New guidance to reduce epidurals and a target rate of 20% for C-Sections

[HmmThinkingAboutIt]

New guidance being issued by the RCOG, the NCT and the RCM is urging to decrease C-Sections to a target of 20%, to decrease epidurals and to make Midwife Led Care the default for low risk women. The document is here

This guidance is controversial and goes against the position of NICE, the NHSLA, and the DH.

I've already posted this in the Childbirth section, but I do think this needs a wider audience, and to get this seen by as many people as possible and it was suggested I posted this here rather than AIBU. Original thread is here

I do think this is definitely a Women's Rights issue for a couple of reasons:

Firstly its the language being used in the document. Its extremely paternalistic. It talks about getting the GP to influence patients to make 'good choices'. (I've expanded on how I feel about this on the other thread) and is extremely patronising and almost about trying to get women to behave in the correct manner rather than doing whats in their best interests.

Secondly theres the conflict of interest this causes - if a midwife/doctor is under pressure to achieve a target of 20% how are they going to do this as well as put the needs of the woman first?

Then theres the issue of restricting women's choices and options; especially with regard to pain relief.

The RCM, RCOG & NCT document has caused so much concern amongst a number of campaigners that its lead to them to issuing a <a class="break-all" href="https://docs.google.com/viewer?url=www.electivecesarean.com/images//12-aug-24%2520rcog%2520ccg%2520press%2520release%2520final.pdf" rel="nofollow" target="_blank">joint statement which sums up all the issues far better than I can.

I find the whole thing quite alarming and frightening. I don't appear to be alone if the other thread is anything to go by.

I know its all a bit of a read and apologies in advance, but this is important and doesn't seem to be being reported anywhere else, and I do think this needs to 'get out there' for discussion and debate.

By the emphasis being on the support as pregnant women should be seen as individuals each with valid opinions rather than a one size fits all homogenous group. To some women an elcs might be the most important option - to others a home birth. Both are equally valid. And yet it all boils down to money and resources. So highlighting that if you do this ( one to one care) results in saving money ( less epidurals, less emcs) should be the way forward? And not focussing straight on the cost-cutting bit?

PMHull

Thank you so much for all your hard work. It means a lot to women like me:)

LaVolcan

You said that for most women the default place of birth is a CLU. Perhaps that may be true, but from my understanding MLUs and home births are both legitimate and available options on the NHS. They are not just recommended for high risk pregnancies, which isn't all that unreasonable. Sort of like how c sections are not recommended prior to 39 weeks of gestation or for women who want 6 kids. Every choice has to be available with some sort of safety protocol in place.
I could argue that most women in the UK end up with midwife led care, whether they want it or not. What about women who prefer consultant led care?
The new guidelines seem to suggest that most women will be "advised" (read:forced) to give birth in MLUs and that epidurals and c sections will be discouraged. How is that fair?!

Your posts reminded me a bit of what Cathy Warwick said in response to women being denied epidurals and c sections-"Well, many women are being forced into c sections and epidurals even when they don't want them". So is the solution to one set of women being denied their rights that we move onto another set and take away those choices with a tit for tat mentality?

The solution is to get rid of the paternalistic attitude that exists among BOTH obstetricians and midwives. They think they get to decide what is best for a woman and her body, whereas she should be the one to make that choice. Women who don't want interventions should be supported to have a natural birth, and women who want epidurals and c sections should have every right to get them.

The way to reduce c section rates isn't to deny that choice to the small group of women who ask for the procedure, but to ensure that women who want a vaginal birth don't end up with unnecessary c sections.

"But I still dont think it's very feminist to endorse what could be argued is mass mulitation of women which is done for men's benefit often on ill informed women."

What are you talking about?!?!

Are you seriously saying that epidurals are a "mass mutilation of women"? And what kind of benefit do men get from them?

It isn't very feminist to assume that all women who ask for epidurals or c sections are automatically "ill informed". It's downright patronising to think like that.

