Journal of Obstetrics and Gynaecology, May 2014; 34: 317–321 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.873776
OBSTETRICS
Maternal request for caesarean section: Audit of a care pathway B. Green, J. Evans, S. Subair & L.M. Liao
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
Women’s Health Division, University College London Hospitals, London, UK
This report is based on an audit of the delivery outcome of a specific care pathway for women who had made a maternal request for caesarean section (MRCS). The study took place in a UK inner city National Health Service maternity unit with 6,000 births per year. All 31 multiparous and 16 nulliparous women on the pathway were included. All of the former group had delivered vaginally, all reported having experienced their previous birth as traumatic, and all subsequently delivered vaginally. Of the 16 nulliparous women, six delivered by planned caesarean section; four delivered vaginally; four had an instrumental delivery and two had an emergency caesarean section. A designated multidisciplinary care pathway that incorporates education and support may have the potential to help more women to achieve a normal delivery. More research is needed to assess its potential for reducing unnecessary caesarean deliveries and for improving user experience. Keywords: Anxiety, caesarean section, maternal request, psychology, user experience
Introduction The National Institute for Health and Clinical Excellence (NICE 2011) guidance that allows all women access to a caesarean section (CS) without a medical reason, places many NHS maternity units in an unenviable position. On the one hand, most units are told to reduce CS rates and to curtail unnecessary interventions, in the interest of cost control. On the other hand, they are mandated to offer the most expensive mode of delivery, even if it is purely a personal preference. Some studies suggest that relatively low numbers of women elect to have a CS despite this choice, so the widespread concern about a rise in maternal request for CS (MRCS) is unjustified (Bragg et al. 2010). These studies however, pre-dated the most recent guidance (NICE 2011). Public and professional unease concerning the increased overall numbers of CS and the regional variations in its rates has been evident for some time. A number of UK studies have explored factors influencing CS rates (McIlwaine et al. 1995; Robson et al. 1996; RCOG 2001; Bragg et al. 2010). The most common factors appear to be fetal compromise, prolonged labour, previous CS and breech presentations, with ‘maternal choice’ cited as the fifth most common reason. There is a paucity of national data reflecting the actual numbers of women who choose CS for no identifiable medical reason. In their recent study exploring variations in CS, Bragg et al. (2010) suggested that 72% of elective CS is made up by women
with a breech presentation or a previous CS. The remainder of elective CS are largely made up of women with maternal or fetal complications necessitating a planned CS. This finding echoes earlier suggestions that concern of vast numbers of UK women electing to have a CS as a lifestyle choice is unfounded (McIlwaine et al. 1995; Robson et al. 1996). Nevertheless, the proportion of women having a spontaneous vaginal birth has dropped significantly over the past two decades. For example, in 2006, spontaneous vaginal birth rates fell to below 50% (Birth Choice UK 2009). This fall is attributed to a rise in intervention during labour. Darra (2009) and others have pointed out that normality should remain high on the maternity service agenda. Normality is central to the professional standing and identity of midwives. Despite the drive to promote normality, there has been no observable increase in the number of women safely achieving a spontaneous vaginal birth, for reasons not fully understood and beyond the scope of this paper. The current report is based on an audit of a pilot intervention that aimed to circumvent the potential conflicts and dilemmas around MRCS. The work was undertaken before the launch of the new CS guidance. However, the lessons learned from the attempt to engage women in a more in-depth discussion about MRCS remains applicable and critical.
Method Background of MRCS pathway development Approximately 6,000 women give birth each year in our busy inner city hospital maternity unit, where we provide care for women both at low and high risk of complications during pregnancy and labour. Our CS rate was above the national average at 32% and rising. There was multidisciplinary in-house agreement that steps should be introduced to improve our understanding and develop appropriate solutions. This was the rationale behind our pilot work. The aim of our pilot MRCS care pathway was to increase consistency of advice and practice among doctors and midwives, decrease decisional conflicts and ensure equality of services for all women. Pathway development was informed by a number of observations over the years. In 2010, our maternity information system indicated 80 MRCS cases. A manual audit of the 80 records identified only 27 clearly documented cases of maternal request. Previous traumatic vaginal delivery accounted for the majority of these cases. In 2011, with the introduction of our local care pathway, MRCS was identified in 57 records,
Correspondence: L.-M. Liao, Women’s Health Division, University College London Hospitals, 2N, 250 Euston Road, London NW1 2PG, UK. E-mail: lih-mei. [email protected]
