BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme No. 4 - Caesarean Sections
RADIO 4
TUESDAY 29/05/07 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
PATRICK O'BRIEN
DAVID DAVIES
MICHELLE MOHAJER
SUE BRESLIN
JANE JEMPSON
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MATTHEWS
My name's Jenny Matthews. I've got baby Amelia. I came in, I was six centimetres dilated, they did some tests on her and her heartbeat wasn't very regular, so they decided to take me into theatre and apparently she was a bit sideways, so they had to perform an emergency Caesarean. I was considered a high risk because of my previous experience, so yes they anticipated I would probably have to have one and they've also said if I have anymore children I will have to have another caesarean because now I have two scars.
Last time I managed to labour myself - I had a water birth - and I managed to dilate to nine centimetres and then Dylan had meconium in his water so they had to get me out and then he went into distress and so did I and it all ended a bit badly, so ... It's been a lot less stressful. One because I knew what to expect but also because it was so short. The last time was 12 hours, this time was only three, so it was - my body had to endure less.
PORTER
Jenny Matthews with her new baby Amelia on the postnatal ward at St Mary's Maternity Hospital in Portsmouth - where we will be returning a little later on to discover why one in four pregnancies in Britain now end in Caesarean section.
Portsmouth has a Caesarean rate close to the national average but there is tremendous variation with some units doing far more than others. At just under 12%, the Royal Shrewsbury Hospital has the lowest Caesarean rate in the NHS, and a third of the rate in some London hospitals. I'll be travelling to Shropshire to find out why.
And I'll be discovering what life is like after a Caesarean in light of growing evidence that, contrary to what many women believe, a surgical delivery won't necessarily leave them intact "down below" and protect against postnatal complications like incontinence and sexual difficulties.
My guest today is Mr Patrick O'Brien, he's a consultant obstetrician at UCH and spokesperson for the Royal College of Obstetricians and Gynaecologists.
Pat, before we debate the pros and cons of having a Caesarean section - and the factors behind the rise in the number - let's talk about the actual operation. Where does the name come from?
O'BRIEN
Well some people say that Julius Caesar himself was delivered by Caesarean section but I don't think that's true. I think the true story is that during his time he passed a law saying that if it looked as if a mother was going to die during childbirth that the baby must be cut out and delivered safe before the mother dies.
PORTER
And what does it practically involve, what do you have to cut through?
O'BRIEN
Well in the old days it was a very dangerous operation but it's very, very safe now. What it involves usually is that once the woman has an effective anaesthetic then we cut through the abdominal wall, the sort of the skin and the muscles, and through the wall of the womb and deliver the baby that way.
PORTER
Because the womb is sitting literally underneath the abdominal wall in a woman who's fully pregnant, there's nothing else to go through.
O'BRIEN
Just about, I mean the bladder's in between and we need to move the bladder down out of the way before we can get to the baby but yes more or less the womb is just sitting there.
PORTER
And you cut the womb as low as possible, presumably, on the muscular wall?
O'BRIEN
Yeah we make it low down sort of across, in the old days the typical Caesarean section was an up and down cut in the womb but nowadays most of the cut is low down in the womb traverse.
PORTER
You mentioned anaesthetic there, obviously crucial, but one of the big changes recently - well not recently but I mean over the last few decades - has been the push towards local anaesthesia - epidural and spinal - why's that?
O'BRIEN
Absolutely, well that's been a huge advance over the last 20 years and it's because it's much safer both for the mother and the baby. The first thing is the mother's awake, so she gets to see her baby straightaway and hold her baby quickly and feed her baby straightaway after the operation. It's much safer because the mother's awake then she's always breathing for herself. Under general anaesthetic, when the mother's asleep, then she has to be on a ventilator machine and that carries some extra risks. It's also safer for the baby. Under general anaesthetic the drugs cross the placenta, they get to the baby, so often the baby comes out asleep as well and not breathing as well. Whereas with epidural the baby comes out wide awake.