My grouse against these self proclaimed feminists is that they keep repeating the mantra "My body, my choice" to passionately support home birth and VBAC(which aren't exactly risk free), but when it comes to a woman's right to choose an epidural or a c section they get outraged and automatically assume that such a woman is "uneducated" or "ill informed". In fact, they end up supporting the idea of her being denied that choice.

So "My body, my choice" comes with limiting clauses then does it? It's your body and your choice as long as you choose a home birth at Ina May Gaskin's farm or a drug free labour. But if you dare to choose a more medicalised approach, then you must be misinformed and it is no longer your choice.

Makes ZERO sense and is sickeningly hypocritical.

If it's her body and her choice then it can be ANY choice irrespective of whether you agree with that choice or not. That's feminism.

WantsToBeFee I am a bit puzzled as to how you have read all that into my posts. I referred to most women being sent to CLUs - but referred to it as being some sort of idealised CLU - which doesn't exist in real life.

You said I could argue that most women in the UK end up with midwife led care, whether they want it or not. What about women who prefer consultant led care? What indeed? How does my reply saying that in practice women are often not attended by anyone go against that?

I said (Or at least an idealised version of the CLU where they are all well staffed and can immediately spot a problem and attend to it. Not the CLU where you never see the same person twice and go unattended for long stretches in labour, never mind get to actually see a Consultant.)

How do you make an inference from that this is saying that women should be denied the chance to see a Consultant? When I had my first child I naively expected that a CLU booking meant just that. I didn't expect it to be a two hour wait to see - well who? I wouldn't have bothered if had known that the nearest I would get to him would be having his name on my notes. As far as I can tell that's the reality for most women and it might be more honest to tell them so.

It would also be more honest instead of telling women that they can have an epidural and they shouldn't have to wait more than 40 minutes that the key thing is that they have got to get across the threshold first - not be sent home because the hospital is too busy and you are not in established labour dear (even though you need support.)

Homebirths are a theoretical option for all women but provision varies. Some places are geared up to them; others have probably hardly seen a home birth in 50 odd years unless it's an accident.

MLUs? Well, it depends where you live, but there will be a good chance that if your nearest one hasn't already closed down it will soon be, so I can't see many women having births in them in future.

LaVolcan I thought MLUs were being encouraged now based on all that I've read and heard and I highly doubt that they will shut them down in the future.
If anything, there seems to be a push to encourage home births and MLUs and discourage epidurals and c sections.

Moreover, the same can be said about epidurals and c sections. Theoretically they are an option for all women now, but despite the recent NICE guidelines update, women are still being denied that choice. The provision for c sections and epidurals varies as well.

The question is is any woman getting the birth she wants?

Hmm, I doubt it. More likely that they will get closed down, and more women will be shunted into the CLU to be left unattended. But perhaps I am too cynical.

Patron Yes their classes seem to leave a lot of initiative to the individual instructor. But on an organisational level they consistently advocate for guidelines like these.

White Well yes but that's not what the target actually is about. Apart from which this 20% business is only one element of the guidelines. Making midwife led birth units the default for low risk women means restricting their access to CLU's.

LaVolcan I agree about the odd priorities. But continuity of care and one to one support aren't actually valued or wanted by all women either! Woman-centered care should include those who, for example, just want an epidural or a caesarean and aren't particularly bothered about whether they're getting one to one support or continuity of care or not. So why should targets focus only on that?

And surely the reason why none of this happens is that it costs money and women don't kick up any stink about birth. Those with bad experiences usually just want to put it behind them. Ironically enough the ideology of natural birth feeds into the ignoring of the issues too. If birth is so natural and normal then why should women need pain relief, caesareans or one to one care and support etc.? It's rife as is clear from the comments on any article about this in the press.

I was very anti epidural and am a keen advocate of natural birth with as few interventions as possible. However I am disgusted by the attempt to force women to give birth in an "approved" manner.

