Mummy stuff, Pregnancy

The Beauty of Choice – NHS NICE guidelines for elective Caesareans

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About four years ago, when I was pregnant with my first child, I was appalled to find out that in the UK, women did not get to choose the way they wanted to give birth. Sure, you had the (potential) choice of a birthing centre versus a maternity ward and sometimes even a homebirth, but to me, real choice about giving birth would have included the choice of a planned Caesarean section.

I am not contra natural birth. I am sure it can be a wonderful thing, if it works. I just think that it’s not for everyone – and after the experience I had with little L, it most certainly isn’t for me. Back then, after 12 hours of ‘unsuccessful’ labour and a midwife that was the gynaecological equivalent to the dentist in The Marathon Man, little L’s heart rate dropped dramatically and she was born via emergency Caesarean. I found out later that due to her head circumference and thanks to continuously banging her head against an almost closed cervix (remember the TV series Coneheads?), the ugly alternative would have been a forceps delivery – which is my personal nightmare idea of giving birth. In that sense: Hurrah for the C-section!

Had I been in a different country, a country that offers women more choice, I had chosen a C-section right away. I never viewed natural childbirth as particularly empowering; neither did I ever develop the desire to connect to my most primal self by pushing a baby through my vagina. It’s nothing I ever wanted to experience.

It (almost) amuses me when people try to hold the porn industry responsible for a woman’s refusal to stretch her most private bits to the max. I can assure you, I haven’t watched too much porn, nor am I being put under pressure by anyone to ‘stay in shape’. It’s what I want – and I am more than happy that the new NHS NICE guidelines state that this is reason enough to offer me a planned C-section.

We are quick to dismiss anti-abortion remarks as anti-feminist. How come that I can – theoretically – get stupefyingly drunk, have a one-night stand, get pregnant as a result and am then entitled to an abortion? Why should choice over my own body end once I have decided to keep the baby?

There is no research that suggests that a baby, born at full term via Caesarean, has any disadvantages compared to a baby born via natural birth. It is estimated that the major chunk of additional cost (about £500,000) will stem from mental health treatment that will be offered to women in an attempt to overcome their anxieties of childbirth. Just to give you a number to compare this with, the cost of obesity for the NHS has been £15.8 billion in 2007 and is estimated to reach £27 billion by 2015. Additional Caesareans don’t come cheap, but they are by no means the biggest position on the NHS bill.

Maternal request for CS (excerpt from the NHS NICE Guidelines cg132)

  • 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 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 unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS

So. What’s your thought on planned Caesareans?

33 Comments

  1. Absolutely agree, I only wish I had an elective section on my first baby rather than my second. I’ve never heard the porn argument before! I wanted a section and it was right for me and my baby and it was a fabulous experience.

  2. This is really interesting, as you know I have quite strong views on the subject and was very keen for a VBAC this time around but ended up with a c section, which i loved and was so thankful to be offered. After what I went through (the days of ineffective labour, yuck) I think my stance on this has changed. I’d still like women to be better educated on how birth can be and wish their wasn’t such a terrifying stigma about how painful it is (it hurts, obviously, but different pain management techniques) but like you I also now think that women should be able to choose.x

  3. I had Littleboy 1 by emergency c-section in what turned out to be a very frightening experience of placental abruption. When it came to the second pregnancy, I wanted an elective c-section rather than VBAC, but was forced to attend all sorts of counselling sessions about VBAC telling me that it was all worth it. In the end, I had complications which meant I had no choice but to have another c-section, but I felt I was being very pushed to go for VBAC. If that experience had ended with another emergency section, I would have felt very let down.

  4. I’m fascinated by that, I had three of my four kids in London, public health, and there did not seem to be any constraints. About half of women here in the US have C-sections (many of them seem elective) and a huge percentage of the of the rest of the women have induced labour. I don’t get the inducing labour, seems to make it more painful. In the end every woman should go with what she feel comfortable with, don’t you think?

  5. I had both of my children via planned c-section and I would not have had it any other way (couldn’t actually for medical reasons but that is besides the point). The end result produced two beautiful children, no less healthy or at risk than children born the natural way.
    It should be a woman’s choice which way she decides is best to bring her children into the world and no one elses.