PORTER
One of the problems of course with local anaesthesia is you always worry about feeling something, what would the woman feel during the typical operation, say, under epidural?
O'BRIEN
Well it's a very strange thing having a Caesarean section under epidural, not that I've ever had it myself of course, but an epidural takes away the pain completely, so the woman feels no pain at all. But what she does feel is touching or pressing all the way through. Now as long as she's been warned about that then it's absolutely fine but if it hasn't been mentioned before it can be quite scary because the woman feels the touch and thinks - oh this isn't working - so it's a strange feeling but it takes the pain away completely.
PORTER
Of course the other thing about doing things under local is that the partner's often there as well, does that affect the way that you work as a surgeon?
O'BRIEN
It is - it's very, very good actually I think having the partner there, it's great support for the woman herself, it makes the whole experience much more enjoyable and it's great for the partner to be there as well, it's a life changing experience and most men - most partners - will relish the opportunity to be there.
PORTER
If not the noises that ...
But what sort of problems might prompt a doctor to suggest delivering a baby surgically? David Davies is consultant obstetrician at the St Mary's Maternity Hospital in Portsmouth.
DAVIES
There's a variety of different reasons for needing a Caesarean section. Some Caesarean sections obviously are undertaken as a planned procedure because there is some problem either with the mother or the pregnancy that makes it safer for mum to have an elective planned procedure. But the majority of our mums are delivered by Caesarean section for emergency reasons and looking at last year's data about 63% of the Caesareans we did last year were emergency or unplanned Caesareans and that can be for a number of reasons, it might be there's a problem crops up in labour - baby may show signs of becoming tired and not coping very well; the labour itself maybe going very slowly and mum might be running out of steam; sometimes it's because the baby's the wrong way round in the breech position; increasingly there are medical conditions that affect mums that it is probably safer for mum to have a calm planned procedure than run the risk of a Caesarean section in the wee small hours of the morning. But over the years we've certainly seen, as I think most other parts of the country have, a slow steady increase in the Caesarean section rate, about 10 years ago our Caesarean section rates would have been about 18% and it's just slowly creeping up and year on year we normally see somewhere in the region of around about a half a percent to one percent rise.
PORTER
But is that due to changing medical practice? Or changes in women who are having children?
DAVIES
Certainly there are changes in the pregnant population, we've certainly noticed a marked change in the last three or four years in Portsmouth. We are seeing mums who are having their babies at an older age, mums who are starting second families with a new partner many years after the first partner. We are, unfortunately, going through an epidemic of obesity and general lack of health in the population and it's now not unusual for us to be looking after mums who are well over 100 kilograms in weight. We're seeing an epidemic of diabetes as a result of that. Also in Portsmouth because we have a very highly regarded neonatal intensive care unit we do take a lot of very high risk pregnancies from other parts of the country to look after the mums and deliver the babies here.
PORTER
But what about maternal demand - women who request a Caesarean because they don't want to deliver vaginally?
DAVIES
All mums having their first pregnancy would only have an elective Caesarean section if there was an absolute medical reason, as we don't have a policy in Portsmouth of agreeing to a Caesarean section on demand without there being a medical indication. However, obviously mums come back in second and third pregnancies, having had a variety of different experiences; we see some mums who for one reason or another may have found the experience of her first birth to be very traumatic and can't sometimes face the idea of going through the uncertainty of a labour again, worries about, for example, repeat of an extremely nasty tail end tear, for example, puts some mums off. And they very often ask if it's possible for them to have an elective Caesarean section right at the outset of the pregnancy. And then of course there's an increasing group of mums who have had a previous Caesarean section, these mums increasingly now I think are coming back to book in their second pregnancy having already decided that perhaps they don't want to undergo the uncertainties of labour again, particularly if they, for example, had a long labour first time round and then ended up in an exhausted state with a Caesarean section. It's like everything else, if we could guarantee 100% certainty to them that they would have a nice normal delivery and they wouldn't have any risk of having another Caesarean section some of them would be very happy to give it a go. But the reality is that in the very best circumstances these mums have somewhere between 40 and 80% chance of success and a lot of them are much keener to have a nice calm planned pre-booked procedure.
