This is a good question.
Now I need to be careful re: confidentiality.
Many years ago I cared for woman x, I was studying at the time, so x became one of my continuity of care women. She had been in several foster homes, of these she was sexually abused in x of them. In the meeting with the midwife, woman x said she wanted a MRCS, the midwife replied ‘no, we don’t offer MRCS. Its against policy’ I protested on x’s behalf, ‘but surely it must be the woman’s choice!!’. The Midwife gave me a pitiful look and said ‘sorry, no’.
I privately spoke with the midwife after the antenatal appointment and asked her ‘given this young woman’s history, don’t you think we should consider her wishes?’ The midwife eventually sighed and said ‘listen you can speak to the Head of obstetrics if you want, but she will also tell you its a no.’
I arranged an appointment and x and I attended a meeting with Dr. x obstetrician and clinical director of the maternity unit. Dr. x spent hour an hour with us. First listening to x’s wishes, then Dr. x explained in detail the benefits of CS and a longer list the risks (to be honest I didn’t know there were so many risks, I thought it quite a common, straight forward procedure). Dr. x then explained the risks and benefits of vaginal birth. Throughout woman x insisted on having a CS. Dr. x replied ‘ok on one condition, you do some homework for me, go home and look at the research. Once you have done that we’ll meet again.’ Woman x I was now seeing regularly, attending appointments with her, we chatted a bit about birth, only if she asked me but mostly talked about everything non-related to birth music, shows on TV etc. She did ask me once though, how do women have an easy birth? I replied ‘I don’t know? I have heard from women that being in the shower helps, some say they were able to get in the flow more being on their own. I read also that bright lights can sort of wake you up, maybe more stressful I guess. I don’t know, sorry?’ We met Dr x 3 weeks later, woman x had made her decision she wanted a MRCS. Dr. x wasn’t happy bout it but accepted her choice, asked her to sign a consent form and the plan was made and a c-section date booked. 3 weeks later, I got a text message the night before woman x’s c-section booked for 6am the following morning. Woman x texts me ‘I am going to the hospital, can you come?’, I grab my keys, next text message I read running up the hospital stairwell, ‘midwife says I am fully.’ What the hell! I arrive on labour woman x is on the bed, semi-recumbent position. The midwife appears at a bit of a loss, she has not met woman x before, I explain in private woman x history. The midwife says ‘well I guess the choice is hers’. We both enter the room, I say to woman x, ‘you absolutely can still have a c-section if you want.’ The midwife nods in quiet agreement. Woman x looks at me and says ‘well I’ve come this far, I might as well do it.’ With the next contraction she starts spontaneously pushing and delivers a bonnie 8.8 pound beautiful baby. After the birth, I asked woman x what happened at home? I wanted to say ‘what the hell just happened!!!? but though we had become friends, I thought I should keep some level of professionalism. She just shrugged, you know how you said ’bout shower, keeping it dark..’ I vaguely remembered, ‘well I did just that.’ I replied ‘On your own??!!’ Yes in the bathroom, on my own. ‘Did you know you were in labour?’ I guess I knew something was happening. It was ok. I just figured it was braxton hicks.’ When did you realize it wasn’t!? ‘When I really really wanted to push.’
Dr. x arrived just after the birth in a flurry of excitement. I’ll never forget that moment of Dr. x meeting woman x. She had my full respect, they both did.
A year later, I was no longer in the country, woman x emailed me ‘I have good news I’m having another baby I’m x weeks and due x I’m going to go natural with this baby as well. It’s going to be a handful with two. Please keep in touch would love to keep in touch. As you were a big part of mine and baby x’s life.’
Not too long ago, at a booking with a woman having her first baby she anxiously asked me if MRCS were possible at x hospital. I gently asked her, her reasons for requesting a CS. She replied ‘I have a fear of birth. I have done my research. CS is safer than vaginal birth.’ This woman was educated, she quoted me statistics, and spoke eloquently. I reassured her that though we wouldn’t normally routinely agree to an MRCS her wishes would be heard and respected. I excused myself for a few moments and asked the senior midwife, she told me, ” woman x, absolutely would not be allowed to have [MRCS] because she has no medical problem that would warrant it.” I explained to Francis that I had cared for a young mother in x and we had discussed her wishes of an MRCS with the Consultant obstetrician. Midwife x advised me to refer her to Consultant Midwife.
At hospital x there is a clear referral pathway for all women requesting care outside the recommended guidelines. For example a VBAC wanting to use pool in the AMU, history of PPH over 1L wanting to use AMU, MRCS. Woman x met with the Consultant Midwife for over an hour and they together with also the Consultant obstetrician’s input discussed the risk and benefits of all options and a individualised plan was made and shared with the team.
