Since 1985 the World Health Organisation (WHO) has considered that the ideal caesarean rate should be 10 to 15%. I’ll stir the pot immediately by saying that I think that’s probably crap. This figure is based mainly on a demonstrable effect of caesareans on maternal and neonatal mortality. In other words, if you do less
than that percentage, then more babies and mothers die. If you do more, then probably no less babies or mothers die. I agree with that.
The WHO says in their statement (link HERE) regarding caesarean section rates that “there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure”. What does that even mean? Who gets to decide whether the procedure is required or not – the woman?, her carer?, the W.H.O.? Most of the time caesareans are not required just to save life but.....
There are plenty of live women locked up in mud huts in sub Saharan Africa that leak urine and faeces from their vaginas via fistulas.
There are plenty of live women in Australia who have had babies dragged out their vaginas with forceps by well-meaning obstetricians who had one or both feet on the end of the bed. Some of those women have significant issues with incontinence and prolapse.
There are many live babies who will never reach their full intellectual potential due to oxygen deprivation during labour.
And yet the WHO states that “The effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being are still unclear.” I can’t say from a population basis that this is not the case but speaking from a personal viewpoint, I have seen many cases where caesarean sections should have been performed to prevent serious harm to the mother and the baby.
Commonly listed serious harms to the mother with caesarean section are things such as maternal transfusion, ruptured uterus, unplanned hysterectomy and admission to ICU. These serious harms, with the exception of maternal transfusion, are rare. Even maternal transfusions are uncommon. Less serious but far more common harms to the mother occur on labour wards every single day. The problem is that the subsequent effects of those harms are often not seen until sometimes decades later and are then sometimes trivialised by comments such as “that’s just part of having babies”.
2001. First year of obstetrics training. Called to delivery ward to do some stitching after a “normal” vaginal delivery. With the woman in stirrups and a truckload of local anaesthetic injected I attempted to put things right. I gave up after about 15 minutes and called for reinforcement. The consultant for the day duly arrived and patiently talked me through the repair which took a long time. We debriefed outside and his first comment was that where he did his training that was referred to as a “London bus”. My confused expression led him to explain that this meant that the patients nether regions looked like a London bus had driven through them.
Yes, even with a “normal” vaginal delivery – perineal trauma can be severe. Damage can occur to the connective tissue (ligaments/tendons), the pelvic floor muscles, the anal sphincter (the muscle around your anus) and to the nerves that supply those muscles. When you consider the phenomenon of a rockmelon passing through the confined space of a tube (the vagina) which on average measures between 2.5 and 3.5 centimetres in width – it’s amazing that more damage does not occur.
Initially, most women (particularly first timers) won’t feel quite right “down there” for a period of weeks. Slowly but surely though, in the majority of women, the stretching and tearing that occurs during a vaginal delivery repairs itself. It will take longer if an episiotomy cut has been made. It will take longer if there are significant tears to the deeper muscles. In reality things will never feel quite the same in that area of your body once a baby has come out of it.
So what are the major problems that can result from a vaginal delivery?
Urinary incontinence –The involuntary loss of urine. The risk of this is increased with being older at the time of your delivery, having more children, being obese, having bladder problems BEFORE childbirth (yes, some women have NEVER been able to jump on a trampoline with confidence). Pelvic floor exercise both before and after decrease the risk of incontinence. It is likely that having a caesarean section has some protective effect on the development of stress incontinence – until you’re about 50. Then the protective effect is largely lost.
Faecal incontinence – The involuntary loss of faeces. The risk of this is increased with damage to the anal sphincter (the muscle around your anus), having your first baby, some types of episiotomy, and assisted delivery (worse with forceps than Ventouse – that’s the suction cup). The risk is likely not related to the size of the baby or having an epidural. Some faecal incontinence is related to damage to the nerves supplying the anal sphincter and the muscles of the pelvic floor rather than damage to the muscles themselves. Research results are mixed but on average a caesarean likely doesn’t protect you from all causes of faecal incontinence.
Uterovaginal prolapse – The loss of support of the uterus and/or vagina leading to a bulging or sagging of the uterus or the vagina. There is no doubt that prolapse is caused by childbirth. One look at the graph below clearly shows that the more vaginal deliveries that a woman has, the greater the risk that she will develop a vaginal prolapse. However, a caesarean section will not necessarily be 100% protective for preventing development of prolapse in a given woman.
I can hear your brains tick, tick, ticking. You’re thinking “So he started this whole blog saying that the WHO is wrong about how many caesareans are being done. He’s told the story about a patient he once looked after whose perineum after childbirth looked like, and had the structural integrity of Swiss cheese and he’s then stated that there may be some protective effect of caesareans on at least prolapse development. He’s now going to go on and tell us how marvellous caesareans are and that more should be done.”
Well you’re right, sort of, but I’m not going to say that more caesareans should be done. And I’ll tell you why…
1. Caesareans can be bad for Mums
Your chances of dying from a caesarean birth are about double that of from a vaginal delivery – I’ve not seen a woman die from childbirth of any kind – it’s rare in developed countries. But it is still twice that very small risk.
