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 422.


    'Not bothering to give birth takes away from the whole experience'?

    Have you done it have you? All experiences are different. Not all movie magic.I would want my husband there to offer emotional support but determining how I use MY body would be my choice.

    I find it quite sickening when I read men or women essentially condeming a women for not giving birth naturally.

  • rate this

    Comment number 421.

    C-Sections occur at many hospitals due to lack of enough experienced mid-wives. My wife was induced and had a C-Section due to foetal distress, an experienced mid-wife would have known baby was not ready. The second time the baby was breach.

    This is not about choice it is about quality of foetal care - it still is not good enough. Closing midwife lead units will just make things worse.

  • rate this

    Comment number 420.

    Hang on a minute. Stop blaming the women for this. I don't believe many women are choosing C-section. I believe that women need to be supported more before they give birth, enhance their belief that they can give birth vaginally. Society needs to stop viewing birth as a medical procedure and think of it as natural. Ppl are afraid of getting sued and offer intervention at the first opportunity

  • rate this

    Comment number 419.

    I had a dreadful experience giving birth to my first child & even have difficulty talking about the episode now 10 years later, but would never have considered a c-section unless it absolutely necessary. I think a lot of women fear childbirth but it is totally natural and not a reason for a major expensive operation.

  • rate this

    Comment number 418.

    I was happily having breakfast watching the news; then this appeared and I practically threw up. A kid that had just popped out, covered with blood and bodily fluids. It was worse than a horror movie. There was no warning or advisory. I object most strongly to this disgusting spectacle being spashed across our screens in such an overt fashion. Has the BBC no decorum and decency left?

  • rate this

    Comment number 417.

    More choice for women and how they want to give birth.

    All this stuff about natural childbirth being the correct way is a load of old rot and the sort of nonsense that individuals of certain religious faiths have promoted for years.

  • rate this

    Comment number 416.

    Why is this even a debate. if you go to an NHS hospital just do what your told. If they say have a normal birth do it and if they say have a c-section do it. Stop complaining and listen to the doctors and do what they say, thats what they are being paid for

  • rate this

    Comment number 415.

    I don't understand the concern, it isn't many women who would opt for CS out of choice. Those who ask fo CS where no medical need exists will be reassured re natal care & given all the info needed to make the best choice (Armed with facts most would plump for natural if they can!) Anyone concerned re cosmesis or with serious anxiety issues will be given counselling to help make a better decision.

  • rate this

    Comment number 414.

    I said nothing about a fathers 'right to be there' - i said you can't discount some men's opinions. (ie deciding on having an *unneccesary* c-section and not involving the father.)
    I wasnt disagreeing that women are the ones that give birth, but it does take two to make a baby.

    deciding to have kids but "not bothering" to give birth takes away from the whole experience

  • rate this

    Comment number 413.

    My wife and I were denied a c-section in our last pregnancy and lost our baby at full term on the due date. Had he been delivered by c-section a week earlier he would be alive. Surely this is the womans choice and I am glad this seems to have been recognised.

  • rate this

    Comment number 412.

    Offering a c-section to all is mad! I've had 3 kids and wouldn't have missed natural labour for the world. Yes it hurts, but it's an incredible experience and I found it extremely empowering. Yes, c-sections should be there for emergencies and prolonged labours but choosing to have one because you are scared is ridiculous. Natural labour should be promoted all the way.

  • rate this

    Comment number 411.

    @ProfPhoenix 333, my goodness you are ignorant

  • rate this

    Comment number 410.

    I would really like to know what will happen and who will get blamed when something goes wrong. We live now in the blame culture. When things go wrong with spinal anaesthetic it can go catastrophically wrong - why has this and other major complications than may occur (it is major abdominal surgery we are talking about here) not hitting the news bulletins today?

  • rate this

    Comment number 409.

    To: 366.Joanna

    I am sorry to hear the awful time you had during the birth of your baby and afterwards. Yours imho is a case where there was a medical need for a c-section.

    The article is about giving the choice of a c-section to women who do not need it for medical reasons and I cannot understand why any women would want to go through major surgery when it wasn't necessary.

  • rate this

    Comment number 408.

    I'm not a great believer in C-sections believing that they are for emergency cases only. However, if people have paid in tax and NI contributions for years then I would say they are entitled to have one if they so wish as they have paid for them in advance. Why do people always assume the NHS is free - it is for some for certainly not for everyone.

  • rate this

    Comment number 407.

    Where do all the ludicrous comments about figure conscious women come from? Come on think about it...! I have given birth naturally but understand some womens fear, & have seen too many friends suffer the horrer of emergency c-sections. Stop assuming we are all vain, self absorbed air-heads, we are mothers & more than capable of making the right decisions for us & our children.

  • rate this

    Comment number 406.

    women's bodies are designed to give bith naturally. why would anyone chose to have a major operation when they can go through the most amazing and mind-blowing (albeit painful) experience by giving birth the way nature intended?! I'm glad I had natural birth's with my son's and would never willingly chose a c-section unless medically necessary. women shouldn't fear giving birth naturally!

  • rate this

    Comment number 405.

    I had my 3 kids at home, but a number of my friends had traumatic, humiliating hospital births and one would not have another child unless her doctor agreed to her having a c-section after the dreadful experience she had had. Home births can be empowering, wonderful experiences - maybe the money would be better spent on training midwives?

  • rate this

    Comment number 404.

    If you want a C section then fine. Should the NHS pay for it? It depends how the overall costs stack up against each other and if it costs significantly more for what is choice rather than clinical necessity then it would be reasonable to question that choice being taxpayer funded when other patients are perhaps being withheld expensive drugs that might prolong their life. Who should pay?

  • rate this

    Comment number 403.

    347- What a mean-spirited comment. We have laws in place to prevent the unnecessary (note the keyword 'unnecessary' here) suffering of animals, but when it comes to women, unnecessary suffering is suddenly OK ?
    That's almost scary.


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