Positive Health Online

Much has been made by the general press about the revised guidelines on Caesarean section (CS) produced by the National Institute for Healthcare and Clinical Excellence. [NICE November 2011] Since the original guidelines were published in 2004, new evidence has come to light, and opinions have changed on the benefits and risks of CS and of other clinical situations which impact on whether or not a mother is offered an operative delivery.

The media interpreted these recommendations as meaning that CS would now be available to all women on request, but this is not the case. The new guideline focuses on identifying valid medical indications for CS, whilst being mindful of the need to reduce a national CS rate of around 25%. Obstetricians too readily resort to CS when other, more natural, solutions may be acceptable. The guideline serves in part as a reminder to professionals to provide more comprehensive information to enable women to make informed choices about their mode of delivery.

Few women truly appreciate the potential short-term complications of CS including infection, haemorrhage and thrombosis, nor of the long-term sequelae, such as prolonged immobility, urinary or bowel problems, adhesions leading to abdominal pain and even postnatal depression. There is also an increased risk in future pregnancies of placenta praevia (low lying placenta), bleeding and uterine rupture. Often, they perceive CS as the 'easy' option, avoiding labour pain and over-stretching of the perineum (women often referred to as being 'too posh to push'). They do not realize that they have not only given birth to a baby, but have also had major abdominal surgery equivalent to an appendectomy.

Of course, there are some women for whom a CS is advisable, including twin pregnancy when the first foetus is not head-first, placenta praevia, HIV not being treated with anti-retroviral medication and genital herpes infection developing for the first time in the third trimester. However, occasionally the recommendation for CS is debatable, such as breech presentation (when the foetus is presenting bottom first), since in many cases it is perfectly feasible for the mother to attempt a vaginal breech birth. Conversely, NICE does not advocate CS for everyone and suggests that there are certain circumstances when a normal vaginal delivery is preferable. These include twin pregnancy in which the first baby presents head-first, small babies, either due to prematurity or poor intrauterine growth, women with HIV on anti-retrovirals, hepatitis B or C or recurrent genital herpes at term. In addition, women with a body mass index of more than 50, with no other medical or obstetric risk factors, should be encouraged to attempt a normal delivery because the risks of CS far outweigh those of vaginal birth.

NICE has advised that women's personal physical, emotional and social circumstances should be taken into account when deciding on the mode of delivery, but the media focused on the recommendation that women with extreme anxiety about vaginal birth should be given an opportunity to consider CS. This does not mean the normal worries which almost all women have about birth, but the far more extreme and uncontrollable fear of childbirth - tocophobia - which is thought to affect up to 10% of women. It may or may not be associated with previous traumatic birth experiences or conversely, fear of the unknown, but is almost certainly compounded by socio-cultural, educational and other factors.

Primary tocophobia occurs before the first pregnancy and causative factors may be traced back to adolescence, or there may be a history of rape or other sexual abuse. Secondary tocophobia occurs following a traumatic or difficult delivery in the first pregnancy, and can seriously affect mental and emotional wellbeing in subsequent pregnancies, sometimes leading to antenatal and/or postnatal depression or post-traumatic stress disorder. Occasionally the problem is so severe that women request termination or sterilization.

Complementary Therapies for Tocophobia
The NICE guideline advocated that women with an extreme fear of childbirth be referred for counselling in the first instance, giving them an opportunity to work through their fears. If, after receiving appropriate treatment, a woman remains overly-anxious about the birth, CS is a possible option. However, complementary therapists are in an ideal situation to recognize this condition when working with pregnant clients, to listen to women's fears and to refer to appropriate sources of help as necessary. This does require the therapist to have well-developed listening skills, to acknowledge the limits of their own skills and know when to refer to a more specifically-trained and experienced colleague.

Hypnotherapists are seeing an increasing number of women suffering from tocophobia and can often treat them very successfully. A review of several studies indicated that hypnosis is consistently more effective than conventional care, counselling and antenatal classes in reducing women's anxieties about birth, [Landolt and Milling 2011] although a systematic Cochrane review found variable results for a range of mind-body interventions.[Marc et al 2011] Hypnosis has also been shown to be effective in altering women's perception of pain in labour, reducing anxiety and fear and instilling self-confidence, generally improving their coping abilities.[Abbasi et al 2009]. The fact that pregnant women may be more readily hypnotizable than non-pregnant controls may contribute to the success of hypnosis for childbirth preparation and for pain relief during labour [Alexander et al 2009] and can contribute to a reduced need for analgesia in the first stage.[Vander Vusse et al 2007]

