At the moment, around a quarter of all births are carried out by caesarian section, usually for medical reasons such as foetal distress, mother’s exhaustion, or position of the baby in the womb. Most of these are classed as emergencies, but many are ‘elective’ if it is known that a vaginal birth may not be feasible (e.g. if the mother has already had three caesarian sections before).
The emphasis from the National Institute for Clinical Excellence (NICE) has historically been that caesarean sections are not a matter of ‘choice’ but are supposed to be only used if necessary for medical reasons. Women cannot simply choose to have a caesarean section – mainly because it is major (and costly) surgery.
Now, though, NICE is preparing a new draft of guidelines, the first since 2004, based on the latest research in this area. The guidelines cover things like when caesarian sections are to offered and what procedures should be followed. The really interesting bit for pregnant women, though, is to whom caesarean sections are to be offered under the new guidelines. The new guidelines say that pregnant women are to be given more evidence about caesarean sections (like why it might be necessary, what are the risks/benefits, what effect they are likely to have on future pregnancies) but crucially also say that the decision about whether or not to offer a caesarean section will have to have taken into consideration the woman’s circumstances, concerns and priorities. In other words, women will have more say over whether they are given a caesarian section.
The guidelines specifically list what procedures should be followed if a pregnant woman requests a caesarean section. These are:
explore the reasons for her choice. If there are no medical reasons, explain the risks and benefits of caesarean sections vs vaginal deliveries;
if the woman’s request is based on her fear of childbirth, counselling should be offered by a therapist with expertise in perinatal mental health to support her. If she still wants a caesarian section after that therapy, she should have one;
if an obstetrician refuses a request by a woman for a caesarean section, they should refer the woman to another obstetrician in the NHS, in the same unit, for them to do the caesarean.
The guidelines also clarify that the following medical conditions warrant a caesarean section:
if the baby is in breech at term and it hasn’t been possible to turn the baby manually;
if the mother is carrying twins where the first baby is in breech;
if the placenta covers the cervix (aka placenta praevia)
if the mother has HIV and/or Hepatitis C;
if the mother has genital herpes simplex virus (HSV) in the third trimester.
So the guidelines stop far short of routinely offering caesarian sections to all women, but they do make it a little easier to get one, and also give the woman a greater voice in her care.
There are guidelines that say which cases shouldn’t be offered a caesarian section. These are:
a premature birth;
twins where the first is presented in the correct position and the pregnancy has been free of complications;
a ‘small’ baby;
the mother has a body mass index over 50
The guidelines are expected to be finalised and released next month (November 2011).
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