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Making decisions about birth after caesarean

Messages to health professionals

We asked the women who took part in our study to reflect on their experiences and tell us what messages they would like to give to health professionals. Several were very satisfied with the care they had received before, during, and after birth and did not have anything specific they wanted to say. However, others made a range of suggestions about how they thought care for women who have had a previous caesarean could be improved.

Communication
Listen carefully to what a woman is asking advice about - choosing how to give birth is a big decision

 

She thinks health professionals need to be good listeners and should be prepared to give...

She thinks health professionals need to be good listeners and should be prepared to give...

Age at interview: 40
Sex: Female
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What message would you send to health professionals who give advice to women in this situation?

'I think to listen very carefully, to be good listeners, but also to give very straightforward advice, because I think as a pregnant person, I think you are looking for advice. I think it's something you do perhaps once or twice in your life and therefore it's something which is quite a big decision to make. And they've seen many pregnancies and many deliveries, I think they have to be prepared to give honest advice from their experience.

  • Allow enough time for discussion 
 

She thinks health professionals need to allow women sufficient time to discuss their options....

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She thinks health professionals need to allow women sufficient time to discuss their options....

Age at interview: 31
Sex: Female
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And what message would you give to health professionals who, who provide the information to women making this decision?

I think to be honest that... I mean, the best thing probably is that, is to be able to spend time discussing it with somebody, if that's what they want. I mean, that's probably what's at the biggest, well, apart from money, I think that's probably what's at the highest premium in healthcare is time. You know, time to spend with, with your patients and I think particularly with things like ante-natal clinics where you're coming in to have your blood pressure done and things like that, there's often a big, you know, there's often a lot of people to get through. We're quite lucky here because there's not that many, you know, it's not particularly densely populated area, so the midwives are always quite happy to chat to you, but I think you are always aware that there's somebody else in the waiting room, you know, so '
 
  • Treat women as individuals and tailor information to their personal circumstances
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    It is important for consultants to know their patients' individual circumstances so they don't...

    It is important for consultants to know their patients' individual circumstances so they don't...

    Age at interview: 38
    Sex: Female
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    Well, my consultant, the consultant that I saw at the [hospital], I found was a bit disappointing because he didn't seem too informed on, on my case. It seemed like he hadn't read my notes. And it seemed like he was just following a sort of automatic advice-giving session, where he wasn't taking into consideration my-, my information and was just trying to push me into putting off the decision or going for a vaginal birth. Whereas the midwife' yeah, obviously given the information that was supplied to her about my background, she was quite, she quite agreed that I was right to, to go for the caesarean and that I was' she backed me really. I mean, I think after, straight after I'd given, I gave birth to [son's name] with the caesarean after the [induction], I took the decision that if I did have another child [laughs] it would be with an elective caesarean. So it was really something that I had, I was quite determined to do when I took the decision' quite early on.

  • Don't make a woman feel guilty about opting for a caesarean
 

She thinks women should not be put under pressure to attempt vaginal birth if their chances of...

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She thinks women should not be put under pressure to attempt vaginal birth if their chances of...

Age at interview: 37
Sex: Female
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I think that women do need to be informed as much as possible and that you know, I think, I think' one thing I think is that'. I suppose and this goes against what I, what I really believe in, because I do think if you can have natural childbirth it's, that's what I would want, is that because it was a planned section, if there is, if the chances are that it isn't going to happen naturally, like it was with me, that women should be given' that it should be a section because everything was so calm and, and fantastic, but I mean' and if I'd gone ahead and been induced and then had, had a section it would all been a bit more sort of frantic and a bit more' not as safe. And I think that if there is no chance really' and I think you're really talking about the medical profession, particularly the midwives who, I just, they're fantastic, but they were really trying to push for me to go and try and have natural labour. And that wasn't going to happen. So it's this whole thing again with like' like breastfeeding, you know, I mean, I've, the pressure there with the breastfeeding, it's like almost the pressure with natural childbirth. It's a similar thing that' and then some women can't breastfeed and some women can't give birth naturally and so they live with guilt. And I just think that's wrong.
 

Providing Information 

  • Discuss options for birth early on when talking to a woman who has had a previous caesarean
 

Health professionals should inform women that there is a decision to be made and provide them...

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Health professionals should inform women that there is a decision to be made and provide them...

Age at interview: 31
Sex: Female
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I didn't know anything about it until I'd gone in for my twenty week scan and I was approached about it then and for me, it was almost like a breath of fresh air because at that point, up until that point, I really didn't know that I had a decision to make, it was almost drummed into me that because I'd had a section before, you'll have to go through a trial of labour this time. So, I really didn't realise that a) I had a decision, and b) I didn't realise, I knew the risks involved of having a section, but I wasn't really aware of all the risks involved of going through a trial of labour, so that was really good for me to read up on that as well. And to be able to compare both, and to work out in my head which, obviously I rated as the worst.

  • Provide information in a format that a woman can take away to read and revisit in her own time 
 

She found it helpful to use a decision aid that allowed her to revisit information and think...

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She found it helpful to use a decision aid that allowed her to revisit information and think...