PORTER
David Davies at St Mary's Maternity Hospital in Portsmouth. You are listening to Case Notes, I'm Dr Mark Porter and I am discussing Caesarean section with my guest, obstetrician Pat O'Brien.
Pat, Portsmouth is very average, as we said, in terms of the number of women who have a Caesar there. You work in London where rates tend to be much higher - sometimes up to one in three women in some hospitals - why do think that is?
O'BRIEN
Well I think there are a number of factors and we just heard some of them, like the increasing age of the population that we look after, increasing numbers of women who are overweight, we know that increases the risk of Caesarean section ...
PORTER
That's happening in Portsmouth presumably as much as it's happening in London isn't it.
O'BRIEN
True but probably the factors that are specific to London are the ethnic makeup in London, I mean there's no doubt that the ethnic mix in London is great compared to many parts of the country. And we know that certain populations in themselves are more likely to end up with Caesarean section. So, for example, the Bangladeshi population has a much higher rate of diabetes in pregnancy than other populations and that increases their risk of Caesarean section. And there's also a lot of social deprivation in London and it's well recognised for many years that social deprivation, for a variety of reasons, increases your chances of Caesarean section as well.
PORTER
What about this too posh to push, this - I don't really want to get down into women from different social classes but I mean maternal demand - women who just want to have a Caesarean because they want one. I mean is that as big a factor as it's been made out to be recently in the media?
O'BRIEN
I don't think so. I mean a big survey just a couple of years ago showed that of all Caesarean sections only 7% are women who specifically ask for it in the absence of a medical indication. I suppose what's changed is that 10, 15 years ago it was virtually unheard of whereas now it does exist as a phenomenon but it really is a small minority. And I know the press pick up on it a lot but actually it's a small part of our practice.
PORTER
Well the maternity unit at the Royal Shrewsbury Hospital has the lowest Caesarean rate in the country - and it has had for some time. According to the latest official figures - from 2005 - 14% of women at Shrewsbury have their babies via Caesarean, compared to the national average of 23%. And last year's unofficial figure - at under 12% - looks set to maintain the unit's position at the bottom of the Caesarean league. So what's Shrewsbury's secret?
One factor could be their midwife led units where women with uncomplicated pregnancies are encouraged to give birth naturally. Dr Michelle Mohajer is the lead obstetrician at the hospital.
MOHAJER
There is no doubt that the division of high and low risk maternities is a big contribution and I would have to say it's probably the major contribution. The ability or facility to allow low risk women to deliver in midwife led units is very beneficial and in normal pregnancies doesn't put them in the sight of the doctors where unnecessary intervention often happens.
PORTER
It suggests that we doctors do have slightly itchy fingers.
MOHAJER
We do have itchy fingers and I think the more that the midwives are allowed to look after their normal pregnant women who are just undergoing a physiological process is an advantage. And in so many units round the country where all pregnant women go to one delivery suite they don't have that privilege.
PORTER
Do you think it's anything to do with the local population here?
MOHAJER
Again I'm sure that is yet another big factor, we have a large geographical area, it's a big rural community, we have low ethnic minorities and they have quite different perinatal outcomes, obstetric outcomes, than the Caucasian population. We do feel that that must have got something to do with it. There is a degree of geographical isolation because Shropshire is quite remote from a lot of other cities in the country.
PORTER
So good country breeding stock.
MOHAJER
Yes I think that is true.
PORTER
What about the attitudes of obstetricians that work here, I mean you're obviously aware that your rate was low, is it something you try and keep low, do you actively try and reduce the number of Caesareans?
