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 noindex" 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.

[NanBullen]

my first birth - no pain relief apart from g&a which only works for me unto a point. I asked repeatedly for an epidural but was told i didn't need one because i was dilating so well. the midwife seemed to miss the fact that because i was dilating so well i was in unbearable pain. in the end needed a ventouse as i found pushing so painful. then had retained placenta, still no pain relief even after being put back into labour and agony for 2 hours until it could be removed in surgery. This was my so called "natural" birth.

second birth - saw many consultants and the head midwife at addenbrookes hospital to try and get a cs. no luck. saw a counsellor at same hospital who said i had ptsd but still couldn't have a cs, as one bitch consultant said, i shouldn't just assume i could have a cs "on a whim" Had to involve the head midwife to try and ensure that i would be guaranteed an epidural, had to get her to sign off on my birth plan (like I'm a fucking child) to say that as soon as i was in active labour (4cms dilated according to her, 3cm according to me!) i could have an epidural.

Long story short (sorry!) I got the epidural and pushed dd out in 2 pushes because i had no pain Although not before the same bitch consultant came into the room saying the epi should be turned off so i could push better

Sorry this is soo long, but why, why, why did i have to go through so much pain in my first (apparently natural) birth and then have to fight so hard just to be sure i could get the pain relief i wanted in my second? this was only last year! Where were my choices?

I think all women should have the choice to give birth however they want (safely) and the option to change their mind whilst actually giving birth.

sorry about the long post, this just makes me so fucking angry!

[FrillyMilly]

NanBullen my midwife was saying the same, I was blacking out with the pain! I couldn't sit down as it was too painful so I was kneeling on a bed holding on to the side and blacking out as each contraction peaked. Luckily my husband could see how much I was losing control and stuck up for me. This was in January.

[WantsToBeFree]

Margery

Most women know they can legally refuse anything. But do you really think it's that easy when you have bullying, patronising HCPs giving you 'advice'? It isn't always so simple.

And no birth CANNOT always be done without injury, whether it's surgical or vaginal. There are ways to minimise tearing, pain and discomfort but it cannot be avoided altogether.

[WantsToBeFree]

And do you reallly think that there aren't any female OBs in 2012?!

I don't know a single doctor who does random c sections to fit his "golfing" schedule. I've only seen doctors who will refuse to perform c sections and literally force women to have vaginal births. Honestly, where are these so called c section loving doctors? I've only met the ones who will refuse to perform them unless someone is dying.

[WidowWadman]

Margery

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

fucking cascade of intervention scaremongering makes me still angry. First time round I was so scared of the "cascade of intervention" that I refused any pain relief, even cocodamol when I already was in insane pain (thanks to the oxytocine drip). It was a lot of hard work for the midwife to convince me to give myself a break (in the shape of gas and air which did fuck all for me, and Meptid which was brilliant).

Yes, I ended up with a CS, but I doubt that it was the pain relief, which I agreed to way later than neccessary (nor was it the induction), which led to it, but just basically an unlucky draw.

I've given myself way too much grief and had too much unneccessary pain because of the "empowerement" promoted by the lentil weavers. I could have saved myself a lot of pain, if I hadn't been so paranoid.

Yes women should make informed choices, but misinformation doesn't only come from doctors.

[WidowWadman]

(and before you say I should have refused induction - meconium stained waters without any signs of labour are not a situation where I thought it'd be in the interests of my child to hang about and wait and see)

[FrillyMilly]

How do the NCT back up their mantra of 'cascade of intervention'? To me correlation does not imply causation in this case. There is no way of knowing what intervention would have/would not be necessary with/without induction, epidural etc do how can they state it as if it's medical fact.

If I had syntocin then epidural is that a cascade? I needed syntocin because I was 6cm dilated for over 4 hours and my contractions started to weaken. What was my alternative to this intervention? Surely most people who have the syntocin drip do so for a reason and most people I know who have got to the point of having syntocin will do anything to have their labour be over. If you have an 'easy' or straightforward labour then of course you won't need intervention epidural or not. The more I read about the NCT the more I dislike them.