  6. People should do exactly as they wish providing all is safe- if you were having any other kind of operation or procedure you would have choice! I’m still hoping they invent some way of popping the baby out without any kind of gown, cuts, pushes etc but that’s clearly never going to happen unless you have a surrogate and quite like the idea of a little person growing.

  7. I am a firm believer in choice both ways. I had Maxi by a crash section after an abruption. very scary and traumatic. I really wanted to have a natural birth with Mini (VBAC), but wasn’t even given the option and was far too ill to even fight them.

  8. Hi! I had my son by emergency c-section as his heart rate dropped suddenly after a very long induction. Much the same as you I do think that if his heart rate hadn’t dropped I would have been faced with a forceps delivery as I don’t think I would have been able to birth him naturally (both due to his big head and me being completely exhausted!) He is now 18 months and we’re beginning to think about number 2 but I have no idea what options will be available, or will be the best option for me. I have friends that have had a VBAC but like you I don’t really feel any primal need to give birth that way, and I’d much rather have a planned csection than a repeat of my birth experience with my son.
    I do wonder whether the NICE guidelines are actually followed. From everything I’ve read, any form of induction is not recommended for mums with previous csections as it puts pressure on the existing scar that can lead to ruptures. It’s a bit scary to think about really as there are so many pro’s and con’s to both! xx

  9. Um very interesting. How things change over the years. My first child born 23 years ago was a forceps delivery I was in too much pain to even think about a c-section but I knew it could have ended that way. Second child two years later born after a 45 minute labour on the sitting room floor (I blame the raspberry leaf tea). Third child (a year later) text book 8 hr labour with me in complete control and no pain relief. 11 years ago Little Man, emergency C-section as there was something in front of his head and nobody seemed to know what and for me it was the worst experience of my life. Not only is the recovery far more prolonged (it is major surgery after all) but I haemorrhaged when he was 10 days old as I didn’t start to bleed after he was born. I ended up in hospital for three days and then proceeded to bleed so heavily for the next three months I couldn’t really leave the house, got sent to hospital twice by my GP where nothing was done and paid to go private in the end only to be told it was hormonal and got put on some tablets which stopped it after a matter of days. I stayed on them for two years and was weaned off them as my body and cycle got back to normal. Had he have been my first child, I would never have had any more. Personally I do believe women should have a choice but don’t understand why anybody would opt for one unless it was necessary.

  10. I do think you should have a choice too. But what I really really hate is those people who seem to imply that because they didn’t have any pain relief, they are somehow a better person. You wouldn’t have root canal work done without an anaesthetic. And that guff about childbirth being natural etc, death by cancer is natural but we offer people pain relief, or people in third world countries giving birth without pain relief – just look at the mortality rates. And anaesthetics were introduced specifically to help women in childbirth. (my other bugbear is people who think they should have the same midwife throughout their whole labour. They seem to forget midwifes can be people too, with lives and families; that the midwife’s children might like a story before they go to bed or that they might have a elderly relative with care needs.)

    PS – I’m not a midwife or a nurse.

  11. I always wanted drug-free ‘natural’ births but it didn’t quite go that way with either of my kids. My 2nd birthing experience was extremely traumatic and now every time I hear of someone having a c-section I am jealous and upset that I didn’t consider it…

  12. I’m all for choice but really believe it should be about informed choice and that there should be a degree of discussion about the reasons for making either choice

    Interestingly medical professionals seem to get equally fussed about homebirths and c-sections rather than focusing on empowering women to get the best birth experience for them (and the safest for the child but also such that the woman doesn’t end up mentally or physically traumatised)

    Having had two homebirths (2nd wasn’t meant to be but…) and discussed this with my SIL who has had 3 c-sections there are advantages and disadvantages to both – what we need to focus on is what is right for that woman at that birth and not generalisations

  13. Oh hun so nice! Congrats! Like you i also had an emmergency csection the 1st time. I would love to have a water birth this time but they say they don’t have the facilities in case something bad happens to me… Oh well. I would love to try to have a normal birth as well but not if it means to go through the same nightmare like last time! It was horrible.
    PS:Would love to see you soon x

  14. jen says

    I am only for planned C-sections when they are deemed medically necessary (a real physical medical need), e.g., placental issues, huge baby, health of baby or mother, multiple birth situation, etc.

