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Making decisions about birth after caesarean

Information needs/sources in previous pregnancies

For most women, finding out that they are pregnant brings with it a wealth of general and more specific questions and concerns for which they want reliable information. However, knowing which sources to trust and how to separate objective information from rumours and anecdotes can be difficult. Under NHS guidelines, women should be provided with a range of services to help them prepare for labour, birth and motherhood: a series of maternity appointments with qualified midwives, information leaflets in the form of 'pregnancy packs' and the option to attend antenatal classes. In addition, many women seek out information from books and magazines, TV programmes, websites and, of course, other women.

 

She thinks having access to trustworthy information is particularly important during a first...

She thinks having access to trustworthy information is particularly important during a first...

Age at interview: 30
Sex: Female
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Yes, I think for the first pregnancies definitely. Subsequent ones, I probably wouldn't bother, but first pregnancies, you're reading everything and looking at everything that you can get your hands on. So something that's interactive and has got facts that you can trust because it's from a trusted source, rather than from say a mother and baby magazine that might be pushing some particular angle, would be very useful for first pregnancies.
 

For most women we spoke to, their previous pregnancy had been their first experience of being pregnant. There was wide variation in the amount and range of information women had wanted and had received during that pregnancy. A few women had wanted to know everything there was to know, not just about labour and birth, but also about the development of the baby throughout pregnancy. They had used the library and the internet to do their own research above and beyond what they had learned from health professionals. Others had found the information they received through their midwives more than sufficient. A few women felt that some of the material presented on TV programmes, in women's magazines or on the internet could be more scary than informative. However, others had enjoyed the level of detail these sources provided.

 

The antenatal classes provided her with all the information she felt she needed. The breathing...

The antenatal classes provided her with all the information she felt she needed. The breathing...

Age at interview: 41
Sex: Female
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And what kind of information did you want with it being your first pregnancy, what kind of things did you feel that you'd want to know about?

Can't really remember now whether I' because we had the antenatal classes which provided probably the wealth of information that I needed and they thought of spoke through' talked you through breathing, the epidurals and the breathing was something that I was very conscious of and I sort of was practising that and I think that's what helped my labour. Because I seemed to cope just with the breathing and the TENS machine, but it probably also helps I found out I have a high pain threshold as well, so [laughs]'

And how many classes did you attend?

About half a dozen.

And was that local?

Yes.

Okay, and now thinking back, what kind of information did you want to receive?

Probably what they provided us with, yeah, because'

There wasn't anything that you feel that you could have really done with knowing?

I don't think so, no, no.

 

She thinks that sometimes it can be better not to know too much and to put your trust in the...

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She thinks that sometimes it can be better not to know too much and to put your trust in the...

Age at interview: 31
Sex: Female
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Is there any way you could have been more prepared, do you think? 

I don't think so really, because one of the few things I have learned is that sometimes a little bit of information is not a good thing. At the end of the day you're putting yourself in the hands of the professionals and they kind of know best, so you don't really want to know too much.

Okay. So you think you could possibly know too much and that it would be a bit scary?

I think that's my own fault though, because I did read up on it an awful lot.
 
 

Even though she admits that seeking out information about birth and labour can be scary or...

Even though she admits that seeking out information about birth and labour can be scary or...

Age at interview: 26
Sex: Female
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And what information did you get, where did you get your information from in the first pregnancy? Did you go to antenatal classes? 

Yes, yes. I went to antenatal classes and I got information off like my mother-in-law and my mum and you read books. I know people say, 'Oh don't read too many!' because, you know, it's obviously other people's opinions, but I found it quite interesting. And also on some of the channels on Sky as well, I found them interesting even though'

I always think- don't you think they're scary?

Um'

I think they're terrifying.

Yes and no, but [hesitation]' I mean, when my partner was working at his previous job, his ' his boss sort of said, 'Oh I don't want to know, I don't want to know', and she didn't want to know anything about the actual contractions or anything whatsoever, the labour. Okay, it just so happened that she did have a caesarean in the end, which was kind of lucky in a way, but I'm one of these people that like to find out as much information as I can so I can sort of prepare myself in that regard. I mean, I can remember saying to my partner when we went to the antenatal. I said 'Oh, if it's a load of breathing I don't want to do it. If they're starting to do all this huffing and puffing it's going to be so embarrassing'. But it was very good, very informative. But still, at the end of the day you don't really know what to expect.