[skrumle]

"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?"

increased risk of something - placental abruption i think? i had an argument with a registrar who wanted to book me in to be induced at 7 days over as that was what suited the hospital. when i refused i was lectured on how this was a totally natural process, no different to spontaneous labour, just a helping hand, etc and when i asked why i couldn't have pessaries inserted then go home he had to admit that actually there were increased risks...

i ended up going in to be induced at 12 days over, had to have a senior nurse administer pessaries each time because no engagement meant an increased chance of the cord prolapsing, started to contract but ended up needing syntocin which meant i had to be monitored, if i moved the monitor lost trace so i insisted on having an epidural as there's no way i could cope with the pain while lying at an awkward angle, didn't progress at all for 8 hours then went from 3cm to 10cm in an hour, baby in distress, failed forceps, emergency CS with 2 litres of blood loss.

it was STILL a better experience than first time round ;) and if i was ever PG again i would insist on a scheduled CS due to the combination of my previous obstetric complications. the CS i ended up with was probably unavoidable as DS was stuck due to really broad shoulders, so it wasn't really a cascade of intervention situation.

i don't think targets have any place in determining care for an individual patient and while i can see why they are created i think they are far too "one-size-fits-all". i also loathe the fact that the reporting of this focuses on the choices women make when IMO most women who end up with a caesarian feel that they had no real choice but to opt for that.

[rosabud]

Having read all of that feel very undecided about it! My eldest is 15, my youngest 7 so my experiences are probably out of date but I was in the "natural birth" camp, mainly as I was terrified of hospitals/ doctors etc. Won't bore you with my actual experiences but I felt that there was far too much pressure to have medical interventions.

Re the argument over pain relief. The thing with child-birth is that it is a natural process so your body is in charge and telling you what to do, eg you will know when you ought to be walking around, when it's time to squat/lay down/hang from the ceiling etc and the contractions control your urge to push and all that. So if you have blocked out all those instincts with pain relief then, surely, there is more chance of things going wrong and intervention then being needed? So there is a reason why you are supposed to feel everything, which means the pain too, in childbirth. BUT there are lots of natural ways to cope with that pain, the most important must be feeling happy in your environment. A medical environment where movements and other comforts may be restricted is therefore not the best place to be in for giving birth.

From that logic, I do agree with the feminists that have said that choosing which medicalised version of birth a woman would like is not a choice at all, that the whole debate is wrong in the first place. I do sympathise with the women who feel they have the right not to feel any pain at all, but I think there must be better ways to deal with that reluctance than to say, OK have lots of medical intervention.

[WidowWadman]

Yes, childbirth is a natural process, but so is tooth decay, menstrual cramps or developing kidney stones.

[LackingNameChangeInspiration]

Rosabud if I had naturally been having the type of labour you describe in your second parragraph I wouldn't have had any pain relief, and I don't actually know anyone who had pain relief and was having the type of birth you describe there either. Most people give natural a go first then, only when its NOT working out how you describe to they choose interventions. My body wasn't allowing me to do what my body was telling me to do.. and like most women who chose to move on to more medical pain relief I DID try things like TENS, Birth pool etc first. What you describe there is what I thought would happen, what I thought my body would do, but it didn't, not that time anyway! It might next time it might not, I hope it will and will plan for that but I also don't want to be forced to continue down that route if it is NOT working naturally and believe I should have that choice

your post reads like you think there are a lot of women walking in saying "hook me up" at the first contraction so that they never even TRY to see what their body will do with the pain, but I don't think that's the case for most women who do end up choosing interventions, its not about avoiding all pain - I'm actually surprised that a woman who has given birth would say that about other women! there is no "no pain at all" route anyway? what is it? epidural isn't no pain whatsoever, CS CERTAINLY isn't, do you really think that many people choose have these painful and risky interventions because they think it will fulfill their right to feel no pain whatsoever?

[FrillyMilly]

Nature doesn't know best or always work. With first labour I wanted to be active, I got to 6cm without even a paracetamol. I walked around using gas and air for four hours having contractions every minute, I had the urge to kneel and push. I was still only 6cm. My body got it wrong. Being in hospital does not bother me one bit and being encouraged to have a home birth would have made me very uneasy. Everyone is different and we need to ensure women are able to access the birth they want/need whether that be at home or at hospital.

[NanBullen]

well rosabud, when i felt everything in my first delivery, more things went wrong and there was a lot of intervention needed. I couldn't move or hardly breathe because of the pain.

I agree that it may have helped for me to walk around for example but i literally couldn't move. And this was my so called "natural" birth. My second birth where i couldn't feel anything went more smoothly and easily, and no interventions (apart from the epidural i suppose!) So my experience is the exact opposite to yours. And just as valid. Yet hospitals are more geared to helping women have a more "natural" experience even when, as in my case, this isn't the best way for me to give birth.

Obviously this is only my experience and everyone is different. Which is exactly why women should have more choice when it comes to pain relief and interventions.

It didn't help me knowing that there was a birthing ball available, or a pool, or I could walk about if needed. What would have helped me would be knowing that alongside these things, more medicalised pain relief was available.I would happily give birth in an American hospital. To know that I could have an epidural whenever i wanted it? Wonderful!

[NanBullen]

Actually, if I ever had any more children (ain't gonna happen!) I would quite happily be knocked out just before my due date then woken up and presented with a baby. Even before giving birth the first time i had no desire to experience it, just wanted it over with!

