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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme No. 3 - The Nose
RADIO 4
TUESDAY 22/05/07 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
JULIAN ROWE-JONES
HUGH WHEATLEY
CHRISTOPHER HAWKES
MIKE THOMAS
PRODUCER:
JOHN WATKINS
NOT CHECKED AS BROADCASTbr />
PORTER
Hello. "As plain as the nose on your face" may be a popular idiom for something that's clear and obvious, but from a medical perspective there is nothing plain about the nose. It's a complicated organ that plays a key role in a number of important functions - both aesthetic and physiological. Functions which most of us take for granted - at least until something goes awry.
CLIP
It's affected my life in a very strange way because you don't actually realise how much you use a sense until it's gone, you just take it for granted. And having a young child things like just changing his nappy, I can't smell when it needs changing; going shopping for perfume; smelling if something's burning; lots of things you wouldn't even think about.
PORTER
And what if you don't like the shape of your nose? I'll be meeting two people who've had their noses remodelled, and finding out about the challenges faced by surgeons advising someone who is unhappy with their nose - whether it's been squashed in an accident, is too big, too bent, too small, or just not as perfect as Brad or Angelina's.
And I'll be talking to one of the men behind the latest research into the link between inflammation of the lining of the nose - rhinitis - and asthma. To discover why the World Health Organisation thinks treating nasal symptoms, in conditions like hay fever, could help control cough and wheeze in people with asthma.
My guest today is Julian Rowe-Jones, he's a consultant rhinologist and nasal plastic surgeon at The Nose Clinic in Guildford.
Julian, let's start with the basics - what does the nose do, what are the functions?
ROWE-JONES
Associates are air conditioning units, so it warms, humidifies and filters the air that we breathe so that that air is ready for the lungs and is optimised for the lungs. And of course it's what we smell with.
PORTER
And it's also a pretty important landmark as well - sitting there in the middle of the face.
ROWE-JONES
Yes it is and of course you can't hide it - you can't wear clothes to disguise it, you can't pull a hat down over it - so yeah I think it's something that people if they're not happy with are very concerned about.
PORTER
Take us through the nose along the path that air travels, let's have a look at the structure. So air enters through the nostrils, what happens to it then?
ROWE-JONES
It's directed - there are structures called terminates, which are like sausages inside the nose and they direct the air upwards towards the area where the smell nerve endings are and then backwards and then into the lungs through the back of the throat.
PORTER
And looking at those nerve endings - talking about the smell - that's actually where part of the brain almost literally drops into the top of the nose isn't it, so it's a direct sense.
ROWE-JONES
Absolutely, there's a little plate with tiny holes in it at the top of the nose and the nerves come directly through from the front part of the brain through into the roof of the nose.
PORTER
And what determines its shape and size, well what holds the nose up - it's not all bone is it?
ROWE-JONES
No, I usually describe it to patients on the outside as being in thirds. There's an upper bony third, which is like a roof and then there's a middle third which is a bit softer, a bit like hard plastic and that's the top of the mid-line partition of the nose and then the tip of the nose, which is the third part, floats on the end.
PORTER
The squidgy bit.
ROWE-JONES
Yeah.
PORTER
And what about its size, I mean does the nose stop growing, is all of that growing right through into adult life?
ROWE-JONES
Really and truly things stop growing at about 16, it's the partition inside the nose, that we call the septum, that projects and pushes the nose forward and it's when that stops growing that the rest of the nose really finishes. But people do say to me does my nose carry on growing as I get older and they have this vision of this great thing hanging off the middle of their face but really I think everything just becomes a little bit less tight and less elastic as we get older.
PORTER
Well one of the downsides of being such a prominent structure is that the nose is very susceptible to trauma. Nasal fractures are an everyday sight in most A&E departments and can result in significant deformity if they are not managed properly. Hugh Wheately is a consultant ear, nose and throat surgeon at Gloucestershire Royal Hospital with a special interest in cosmetic surgery.
WHEATLEY
Basically if you've got a broken nose it's either going to be straight or not and you can either breathe through it or you can't. Often when you turn up it's quite swollen and it's quite difficult to assess whether it's bent or not. For that reason often the casualty person will refer you to the ENT clinic about seven days later when the swelling has gone down. We like to make sure there's not a thing called a septal haematoma, that's a blot clot that's collected in the septum, which is the middle bit of the nose, if we leave a septal maematoma it can actually kill of the cartilage in the nose and you get a collapse of the nose.