The most common issues women had wanted to know about concerned methods of pain relief and breathing techniques during labour, stages of labour and different birthing positions. A few women had more specific information needs arising from their special situations. For example, one woman with a breech pregnancy was keen to find out about possibilities for making her baby turn. Another woman had been told that her baby was very large and she would have liked more specific advice on how she might prepare for his birth.

 

Having been told that her baby was large, she would have liked to receive better information and...

Having been told that her baby was large, she would have liked to receive better information and...

Age at interview: 37
Sex: Female
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Can you remember the kind of information that you wanted when you were pregnant the first time?

'Not really. Everything really, I suppose [laughs]. A lot of things, I read an awful lot' 

And what information did you get, did you get everything' or some of it?

Some of it, I didn't read it in as much detail as I have done. 

So in what ways could it have been better, the information provision in your first pregnancy? 

I'd say now in my second pregnancy as well, possibly not as medicalised, possibly the fact that when I was told that I was having a large baby, ways of dealing with it. Maybe perineal massage, you know, to avoid episiotomies. The likelihood of the pain being uncomfortable if the position of the child was wrong, um' other ways of managing it. And psychological support rather than it being completely labeled as someone who's having a large baby' and therefore a potential difficulty.
 
 

She tried various methods to turn her breech baby, but it didn't work. She found books more...

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She tried various methods to turn her breech baby, but it didn't work. She found books more...

Age at interview: 31
Sex: Female
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I wanted to know really, how safe it was for her to be turned. I also wanted to know the, really just, because obviously this was my first pregnancy, just you know, how possible was it for her to turn by herself and some home methods of trying to turn her. There was all sorts of weird and wonderful things on the internet about putting a cold bag of peas at one end of your stomach and all sorts of, and getting into a certain position and putting your feet up, and, so I tried all that.

And what information did you get with that first pregnancy?

About the elective caesarean, or about?

About pregnancy in general, the whole thing, where did you get your information from?

You, you get a little bit of information from the midwives, when you book in an appointment, which I think was eight weeks, at the time. Most of the information I got was from a book I'd bought called 'What to expect when you're expecting', it's a bit like an encyclopaedia of pregnancy, and I just found that really useful because some of the things you worry about, the niggles are just explained in English, and they're quite normal. So yeah, so most of it from the book, really.

Did you go to ante-natal classes at all?

Yes, I did go to ante-natal, but to be honest, at that stage, I knew that my daughter was breech, and a lot of was based, was based on talking about pain relief in labour and actually the delivery itself really, and breastfeeding.

And did they mention much about sections, or '?

No. It was mentioned, it was mentioned in the class that was talked about methods of delivery and pain relief and it was mentioned for about five minutes, and that was it.

For most women, midwives played a key role as information providers. Only those women who had booked a planned caesarean reported having access to an obstetrician before giving birth. Most women were looked after by a team of midwives. For some women, this system worked quite well. Even though many women said they would have preferred to see the same person at each appointment, they still felt the level of care was good. Midwives were often described as friendly and approachable, but some women said the system could make the relationship feel a bit too business-like. A couple of women felt particularly let down by the lack of continuity they experienced in their antenatal care. The very few women who were able to see the same midwife throughout their pregnancy knew that they could count themselves lucky.

 

She was lucky to have the same midwife throughout her pregnancy and birth, so she could build a...

She was lucky to have the same midwife throughout her pregnancy and birth, so she could build a...

Age at interview: 40
Sex: Female
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And what was your relationship with your midwife like with your first pregnancy?

Very good, very good. In [town] which is where we lived, where [name of son] was delivered, they have a' you have a one to one with your midwife, so that's the only midwife you see. I'm not sure what it's called but they' its dedicated to that midwife, and the midwives you see on a regular basis and they come to the hospital when you go in to the maternity ward. And they come and see you afterwards as well. So it's really a nice connection and a very good rapport. So it's slightly different here because you see various' there's not a connection with the midwives as there was with my previous one. 
 
