Women can choose Caesarean birth

A Caesarean section taking place A Caesarean section can be necessary for medical reasons

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Pregnant women who ask for a Caesarean delivery should be allowed to have the operation, even if there is no medical need, according to new guidelines for England and Wales.

The National Institute of Health and Clinical Excellence (NICE) states that women should be offered counselling and told of the risks first.

Ultimately, however, the decision would be made by the mother-to-be, it said.

NICE said this was "a very long way" from offering all women surgery.

The last set of NICE guidelines, which were published in 2004, clearly stated that "maternal request is not on its own an indication for Caesarean section" and that clinicians could decline the procedure "in the absence of an identifiable reason".

The rules on requesting a C-section have been revised. Clinicians say this is to bring the instructions into line with what is already taking place in hospitals.

Birth fear

Start Quote

It's not a major operation that most pregnant women are interested in or want to have”

End Quote Malcolm Griffiths Consultant obstetrician and gynaecologist

The 2011 guidelines say that women requesting a C-section because of anxiety should be offered mental health support. A phobia of childbirth is thought to affect 6% to 10% of women.

Nina Khazaezadeh, a consultant midwife at St Thomas' Hospital, says she often meets patients who want a Caesarean due to a "perceived lack of control, fears of inadequate care provision and lack of support during labour and delivery".

"But, after a discussion of all the pros and cons of both types of birth, and having been assured of one-to-one midwifery support and an individualised birth plan, they will choose to try for a vaginal birth."

The updated guidelines state that if such women still wanted a C-section, they should get one.

Women with no medical need can also ask for a Caesarean section. The guidance states that they should be told of the risks and discuss their request with a clinician, but their request cannot be denied.

Malcolm Griffiths, a consultant obstetrician and gynaecologist who led the development of the guidelines, said: "Caesarean section is a major operation, it's about as major as a hysterectomy.

"It's not a major operation that most pregnant women are interested in or want to have."

Dr Gillian Leng, deputy chief executive of NICE, said: "This guideline is not about offering free Caesareans for all on the NHS.

"It is about ensuring that women give birth in the way that is most appropriate for them and their babies.

"Offering these women a planned Caesarean section in these circumstances is a very long way from saying that Caesarean section should automatically be offered to every woman."

New rules

The risks

Planned Caesarean section may reduce the risk of the following in women:

  • pain during birth and for the next three days
  • injury to vagina
  • haemorrhage
  • shock

Planned Caesarean section may increase the risk of the following in babies:

  • intensive care admission

Planned Caesarean section may increase the risk of the following in women:

  • longer hospital stay
  • hysterectomy
  • cardiac arrest

Source: NICE

There will be wider changes to clinical practice.

Being HIV positive will no longer be treated as grounds for an automatic C-section. Improvements in anti-retroviral therapies mean it is now safe for some woman with HIV to deliver vaginally.

There will also be changes to break the mentality of "once a Caesarean, always a Caesarean".

The latest evidence suggests that even for women who had up to four previous C-sections, that the risks of fever, bladder injuries and surgical injuries were the same for planned vaginal and planned Caesarean deliveries.

Also it had been thought that giving women antibiotics to protect against infection during surgery could be damaging to the baby. NICE says medical evidence says this is not the case and that women should now be given antibiotics before going under the knife.

In the UK, about one in four births is by Caesarean section. The rate has been roughly static for the past four years following years of increases. Across Europe figures vary widely from about 14% in Nordic countries to 40% in Italy.

Graph showing rise in C-section rate

NICE believes that overall, the rate could fall after the introduction of the new guidelines.

Wendy Savage, a retired professor of obstetrics, said women requesting a C-section were not responsible for the rise rather "it is obstetricians that are too keen to do it".

On vaginal births she said: "They don't know how to do it most of them now because they haven't been trained how to do it.

"It is up to us to put our house in order and stop doing Caesareans too easily.

"We're doing too many first Caesars and secondly we're doing too few vaginal births after Caesarean section."

Cathy Warwick from the Royal College of Midwives: 'It doesn't differ from the current practice going on in many maternity units'

The changes will come at a cost to the NHS of around £0.5m, largely from the cost of mental health services for women with anxiety.

The cost of a planned Caesarean section was estimated at £2,369, with a planned vaginal birth costing £1,665.

Maureen Treadwell, co-founder of the Birth Trauma Association, said: "We are delighted that this updated guideline recognises the terrible impact that fear of childbirth can have on women and their families."

Cathy Warwick, chief executive of the Royal College of Midwives, said: "If midwives are able to help women to understand what their choices mean for them and their baby and feel they will be supported in labour then very few women will want an elective Caesarean section.

"They will be making decisions from a fully informed position and from a position of trust in maternity services, not one based simply on hearsay."


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  • rate this

    Comment number 82.

    Man writes.:- Unless its for serious health reasons, be it the mothers or the babys, then women should give birth naturally.

  • rate this

    Comment number 81.

