Important: This is intended as general information only. It may not apply to your specific situation. It is not a substitute for medical advice. If you have a question or concern, please raise it with me at your next appointment or contact me sooner if it's urgent.
Delivery by Caesarean Section
This can be a contentious topic and you may find yourself bombarded with advice from various friends and relatives about whether you “absolutely should” or “definitely shouldn’t” have a caesarean for the delivery of your baby. Like most issues about which there is controversy, there is no absolute right answer that applies to all women and all pregnancies. The best option for you and your baby will depend on the nuances of your particular situation and may change over the course of the pregnancy or even the labour.
To start, a quick word about definitions. I have noticed that many people are confused about the terms ‘elective’ and ‘emergency’. With regards to caesareans (or for than matter, all operations) this just refers to whether the procedure has been booked ahead of time in an allocated and staffed operating theatre (elective) or performed without prior planning (emergency), in which case we usually need to arrange theatre time and staff at short notice. Many people seem to think that ‘elective’ means that the woman or her obstetrician has chosen a caesarean without a good medical indication. This is far from the case. We may do an elective (planned) caesarean for a women if she or the baby has a serious medical problem and vaginal delivery is not an option. Conversely, we may do an emergency (unplanned) caesarean for a much less serious issue if a woman who had planned to have a caesarean comes into labour before the scheduled procedure.
Reasons for caesareans in labour
Most (about 4 out of 5) women who go into labour spontaneously are able to have a vaginal delivery. These are pretty good odds. However, this means that about 1 in 5 will need to have a caesarean in labour. There are two basic reasons for this – fetal distress and obstructed labour.
We spend a lot of time thinking and talking about what labour is like for the mothers. It’s important to remember that labour is hard work for the babies as well. Most babies, especially if they are well grown and have healthy placentas, cope well with the stress of labour. Some, however, become distressed in labour. When obstetricians and midwives talk about babies becoming ‘distressed’, what we actually mean is that they are showing signs that they may not be getting enough oxygen to their brains. Obviously, this is a serious issue. If it cannot be resolved, the only sensible option is an emergency caesarean. While this may sound pretty scary, remember that the labour ward midwives and I will be watching your baby carefully during your labour. We aim to intervene in a timely fashion if your baby is showing signs of distress – we don’t wait until the situation becomes dire.
Obstructed labour occurs when the baby’s head is too large to fit through the mother’s pelvis. The uterus continues to contract and the baby’s head and the cervix become progressively more swollen. These changes are obvious on vaginal examination. There are also other signs that tell us that the labour is obstructed such as the maternal temperature and heart rate increasing, and the fetal heart rate increasing. Not much can be done about this situation other than a caesarean. It is very difficult to predict which babies will become stuck in which pelvises. Many methods have been tested over the years and none have been found to be good at predicting this situation. It’s not all about size – we’ve all seen small women have large babies vaginally without too much trouble, while some larger women will have obstructed labours with average or even small babies. However, if it looks like there is a clear mismatch between the size of you and your baby, I’ll discuss the various options with you and we’ll make a decision together about the best course of action.
Reasons for caesareans prior to labour
A caesarean may be done prior to labour for various reasons. These include placenta praevia, problems with the mother’s health, concern about the baby’s wellbeing to such a degree that we would not wish to subject him or her to the stress of labour, abnormal position of the baby, previous uterine surgery…the list goes on. Rest assured, if you find yourself in this position, you and I will have discussed the situation in great detail and I will make sure that you understand the reasons behind my recommendation.
Maternal choice caesareans
As you may be aware, a small but significant group of women chose to have elective caesareans without a clear medical indication. Contrary to popular belief, this is not usually because they are ‘too posh to push’. Their reasons are usually much more complex than this and their decision much more considered. There are pros and cons to both caesareans and vaginal deliveries and different people weigh up the risks and benefits differently. I believe that women are entitled to chose how they wish to give birth, with the proviso that they understand that all options carry risks and benefits, and that plans sometimes have to be changed at short notice to ensure the safety of all involved.
There are many arguments for and against ‘maternal choice’ caesarean sections and I don’t intend to discuss them all here. If you think you may wish to have a caesarean, please tell me and we’ll discuss it in detail over the course of the pregnancy. Generally speaking, I will respect your choice but I will expect you to be able to justify it, so that I can be sure you understand the pros and cons.