PORTER
And what about x-rays?
WHEATLEY
We tend not to x-ray nasal injuries, for a simple reason that all we need to know is that the nose is straight, it's either straight or it's bent. If it's bent we'll need to correct it, if it's straight we don't.
PORTER
So assuming the nose is not straight, the patient's not happy with it, they'd like something done about it, do you have to do that as a matter of urgency or can it wait?
WHEATLEY
If it's a recent injury then the bone hasn't set so it's still quite mobile and in that case we can do what we call a manipulation under anaesthetic and simply push the nose back into shape.
PORTER
And that can be done up until how long after the injury?
WHEATLEY
Normally about two weeks, after that the bone starts to set and we actually have to then refracture the nose with a slightly more aggressive operation and more invasive.
RANDALL
My name's Jack Randall. Basically when I was about 16 someone tried to mug me...
PORTER
You got punched or kicked in the nose.
RANDALL
I got punched, I think it was about close to 40 times, in the face, so it was quite bad. The bridge of my nose was basically on my cheek but at the time I managed to push it as close to the centre as I could.
PORTER
So what happened then, what did the doctors do there and then?
RANDALL
Basically at the time there was not a lot they could do, because obviously the swelling and everything and the bruising and everything like that so they couldn't actually tell whether it was broken. So I just basically took painkillers.
PORTER
And what was practically involved in having it straightened, as far as you were concerned?
RANDALL
Basically I think it was just - because my septum was deviated as well, so I think it was to move this across and then just straighten the bridge out and do all that sort of work.
PORTER
All done under anaesthetic. How did it feel when you work up?
RANDALL
Strange yeah. When I came round it was okay I didn't really feel that much but the painkillers I didn't very much like them, so I didn't actually take them, so the pain was quite horrific. It was the days after - the following days after - that I found the worst because it was very hard to sleep, I couldn't breathe through my nose because I had packs in there and I was waking up a lot and I didn't get very much sleep afterwards.
PORTER
How long before you were back to normal?
RANDALL
It's still very tender around here, I wouldn't go boxing or anything like that really...
PORTER
Should hope not.
RANDALL
But it's still quite tender but it's actually very much normal, as far as I'm concerned, now that the swellings settled down, it actually looks how I would.
WHEATLEY
Normally if it's a simple deviated nose then just refracturing it around the old fracture site and trying to push it back into place will often do the job.
PORTER
And how do you hold it in the new position because you've got an arm in plaster but it's not quite so easy to splint ...?
WHEATLEY
It is quite difficult to splint the nose, we do use various splints that - thermo plastic splints - I personally use plaster of paris and just cut it to shape and stick it on the nose with a bit of elastaplast. The dressings aren't brilliant at holding it in place, it's more to remind people that they've got a fragile nose and not to knock it and be gentle with it.
PORTER
And how long would that take to heal and get back to normal?
WHEATLEY
I would leave the dressings on for a week and then see them back in the clinic and remove it. The nose at the actual site will be tender and will still be a little bit mobile, so you have to still be careful with it. Noses, like any other bones, take a good six weeks to heal up.
PORTER
But dealing with broken noses is only part of Hugh Wheatley's reconstructive work. Emily Clutterbuck's nose changed shape when, for no obvious reason, part of her nasal cartilage collapsed during her late teens. And it took her a while to pluck up courage to do something about it.
CLUTTERBUCK
Well it was probably about a year before I had the operation and I noticed whereas before my nose had been straight that a few months beforehand I noticed sort of it had gone wonky. So my nose dipped on one side and had a bump on the other and so my nose sort of had a crooked effect.
PORTER
And then how did you feel when you first noticed it, it's not very nice noticing something's wrong with you nose?
CLUTTERBUCK
No, it wasn't great for the self esteem but you know ...
PORTER
Did it worry you enough to behave differently when you were out with other people?
CLUTTERBUCK
Oh yeah, sometimes in photographs I'd sort of turn so that my nose wasn't really on view or anything because on the side it looked okay but when you were full front on I could really notice it. And then I did get to a stage where I did want to have something done. And I went to the doctor and I explained this problem and he wasn't actually sure what it was, so he referred me on to Mr Wheatley.
