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Making decisions about birth after caesarean

Roles of health professionals in decision-making

Health professionals have an important role to play in women's decision-making about birth after caesarean. Clinical guidance recommends a model of shared decision-making between health professionals and women*. In this model, doctors and midwives provide women with information about birth choices and support them in reaching a decision. Hospital consultants can usually provide women with information about why they had a caesarean previously and how likely they are to experience similar complications again. Community and hospital midwives will also often be able to advise women about the risks associated with different ways of giving birth and to reassure them about any concerns they have.

For most women we talked to, advice and information received from health professionals played an important role in reaching a decision, but they also considered the views of their partners, family and other women. (See also 'Women's experiences of making the decision' and 'Role of partners and others in decision-making'.) All but two of the women also used one of two versions of a decision-making aid that provided them with additional information about the risks and benefits of different ways of giving birth as part of their participation in a clinical trial (see 'About the interviews and the DiAMOND trial').

 

Talking to a consultant about why her previous caesarean had been necessary and learning that...

Talking to a consultant about why her previous caesarean had been necessary and learning that...

Age at interview: 41
Sex: Female
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I had decided to try, try natural. Initially, I was undecided but having read the leaflets the- I can't remember whether it was the hospital or the midwife gave me, about caesarean or natural birth, I had a consultation with the consultant and I had various questions to ask then, and she answered my questions and put my mind at ease about trying for a natural. 

She'd gone over sort of what had happened in my previous birth and she said well there obviously weren't any medical complications there, I think it was due to the fact that the cord had got wrapped round the baby and they were concerned about his heart rate, but she said that it may not go that way again, and I would be monitored throughout.

And did you feel confident that you, you would have a fair chance of a natural delivery?

Yeah, she, she seemed very confident as well. So that was quite reassuring. 
 

Many women felt very happy with how health professionals had supported them in their decision-making. Most had not received much information about birth after caesarean before attending their first hospital appointment. While most had a preference for how they wanted to give birth to their next child, many felt uncertain about how realistic their wishes were. Many also had questions and concerns that they wanted clarified before making a final decision. Several women said getting support for their birth preference from an experienced doctor or midwife was very helpful and reassuring. For a few who had felt uncertain, talking things through with a sympathetic health professional helped to make up their minds. (See also 'Information needs & attitudes in next pregnancy' and 'Views on information from health professionals')

 

The consultant told her that in her position she, too, would have opted for a caesarean. This...

The consultant told her that in her position she, too, would have opted for a caesarean. This...

Age at interview: 40
Sex: Female
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I met a consultant last week who had a little bit of a, an examination of my tummy, and sent me for an extra scan, because they thought perhaps the baby might be slightly small.

But I met with a, a female, a registrar about two months ago and I think she was' she really went over the birth plan with me, which I found most helpful. She was expecting a baby herself so I think she kind of understood.

Right. And can you tell me a little bit more about the discussion that you had with her?

Yeah. She had a good look at the notes and said, 'You know, really, I think if I was in your shoes then I would go for a section, too'. She said just perhaps failure to progress was maybe slightly small or maybe it was a big baby, or, you know, whatever, but just for health reasons, on this occasion she said, 'I really think that, you know, that would be best for you'. So that helped tremendously.

 

Speaking to the midwife helped her to make up her mind to have a planned caesarean. The doctor...

Speaking to the midwife helped her to make up her mind to have a planned caesarean. The doctor...

Age at interview: 31
Sex: Female
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So when would you say that you made the actual final decision and stuck with it?

That was not that long ago. It was' I suppose I'd had it in my head before my thirty-four week scan, and when I had my thirty-four week scan, so that was five weeks ago now, and the placenta had moved, and everything was fine. And I was back to like' 'There's no real reason for having a caesarean.' I think that was when I made the decision through speaking to the midwife. After the scan, she did say to me, she said, 'I think you sound like your mind's pretty much made up'. And she said, 'I'll get a doctor to come in and speak to you.' So when the doctor came in and he read all my notes from the first birth. And he did say, he said, 'I can understand why you're making this decision.' I mean, it's just wasn't a good birth and I didn't get anywhere. So he was, 'Right, so I mean you want' you basically want a section', and I just went, 'Yeah'. And that was about five weeks ago now.
 