A quick word about pain. Some women request caesareans because they are worried about their ability to cope with the pain of labour. For some women, this is such a source of anxiety and distress that a caesarean is a reasonable choice. However, while a caesarean certainly hurts less than a labour and a vaginal delivery (after all, you have an anaesthetic), the recovery from a caesarean is more painful than the recovery from a vaginal delivery, so there is a bit of a trade-off. Sadly, there is no completely pain-free way to have a baby. However, if pain is a major concern for you, my opinion is that the least painful way to have a baby is a vaginal delivery with an early epidural. That way you can avoid most of the pain of the delivery and still benefit from the less painful recovery process.
The procedure itself is fairly straightforward. Most women will have a spinal or epidural anaesthetic that makes them numb from the lower chest downwards. With a few important exceptions, this is safer for the mother and the baby than a general anaesthetic and has the added bonus that you are awake to experience your baby’s first moments. This form of anaesthetic does not make you completely numb but it takes away your ability to feel pain. You can still feel movement and pressure. Like having any procedure done under local anaesthetic, you will be aware that something is happening but it is not painful. A catheter is placed in the bladder after the anaesthetic.
The incision is low on the abdomen (2cm above the pubic bone) and 10-12cm wide. It usually takes about 10 minutes to open the abdomen and deliver the baby. A screen will be put up so that you and your partner don’t have to see any of the actual operating but you can see your baby as soon as he or she is born and, after a quick check with the paediatrician, hold you baby for the rest of the operation. It takes a further 20 to 30 minutes to put you back together.
Risks of caesarean sections
All operations carry risks of minor and major complications and a caesarean is no exception. It’s important to bear in mind that a vaginal delivery also carries risks. For all operations it is important to understand the risks and that the potential benefit outweighs any risks. Childbirth (both vaginal and caesarean) has the added complication that we are considering the wellbeing of two people – the mother and the baby. In some situations, one person (usually the mother) takes the risk so that the other (usually the baby) can get the benefit.
There are three basic things that can happen in any operation: an infection can be introduced, there is the possibility of bleeding and there can be inadvertent damage to other structures around the site of the operation. These risks are small and over the years we have developed various surgical and anaesthetic techniques to minimize the risk of these complications and deal with them should they occur. The greatest risk of a caesarean, which is also the biggest risk of a vaginal delivery, is bleeding. The anesthetist and I, between us, have lots of techniques and medications that we can use to control bleeding. However, if you lost a dangerous amount of blood, we would give you a blood transfusion. If we got to the end of our list of techniques to stop bleeding and were still unable to control your bleeding, I would perform a hysterectomy. This is a last resort and is only done in the event of life threatening bleeding. It is rare that this is necessary and it should be borne in mind that it can happen after a vaginal delivery as well.
A fourth risk of any surgery, but particularly surgery in the pelvis during pregnancy, is that a deep vein thrombosis (DVT) can develop in the veins of the pelvis or legs. To make this less likely, I routinely give an injection of a blood thinning medication once a day until discharge from hospital.
Recovery from caesarean sections
There’s no doubt that the recovery from the average caesarean is worse than from the average vaginal delivery. Having said that, we are very good at controlling post operative pain and have many painkillers at our disposal that are completely safe while breastfeeding. Our aim is to keep you comfortable enough to be able to move around freely and be able to take care of your baby. Most women will be up out of bed the morning after their caesarean. You will be restricted in terms of heavy lifting for 6 weeks (the general rule is not to lift anything heavier than your baby) and you shouldn’t drive a car for 4 weeks.
You’ll have to have a caesarean next time as well
Not necessarily. After a single caesarean, many women can have a vaginal delivery (see the VBAC information page). Obviously this does depend on the reason for your caesarean and what happens in the subsequent pregnancy.
A caesarean is bad for the baby
Not true. If anything, a caesarean is probably safer as it avoids the stress of labour. However, providing the baby is healthy prior to labour and his or her health is monitored closely during labour, a vaginal delivery is usually a safe option. Some babies can only be safely delivered by caesarean.
A caesarean will make it harder to breastfeed
This is nonsense. People also say this about epidurals. Ignore them, they don’t know what they’re talking about.
A caesarean will protect your pelvic floor
Hmmn, tricky. Avoiding pelvic floor damage is one reason some women chose to have a caesarean. However, some pelvic floor damage occurs due to age and just being pregnant (regardless of mode of delivery) and a caesarean is not completely protective. Some women who have only had caesareans, and some who have never had children, still develop urinary incontinence. However, a vaginal delivery can further damage the pelvic floor so a caesarean does offer some protection, Injuries to the anal sphincter, which can affect faecal continence, are usually due to vaginal delivery (thankfully this is unusual).