried to discuss birth options I've been told "it's too early to think about that" but the NICE guidelines say women who are anxious about childbirth should potentially be "offered perinatal MH support". If it was actually anxiety or some unresolved trauma driving my wish for an ELCS then what mental health support could they offer me at the late stage of 38/39 weeks that would be effective?

Hi op,
I have requested an elective. Section myself after complications from my first vaginal delivery.
They wouldn’t sign it off at 12 weeks when I went in and I have to go back at 34.
I hope they are not going to start messing me about at a later date as I have been clear from the start about what I want, and why, and like you I don’t have mental health reasons, I have wanting to avoid a second horrible vaginal delivery reasons. And the possible depression that will follow the second horrible vaginal delivery. But nothing wrong with my mental health at the moment. It’s enough to push someone into a mental health problem with the nasty bullying tactics that they use however.

Anyway, I digress, what I think I would do in your situation is contact pals and a senior midwife at the hospital - I think they call them supervisors of midwives.
Explain that you feel you are making the right decision but actually are worried you are being pushed into this mental health appointment at the last minute, and the uncertainty is making you extremely dissatisfied with your care and is causing you high levels of stress. Tell them you are worried that all of these delays will mean you will be left without a choice as it will be left so late, and that will mean you have been unable to look into what other hospitals could offer in your area, due to lack of transparency about how they deal with elective request cs.

Finally I would strongly urge you to look at this page.
www.birthrights.org.uk/maternal-request-caesarean/

This charity have compiled a report into Elcs in uk health trusts.
They have an interactive map with all of the trusts that they contacted. See if your trust responded to them, and what their response was/whether they have a clear guideline on elcs.
I do think the more informed you are the better.
I am hoping that soon, it will be a breech of human rights for them to treat women this way and refuse them options, when they are well informed.
Good luck and please let us know how you get on.

I’m having an elective c section. Mine is on mental health grounds as I have severe anxiety and it’s my first birth.
It took a fair few appointments and jumping through hoops, but I stood my ground and got there in the end. I’m having mine at 39+4.

I will be having first birth elcs based on my own research however ( not pregnant yet ) but in discussion with nurse and doctor at clinic they will flag me as tokophobic as my concerns come under being anxious 🤣.

Still debating wether I will go private where my views are more respected . NHS elcs only costs £80 more than an uncomplicated VB ( before any complications ) so it’s stupid that they make this about cash .

^ a recent paper demonstrated this .

Ugh. I am so sorry you are going through this. I had 40 hours of labor followed by an emergency cs with my first and a VBAC with a post-partum hemorrhage for my second. If I had it to do all over again, I would have had an elective cs with both. I think it was medically irresponsible for me to have been encouraged to have a vaginal birth in both cases (for slightly different reasons). My children and I almost died.

@GeeLondon
Still debating wether I will go private where my views are more respected . NHS elcs only costs £80 more than an uncomplicated VB ( before any complications ) so it’s stupid that they make this about cash
I know exactly what you mean and at one stage I too considered this, however I would probably advise against this now. I now realise that if I had paid to go private it would have been to protect my pride as it was offensive and shocking to be treated as someone that was incapable of researching facts and making an informed decision. What I have come to realise is that if you just ignore all the judgement and labels they place on you then you get what you want (your preferred mode of delivery) and you help prove to the medical professionals in the NHS that they can't just steamroll women that want to exercise their rights.

I wrote earlier that I'm convinced that the whole process (for my Trust at least) for ascertaining a MRELCS is designed to frustrate and shame women so they either drop their request or go private. I know this sounds a bit extreme, but there is no other reasonable explanation for some of the things I've experienced or have heard about others experiencing.

slightly off topic but what I found really frustrating was that the consultatants have different opinions & it’s confusing. For my 2nd DC I was offered a CS at 39 weeks (some medical reasons). I was actually quite suprised as it wasn’t what I expected. Eventually consultant & I agreed to be induced at 38 weeks (I didn’t want a CS). I had regular consultant checks (all different individuals) over the 3 days I was on the ward. Some were mega negative about me trying “naturally”, & after I decided to have a semi elective CS as I knew baby wasn’t ready some tried to put me off!

Thank you all.

Have looked at the link ocassionalalice posted and my trust responded to the FOI request but refused to provide the number of MRELCS they've performed due to "patient confidentiality". The other questions were answered in a very vague wishy-washy way...we don't have specific guidelines but we're in the process of writing them, we don't have leaflets for women but we will have some soon that kind of thing. They have said that they feel they are complying with the NICE guidelines around MRELCS but all this really means is they have to listen to maternal requests, not grant them.

I am starting to doubt myself now to be honest. I feel like I'm being selfish asking to take up NHS staff and theatre time for an op that the professionals consider "medically unecessary" and if they're so against ELCS then maybe they're right. Lots of women give birth to big babies vaginally with no problems so maybe I'll be lucky.