Age at interview: 33
Sex: Female
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Probably, actually, probably about eighty-five percent of the decision was based on actually having a chance to think about the information out of the' a hospital setting, a home setting.

So is that another important factor about it, the fact that it was here and not in somewhere in hospital?

Well, I think that when you're somewhere clinical' you know, sometimes, I, I felt confident to say I couldn't, I hadn't made a decision. I didn't feel under any sort of pressure that I had to have made a decision there and then but it gave me a chance to go away and sort of think about it again with information at my fingertips. Whereas if I'd just gone away, I would have just gone away with the sort of verbal conversation that we had, kind of thing, which was, you know, as weeks go by, you don't retain the information or you're not really sure exactly what's been, been said to you, so I thought that was quite useful.
 
  • Don't gloss over complications if a woman wants to discuss the risks of labour and birth
 

She thinks it's important to be confronted with the facts, even if they can be scary.

She thinks it's important to be confronted with the facts, even if they can be scary.

Age at interview: 26
Sex: Female
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I mean, I think to some extent you, you have to be blunt, to say look, this is what could happen, because if you sugar coat too much, do you know what I mean, and then when someone- something actually happens to someone, you know, they're kind of shocked then. It's like, 'Whoa, I didn't realise it was going to be like this and ahh'", you know? I think in some ways you do need to be blunt and sort of say this is this and that's that.

I think with midwives, they can sometimes skirt round things a little bit, whereas obviously the program, if you wanted to know about a certain thing, it would give it to you, you know, in plain English. It's like, 'Yes, this is this, that is that, boom, boom', whereas like I said, I think sometimes- I don't think they mean to but I think sometimes they can skirt round it a bit and say, 'Oh, well that's nothing to worry about', or 'Well, no, no', or you know, so, but if you really do want to know about certain things then yeah, I think that's quite a good thing to, to click on and have a look at, I think.

  • If a woman hasn't experienced labour provide more information about different kinds of pain relief and how it might affect the birth process
  • Bear in mind that a woman who wants a VBAC (vaginal birth after caesarean) might need to refresh her knowledge about labour and birthing positions
 

Health professionals need to be aware that women who have had a caesarean without labour may need...

Health professionals need to be aware that women who have had a caesarean without labour may need...

Age at interview: 32
Sex: Female
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And if you were to give a message to the health professionals that give information to women who are planning a second delivery what information do you think health professionals should be providing, what message would you send to them? 

I think they need to, what, for the second time, you mean? I think, yeah, they need to remember that you know, you've had a C-section so you might need a bit more... If you are going to try for a natural birth, you might need a bit more information about that, because as a second time mum you're sort of thought, you know, you don't see the midwives as often and you have one, and you could ask to go to the normal ante-natal classes, but usually you have one, if you're lucky, you know, to meet other second time mums. But you know, you might want a bit more information about labour and pain relief and things if you didn't experience it the first time.

  • Midwives might be better placed than consultants to offer information to women during pregnancy
 

She thinks midwives are best placed to give women information, because they are the professionals...

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She thinks midwives are best placed to give women information, because they are the professionals...

Age at interview: 37
Sex: Female
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Who is the most important health professional do you think to provide the pregnancy and delivery, delivery especially, information?

Well for me, it was the midwife really, definitely, because that, that' but I think that's because they're the people that I had the most contact with, so they're the people that I got to know and the midwife was obviously, my midwife, one of the midwives that I'd met quite, on quite a few appointments was there for the delivery. And that, that meant an awful lot to me, the fact that she was there, because she was somebody that, she was a face that I knew in a room of, although they were fantastic people, I didn't know any one of them, you know. Oh, apart from the doctor, sorry, who I'd seen the day before.
 

Supporting women's decision-making

  • Ask a woman how she wants to be involved in decisions about method of delivery - some women want advice, others just want information 
 

Before her VBAC, she would have found it helpful if doctors and midwives could have advised her...

Before her VBAC, she would have found it helpful if doctors and midwives could have advised her...

Age at interview: 22
Sex: Female
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And what, what message would you send to health professionals who counsel women and advise them about this decision?

One to obviously really go into detail about the pros and the cons, let them take that information home with them so they've got it there all the time, so if things, we forget things, they can sit there and read up about it in more detail. And it obviously would be really nice for them to advise you what the, the best option is, but obviously this study might maybe help them do that, they might be able to work out what the best option is.

  • Make sure the information you offer is accurate and up-to-date
 

She thinks health professionals should make sure that information that might influence women's...

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She thinks health professionals should make sure that information that might influence women's...

Age at interview: 33
Sex: Female
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And what message would you sent to health professionals who advise women about second deliveries?  What would you say to the midwives and consultants, what would you tell them?