318
B. Green et al.
of which only six episodes were for maternal request with no underlying medical reason, all of whom were nulliparous women. This equates to approximately 3% in 2011 of elective caesarean sections actually undertaken for maternal request, as were consistent with former audit data.
Statement of intent of MRCS care pathway
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
Pearson et al. (1995) emphasised improved clinical outcomes as a fundamental goal of pathway developments. We recognised the need for the aims of the care pathway to be made explicit. The MRCS care pathway being piloted was founded on the core principles of the 2004 guidance on caesarean section (NICE 2004), with the following set of stated objectives: • Coordination of a multidisciplinary team (MDT) approach to minimise duplications and cross communications • Provide a framework for collecting data to identify which women are requesting CS and for what reasons • Record discussion of all potential benefits and risks of CS versus vaginal delivery • Offer anxiety reduction interventions where MRCS is anxiety based.
Implementation of MRCS care pathway Figure 1 provides a summary description of our care pathway. All women were to be informed at booking that MRCS was not encouraged at the unit but that additional support would be made available to overcome psychological barriers to normal birth. This information was also available on the maternity unit website and displayed in the antenatal clinic areas. MRCS women were directed to consultant midwives. All women were offered appointments with one or two midwives during their pregnancy and the opportunity for follow through in their birth. Reasons for MRCS were explored. A discussion about birth options would take place at least once during their pregnancy. For women who had previously succeeded in vaginal delivery, the consultant midwife offered educational input on the high probability of a vaginal delivery for the impending birth. Women were further reassured that their birth would be either attended by the consultant midwife for whom the telephone number was provided 24/7 or one of the other members of the team. The birth plan was then documented in the woman’s notes. All of the women were offered the opportunity to see a consultant obstetrician if they still preferred to have an elective CS. Clinical psychology input was
Women informed at booking by midwives that ELCS is not usually offered without an identified medical reason
Agrees to vaginal birth Routine antenatal care pathway
• • • • •
Continues to request CS Refer to consultant midwife or other experienced midwife in their absence
Consultant midwife Woman’s knowledge of CS and vaginal birth explored, benefits, risks and alternatives explained Explore anxiety and fear around vaginal birth and indication for CS Offer education about normal birth Discuss MRCS without clinical indication is not generally encouraged at this unit Advise CS is not safer than vaginal birth
Underlying anxiety issues
Referred to obstetrician to discuss elective caesarean section
No underlying anxiety issues
Decline elective caesarean section
• •
Plan for vaginal birth Birth planning with consultant midwife Referral to midwifery team (Isis centre for all out of area women)
Figure 1. Audited clinical pathway for MRCS.
Maternal request for caesarean section intended to be part of the care pathway but it was not formalised until the end of the audit period.
Participants
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
A total of 50 women who presented for MRCS were identified from our records for the audit period. Of these, three declined the care pathway and chose to secure a CS delivery in the private sector for personal reasons. All remaining 47 women on the MRCS care pathway were included in the audit. The majority were referred during early 2nd trimester. Demographic data and birth outcome data were retrieved from the maternity information system (Table I). The women were predominantly white British and only a small percentage were from higher socioeconomic groups (see Table III).
