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Making decisions about birth after caesarean

Taking stock of birthing experiences: Women's views on choice about birth

Interview 27

Interview 27

Age at Interview: 31
Background: No details given.

Brief outline:1st child was breech, had planned caesarean. Struggled to breastfeed and felt low for long after. Wanted planned CS with 2nd child, but felt pushed into VBAC by clinicians. Went into labour early and had emergency CS at 38 weeks, found experience worse than previous.

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Jill's story
Print First pregnancy and birth Her first pregnancy was planned. She had low blood pressure and painful false labour (Braxton Hicks) throughout, but no other complications. At the 20 week scan she found out that her baby was in a breech position and advised to have a planned caesarean. The hospital did not offer the option of having the baby turned manually and after reading up on breech babies, she herself also felt that ECV (external cephalic version) might be too risky. She tried several other tips and tricks that she had found in books and on the internet, but her baby didn't turn. She attended antenatal classes, but found them of limited use, as by that point she felt quite certain that she would not go through labour and vaginal birth. Caesarean was only covered very superficially and most of the information that she had about it before her operation she had to find by herself. She had a good relationship with her midwives, but would have preferred to see the same person each time. Her caesarean was scheduled for 8 days before her due date. The procedure was quick and smooth and her daughter was born healthily. After the caesarean, she felt disappointed that she had not been able to have her child 'the intended way' and was sad that she did had missed out on what she imagined to be a more immediate bonding experience after vaginal birth. She had been very keen to breastfeed her daughter, and her difficulty to do so further contributed to her low mood. She ended up expressing breast milk for 1 month instead. Her recovery was slow. She contracted a uterine infection and her scar was very painful for six weeks. She experienced depression for a year after her daughter was born, but gradually recovered with the help of anti-depressants and counselling. Second pregnancy and birth Her second pregnancy was more difficult than her first one. She had low blood pressure and painful false labour again, but also experience increased dizziness and nausea. As her bump grew, the area around her scar became very tender and she had to go into hospital a couple of times to have it checked out. She only started thinking about how she wanted to deliver her second child after the 20 week scan. Up until then she had felt convinced that her baby would be in a breech position again and she would have no choice but to have another caesarean. Her baby turned out to be head down and she felt pushed by her doctor and midwives to have a vaginal birth. However, the information she received about how her labour would be managed was vague and conflicting. Additional information she got through taking part in the DiAMOND trial made her aware that her own preferences about how to give birth should be taken into account. Making the decision was difficult. After considering all the risks and benefits of different ways of giving birth and taking into account that her baby was bigger than average, she decided to book a planned caesarean. Her husband supported her in communicating her wish not to attempt vaginal birth even if she should go into labour early to medical staff. Her caesarean had been scheduled for 3 days before her due date. During week 38, she woke up in the night with what she thought were tummy pains. When the pain grew stronger, she phoned up the hospital and was told to come in. Her waters broke and she was found to be 3cms dilated. The monitors showed that her baby was experiencing distress, and she was rushed into the operating theatre for an emergency caesarean. The epidural she received did not work as well as with her first caesarean. The needle hit a nerve and caused lasting numbness in her left knee. The caesarean itself was over quickly, but very different to how she had imagined it to be. She did not feel involved in what was happening at all and found that staff were talking amongst themselves rather than to her. Afterwards, as the hospital was very busy, she had to stay in a makeshift recovery room for 6 hours. Her uterus did not contract naturally and she received two courses of antibiotics. She experienced a lot of pain and needed to stay in hospital for 3 days. She attempted to breastfeed her son, but struggled to produce enough milk, which she thinks might have been due to the stressful hospital environment. She eventually bottle-fed her son, but the disapproving reactions of hospital staff made her feel guilty. Comparing her first and her second experinece of caesarean, she had a lot more pain and stress second time round. The fact that her baby was showing signs of distress made the birth quite traumatic, and understaffing at the hospital made recovery more difficult than it should have been. She would have liked to talk about what had happened to a midwife or doctor, but was not offered the opportunity. After returning home, she felt very low. After consultation with her GP she decided to go back on anti-depressants and has felt a lot better since. She would advise other women to seek out their own information rather than rely on the guidance of health professionals as she thinks all too often their recommendations are based on general policies and do not take into account the needs of the individual patient.

