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Making decisions about birth after caesarean

Views on information from health professionals

Women who become pregnant again after a previous caesarean have specific information needs. How much information women feel they need is a matter of personal preference, but usually they want to find out how having had a caesarean previously might affect their pregnancy and next birth. Many will look towards health professionals - community midwives, GPs, health visitors, consultant obstetricians and other hospital staff - to inform them about their options and provide reliable information about the different ways of giving birth. Many women also seek out information from friends, books, magazines, TV programmes or the internet but talking to health professionals allows women to discuss their individual circumstances, get answers to specific questions and receive reassurance about particular concerns (see also 'Views on information from other sources' and 'Information needs & attitudes in next pregnancy'.)

 

She found it helpful that her doctor tried to find out what she wanted and offered her...

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She found it helpful that her doctor tried to find out what she wanted and offered her...

Age at interview: 32
Sex: Female
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Yeah, I probably paid more attention to what the doctors have said. I've had two appointments with the doctors at the hospital and I probably listened more intently than I possibly did the first time round to what they've said. The second one, Dr [Doctor] was fantastic because she really, really tried to get to the root of what I wanted. And that was really important. She wasn't just reeling off at me the facts and the medical situation, she was actually trying to find out what I wanted and she reassured me that it wouldn't be what it was before, that the drip wouldn't even come into it. I feel more' prepared to have a caesarean 'if it comes to it. I'm psyched up for it this time, I'm ready. I know what it'll incorporate and I'm sure it'll be for the best, if it happens. I think I can be more reasonable about it this time. Having been there, there's more risks second time round so it makes more sense, if it's necessary, to go for it. I don't know [laughs].
 
 

Health professionals thought that as a second time mother she needed less support, but she would...

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Health professionals thought that as a second time mother she needed less support, but she would...

Age at interview: 31
Sex: Female
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Because with it being my second, I didn't really get that much information. I was actually quite disappointed in that' I, you don't obviously get as many appointments with your second and I also wasn't able to attend ante-natal classes because they were full. And first time mums obviously would have to go. So I did, I did feel with my second that you were kind of, 'Okay, you've done it before, so away you go', but I kind of felt well, yeah, I've done it before but I had problems the first time, which is why I really need a wee bit more information, but there's only so many staff and so many places in classes and things, so I understand why, why I couldn't go to classes and things.
 

The women we talked to in this study also were participants in a clinical trial that tested two computer-based decision aids ('The DiAMOND trial'). Both decision aids provided detailed information about a broad range of complications associated with different ways of giving birth, and all but two of the women received one version or the other. Research conducted in preparation for the trial had suggested that there is was little information available specifically for pregnant women who have had a previous caesarean. Also, women can find it difficult to seek such information from health professionals when, as one woman put it, 'you don't know what it is that you don't know'.

We asked women what they thought about the information they'd received from health professionals during their pregnancy. Their comments were influenced by having used the decision aid as an additional source of information and they often drew comparisons between what they had learned from health professionals and from their involvement in the trial.

 

She asked to see a consultant early on in her pregnancy to find out whether the problems with her...

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She asked to see a consultant early on in her pregnancy to find out whether the problems with her...

Age at interview: 32
Sex: Female
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'I asked at my booking in appointment with the midwife, you know, obviously I was' that was one of my questions as soon as I knew I was pregnant, but they just said, 'Oh you, you know, you'll have to see.' That's when I knew I wouldn't be under midwife only care. But it was all sort of, you know, 'You've got to wait until you see the doctor.' 'they wouldn't comment on anything. 

No, and to be honest for me it's always been that' it's not like [Son] was breech or I had pre-eclampsia, it's not like one of the conditions that you read in a book, so you know whether it's likely to happen again or not. My thing was, I know why I had the Caesarean because he wasn't moving and my placenta wasn't functioning properly, but my whole thing was I know I could, I could try labour if my scar was up to it, but would the placenta thing happen again. So I had to find that out from a doctor, so I couldn't visualise, you know, because they might have said to me, 'Yeah, it looks like you don't go into labour early enough or something so we'll have to do a planned Caesarean at' early.'

And when did you discuss that with the doctor?

That was in this pregnancy when I'

Can you remember when?

It was about twenty weeks I think. Because I asked to see him quite early because as soon as I knew I was pregnant I wanted to have a vague idea about whether I'd definitely have to have a Caesarean or not. So I requested to see the consultant' Because I think sometimes you don't get to see them till later on.
 