PORTER
So what did your surgeon say to you when he saw you, what were you offered?
CLUTTERBUCK
Well he had a look at it and I think he put a camera up my nose as well and he offered the fact that I could leave it like it was or I could have the rhinoplasty to actually straighten the nose, which was done a few months after I saw him.
PORTER
And was that done on the NHS?
CLUTTERBUCK
Yeah it was.
PORTER
And was there difficulty getting it done on the NHS because you were having it done for cosmetic reasons?
CLUTTERBUCK
Not that I was aware, no, because he said about a six month waiting list. I had the appointment in September and then I had the operation done in the February, so it was quite a short period of time.
PORTER
And when the bandages came off for that first time, that's the big moment isn't it, that's when you see your new nose or was it a new nose or was it actually going back to what you'd originally had?
CLUTTERBUCK
No, it was amazing, my nose was just straight, everybody noticed it as soon as the bandages came off, it was like you know wow I've got a straight nose.
PORTER
And how did that affect you, you obviously felt a bit more confident with it?
CLUTTERBUCK
Oh definitely, my self esteem really was a lot better after that because I wasn't paranoid - people - you know I'm thinking people are looking at it and thinking I'm the girl and her nose is wonky. But I just felt better in myself really.
PORTER
And the acid test - can you stare the camera straight into the lens now?
CLUTTERBUCK
Yeah I can now.
PORTER
A very content Emily Clutterbuck talking to me earlier. You are listening to Case Notes, I'm Dr Mark Porter and I am discussing the nose with my guest nasal surgeon Julian Rowe-Jones.
Julian, Emily and Jack, who we heard in the package there, had their noses straightened on the NHS but most nose jobs or rhinoplasties are done in the private sector. What's the most common complaint you see among your patients coming to you to have their noses remodelled?
ROWE-JONES
Actually although I guess the main complaint is the nose is too big and they'd like a smaller nose, behind it all is a lack of self confidence and it's the nose that personifies this lack of self confidence and they tell me they can't relax, they can't go into a bar because if they do they catch their image in a mirror which they don't like, it puts them ill at ease. So it's actually not strictly a vanity issue I don't think, it's a psychological confidence issue that focuses on the middle of the face.
PORTER
Well to that extent you must get people who come in with - I don't want to use the word normal nose here - but to you outwardly looks like a perfectly normal nose, it's neither too big, too small, it's not got a bump in it but they obviously perceive there's something wrong with it. Do you actually put some people off having an operation, do you talk people out of it?
ROWE-JONES
I would, yes, definitely. I think one has to bear in mind that there are some patients who have body image problems and their nose just is what they've chosen to focus on to represent that. There are aesthetic guidelines, cosmetic guidelines, that give us a way of measuring whether the nose is normal or not and I actually find taking pictures of the patient's nose, putting them on the computer, and showing them these angles and lengths and dimensions are very helpful because then they can see that actually their nose fits in what might be considered normal and then I advise them against surgery.
PORTER
What about people - do you ever get people coming in with pictures saying I'd like a nose like that? I mean I jokingly referred to Brad and Angelina's noses early on but I wonder whether that does actually happen - do people come and say I'd like to look like him?
ROWE-JONES
It does and people will bring portfolios and that rings alarm bells for me a little bit. It's helpful in that it can be an aid to them communicating what sort of nose they like but I do say to them you can't pick a nose out of a magazine, it's just not possible, where you finish up with after surgery depends on where you start.
PORTER
Yeah and it must worry you as a surgeon if they've got expectations that they want, you can't guarantee exactly what the nose is going to look like, you can get pretty close.
ROWE-JONES
I think that's absolutely right, again that's the risk with manipulating images on computers, that you can give anyone a beautiful nose but it doesn't necessarily represent what you can do in surgery. And for me giving a patient realistic expectation is absolutely paramount.
PORTER
So you screen the patient, they're suitable for surgery, you think you can do what they would like, practically what's involved, obviously it's a complex procedure, different approaches, but roughly how do you go about reshaping somebody's nose?