She was disappointed to have a planned caesarean because her daughter was breech. But she thought ECV too risky and the hospital did not offer it, anyway.
Print Well, it was planned, completely and I didn't go into labour at all. It was planned, because she was breech, and she was breech right the way through my pregnancy, so it was an elective caesarean, I hadn't gone into labour at all, and it was about eight days from the due date, eight days early. So, how did you feel about the fact that you knew that you were having a planned section? Apprehensive, I think, probably, a good word to use; a bit disappointed because I was the only person, I think, that I knew of that had had an elective caesarean, but also relieved I think, to know exactly when your child's going to be born. It's quite, that's quite nice, quite nice to know, but yeah, and I was very scared because obviously the risks are, are pointed out to you and the complications. I was given a choice, but, it you can call it a choice, it was, “We don't turn. We would strongly advise you not to try for a natural delivery as your child is breech. We would strongly recommend an elective caesarean. We do not do”, sorry, I can't remember the actual proper name for it when they actually turn, try and turn the baby. They didn't perform that procedure at that hospital at that time, and I was told that if I wanted that, I'd have to basically go elsewhere for that. And how do you feel about that? Because I wasn't, because I was quite happy at that time with an elective caesarean because I thought that's the safest option. I'd read about turning the baby and I realised there were some risks involved. No-one could tell me why she was breech, you know, I'd had a couple of scans and people, and they couldn't say why she was breech and I'd, and I'd read also that there can be complications. They could even turn the baby and then the baby can turn back again, and there can be a low-lying placenta, the placenta can get caught, so I'd made the decision that a elective caesarean was best for my daughter and myself, and so I was quite happy, but I think if had I not been, it would have been very hard for me to go elsewhere, it would have made the decision very hard, because they weren't very forthcoming with other options.

She tried various methods to turn her breech baby, but it didn't work. She found books more useful than antenatal classes and would have liked better information about planned caesarean.
Print I wanted to know really, how safe it was for her to be turned. I also wanted to know the, really just, because obviously this was my first pregnancy, just you know, how possible was it for her to turn by herself and some home methods of trying to turn her. There was all sorts of weird and wonderful things on the internet about putting a cold bag of peas at one end of your stomach and all sorts of, and getting into a certain position and putting your feet up, and, so I tried all that. And what information did you get with that first pregnancy? About the elective caesarean, or about? About pregnancy in general, the whole thing, where did you get your information from? You, you get a little bit of information from the midwives, when you book in an appointment, which I think was eight weeks, at the time. Most of the information I got was from a book I'd bought called “What to expect when you're expecting”, it's a bit like an encyclopaedia of pregnancy, and I just found that really useful because some of the things you worry about, the niggles are just explained in English, and they're quite normal. So yeah, so most of it from the book, really. Did you go to ante-natal classes at all? Yes, I did go to ante-natal, but to be honest, at that stage, I knew that my daughter was breech, and a lot of was based, was based on talking about pain relief in labour and actually the delivery itself really, and breastfeeding. And did they mention much about sections, or …? No. It was mentioned, it was mentioned in the class that was talked about methods of delivery and pain relief and it was mentioned for about five minutes, and that was it.

She needed antibiotics after developing an infection. The pain from her scar made it hard for her to breastfeed and she did not receive much support from hospital staff.
Print Did you have any complications that you think were associated with having had a section? Yeah, well, I had a, well my uterus didn't go back so quickly as it should have done and they discovered I had an infection, so I was on antibiotics for a week or so with that. And then, I just had a lot of pain afterwards, so… and I think it was just, it… that was the main thing, obviously that, that the infection, but also, I think the… I found it very hard to breastfeed because obviously I was in a lot of pain, and there wasn't really any sort of support given to me for, for the breastfeeding afterwards, so I, I knocked it on the head. And how long did you manage to do it for? Well, I tried unsuccessfully for a number of days and then I actually hired an electric pump for a month and expressed, so it was about a month all in all, really. But… And did you have any worries, long-term worries that either you or your daughter were affected by how you delivered? No, no. And did you have any difficulties going to the loo or resuming your sex life after? Going to the toilet was very painful for about three or four days afterwards. Whilst they give you things like peppermint tea and stuff like that in hospital, it's still, you know, obviously because everything's been pushed and shoved around, it's still very, very painful. Sex life, no, no complications as such through the C-section, just obviously, obviously, very sort of… the whole area was a bit painful really for a while.

