Navigating C-sections by (maternal) request
Barring any complications, a natural birth is the ideal mode of delivery for mother and baby
For many first-time mothers, pregnancy is an exciting time, with promises of tiny onesies, beautiful safari-themed nurseries and, of course, the birth of their first-born child.
That last birth part, however, can be tricky. Barring any medical or obstetrical contraindications, a vaginal birth is the ideal mode of delivery for both the mother and her newborn. Some women, however, envision a vaginal delivery to be a painful, traumatic, and a possibly inelegant process they would rather avoid.
A planned Caesarean section (C-section) may seem like the more controlled way to welcome their baby into the world. These C-sections, performed without any medical or surgical reasons, are referred to as a Caesarean delivery on maternal request (CDMR).
Physicians facing a CDMR request must navigate the delicate balance between empowering women to advocate for their health and “doing no harm,” one of the core ethical principles rooted in our Hippocratic oath.
So challenging are these discussions that the Society of Obstetricians and Gynaecologists (SOGC) recently published guidelines to help clinicians navigate these layered conversations.
There is surprisingly little data on the number of CDMRs performed yearly, but what is wellestablished is that the overall rate of C-sections in Canada is on the rise, now at a staggering 28 per cent. The majority of these surgeries are obstetrically necessary, with the benefits to the mother and baby’s health far outweighing the surgical risks of infection, bleeding, bowel or bladder injury, or blood clots in the lungs.
If you asked women recovering from their first C-section, most will not have suffered any of these complications. What these women might have experienced, however, is a delay in starting skin-to-skin contact with their newborn, a lengthy hospital stay, and a painful surgical recovery requiring prescription pain medications and lasting for up to six weeks postpartum.
While women who are still pregnant with their first child may not be prepared to think of their potential next pregnancies, maternity care providers are considering it — primarily because the impact of one C-section on subsequent deliveries is so significant.
Most women will expect a surgical scar to form on their skin, but they might not be aware that the same scar tissue can form around their major abdominal organs. This increases the rates of all the surgical risks mentioned earlier in future C-sections.
Some women may also not recognize that, like the wound on their skin, the opening that was made in their uterus to deliver the baby must also heal after surgery. Rarely, that scar on the uterus has trouble withstanding the pressure of another pregnancy and may break down during the next delivery. This is an obstetrical emergency called a “uterine rupture,” which can be very dangerous for the health of both the baby and her mother.
In pregnancies that follow a C-section, the placenta (the organ that allows your baby to grow) may attach in an unhealthy manner to the uterus, and may invade through the previous C-section scar and the uterus into the bladder and the bowels.
This condition, called an “invasive placenta” is directly related to the number of C-sections a woman has experienced and increases a woman’s risk of premature labour, bleeding, and the permanent removal of her uterus (a hysterectomy) during her delivery.
With all this in mind, you can see why it’s uncomfortable for maternity care providers to recommend CDMRs. What we must do, however, is explore deeply and repeatedly the worries and experiences that have led a woman to request a CDMR in the first place.
Some may fear pain, and reviewing the spectrum of available pain management options in labour may alleviate these anxieties.
Others may worry about developing a “leaky bladder” after a vaginal delivery; reviewing that a C-section is only protective against urinary incontinence after a woman’s first delivery, but that the protective benefit is lost, irrespective of which way a woman delivers, after her second baby, may be important.
Some women may point out that any woman attempting a vaginal delivery may ultimately be recommended a C-section, and that planned C-sections are far safer than those performed in an urgent manner. We would have to agree and reassure them that protocols are in place in every obstetrical hospital to ensure that both planned and unplanned vaginal and Caesarean deliveries are held to the highest standards of obstetrical care.
Finally, some women may listen to all our concerns about CDMRs, but may, after all, still request this as their mode of delivery.
To these women, we promise to respect your decision.
After all, our only goal is to get you and your healthy, onesie-clad baby home to your beautiful safari-themed nursery as safely and happily as possible.