 

She felt that the relationship with her team of midwives was very basic and businesslike.

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She felt that the relationship with her team of midwives was very basic and businesslike.

Age at interview: 32
Sex: Female
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What information did you actually get? If you can remember where you got the information from?

In the pregnancy pack.

And did you go to antenatal classes? 

Yes, I did antenatal classes but I don't remember getting a great deal from that, to be honest.

Right, but the pack was more'?

'the pack was more useful, I think.

And what was your relationship like with your midwife with the first pregnancy, or midwives?

Hm' Basic, very basic, very businesslike really, come in-' They're lovely, but it was kind of 'come in, do what had to be done, go' type thing. There's one who I've got much more of a' I don't know, friendly relationship with now second time round from remembering her from the first time and they are very friendly, but it's just down to basics and then 'off you go', type of thing.
 
 

There was no continuity of care during any of her pregnancies. She found it hard having to re...

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There was no continuity of care during any of her pregnancies. She found it hard having to re...

Age at interview: 38
Sex: Female
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And what was your relationship like with your midwives in your last pregnancy?

To be honest throughout each pregnancy there's not been a sort of continuity at all, I don't think I've' it's very rarely that I've seen the same midwife twice which you know, they're all very nice and they're all pleasant, I'm not criticising that but they all are starting from scratch with your notes. But I think that's just the way that surgeries seem to run.

And what about seeing Obstetricians how was that in the last pregnancy?

I think I just saw them hardly at all.

And you said that it was more of a discussion the decision about how you were going to deliver that time; did you feel that you were included in'?

It was' yeah not with my own GP. My GP I was with at the time I didn't really have much to do during the pregnancy because it was joint care with [Hospital] so it was a doctor at the [Hospital]. But again at [Hospital] you don't see the same doctor twice. I think that's what I found hardest about anything that you're starting again with everybody. And every time they look at your notes and they make the same comments and they ask the same questions and you're thinking just you know'

Talk to each other?

Yeah.

Okay so did you make a birth plan with the last pregnancy?

No because it was' I'm assuming because it was a caesarean I don't think we actually did any sort of detailed thing with that.

So in what ways do you think your treatment or care could have been better last time?

For the caesarean?

Mmm in terms of preparation, information provision?

Basically just to see the same face. I don't think there was anything that they could really tell you, I think once you know you're going for a caesarean part of your mind just shuts off from it, or part of my mind because you know what's going to happen and it takes away the thinking, because you know you're not going to have any control at all.
 

Most women in the study had attended NHS antenatal classes, and a couple of women had also attended classes run by the National Childbirth Trust (NCT). NHS antenatal classes are usually taught by midwives and are free of charge, though they can be crowded and places are often limited. NCT classes tend to be run in smaller groups and charge a fee. A couple of younger mothers had not been offered the option to attend classes, though one of them had attended a 'Young Mum's Bump Club' instead.

Of those women who had attended antenatal classes, several judged them to be a very helpful source of information, and most women said they found them helpful to a degree. However, a few women commented that the information had been quite basic. One woman who knew she was going to have a planned caesarean found much of the information irrelevant to her. A few other women said the emphasis on 'natural birth' in their classes had been unhelpful as it led them to have unrealistic expectations. A couple of women saw their classes mainly as an opportunity to make contact with other mothers and looked elsewhere for more in-depth information. 

 

She found her antenatal classes the most useful source of information. They included a visit to...

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She found her antenatal classes the most useful source of information. They included a visit to...

Age at interview: 36
Sex: Female
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How, how you wanted, what the information was that you wanted to know. What were the important things?

Well, I suppose things like, oh, just about the labour. How, you know, the different sort of, not forms of labour, sort of, just the different areas of labour; how long this, the first bit, I can't think of the terminology'

Stages?