Having a caesarean was the right thing to do at the time, but even so it made her feel 'a bit of a failure'. She felt she missed out on the initial bonding phase with her baby.
Print How did you feel about the fact that you'd had a section and how you felt about the way that your daughter was delivered? Yeah, and I think I said… did I say, obviously I was a bit disappointed that I couldn't deliver her naturally, but it was the safest option, and you know, there's nothing wrong with her now. She's a very, very intelligent little girl, you know, I couldn't ask for, couldn't ask for a better daughter really, so, you know, it was the right thing to do. And did it affect how you felt about yourself at all, the fact that you'd had a section? Yeah, I, for, I think, I for a while went through a phase of feeling like a bit of a failure, as a mum, and I hadn't made that bond, the initial bond like you do by delivering vaginally, and it's very psychological. Because you know so many people that deliver naturally and there's, I mean, there was one person I knew I think out of the whole of the ante-natal class that had a C-section, you tend to feel in a minority group. How long did that last, that feeling? A couple of months.

She did not see her midwives much in her second pregnancy and was unsure where to look for balanced and reliable information, so she was pleased to take part in the DiAMOND trial.
Print It was just, it was nice to know that it was a decision that I could make and there actually was, you know, I did have a choice, because that's not explained to you at all. It's a case of you see the midwives very little the second time round anyway, in your second pregnancy, and it's very much a case of “oh, you've had a section before because your daughter was breech, but you know, this child may not be breech and so there's no problem, you can go through a trial of, you can have a normal delivery”. Well what happens if I don't? “Oh, we won't talk about that now”, it's, it's very much a case of that's their attitude so for me it was… and also I was thinking you know, how am I going to get some more information. I know that I can go on the internet and I can, you know, but it would be great if there was someone in the health profession that I can talk to that's really unbiased and they can just give you the facts as they are, basically. And, to… when I was approached to be part of the study, well, I nearly bit the lady's hand off, I was like “yeah! You must have been reading my mind, this is what I need” [laughs].

She was scared about rupture of the scar and did not feel reassured that she would be able to stop labouring and have an emergency caesarean when she wanted to.
Print Overall, what do you think is the one main reason why you didn't want to have a trial of labour and why you wanted to opt for another section? If you had to say one reason? One reason, I was worried of rupturing and going through an horrendous labour, even though they say to you, even though midwives did say to me, “Oh, we won't let you go as long”, there is no definitive, there's nothing written anyway, or cast in stone that says, “Okay, a lady that's had a previous section will only labour for x amount of hours and if this happens, you know, this will happen”, nothing is written, it's very wishy-washy, it's almost a case of, “See how much pain this woman can stand, if it gets to a point where the baby is not making progress then we'll, then we'll think about a section”, so there was no definitive answer for me and that was very worrying and I didn't want to go through hours and hours and hours of labour with, with the threat of rupturing, only to discover that I'd have to have an emergency section, that was my biggest fear.

She had not been aware that she could choose to have a caesarean instead of a trial of labour. Using a decision aid gave her more balanced information on the pros and cons of each.
Print 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.

She suspects most midwives tried to push her into a trial of labour and disapproved of her decision for a caesarean, because they are driven by an agenda to reduce NHS costs.
Print 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.

