NICE consultation on draft quality standards for Caesarean section - what are your thoughts/experiences?

[MylinhMumsnet]

Hello,

We've been asked by The Quality Standards Team to contribute to a National Institute for Clinical Excellence (NICE) consultation on the draft quality standard for Caesarean section (CS). The draft standard is made up of a set of measurable statements and the consultation asks for your thoughts on these statements.

The background information provided by the consultation states:
"Caesarean section (CS) rates have increased significantly in recent years. In the UK 20-25% of births are by CS, up from 9% in 1980. The draft standard focuses on improving the information available to women who may request or need a CS. The draft standard also focuses on reducing potential risks or complications for the woman and the baby."

The consultation is interested in hearing your views on nine draft quality statements, listed in the consultation document (pages 3 & 4). These range from ensuring pregnant women who request a CS discuss their choice with their maternity team, to involving a consultant obstetrician in the decision-making process, and to exploring procedural options when there complications arise during labour.

The questions asked by the consultation are:

1. Can you suggest any appropriate healthcare outcomes for each individual quality statement?
   
2. What important areas of care, if any, are not covered by the quality standard?
   
3. What, in your opinion, are the most important quality statements and why?
   
4. Are any of the proposed quality measures inappropriate and, if so, can you identify suitable alternatives?
   
   Please post your thoughts on these questions and, of course, anything else you want to say on this thread. The consultation closes on 24 January 2013 at 5pm.
   
   Thanks,
   MNHQ

[JumpHerWho]

just lost a really long post, detailing each horrible part of my post natal experience.

Not typing it again, but there are and will be many, many posts saying the same thing.

It's major surgery, start treating women who've had it with a bit of care.

And healthcare assistants in my experience are about as much use as a random in the street when it comes to breastfeeding support, but will try anyway, even the male ones. And won't call a midwife if you ask them to.

[PPT]

Agree with what AlexanderS has written- I cannot understand why a woman, who has had major abdominal surgery, is expected to jump out of bed, less than 12 hours later and given pitiful pain relief.

For me too... Breast feeding was very difficult to establish, because even though my son would latch on in front of mw's none of them would take the time (doubt they had it) to actually sit through a feed. He'd drop off the boob 2 minutes later.

I was incredibly sore, and cried a lot. I felt I was treated like a bit of a hindrance despite having had a crash caesarean with pre-eclampsia and triple cord wrap round ds's neck.

I had no debrief about wound cleanliness or future pregnancies.

Would like to see an increase in private rooms available for c-section patients (they are in for longer and need to rest to recover... Again, it's MAJOR surgery)- but not have to pay for them through a fee.

[Ariel24]

AlexanderS I'm so so sorry you had such an awful experience, what you went through is appalling. I felt my postnatal care was lacking but only due to such severe staff shortages, the midwives were all lovely though and did the best they could in the circumstances. The midwives and care assistants you had the misfortune to meet sound absolutely vile. Your comment just hit the nail on the head for me as well, that with any other major abdominal surgery you'd be encouraged to rest and be looked after but after a c/s it's totally different.

[Meglet]

I'm with AlexanderS, not exactly the same things happened to me, but the lack of care was the same. The feeling of being totally alone (but in the noisy PN ward from hell) after a major op and caring for a newborn was terrifying . I remember crying on the bed with 2 day old DS telling him I'd get us out of there as soon as I could .

I did choose to have a birth debrief after my EMCS when DS was 12 months old. All very straightforward, running through why it went tits up (broken cervix which we didn't realise was broken) and was told by the midwife to never attempt natural birth again. The midwife also apologised for the dire PN care and said it was pretty bad in most cases, they'd put money into ante-natal but not into the PN care. So it's not just the new mothers who think it's shit, some of the staff are in despair over it too.

As did the gynea nurse booking me in for my hysterectomy, and it wasn't a subtle rant, she said it was disgusting how post-natal CS women were treated and I was not going to be expected to move for at least 48hrs post hysterectomy. I was off paracetamol 5 days after that op (and only took morphine the first day), far far less than the pain-killer fest I had after my cs's.

And what is so bloody awful, is that my EMCS was 6yrs ago and I am still upset about the PN care.

What I will say is that I can't fault the ante-natal midwifes, consultants and theatre staff in either of my sections (emergency and planned). They were bloomin wonderful.