'Not, not to rush your patients when they are feeling anxious. Because my sister, I took her for a scan last week and some, some seemed quite keen about the pregnancy and seemed excited whereas some professionals didn't seem interested; they just want to get you in, get you out, and I think it's just spending that bit more, and I know you've got so many people that, you know, the waiting lists and you know, appointments, you can just go on and on really, can't you, and you have got to give yourself limits to spend so much time with patients. I don't know. Maybe if they're unsure on something, like I said with the birth weights, if they're unsure, don't give false information, you know, not to sound nasty but to be cruel to be kind, you know, tell people you have got to be open-minded. It's like with the birth, you know, there's me thinking, 'Oh, it's an eight pound baby', and it wasn't. And like I said, if you tell somebody, 'Oh, no, you've only got a seven pound baby, you know looking at the scans and the size', and then they end up giving birth to a ten pound baby that gets stuck because the pelvis is too narrow, it's, it's things like that, isn't it, really, that you're sort of, if things are done a little bit sort of more, like measurements and appointments, taking more time over certain details, that perhaps there wouldn't be difficulty in childbirth, that, you know, perhaps sometimes, if they know it's going to be a big baby and this person could struggle, because obviously they say to them, you know, give them the opportunity to try a natural delivery, but when literally push does come to shove, they can't push a big baby out and then it ends up being a manic situation, where a C-section's got to be done, like now, isn't it. It's, it's just, I don't know, it's a whole circle of scenarios really, isn't it.
 
  • Respect and support a woman's decisions, even if you don't agree with them
 

She thinks it's important that health professionals take into account women's past experiences...

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She thinks it's important that health professionals take into account women's past experiences...

Age at interview: 31
Sex: Female
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And if you were to send a message to health professionals who inform women at this stage, when they're making the second decision, what would you think health professionals ought to think about?

'I think they need to take into account the emotional state of the woman as well. I mean, if you've had a really tough time the first time then it might change how you, you know, you wouldn't, this is going to sound terrible, but sometimes some of them can be a little bit pushy in putting forward their own personal belief in what's best for you. Some are very good and they just, they just give you the information and they, they try to answer your questions and don't sway you either way. It's a bit like with the breastfeeding but then you do get some who, they may not come right out and say it directly but you can tell that they have a personal preference to what you should be doing, and I think it's very important that they don't try and persuade you either way.
 
  • Explore to what extent a woman wants to be involved in decisions about her care during birth itself

Discussing vaginal birth after caesarean

  • There are many complex reasons why women might have a preference for planned caesarean, and it is seldom simply a matter of convenience
 

Health professionals should be careful not to stereotype women who ask for a caesarean as simply ...

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Health professionals should be careful not to stereotype women who ask for a caesarean as simply ...

Age at interview: 31
Sex: Female
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And what message would you send to the health professionals that advise women in this situation?

Well, I'm not sure really. I think, I think that they need to be really thinking about the interests, the interests of the patients, rather than just the cost to the NHS. And I think that they need to be more realistic and more open-minded about what the, the patient wants.

Certainly on the ward after I'd had [baby's name] when you say that you've had two sections, particularly to this one particular ward midwife, and I said the reason why I had the second section was obviously an emergency, but it was planned before, there was almost kind of a, a how can I describe it? You're frowned upon for that, for making that decision, so I think people just need to be a bit more open-minded. At the end of the day you know, it's not a case of being too posh to push, you know, you're not some rich superstar that's paying to have it you know, and paying to have a tummy tuck and everything else that goes with it, and you're not staying in a four star hotel cum hospital, you know, you're making the decision because it's the best decision for you and maybe it's the safest decision for you and you know, if that's what you want then they should, you should be able to stand by that decision and they should, the health professionals should then be able to respect you and support that decision.

  • You may need to reassure a woman that there is no hidden agenda to persuade her to attempt VBAC 
 

She thinks the NHS have a hidden agenda to push women into vaginal birth to save costs.

She thinks the NHS have a hidden agenda to push women into vaginal birth to save costs.

Age at interview: 42
Sex: Female
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I'd like to know, do you know what I would love to know is why the NHS have this agenda. Is it saving money or is it, is it, I mean they always portray it as for the patients' best interests [laughs]. But I'd just love, I'd be interested to know. I'd love to know, I would, would, just that I think, I just do think that locally you should be able to get an impartial, both sides, these are the risks, you make the decision. And then I wouldn't have to pay a fortune and travel away from home.

And I do also think that they should let you see a proper consultant, especially if you're over forty, without any battle attached to it, it's a reasonable request.

  • If a woman wants to attempt vaginal birth, be encouraging  - don't use negative terminology such as 'trial of scar'
 

She understands that health professionals have to inform women about all the risks but thinks...

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She understands that health professionals have to inform women about all the risks but thinks...

Age at interview: 33
Sex: Female
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And what message would you send to health professionals who advise women on this decision?

I would say that they need to obviously encourage and promote the fact that it's possible, and try and dissuade right at the very start sort of negative image of, 'Oh, you can't possibly do this', understanding that they have to give people sort of the full facts tha' the reason why you've had a section in the first place might influence the reason why you might need one again, or not need one again. But I think from a very early sort of stage in pregnancy, they should be promoting you know, 'You'll be able to have your' a good chance of being able to have your baby naturally', rather than sort of even mentioning the word section again. I think you know, if that wasn't brought in until a later, later stage it might be'

  • A woman who wants a VBAC might find it helpful to hear the experiences of others who have done it 

Last reviewed August 2018.

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