MOHAJER
No I don't think that's true, I think what we do is perpetuate the ethos that we have in this unit where - you know the philosophy that normal pregnancy should have a normal outcome and you know we have a very well trained, very committed, group of midwives who manage to run the midwife led unit very, very safely, all by strict protocol that is annually updated, you know everything is quite tightly run so that anybody that veers away from that normal protocol will be transferred under consultants care.
PORTER
Obviously the reason for doing a Caesarean section, whether an elective or emergency, is to reduce the risk somehow to mother, baby or both and therefore the worry would be that if you've got a very low Caesarean rate that some problems are arising as a result of that. Is your low Caesarean rate reflected in any increase in maternal complications or perinatal complications with baby?
MOHAJER
Again you know we regularly audit our perinatal outcome, our maternal outcome, and there is - certainly our perinatal mortality rates are on a par with the rest of the West Midlands and with comparable populations around the country procedures.
PORTER
How do you handle women who come in, maybe with their first baby, saying look you know I really don't want to have my baby vaginally because I'm worried about the pain, I'm worried about the repercussions afterwards, please can I have a Caesarean?
MOHAJER
Fortunately it's not a common occurrence and I do think that the majority of healthy women in Shropshire wish a normal birth. I think I've had more occasions where we've thought a Caesarean section was necessary and they're asking please, please can I have a normal birth this time. But the woman that does have that fear the important thing is that we actually try and identify what the fear is and why there is a problem and pain is certainly one of them - a lot of women are - feel that they won't be able to cope with the pain of birth. Some of them it is social planning, that it just seems more convenient. And what we try to do is actually go through and address their fears, such as if their big fear is of pain then we try and ensure that they can have an epidural when they come in, in labour. If it's a matter of convenience for timing of delivery then we may suggest perhaps an induction of labour at a planned time. And I would say that most of the time we can come to terms and meet them halfway. We've had very rare occasions where a woman will really not - insist that that's what she wants and our last resort, if you could call it that, is that we refer them for a second opinion to another consultant, either within this hospital or to one of the hospitals in the region.
PORTER
Dr Michelle Mohajer.
Well another factor that could help explain Shrewsbury's low Caesarean rate is that they allow women in their midwife led units to labour for longer before intervening. Sue Breslin is Divisional Manager for Women's Services.
BRESLIN
There is a normal standard pattern for the progress in labour that's been used by hospitals for a long time without really being evidence based, it's just that we assume that a woman in good labour, certainly having her first baby, should - the cervix should dilate at one centimetre an hour in the first stage of labour and that her second stage, or pushing stage, shouldn't last longer than an hour. And when we apply those rules we obviously have to transfer a number of women up to the consultant unit from the low risk unit because they're starting to breach that rule and that policy. There was some work done in Wales about leaving women longer, allowing them longer in first stage and up to two hours in second stage and the work that was done didn't show any detrimental effect on the women. So we actually trialled that guideline in one of our low risk units and audited the results and they were very positive. So we then incorporated that into all of our low risk units and we've just audited it again and the results have been very good and have shown a reduction in women transferred in labour, therefore an increase in normal births without any harmful effect on the babies or the mothers.
PORTER
And is this something that's being adopted nationally or is this a small trial?
BRESLIN
Well I suspect it will be, it will be rolled out nationally. Obviously if you don't have low risk units and if you are managing labours medically then having it longer is not maybe what you're trying to achieve because on a consultant unit, in all honesty, to have a normal labour who is going to be there for 24 hours walking around would be an irritation and also would block that bed, if you need all your beds quick turnaround because of the pressure on those beds, you're not going to be able to offer that length of time to allow normal processes to occur without interference. So the chances are that you will be interfering with that labour, you will be putting drugs up to hasten the labour so that she can be delivered quickly. And from the mother's perspective if everyone around her is delivering and she's the only one who's not then her mental attitude to her labour will be changed and she'll become unsure and demotivated because she's the only one not delivering whereas in a unit that's quiet and normal then what she's doing is normal and she's empowered to continue.
PORTER
Sue Breslin talking to me at the Royal Shrewsbury Hospital.