[JumpHerWho]

Nodding at so much of what you both write Alexander as Meglet. I too had

I'm actually quite traumatised by it, this thread is triggering so many feelings. I can't be literate about it because it hurts so much to think back to how uncaring the staff were and how little help I had. I too passed out in the shower, following huge blood loss and no transfusion. I failed to breastfeed, despite huge pressure there was no support and no understanding of how much pain I was in, the bf counsellor said to DH 'does she actually really want to breastfeed?' because I was crying out in pain every time DS latched on, of course I bloody did, it makes your uterus contract and it had been cut open merely hours beforehand, and paracetamol wasn't quite cutting it strangely enough

[looby72]

I'm 7 weeks post c section, required due to previous pelvic floor repairs in 2008 and 2009, following a total mis managed vaginal delivery. Prolonged 2nd stage, neglect of medical staff etc etc.

However, following pelvic floor repairs, was not allowed to get out of bed for 48 hours! Comparing to a section, no electric bed and advised to get up and out of bed asap, with no assistance or advice on what to expect. To say you had just had major surgery, there was little assistance with the baby, on one occassion the baby nearly choking following some vomiting, because i could not move quick enough to lift him. Needless to say I chose to keep him on the bed with me, just easier!

I was discharged home on day 3, and have to say it was the best thing. Poor nutrition, limited support, having to constantly ask for appropriate analdesia and not getting any rest due to noise and regime of a ward with lights on at daybreak etc...not remotely relaxing.

Midwifes back home, equally as disappointing and varying in there warmth and level of care. Post natal care pretty rubbish, however cannot fault actual theatre staff, medical team carrying out the op or recovery staff, very understanding, even facilitating skin to skin contact.

[debtherat]

Quality of post op care is appalling - lack of fluids, no access to buzzer to call staff, no support with b/f - luckily my EMCS was 2nd baby so knew what to do but positioning with drip and major stomach wound (and massive depletion of energy that goes with GA) was still tough. First time mums after ECMS trying to breastfeed not supported - lots of crying mums and babies - mums still in shock. My humiliation was being told to get myself to toilet now (after 1 bed pan ) and 16 hours after surgery and getting up I bled profusely over the floor, lost my sanitary towel as not attached properly by night staff. And all the time the desperate pull back to the baby who needs to be loved/looked after more than you need to recover. I had one of the most vivid experiences of my life leaving the hospital after 3 days...I came out into a cool February evening, sun just setting, sliver of a moon and one star and I just wept at the joy of being alive still - I told my DH that if I could I would have knelt and kissed the ground. I am eternally grateful to the surgeons who saved me and my son.

[LoopsInHoops]

I felt horrifically bullied into trying for a VBAC, after a stillbirth and premature birth b c-section. I stood my ground and was scheduled an ELCS, but went into labour early. For 2 days of latent phases labour I asked and pleaded to have a c-section, but they were insistent on a VBAC, despite my wishes and very real fear. Eventually, after the support of some wonderful MNers who are midwives, I got the courage to demand to see a consultant, who examined me and discovered bleeding, so I had to have an EMCS.

After the trauma of my first c-section, when I delivered a still born twin and a 32 week live twin, the resulting PTSD meant that I needed extra care. I requested to see a specialist midwife (again, thanks to advice from MN) who helped me put measures into place to make things easier. Seemingly. I had requested a very low level of a tranquiliser before the surgery, as the simple thought of it (even now) makes me cry and want to throw up.

Just before my 2nd c-section, with the above in mind, the anaesthetist came to see me to persuade me not to have the tranquiliser. I was exhausted and frightened, not having slept for 2 days, and being told I was bleeding and needed EMCS, I relented and allowed them to forgo the tranquiliser.
The part that I was/am afraid of is the spinal needle, not the surgery itself. I explained this, and the anaestheist seemed sympathetic and assured em that I wouldn't see the needle and that part would be quick and pain-free.

After multiple attempts to insert the needle, resulting in A LOT of pain and bruising all up my spine, the junior (why? why me? surely it makes sense in this case not to use your junior on me?) gave up and called for help, so the consultant anaesthetist ended up inserting the spinal properly. I still am very cross about this.

PN care not great either time. The first time, I was very fortunate to be in a separate room for bereaved mothers. This was fantastic, but unfortunately not geared up to bereaved mothers with live babied. DTD2 was in NICU, and I was expressing milk. I had to ring the bell and wait for the pump, then ring again for it to be taken away and sterilised. After a few days (bearing in mind DD was tiny and in NICU, also bear in mind this was my first pregnancy and all happened 2 months early so I wasn't prepared) my pump attachment came back with milk on. I didn't know I was upposed to be washing it before sterilisation. So tiny 4lb DD in an incubator in NICU had been tube fed dirty milk. :(

Sanitary protection - this isn't something you can do yourself to begin with, so health assistants shouldn't really complain if being asked to help with this.