It took her some time to realise she had gone into labour. Once at the hospital, staff advised an emergency caesarean. It was a very stressful and frightening experience.
Print Well, I'd never been in labour before, because I didn't actually go into labour with my first daughter, with my first child [yeah] and it was… I was booked to have an elective section, I think four days, yeah, sorry, three days before my due date but on the thirty-nine plus one day, which was the Saturday night, I sort of woke up in the early hours of the morning with niggling tummy pains and didn't really think much of it and then two hours later woke up with really bad stomach pains again, not realising that I was in labour, and then after taking some paracetamol, it wasn't going away, it got worse. I woke my husband up, and as I went to wake him up, my waters broke, and at that point we decided then to phone the midwife. We paged the midwife, paged her twice and she didn't ring back so I phoned [Hospital] hospital direct and they got someone to ring me back and because on my notes obviously it says that “Mrs [name] is not to go through a trial of labour”, the midwife on call at the time at the hospital said, “Obviously you need to get in straight away” but she had to clarify whether I would be going to [Hospital 1] or to [Hospital 2], because [Hospital 1] was full, in fact they were over full. So they phoned back within sort of ten minutes to say no, they could fit me in, to come straight in so I think we went in about half past six that morning, and when I was in there I… the consultant gave me an internal examination and told me that I was three centimetres dilated, he was back to back and that they wanted to go ahead quite quickly with a C-section, because the waters were of a funny colour and they were worried that he was in distress, and he was born at 10.07 that morning, and it was not a very nice experience, having an emergency section. And then I had to wait in the recovery room for approximately six hours because they never had a bed, so I had to wait 'til Sunday evening really before I could go onto the ward. And how do you feel about the way that you delivered this time? It wasn't very nice. It was very, I would say probably for the first ten days, that includes the time I had in hospital, I was not really with it. I was very spaced out because it had been such a shock, and it's completely different to having a planned section. Just a couple of things, for example whilst they try to make you sort of as relaxed as possible, you know, I was obviously contracting, which I'd never done with my first pregnancy. When they actually got me into the operating theatre, they couldn't find [baby's name]'s heartbeat, then when they did it had dropped, but no-on was actually telling me this information, they were just talking amongst themselves, which then made me feel even worse. When the anaesthetist put the needle in my back, she touched a nerve, because she was rushing, well, I wouldn't say she was rushing, but obviously because it was an emergency, and I've now got numbness in my knee, which they say will probably never come back and, but where they've sort of damaged this, this nerve, and when he was born it took a lot longer obviously to stitch me up because there was obviously a lot of scar tissue there from the previous section so, and because as well the, the two recovery rooms that they have were full, I had to go into a separate room, which they'd made into a recovery room, and then wait there for sort of six hours, which, yes, it was a bit scary really. And I don't know if you could say which bit was worse really because it all sounds quite a horrendous experience, but what was it like going into labour, because that must have been, I would imagine quite terrifying because that's not what you wanted to do? Yeah, it was very frightening actually. Because I'd been having Braxton Hicks practice contractions all throughout my pregnancy [yeah] and I just thought, “Oh well these are more of them but they're obviously getting a bit more painful because I know I'm only a week away from my due date”, and I'd been into hospital the previous week with similar sort of pains and they'd said to me, “Well, we think, we think you've had a show”, because I'd described what happened, they said, “Whilst these practice contractions are quite strong, they're not actually”, they wouldn't examine me but they said they didn't think they were doing anything and basically to take paracetamol and to go home. And that was exactly a week before, so I just thought they were more of the same, but just, just felt a bit stronger, and then when my waters went, I mean, I was always told that when your waters go, it's a gush, but this was just a tiny trickle, so I was just leaking rather than gushing and at first, I really didn't have a clue what was going on, I really, really didn't realise that was what it was. And then when I actually realised and… but then actually realised, “Hang on a minute, the waters aren't clear”, I knew something was wrong, I was really upset and really frightened then. And then I knew obviously what was happening and realised that you know, he was going to be born on Sunday and not Wednesday. So, yes, it was pretty frightening, because mentally I wasn't prepared, mentally I was prepared to go into hospital on the Wednesday and have him born by elective section, because that's what I'd geared myself up for, so to actually go into labour, I wasn't mentally prepared for that really.

