Is a caesarean the right choice for you?

They’re touted in the media as the birth of choice for celebrities and other ‘too push to push’ women who have the money and lifestyle to buy whatever delivery they want. Who wouldn’t want a pain-free birth with an optional mummy tuck thrown in so you’re back to a size 0 within a couple of weeks? And rates are going up among the rest of us, too. In 1980, nine per cent of all UK births were by caesarean. Today, just over 24%, or 170,000 births, are by c-section. 

But if c-sections are really as great as all that, why does the World Health Organisation insist that the recommended rate should be 15% of births? Leading midwife Louise Silverton, who is deputy general-secretary of the Royal College of Midwives, has recently come out and said that the UK c-section rate is ‘unacceptably and needlessly high’. She believes that they’re now seen as a normal, easy, pain-free way of giving birth by women who don’t realise the dangers, and that medical professionals also – wrongly – see them as a normal form of delivery.

So what’s the bottom line? Should you be lobbying your consultant for a c-section when your due date comes round… or are they not as great as all the too posh to pushers would have us think?

Complications

First, a few facts. Make no doubt about it, a caesarean section is a major operation and as such doesn’t come without the risk of complications – such as bladder injury, developing a blood clot, wound infection, effects on your subsequent fertility and your ability to look after your newborn, to name but a few. Says Cathy Warwick, spokesperson for the Royal College of Midwives (RCM): ‘Women should be aware that a caesarean section is a major surgical procedure. There is clear evidence that some c-sections are unnecessary and put women and their babies at risk.’

Second, undergoing a caesarean can leave many women suffering from psychological, as well as the physical, side effects. Although studies show you are no more likely to suffer from postnatal depression after a c-section than women who have given birth normally, links have been made between c-sections and post-traumatic stress disorder. ‘Women talk about feeling robbed of a birth experience and have been left with feelings of guilt, deep sadness and anger,’ says midwife Laura Abbot.

Chrissie Scott, 29, from Warwick is mum to Grace, now three. ‘I was three days into labour and only 1.5cm dilated when Grace’s heart rate plummeted,’ she says. ‘The consultant insisted on an emergency caesarean. I trusted his judgment and I’ll never know whether I could have delivered naturally but I felt I’d been cheated. I didn’t give birth to Grace, she was delivered. I had feelings of failure and I also felt guilt at the risks I’d exposed her to.’

Indeed, research by Queen’s University Belfast shows children born by caesarean are at greater risk than babies born vaginally. For one thing, they have a 20% higher risk of developing type-1 diabetes. One of the theories is that c-sections may affect the development of the baby’s immune system as she’s exposed to hospital-borne rather than maternal bacteria first.

Another study from Denmark also reveals that babies born to mothers who have elective caesareans are four times more likely to suffer respiratory problems than those delivered naturally. It’s thought that the hormonal and physiological changes associated with labour are necessary for the lungs to mature, but these changes do not happen during an elective caesarean.

When it comes to breech births and multiples, c-sections are safer than vaginal births – but they account for a small percentage of the total. The latest figures for England and Wales show that less than three per cent of babies are twins or triplets, and even rates of multiple births after IVF are falling as clinics now tend to transfer single embryos.

Doctor knows best?

It’s not only a matter of extra risks for mum and baby; it seems that many of us may not even want c-sections.

A recent study by researchers in Sydney, Australia, where the caesarean rate is 30%, found results at odds with this astonishingly high percentage. When 102 first-time mums were questioned on 17 birth complications, including vaginal prolapse and emergency caesarean, only two per cent said they would opt for an elective caesarean. This compares with 11% of midwives, 21% of obstetricians and 50% of urogynaecologists.

‘This research shows that women who are pregnant with their first baby are prepared to take greater risks than clinicians when deciding between a vaginal delivery or an elective caesarean section,’ says Professor Steer. ‘The study may also indicate that doctors are biased by their inevitable involvement in complex cases, or labours where things have gone wrong.’ This is backed up by another study from University of Cambridge researchers, in which two thirds of obstetricians admitted anxieties over being sued influenced their decision to opt for a surgical birth.

No option

Around 14% of the 629,207 babies born in the UK between 2006-2007 were delivered by emergency caesarean due to complications during birth.

‘For some women, a caesarean section is essential when emergency situations, such as the uterus rupturing during labour, occur,’ says midwife Laura Abbott. ‘Under these circumstances, a surgical delivery is necessary to ensure the wellbeing of both mum and baby.’ As Faith Marshall, 26, from Cornwall and mum to Jacob, seven months, knows well. ‘My labour was seemingly straight forward until I felt an agonising ripping sensation in my abdomen,’ says Faith. ‘I began bleeding heavily and was rushed into surgery with a suspected rupture in my uterus.