And water! Those piddly little glasses every few hours are not enough. Jugs should be freely available and replenished often.

Yes to not enough painkillers. First time this was fine, not second. Yes to being expected to be up and showering after a few hours. I also passed out in the shower. Awful and unnecessary. Food trolley - no-one to get food even for those who had just had surgery, other patients post-op expected to serve themselves and the others.

[LoopsInHoops]

Oh, and KEEP THE BOUNTY VULTURES AWAY FROM PATIENTS!

[BasicallySFB]

One EMCS.

Postnatal care MUST be covered in depth. I've had x 9 abdominal surgeries - with my EMcS, after 8 hours when epidural had worn off and the 10mg morphine I was given in theatre was long gone, I was given 2 paracetamol, and told 'youre a mother now, not a patient'. On the second day, at 20 hours post section, I was told to get out of bed to take DS to the feeding room (no feeding in bed) and left bleeding in a chair.

There's NO other major surgery that would lead to such horrific post op care. It felt like I was being punished for a 40 hour failed early induction.

[TheSamling]

Jesus, the disparity of care received between women on this thread is crazy!
I'm so sorry for those of you who have had some frankly negligent and inadequate care. I'm sure if a study of birth experience and incidences of PND was undertaken the NHS would see a real case for throwing some money and time at this problem. This doesn't just effect the women involved, but they tiny babies and the start they get in life, which in turn effects their whole lives.

[Gatorade]

I think this is a difficult one as those so are so terribly unlucky to have received poor care will always be more vocal than others. Clearly nobody should ever receive awful care, but I don't personally believe this is typical.

I had an EMCS due to cord prolapse with my DD, the after care was amazing. I had to talk the midwives into removing my catheter so I could get properly up and about 8 hours after surgery (for me this was the right decision, I healed very well with no significant pain despite the surgeon describing my wound as 'large as we had to slash and grab'). I was happily walking around the ward with DD within 18 hours of the surgery.

Different people heal differently, have different pain thresholds and emotionally cope with situations differently.

In terms of the actual framework which is set out in the linked document (pre care directed) my recent experience (I am pregnant with DC2) is that most of it appears to already be in place where I am. Despite having wanted a 'natural' birth with DD I am terrified of the same this time around and the midwife I have spoken to has said that an elective will not be a problem and the views I have received have been balanced and not heavy on the risks of a c section only.

[LoopsInHoops]

They let you walk around the ward with a baby?

And no feeding in beds is utterly bonkers. What a stupid rule!

[Gatorade]

Also, I think a debrief post EMCS is very important for emotional well being and to help to not fear a future pregnancy. My consultant was fantastic in this respect and took time to explain what had gone wrong and the likely reasons why before I had even left hospital (I think it helped that I was at a relatively small hospital and was well known to the consultant following a 20 week loss in my first pregnancy)

[Gatorade]

Loops Yes, I walked to the communal room and to the bathroom with DD as I didn't want to leave her, I wouldn't have done this any earlier or if I experienced any pain or numbness.

[LoopsInHoops]

No-one (apart from staff) is allowed to walk anywhere with the babies at the hospital I had DCs. You have to wheel them in those fishtank cots.

[cleanandclothed]

The NHS currently seems very happy to stress that it is major surgery if you are trying to get an ELCS - but then very happy to ignore that you've just had major surgery when you are on the postnatal ward.

Completely agree with this. I haven't had a C-section but have been on post natal wards with women who have and who were given v little help. Last time, a women who still had a catheter in, compression stockings and who had been told not to get out of bed, was left for ages while she buzzed for help to clean her baby and get some sanitary protection. She asked everyone who came and lots basically said 'not my job' then the midwife came and said, in front of her to the assistant 'we have to do her she is just going to keep buzzing until we do'. She was then told that her DH should be in during all visiting hours to help (might be nice to be told beforehand, and what about lone parents) and the baby was swaddled by the midwife so the mother could pick it up out of the cot, despite guidance being given in the hospital not to swaddle.

A C-section is a distinct possibility for me with DC3 (2 3rd degree tears) and I am really horrified by the thought of the post-natal care.

[elizaregina]

1. NO CONSIstency of atttitudes to women asking for ELC. Widley different expereinces on here some women even with severe physical probs from past labours have been written off and denied.
   