Extreme anxiety upsets the delicate balance of hormones, increasing cortisol, adrenaline and noradrenaline and reducing serotonin and the essential childbirth hormone, oxytocin. Manual therapies which reduce stress hormones, particularly cortisol, facilitate increased production of oxytocin. These therapies may help women to cope better with the emotional and physical factors which can adversely affect pregnancy progress and general maternal coping strategies. It has been shown that regularly receiving complementary therapies such as massage or aromatherapy in pregnancy helps to promote normality towards term, facilitating spontaneous onset, normal progress and a positive outcome to labour.[Field 2010; Field et al 2005; McNabb et al 2006]

Similarly, reflexology enhances serotonin, the body's natural 'feel good factor',[McVicar et al 2007] and it is thought that the mechanism of acupuncture produces physiological effects which can effectively improve the pathology of post-traumatic stress disorder.[Hollifield 2011]

Advising women with a fear of childbirth to attend classes which encourage social interaction as well as movement and exercise can be valuable in increasing awareness that other women also feel anxious about the birth, helping them to realize that they are not alone. Finnish research demonstrated that there was a greater number of withdrawals of requests for CS following group psycho-education and relaxation in an experimental group than in either a control group or in previous studies.[Saisto et al 2006] with women reporting that sharing their feelings was more significant than gaining information. Yoga may be helpful in alleviating anxiety and depression through a reduction in cortisol and enhancing the immune system,[Field 2011] particularly in the third trimester,[Beddoe et al 2009] as may tai chi or autogenic training.[Marc et al 2011]

Encouraging women to talk about their impending labours, before, during or after their complementary therapy treatment, can be valuable in helping them come to terms with their situation. Mackereth,[2009] in his reflexology practice with multiple sclerosis sufferers, referred to this as "creating a space" for clients to share their thoughts and emphasises the nature of the therapeutic relationship. The same applies to therapists working with pregnant clients, especially since there is such a shortage of midwives, resulting in limited time for individual mothers to express their concerns at length.

Conclusion
Caesarean section is not a birth option to be taken lightly. Women's bodies are designed to labour and give birth, and CS is the most extreme intervention possible in a normal physiological life event. Whilst it may be necessary - and is sometimes, life-saving - to have a CS, women need to understand that the risks are generally greater than the apparent short-term benefits, especially when there is no real medical (i.e. physio-pathological) indication for surgery. Of course, conventional maternity care, particularly from midwives, also encompasses psycho-emotional and social aspects and it is important that women's fears are addressed, but limitations of the service often mean that resolution is difficult.

Empathetic care from complementary therapy practitioners can go a long way towards easing women's anxieties, offering them some 'me time', a safe environment in which they can voice their fears, and relaxation treatment aimed at reducing stress hormones and facilitating homeostasis.

References
Abbasi M, Ghazi F, Barlow-Harrison A, Sheikhvatan M, Mohammadyari F. The effect of hypnosis on pain relief during labor and childbirth in Iranian pregnant women. Int J Clin Exp Hypn. 57(2):174-83. 2009.
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Beddoe AE, Paul Yang CP, Kennedy HP, Weiss SJ, Lee KA  The effects of mindfulness-based yoga during pregnancy on maternal psychological and physical distress J Obstet Gynecol Neonatal Nurs.  38(3):310-9. 2009.
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Mackereth PA, Booth K, Hillier VF, Caress AL  What do people talk about during reflexology? Analysis of worries and concerns expressed during sessions for patients with multiple sclerosis Complement Ther Clin Pract.  15(2):85-90. 2009.
Marc I, Toureche N, Ernst E, Hodnett ED, Blanchet C, Dodin S, Njoya MM  Mind-body interventions during pregnancy for preventing or treating women's anxiety  Cochrane Database Syst Rev.  6;(7):CD007559. 2011.
McNabb MT, Kimber L, Haines A, McCourt C.  Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth?-A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth. Complement Ther Clin Pract. 12(3):222-3. 2006.
McVicar AJ, Greenwood CR, Fewell F, D'Arcy V, Chandrasekharan S, Alldridge LC.  Evaluation of anxiety, salivary cortisol and melatonin secretion following reflexology treatment: a pilot study in healthy individuals. Complement Ther Clin Pract. 13(3):137-45. 2007.
NICE 2011 Clinical Guideline 132 Caesarean section. Viewed at www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
Saisto T, Toivanen R, Salmela-Aro K, Halmesmäki E. Therapeutic group psychoeducation and relaxation in treating fear of childbirth. Acta Obstet Gynecol Scand. 85(11):1315-9. 2006.
VandeVusse L, Irland J, Healthcare WF, Berner MA, Fuller S, Adams D. Hypnosis for childbirth: a retrospective comparative analysis of outcomes in one obstetrician's practice Am J Clin Hypn.  50(2):109-19. 2007.