Specific bits of information from health professionals often acted as final puzzle pieces in women's decision-making, making them feel more confident about the preference they had already. A couple of women were considering a vaginal birth but worried that they might end up with another long labour followed by an emergency caesarean. They felt reassured when health professionals told them that they would be closely monitored and not be left to labour for as long as previously. A couple of women also felt relieved to learn that they would not be induced. On the other hand, a couple of women said that not getting precise information about how their labour would be managed should they decide to attempt vaginal birth had contributed to their decision to have a planned caesarean instead.

 

She felt reassured in her decision to attempt vaginal birth when the consultant told her she...

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She felt reassured in her decision to attempt vaginal birth when the consultant told her she...

Age at interview: 31
Sex: Female
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I think because I'd been there before I was a bit more confident about what to expect and, because people had, you know, because various doctors or midwives or what-have-you at the ante-natal appointments had made, you know, they'd all looked at the notes and asked me about how, you know, about [daughter's name] birth. And the doctor, I think it was the consultant who had said' I'm pretty sure it was the consultant who had said that there was no way that they would let me labour for as long as I'd, you know, he said, 'We wouldn't let you labour for as long as you did with your first child anyway', and I think that was quite significant, because I just, you know, the first time I was there, I was in labour at home the whole day and then I was in labour in the hospital for, you know, nearly twenty-four hours as well before they finally decided that they were going to give me a section. 
 

For a few women, their midwives became important emotional allies in the decision-making process. This was particularly the case for one woman who decided to attempt VBAC and refused to be closely monitored during labour against the advice of her consultant. Women found it particularly helpful when midwives had personal experience of either VBAC or planned caesarean themselves.

 

Her midwife was very supportive of her decision to attempt vaginal birth even though her...

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Her midwife was very supportive of her decision to attempt vaginal birth even though her...

Age at interview: 37
Sex: Female
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I saw a midwife and I made a very strong bond with one of the midwives in the team and she regularly sort of supported me. And she was on the phone as well, if I needed to talk. Because there was an additional thing as well that they wanted me to have a section for. Because my baby on the scan - I can't remember was it the thirty-six week scan... Looked as though she was going to be quite big and her head circumference was smaller than her shoulder, I think. So there was a risk of shoulder dystocia, I think it is' yeah' 

So I had two risks' having another section and the possibility of the shoulders getting stuck. And my midwife was very supportive over the idea of VBAC, she would come home, come into my home and talk to me and reassure me about any issues, and, at times when I was having these negotiations with the consultant, you know, I found it quite difficult because I had to be very strong and she was there as a supporting network saying, 'Yes, you can do this' and 'We'll be there for you'. And actually this midwife delivered me, wanted to deliver me and she ended up working a night shift to deliver me, she was feeling that strongly about my need to deliver naturally. 

So she was a very, very strong supporting influence for me, which made a huge difference.
 

Women differed in how much they wanted to be involved in the decision about how to give birth to their next child (See also 'Women's views on choice about birth'). This influenced the expectations they had towards health professionals. Some women described encounters with doctors and midwives that had followed the model of shared decision making outlined in the clinical guidance. 

 

She went along with her consultant's advice to have a repeat caesarean but did not feel put under...

She went along with her consultant's advice to have a repeat caesarean but did not feel put under...

Age at interview: 40
Sex: Female
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And to what extent, if any, was your decision informed by the information program that you saw at the start of the study?

A large part of that was determined through the program and also on the advice of the consultant at the hospital before delivery. She thought it would be best if I did have a section.

If you can explain what role the information program had in that decision?

Just the benefits to the baby, mainly, and obviously the risks and also, in a selfish way, for myself too.

Because I know that you specifically said about having uterine rupture and you were also concerned about breathing problems weren't you?

The breathing aspects, mm.

And what information did the consultant give you?

Just from, from previous delivery, how difficult it had been and the way in which it had resulted in a caesarean in the end and she felt that perhaps it would be best if, you know, we did a planned section and didn't attempt in any way to go ahead with normal delivery.

And to what extent did your view change during your pregnancy, if at all?

I wouldn't say so. I think after the experience, from the first time, once I'd kind of come to terms with having had a caesarean, which I believe is quite normal for people to have in the beginning, that you felt a bit cheated by the fact that it wasn't a normal delivery, after that, I didn't change at all in my own mind, it was going to be a caesarean.

And what do you think your role was in the, the decision-making and the process, this time?

Despite the consultant, you know, telling me that perhaps that would be the best way to go originally, I still think that, you know, if I really had wished to, to try it naturally then, you know, they would have gone with that decision. In no way was I being pressurised into having a selective caesarean, or an elective, should I say, caesarean, but I felt that really, I was the one who had made the final decision and had made the decision in the first place, that's what I was going to have.

