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A Caesarean section in progress.

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There has been a lot of discussion about the proposal that women should be allowed to opt for a C-section even when their doctor doesn’t feel there is any medical reason for it. As with so much that is written about the NHS, I fear this may all be a fuss about nothing. I’ve had a look at the detail of the new NICE (National Institute for Health and Clinical Excellence) guidance and not much will really change.

Before I go on I feel I should state my own position on the matter. I’ve had both an emergency C-section and a ‘natural’ (for want of a better word) birth. I don’t have any kind of ideological preference for one or the other. I don’t think my natural birth was a huge achievement and my C-section was not a quick and easy option. Neither were a walk in the park but both got the job done. Neither has impacted on how I ‘bonded’ with my babies and, although I was initially disappointed to have needed a C-section, neither have affected the way I feel about myself. There were certainly pros and cons to each. If I have another baby I’ll make my choice as the situation unfolds, weighing up my own feelings and the advice of my doctor.

I don’t think anyone wants to see C-sections becoming the norm mainly because it is not the easy option women may have been led to believe by TV dramas and of course there is the issue of cost. C-sections cost significantly more than natural births and when maternity services struggle to maintain enough midwives and NICU incubators it is difficult to justify funding for a procedure that is not strictly necessary.

However if you read the NICE guidance (you can find all 275 pages of it here and the relevant bit is page 97-104) they are not proposing that you can just stroll in and demand a C-section because it seems like a good idea. It recognises that the main reasons for requesting a C-section are a lack of good information about both birth options or a traumatic previous birth experience. Just to be clear here is some of the relevant chapter that sets out what should happen:

When a woman requests a CS the first response should be to determine the reason for the request and the factors that are contributing to the request. This can then be followed by the provision of information comparing the risks and benefits of planned CS and vaginal birth.

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.

For all 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.

An obstetrician has the right to decline a woman‟s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.

essentially, it proposes providing accurate information and, if appropriate, mental health support in an effort to find a solution that both the woman and doctor is happy with but if after that the woman still wants a C-section then that should be arranged. It seems to me entirely reasonable to try and solve whatever the problem is but if that isn’t possible then the final choice should be the woman’s. I sure that this is probably what already happens unofficially in many hospitals and I really can’t see it leading to a significant increase in the number of C-sections.

It is similar to current arrangements that allow some patients with an extreme phobia of dental work to have their procedure carried out under general anaesthetic because even though it is not medically necessary and carries a small increased risk this is outweighed by how traumatic they would otherwise find it.

My only slight reservation is that if the evidence (both in terms of safety and the 2 day and 3 month post birth satisfaction rates) for both procedures is similar, as the NICE document shows, might it not be a good idea to focus on improving the safety and experience of vaginal birth (better facilities, one to one midwife care, improved access to pain relief etc) rather than just accepting that people will be traumatised by their experience and will therefore want a C-section?

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