    Had to come...
    Men and Women can't be bothered to marry and be structured parents.
    Women can't be bothered to bring up their own tick box children.
    Now can't be bothered to give child birth correctly.
    Only leaves NHS to do the egg removal, fertilisation and child put into state raising.
    Mumsy & Popsy can visit sprog on Saturdays when they've nothing in their diaries!

  • rate this

    Comment number 80.

    This is tricky, so many of us had the 'elective bad' mantra drilled into us, we find it hard to see the elective / no medical reason side - sorry. on a similar note i was sneered at for requesting painrelief meds during no2 - had the meds, amazing, took the edge off, left me with energy for the 'big push' and no side effects for us- maybe we / i should stop being so pious?

  • rate this

    Comment number 79.

    I think it is wrong to assume the mother is making the choice for her oen needs and wants. Being forced to give birth in a way that you do not think is best for you could result in bonding issues. Also its not like vaginal birth is not without risks and post birth complications. Mothers should have the right to choose. With counseling they may even change their minds.

  • Comment number 78.

    All this user's posts have been removed.Why?

  • rate this

    Comment number 77.

    Medically, it has been proven it is better for the baby to be born naturally so surely this is what we should try to do! I gave birth this was and had quite a traumatic time but would still opt to do it all over again. What is concerning is the different attitude of each borough in london. 2 friends both had c-sections with 1st baby. One borough pushed for natural on 2nd and other for csection!

  • rate this

    Comment number 76.

    Caesar wasn't born by caesarean section at all. With this degree of accuracy you could work for NICE.

  • rate this

    Comment number 75.

    wrong wrong wrong. It should be based on medical need. Now go tell the cancer patient, or any of the 20,000 patients who have been waiting for over a year for their treatment or the many thousands who are denied drugs, that they will have to wait even longer or go without as the money has been spent on patients too posh to push.

  • rate this

    Comment number 74.

    The NHS is creaking already and there is a severe shortage of midwifes, just how are they going to fund this?? These are expensive operations and women spend longer in hospital.
    If women are concerned about giving birth, then do not get pregnant, IT IS NOT COMPULSORY.

  • rate this

    Comment number 73.

    This is total and utter rubbish. It doesn't matter what politicians or surveys say - at the end of the day DOCTORS dictate what happens with women and their births. The reason c-sections have increased is because it's more convenient for the doctor. Women are encouraged to have a "birthing plan" and almost all of them are ignored just so the doctor is not inconvenienced.

  • rate this

    Comment number 72.

    I had to have an emergency caesarian when I had my twins in 2004 and even though it all went well I feel robbed even 7 years later. I would say if its your first and last and your able to do a natural delivery give it a try.

  • rate this

    Comment number 71.

    For many women, it's really not case of choosing caesarean because they are 'too posh to push'. I'm 38 weeks pregnant with my 2nd child, who was born by emergency caesarean following a failed induction and subsequent mistakes made by doctors at the hospital.
    This time, I currently have no choice of a repeat c-section because the PCT group won't pay for it. This change should help people like me.

  • rate this

    Comment number 70.

    68.Lady Samantha
    As a man I find myself nervous of adding to this debate in case I get accused of not understanding so all I will do is agree with every word you've said.

  • rate this

    Comment number 69.

    The report states that C-section (including adverse events) costs £2581, vs £1963 for vaginal birth. Significantly, they do NOT predict an increase in the total number of C-sections, so costs will be similar (although expert opinion is the lowest form of evidence). They also recognise that access to counselling for women with perinatal anxiety should be improved, so they make an informed choice.

  • rate this

    Comment number 68.

    If a woman wants a caesarean for no medical reason then she should pay for it. My daughter couldn't even have braces on the cash-strapped NHS [£2,200, ladies and gentleman is the sum I had to find] and yet they can find money for unnecessary surgery on vain women. People can't get cancer drugs but posh tottie can have a C section courtesy of the tax payer!!!!!

  • rate this

    Comment number 67.

    Then they should have to pay the extra costs for it.

  • rate this

    Comment number 66.

    To Tim (16). Indeed many women did die in childbirth - that's called "natural selection" and it's what makes the species strong. Most of what we do today to allow people who cannot have children naturally to give birth (including IVF) weakens the gene pool. In another 2 million years we won't be able to reproduce without using technology!

  • rate this

    Comment number 65.

    From a feminist perspective, I've never understood why women would be appalled if one were to criticise an abortion but it's okay to condemn a c-section. Surely both are about women making informed decisions about their own bodies? At our NCT post baby 6 week meet up, the first 7 women had emergency c-sections. For me, the birth was a means to an end, not an end itself.

  • rate this

    Comment number 64.

    Caesarian section when necessary. Birth complications of course, to save the mothers and baby's life of course. Otherwise no. It is a rewarding NATURAL and beautiful experience.

  • rate this

    Comment number 63.

    ther3e has to be a difference between wanting and needing and it should be the job of the professional to judge which is which after all they have been trained about such things.
    It seams more and more just want the easy way out, well if you dont want to give birth naturally dont get pregnant
    If you medically need to have a C section then you should of course get it for free otherwise pay for it


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