Maternal Request Caesarean Sections


21 Apr 2024

Maternal Request Caesarean Sections

My Expert Midwife
Maternal Request Caesarean Sections

A rising number of women are now requesting planned Caesarean Sections as their preferred option for birth. Referred to by healthcare professionals as a maternal request section, they are not to be confused with elective C-Sections.


As April is C-Section awareness month we discuss the pros and cons of maternal request sections.

 A maternal request section is quite different from an elective section that has been recommended by the obstetric team based on the most up-to-date and highest-quality evidence. A maternal request section is a personal desire to avoid labouring, or having an induction of labour, for any reason, and this type of request is becoming increasingly common. 

Rates of C-Sections are rising globally; Dominican Republic 56%, Brazil and Cyprus 55%, Egypt 51%, Iran and Turkey 47%, Romania 46%, Italy 38%, USA and New Zealand 33%.

Nordic countries have the lowest rates. Iceland has the lowest rate in Northern Europe; only 15%, and 17% in Norway, where strict guidelines control the offer of elective C-Sections.


Birth Planning and Education

All pregnant women in the UK are advised to consider the chance of requiring an unplanned C-Section and to make a birth plan for Plan A, spontaneous onset and vaginal birth, but also to have a Plan B for if things deviate from Plan A to include C-Sections. All antenatal education classes, whether NHS or private, should include information on birth options as we know that being forewarned is to be forearmed. 

Because we know the statistics demonstrate more than 30% of UK births are by C-Section our On-Demand Antenatal Classes do this, but we hear many course providers give only scant attention to the topic particularly those that heavily promote the “birth is easy" ideology. Our classes are presented by Registered Midwives, a Consultant Obstetrician, and an Anaesthetist.


Unplanned C-Sections

Half of all C-Sections in the UK are unplanned, or emergency. Healthcare professionals categorise the urgency of a Section as follows: 

Category 1- when there is immediate threat to life of a woman or baby 

Category 2 -maternal or fetal compromise, not immediately life-threatening

Category 3- no maternal or fetal compromise but needs early delivery 

Category 4 - elective delivery timed to suit the woman or the obstetric unit/staff. 


Why do women request C-Sections?

Having major abdominal surgery and a baby on the same day is not an easy option to become a parent.

Most maternal requests are due to a fear or anxiety about childbirth, a genuine recognised fear called Tokophobia, and some are as a preference to the prospect of an Induction of Labour with women feeling that if they do not start labour naturally then they would rather have an operative birth. 


What happens following a Maternal Request for C-Section?

 When a request for C-Section is made the hospital that the woman is booked with should arrange a referral to, and an appointment with, an expert in perinatal mental health to discuss her concerns; most UK NHS Trusts have specialist midwives conducting these appointments. Women are told that they do not have to accept this offer of support and discussion of their request however the guidance from NHS Trusts is that if a woman still wants a caesarean birth, after discussing the reason for the request with the hospital then the hospital should offer them a section. Our advice, as Registered Midwives, would be for women to accept the appointment and complete the process and pathway of discussing their request, this way they will feel confident that they are making a truly informed decision.

We know, from experience, that many women who discuss the request change their minds once the topic is explored with the experts and information is given on the risks of surgical births as opposed to vaginal births. Often the request is because of a previous traumatic labour experience and trauma-informed care pathways can often be put in place to alleviate anxiety, cancelling the request for the surgical option. 

As expert Midwives we counsel, advise and support women to process their feelings about birthing, and to consider their options well in advance of their estimated due date (EDD). Fear of the unknown or misinformation from friends, family and social media can lead to women becoming almost phobic of an Induction of Labour and request C-Section rather than accept the offer of an induction.

Every obstetrician can opt to NOT perform a Caesarean which has been requested if, in their view, it is not necessary. The Hippocratic oath, which all doctors are held to account by, states that they are bound to “do no harm” and as unnecessary abdominal surgery carries more risk of harm than vaginal birth in this regard, we support our medic colleagues and feel they should have the right to say No. However, we do have understanding and sympathy for women who have complex mental health issues around birth and would agree that in some instances agreeing to a maternal request is absolutely the right thing to do. 

After hearing the reason for requesting a C-Section, and discussing it, the obstetrician should inform the woman making the request of their opinion, and if necessary, refer them to another obstetrician if their opinion differs. If all obstetricians in a unit take the same view and are unwilling to agree to a maternal request C-Section, women should be referred to an obstetrician in a different hospital who would be willing to perform the surgery.

In March 2022, “The Ockenden Report” was released about English maternity care and lists essential actions that all English NHS Trusts should be conducting:

 “Essential Action 7” of the Ockenden Report states: “All Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for Caesarean delivery.” This clause has seen a proliferation in requested C-Sections.

Antenatal appointments and education should give women the time and opportunity to discuss the benefits and potential risks of Caesarean birth compared to giving birth vaginally with their care team. 

There has never been a legal case in the UK on the entitlement to maternal request Caesarean births. But women do have a right to make decisions about the circumstances of birthing their baby. As Registered Midwives, we would encourage women to do so with the obstetric experts involved in their care who have access to their medical records and to accept and fully explore alternative referrals offered such as trauma-informed care pathways. A legal precedent does, however, exist in the Montgomery v Lanarkshire Health Board (2015) case, where the Supreme Court stated that if there is any increased risk in a vaginal birth, a woman should be offered a Caesarean birth.


What happens at a C-Section? 

A C-section is roughly a 45-minute operation although this of course depends on the individual case circumstances, and whether the Section is elective or emergency. The longest part of the operation is usually the part following the birth of the baby when the surgeon is checking for any damage and putting the layers back together.

Whether planned or emergency women need a good working anaesthesia on board before the C-section can begin. This will be a decision made between the Obstetrician and the Anaesthetist who will then counsel their patient about options and advise of any preferences which may include an epidural top-up, a spinal anaesthetic, or a General Anaesthetic (GA).

Women having a C-section will be dressed in a surgical gown and any jewellery will be removed or taped up for safety reasons. Ideally, the Theatre team will want to have access to a nail bed that is not painted so they may request permission to remove polish from at least one finger- or toe-nail – this is so that they are able to accurately monitor Oxygen saturations. Women will also have other vital stats monitored, heart rate, blood pressure and respiration.

Women will have two cannulas sited, one in each hand or arm, for intravenous fluids and medication, they will also have a catheter inserted to empty their bladder and to keep it emptying whilst the woman is recovering from the anaesthetic. Midwives will be able to monitor the urinary output and colour using the catheter bag or a urometer which gives a more accurate volume.

The surgical technique is the same regardless of the category of need; category 1 is a lot speedier than category 4, and as a result, the scar may be less neat, but the layers that the surgeon cuts through are always the same.

Blood loss can be 500 to 1000mls and more in some cases, although the healthcare team involved with the surgery will anticipate this and will be prepared to mitigate an increased loss with the use of medication. 

A surgical wound dressing is applied in theatre and removed as per the surgeon’s instruction, anywhere from 24 hours to 7 days depending on maternal BMI, build, and weight distribution. Negative pressure dressings have embedded suction functions to help reduce the risk of surgical site infection. Surgical Site Infection rates vary between 3-15% meaning many women require antibiotics and further treatment, and some may require re-admission to hospital.

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