I still really, really don't want to be induced though as every woman in my family who has had an induction has had a horrendous labour with every intervention going and ended up with EMCS at the end of it. If I was to agree to drop my request for an ELCS and have a vaginal birth but then my labour fails to progress can they insist on inducing me or can I refuse? I just don't have any faith at all that they will listen to me or respect my wishes.

Do not feel bad!
This is how they win, by guilting women into making a decision that they don’t want. In any other way it would be considered bullying and unethical. If you had back problems that an op could solve would you put off and make do with physio which you didn’t feel was sufficient just to avoid the use of nhs staff time?
Cs is statistically very safe. It’s the option that many obstetricians themselves take.
For women in our situation we have already had one normal delivery where we encountered problems, why shouldn’t we have an option?
I will most certainly be asking my consultant, if they try and refuse me, who will be responsible if they force another vaginal delivery on me and it goes wrong?
I will be making it very clear that I don’t consent to normal delivery, I certainly wouldn’t comply with any induction, they are forcing me against my wishes, and if they chose to wait until the baby comes out by default vaginally, if/when something goes wrong, I was forced into this route.

Could you ask about referral to a different hospital?

I echo what @occasionalalice has said and don't allow them to unduly influence your decision making process. I an generally a huge advocate of listening to professionals and experts, however this is one area where I have experienced such horrendously biased "advice" that I would definitely encourage every pregnant woman to look into the statistics and facts for themselves rather than rely solely on what doctors/midwives tell you.

You don't need to feel an ounce of guilt about the cost of the procedure as it has been calculated that the actual average difference to the NHS between a natural birth and csection in the long term is less than £100. The focus on money is driven by how the NHS apportion the cost of each mode of delivery internally (I e. Which cost centre ends up picking up the tab) so consultants are incentivised to push for vaginal births knowing that the cost of dealing with the complications will fall elsewhere and not come out of their budget.

In terms of NHS resources then once again it's a really mixed bag. The initial level of resource needed to perform a ELCS may be less than the average vaginal birth (this isn't guaranteed though), but fixing prolapses, dealing with incontenience all takes up resources and are all statistically more likely to happen if you have a vaginal birth. Of course you could end up with other complications following a C-section however my point is that it isn't as simple as saying that "vaginal birth is cheaper and requires less NHS resources".

I think you can stop at any point. My induction consisted of 2 pessaries, that’s as far as I went before having a CS, although there was risk if they broke my waters so maybe it was easier for me to be heard of that makes sense. I was induced with DC1 as they were worried re growth. I just had a pessary & 1.5 hour active labour so had assumed it would be like that 2nd time.

I’ve been through it all requesting an ELCS this time and that is after two previous traumatic deliveries and a MMC last year which almost killed me. All of my babies have been large (10lb+) and this one is set to also be large. They have tried every tactic in the book to deter me and I’ve had to speak to five separate health professionals before being in the position where I am now, at 35 weeks finally having a c-section booked in. They haven’t just run through the risks in the normal way a consultant would before any surgery, I’ve essentially had every scaremongering tactic in the book. The last consultant I saw essentially assured me I would wind up having a hysterectomy as a result of the ELCS . It’s been a hideous experience and I’m glad this is the last time I’ll have to do it.

The guidelines may now state that women are allowed to request an ELCS for any reason they wish but they make it as difficult as possible to obtain to an extent I imagine some women are scared off having one, that seems to be their goal. Horrible, you have my sympathies.

OP, they're not following NICE guidelines if they flat out refuse an ELCS. The guidelines are all about woman-centred care: you can't be forced into a VB, an induction, or a CS. They all need your consent. And if you don't consent to a VB after they've tried to persuade you, then they are supposed to offer ELCS.

Of course, NICE guidelines don't stop some consultant teams treating you like absolute shit if you don't agree with their choice of treatment. I too had to push back against consultants who were keen to induce for a different condition despite the evidence (and RCOG and NICE guidelines) saying that it didn't help outcomes and increased risks of complications. I deal with statistics and research papers as part of my job, and once they saw I was able to talk the talk (and was referencing a more up to date meta-analysis than they had read), they backed down and actually agreed i was right

There's a cultural remnant of "silly hysterical woman" in some obstetrics depts, which means maternal wishes are viewed as irrational things to be soothed away rather than well-informed decisions about to proceed with healthcare. Half the battle is persuading the consultant that it really is a well-informed choice, and not one based on reading things "off the internet". You could print out the NICE guidelines on maternal request ELCS, or this Cochrane review on the questionable benefits of induction for large babiess*, to help your choice look as rational and informed as possible.

What on earth?! I’m sorry that you have been treated like this. I second looking at the Birth Rights website and I’d also consider putting in a complaint through PALS. Do you have a midwife? I believe there is an appeals process regarding birth choice but thibk that may be more to do with vaginal births although worth looking into. Hope you get this sorted and have the birth you want!