For many women, it was important to get information that was tailored to their personal circumstances and medical history and the decision aid couldn't provide this. They were keen to find out whether problems that had led to their previous caesarean were likely to happen again and how likely they were to have a vaginal birth after caesarean (VBAC) if they decided to try. Many women thought that talking to a consultant at their hospital appointment had given them valuable information about their personal risk. However, one woman was convinced that she wouldn't be able to have a vaginal birth on the basis of her family history and felt disappointed to receive 'standard advice' that didn't consider her specific situation.

 

She was disappointed that the consultant she saw at the hospital was just going through standard...

She was disappointed that the consultant she saw at the hospital was just going through standard...

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 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. 

Women who have had a previous caesarean will typically have two or more hospital appointments with a consultant obstetrician to talk about their birth preference and possible risks and complications. However, the first appointment is often scheduled to happen at the time of the 20 week scan, so many women will not receive specific information about birth after caesarean earlier on in pregnancy. Looking back, some women thought that the timing of information received from health professionals could have been better. One woman asked to see a consultant early in her next pregnancy, because she was keen to have her questions answered as soon as possible. A few women had been given information about what their caesarean might mean for future pregnancies immediately or soon after their previous birth, but many had not. Some of those who received information at that point said thinking about another baby had been the last thing on their mind back then. 

 

After her previous caesarean, she was told that the shape of her pelvis might cause her problems...

After her previous caesarean, she was told that the shape of her pelvis might cause her problems...

Age at interview: 30
Sex: Female
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Were you given any information at the time, after you'd had a section about the fact that it might have implications for a future delivery? Did anybody kind of debrief you afterwards that because you'd had a section, that you might have to deliver by section again the next time around?

Only one thing was said to me, and then it wasn't ever followed up. One thing was' who' I think it was my midwife, my local midwife that I know, said to me that it was unusual, the reason why I had a caesarean, that his positioning, that was quite unusual and that I may have to' it could have been because he had a big head, and the shape of his head, or it could have been me, it could have been the shape of my pelvis and that, if I was ever to get pregnant again, they would probably scan or x-ray or something, my pelvis to see. Because obviously if it was my shape, that it would have to be another caesarean. And, I remember her saying that, but at the time you think, 'Oh, I'm never getting pregnant again!' But then I remember saying to my doctor at some point about it, when obviously it did come into my mind that I might get pregnant again, and he said' sort of dismissed it and said, 'Oh, well, that's something we'd think about if you got pregnant again.' And then once I was pregnant, I did mention it to, either him or my midwife, and they said, 'Oh well, we wouldn't scan you now you're pregnant' or something. So it was' that has remained, has remained something a bit strange really, that that was said and then' nothing after. It never seemed to be the right time.

Several women received leaflets from their doctor or midwife about the advantages and disadvantages of different ways of giving birth. Most found it helpful to have written information that they could read and revisit in their own time. However, one young woman pointed out that such information might be particularly useful before attending appointments rather than afterwards. Similarly, several women said they found it helpful to have gained information from the decision aids before talking to health professionals, because they felt better informed and more confident to ask questions.

 

After she had booked her caesarean, she received a leaflet describing the pros and cons. It would...

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After she had booked her caesarean, she received a leaflet describing the pros and cons. It would...

Age at interview: 19
Sex: Female
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Like with the elective section, there was like, well' I've got a information sheet now of having an elective, and it tells you like the, the risks as well? And sort of, how likely things are to happen like and how at risk you are. And I suppose you've got to look at it' things over a sort of wider' you can't just look at things and think, 'Oh well, because of that' I'm not going to do it because of that', because you've just got to look at everything really.

And where did you get the information sheet? Was that from the hospital?

Yeah, that's what the consultant gave me, and that's really good. That's probably, apart from obviously with the DiAMOND study, that is the best information sheet. But I think they should have given you that, before you actually see the consultant and they say well, we've booked you in. I think you should get that the first time you go up and see the consultant' instead of after. Because like that-, that would be, that would have been sort of good for me to know before. If I wouldn't have been, like had all the information before, like the questionnaires and everything and the lady coming round with the computer and that for the information, I wouldn't' have known half of that stuff so I probably wouldn't have made' such an informed. Like the decision would've been a bit more' Not quite as sure. But with this information sheet, if they would have given me that before, that probably would have given me just as much information as what I got from the DiAMOND study really.