The pain she felt after her emergency caesarean was much worse than after her previous section. She also felt let down by the lack of continuity in staff.
Print It wasn't planned, so mentally I wasn't geared up for it. The fact that they were… it was over the bank holiday weekend, so they were, they actually told me they were short-staffed, the hospital was full, and I was just in horrendous pain afterwards. The pain of the operation, from what I can remember was ten times worse this time around than the first time. Now whether that's because you've got previous scar tissue there, but I just was in so much pain, it was just unbelievable the first twenty four hours were horrendous. That was my next question really, if you compared the two experiences…? …yeah, it was worse this… …and was that the biggest difference, the pain, for you? The pain, the pain and I think that, the pain and probably because there was no risk to [daughter's name] as such when you know, when I had an elective section, the reason I had that was because she was breech, she wasn't in any distress or anything like that. This time around, you know, I'd gone into labour and, which was fine, but the fact that the waters were a funny colour and then, and then obviously his heartbeat was dropping I think with each contraction, so it was quite… even thought they said it was a semi-emergency section, not, because you have, they have to fill out a form, class what they rate it as and you have to sign a consent form, so it was classed as a semi-emergency section. It, by the time we'd got into surgery, sorry, into the operating theatre, and I was actually on the bed, they were sort of, you could see that there was a little bit of panic going on, and the whole experience to me was more frightening and a lot more painful than the first time around. Everyone was more relaxed the first time around. This sounds an obvious question in view of what you've said, but in what ways was it different to what you expected it was going to be like, I mean, the whole thing was completely different to what you expected it to be? I think probably the pain. I mean, obviously the first time around, I never had any pain with the epidural at all, no problems whatsoever, and that was absolutely horrendous, the pain of that, I can, I can still remember that now. The section itself, well, you know, once you're led down, it takes about five minutes for, five minutes I think for [baby's name] to be born and then it was longer to be stitched up, like I said. The, afterwards as well… I felt before, I was cared… before, the midwife stayed with me, went into the recovery room, she was… the midwife I had with [daughter's name] it was very, you know, she was there all my, you know, the whole time. Because this was a bank holiday weekend, and it was a Sunday, there was no continuity with the staff and I was put in a room afterwards that was made, as I say it was like a makeshift recovery room and the midwife that actually was there that had delivered, was there when [baby's name] was delivered, was sort of with me for half an hour, then went off for a coffee break, and then came back for half an hour and then finished her shift, and then someone else came in, who was only there half an hour to give me a wash, then someone else came in, then someone else. There was no continuity, where last time, I had… my midwife was there the whole time, right the way through until I actually went onto the ward, so I didn't have that this time round. And how did that make you feel, having all these different people coming in? Really unsettled actually, and really, almost like I was in the way and a real inconvenience because it happened over the bank holiday weekend.

She had not realised that she could refuse to have a VBAC until a midwife told her so, following her 36 week scan.
Print I would say just really try to be open-minded, as open-minded as you can and try not to be influenced by the medical profession if you have a strong feeling or a strong view that you want to go for a trial of labour then make sure that, you know, your opinion is heard, you know, your feelings are heard, and make sure that you express them. Or if you want, you know, if you want to have a section, make sure that you make that absolutely crystal clear as well because I think if you don't make that crystal clear, the opinion is, “This lady will go for a trial of labour unless she says otherwise”.

Based on her own experience, she thinks women who want a planned caesarean need to state this clearly because health professionals tend to assume that VBAC is the obvious choice.
Print I would say just really try to be open-minded, as open-minded as you can and try not to be influenced by the medical profession if you have a strong feeling or a strong view that you want to go for a trial of labour then make sure that, you know, your opinion is heard, you know, your feelings are heard, and make sure that you express them. Or if you want, you know, if you want to have a section, make sure that you make that absolutely crystal clear as well because I think if you don't make that crystal clear, the opinion is, “This lady will go for a trial of labour unless she says otherwise”.

Health professionals should inform women that there is a decision to be made and provide them with the necessary information.
Print 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.

Health professionals should be careful not to stereotype women who ask for a caesarean as simply 'too posh to push'.
Print 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.

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