[LackingNameChangeInspiration]

its just not a one size fits all thing.. which is why you need choices

I would not relax more at home, I was VERY conscious of moaning and groaning because I live in a flat and didn't really want my neighbours to be an auditory audience to my birth thanks v much, especially the prim old batchelor who lives upstairs! I could not relax till I got to hospital!

I've spent half my life in hospitals and was much more relaxed there.. I've worked in hospitals since my teens, my father had a spinal injury when I was a kid so many of my happy childhood memories of spending time with him happened in hospital settings.. lots of doctors etc in the family

My NCT teacher TOLD me I would be more relaxed at home she TOLD me that by comparison I would not be able to relax into labour in hospital, and therefore would start the intervention cascade if I choose hospital not home

who the fuck are they to tell me where I feel relaxed?

and with CSs, how you FEEL about your birth effects you for months/years afterwards, it matters! the NCT lot will often tell you that you'll feel shite about your birth if you have a CS which is rubbish

This is really about the NCT telling women how they feel about what!.. as usual!

[seoladair]

Rosabud said I do agree with the feminists that have said that choosing which medicalised version of birth a woman would like is not a choice at all, that the whole debate is wrong in the first place

But Rosabud, that's tantamount to saying "you have a choice, but only the choice we approve of". How can that be a choice?

[seoladair]

I can never get bold to work
This is a test - please ignore
I wonder if it's a problem with Mozilla.

[seoladair]

Aha - it worked that time. Strange. Sorry - carry on debating!

[WidowWadman]

Sealeodair "But Rosabud, that's tantamount to saying "you have a choice, but only the choice we approve of". How can that be a choice? "

To be fair, that view is consistent with some feminist views regarding choice - with the patronising and frankly insulting underlying theory of women not being capable to escape indoctrination - their solution is to replace one type of endoctrination with another. Pretty offputting. It doesn't matter much whether its birth, sex, or anything else to do with a woman's life. Other people will tell her what she must do, and that their way is the only way.

[rosabud]

Yes I do see the point of those who have disagreed with me, I do understand what you are saying.

Lacking, I did sort of feel that some on here were arguing for being hooked up straight away, that it is a choice to say no pain at all, c section on demand or whatever. And, of course, that is a valid choice!

Of course I'm not suggesting that people should only choose to "go natural" or not to have medical intervention when things go wrong. The problem comes when childbirth is seen as a potentially horrendous experience where things go wrong. Like the poster who said that tooth decay and kidney stones are also natural processes! Yes but they are illnesses - childbirth is not an illness, it is actually something that is supposed to happen and for many women will go OK. Perhaps by trying to reduce the rates of c sections etc, that balance, which seems to be disproportionately in favour of "it's an illness/ it could all go horribly wrong" at the moment, might get back into perspective.

[WidowWadman]

"es but they are illnesses - childbirth is not an illness, it is actually something that is supposed to happen and for many women will go OK"

Childbirth is not an illness, but a hugely dangerous event in the life of mother and child. There is no evolutionary pressure for the process to go ok most of the time, as long as enough women and children survive it.

And it's not only dangerous in humans (who have the added problem of birthing infants with relatively huge heads compared to other animals). Just look at how many ewes are lost in each lambing season.

It's natural to give birth, it's also pretty natural to experience grave injury or even die in childbirth.

[Sioda]

That's so true Widow. I've had that in conversation with breastfeeding advocates and natural birth advocates so many times. Women who choose formula or caesareans or whatever can't possibly be making a free choice. It must be the result of outside forces - cultural attitudes, lack of support or education, propaganda, indoctrination. Their free will is completely denied. Of course it's impossible to prove that you have made a free choice and that it's not just your internalized sexism acting because you can't prove a negative.

And if you point that out you'll be subjected to Sociology 101 as if you're some kind of idiot. Some original thinker will point out that we all grow up in a patriarchal society, we're formed by those experiences etc., then they'll treat you to the history of formula company propaganda etc. or the patriarchy of the medical profession and attitudes to childbirth or whatever. It's amazing how many people are total cultural determinists when it comes to other people's choices, but never their own. They, naturally, have attained free will.

[seoladair]

Sioda, you're spot on!

[rosabud]

Sioda, I do agree BUT often the history will be due to huge lack of choice - for example childbirth bacame very medicalised, formula became the norm etc in the 50s and 60s to the extent that the natural breasfeeding lobby were facing an uphill struggle so their "choice" was being removed so, of course, they will argue more vociferously to regain that balance.

[seoladair]

Rosabud, that's true. The problem is that when people become ideological, they get so carried away that they often end up working against the very people they are trying to help.