A letter addressed to women who have just had a caesarean section with brief explanation on their CS and emphasising that there are good prospects of vaginal birth in a future pregnancy. The letter is intended to be given before discharge from hospital.
In March 2021, QS32 was updated in line with the latest NICE guidance for caesarean section. This shared learning example has been reviewed and continues to align with the updated quality standard.
- Caesarean birth (QS32)
Aims and objectives
Our main aims were:
1) Reduce our high CS rate of 27%
2) Educate women and their carers on the prospects of vaginal birth after CS (VBAC)
3) Reverse a perception in our community that women who had a CS were more likely to have a repeat CS than vaginal birth in future pregnancies. This would allow a more balanced outlook and discussion at booking for the care of their pregnancy.
The letter was one of a package of initiatives put together to help reduce our CS rate. The other components of the package were increased consultant presence on the labour ward, inducing labour for women with previous CS and wishing to have VBAC, and the later establishment of a VBAC clinic.
Reasons for implementing your project
The NICE caesarean section quality statement 8 states 'Women who have had a CS are offered a discussion and are given written information while in hospital about the reasons for their CS and birth options for future pregnancies'.
The quality standard quality statement 1 also states that 'Pregnant women who have had 1 or more previous CS have a documented discussion of the option to plan a vaginal birth'.
This explanatory letter forms part of our information giving strategy to implement these statements and the wider underpinning guideline and quality standard.
Before our initiatives, our unit's CS rate had risen to 27% in 2004. We felt this was relatively high for our low risk population. Women with previous CS in our unit, booking for antenatal care, had a particularly high rate of asking for a repeat CS. This seemed to be partly from having been told either shortly after their previous CS or on discharge into the community that they would need a repeat CS in future pregnancies. Some were not sure why they had an emergency CS and did not feel they could go through the process of attempting VBAC.
We also had feedback from the community that some women who had a previous CS were reluctant to come into our maternity unit to labour as they felt they were more likely to be offered an emergency CS than be allowed to try to have a VBAC.
Discussions at antenatal booking often failed to achieve the desired effect of encouraging VBAC. We determined that it was valuable to educate the women having CS and ensure that they left hospital with a good understanding that if there were no other problems, they had about 75% chance of a vaginal birth in future.
We envisaged that the steps we were taking would filter through and after a few years women coming through would not have the same preconception that a previous CS meant they needed a repeat CS.
How did you implement the project
The high CS rates that had brought the situation about were due to many factors, including inadequate early information. We first had to get consensus among obstetricians, using contemporary literature, as it was important to apply the package of measures and practices to all women, irrespective of the consultant under whose care they were booked. Once consensus was achieved, we drafted a letter that was agreed to by all, designed to be addressed in person to women who had a CS and to be given before they were discharged home after their CS.
We did not incur any additional costs in the production of this particular initiative. Other concurrent initiatives, e.g. increased consultant presence had significant cost implications.
We monitored and still continually monitor our CS rates, which reduced after the introduction of the package of measures, which included the CS letters. The rates reduced from 27% to 24%. The frequent anecdotal reports of women reporting at booking that they thought a previous CS meant always needing a further CS became rare. This meant that the aim of educating women in the community had been achieved.
Key learning points
- Give the information early (before discharge from hospital or as soon as feasible afterwards). After the mother has left hospital, other sources of information come in. Information or advice given by friends or family may be out of context with the mother's clinical situation. However, such advice may become deeply established and difficult to reverse by the time the mother presents later, often in a future pregnancy.
- Make information brief and easy to understand, avoid long letters or a lot of detail at a time when the mother is dealing with the newborn and a lot of other new information.
- Provide the option of returning to discuss details when more receptive to the relevant details.
- Have agreement with all responsible for the care of women, so that practice can be uniform. Having individual consultant obstetricians keep different practices will undermine the objective of encouraging VBAC for women who wish it.