Elective caesareans

More of us than ever are choosing to have a caesarean rather than go through a vaginal birth. Are we becoming a nation of mums who are simply too posh to push?

Caesareans have saved the lives of many mums and babies, but today, a startling number of these operations are not carried out for medical reasons. In fact, nearly half of all caesareans are now ‘elective’ – that is, women are actively choosing to have them rather than giving birth naturally.

There are a number of reasons for this, as Sue MacDonald from the Royal College of Midwives points out. ‘Fear of labour is a big factor,’ she says. ‘When you’re pregnant, everyone starts telling you their birth stories, so you hear things like: “there was blood up the walls and the midwife was horrible!”’

This doesn’t help, but sometimes these fears are understandable. ‘A large proportion of women who choose a caesarean have been traumatised by a previous labour. They don’t want to go through it again the second time around,’ she explains.

The convenience of caesareans

Another reason for the rise in elective caesareans is the belief that they’re easier and less painful. At the Portland Hospital in London, where many celebrities choose to give birth, 30 per cent of women ask to have a caesarean when there’s no medical reason for having one. And the image of celebrities sweeping into hospital, having their babies and sweeping out again, looking glamorous and unscathed, only serves to increase this perception that caesareans are the easier option.

Our modern obsession with convenience is also contributing to the rise in demand for caesareans. While many expectant mums excitedly await the first twinges of labour, whenever they may come, others want to have a date in their diary.

If your partner only gets two weeks’ paternity leave and has to book it in advance, you may not want to spend 13 days waiting around for nature to call, or risk him missing the birth altogether.

And if you have to arrange childcare for older children, booking a date for a caesarean means you can make plans in advance for them to be looked after.

Will you get what you ask for?

The NHS doesn’t have a specific policy on elective caesareans, and whether you get your wish is largely down to which doctor you see and how strong an argument you make.

‘On the whole, doctors are reluctant to agree to an elective caesarean without good reason, because of the higher risk involved,’ says M&B midwife Helen O’Dell. ‘Most doctors would normally encourage a natural delivery if your pregnancy has been uncomplicated.’

But, despite this reluctance, the number of elective caesareans is likely to remain high, with women and doctors finding medical reasons to go ahead with the operation, even if it’s simply because a mum has ‘severe anxiety’ about a natural delivery.

It is now accepted by many doctors that a small proportion of women are genuinely phobic about a vaginal delivery, and they may be better off having a caesarean, for example.

If you do want a caesarean, doctors are obliged to explain the risks of the anaesthetic and of the surgery itself. After that, it’s usually a question of convincing them that your fears, or your need to know the delivery date, justify all the risks.

Is it the easy way out?

‘Some women think that caesareans are a way of avoiding the pain of labour,’ says Helen. ‘But although you won’t get contractions or have to push your baby though your vagina, going under the knife means a longer recovery time and the prospect of pain for weeks, if not a few months. It should never be taken lightly – a caesarean section is a major operation.’

You also need to consider what will happen after your baby is born, stresses Helen. ‘Having a newborn makes incredible demands on you. Women who’ve had caesareans suffer more pain afterwards and are slower to return to normal activity levels.’

Sleepless nights with a newborn are tough for everyone, but if you’re hobbling around in pain, it makes it all the more difficult to get through those first few weeks.

Of course, some caesareans are necessary, and can decrease the risk to mother and baby. But this is very different from choosing to take the risks involved simply to avoid giving birth naturally.

Pros and cons of elective caesareans

Pros

√ Convenience – you can arrange work and older children’s care around the birth date
√ Procedure is quick, so you’re not tired due to a long labour
√ Delivery itself is pain-free
√ You and your doctor can agree on what will happen, and when
√ You avoid the possibility of having to have an emergency caesarean
√ Your vagina won’t be torn, cut or stitched

Cons

X Your risk of death is four in 10,000, compared to one in 10,000 for a vaginal delivery
X The risk of haemorrhage is two times higher than for a vaginal delivery
X The chances of getting an infection are 10 times higher than for a vaginal delivery
X The risk of thrombosis is three times higher than for a vaginal delivery
X Post-op urinary infections are more common
X The wound is painful for several weeks afterwards
X The pain will restrict your ability to do everyday things for yourself and your baby
X It can affect your ability to have another baby
X Some women later feel like they’ve missed out on a rite of passage by not having a natural birth, and even have trouble bonding with a baby they’ve not pushed into the world themselves

Do remember that the risks involved in emergency caesareans may be more significant

What happens during a caesarean?

· Before the operation, a urinary catheter will be inserted so that your bladder remains empty during surgery. Your tummy will be cleaned and a bit of your pubic hair shaved where the cut will be made. In most cases, you’ll be able to wear your own nightie or t-shirt if you prefer.

· You might be given some medicine to neutralise your stomach acids, and you’ll probably have a drip in your arm and a heart monitor put on your chest to measure your heart rate.

· The anaesthetist will give you either a spinal block or epidural anaesthetic and will check that you’re not able to feel any pain, usually by touching your skin with cold water or ice and asking if you can feel it. In some cases, a general anaesthetic is given, but this is usually only done for women who don’t want to be awake during the operation, as it adds to the risk involved in surgery.