So you think you should have had that before you'd seen the consultant and'?

Yeah, because I seen the consultant, going back before Christmas, just before my twenty week scan. And there was sort of' they could have given you it then, if they knew' Although they don't know that you're definitely going to go in for a section, I think they should have given you that.
 

A few women commented that they had received conflicting pieces of information from different health professionals. This concerned issues such as their chances of having a vaginal birth, when to report to hospital, being monitored during labour and whether they would be induced.

 

She had conflicting advice from the community midwives and from staff at the hospital about her...

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She had conflicting advice from the community midwives and from staff at the hospital about her...

Age at interview: 37
Sex: Female
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More suited to my needs would be more contact with medical professionals, I think. But having said that, I, I felt like I had enough, I don't think I' because the midwives were so fantastic, so' I suppose that's one thing I found quite difficult, the conflicting advice between midwives and hospital, in that my midwife team were very, very keen for me to try and have a natural labour and to keep on sort of focusing on that. Whereas the hospital were, 'It's very unlikely that's going to happen', so I suppose that, the conflicting advice between those two sets of professionals, I found quite difficult.
 

A common perception was that midwives seemed more supportive of VBAC whereas consultants seemed more likely to emphasise the risks of VBAC over the advantages. However, a few women thought that all NHS staff were driven by an agenda to promote vaginal birth and reduce the number of caesareans. They felt that the information they'd received from health professionals within the NHS was one- sided in favour of VBAC. One woman felt so strongly about 'not being given the whole story' that she went to see a private consultant instead.

 

She felt that the risk information she received from NHS doctors was one-sided. She sought out a...

She felt that the risk information she received from NHS doctors was one-sided. She sought out a...

Age at interview: 42
Sex: Female
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What was your motive for seeking a private consultation? 

Because the girl, I just felt she was so' what with the information she gave me. I knew that there was two sides. I think, I think the fact they told me all the risks of a caesarean, nothing the other way, is wrong. I knew that, I mean, I'm not stupid. And the other thing, I'm forty-two and I said, obviously I had the bungle with my anaesthetic, I said could you guarantee me I'd have a consultant doing my anaesthetic and a consultant doing my surgery and she said, no, we can't do that and there's no extra risk to being forty-two, which is nonsense. Everyone says, everything you read, it's more risky as you get older, having a baby. So I just felt they were completely unsympathetic and, you know' I think they have their agenda, which is 'push for a natural birth' and they're not really listening to you. So I thought, I'll just go elsewhere [laughs].

So the plan is to have the private consultant do the elective caesarean, [Up in London] you've got a date and you're happy?

Yeah, I mean, I'm still nervous, I mean, things can still go wrong. But at least I know it's a top consultant, loads of experience, you know, he's done loads of them. I mean, that's the other thing, you know, that guy that did (the epidural), you see I was very' I've never really had much surgery or anything to do with hospitals in my life so I'm lucky. But that guy, the trainee putting in the needle eight times, I thought, what if they put a trainee doing my op? I was just worried, because it was horrendous. And the fact that they wouldn't address it for the second time. Now, I do believe, because people have said to me, you could fight the fight with them and keep going, but you know, I haven't the energy at the moment, you know, and also I think they only see special cases, like if you're really ill or if you're a smoker or, I don't know, I don't know what they take as a special case and give you a bit more better treatment. Twins? I don't know.

So how would you say you feel about the information that you were given by the person locally?

Bad information, you know, not both sides of the story, not taking into account what I, my previous experience. And also they're saying there's no extra risk to a caesarean when you're older. As far as I know, that is rubbish, so, not good.

So you felt you were more able to discuss your fears and anxieties and, and what you wanted with this other person?

Well, yeah, but then you're paying aren't you an awful lot of money, but then they have the time. But yes, yeah totally. I've been able to discuss everything and I've been given both sides and not pushed in either direction, which is probably hard for him, because for all I know he might have, he might think natural birth is best the second time but they don't, if you're professional you can keep away from that, can't you? So I just got both clear sides. But he did- well, the only thing he says is that at twenty weeks, when I went to see him, he said it is entirely reasonable to have an elective caesarean the second time if you've had a caesarean before, so I suppose that's the only thing he said positively about it, so, but that's not pushing you in either direction, but it's a reasonable request, which I wasn't made to feel locally.
 