£200 ? Well, that's a drop in the ocean compared with the weekly cost to the NHS of drug and alcohol-related incidents, sporting accidents and all manner of self-inflicted injuries. But obviously the needs of a woman in labour comes way down the batting order compared to a habitual drunk being admitted for the 3rd time in a day. Fucking great.

A lot of women are ill informed though.

Not everyone is like a typical MNer have you seen the 'other site'?

re: mass mutilation I was referring to c sections rather than epidurals

Margerykemp

1. Most hospitals will go over all the risks of a c section and make the woman sign a consent form before performing a planned c section (there may not be enough time in emergencies). So women who have planned c sections are not ill informed. Even if an individual woman's reasons to have a c section seem uneducated to you, who are you to say that she can't decide what to do with her body? Her body, her choice- there can be no exceptions and clauses to that. You either believe in it fully or don't bother.

1. C sections are a mass mutilation of women? Seriously?

What about routine episiotomies and forceps which may cause fourth degree tears? Is that acceptable merely because the baby came out vaginally? I don't care if this sets the NCT into a tizzy, but childbirth in any way shape or form is brutal- there is no painless, easy, gentle way of doing it. There will be blood, there will be some form of injury, there will be pain. To call c sections "mass mutilation" is the worst kind of over-exaggeration ever.

And would you care to clarify what men could possibly be getting out of the high c section rates? (since you mentioned in your earlier post that they are done for mens' benefit)

Margerykemp said "A lot of women are ill informed though."

Margery, a lot of women who undergo vaginal birth are woefully uninformed too, and are shocked by the brutality of it all. But presumably that's OK with you, because it's "natural".

What about the many babies who are deprived of oxygen during birth, and end up with conditions such as cerebral palsy because natural birth zealots midwives fail to call in the consultants before the damage is done, in an effort to avoid c-section?

P.S. I should clarify that my natural birth zealots strikethrough does not refer to all midwives!

Margery "A lot of women are ill informed though." You could do with a good hard look in the mirror.

Wants You'll only get The Rage arguing with people like Margery. Just saying.... Anyway, extremists like her are the best anti-NCB argument ever.

40 odd years ago though women did campaign not to have routine episiotomies. First baby = episiotomy, second and later = episiotomy, why? Because you had one before.

Not that 4th degree tears are an improvement! A better standard of intrapartum care might help here.

I always wonder how many EMCSs, forceps & ventouse happen because of inductions? Especially for inductions where the reason is being overdue - which could be 10, 12, 14 days over your due date, depending on the policy of your hospital.

LaVolcan

Not all women want to be the "44 weeks mommas" (a latest fad in the grand USA). Most are happy to be induced once they're 12 days or so past their due date as they realise the increased risk of stillbirth post 41 weeks and the increased risk of complications like shoulder dystocia with an overdue baby.

Again, they key here is choice.

I didn't know that shoulder dystocia was related to being overdue - I believe it's not even necessarily due to size. I don't know how much reliable information there is about stillbirth even? I know that stillbirth rates haven't significantly changed in recent years, so whatever we are doing now to prevent them doesn't seem particularly helpful.

No, not all would want to go to 43 weeks let alone 44 but as you say the key is choice and it should be informed choice. Not 'we will book you in for induction... you don't want a dead baby do you? ' kind of information.

I still think it would be useful to know how many inductions and for what reason, ended in instrumental/CS deliveries. I don't even know whether they keep such statistics.

LaVolcan

The bigger the baby, the greater the risk for shoulder dystocia. Obviously, shoulder dystocia can occur even when the baby is small, but SD is definitely more common in babies weighing over 3kgs. You'll find plenty of research to back this. And needless to add, overdue babies are more likely to be bigger.

Furthermore I've read plenty of research papers that prove the risk of stillbirth increases after 41 weeks. There was even a recent study that showed how elective c sections at 39 weeks could actually prevent a certain number of stillbirths.

