Thursday, November 24, 2011

NICE caesarian section guidelines

NICE released a new guideline for caesarian sections today. In it they address the issue of maternal request for a caesarian section. They say that if a woman requests a CS because she has anxiety about childbirth, it should be discussed and she should be offered support. If she still wants one, she should be offered a planned CS.

Deciding how to give birth to your child is a really difficult and emotive issue. Everyone wants what is best for their baby and themselves, but how do you know? Without being able to see into the future, how do you know what is best. Before I had my first child, I had dreamy ideas about no pain relief and a two hour delivery (I knew I was being optimistic, but I didn't realize JUST how optimistic!)

I ended up with an emergency caesarian section due to foetal distress. My baby spent 4 days in SCBU with what I called 'boy flu', he was quite well in himself, there were just a few things that weren't right. I was really lucky, I recovered well, I was hovering the stairs (behind my midwife's back) and driving really quickly. My son was well and I even managed to breast feed him.

At the same time, a friend of mine also had a caesarian section. She ended up with an infection (I note that the new guidelines recommend antibiotics to be given sooner than previously.) She was readmitted to hospital and was unwell for weeks. She had a really rough time.

So, when it came to baby number 2, I had a choice. VBAC (vaginal birth after caesarian) or elective section. My doctor (you have to have consultant led care after a caesarian, rather than midwife led care) advised my to have a VBAC, but I knew that if I pushed it, I would be allowed to have a section. I also knew that I wouldn't have to 'push' very hard.

So, pros of a section…convenient (especially when you have childcare to think about), MUCH less pain. Generally not a bad option, quite appealing in fact. Cons of a section….not being able to drive afterwards, not being able to pick my nearly 2 year old up. Oh, and it's definitely not great if you continue to have sections, lots more problems there.

Oh yes, and then there are the medical considerations too. I know I'm a doctor and that they are important, but in reality it's the other things that your mind puts first. Section, apparently more chance of breathing problems for the baby as it's not squeezed through the birth canal so the fluid in its lungs doesn't get squished out. On the other hand, less incontinence and less risk of uterine rupture (although even with a VBAC that is small.) But… what if my baby gets stuck in the birth canal and has brain damage, surely a section will prevent that??

The problem is there are complications with both ways and if you knew you were going to have problems with one, you'd choose the other. Obviously you don't. So how about looking at the evidence?? Well, evidence is always more complicated than 'yes' or 'no' in medicine. It depends on lots of things: what the study was actually looking at, how many people they looked at, their methods, the way they present results…multitude of things. One would think that 'medicine', 'the scientific world' would all do perfect experiments, designed to answer perfect questions and then write them up perfectly so that everyone can agree on what they are supposed to do. Unfortunately not. Not only that, but some papers contradict other papers.

So, where does that leave us? How about I tell you what the NICE guidelines say? After all, they have just spent hours and hours of very experienced people pouring over all the papers that are out there. So, they have pretty much summed it up for us.

They say that a planned caesarean section compared with a planned vaginal birth for a women with an uncomplicated pregnancy and no previous section may reduce the risk of pain during birth and 3 days afterwards; injury to the vagina, early hemorrhage (bleeding) and obstetric shock (bad, very bad). It may increase the time the woman has to stay in hospital and increase the risk of hysterectomy (caused by bleeding) and cardiac arrest. It may also increase the risk of the baby being admitted to the neonatal unit.

Interestingly they say that there is no difference in the rates of problems with babies' brains or breathing problems. (Although it is worth noting that the Royal College of Obstetrics and Gynaecology recommends giving steroids to preterm babies to prevent 'respiratory distress syndrome' (breathing problems in babies). It recommends giving them for preterm deliveries for babies under the gestation of 35 weeks, BUT if the mother is having an elective section, it recommends them for under the gestation of 39 weeks.)

It is also worth noting that they have recorded all the 'evidence quality and reference' as either 'very low' or 'low'…

So, what does all this mean for the NHS? In truth, I suspect it won't change very much. Before these guidelines one would hope that if a woman was that scared of childbirth, their midwife would have picked up on it and if her fear were that bad, she would have been offered a section. I surely know of people who have been offered sections first time round for no 'medical reason'. Now at least, they have the backing of NICE.

Oh, and what did I opt for? A VBAC. I can't really explain why. I just did. I had an episiotomy and it was really painful (epidural cited 3 times, that sort of thing.) Let's face it, generally, child birth is really painful.

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