ROWE-JONES
It comes back to the three thirds that we talked about earlier really. I operate on everyone with - under a full anaesthetic, so they're fast asleep. And then it's so important that before surgery you have a game plan, so that you discuss what you're going to do with the patient beforehand and what you think you can achieve for each brief bit. And then I project, in the operating theatre, the image of the patient on the wall, so I've always got their before surgery pictures, and generally tunnel up under the skin, without being too gruesome, shave off bone and cartilage and nowadays reshape particularly the nasal tip with stitches and bits of tissue that we've borrowed elsewhere.
PORTER
And you're working - so you're working from inside the nostrils?
ROWE-JONES
Usually we are, yes, the more complex cases we might make a little cut on the outside so we have a better view but generally speaking it's from inside. And I think modern rhinoplasty cosmetic nasal surgery looks to reshape rather than remove tissue because the nose is stronger in the long term then.
PORTER
Which brings me on to my next question: what can go wrong, what do you warn your patients about?
ROWE-JONES
I think the complications relate to the fact that you're operating on something that's living, it's not carving marble and there's a degree of unpredictability, both in how the nose heals afterwards and also in trying to judge things because you're operating under a blanket really and it can be very difficult to judge at times.
PORTER
So the biggest complication you might not meet the patient's expectations?
ROWE-JONES
Yeah, yes absolutely.
PORTER
What about function, I mean we talked about the nose is important for lots of different functions, can having rasping away inside the nose can it affect sense of smell or any of those sorts of problems?
ROWE-JONES
It shouldn't do and again just as you suggested earlier if we try and preserve structures and reshape them rather than remove a lot of tissue, as was done in the 60s and 70s when people wanted a little Hollywood button for a nose, we're much less likely to disrupt the function.
PORTER
Well let's leave the aesthetics and move on to function. Arguably the most important function of the nose, we've already mentioned, is the sense of smell, which in turn plays a key role in our sense of taste.
Most of us will have experienced temporary impairment at some time - normally during, or immediately after a cold, hay fever or bout of sinusitis. But for some people not being able to smell - a condition known as anosmia - is permanent, and often a sign of more worrying underlying problems.
DUNN
My name's Andrew Dunn and I did have a sense of smell until I guess my mid 20s when I fell off a mountain. And I didn't realise I had no sense of smell until I left hospital about nine days later. Of course the thing it affects most is food because flavour just about vanishes. I can detect spices but I can't really detect herbs at all, so for instance I cannot detect garlic. With nice aromas and flavours they're a waste of time on me.
FORSYTH
My name's Amy-Jo Forsyth. I can't smell properly due to a car crash I had a year ago. I suffered whip lash. I was out at a restaurant about a week after I'd had my car crash, I started eating my meal and thought I actually cannot taste anything. It was something that came on very quickly.
HAWKES
I'm Dr Christoper Hawkes, I'm a consultant neurologist at Queen's Hospital in Romford. My particular interests are in disorder of smell and taste. The typical person would be somebody who's had a bad cold and the smell sense hasn't come back, they've got sinus disease and so on. The person who comes to me may have had a head injury, that regularly does damage the sense of smell, and the other patients tend to have a variety of diseases which we loosely categorise as neuro-degenerative and the main ones here are Parkinson's Disease and Alzheimer's Disease.
BAYLISS
My name is Alan Bayliss. I first became aware of my loss of smell 25 years ago because my wife could smell things that I couldn't. Particularly gas on our sailing boat, we had a gas cooker which leaked, my wife could smell it, I couldn't smell it at all. It wasn't until I lost coordination of certain limbs and saw Dr Hawkes, as a result of this, that he suspected that my loss of smell was a result of the onset of Parkinson's.
HAWKES
There have been a variety of studies that suggest that loss of smell may be the very first sign of Parkinson's Disease. This can predate the onset of typical features of Parkinson Disease which are tremor and rigidity and so on, by maybe as much as 40 years. So this is quite a valuable bit of information if we can really clench it.
BAYLISS
When I first diagnosed with Parkinson's I was in self denial really. But Dr Hawkes wanted to carry out the test with smell cards which proved to me that I certainly hadn't got a very good sense of smell. Mary, my wife, came to the test with me, she was far more successful than I was. I detected about four smells out of 20, she detected 15 out of 20 and this just really pointed out that she'd often said that my sense of smell was rather poor.