Results There were no adverse neonatal outcomes. Table II indicates the number of antenatal appointments with the consultant midwife; most women were seen for 3–4 appointments. For the 31 multiparous women presenting for MRCS, all reported previous negative experiences of giving birth, the most common themes being a lack of support and empathy from maternity staff. Upon provision of continuity of care by a consultant midwife for both pregnancy and labour, none of the women required referral to an obstetrician and all of them delivered vaginally. Of the 16 nulliparous women, all expressed a fear of childbirth. Table III shows the modes of delivery for this group: 6/16 elected to have a CS and all were supported by the consultant midwife during their operation. Importantly, the CS provision did not alleviate anxiety for this group of women, whose anxiety was palpable, even when they were on the operating table. Three of the six women required sedation during the procedure. Their anxiety clearly remained unresolved despite the offer of a planned CS. Of the remaining 10 nulliparous women, two had emergency CS and four instrumental delivery. Two of the four women who had instrumental deliveries had forceps delivery and were the only two in the cohort who reported significant dissatisfaction with their birth outcome.
Discussion Our local pilot intervention was an attempt to learn more about MRCS trajectories. Our observations lead us to believe that additional support for the women via a designated multidisciplinary care pathway is indeed warranted. Under current NICE guidance, it is recommended that the reasons for MRCS should be skilfully explored and that appropriate support should be offered. If after
Table I. Demographic details of women who requested elective caesarean section. n Age (years) 30–39 40 Ethnicity Caucasian Black African Other Social class Professional groups Elementary occupations
319
Table II. Number of antenatal appointments with the consultant midwife. n Number of appointments (in addition to other antenatal care appointments) 1 2 3 4 Parity P0 P1 P2 Total women seen
6 25 11 5 16 30 1 47
discussion and where women are fully informed of the risks and benefits of the procedure MRCS remains the desired option, her decision should be respected. However, ‘support’ is a very broad concept and there is scant research to identify effective interventions that help women reach a balanced (rather than anxietydriven) decision on their mode of delivery. It was unsurprising that almost two-thirds of our cohort presented poor birth experiences as a reason for their current MRCS. Research shows that the proportion of women who suffer post-traumatic stress disorder (PTSD) after childbirth ranges from around 2–9% (Beck et al. 2011). Poor birth experiences, whether or not they meet PTSD threshold, can have a negative impact on womens’ physical and psychological wellbeing and is a decisional factor for the mode of the next delivery. While MRCS is understandable for these women, research also shows that for women who have had one vaginal birth previously, the chance of a successful vaginal birth is ⬎ 95% (Grobman et al. 2007). These women are thus an important group to focus on, in order to develop sensible responses to MRCS. Empathic communication in the context of high quality professional input is most likely to result in positive birth experiences, regardless of normal or instrumental delivery (Commission for Healthcare Audit and Inspection 2007). With adequate psychological support, a proportion of women presenting for MRCS can potentially achieve a normal and satisfactory delivery. For women who have been poorly served in their previous birth, it has the potential to be a healing experience. In the words of a service user in the current study: ‘I can’t believe that everything was so different … and I am so pleased that I didn’t have the caesarean section – incredible that birth can be such a positive and fulfilling experience, that I had everything the way I imagined it would be. That the NHS can provide such high levels of care is truly inspiring’. Nulliparous women present an overlapping but also different set of challenges and uncertainties related to labour and birth Table III. Birth outcomes. n
40 2 42 3 2 6 41
ELCS Emergency CS Forceps Kiwi SVD no tear SVD 1st or 2nd tear Total ELCS, elective caesarean section; SVD, spontaneous vaginal delivery.
6 2 2 2 20 15 47
320
B. Green et al. Women informed at booking by midwives that ELCS not encouraged without identifiable reasons
Continues to request CS Refer to consultant midwife
Agrees to vaginal birth routine ANC
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
Consultant midwife Initial consultation by phone and e-mail/continuity of carer/birth methods education/psychological support/referral to perinatal mental health/referral to routine ANC/birth planning (some or all of the above – as appropriate for individual women)
Clinical psychology (designated clinic) Assessment/treatment/ triaging (some or all of the above as appropriate)
Significant psychological issues
No significant psychological issues
Consultant obstetrician Discuss CS/booking for planned CS/referral to consultant midwife (some or all of the above – as appropriate)
Figure 2. Modified MRCS pathway based on audit and NICE 2011.
