Key learning points:
– It is essential women have access to accurate, evidence-based, up-to-date information on the risks and benefits of different modes of delivery
– Community midwives should remain updated on the latest evidence in relation to planned caesarean sections as an option for birth
– Midwives working in the community should endeavour to make women feel able to take the necessary time to discuss their feelings around mode of delivery
In the United Kingdom approximately 25% of babies are born by caesarean section.1 There is considerable variation across the country and this overall rate is split into emergency and elective caesarean sections. Maternity statistics for 2013 to 2014 report a caesarean section rate of 26.2%, with 11% of those caesareans planned and 15.2% being emergencies.2
Women have planned caesarean sections for a range of reasons. Doctors will not usually recommend a caesarean section unless it is necessary for medical reasons. However, evidence suggests that doctors are now more likely to agree to a maternal request for a caesarean section than in the past.3
The most common reasons for a planned caesarean section, with percentages in brackets as reported by Bragg et al, 20104 are:
– Breech presentation (89.9%).
– Placenta praevia or placental abruption (85%).
– Previous caesarean section (70.8%).
As well as those planned caesarean sections that are recommended on medical grounds, some women wish to opt for a caesarean section in the absence of any such indication.
Women who think they might want to request a caesarean section may want to talk this through with their community midwife and this should be encouraged. They may also wish to have a discussion with their obstetrician, anaesthetist and/or a paediatrician, an option that should be facilitated by the community midwife.
Why do women request caesarean sections?
It has been proposed that fear is the reason women request caesarean sections.5 Fear can have a variety of causes, including:
– Fear associated with a previous complicated birth – such women should be encouraged to talk through their previous birth experiences either with a midwife or specialised birth counselling service, if a local one exists. Going through the notes from a previous delivery can often prove beneficial for women and can help them to make a decision about mode of delivery.
– Fear of injury to themselves or their baby – women may believe a caesarean section is safer than vaginal birth. Concerns about perineal trauma and damage to the pelvic floor have been reported.5
– Some women are very anxious about delivery and may have a genuine and morbid fear of vaginal birth – true fear of birth is difficult to quantify, however several studies have reported rates ranging between 7% and 26%, with 6% describing the fear as ‘disabling’.6
– Tocophobia (the severe fear of pregnancy & childbirth) – the most recent National Institute for Health and Care Excellence guidance on Caesarean Section, CG1327 recommends that such women should be referred to a suitably qualified health professional with expertise in perinatal mental health for assessment and support, which might ultimately result in a planned caesarean section on medical grounds.
For all women requesting a caesarean, the opportunity to discuss her thoughts and fears and to talk through labour and birth, the options for pain relief, positions for delivery and choices available to her may help to alleviate some of the anxiety they feel. Care must be taken with all birth discussions as some women may have deep-seated fears around birth which may stem from very traumatic experiences such as sexual abuse or rape.
Ultimately, if a woman feels strongly enough that they cannot consider a vaginal birth they can request a planned caesarean section. If a woman’s obstetrician does not feel they can support her choice, she can ask to be referred to another obstetrician. Women may even need to transfer their care to another unit if their choice for a planned caesarean cannot be supported locally.
The risks
Irrespective of the reason for opting for a planned caesarean, women require information on the risks and benefits of the various modes of delivery.
Most women who have a planned caesarean section recover well and have healthy babies. However, there are additional risks for women who have a caesarean section and their babies. It takes longer to get back to normal after a caesarean section and future births will be more complicated.7,10
Having a planned caesarean may give women a greater sense of control over their labour and alleviate their anxieties about the uncertainty of going into labour. It may also reduce the incidence of abdominal and perineal pain during birth and on the third day after delivery, perineal and vaginal injury, early postpartum haemorrhage and obstetric shock.10 However, a caesarean section is a major abdominal surgery and does have associated risks.
The main risks for a mother are wound infections (which are common and can take several weeks to heal), deep vein thrombosis (DVT), a longer stay in hospital, increased pain the first two days and an increased risk of a hysterectomy due to postpartum haemorrhage.1,7,10 These risks are greater if a woman is obese, however serious complications are rare in women who are young, fit and healthy, of normal weight and for whom this is their first planned caesarean section.1,7
The most common problem affecting babies born by caesarean section is temporary breathing difficulty, which means the baby is more likely to need care on a neonatal unit than a baby born by vaginal delivery.