SCOWLS
My name's Mark Scowls. I have congenital anosmia, which means I've not been able to smell since birth. I wasn't really very aware during my childhood but I knew that I couldn't smell flowers and I couldn't smell very strong smells. When I was about 16 or 17 I went to the doctor to ask about it and what they did was they gave me a brain scan and they came back and just said basically it's one of those things, which is what they said 20 years ago.
HAWKES
In Mark's case the test suggests that he has no sense of smell at all from birth and he probably has a condition that's extremely rare where the actual nerve processes that come from the top of the nose to make contact with the under surface of the brain have never properly developed.
SCOWLS
To be honest it's not a big disability towards me because as I've got no other reference as to what a smell is I don't know what I'm missing. The only concessions really I make to it are that like most people I have a smoke detector in the house, also have a carbon monoxide detector because I have gas in the house. It's just that when people say to me can you smell the flowers, I just can't smell anything at all.
BERRY
I'm Colin Berry and more than 20 years ago now I had a rock climbing accident and I got quite a bad head injury and with it I lost my sense of smell. In the early days of my anosmia I had a problem in a lab that I was working in, there was a Bunsen burner burning and a kitchen roll was next to it, the window was open, and it flapped around and caught fire. People came out of the nearby offices to find out what was happening and unbeknown to me there was this blazing fire behind me and I couldn't smell the smoke. So there are potential dangers to it.
HAWKES
Patients who lose some or all of their sense of smell from head injury can make a degree of recovery. Local changes in swelling in the nose which will damage the sense of smell initially but if that subsides, as it usually does with treatment and time and so on, the smell sense may return. But if the head injury has caused actual shearing of the nerves then the prospects of recovery are poor and it really depends on the regenerative capacity of the smell nerves. Now turning to the degenerative diseases, like Parkinson Disease and Alzheimer's Disease, unfortunately right now there is no curative treatment for that. It's really a waiting - a deeper understanding of those two conditions and whatever helps Parkinson's and Alzheimer's Disease may well help the sense of smell in addition.
PORTER
Dr Christopher Hawkes at Queen's Hospital in Romford.
Julian Rowe-Jones. We've covered shape, we've covered the sense of smell, now I'd like to move on to conditions that affect the lining of the nose - rhinitis and sinusitis.
Both extremely common - and one and the same thing?
ROWE-JONES
Yes I think in the majority of cases that's true. It's a continuous carpet of mucus membrane lining the nose through little holes into the sinuses which are I'd describe as bony boxes in the skeleton of the face. We don't really know what they do, they maybe resonating chambers for the voice, they maybe crumble zones to protect the brain if we're injured, which sounds pretty ghastly really.
PORTER
But they're pretty dependent on these drainage channels aren't they.
ROWE-JONES
Well I think they are for two reasons. One, the drainage channels let mucus out so it doesn't become stagnant and get infected but they also let the air in and it's air getting in that keeps them healthy really.
PORTER
There are lots of different reasons why somebody might have inflammation of the lining from infection, viruses, common cold etc., through to allergies - pollen, particularly at this time of year; house dust mites, etc. etc., now treating those using things like allergen avoidance and antihistamines and anti-inflammatory steroid sprays is something that would normally fall into the GPs' domain, so why would people end up seeing you, needing to see a specialist?
ROWE-JONES
I think it's really because they don't respond to the treatments they've had, it's not - surgery isn't a replacement for those treatments, it's just they don't work for some patients.
PORTER
But there will be some people who might benefit from surgery, historically - and we're looking at improving the drainage to the sinuses mainly here with surgery - historically it's not a great reputation.
ROWE-JONES
It hasn't and I think that's because it's been employed across the board, rather than for carefully selected patients. But patient satisfaction rates are very high in carefully selected groups. And I think it's also true to say the surgery's much more delicate nowadays, we have telescopes to look inside the nose, cameras, smaller more precise instruments and most recently balloon sinuplasty, which is like angioplasty, so we can stretch the drainage holes by inflating a balloon rather than actually cutting a hole.
PORTER
So you're selecting your patients more carefully and the procedures that you're offering them are minimally invasive?
ROWE-JONES
Absolutely.
PORTER
Well rhinitis doesn't just have implications for the nose - there is growing evidence that it may aggravate cough and wheeze in people with asthma. So much so that the World Health Organisation has launched the ARIA initiative - Allergic Rhinitis Impact on Asthma - to increase awareness of the link among doctors globally. Mike Thomas is a GP in Gloucestershire and Asthma UK research fellow at the University of Aberdeen.