outcome. While six nulliparous women on the MRCS pathway elected to have a planned caesarean section, 10 women felt enabled and supported to consider attempting a vaginal birth. In nulliparous women, the reason for MRCS is often multifactorial, including cultural, familial and psychological factors (Hofberg and Ward 2003). Fear of childbirth may transmit over generations and this can produce a second generation effect of a mother’s own unresolved frightening experience (Uddenberg 1974). For some women who are terrified of giving birth, there may well be background psychological difficulties, for which the plan for a CS is unlikely to be an effective intervention. Therefore, whatever mode of delivery, escalation to a psychological or in some instances psychiatric assessment and appropriate management is required. As stated in Midwifery 2020 (Dodwell 2011), it is fundamental for midwives to recognise that some women will require more input from maternity services, while others will require less, and some will require additional interventions. This is an aspect of the pathway that we would like to formalise and strengthen. Our resultant new pathway, further modified in light of the new NICE guidance (2011), is summarised in Figure 2. Fear of childbirth has been associated with anxiety proneness in general (Wijma and Wijma 1992). When a woman says, ‘I’m terrified of giving birth’, maternity staff, by virtue of their training, will rightly focus on ‘birth’ and either direct her to a surgical trajectory or offer unrealistic reassurance to steer her towards the opposite. What we may need to do more of is understand the terror – how does it manifest itself; what skills are needed for effective management of it and what are the most effective ways for maternity staff to acquire these skills?
While MRCS numbers may not be an issue, at least for now, reasons for elective surgery are likely to be complex and deserve careful exploration. A richly layered formulation of MRCS, especially in nulliparous women, is as yet absent in the professional literature. In future, more detailed studies are needed to inform policies and best clinical practice. More integration of the behavioural and social sciences in research will lead to an interdisciplinary understanding that can benefit women and society. Authoritative multidisciplinary research in MRCS remains an unmet need. Interestingly, only 6/47 of the women in the study were from the most socioeconomically privileged grouping. The remainder were from the middle socioeconomic groups that are representative of our local population. Women presenting for MRCS no longer fit the social ‘too posh to push’ stereotype, if they ever did. An evidence-based MDT care pathway for MRCS could have the potential to significantly improve user experience, reduce unnecessary CS episodes and associated costs. Such a pathway can benefit women without compromising the new care guidance (NICE 2011). However, much more investment in multidisciplinary research informed by psychosocial frameworks is needed, in order to account for MRCS and test different strategies for approaching the phenomenon.
Conclusion A designated multidisciplinary care pathway has the potential to help women achieve a normal delivery, especially for multiparous women who have previously delivered vaginally. More investment
Maternal request for caesarean section is needed to build research evidence to formulate and evaluate the most effective and efficient interventions for safely reducing unnecessary CS and enhancing user experience.
Acknowledgements The authors would like to express their thanks to Sureya Ali for her assistance with the preparation of this manuscript. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
References Beck CT, Gable RK, Sakala C, Declercq ER. 2011. Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey. Birth 38:216–227. Birth Choice UK. 2009. Latest maternity statistics for England and Scotland. Historical normal birth rates for the London region. London: Birth Choice UK. Bragg F, Cromwell DA, Edozien LC, Gurol-Urganci I, Mahmood TA, Templeton A et al. 2010. Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study. British Medical Journal 341:5065–5072. Commission for Healthcare Audit and Inspection. 2007. London. Darra S. 2009. ‘Normal’, ‘natural’, ‘good’ or ‘good-enough’ birth: examining the concepts. Nursing Inquiry 16:297–305.