Your morbidity is increased - longer recovery time and longer hospital stays, operative complications, cardiac arrest, wound haematoma (clots in the wound), infection, anaesthetic complications, pelvic scarring, venous thromboembolism, haemorrhage requiring hysterectomy, impaired mother-baby bonding, decreased breastfeeding success, loss of “experience of birth”
Problems with future pregnancies - unexplained stillbirth, placental abnormalities (where the placenta grows into the muscle of the uterus or over the cervix), uterine rupture, possibility of caesarean scar ectopic pregnancy
2. Caesareans can be bad for babies
While there is probably a decreased risk of late pregnancy stillbirths and some neurological injuries at birth, there is an increase in the risk of fetal lacerations (cuts on the baby from the scalpel), increased transfers to neonatal ICU (mainly from problems related to difficulty in breathing) and increased problems with breastfeeding
3. Caesareans are bad for the economy
Sounds like a lame reason to not do more caesareans BUT caesareans are EXPENSIVE compared to normal deliveries. Increasing the number of caesareans would stretch the limited health dollar even further. The waiting times for other elective surgery would be even longer. More staff, more operating theatres, more of everything would be needed.
4. MOST women don’t have major problems after a vaginal delivery.
It is really important to remember that most women deliver vaginally and do NOT have severe pelvic floor injuries. In the course of a woman’s lifetime……..
30% develop urinary incontinence - 70% DON’T
11% develop faecal incontinence - 89% DON’T
11% have surgery for symptomatic
prolapse - 89% DON’T
Can we prevent these problems without resorting to extricating all babies via the sunroof?
To some extent – YES!
Have babies at a younger age
Perform pelvic floor exercises – both before AND after the baby arriving
Avoid assisted delivery and if you can’t avoid it then use…..
Ventouse rather than forceps
Try to avoid episiotomy
The real difficulty is trying to figure out which are the women who would truly benefit from a caesarean before labour even starts. Unfortunately, none of us currently have a crystal ball which will tell us that. There are research centres around the world trying to work out those women who are at very high risk of operative delivery (caesarean, forceps or Ventouse) during labour and offering them an elective caesarean section. Hopefully we will then less commonly find ourselves in the situation where in order to safely deliver the baby and reduce harm to the mother that we are forced to use techniques (e.g. forceps) that we know may increase that woman’s chances of having problems down the track with bladder or prolapse issues.
Some people might say – well, why don’t you just do a caesarean in that situation? Well, if the head is way, way, way down in the pelvis then you’re going to cause far more harm to both the mother and the baby if you try and drag that baby back up and out through a cut in the abdomen than by skilfully delivering it through the vagina with a Ventouse or forceps. I use forceps sometimes. I prefer to use the Ventouse. It’s all about what is the most appropriate tool in a given situation. Sometimes the most appropriate tool is a caesarean section, even at fully dilated.
Many groups have got on the bandwagon recently about reducing the caesarean section rate. They beat their drums about how more forceps should be done to reduce that rate. All the while there is more and more evidence being produced that forceps themselves are a major cause of trauma in obstetrics.
In each and every situation that I'm confronted with at the pointy end of a pregnancy I try to determine what the best action (or sometimes inaction) is to get the most benefit for both the mother and the baby. Some of you will look back on your labour and remember pleading with me to help you. You wanted me to pull that baby out because enough is enough! You will remember standing or sitting at the end of the bed and encouraged you to keep pushing, that you’re doing really well and to keep going and you can do this yourself. Hopefully now after reading all of this you’ll know why I wanted you to do it under your own steam and without the assistance of obstetrical hardware. But then again you may still think I was being a lazy prat with sadistic tendencies.
The issues surrounding how babies are born are far more complex than a basic question of should they come out your tummy or your vagina. Each and every woman’s decision about how they wish to deliver their baby is personal. Most women want a vaginal delivery and are happy when they can achieve that. Some women want a cesarean delivery and are happy when they can achieve that. Everyone wants a live and relatively undamaged baby and mother at the end of the process and most achieve that regardless of which way the baby comes out.
When writing something like this I can’t help but think about my daughter Sophie’s birth. It was my wife’s third delivery. I have two stepsons. The labor was fast and furious – three hours from when things really got going to when Sophie arrived. During that time, I was amazed at the strength of my wife. I remember the moment that Sophie arrived and then the afterglow of her lying on my wife’s chest was something I’ll never forget. Is the loss of that interaction – between three individuals – at a caesarean, a bad thing? In this day and age, the clinical sterility of the cesarean is reduced in comparison to former days. Mothers get skin to skin contact almost immediately in the majority of cases. They are often enjoying their first breast feed in the recovery room. But are we missing something vital from that messy, smelly, almost primeval process that we call the normal vaginal birth. Maybe? Probably? However, as I say to a lot of my pregnant patients – you need to keep your eye on the prize - a live and relatively undamaged baby and mother at the end of the process is the aim. Also, regardless of which way your baby comes out – it’s the next 18 years that you put in which determines how well you did as a parent, not that one day in a lifetime that was your baby’s birthday.
So Dr Warren – should I have an elective caesarean section??
I’ve had three previous cesareans - YES
I’ve had 4 previous normal vaginal deliveries and I want to protect my pelvic floor - NO
I’m having my first baby with an estimated fetal weight of 4500g who’s head is not engaged at full term and all my female relatives have terrible pelvic floors and I’m overweight - probably YES
I’m having my first baby with an estimated fetal weight of 3000g who’s head is well engaged at full term and all my female relatives have great pelvic floors after their multiple vaginal deliveries and I’m slim - Probably NO
Am I a fence sitter - ABSOLUTELY YES!
Addendum – If only we were all produced like movies set in the future like “The Matrix” - it would make things so much simpler.