    I was naturally terrified for my first birth—yet my older sister had 3 c-sections and I knew the recovery was no picnic. Turns out I give birth nothign like her (I also am an exercise fanatic-she is a couch potato). Epidural with self-admin. pump for the first as soon as felt the first twinges of pain. Perfect. laughed through the whole thing up and walking soon after! To think I could have tortured myself and given myself a huge scar and major surgery for nothing if I just went ahead and planned a C.

    Second birth–fast and furious. Astounded when I got to delivery and they said I had no time for an epidural.. Seriously–WTF??? I told them to give me anything. Told me sorry it was too late…really? A shot of vodka would have taken some edge off and wouldn’t have harmed the baby at that point. He popped out 2o min later and I now have ‘natural birthing’ brag rights (not that I ever wanted them).

    I am against C-sections for vanity and plain convenience. I also didnt’ find out the gender of my boys ahead of time so you could call me ‘old school’. I love the element of surprise–esp in this day of social media where we know everything about everyone.

  15. jen says

    Let me clarify–if there was a C-section the first time around I am definitely for a planned C-section the second time around. I don’t know all of the statistics on VBAC but I know my sister had planned C-sections after the first baby was born that way from a completely stalled out labor. She was convinced it was the safest way.

    Good luck!!!

  16. Happymiddlemum says

    I also think C sections should be for medical reasons only. In my experience, once you are pregnant, the NHS likes to tell you what to do. And they generally tell you as if you are 5 years old. 🙂

  17. The NICE guideline update in November 2011 was a great step forward in trying to establish recognition of a planned cesarean as a legitimate birth choice. Unfortunately however, the guideline has not been accepted in all hospitals throughout the UK, and many women remain unsupported and even openly criticized when they make this request.

    For the vast majority of women, this birth choice is not about convenience or vanity (unless vanity in this context refers to protecting their sexual health, in which case yes, some women do cite this as one reason for their choice), but rather it is about wanting to avoid the very real risks associated with a trial of labor (for their babies and themselves), its inherent unpredictability, and fewer perceived benefits of a natural birth (e.g. viewing it as a rite of passage or empowering experience).

    I had a planned cesarean for both of our children’s births, and am co-author of a new book (written with a doctor) called ‘Choosing Cesarean, A Natural Birth Plan’. We do not seek to encourage women to have cesarean births, but we strongly defend this birth choice and offer useful information (e.g. surgery risks, what happens on the day, useful tips, birth stories, plus facts about the pelvic floor) that any pregnant woman may like to know.

  18. Jenny Hao says

    The NHS cannot afford elective C-sections. However, I am in support of women who want to have C-sections done privately.

  19. Understandably, many people believe that there is an issue of cost for the NHS, but this is not the case, and indeed the NICE guideline states: “On balance this model does not provide strong evidence to refuse a woman’s request for CS on cost-effectiveness grounds.”
    How does it reach this conclusion? By looking at one single downstream cost of planned vaginal deliveries (PVD), and finding that the £720 difference in cost bewteen maternal request and PVD reduced to just an £84 cost difference when urinary incontinence costs were factored in. If you imagine all the other costs associated with PVD, including for example pelvic organ incontinence, the short- and long-term care of injured infants, plus litigation, it becomes increasingly clear that maternal request cesareans are as affordable – if not more affordable – than PVDs.

  20. Your post and the comments are so interesting. I’ve changed my thinking on this s lot and agree more and more that it should be about choice for the mother, although that should be as educated a choice as possible, which is therefore up to the care giver and mother to go through the options and what the associated risks etc are.

    I also think that calling vaginal birth ‘natural’ immediately puts a stigma on a caesarean birth (note I also think that it should be called a caesarean birth not section). Perhaps if we changed the language in these subtle ways that would also change people’s perceptions?

  21. Very interesting question. I don’t really know what to think, because it is a complex issue. Yes, I agree that women should have the right to choose, but I also think that it would be a pity (though can’t explain why) if that led to the Caesarean rate going up significantly – and I think it would. I suppose I think that Mother Nature should be given first chance, but that’s just me. I wouldn’t assume that other women would or should think the same.