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Dodwell M. 2011. Midwifery 2020: Quality midwifery care that meets women’s needs. AIMS Journal 23:12–14. Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ et al. 2007. Development of a nomogram for prediction of vaginal birth after cesarean delivery. Obstetrics and Gynecology 109:806–812. Hofberg K, Ward MR. 2003. Fear of pregnancy and childbirth. Postgraduate Medical Journal 79:505–510. McIlwaine G, Boulton-Jones C, Cole S, Wilkinson C. 1995. Caesarean section in Scotland 1994/5: A national audit. Edinburgh: Scottish Programme for Clinical Effectiveness in Reproductive Health. NICE. 2004. Clinical guidelines: caesarean section. London: National Institute for Health and Clinical Excellence. NICE. 2011. Clinical guidelines: caesarean section. London: National Institute for Health and Clinical Excellence. Pearson SD, Goulart-Fisher D, Lee TH. 1995. Critical pathways as a strategy for improving care: problems and potential. Annals of Internal Medicine 123:941–948. Robson MS, Scudamore IW, Walsh SM. 1996. Using the medical audit cycle to reduce Caesarean section rates. American Journal of Obstetrics and Gynecology 174:1. RCOG. 2001. Induction of labour. Royal College of Obstetricians and Gynaecologists’ evidence based clinical guideline no. 9. London: RCOG Press. Uddenberg N. 1974. Reproductive adaptation in mother and daughter. A study of personality development and adaptation to motherhood. Acta Psychiatrica Scandinavica 254:1–115. Wijma K, Wijma B. 1992. Changes in anxiety during pregnancy and after delivery. In: Wijma K, von Schoultz B, editors. Reproductive life. Advances in research in psychosomatic obstetrics and gynaecology. Lancashire: Parthenon. p 81–88.
OBSTETRICS
Maternal request for caesarean section: Audit of a care pathway B. Green, J. Evans, S. Subair & L.M. Liao
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
Women’s Health Division, University College London Hospitals, London, UK
This report is based on an audit of the delivery outcome of a specific care pathway for women who had made a maternal request for caesarean section (MRCS). The study took place in a UK inner city National Health Service maternity unit with 6,000 births per year. All 31 multiparous and 16 nulliparous women on the pathway were included. All of the former group had delivered vaginally, all reported having experienced their previous birth as traumatic, and all subsequently delivered vaginally. Of the 16 nulliparous women, six delivered by planned caesarean section; four delivered vaginally; four had an instrumental delivery and two had an emergency caesarean section. A designated multidisciplinary care pathway that incorporates education and support may have the potential to help more women to achieve a normal delivery. More research is needed to assess its potential for reducing unnecessary caesarean deliveries and for improving user experience. Keywords: Anxiety, caesarean section, maternal request, psychology, user experience
Introduction The National Institute for Health and Clinical Excellence (NICE 2011) guidance that allows all women access to a caesarean section (CS) without a medical reason, places many NHS maternity units in an unenviable position. On the one hand, most units are told to reduce CS rates and to curtail unnecessary interventions, in the interest of cost control. On the other hand, they are mandated to offer the most expensive mode of delivery, even if it is purely a personal preference. Some studies suggest that relatively low numbers of women elect to have a CS despite this choice, so the widespread concern about a rise in maternal request for CS (MRCS) is unjustified (Bragg et al. 2010). These studies however, pre-dated the most recent guidance (NICE 2011). Public and professional unease concerning the increased overall numbers of CS and the regional variations in its rates has been evident for some time. A number of UK studies have explored factors influencing CS rates (McIlwaine et al. 1995; Robson et al. 1996; RCOG 2001; Bragg et al. 2010). The most common factors appear to be fetal compromise, prolonged labour, previous CS and breech presentations, with ‘maternal choice’ cited as the fifth most common reason. There is a paucity of national data reflecting the actual numbers of women who choose CS for no identifiable medical reason. In their recent study exploring variations in CS, Bragg et al. (2010) suggested that 72% of elective CS is made up by women
with a breech presentation or a previous CS. The remainder of elective CS are largely made up of women with maternal or fetal complications necessitating a planned CS. This finding echoes earlier suggestions that concern of vast numbers of UK women electing to have a CS as a lifestyle choice is unfounded (McIlwaine et al. 1995; Robson et al. 1996). Nevertheless, the proportion of women having a spontaneous vaginal birth has dropped significantly over the past two decades. For example, in 2006, spontaneous vaginal birth rates fell to below 50% (Birth Choice UK 2009). This fall is attributed to a rise in intervention during labour. Darra (2009) and others have pointed out that normality should remain high on the maternity service agenda. Normality is central to the professional standing and identity of midwives. Despite the drive to promote normality, there has been no observable increase in the number of women safely achieving a spontaneous vaginal birth, for reasons not fully understood and beyond the scope of this paper. The current report is based on an audit of a pilot intervention that aimed to circumvent the potential conflicts and dilemmas around MRCS. The work was undertaken before the launch of the new CS guidance. However, the lessons learned from the attempt to engage women in a more in-depth discussion about MRCS remains applicable and critical.