'the stages, thank you, so how long the stages last, the sort of pain that's involved, different pain relief available, sort of where you can have it, like at home or in the hospital, whether water birth was available, you know, all that sort of information really.

And what information were you given?

Quite a lot by the midwives actually. They had a lot of leaflets on different things, and I also went to the ante-natal classes, which I found very useful. And having friends that have already had children, I just sort of picked their brains about their experiences, and bought a couple of books, not too many books.

And what was the most useful, do you think?

Probably talking to people who have already been there, and the ante-natal classes, actually.

And were they NHS classes?

Yes.

And, can you remember if they covered anything about the possibility of having a section, or maybe an instrumental delivery?

Yes, when we visited the hospital, they went through all that, the sort of forceps and, ventouse and those sort of things, but' yeah, I think they did talk about caesarean, but I think it was often sort of assumed that most people would go through a normal delivery, and you're given the statistics about how many people have caesareans. I think it was one in three or something, and three of us in our class actually did have caesareans, but not a lot more than that really.

 

She thinks the emphasis on natural birth in her NCT classes made it harder for her to come to...

She thinks the emphasis on natural birth in her NCT classes made it harder for her to come to...

Age at interview: 42
Sex: Female
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Yeah, with hindsight, I must admit particularly NCT [National Childbirth Trust], they're very anti going for any surgery and I think I was a bit indoctrinated by that and looking back, that's a bad idea. Because you've got to think hundreds of years ago when they didn't have intervention you had dead women and dead babies didn't you? So, that's how I see it now. So, I think, I probably wouldn't recommend the NCT to, to everybody. Basically the NHS does, they did cover caesareans. I think the trouble is, it was something I didn't want to think about at the time, so I can't really argue about the information I got at the time. Perhaps they should say though, perhaps what they should do is to say that statistics are that this might happen, which are fairly high I understand. I mean, we're not really told that, so therefore it was a bit of a shock for' that's the other thing with me, I think it was all a shock that it didn't happen properly.
 
 

She got most of her information from books and the internet and saw the antenatal classes mainly...

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She got most of her information from books and the internet and saw the antenatal classes mainly...

Age at interview: 31
Sex: Female
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And what information did you want with that pregnancy? What did you want to know? 

Throughout my whole pregnancy, I was just so ill, I wasn't really, I was just kind of looking to, to have the baby eventually out. I think that made me want a natural pregnancy more because I'd had such an awful pregnancy, sorry, labour, I wanted a, a bit more natural labour, but it just wasn't meant to be.

And did you go to ante-natal classes?

I did, yes.

And how useful were they?

Most useful thing about them for me was' I tend to, I know you shouldn't, but I tend to read a lot of books and go on the internet and things like that. They were good to meet other mums, who were going to have babies the same age as me. It didn't work out that way because I went back to work very, very quickly, so, it wasn't quite as good as I'd expected, but I was really looking more for companion side of things from ante-natal classes.

Right. And you said that you looked at books and the internet as well. What kind of information did you get from there?

Just information on, you know, what pain relief was available, what sort of things could go wrong, just really anything to do with, with labour really.
 

We asked women whether the information they had received during their previous pregnancy had helped them prepare in any way for their experience of caesarean. A couple of women who had received information on risks and complications beforehand had found it helpful and reassuring when things didn't go to plan. However, several others said that birth complications had either not been discussed at all or not been discussed in sufficient detail to be of use. A few women did recall receiving information on complications as part of their classes, but had not wanted to engage with this information at the time.

 

She didn't rate her antenatal classes very highly, but the fact that they had covered...

She didn't rate her antenatal classes very highly, but the fact that they had covered...

Age at interview: 24
Sex: Female
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And what information did you get when you were pregnant the first time, if you can remember where you got information from and what they told you?

From the midwife like leaflets, like about labour and went to a few antenatal classes.

What were they like? 

Well, I think I went to two, I don't think they were really' didn't think they were any good to be honest with you really.

Do you remember the kind of things they covered in them?

One of' one class was alright, it was' they covered labour and all the things that could go wrong. And it sort of went' so when it happens at hospital, when something ruptured I wasn't worried at all, because it was sort of- they'd covered it.