A few other women encountered a more paternalistic style, with health professionals telling them firmly what they thought was best. On the other hand, several women described health professionals as taking a 'hands off' approach, asking them for their birth preference without providing any kind of guidance. All of these models worked well as long as they matched women's own preferences for involvement. 

 

She decided to attempt VBAC after talking to an experienced midwife She found it helpful to get...

She decided to attempt VBAC after talking to an experienced midwife She found it helpful to get...

Age at interview: 37
Sex: Female
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I think it was one particular conversation with a midwife that really' cemented my thought that I was definitely going to go for natural. I think I'd probably gone in thinking, 'Oh, I don't know, I might go for C-section', and it was just a conversation I had with her, and she was an older midwife, actually. And I just thought, 'Yeah, she's speaking a lot of sense there, I'll stick with it'.

And was that about confidence, or about reassuring you, or'?

Yeah, she just, she had' yeah, she seemed to know, because she was slightly older, I think she had a lot more experience and had probably seen a lot more mums and she just filled me with confidence actually, a lot more. And she was quite, you know, sure about it, whereas a lot of people say, 'Well, the decision's up to you at the end of the day', and I thought, 'Yes, I know, but I want...', so she was almost telling me and it was quite nice to be actually told [slight laugh].

However, conflict arose in situations where women expected either more or less guidance from health professionals than they actually received. A few women who felt well-informed about all the risks and had very clear preferences of how they wanted to give birth saw the purpose of their hospital appointment mainly as informing health professionals of the decision they had reached rather than discussing it afresh. 

 

She was convinced that a caesarean was the best option for her given her previous medical history...

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She was convinced that a caesarean was the best option for her given her previous medical history...

Age at interview: 38
Sex: Female
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And from the outset, you've had a preference about how you want to deliver this time, you've wanted to go for an elective section?

Oh, yeah, absolutely.

And that's been from the beginning, and'

Yeah, well, even from when we were trying to conceive. And as I said, I was, I was completely certain that I would get the elected caesarean. 

And at no point have you changed your mind? 

No. When I went for my twenty week scan' I was speaking to the, to the consultant and he was trying to put, put off my decision. But' even just talking about it with him, even just, that, that slightest, slightest doubt that I might not be allowed to have an elected caesarean just really agitated me at the time and I just said - I said, 'No, I'm not leaving here 'til I've got the date plan'.
 

A couple of women were surprised when doctors just asked for their preferences instead of engaging them in discussion. Another couple of women who were told that the decision was up to them, said they would have preferred to get more guidance as they did not think they had the medical expertise to make such an important decision by themselves. One woman was pleased that a midwife she trusted was prepared to give her firm advice rather than just leave things up to her.

 

She was surprised that the consultant just asked about her preference rather than engage her in...

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She was surprised that the consultant just asked about her preference rather than engage her in...

Age at interview: 38
Sex: Female
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And do you feel that you've had the right quality of information for you this time?

Yeah. The only thing is, at the time when the decision was actually made... the doctor that saw me - I felt that it could have' which is probably a good thing, but it wasn't particularly a discussion. It was more, 'Have you thought about what you want to do?' 'That's fine... I agree with that', ...and that was sort of it. It wasn't a sort of real two way process.

So they didn't really give you enough information for you to make a really informed decision, or they didn't really discuss it?

They sort of did that afterwards. It was a bit of a... you know, literally... "What do you want to do?" And then when I said I was thinking about this [caesarean], they said, "Right, well, we'll just have to outline..." Almost as if it was read out... "This will happen", "You need to bear in mind this, that, and the other". But it was not exactly rushed but it was sort of just a sort of practiced'

All day?

Yeah. 

And what about the relevance of the information, do you feel that it was tailored enough to your own needs?

Yeah.

And the timing? Because you said before about the timing of the decision, do you think you'd have liked that earlier do you think?

I would have probably liked a chat with a doctor earlier on... but it wasn't essential. I think in a way you get a lot of pressure from family and friends as well and part of me wanted to know so that I could stop them asking me what I was going to do.
 
 

She would have liked her doctor and midwife to tell her which way to go instead of leaving things...

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She would have liked her doctor and midwife to tell her which way to go instead of leaving things...