Method Background of MRCS pathway development Approximately 6,000 women give birth each year in our busy inner city hospital maternity unit, where we provide care for women both at low and high risk of complications during pregnancy and labour. Our CS rate was above the national average at 32% and rising. There was multidisciplinary in-house agreement that steps should be introduced to improve our understanding and develop appropriate solutions. This was the rationale behind our pilot work. The aim of our pilot MRCS care pathway was to increase consistency of advice and practice among doctors and midwives, decrease decisional conflicts and ensure equality of services for all women. Pathway development was informed by a number of observations over the years. In 2010, our maternity information system indicated 80 MRCS cases. A manual audit of the 80 records identified only 27 clearly documented cases of maternal request. Previous traumatic vaginal delivery accounted for the majority of these cases. In 2011, with the introduction of our local care pathway, MRCS was identified in 57 records,
Correspondence: L.-M. Liao, Women’s Health Division, University College London Hospitals, 2N, 250 Euston Road, London NW1 2PG, UK. E-mail: lih-mei. [email protected]
318
B. Green et al.
of which only six episodes were for maternal request with no underlying medical reason, all of whom were nulliparous women. This equates to approximately 3% in 2011 of elective caesarean sections actually undertaken for maternal request, as were consistent with former audit data.
Statement of intent of MRCS care pathway
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
Pearson et al. (1995) emphasised improved clinical outcomes as a fundamental goal of pathway developments. We recognised the need for the aims of the care pathway to be made explicit. The MRCS care pathway being piloted was founded on the core principles of the 2004 guidance on caesarean section (NICE 2004), with the following set of stated objectives: • Coordination of a multidisciplinary team (MDT) approach to minimise duplications and cross communications • Provide a framework for collecting data to identify which women are requesting CS and for what reasons • Record discussion of all potential benefits and risks of CS versus vaginal delivery • Offer anxiety reduction interventions where MRCS is anxiety based.
Implementation of MRCS care pathway Figure 1 provides a summary description of our care pathway. All women were to be informed at booking that MRCS was not encouraged at the unit but that additional support would be made available to overcome psychological barriers to normal birth. This information was also available on the maternity unit website and displayed in the antenatal clinic areas. MRCS women were directed to consultant midwives. All women were offered appointments with one or two midwives during their pregnancy and the opportunity for follow through in their birth. Reasons for MRCS were explored. A discussion about birth options would take place at least once during their pregnancy. For women who had previously succeeded in vaginal delivery, the consultant midwife offered educational input on the high probability of a vaginal delivery for the impending birth. Women were further reassured that their birth would be either attended by the consultant midwife for whom the telephone number was provided 24/7 or one of the other members of the team. The birth plan was then documented in the woman’s notes. All of the women were offered the opportunity to see a consultant obstetrician if they still preferred to have an elective CS. Clinical psychology input was
Women informed at booking by midwives that ELCS is not usually offered without an identified medical reason
Agrees to vaginal birth Routine antenatal care pathway
• • • • •
Continues to request CS Refer to consultant midwife or other experienced midwife in their absence
Consultant midwife Woman’s knowledge of CS and vaginal birth explored, benefits, risks and alternatives explained Explore anxiety and fear around vaginal birth and indication for CS Offer education about normal birth Discuss MRCS without clinical indication is not generally encouraged at this unit Advise CS is not safer than vaginal birth
Underlying anxiety issues
Referred to obstetrician to discuss elective caesarean section
No underlying anxiety issues
Decline elective caesarean section
• •
Plan for vaginal birth Birth planning with consultant midwife Referral to midwifery team (Isis centre for all out of area women)
Figure 1. Audited clinical pathway for MRCS.
