Saturday, 16 April 2016

Choosing A Caesarean, And Having that Choice Refused.

I seem to write endlessly about caesareans on here, it was never my intention with this blog, but hey that's the joy of having one's own little online vanity project. Often I'm writing in response to news articles on the subject and almost always those talk about the terrible rise in C sections, how unecessary they are etc. etc. It's seems very odd then to have been seeing stories yesterday about the dangers of women being denied caesareans. Except that those headlines chime more with my own experience.

Options?

Almost two years after MissE was born I attended a birth "debrief" at the hospital. I'd been trying, all that time, to just forget about it. I had a healthy baby after all and that's supposed to be all that matters. Dwelling on how horrible the birth had been for me seemed self centered and unforgivably ungrateful, two attributes no good Mother is supposed to display. But we were thinking about baby number two and I wanted to at least understand what had happened and why and perhaps be a little better prepared next time.

To that end, I asked what my options would be. I had imagined the hospital would be supportive of a VBAC (Vaginal birth after caesarean), they had been keen to tell me, almost as soon as MissE was born, that I could have one with the next baby. But I hadn't expected to be told so firmly that I had no choice, I would have to attempt a VBAC, it was hospital policy.

At the time I was undecided, if anything I swayed towards wanting the VBAC, it was a chance for a do over, to show I could do the whole birth thing after all, lay some personal demons to rest and perhaps avoid another long and terrifying postnatal stay. But even so, I was shaken by the assertion that I had absolutely no voice in a decision about my own body.

I was also told that there could be no short cut to a C section if the labour went badly again. I would have to work my way through the same list of medical interventions all over again, each one spaced out by the specified hours of waiting and contracting. I did have the right to refuse the interventions, but not to demand one I wanted, so those hours would always remain.

The only other option, were I to persist in my unreasonable request, would be to try to convince the team's psychiatrist that a caesarean was vital to my mental health.

In effect, there were two way to "choose" a caesarean, serve your time for the required number of hours in  a difficult labour or convince someone that your decision wasn't considered, informed or pragmatic but the symptom of a psychological condition.*

Hospital Policy

I can't say for sure why this was the hospital policy, I very much doubt it was based on safety or clinical consideration as, although there are certainly risks to caesareans, over all it is questionable if they are greater than for a VBAC and every case is different. As far as I could tell a VBAC would have been very slightly safer for me but equally slightly riskier for the baby and of course that all assumes that the VBAC works out, an emergency C section is much riskier than a planned one.

Which leaves me to to speculate on two possibilities. Either the hospital wanted to stop women having C sections so they could reduce that much talked about % caesarean rate or they were trying to cut costs.

Which is where this weeks news stories come in. They stem from the tragic case of a baby who died from oxygen starvation after extended attempts at an instrumental vaginal delivery. His mother had asked throughout the pregnancy and birth for a Caesarean, having been warned she would need one after a previous difficult birth but she wasn't listened too. Instead she got ventouse, forceps and an episiotomy, the instruments used with such force that she was repeatedly pulled off the bed. Eventually an emergency C section was done, in the rush the mother had to have a general anesthetic and the father was sent out to wait alone with no idea what was going on. But it was too late and baby died a few days later. The coroner investigating concluded that the hospital, and others were denying women C sections in an effort to save money.

Money

The money thing though is tricky. I've seen various figures chucked into this story saying a c section is twice or four times the cost of a normal birth. I have no idea which, if any, are accurate so I'm not going to list them here. To me those figures are a bit meaningless anyway. Firstly, no woman gets to choose between a C section and a normal birth because no woman gets to choose a normal birth. You can hope for one, as I did with Miss E, but if it doesn't work out that way and you end up with all those hours and interventions and the emergency Caesarean then that "normal" birth is suddenly way more expensive than a quick elective C section (In the states, elective C sections are often considered cheaper because they are so much quicker).

Also, I am not convinced that cost is the major driving force behind refusing women C sections. Which ever figures you use, the difference in cost isn't actually huge, we're talking a grand or two not tens of thousands here. Surgical birth may be more expensive, but frivolous maternal request caesareans are not to blame for the troubles in our beloved NHS.

To me a more likely culprit is those percentage targets and the wider, deeper, paternalistic treatment of pregnant women. For every story of a women denied a caesarean there is another who felt forced into one.

The charity Birthrights held a conference this week called; Policing Pregnancy. It looked not just at birth but at some of the other ways in which pregnant women are treated not as rational , individual human beings, but as merely potentially hazardous vessels for the future generation. This Storify of tweets from the event is well worth a look.

When I did get pregnant again, my uncertainty over how I wanted the baby to be born disappeared almost immediately. My desire to prove myself by finally having a vaginal birth just went. I knew I wanted the safest possible option for my baby and that I would rather know in advance that I would have to endure a c section than leave it up to chance again and risk another emergency one.  But this decision meant that I spent the first few months of that pregnancy absolutely dreading my first appointment with the obstetricians. It hung over me as a constant dark cloud. I had moved to a new area and a new hospital but that first consultant's assertion that I would have to have a VBAC or else fight my case with the psychiatrist, stuck with me and I didn't feel like I had much fight left.

He Listened

I was called into that first appointment, unusually for the NHS, a little early, before my husband arrived. I sat alone in the chair next to the doctor and tried to summon the courage to stand up for myself. I couldn't entirely keep back the tears when he asked me to tell him what had happened last time but the odd thing was, he listened. He said he was sorry I had been through that and then he asked me what I wanted this time. He didn't tell me what I should do, what his opinion was or what hospital policy dictated. He did apologetically say that he had to tell me a VBAC would be safe but otherwise he said very little, other than to answer my questions.  After a while the consultant came in, one of those "old white men" who are supposed to want to tell women what to do, but he listened too and wrote in my notes, so that no one could over rule it, that this time it would be my choice. I was a capable human being, I could weigh up options and reach a decision that wasn't the product purely of ignorance, fear or mental illness. The person who would decide what would happen to my body, was me.

SB

*This took place shortly prior to the introduction of NICE guidelines which recommended women wanting a C section without medical reason should be given counselling to look into their fears but ultimately given the surgery if that remains their choice. Done well, this sounds like a good idea although it seems in practice it doesn't always happen and there is a fine line between exploring a woman's fears and trying to persuade her to change her mind. Arguably with one emergency C section already under my belt my request wasn't entirely without medical reason anyway.