· A screen will be put across your chest so that you won’t be able to see the doctor making the cut – a horizontal slit along the bikini line. If you want to see your baby being lifted out, you can ask for the screen to be lowered. The actual delivery takes about 10 minutes, but you’ll stay in theatre for another half-hour or so, as the placenta needs to be delivered and your wound stitched.

During the operation, you’ll hear lots of clinking of surgical instruments and sucking as the amniotic fluid is drained away. The surgery doesn’t hurt at all, but you’ll feel strange pushing and pulling sensations, a bit like someone rummaging around inside you.

…and afterwards

A spinal anaesthetic takes between two and three hours to wear off, and the effects of an epidural can last for up to six or eight hours. When the anaesthetic wears off, you’ll need painkillers for the next day or two.

After surgery, you’ll spend some time – how long varies on your condition and the availability of a bed to move you to – in a recovery room. If your baby’s well, he’ll be with you, as will your birth partner, while your vital signs are monitored and until you’re fit to go to a ward. This is often the first place new mums breastfeed their baby. Sometimes a phone will be available, so you can start announcing your baby’s birth.

The catheter may stay in for a full 24 hours after the operation, and you’ll need to take some heavy-duty sanitary pads into hospital because the vaginal bleeding can be the same after a caesarean as after a natural delivery.

Your scar, which will be very red and tender at first, will slowly fade to a white line that will be difficult to see after a year or two. It’s usually 15-22cm (6-9in) long.

When can I…

cuddle my baby?

Your baby will be put in your arms almost immediately, provided he looks healthy and doesn’t need medical attention. You can have a hold before he’s cleaned up and weighed. If you’ve had a general anaesthetic, he will be given to your partner as soon as possible, and if he’s well, will stay by your side until you wake up and can hold him.

breastfeed?

Sometimes you’ll be able to do this in theatre, or very soon afterwards. You’ll need help getting your baby into a position that’s comfortable and doesn’t put pressure on your wound.

get out of bed?

Your midwife will encourage you to stand up and walk around as soon as possible after the birth, probably when your anaesthetic has worn off. The sooner you try, easier it’ll get.

go home?

Most women stay in hospital for four or five days after a caesarean, but if you’re recovering well and feel ready to leave earlier, it’s possible.

push a buggy?

This might actually be one of the most comfortable ways to get around at first, as the buggy gives you some support while you’re still in pain. But the pushing is the easy part. Lifting your baby in and out is more difficult, and lugging a buggy onto a bus or out of your car boot is not something you should try in the first few weeks. 

start exercising?

After your six-week check-up with your doctor.

lift weights?

You shouldn’t lift anything heavier than your baby before your six-week check-up (including a toddler, if you have one). After that, start with small things and do only as much as feels comfortable.

do housework?

It’s better to do as little as possible while you recover, so accept any offers of help. Reaching up to cupboards or to peg out washing will hurt for the first few weeks, as will spending long periods standing up, so ironing might be more comfortable sitting down.

drive a car?

After six weeks. An emergency stop would be very painful before then, and some insurance policies won’t cover you if you’ve just had an operation.

have sex again?

Medical advice on when you can have intercourse again is generally ‘when you feel ready’, but for most women this is around the five- or six-week mark.

try for another baby?

If you’re yearning for another baby already, it’s best to wait a full year before getting pregnant again so your scar has time to heal completely. If your caesarean delivery was for medical reasons, it’s not necessarily the case that you’ll have to have another one with your next baby.

The rise in caesareans

Caesareans are becoming safer all the time, but still carry a much higher rate of infection and haemorrhage than a vaginal delivery, and take weeks rather than days to recover from.

The caesarean rate in NHS hospitals is now at about 22 per cent, and more than nine per cent are classed as ‘elective’ caesareans. That’s a huge jump from 10 years ago, when only five per cent of women were having elective caesareans, and the total caesarean rate was under 13 per cent. Go back a few decades, and the total caesarean rate was just three or four per cent.

Mum’s story

‘It was the only way for me’

Even before she became pregnant, Cindy Herraman-Stowers, 38, from Southampton, knew she wouldn’t be able to go through with a natural birth

‘I had two traumatic childhood experiences in hospital which left me with a fear of needles and anything medical. Before getting pregnant, I talked to my gynaecologist about my terror and she advised me that if I became pregnant, I could have a caesarean under general anaesthetic. Six weeks later I discovered I was pregnant, and although I was petrified, I knew in advance what was going to happen. I was well aware of the risks of having a general anaesthetic and what was involved in the surgery.

‘I decided to go private, at a cost of £5000. Baby Isabella was born at Princess Anne Hospital, and put into my arms as soon as the anaesthetic wore off. It was love at first sight; fact that I wasn’t conscious when Isabella was born made no difference to our bonding.

‘I’m sure it’s more shocking for women who go through hours of labour and then have a caesarean. I had nine months to get used to the idea.

‘I was also able to plan in advance for the pain afterwards. The recovery was tough, but I expected it,’ she says. I’d been told it would take six weeks and it was six weeks. If I have another baby I’ll do the same thing.’