In an issue that focuses on vaginal birth after caesarean (VBAC) Gina Lowdon and Debbie Chippington Derrick of Caesarean Birth/VBAC Information report on the phenomenon of maternal requests for caesarean sections.
Why bother going through the process of giving birth vaginally when you can have a planned caesarean section? Increasing numbers of women today appear to be subscribing to this view. Maternal request for delivery by caesarean section is reportedly on the increase and has been blamed, in part, for the continuing rise in the caesarean section rate.
The level of maternal request is a controversial issue. The National Sentinel Caesarean Section Audit report notes that studies report rates of maternal request ranging from 1.5% to 48%1. Much of the variation is due to unclear definitions of 'maternal request' and whether there was also a supporting clinical indication.
But the use of 'maternal request' as a reason for carrying out surgery is a non-sense, since it simply indicates who instigated the decision. Clinical indications are not, after all, lumped together under 'obstetric preference'. Until audits standardise the terminology and sub-divide 'maternal request' into the underlying reasons why women prefer to undergo surgery, serious debate of the issue will be hampered.
Regardless as to the actual level of maternal request and the methods used to quantify it, there is no denying it is very much an issue of our time. The amount of media coverage and the frequency with which 'maternal request' is cited as a barrier to the reduction of caesarean rates, demonstrate that this issue is of concern to a great many, both in the childbirth world and our society as a whole.
Since the dawn of time labour and birth through the vaginal passage have been an inevitable consequence of pregnancy, a journey through to life. There was no alternative to vaginal birth, except death.
In this new millennium, women do have an alternative, one that has been provided by the wonders of modern technology - women today have choice, something that women in ages past did not have.
Why do some women consider caesarean delivery more advantageous and more in keeping with the 21st century?
A caesarean is a modern way to have a baby, involving the use of technology. Modern technology features highly in our daily lives. We are at ease with it and find it reassuring. The latest and most up-to-date technological equipment is much prized and sought after in all areas of our lives.
A caesarean is a medical operation. Birth is currently seen as a medical event as it usually takes place in hospital. Is a caesarean operation not therefore a logical conclusion to pregnancy for women of this millennium?
A caesarean can be scheduled. Few of us can get through a day in our modern world without a watch and a diary. Our daily lives are ruled by time and by carefully planned appointments. Choosing the date of the baby's birthday has considerable appeal in this context for some women. We have become accustomed to leading our daily lives in a way that pays little heed to the natural flow of events. For example, modern technology allows us, in many respects, to disregard the divisions of night and day or the seasons of the year.
A caesarean is quick in comparison to most labours. We live in an age when the quicker something can be achieved the more advantageous it is perceived to be - whether this is making a cup of instant coffee, washing the laundry, travelling from a to b, or sending a communication. In our society time is money.
A caesarean is perceived as pain-free. The operation is carried out under anaesthetic and therefore there are no pains of labour to be endured. The "wake me up when it's all over" scenario appeals to many women.
A caesarean avoids the need for a baby to make the journey through the birth canal. Many women worry about how something as large as a baby could possibly fit through such a small opening. Some women fear the baby may be 'squashed' and damaged in the process.
A caesarean is clean. The antiseptic nature of the operating theatre is very different from the physical exertion of labour. No sweat and tears. The mess of amniotic fluid and blood is dealt with out of sight. Urine is catheterised. There are no lumps of poo emerging from the rectum, pushed out by the baby's head as it journey's down the vagina. Is this not more in keeping with our aseptic society?
A caesarean is clinical - and therein perhaps lies its biggest attraction. Planned caesarean birth avoids the necessity for the many probings of the vagina, which have become routine during what is termed 'normal' birth today. A woman can more easily maintain a degree of professionalism and detachment in her relationship with her carers since the private areas of her body are left unmolested and unsullied.
With these advantages in mind, does caesarean delivery not fit rather well with the ethos of our society in this new millennium?