Maternal request for caesarean section intended to be part of the care pathway but it was not formalised until the end of the audit period.
Participants
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
A total of 50 women who presented for MRCS were identified from our records for the audit period. Of these, three declined the care pathway and chose to secure a CS delivery in the private sector for personal reasons. All remaining 47 women on the MRCS care pathway were included in the audit. The majority were referred during early 2nd trimester. Demographic data and birth outcome data were retrieved from the maternity information system (Table I). The women were predominantly white British and only a small percentage were from higher socioeconomic groups (see Table III).
Results There were no adverse neonatal outcomes. Table II indicates the number of antenatal appointments with the consultant midwife; most women were seen for 3–4 appointments. For the 31 multiparous women presenting for MRCS, all reported previous negative experiences of giving birth, the most common themes being a lack of support and empathy from maternity staff. Upon provision of continuity of care by a consultant midwife for both pregnancy and labour, none of the women required referral to an obstetrician and all of them delivered vaginally. Of the 16 nulliparous women, all expressed a fear of childbirth. Table III shows the modes of delivery for this group: 6/16 elected to have a CS and all were supported by the consultant midwife during their operation. Importantly, the CS provision did not alleviate anxiety for this group of women, whose anxiety was palpable, even when they were on the operating table. Three of the six women required sedation during the procedure. Their anxiety clearly remained unresolved despite the offer of a planned CS. Of the remaining 10 nulliparous women, two had emergency CS and four instrumental delivery. Two of the four women who had instrumental deliveries had forceps delivery and were the only two in the cohort who reported significant dissatisfaction with their birth outcome.
Discussion Our local pilot intervention was an attempt to learn more about MRCS trajectories. Our observations lead us to believe that additional support for the women via a designated multidisciplinary care pathway is indeed warranted. Under current NICE guidance, it is recommended that the reasons for MRCS should be skilfully explored and that appropriate support should be offered. If after
Table I. Demographic details of women who requested elective caesarean section. n Age (years) 30–39 40 Ethnicity Caucasian Black African Other Social class Professional groups Elementary occupations
319
Table II. Number of antenatal appointments with the consultant midwife. n Number of appointments (in addition to other antenatal care appointments) 1 2 3 4 Parity P0 P1 P2 Total women seen
6 25 11 5 16 30 1 47
discussion and where women are fully informed of the risks and benefits of the procedure MRCS remains the desired option, her decision should be respected. However, ‘support’ is a very broad concept and there is scant research to identify effective interventions that help women reach a balanced (rather than anxietydriven) decision on their mode of delivery. It was unsurprising that almost two-thirds of our cohort presented poor birth experiences as a reason for their current MRCS. Research shows that the proportion of women who suffer post-traumatic stress disorder (PTSD) after childbirth ranges from around 2–9% (Beck et al. 2011). Poor birth experiences, whether or not they meet PTSD threshold, can have a negative impact on womens’ physical and psychological wellbeing and is a decisional factor for the mode of the next delivery. While MRCS is understandable for these women, research also shows that for women who have had one vaginal birth previously, the chance of a successful vaginal birth is ⬎ 95% (Grobman et al. 2007). These women are thus an important group to focus on, in order to develop sensible responses to MRCS. Empathic communication in the context of high quality professional input is most likely to result in positive birth experiences, regardless of normal or instrumental delivery (Commission for Healthcare Audit and Inspection 2007). With adequate psychological support, a proportion of women presenting for MRCS can potentially achieve a normal and satisfactory delivery. For women who have been poorly served in their previous birth, it has the potential to be a healing experience. In the words of a service user in the current study: ‘I can’t believe that everything was so different … and I am so pleased that I didn’t have the caesarean section – incredible that birth can be such a positive and fulfilling experience, that I had everything the way I imagined it would be. That the NHS can provide such high levels of care is truly inspiring’. Nulliparous women present an overlapping but also different set of challenges and uncertainties related to labour and birth Table III. Birth outcomes. n
40 2 42 3 2 6 41
ELCS Emergency CS Forceps Kiwi SVD no tear SVD 1st or 2nd tear Total ELCS, elective caesarean section; SVD, spontaneous vaginal delivery.