* Primary request for Caesarean for anxiety related to labour/birth outcomes
I met with x ….. to explore her wish to have an elective Caesarean. We discussed and explored x’s thoughts, feelings and wishes. X explained…her reasons for this are:
* Feels that an elective Caesarean is safer and more controlled than vaginal birth.
* Nervous about getting postnatal depression (following her x’s experience) and feels this is more likely to happen with a complicated vaginal birth.
* Concerned about instrumental birth and injury to her or baby.
* Anxious about having vaginal/perineal trauma and this leading to problems with her bladder/bowel.
* Researched her options and whilst her ideal birth would be a natural water birth she does not feel this is a reasonable/realistic outcome for her as she is concerned about being in pain and would likely opt to have an epidural.
We addressed each of these concerns individually and discussed the advantages and disadvantages of vaginal birth and elective Caesarean section. I explained the reasons why we would strongly not recommend a Caesarean section without a medical indication for there is an increased risk of: thromboembolism, infection, bleeding resulting in hysterectomy, complications in subsequent pregnancies, anaesthetic and surgical complications (including potential bladder/bowel injury), increased length of hospital stay and recovery and baby being admitted to the neonatal unit for respiratory problems. We explored the potential medical benefits with a planned Caesarean section, such as a possible reduction in: abdominal and perineal pain during the birth and up to 3 days postpartum, vaginal/perineal trauma, early postpartum haemorrhage and obstetric shock.
I explained that there is an increasing amount of evidence that suggests that exposure to the normal flora in the vagina that occurs during a vaginal birth is of benefit for life-long health. Whilst it is difficult to establish the true extent of this benefit the evidence suggests higher rates of childhood respiratory and gastro-intestinal illnesses, allergy, and also weight issues in individuals who were born by elective Caesarean section compared to those born vaginally or by emergency Caesarean section during labour.
I explained that bladder and bowel injury is not exclusive to vaginal birth and can happen with Caesareans (although uncommon) and whilst most women will experience some bruising or tearing to the vagina/perineum with vaginal birth the majority of these heal well without complications. Only a small proportion of women will have a severe tear (third or fourth degree) and the majority of these also heal well without any ongoing or long term problems. I explained that occurrence rates of these types of tear vary; some studies suggest a prevalence of 3.8% with first time mothers and 2% of second time mothers and a recurrence rate of severe tears of approx. 7%. Whilst it is hard to predict what will cause a tear of this nature there are some associated risk factors such as:
* Previous third/fourth degree tear
* First baby
* High birth weight
* Shoulder dystocia
* Advanced maternal age
I explained that because it is difficult to absolutely predict it can be hard to prevent it from happening again, however there are certain practices which have been found to be beneficial when caring for the perineum such as:
* To offer the application of a warm compress in the second stage of labour as this may reduce perineal trauma.
* It may be appropriate and have some benefit to avoid standing birth positions and the use of the birthing stool in the second stage.
I have shared with x our hospital/local figures regarding our Caesarean section, instrumental, normal birth and third/fourth degree tear rate. In addition I have provided x with and discussed with her the RCOG written information on Instrumental Birth and Caesarean section and the Birth Place Study Decisions leaflet (2014). We went through the key findings from the Birthplace Study (2011) including the likelihood of having a Caesarean in labour, instrumental birth, uncomplicated vaginal birth and having a baby being born with a poor outcome in each birth setting. http://www.nhs.uk/Conditions/pregnancy-and-baby/Documents/Birth_place_decision_support_Generic_2_.pdf
X is aware that most women and their babies who are at low risk of complications recover well from birth however there are additional risks to consider for both her and baby with a Caesarean. In addition having a vaginal birth means she is more likely to be able to have skin-to-skin contact with her baby immediately after the birth and breastfeed successfully, the recovery is likely to be quicker and she should be able to resume her normal activities/drive sooner and subsequent births are likely to be more straightforward.
We discussed how we can best support her in view of her fears and our recommendation, such as supportive birthing planning to seek solutions to certain elements that cause her particular concern, which she has after some thought over the weekend, declined with thanks. Whilst x understands the risks associated with having an elective Caesarean she feels this is the safest/right option for her and baby.
On speaking with x today she reports she is feeling less anxious and is actually excited for the first time about the birth with the prospect of having an elective Caesarean.
Please do not hesitate to contact me if you have any questions,
With Best Wishes
XX Consultant Midwife
Woman x met with the obstetrician a CS date was booked and she had her baby via MRCS on xxx.
This is what I mean by informed decision making. And yes I absolutely do support MRCS, as I do any woman’s choice.
Source : http://www.skepticalob.com/2017/05/sheena-byrom-and-the-moral-bankruptcy-of-uk-midwifery.html