Did it talk about having sections at all?

Very slightly in there they did.

And did they say anything about having an instrumental delivery, when you have Ventouse or forceps?

Yeah.

 

Her antenatal classes did not cover caesarean in detail. At the time she didn't want to ask...

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Her antenatal classes did not cover caesarean in detail. At the time she didn't want to ask...

Age at interview: 32
Sex: Female
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'so I went to all the antenatal classes and there was lots of information about labour, but none about Caesareans! I think they mentioned in once [laughs]. You know, that this sort of could happen. I think that's probably why I hadn't' I know, I knew Caesareans happen, but it was almost like they don't happen to many people. So I think that's why I kind of hadn't thought about them until it sort of happened really.

So thinking back now with hindsight, would you have wanted more information about sections?

Yeah, yep.

And can you think what kind of information? 

What happens really and why, you know, why you might have to have one and' Because I think like if your baby's breech or something you probably get spoken to about it by the midwife on a one to one, but not in the antenatal classes. 'So yeah, why you'd have to have one and what it entails, what they actually do. And the recovery and things afterwards.

And was the information that you were given about having a Caesarean useful?

I don't remember. I mean, they mentioned it in an antenatal class and I'd read books and things so I, I knew what a Caesarean was and I knew roughly what happens' but, you know, when it was happening' I sort of found out more afterwards really I suppose.

And you said you had this team, team of midwives?

Yeah.

Do you think that they checked how you were feeling about, your anxieties about your pregnancy and how you were going to deliver? 

No it was all sort' it's all talked about that everything will be okay, but I suppose that's the only way to go about it really. But I mean, there was lots of information about labour and birth at the antenatal classes and you could ask questions and things, but I- I suppose I didn't, I didn't think to ask questions about a Caesarean. Because it's just sort of glossed over.
 
 

The information she received on planned caesarean did not prepare her for the difficult recovery...

The information she received on planned caesarean did not prepare her for the difficult recovery...

Age at interview: 33
Sex: Female
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And what were the antenatal classes, what were they like? 

They weren't very informative to be quite honest with you. I didn't really learn anything.

Right. So where did you get better information from?

Probably off of the tele, watching birthing programmes. 

Okay.

And reading magazines of course, Pregnancy and Birth, Mother and Baby. 

And what about the obstetrician when you had the growth scan and found out about the breech, did they explain to you about the section at all then?

Yeah. 

What kind of things did they tell you?

They basically just said what the procedure was, and that I would have another scan at thirty-eight weeks just to see whether the baby had moved or not, and also explained that I would need to go to the hospital the day before [the section] to have a scan and then where I had to go for the actual section etcetera.

And with hindsight did they prepare you for how you were going to be after the section?

Probably not as much as one would expect really. That was a bit of a shock for me I think. Although I realised it was surgery, I didn't realise just how difficult it would be to cope with a newborn baby and be so sore as well.

I think maybe it would have been nice to have known about the risks with the second pregnancy, and about what it was like after having the section.

Several women acknowledged the difficulty in a first pregnancy of 'not knowing what you don't know'. In hindsight, many had much clearer ideas about the kind of information that would have been useful for them to have. Most women said they would have liked more information about the likelihood of birth complications during their antenatal care. However, they also acknowledged that health professionals might withhold such information to protect women and avoid scaring them unnecessarily.

 

Knowing more about the likelihood of birth complications might have helped her cope better with...

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Knowing more about the likelihood of birth complications might have helped her cope better with...

Age at interview: 19
Sex: Female
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And what kind of information did you want when you were first pregnant?

'probably they- I think they should give you more information on sort of the possibilities of it. Because I felt like after, I found it difficult because I felt like I'd failed. And I didn't know why. There's a lot' like I know a lot of people who've had babies, and they've had them naturally and I thought, well' basically you feel a bit of a' you've gone through all that and then you end up having a caesarean. I was in labour for sort of eighteen hours, and it just seemed a bit of a' I think they should give you a little bit more information on- on that subject, sort of that you could end up having a section in the end.
 

Last reviewed August 2018.

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