The problem is, however quick, clean and convenient caesarean delivery may be considered, it also has its disadvantages - the most obvious being the post- operative recovery period. Contrary to popular perception, delivery by caesarean section is far from an 'easy' option. Caesarean mothers are never able to jump off the operating table and get straight back to normal.
The operation itself may be completely pain free but the post-operative recovery period rarely continues to be so. There is, of course, a range of painkillers to help mothers through the first few days, but even so moving around, handling the baby and going to the toilet, all present their own difficulties and have to be tackled slowly and carefully. Those diary appointments have to wait.
Caesarean mothers can also find they need to break wind more often. Post- operative wind may also cause discomfort and pain in the abdomen and elsewhere in the body - even in the shoulders - due to pockets of air being trapped.
There is also the scar; usually a horizontal cut of about 5-6 inches (12-15 cms) is made just below the pubic hairline. The upper portion of pubic hair is shaved and can often be itchy as it grows back. Not an easy area to scratch, especially with the presence of a tender scar!
In our society many of us are dependent upon our cars for transport. Insurance companies may not cover caesarean mothers for up to six weeks following the operation. Mothers may not, in any case, feel physically strong enough to control a vehicle, especially in an emergency situation.
Many household chores may be difficult or impossible for caesarean mothers for some weeks after the birth. These can include: changing duvet covers; vacuuming; lifting heavier objects (laundry baskets, toddlers); carrying something as light as a newborn baby up and down stairs; stretching up to reach high cupboards or peg out washing.
If this is not a first baby, a caesarean mother will find it difficult to pick up or cuddle her other children. here is also a longer hospital stay, commonly around five days, meaning a longer separation from her family, which can be problematic.
Some unlucky caesarean mothers suffer post-operative infections. (In UK hospitals around 20 per cent of mothers end up with totally new infections - for caesarean mothers the risk is even higher.) Depending on the type, severity and response to treatment, these can sometimes be quite distressing and can slow the recovery rate quite considerably.
And then of course there are the risks. Caesarean section is major surgery and complications can occur. Mothers die very rarely these days, but the risk of maternal death is higher with caesarean section than with vaginal birth, as is the risk of needing a hysterectomy. Scar tissue or adhesions may cause long- term pain, bowel obstruction, infertility or miscarriage and may make repeat surgery more difficult. Caesarean mothers are also at increased risk of ectopic pregnancy, placenta previa and placenta accreta in subsequent pregnancies.2
A caesarean is not without risk to the baby either. Babies are occasionally cut by the surgeon's scalpel. Babies who are born by caesarean section have a higher incidence of respiratory problems both at birth an in adult life3,4.
Perhaps a caesarean is not quite as practical a solution to the problem of bringing a baby into the world as it might at first seem. But even women who are well informed of the realities of caesarean birth maintain a preference for this form of delivery. Why have we reached the point where women are prepared to face the risks and inconveniences of major abdominal surgery in order to avoid giving birth to their own babies?
Recent decades have not given 'normal' birth a good press. Admittedly outcome statistics have improved dramatically. Mothers die in childbirth so rarely these days that maternal mortality is measured per 10,000 or even per 100,000. Babies are also expected to survive, the perinatal mortality rate is down to 8.7 per 1,000 births5. However there is much confusion over the reasons behind these low death rates with many people believing they are purely the result of advances in medical care (which has been shown not to be the case)6.
Birth is seen as a medical event. Antenatal visits, medical checks and procedures are understood by prospective parents as being necessary to the health and well-being of their unborn child. Compliance with the system is believed to guarantee a healthy baby. Non-compliance implies the mother is prepared to risk her baby's life or health. The majority of mothers, therefore, have little option but to acquiesce and accept, without argument or question, the standard care provided by our hospital maternity services.
Vaginal birth has changed. It is no longer a private time where women give birth to their babies themselves, supported and cared for by a few known, trusted, and accepted attendants in a familiar atmosphere.
What is happening is that the advantages of delivery by caesarean section are being measured against the disadvantages of what vaginal birth has become in today's modern environment. The reasons women are opting for caesareans have more to do with the unacceptability of what happens during what passes as 'normal' labour and birth, than the appeal of major surgery. The realities of what women experience in our labour wards today is hardly inspiring.