Age at interview: 22
Sex: Female
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I've wanted someone to tell me what the right option is really. But nobody-, obviously the doctors and midwife, they, they don't really necessarily recommend which one. They, they keep saying, 'It's up to you, it's up to you' and giving me the benefits and the- the risks, so I'm still sort of thinking, 'Oh, is it all down to me? Am I going to make the right one?' Whereas if somebody said, 'We think you should do this', I would go by that.

And how have you got on with your midwife in this pregnancy? 

Fine. Yeah, yeah.

Has she been able to answer any of your questions?

Yeah, I mean, we only discussed birth plan-wise yesterday, and she didn't really seem concerned about having' attempting for a normal delivery. And I've had a few talks with the consultant at the hospital and, it's the same really, they, they're not really concerned either way. 

Right. How do you feel about that? About that they're not worried. Has that made you less worried?

Not really, because I sort of think they don't understand that I am worried, if you see what I mean. 

Yeah, I do. 'So you've been able to discuss your fears and your expectations have you, this time?

A little bit, a little bit, yeah.

So how involved do you want to be in the decision, because it sounds from what you've been saying like you want them to make the decision for you?

Yeah, yeah.

Why do you think you want them to tell you? 

Because I think they've had a lot more experience with this, and I know they say the percentages on the risks and everything, but I just think it - from a medical opinion I think it would be better if they took reign and said, 'This is what you should do'.
 

Several women felt that health professionals in general, and midwives in particular, were more supportive of VBAC then planned caesarean. A few women said health professionals had tried to push them into attempting vaginal birth. On the other hand, a couple of women said they had felt pushed into having a caesarean by their consultant. Several women felt that the information they had received from health professionals was biased and reflected doctors' and midwives' own agendas. They were pleased that, as participants in the DiAMOND trial, they had access to a decision aid with information that they perceived to be balanced and comprehensive. 

 

She suspects most midwives tried to push her into a trial of labour and disapproved of her...

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She suspects most midwives tried to push her into a trial of labour and disapproved of her...

Age at interview: 31
Sex: Female
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I just wish that the midwives were more open-minded and would talk about both sides more. You know, about your options because... Had I not had to have a section beforehand with my first child, then there's no way in the world I'd have even contemplated having one. But having gone through it before and knowing, reading about all the risks of even trying for a trial of labour, I weighed up the risks and the benefits, particularly through using the decision analysis and decided that [a caesarean] was the best option for me. When you - you can almost see, without them actually saying it, you can see it in their eyes when you tell them. When I was in hospital that day, I was thirty-eight weeks pregnant and I went in because I'd had contractions, then they said to me, 'Oh, you know, what decision have you come to?' And I said, 'Oh I'm booked in for actually a section the following week'. You could see it in their faces, that there's almost a look of disapproval. And when I actually went in, I think it was for my five month scan, and a couple of the midwives said to me then, 'Have you made a decision?' and I said, 'No, I haven't made a decision yet'. They said, 'Oh well, you don't need to make a decision yet, and why don't you just have a trial of labour and if it gets too much or if', I think one of them said, 'If it gets too much or if there are any complications then you can have an emergency section.' So they're very keen to push you down that route, very keen. And another study that I took, took part in, the midwife that came round for that, she was really nice. But again, she was saying that nowadays they wouldn't automatically offer you a section if your child was breech, they'll turn the baby now and you know, "It's all old wives' tales about the chances of you having a rupture if you go into labour are really slim", and "We really actively encourage you now to have a [trial of labour]. You've got a really high chance of having a normal labour and a normal delivery". So she was really pushing that. And at that point I'd not kind of made my mind up, so I felt like she was really trying to push me down that road.

Why do you think that is?

Honestly? [Mm] Cost to the NHS. I think that a planned, an elective caesarean section, they have to have so many people in that room. It's, it's a huge cost to the NHS, whereas if they can get as many people as possible through VBAC, less, whilst you still have to have a midwife, and I think they have to have two other people there because of previous caesarean section, there's, obviously there's a lesser cost. And also it keeps their figures down, because I think [Hospital] have got quite high figures with regards to caesarean sections, so they're trying to keep the figures down. That's the honest answer.

Women's accounts of health professionals' roles in their decision-making suggested that doctors and midwives can make a very positive difference in helping to reach what many women experience as a very difficult decision. However, they also showed the importance for health professionals to be sensitive to women's own preferences for involvement in decision-making and highlighted the challenge of building trusting relationships in a busy healthcare environment.

The National Institute of Health and Care Excellence – NICE guideline on caesarean section (CG132) was published in 2011. 

Last reviewed August 2018.

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