   There needs to be a strict unity across the board and not down to the consultants preference - personal ideas or stats watching.
   
   For me - I saw someone who is part of birth trauma association. I was granted one at 20 weeks ish which was a huge relief. Inspite of my previous labour being so called " text book" - 6 hours established - 24 mins pushing - one small tear.
   
   My consultant took the holistic approach - and saw me as a human with a brain and emotions as well as a pair of hips and a good birthing pelivis!
   
   
2. all care up to the op including the op was fantastic.
   
   
3. care in recovery was fantastic - no problems with milk - its the placenta removal that stimulates milk - baby came out screaming from the get go no lung problems ( at 38 weeks).
   
   
4. overall good care on the ward in terms of caring people and constant attention and people came very qucikly when buzzer was used.
   
   HOWEVER - all adivce was given on personal preference by each CA or MW. Every single time i was told something different.
   
   I was also told by the ONE horrid MW to get moving and turn on my side - but with no guidance - I pulled something as I did a big twist.
   
   So need guidance on how to move after a section - get in and out of bed - move in the bed which is very soft and makes moving even more hard.
   
   
5. remind all staff and keep them plugged into being caring to people who have had major ops! We are thier clients, you wouldnt be horrifcally rude to someone you are serviing in a pub for no reason and expect to keep your job.
   
   
6. wound care- moving advice when you get back on the ward please, not a leaflet weeks later given by HV.
   
   Other than that - the care and staff numbers etc were fantastic. They just needed to be consitent. One lady said I could have oral morphine in between other drugs - another said no etc etc...
   
   
7. Have some ward ettitcute advice somewhere for people to read - ie, your baby cries at night - we expect that you cant help it - but you CAN lower your own voice and keep noise to a minimum. Dont have a mobile convo at 2am speaking at normal volume! Ask all visitors to wash and gel hands when coming onto the ward.
   
   
8. Allow husbands at least the first night in private rooms to help care for the baby and partner. Make this clear.

[LittleAbruzzenBear]

Whilst the care I had for my EMCS and subsequent CS was fine, it is certainly the after-care I found to be horrendous. I agree with another poster who said GP's are dismissive of any health problems afterwards. They are very much it's part of having a baby so put up with it, stop moaning etc.

Another huge thing for me was lack of help with establishing breast-feeding. Especially with DS1. I hadn't had a baby before, I hadn't expected to end up with an EMCS and I didn't know my milk wasn't going to come through until DS1 was 5 days old. As a result when I was struggling to latch him on comfortably/properly as it is, he was starving because my milk wasn't there. I also got a nasty internal infection and got a fever. It took me 3 years to get pregnant again and I think it was psychosomatic because I was scared after my first experience.

[LittleAbruzzenBear]

Oh, also, I was in agony for the half hour journey home in the car. My SiL who went to a different hospital was given morphine and told to put a cushion over her tummy and she was fine. It is all so inconsistent.

[Mercedes519]

Well I'm pleased to say my PN care was great - midwives who helped me with DD, supported feeding her every time I tried and discharged me after 3 days ready to go home.

However before that...

Women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies

This didn't happen.

Pregnant women who have had a previous CS are given the option to attempt a vaginal birth

Being given a LEAFLET at about 28 weeks with No. 2 about VBAC is not how you give an option. There was no further discussion until 38 weeks! I was not happy about not knowing how I was going to give birth - I had loads of questions about things like length of labour, the impact on my SPD, the risk of rupture becase I had done research. They were brushed aside as being something 'we'll talk about later'.

Consideration needs to be given that even though you are having a second baby, if you've had a CS the first time you are MORE worried about natural birth - all the anxieties of the unknown plus the worries left over from the first time.

There should be an informed discussion early on in the pregnancy about options (i.e. more than one), risks and how the conversation will progress. Then throughout they should remember it is your first labour so you WILL need the level of information of a first time mother.

[poppy283]

To add to my earlier comment:

I asked a hv after dc1 was born if I would be offered an elcs next time, she said yes. I asked my midwife at booking appointment when pg with dc2, she also said yes, no one will stand in your way.

So at my appointment, scheduled for 36weeks, I did not expect the consultant to be surprised that I wanted an elcs, or did I expect her to attempt to persuade me otherwise.

If I'd known I was going to have a battle on my hands to choose what happens to my body, I would have brought someone with me, and ome armed with nice guidelines etc.

So sorry to read others have had such shocking pn care, mine was mostly excellent both times.

