For most, a caesarean is not the easier option
Some people may argue that having a C-section is the easiest and safest option for both mum and baby. But Dr Philip Banfield, consultant obstetrician at Ysbyty Glan Clwyd, Denbighshire, explains why this is not necessarily the case
ALYS’ mum presented with reduced baby movements nearly two months prematurely.
It was a cold winter’s night and I was called from a Christmas dinner at Ruthin Castle to review her baby’s heart rate tracing.
The changes were subtle but clear: “I think the placenta is separating and that you’re bleeding behind it”.
This was confirmed when I performed the caesarean section and a tiny Alys was born so horribly anaemic that she needed a blood transfusion.
Alys is bigger now, indeed she is 21 and just going into her fourth year at university.
Caesarean section, also known as caesarean, C-section or just “section”, involves delivering a baby through a cut (incision) in a mother’s abdomen.
This is major surgery, with the risks including pain, bleeding and risks of damage to internal organs that may get in the way.
Having a planned elective caesarean is usually less risky than an emergency situation which may need more urgency for mother and baby.
An elective procedure often feels more controlled and calmer than an emergency.
Overall, we all expect caesarean section to be safe. We undertake a series of safety checks before, during and after surgery.
Antacids are given prior to make stomach contents less damaging should they make an appearance, antibiotics aim to reduce infection and blood thinning injections help prevent deep blood clots, particularly in a population getting heavier.
Making decisions and choices can be difficult – a woman’s capacity to consent may be affected, for example, by labour pains or strong painkillers.
Most women remain awake if possible, with local anaesthetic injected into the back (spinal or epidural anaesthesia).
This carries fewer risks to the mother than a general anaesthetic and means a partner can be in theatre too.
Sometimes there is really no choice because vaginal delivery is impossible.
The risks to mother or baby are too great.
Often though, it is a balance of pros and cons e.g. how easy or difficult it might be to start someone off in labour (induce them), how near the end of pregnancy a woman may be (the nearer to natural labour, the more likely induction will work) and the degree of urgency (is there a need to deliver driven by the mother’s or baby’s well-being?).
This offers choice. What is important to one woman may be different to the next.
Womens’ choice was campaigned for vigorously in the 1990s in the expectation that this would counter a perceived over-medicalisation of childbirth and rising caesarean section rates.
In general, caesarean section has increased risks for the mother versus a perceived decreased risk for the baby.
This is not always so. We try desperately hard not to perform elective caesarean sections under 39 weeks because of more respiratory problems seen in these babies.
Giving mums two injections of steroid if the caesarean is planned under 39 weeks halves, but does not eliminate this risk, although the vast majority of babies will be fine, and the odd one is very unwell so there really has to be a good reason to deliver earlier.
If a woman needing assistance is fully dilated (10cm) it is often possible to avoid caesarean section.
Using forceps or the vacuum cup to achieve a vaginal delivery are generally safe in skilled hands.
It all adds up to having thought about these possibilities and discussed them before birth. If you have questions, ask.
More than two-thirds of women undergoing their first caesarean section could achieve a vaginal delivery safely next time in the absence of ongoing or repeat complications.
Obstetricians worry about rupture of the scar on the womb, but this is rarer than previously thought (less than 1:200) when labour starts naturally.
Importantly, this figure is about the same after two caesareans – the phrase “once a caesarean always a caesarean” is no longer widely practised in the UK.
In general, the more caesarean sections you have, the higher the risks of complications.
Having a number of caesarean sections may be stacking up problems for the future.
We are seeing an increase in the chance of the afterbirth (placenta) sitting too low in the womb for the woman to deliver vaginally, with some invading into the muscle of the womb itself, risking major bleeding.
Both these uncommon events are more common the more c-sections someone has.
Being prepared is key, being unprepared is a huge worry to all.
A couple of weeks ago, I watched the next woman on my routine caesarean section list edge nervously down the corridor to the obstetric theatre.
I stopped her to say “hello” as I had been busy on labour ward. She looked petrified and it was clear that the prospect of what was about to happen was terrifying to her.
I hadn’t seen such fear since cajoling my then teenage daughter onto the Harry Potter Dragon Challenge rollercoaster at Universal several years previously.
We sat down outside theatre and chatted about her previous delivery and how this would be different.
One step at a time and very much taking things very slowly, we helped her with her panic, each member of the large multidisciplinary team assembled buying into the understanding that here was a woman with particular needs.
I have no doubt that an uneventful normal vaginal delivery is better for both mother and baby compared to an uncomplicated caesarean section – for this and subsequent pregnancies.
The recovery in the former is usually much quicker, the ability to care and bond with one’s baby more often easier.
For most, caesarean section is not the easier option.