There is a small risk of the baby being cut during the operation (1-2%), such cuts usually heal without complications and rarely leave scars.1,7 Babies born by caesarean section are more likely to develop asthma and be overweight in later life.1
Future births
Having a caesarean sections will impact on future births and the risks associated with caesarean section increase when women have three or more caesareans. Those risks include bowel or bladder damage during surgery, the need for additional procedures such as a blood transfusion or hysterectomy, the risk of placenta accreta and an increased risk of stillbirth.1
The role of the community midwife
Throughout the pregnancy and birth continuum, women should be at the centre of their care and be supported to make informed decisions that take into account their needs and preferences.
The community midwife is likely to be the most familiar face a woman sees during her pregnancy and, as such, a trusting relationship between the midwife and woman is more likely to develop, within which she feels able to be honest and open about her feelings, thoughts, concerns, fears and wishes.
Women will also discuss these issues with others, both within and outside the health service. They may therefore be exposed to information from a wide range of sources, some of which may be unreliable, out-of-date and based on individual experience. Information from peers and family members is very influential and recent evidence suggests that women are increasingly engaging with the internet as a primary source of information to ask questions that would have traditionally been directed to their midwife.8
The attitude of health professionals has been identified as one of the main factors to influence a woman’s decision making with regard to opting for a vaginal birth after a previous caesarean section.9 It is therefore important that all midwives supporting women with birth choices reflect on their own way of communicating to increase women’s feelings both of being supported and of autonomy in their decision making.
Consultant antenatal clinics are often very busy, with long waits to be seen and short appointment times, which are rarely with the same health professional.
A woman’s community midwife is perfectly placed to be a source of information, support and advice. This means it is essential they remain updated on the latest evidence in relation to planned caesarean section as an option for birth and endeavour to make women feel able to take the necessary time to discuss their feelings around mode of delivery. This presents a number of challenges for midwives who may find themselves in busy community clinics with little time to devote to each individual woman. Depending on the pattern of community care in their trust, community midwives may not spend time in the local consultant unit and may feel somewhat ‘out of touch’ with current policy and practice. In light of this, community midwives must ensure they are familiar with local service provision in relation to the management of planned caesarean sections. In particular they should ensure they are equipped to inform women about the following:
– Where and when the final decision in relation to mode of delivery will be made.
– When she is likely to have her planned caesarean.
– Tests and medication she will be offered before and after the operation.
– Her options for anaesthetic and how to discuss any concerns she may have about this.
– The possibility that her operation may be delayed.
– What to do if she thinks she may be in labour before her operation date (one-in-10 women will go into labour before the date of their planned caesarean).1
– The rationale for other interventions such as an indwelling catheter, anti thrombolytic stockings and low dose molecular weight heparin.
– The need for regular analgesia after the operation.
– The importance of early skin to skin contact, even if she does not plan to breastfeed, but especially if she does (skin to skin contact in the operating theatre is associated with a trend towards an increase in breastfeeding rates at 48 hours and six weeks).11
– The average length of stay following a caesarean section.
Conclusion
Mode of delivery is a woman’s choice and the midwife’s role in this respect is to provide information and support that will empower a woman to make the right choice for her.
References
1. Royal College of Obstetricians and Gynaecologists. Information for you: Choosing to have a caesarean section. RCOG, 2015.
2. Health and Social Care Information Centre. Hospital Episode Statistics, England Maternity Statistics 2013-2014. HSCIC, 2014.
3. McFarlane A, Blondel B, Mohangoo AD et al. Wide differences in mode of delivery in Europe: risk stratified analyses of aggregated. British Journal of Obstetrics and Gynaecology, 2015. DOI:10.1111/1471-0528.13284.
4. Bragg F, Crowell D et al. Variation in caesarean section among English NHS Trusts after accounting for maternal and clinical risk. British Medical Journal 2010;341:c5065.
5. Nwezi C, Penna LK. Caesarean Section for maternal request. Obstetrics Gynaecology and Reproductive Medicine 2011;21(11):327-8.
6. Richens Y, Hindley C, Lavender T. A national online survey of UK maternity unit service provision for women with fear of birth. British Journal of Midwifery 2015;23:8;574-579.
7. National Institute for Health and Care Excellence (NICE). Caesarean Section CG132. NICE, 2011.
8. Nikolova G, Lynch C. Do mothers use the internet for pregnancy-related information and does it affect their decisions during pregnancy? A literature review. MIDIRS Midwifery Digest 2015;25:1;21-26.
9. Tolmacheva L. Vaginal birth after caesarean or elective caesarean – What factors influence women’s decision? British Journal of Midwifery 2015;23:470-75.
10. National Institute for Health and Care Excellence. Evidence Update 35 – Caesarean Section. NICE, 2012.
11. Gregson S, Meadows J, Teakle P and Blacker J. Skin to skin contact after elective caesarean section: Investigating the effect on breastfeeding rates. British Journal of Midwifery 2016;24:1; 18-25.