Pat O'Brien, do you think medical legal pressures are a factor in the Caesarean rate? Are doctors worried about being sued?
O'BRIEN
Well I think the medical legal aspect has always been around, it's impossible to practice in obstetrics without being aware of it. But actually in our day-to-day practice it's a small part of what we do and by and large the decisions that we make with the women we're looking after are based on what's happening with her, what's happening with the baby and what's the best for both of them.
PORTER
So you don't think obstetrics has become overly defensive?
O'BRIEN
No, I think we're conscious of it but I don't think that we're over influenced by it.
PORTER
Okay, enough about the whys and wherefores - what does it actually feel like to have a Caesarean and what are the pros and cons for a new mother and her baby? Jane Jempson is Matron at St Mary's Maternity Hospital in Portsmouth.
JEMPSON
The national guidelines say that if everything is completely normal after a Caesarean section a woman can go home actually after 24 hours. Our local experience I think is most women stay two days before they go home. The women will go home with painkillers because it is an operation that is tender and they're also coping with a newborn baby which, as anyone will know, is tiring. But the women will be supported at home by their community midwife. They will be visited at home according to their needs, which may for one woman be a visit everyday, for another woman perhaps she may choose to come into one of the birth centres and attend one of the postnatal clinics. And one of the most important things a midwife can do as well is ensure the woman, if she has had a Caesarean section, is aware of why, the ramifications perhaps for any future pregnancies and give her the opportunity to discuss her feelings. So having a Caesarean section is an operation which needs to be treated with the respect that any operation is but bearing in mind that the women actually - the majority - would have been healthy beforehand and so can expect to make a quick and good recovery. And other than that there is no reason that they should be treated any differently to any other woman who's had a normal birth.
PORTER
Jane Jempson with a positive take on what life is like after a Caesarean, and one seemingly shared by many Case Notes listeners. Last week I asked you to contact us with your experiences, and lots of you did. Louise Parberry had a Caesar because her first son, Hugh, was breech. Three years later she had Henry naturally.
PARBERRY
The healing I thought took a remarkably short amount of time, I mean really I was on the morphine in the hospital and then after that it was just paracetamol.
PORTER
How quickly did he go home?
PARBERRY
I was there on the Tuesday afternoon for the operation and I was out by Friday afternoon. I was a bit sensitive getting up, I had to be careful not to get up too quickly, you know I can use the kitchen and the toilet downstairs so I slept on the sofa a lot of the time. The stitches came out after a week and the scar took a bit of time to stop being sensitive and it took a few months to soften up and feel more normal.
PORTER
It sounds like you had a pretty smooth course. But you then got pregnant again and - but this time you decided to give birth naturally.
PARBERRY
Yes well the natural childbirth took a bit more time for everything to be okay, like taking a bath and things like that. So I felt more out of sorts actually with the natural childbirth than I did after the Caesarean.
PORTER
So if you were to go back - I mean Henry, your youngest, now is one, if you were to go back again for a third time - Caesar or normal?
PARBERRY
I think I would have to choose natural childbirth just because that avoids having an operation but really the recovery process was actually a lot better with a Caesarean.
PORTER
Louise Parberry talking to me earlier.
Pat, you feel her heart's in with the Caesar given the choice. And I've got another e-mail from a listener here, Penny Thrussel, who also had a Caesar in her first pregnancy, and is hoping to have her next baby naturally at the end of July. Why could a previous Caesarean section be an obstacle to a normal delivery the next time?
O'BRIEN
Well if your first Caesarean section was for a recurring cause, like the baby was too big to fit through a normal size pelvis then there's a very high chance that a subsequent labour would be very dangerous. But let's say your first Caesarean section was for a non-recurring cause, let's say your first baby was breech for example, and then your second baby's coming head first you have every reason to expect that you could have a normal birth this time.
PORTER
So this adage you sometimes hear - once a Caesar always a Caesar - is nonsense?