6 2 2 2 20 15 47
320
B. Green et al. Women informed at booking by midwives that ELCS not encouraged without identifiable reasons
Continues to request CS Refer to consultant midwife
Agrees to vaginal birth routine ANC
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
Consultant midwife Initial consultation by phone and e-mail/continuity of carer/birth methods education/psychological support/referral to perinatal mental health/referral to routine ANC/birth planning (some or all of the above – as appropriate for individual women)
Clinical psychology (designated clinic) Assessment/treatment/ triaging (some or all of the above as appropriate)
Significant psychological issues
No significant psychological issues
Consultant obstetrician Discuss CS/booking for planned CS/referral to consultant midwife (some or all of the above – as appropriate)
Figure 2. Modified MRCS pathway based on audit and NICE 2011.
outcome. While six nulliparous women on the MRCS pathway elected to have a planned caesarean section, 10 women felt enabled and supported to consider attempting a vaginal birth. In nulliparous women, the reason for MRCS is often multifactorial, including cultural, familial and psychological factors (Hofberg and Ward 2003). Fear of childbirth may transmit over generations and this can produce a second generation effect of a mother’s own unresolved frightening experience (Uddenberg 1974). For some women who are terrified of giving birth, there may well be background psychological difficulties, for which the plan for a CS is unlikely to be an effective intervention. Therefore, whatever mode of delivery, escalation to a psychological or in some instances psychiatric assessment and appropriate management is required. As stated in Midwifery 2020 (Dodwell 2011), it is fundamental for midwives to recognise that some women will require more input from maternity services, while others will require less, and some will require additional interventions. This is an aspect of the pathway that we would like to formalise and strengthen. Our resultant new pathway, further modified in light of the new NICE guidance (2011), is summarised in Figure 2. Fear of childbirth has been associated with anxiety proneness in general (Wijma and Wijma 1992). When a woman says, ‘I’m terrified of giving birth’, maternity staff, by virtue of their training, will rightly focus on ‘birth’ and either direct her to a surgical trajectory or offer unrealistic reassurance to steer her towards the opposite. What we may need to do more of is understand the terror – how does it manifest itself; what skills are needed for effective management of it and what are the most effective ways for maternity staff to acquire these skills?
While MRCS numbers may not be an issue, at least for now, reasons for elective surgery are likely to be complex and deserve careful exploration. A richly layered formulation of MRCS, especially in nulliparous women, is as yet absent in the professional literature. In future, more detailed studies are needed to inform policies and best clinical practice. More integration of the behavioural and social sciences in research will lead to an interdisciplinary understanding that can benefit women and society. Authoritative multidisciplinary research in MRCS remains an unmet need. Interestingly, only 6/47 of the women in the study were from the most socioeconomically privileged grouping. The remainder were from the middle socioeconomic groups that are representative of our local population. Women presenting for MRCS no longer fit the social ‘too posh to push’ stereotype, if they ever did. An evidence-based MDT care pathway for MRCS could have the potential to significantly improve user experience, reduce unnecessary CS episodes and associated costs. Such a pathway can benefit women without compromising the new care guidance (NICE 2011). However, much more investment in multidisciplinary research informed by psychosocial frameworks is needed, in order to account for MRCS and test different strategies for approaching the phenomenon.
Conclusion A designated multidisciplinary care pathway has the potential to help women achieve a normal delivery, especially for multiparous women who have previously delivered vaginally. More investment
Maternal request for caesarean section is needed to build research evidence to formulate and evaluate the most effective and efficient interventions for safely reducing unnecessary CS and enhancing user experience.
Acknowledgements The authors would like to express their thanks to Sureya Ali for her assistance with the preparation of this manuscript. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
J Obstet Gynaecol Downloaded from informahealthcare.com by Washington University Library on 12/27/14 For personal use only.
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