I don't see what we will achieve by figuring out how many women who are induced end up with c sections. What's the solution? To stop inducing women who are overdue? That comes with it's own set of risks. And as I said, not many women are happy to be pregnant endlessly- many want to be induced.

And many even gasp, shock want c sections.

I know several people who have had an emcs due to failed induction when overdue. All of them forced to labour for a long time before going to c section, all of them wishing they had been allowed a csection earlier and most of them opting for an elcs for subsequent births. I think ELCS should be offered as an alternative to induction instead of pessaries every 12 hours unless there's no delivery rooms, being left to contract on a ward, being allowed to labour for days, often needing a syntocin drip and intervention. What's natural about that? Surely the process also takes up a lot of resources?

If MLU are to become the default are they going to stop closing them? Our local one is only open if you request it, you have to phone when in labour for the midwives to meet you there. If anything happens its a 20 minute transfer to the CLU at another hospital. If you need to go on to a ward rather than be discharged its a transfer to the CLU. On the information I was given it stated that if your baby needed neo natal care then it would be 45 minutes before the neo natal team arrived in an ambulance from the CLU. I had both my babies at the CLU and I think I saw a consultant once, other than that my care was midwife led.

onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1998.tb10047.x/full

The risk of stillbirth increases gradually from 37 to 43 weeks of gestation from 0.7 per 1000 to 5.8 per 1000.

ukpmc.ac.uk/abstract/MED/1553174

www.ajog.org/article/S0002-9378(01)11435-3/abstract

the risk of perinatal mortality is lowest at 38 weeks of gestation.

Your first paragraph expresses what I was thinking FrillyMilly. I know a couple of people myself who have had the same experience and it's one that I think precious few would choose. I hadn't the heart to ask them whether they were warned that it might take 50 hours and then lead to a CS anyway.

So why not start to question whether these inductions need to be offered? Does the baby need to be got out now, in which case why not offer a CS straight off? Otherwise, can it wait? How many women are offered expectant monitoring?

I was warned, weighed up risk of waiting past 38 weeks, opted for induction, had EMCS after 39 hours... But I never had expections for anything other than a medical birth, and after 12 years of infertility I just wanted baby here safe, and they literally could have done whatever it took to get him here. That was my informed choice - and one I'm very happy with!

Maybe women need more unbiased info way before 41 weeks when they're presented with scary facts and limited options?

LaVolcan I was induced with DC2 due to hind water leak, luckily this was done by breaking my forewaters due to already being dilated but before I was examined at no point was I told what would/could happen and how long it could take. I spent 12 hours on a ward waiting for a bed in a delivery room and another woman on there who had had a pessary had to spend those 12 hours contracting on a ward with only paracetamol and the company of 4 other women and their partners. What an awful experience for her. I think the whole area of overdue induction needs looking at whether that be monitoring beyond 42 weeks, ELCS or pessaries/drips for hormone induction. I can't understand why the pessaries can't be put in at home so at least the women can have early labour in comfortable surroundings perhaps with occasional community midwife visits?

In my experience midwives tell you the bare minimum which limits your control and ability to push for an alternative. Until MN id never known about monitoring beyond 42 weeks induction at term + 10 was given to me as this is what will happen. With DC2 he was also breech until 36 weeks, again being sent for ECV was told to me as 'this will happen' when in actual fact based on my own research I was going to refuse it and opt for ELCS and the possibility of a vaginal breech birth, whilst not for me was never mentioned.

This is what I meant by women being I'll informed- lots of women don't realise they can refuse inductions they don't want, refuse ecvs, etc

Women need to be better informed about the 'cascade of interventions' and make their own informed choices rather than being dictated to be doctors.

A lot of women don't want c sections but end up with them because they were forced into inductions that they didn't realise increased their risk of c section.

This is 'mass mutilation', as are unnecessary episiotomies and 4th degree tears. Birth can be done without injury.

The medicalisation of birth has benefitted men by increasing the job opportunities on OB which has mostly benefitted men. Not even to go into the logistics of births being timed to fit in with their golfing schedule.