‘When I came round from the anaesthetic the surgeon said Jacob had been safely delivered, and my womb stitched. He was clear that neither myself nor Jacob would have survived without a caesarean. ‘It wasn’t the birth I’d wished for, but watching my baby boy grow up is far more important to me than experiencing a natural birth.’

One-to-one

So what about the remaining 10% or 66,550 procedures? Is it true that, as Louise Silverton believes, a planned caesarean is too easy to obtain? Any woman can request a c-section, though NHS guidelines say there must be good clinical or psychological reasons for it.

The majority are preplanned for medical reasons. Conditions such as placenta praevia – where the placenta lies below the baby in the uterus and literally blocks its route to the birth canal – mean that the health of mum or baby could be endangered during an attempted vaginal birth and so are genuine reasons for a section.

However, the Royal College of Midwives (RCM) believes the rate is still worryingly high – and that it could be lower if there was the time to discuss birthing choices and the risks involved with pregnant women during early labour. ‘Choice should be at the heart of care for women, including choice about how their baby is delivered, and that choice should never be denied to them,’ says Cathy Warwick, from the RCM.

The birth rate in England and Wales is rising, with over 20,000 more babies born in 2007 than 2006. This combined with a fall in the number of midwives – currently 5000 short of the RCM target – mean few midwives have the opportunity to counsel women about the options and risks before birth. ‘One-to-one care in labour is known to reduce the number of emergency sections and is recommended for all women in Maternity Matters – the Government’s blueprint for maternity services,’ says Cathy. ‘Yet, at present, this is not always available.’ Indeed, a recent study by the Healthcare Commission, the NHS watchdog in England, found that one in five women was left alone during labour.

Too posh to push

And it’s true that a small minority - at least 1.5% – of women are choosing to have social caesareans where there is no medical case for the surgery. ‘Consultant obstetricians will recommend caesarean sections as a last resort and the procedure is generally safe for mother and baby,’ says Professor Steer. ‘However, social trends over the last few years have resulted in more women requesting caesarean sections.’

Instead of being ‘too posh to push’, part of the decision to have a social caesarean may be down to age. London’s Portland hospital, where Victoria Beckham gave birth to her sons Brooklyn and Romeo, says their planned c-section rate is higher (34%) because their mothers are older (87% of their patients are over 31 years of age). As the ability of a woman’s womb to contract in labour worsens with age it becomes harder for normal labour to progress naturally.

Your choice

So where do we go from here? If you know you don’t want a c-section, it could be worth planning a home birth. ‘The one thing that has reduced the c-section rate is planning a home birth,’ says Laura. ‘A homely environment will help you relax and release all the good hormones needed to help labour progress. Fear is a huge factor when it come to interrupting the flow of labour, so one-on-one care from a midwife you trust can also ease your panic and increase your chances of a natural delivery.’

If you’re advised to have a c-section, find out exactly why so you can explore your options and make an informed choice. It’s your birth and you won’t get a second chance to do this one again. As Laura concludes, ‘What really matters is that YOU feel in control.’

Why you might need a caesarean:

Reasons for an elective c-section:

Baby in breech position.
Multiple babies
Placenta praevia
A severe case of pre-eclampsia making it dangerous to delay delivery

Reasons for emergency c-section:

Baby has an irregular heart beat
Umbilical cord prolapse
Uterine ruptures
Labour isn’t progressing

What happens during a caesarean?

- Most caesareans are done with an epidural or spinal block so you’re awake and can see baby immediately afterwards. General anaesthetic will only be used in emergencies.

- The doctor will make one cut just above your bikini line, and a second in the lower part of your uterus. Your baby is then lifted out. It will only take a few minutes. Your placenta is then removed and you’ll be stitched up. This takes about 30 minutes.

- Although baby is less likely to breastfeed in the first hours after being delivered by c-section, once she does start she is just as likely to continue as those born naturally.

- Your hospital stay may last from two to five days depending on your recovery.

The risks

Although most problems are rare, c-sections can lead to:

- Abdominal pain
- Bladder injury
- Injury to the ureter
- Needing further surgery
- Hysterectomy
- Admission to intensive care
- Developing a blood clot
- Death of the mother
- Infertility
- Problems with future pregnancies including placenta praevia, uterine rupture, or stillbirth.