  22. Lianne Turton says

    I had a very traumatic delivery of my first child who is now 4, due to a midwife that did not believe in pain relief and would rather me ‘use your pain’ to deliver my son, I had to undergo surgery which not only meant I was taken away from my new born for three hours which isn’t ideal when breast feeding. I was also told I could not give birth naturally again and would have to have C Sections in the future. This completely put me off getting pregnant ever again.
    As my son gets older I am really wanting another baby so am having to think long and hard about the delivery. This blog post is very useful, thank you ladies.

  23. HappyMom says

    There are a lot of arguments against the cost to the NHS for a planned C-section. Where I totally agree that the NHS has limited funds and those funds should be respected. The argument follows that the NHS should not treated a smoker who has lung cancer, or the obese person who has diabetes or heart problems?

    Why do they deserve treatment regardless of personal choice and a pregnant woman is some how being forced to justify her personal choice?

  24. Roxanne says

    I have just elected for a cesarean birth for my 1st as I have intense fears of childbirth & the potential complications. An emergency C Section is one of my worst nightmares as it would be the outcome of a traumatic birth leading to a lack of control over the whole situation. I’m scared of developing Post Natal Depression and have made the choice to have an elective cesarean birth in order to have that control over what’s happening. The consultant made me argue my case and presented every risk going to the point he almost made it out like certain death, however I persisted & it’s now booked for two weeks away when I’ll be 40+1. Reading this blog has made me feel empowered that I’ve made the right decision & I do not feel any less of a good mother for choosing this outcome to my pregnancy.

  25. stella says

    coming from a country when csection by appointment amounts to 60% (99% for twins) of the births i have a clear opinion on the issue.

    Greece has received notice fron UN regarding these percentages for not protecting mother’s rights on natural birth. Usually, doctors refer them to csections for no reason whatsoever, other than their own convenience. mothers are too afraid to challenge them and that is that.

    csection is an operation and an emergency procedure. it is not a convenience for the mother or the baby. on the other hand, can be very convenient for the doctor , who could make appointments for 10 csections in a row on a Wed and go to his holiday home for a quiet weekend on the Fri.

    All I am trying to say is that it should not be about just having a choice. it is about having an informed choice about the advantages of natural agains csection to both mother and baby. Imagine jumping from basement to 100th floor in a split second. that’s how the baby feels. This is one of the reasons some csection babies find it hard to adapt and need special treatment in the first couple of days.

    We are all seaking the organic and natural in our everyday life… why not for the most important moment of our kids’ lives? Unless of course there is a medical record or reason behind it… and i am talking from experience.. my birth lasted 20 hours (with painkillers) 🙂

  26. Abbie says

    I am completely pro elective Ceserean! Iv had 2 very traumatic vaginal births, one where one of the doctors was jumping (I believe it’s called fondal pressure and quite medieval)on my stomach o push my 9lb baby out, I was pinned down and told ff for making a noise, this wasn’t in the uk ad only happened 5 years ago! My 2nd labour was just as vile a experience- poo’ing on the table mid push, completely and utterly humiliating! For me there is nothing natural or beautiful in pushing a baby out of my vagina, if I had had the choice in the country I hae both then I would of 100% opted for a Ceserean. I didn’t bond with my babies for a while after the trauma of pushin them out. I am optic for a Ceserean this time
    Round now I’m back in the uk, it’s my
    Choice how I bring my baby into the world . And if bring it into the wouldn’t via my sunroof will give me the beauty of bonding strait away then so be it! It’s gotta be worth a try?! Hurray for elective cesereans :))

  27. Just found this post while googling for the NICE guidelines.

    I wholeheartedly agree with you. A lot of lip service is given to empowering women’s choices, but it seems that those saying this often believe that there is only one “correct” choice; natural birth with no pain relief.

    C-sections are now generally very safe and planned ones are far safer than emergency. They certainly have their down sides but then so does vaginal birth so if we are really championing women’s choice why aren’t those people advocating more home births also backing women who choose a c-section?

