The Elective Caesarean Section Tug of War

Dr. Weeks et al. [1] effectively summarize how litigative and defensive practices, changing pregnancy demographics, and the drive towards patient-led care are leading to an increase in UK induction and caesarean section (LSCS) rates. They describe our current maternity systems which are “designed to support high numbers of low risk births”, and explain how the increased intervention rates are contributing to system overload and a UK maternity crisis [1]. The October 2023 MMBRACE report made a national recommendation to manage elective and emergency LSCS separately, citing failures to do so in the care of many women who died [2]. With the rates of elective LSCS consistently increasing over time, many units rely on utilizing what is hoped to be ‘spare’ time on emergency lists to complete some of their elective work. The scale of the elective overspill is significant. Just prior to the publication of the 2023 MMBRACE report, I conducted a service audit for a maternity department where there are approximately 4000 live births each year. Over a 2-month period, 45.7% of our elective LSCS were performed on emergency lists. Rotating hospitals and speaking to colleagues nationally, I believe this unit is far from an outlier. For many units, these risk-assessed decisions to perform elective LSCS on emergency lists are a well-intentioned necessity, trying to balance service provision for all patients whilst the system is under pressure; however, the MMBRACE report highlights rare but potentially significant consequences of this [2]. In order to alleviate system pressures and manage cases separately to optimise safety, elective lists must be as efficient as possible. This helps to reduce the overspill of elective cases onto emergency lists and reduce out of hours elective operations. Our theatre data, from August to December 2023, showed that downtime in between cases (mean 24 min) and late starts (mean 19 min) had the biggest impact on list efficiency. Surgeon and anaesthetist pairings made comparatively little difference on timings. In our department, the most common reason for delays and subsequent overspill onto emergency lists was having no protected midwife assigned from the start of the list. This highlights a clear, addressable intervention for subsequent service improvement. Returning to the nationwide service pressures, I agree with Weeks et al. that a comprehensive review into maternity care models is required [1]. Following on from the findings of MMBRACE 2023, I believe we need pragmatic recommendations to guide the many maternity services struggling to manage the increasing burden of elective interventions, without compromising the safety of our emergency obstetric care. A. Danson is the sole author responsible for the writing of this letter. The author declares no conflicts of interest. The local departmental audit data from 2023 is not available publicly. The data set may be able available upon request, providing NHS data sharing framework is met.