[RedToothBrush]

Trying to stick to the original questions in MNHQ's post, but a lot of the points actually overlap quite a bit so this is the best way in which I can express this:

1. There is nothing in the framework about for women who have a severe anxiety about childbirth and want an ELCS before they become pregnant for the first time or after a previous birth.
   
   If the aim is to try and help women overcome anxieties, then only taking action once a woman has become pregnant adds to the stress of the experience. Baring in mind that one of the reasons that NICE changed the CS guidelines was to recognise the fact that small scale studies had shown that women with tokophobia had, in extreme cases, terminated their pregnancy.
   
   The emphasis is solely on women once they are pregnant, which perhaps means the success rate of any counselling is likely to be much lower and ineffective as it is a race against the clock.
   
   It also leaves a number of women in a state where they are putting off pregnancy and anxious about the process before it even starts, as they are not formally recognised in any guidance. It is wrong that women have to make such an enormous leap of faith before they are considered important enough to be considered.
   
   The only thing in the guidance that comes close to this, is where women Draft Quality Statement 8: Debriefing where women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies.
   
   There is nothing for women who have had a difficult or traumatic VB delivery, and may want similar help and advice.
   
   
2. Encourage of much clearer separation of Planned CS from EMCS in all planning and commissioning of services.
   
   The two are still being widely lumped together as they are the same procedure, however, the risks and psychological impact on woman are hugely difference.
   
   This is particularly true in the way that risks are being presented to women in a biased way.
   
   When rates of CS are talked about, the number is almost always presented in a single figure - as was the case in the intro that Mumsnet posted to this very NICE consultation. Its very unhelpful as the issues surrounding both can be quite different. It is distorting things in a way that is quite alarming. EMCS are made to look safer and ELCS are made to look more dangerous. This is not helpful in the decision making process.
   
   In using a single figure it is affecting planning, particularly in a climate which is hostile to 'expensive CS' as there are political moves to try and reduce this single figure, rather than to look the two as similar but different issues and on medical grounds alone.
   
   
3. Encouraging all HCP to make publicly available clear procedures and policies about what happens if you want/request a CS or a VBAC before you see a midwife or consultant.
   
   There is no way of finding out the procedure for going about getting a VBAC or ELCS until you are in the system and this means you are very dependant on the individual HCPs you encounter. This means from the word go, women are going into things relatively blind. Making the system transparent and encouraging the promotion of services in some way so that women do not feel that they will have to 'go into battle' in order to be listened to. Many women seem to feel that the decision is immediately out of their hands.
   
   By making policies more open before women even see a consultant or midwife, empowers women to be more able to go and find out information before a meeting and be able to ask the right questions.
   
   Obviously each woman is on a case by case basis, but certainly there must be generalised things that could be put forward so the majority of women have a better idea about whether they are a good candidate for a VBAC or an ELCS.
   
   For example better use of the hospital websites could make a huge difference to this and could be relatively inexpensive.
   
   
4. Better publishing of data would be hugely helpful.
   
   Presently you can chose hospitals on the basis of what facilities they have, but data on method of birth is still quite primitive. Again this is hindering care, with many people, including HCPs having inaccurate perceptions of birth.
   
   Data to show VBAC success rates would be hugely helpful - however, this also needs to be countered with a measure of patient satisfaction with involvement in the decision making process, in the same way that is suggested for maternal request in the Draft Quality statement 1. Rates alone are not reflective of success and should not be treated so.
   
   Also there is nothing to breakdown rates for why ELCS are being done. This should be encouraged, particularly making clear distinctions about ELCS on the basis of mental health reasons, rather than 'maternal request' would be a massive step forward.
   
   The term "Rates of planned CS in women in women where there were no indications for a CS" is somewhat misleading, misunderstood and frustrating in this regard. Its a fuzzy term that makes it an easy target for cuts.
   
   More detailed rates about VBACs and ELCS are important to women to understand that both are available for their individual circumstances.
   
   This is also hugely important to gain greater understanding of why ELCS rates in particular still seem to be increasing (I believe EMCS rates are more stable) in order to tackle issues, rather than be bogged down in politics that are being dominated by the tabloid press and to the detriment of women.
   
   This is also true of EMCS but perhaps to a lesser extent. Women need to feel confident that hospitals are not practising in an overly defensive or being overly adverse to performing CS in certain areas.
   
   How women are being judged when it comes to method of birth is an important aspect that is being woefully neglected. This hopefully would help to address some of those issues.