O'BRIEN
I think that's right, that comes from the past, I mean nowadays we would say that if you've had two Caesareans before probably it's a bit risky to go through labour this time.
PORTER
And the risk is what?
O'BRIEN
The risk is the worry that the scar on the womb - the scar on the uterus is not quite as strong as the womb would have been before the Caesarean section - and the worry is that you're going through labour and it's long and it's - you're having many contractions for many hours that the scar on the womb might begin to weaken or perhaps break which can be a major risk for both mother and baby.
PORTER
In terms of patient satisfaction - vaginal delivery versus Caesarean - any significant difference?
O'BRIEN
Well I have to say my experience is that if a woman really wants a normal birth and has a normal birth then by and large she's very happy and recovers quickly. On the other hand if somebody really wants a Caesarean section and has a Caesarean section by and large she will be very happy and recover quickly. The women that really I think find it difficult to come to terms with things are those women who come in with a really fixed attitude that they want to have a normal birth and they don't want a Caesarean under any circumstances, very often it's difficult to come to terms with that and that can slow healing I think and recovery.
PORTER
Let's look at the benefits of a Caesarean section in terms of looking at the pelvic floor. A lot of women have problems with incontinence and discomfort when making love for instance after a vaginal delivery but they're complications that can affect women who have had a Caesarean too.
O'BRIEN
I think that's true, although it's fair to say that even though pregnancy itself can damage your pelvic floor to a certain extent, there is no doubt that vaginal birth, especially of a big baby, especially if it's an instrumental delivery like a forceps or a ventouse, these are the things that really damage the pelvic floor I think. So yes pregnancy can damage it to a certain extent but vaginal birth is the big culprit.
PORTER
What about the implications for baby, does it make any difference in terms of baby's short and long term outlook whether he or she is born by Caesarean, obviously I'm excluding babies that need to be born by Caesarean because it's an emergency, are there are any risks to baby being born by Caesarean?
O'BRIEN
Well from the baby's point of view actually a planned Caesarean section is safer in that there's no chance of the baby becoming distressed during labour or having a difficult vaginal birth, so by and large it's safer for the baby. There is one proviso to that, you know that when babies are inside that their lungs are completely full of water and in the first minute or two after the baby's born it has to take a big breath, fill its lungs with air and get rid of all of that water and by and large babies that are born vaginally, normally, tend to get rid of that water more quickly than babies born by Caesarean...
PORTER
Squeezed out of them as they pass through the birth canal.
O'BRIEN
Squeezed out and also the stress hormones of labour seem to help. But apart from that, overall, yeah Caesarean section is safer from the baby's point of view.
PORTER
And what about the outcome for mum, I'm looking once again at a planned elective Caesarean section versus vaginal delivery, is there any significant difference in sinister side effects, I mean mortality in what we call mortality and morbidity?
O'BRIEN
Yes, I mean the risks of a Caesarean section are the risks of bleeding heavily, infection in the womb or in the wound or after the operation a thrombosis - a DVT. Now from the mother's point of view the lowest risk of all of those things is a successful vaginal birth, the next risk is the highest risk is with an elective or planned Caesarean section but the highest risk of all is with an emergency Caesarean section. So if you bear in mind that of all the women who aim for a normal birth a proportion will end up with an emergency Caesarean section there's not that much to choose between the two, from the mother's point of view.
PORTER
And very briefly Pat, to end, in terms of the future where do you see the Caesarean rate settling, if it settles at all?
O'BRIEN
I imagine it'll settle more or less where it is, it might creep up a bit but I think there are opposing forces now.
PORTER
I am afraid that is all we have time for. Pat O'Brien, thank you very much.
Next week's programme is all about hip replacements. I'll be finding out about the engineering challenges involved in making artificial joints, and hearing differing views on whether arthritic joints should be replaced or resurfaced. And once again, we would like your help. If you have had a hip op, then please tell us about your experiences - both good and bad - by e-mailing the programme via the website - bbc.co.uk/radio4 - or calling the Action Line on 0800 044 044.
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