Written by Louise Nunn, Perinatal Mental Health Specialist midwife at Chelsea and Westminster NHS Foundation Trust, West Middlesex hospital Site
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Caring for Women Requesting C Section using the Tokophobia Toolkit
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I got involved in this area of care because sometimes the focus ends up being purely on the decision whether to ‘allow’ a woman to give birth by Caesarean but that’s only one part of the issue. Actually, what women want to have is a positive birth experience - regardless of the actual way they give birth - which is why I feel that it’s so important that this pathway comes under the banner of perinatal mental health rather than ’normality' . The primary aim is not to coerce women into giving birth vaginally (although the results show that the majority do end up having successful and very positive vaginal births) but that they felt supported, decisions are made in partnership and if they feel that an planned operative birth is better then we will support them to achieve that - as well as offering timely treatment for underlying psychological distress or anxiety.
Around 2 years ago we developed an antenatal care pathway for women who requested a caesarean section (CS) for a non-medical reason. This came about due to an increasing number of referrals to me for psychological support, when women were late in pregnancy and were highly anxious. There was a fair amount of clinical concern that these women needed better and earlier help and consistent decisions made about their request. It was pretty evident that the request was as a result of significant fear and anxiety rather than the myth of ’too posh to push’, and either primary fear of birth (FOB) or tokophobia in a first pregnancy or secondary FOB (often PTSD) usually due to a previous traumatic birth.
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There was general agreement and support from both obstetricians and midwives to improve care and for the pathway because locally there was a perception that the maternal request elective CS rate was increasing.
Women often make the request - or at least state that they are very fearful of birth - fairly early on in their pregnancy (often at the first booking appointment) and this generates a referral to me rather than to see their obstetric team doctor to discuss the CS. This is really important as it’s crucial to separate the actual request for a CS with the reasons behind it (the ‘why’) and the supportive interventions and treatment to help reduce their fear or trauma.
The most important first step is to acknowledge their request and the significant anxiety that has led to it. I’ve never met a woman who hasn’t thought a huge amount or read up on the pros and cons of a CS before asking for one. They often feel embarrassment or shame about admitting they don’t want a vaginal birth and I reassure them that we will support them but that it’s important to explore the reasons why they feel like that.
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I use some assessment tools, including the Fear of Birth Scale (FOBS) a 2 question tool, and also the Wijma DEQ-A which is a 33 question tool. When women have had a traumatic experience before, I tend to use the Impact of events Scale (IES-R) to assess the level of PTSD.
One aspect that’s really important to consider when using assessment tools is that PTSD or tokophobia is not viewed or portrayed to women as an internal or personal ‘problem’ or a ‘failing’ - it’s often a very rational reaction to the system in which they will give birth in (or had given birth in.
I use assessment tools to help determine which support strategy will be most suitable but also to help women understand their symptoms and reactions, rather than to diagnose ’their’ problem.
Most women will have ongoing support appointments during their pregnancy, including sessions on birth planning. I am also a practitioner for the 3-Step Rewind technique, which is a brief intervention to reduce trauma response and can be very helpful to reduce anxiety in women with birth trauma symptoms. Around 25% also access primary care talking therapies usually on 1-2-1 CBT basis and also our local IAPT perinatal champions run monthly ‘My Mind and Baby’ workshops. These focus on reducing stress and worry, and incorporate mindfulness and relaxation strategies and a whole host of resources. We provide a room in ANC for the IAPT service to see women, to help reduce stigma around accessing talking therapies. We also offer a range of interventions such as free yoga classes incorporating hypno-birthing, and wellbeing and mindfulness events for mums and dads-to-be.
Individualised care-planning is discussed during their pregnancy, some women will wait until they are 36 weeks onwards to decide how they would like to give birth, others need a plan in place much earlier to reduce their fear.
In terms of outcomes, around 55% of first-time mums will convert to a planned vaginal birth, and 92% so far have achieved one. 64% of women who have previously birthed, decide to try for a vaginal birth and 100% who laboured have achieved one.
The most important result is that 100% of women who have been supported through the pathway reported postnatally that their birth was very positive (however they gave birth), and dads also reported the same (particularly important when they had witnessed their partner’s previous traumatic birth).
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For women who decided to have a planned CS, their support doesn’t end at the date being booked as women with FOB are often just as scared of having a CS. The unit offers gentle caesareans and I’m often in theatre to support the parents to make it as positive and calm an experience a possible.
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