However, a couple of women reported the opposite experience, with hospital staff trying to discourage them from attempting VBAC. Several women who had had a VBAC thought that medical staff could do more to encourage women that it was a realistic option (see 'Messages to health professionals'). 

A few women acknowledged that health professionals have to manage a difficult balance, informing women about the things that might go wrong while at the same time supporting them in their decision-making and giving reassurance to their concerns. They thought that having a decision aid that women could access independently and in their own time to find out additional information if they wanted to would be a useful addition to the information provided by health professionals.

 

She thinks midwives don't encourage discussion about complications because they don't want to...

She thinks midwives don't encourage discussion about complications because they don't want to...

Age at interview: 26
Sex: Female
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Well, I mean' I'd probably say my doctor doesn't, hasn't really given me any information as such, and the midwife I think she only tends to give you the information if you ask more, because I don't know whether they sort of want to panic you so much' if that's the right way' of putting it. But I mean, with the study, like I said, it'll say, 'This is what can happen, these are the risks', so you've got them there in black and white. If you choose to read them, you know, that's up to you, if you don't then' but they're there if you, you know, you've got a query or something, but yeah, I'd say like with the midwife it's more if you've got the concern you bring it up to her and she would sort of let you know rather than, you know, 'Well you can have this problem, you can have that problem', so' yeah.

 

She thinks giving women balanced information about all possible risks might conflict with giving...

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She thinks giving women balanced information about all possible risks might conflict with giving...

Age at interview: 33
Sex: Female
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And who do you think the most useful, or most appropriate health professional is to provide this kind of information?

I suppose your midwife. Tricky, because I had sort of hospital and health, you know, health centre care, so it was sort of split between both... maybe, you know, I suppose if you have your sort of doctor or your midwife that you see, they might be the best informed person. As I say, a couple again, I've not had' I suppose it's hard because you're torn between that bit of the person that's trying to give you the information based on they want you to make the best decision for, for you versus the fact that they've got all the information in front of them, which is your, their health concerns as well, so sometimes I think that maybe' not a conflict of interests, that's maybe the wrong words, but you have to give people, you know, all the risks and that's just the way that life is, just these days it sometimes can come across a bit negative from health professionals these days, whereas then they're trying to tell you, 'Actually have a, have a natural delivery', so it can sometimes be a wee bit conflicting.
 

We asked women who they thought was the most appropriate health professional to provide information to pregnant women with a previous caesarean. Most women felt that community midwives should take on this role as they were the ones women saw most often and could build a relationship with. 

 

She thinks information to women should be provided by midwives instead of doctors, because birth...

She thinks information to women should be provided by midwives instead of doctors, because birth...

Age at interview: 37
Sex: Female
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Who do you think is the most appropriate healthcare provider to give the information that women need?

Midwives.

That was emphatic?

mm 

Why not the hospital consultant or '?

Because they're so litigiously minded. They're so' and also it's a medical model. Birthing is a medical' Sorry, I'm just ' I wish I could remember the book. I did read one book and I'm not a person into these sort of home birthing sort of very, dare I say it, hippy sort of naturalistic approach to birthing' But this book just said, 'Look, everyone does this', you know? Medics do it because they've changed it, you know, women used to lie on their back and deliver and that kind of thing. That's not the way you do it. It was very much of a sort of a positive sort of approach to it. A woman's approach to it, rather than' And even if the consultant is female, it still doesn't matter, the medical model is that, you know, we're just getting away from the idea of delivering women in stirrups. They're very much into interventions, which are almost conducive to having a section because they reduce your mobility, they have to monitor, they have to intervene, whereas actually the best thing is just to let it go, let it go naturally. It's just a, it's a medical need, really, to take over a situation and to help the women, I think. I think it's also the medical code, you know, they really do need to' they want to make you comfortable, they want to give you drugs to make you more comfortable. They want to make things better, but actually, standing back and not doing anything, observing and letting the woman do it is almost the best. So it sounds very, very negative unfortunately, but it's just the way. 

But the midwives were very much more' pro the idea of me delivering naturally, supporting what I wanted and even when a double risk had come through, they were relatively happy to support me at home, despite the huge risk.

Even though several women said they would have liked more time with their midwife and to see the same person rather than a team of people, midwives were often regarded as more approachable, more trusted and better placed to provide reassurance and advice when it was needed than hospital consultants. However, a couple of women thought having access to 'neutral' information from sources outside the healthcare system was also very important.

Last reviewed August 2018.

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