    If you’re interested I found you while researching for a blog post on the theme of birth choice:
    http://southwarkbelle.blogspot.co.uk/2014/04/birth-choice-evidence-and-squishy.html

  28. Gina says

    Hi, I just found your blog post, whilst googling NICE guidelines and it’s so refreshing seeing people with the same opinion as myself. I am having a nightmare with my birth plan meetings, as they are only interested in a ‘natural’ birth. Some people seem to take a “holier than thou” attitude when you speak about it but I don’t see why I should be judged for wanting a section. Why does a natural birth make you a better person? I had an emergency one with my first as she was 9 weeks premature and suffering from fetal hydrops. I’ve had awful pregnancies with both, so to know I’d be having my next one in a quick and controlled environment would be so reassuring. Unfortunately I just seem to be repeating myself and getting no where! Even the information they have given me is ridiculously biased, one leaflet just says pros of vbac and negatives of c section! I read my notes when I got home, I realised my midwife had even wrote “Happy to consider a vaginal birth” despite my whole conversation being about wanting an elective. Knowing other people are having the same issues, is reassuring and give me a good case for my next birth plan appointment. Thanks 😀 Fingers Crossed!

  29. Sally says

    I am completely pro-elective c-sections. It is horrific if that choice is taken away from women, who dont receive the best health care in the uk in the first place.

    As for the costs to the NHS, women giving birth is the only thing that will keep the NHS alive as we need more children to sustain our country, not less.
    So I find it a bit surprising that women should be punished for not wanting to have a traumatizing birth experience (which, by the way, also can result in depression and further costs).

  30. Ida says

    HappyMom (April 21, 2013) and Pauline Hull (June 18, 2012) I could hug you ladies for the wise words … A woman should have the choice.
    I gave birth in 2012 and it was very dramatic. They nearly lost me from massive blood loss, I have sustained a 3rd degree tear on top of the performed epistomy, because of the rotational forceps delivery (no consultant available to perform an emergency c- section) I sustained further vaginal bilateral tearing and suffered a prolapse of 2/3 degree. I had one year of physio therapy. I went through a depresion. All of this because I was refused a c-section once the labour got prolonged (which was already an indication for a c-section. I find the NHS advise on birth mode deceptive and misleading. They skilfully manipulate the statistics on c- sections to scare women, as obvoiusly the vaginal birth is much more cost effective (only personel is midwife) comparing to c-section personel needed. You might think that they will consider the potential risk of further costs involved if something goes wrong ( like in my case), but that is not the case for several reasons. Firstly they will not admit to any injuries unless a woman is persistant and doeas her reserch if she feels that there is something not right after the birth (it took me 3 PRIVATE visits and countless NHS visits to find out about the prolapse) Secondly they will try to convince you that all of the injuries sustained are normal and you just have to live with them. If they are sucessful most women will give up at that point as highly possible they will be already too depressed to fight for themselves. So the cost is only a potential cost to the NHS and if they are persuasive enough there will be no further costs for them. On top of the mentioned injuries my baby was born with a bradycardia and a low uper body muscle tone (which after nearly 4 years of fighting for my little one I am finally able to prove) . And Yes… I was also pro vaginal birth with the naive hope expressed im my birth plan, that should the labour be a prolonged one I want to proceed to a c-section before it will become an emergency c-section. Needless to say I was not granted one.

    Right now I am pregnant again and I am in a process of fighting for a planned c-cection, which yet again, despite the previous complications, they try to convince me is not the best option – although doing my reserch (medical sites) I know it should have been granted to me without any discussion. Just ot clarify those are two diferent hospitals (and numbers of different registrars and consultants), as I have chosen to give birth at a different hospital this time, who seem to have a higher incentive to limit the c-sections at all costs.
    If you reserch the statistics carefully you will find out that the percentage of possible complications after an Elective (planned) c- section and vaginal birth are simillar. They will however use the combined c-section complications percentage, which will include the emergency c- sections (who are performed in births with preexisting complcations and do not contribute to the complications) to make it more horryfying to put women off from having them. It is still an illusion that a women has the right to choose or has a choice in regards to the birth mode or al least I do not consider it the right to choose if you have to go through endless talks and fight several registrars/doctors before it will be granted and IF it will be granted to you.
    Just to add further to the stigma of elective c-sections topic… The NHS took apropriate steps already to make it more cost effective. Just look at the ROCG training matrix for obstetric students in 2012 and 2015. What a student/registrar of a second year was not qalified to perform in 2012 he already was qualified to perform in year 2015! The NHS is giving more responsibilities to ever younger and less experienced personel making it therefore more cost effective. And the patient/woman, well… all they need to do is to add more possible complications (including death) on the c-section consent form and they are covered. That is my personal opinion anyway and I do not mean to critisise or discurage any women opting for vaginal birth. All the best to you all ladies.

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