THOMAS
Well allergic rhinitis is a very common problem on its own, maybe a quarter of the whole population have allergic rhinitis but allergic rhinitis is even more common in people with asthma. Probably if you look hard enough about three quarters of all people with asthma have allergic rhinitis but really bad allergic rhinitis that's severe enough to go and see the doctor about is maybe about a quarter of people with asthma.
PORTER
So most people with allergic rhinitis will obviously notice that they've got symptoms whether it be a blocked or runny nose or sneezing or whatever but they regard it in most cases I would imagine as a minor inconvenience as opposed to their asthma which they're very keen to control well because the cough and the wheeze keeping them awake at night affecting their day-to-day life. Does it matter that they're not getting the full and proper treatment for their rhinitis?
THOMAS
Well a couple of things there Mark. In terms of whether it's important in asthma control, well I think there now is an increasing body of evidence to show that rhinitis and asthma are linked and there's a number of reasons why this should be so. First of all the triggers for allergic rhinitis, these allergens that we breathe in through the air, such as house dust mite or pollen or cat and dog dander, that trigger off allergic rhinitis are also the things that tend to trigger off asthma, so there's a common triggering factor in both. And if we look at the pattern of inflammation that occurs in the nose and the pattern of inflammation that occurs in the lower airways in asthma it's very, very similar. Indeed the lining of the nose and the sinuses is continuous with the lining of the air tubes that are affected by asthma. People now talk about the one airway theory where we really shouldn't be looking at the lower airways, as in asthma, and the upper airways as in rhinitis but we really should be considering the whole of the respiratory tract and we should be looking to find a treatment that can actually influence allergic reactions in the whole of this part of the body. There is a body of evidence that if rhinitis is untreated and active then that can have an adverse effect on asthma, so if your nose is angry and runny and if you're sneezing a lot that can actually act as a trigger for your asthma, so although you might be treating the asthma appropriately, the fact that the nose isn't treated can act as an ongoing trigger for the asthma.
PORTER
And looking at it from the other end - is there evidence, is there the same sort of evidence, to show that intervening and treating that rhinitis will actually improve the outcomes for asthma?
THOMAS
I don't think the case is convincingly made yet but certainly there's a strong body of suggested evidence to point in that direction. And I believe that we should be routinely asking patients with asthma about rhinitis symptoms when we see them for a routine asthma follow up and I think first of all if we find it we can treat it, it's a very treatable condition, but secondly I think it is an important factor in poorly controlled asthma and I've got lots of anecdotal reports, lots of my own patients who I've seen, come along with poorly controlled asthma and finally the penny's dropped when we see them sniffing and sneezing that in fact they've got unchecked rhinitis and when we've addressed that we've seen quite major improvements in the asthma control. So I and I think many of my colleagues would believe that this is a very real practical thing that front line clinicians should be taking notice of.
PORTER
Dr Mike Thomas talking to me at his surgery in Gloucestershire.
Julian Rowe Jones, are there any sinister symptoms, red flags if you like, the nasal equivalent of a lump in the breast that ring alarm bells when you hear them?
ROWE-JONES
I think symptoms on one side from one nostril should ring alarm bells because that means there's either something growing in one side which we ought to have a look at with a telescope or that there's a problem with the structure of the nose on one side, which isn't something that's going to respond to medical treatment. So one sided symptoms and especially if there's bleeding.
PORTER
So by symptoms you would mean a blocked nose or a discharging nostril or blood coming from that one side, of course in children it can often be a sign in young children that they've pushed something up there.
ROWE-JONES
And then it smells horrendous.
PORTER
And I expect you've removed a few things from children's nostrils over the years.
We must leave it there. Mr Julian Rowe-Jones, thank you very much.
Now we would like your help with next week's programme please on Caesarean section. If you have had a Caesarean we would like to hear about your experiences - both good and bad - so that we can put them to our expert. And we are particularly keen to hear from you if you are expecting for the first time and want to opt for an elective Caesarean. Or, if you had a Caesarean in your last pregnancy, but would like to give birth naturally this time. If you would like to take part you can e-mail me via our website at bbc.co.uk/radio4 - or phone our action line on 0800 044 044.
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