Vaginal birth today usually takes place in unfamiliar, medicalised surroundings, which are at odds with the private and intimate nature of the birth process. Most women no longer feel safe without all the 'just-in-case' technology, but neither are many able to feel relaxed and comfortable in its presence.
Vaginal birth today usually takes place in front of strangers. Trying to form a formal, business-like relationship with a professional whilst semi-naked and trying to go with the flow of a primal natural process can be difficult, embarrassing and demeaning (and is sometimes a downright impossibility).
Vaginal birth today involves the need to make frequent, intellectual decisions and give consent for procedures under the least conducive of circumstances.
Vaginal birth today involves technology, but its use can be frightening in this context. The purpose of the technology used and the procedures associated with it are often poorly understood, sometimes unexpected, and are frequently associated with unpleasant or painful sensations and invasion of privacy, often by strangers.
Vaginal birth today is portrayed as being dangerous for the baby. Women sometimes have difficulty in believing that an experience that can be so awful for them, can be any better for their baby. The emphasis on electronic fetal monitoring adds substantially to the impression that the baby is in great danger.
Vaginal birth is generally painful. Fear and tension change hormonal states, physically increasing levels of pain, often to a point where women can no longer cope without analgesics.
Vaginal birth today involves an invasion of privacy that would be totally unacceptable in any other setting. Vaginal examinations are commonplace, frequent and may be carried out by different people, none of whom may be known to the woman and some of whom may not even introduce themselves.
Vaginal birth today carries a risk of episiotomy. The idea of someone taking a knife or scissors to any area of the body, especially the vagina, is a terrifying prospect for any woman.
Vaginal birth can be messy. It is usually hard work and women often perspire heavily. There are other body fluids involved too - the amniotic fluid, urine and blood - and there is the placenta (afterbirth).
Vaginal birth can take a long time and can sometimes be quite boring. Women are likely to find themselves immobilised on a narrow bed, strapped up to various machines, possibly numb from the waist down, with nothing to occupy the mind between the often difficult intellectual 'choices' that must be made - except of course the monitors and a sleepy, bored partner who hasn't even managed to locate a comfortable chair.
No, what passes for 'normal' vaginal birth as it is commonly experienced in our hospitals today is certainly not most people's idea of an uplifting experience! The disadvantages of major surgery begin to look less off-putting and after all, the operation has become so much safer these days that the risks are relatively small and can therefore easily be dismissed.
Despite all this, the vast majority of women would still prefer to have a normal, straightforward vaginal birth. However, the sad fact is the majority of modern mothers look back on their birthing experience negatively. Vaginal birth today is no longer the natural process that has served the human race so well for millennia. Measures and treatments that were devised to help the small minority of mothers and babies who needed assistance are now being applied to the vast majority. Recent studies have shown that fewer than 10% of women have a 'completely natural birth'7,8.
So what are the advantages and practicalities that leave mothers who have had positive experiences of vaginal birth wondering why on earth anyone would prefer an operative delivery?
Normal, straightforward, intervention-free, healthy, natural birth is still the safest, most practical and advantageous way for a baby to be born.
Babies born vaginally have a lower risk of respiratory problems. It is widely accepted that the contractions of labour help prepare the baby's lungs to breathe air. Babies born by caesarean section have a higher risk of respiratory distress syndrome than babies born vaginally at the same gestational age.3 Adults with asthma are more likely to have been delivered by caesarean section compared with adults without asthma.4
It is also widely acknowledged that the baby plays a part in deciding when the time is right to be born. It has been commented that babies born by elective caesarean section can show signs of being angry and do not appreciate being delivered before they are ready.
The passage down the birth canal also gives a baby a wonderful all-over massage that wakes up various systems in the body - cranial osteopaths claim to be able to detect whether a baby was born vaginally or by caesarean.
Mothers who feel safe, confident and well supported rarely find the level of pain reaches the point where it becomes unbearable. Their hormonal state supports the process rather than fighting against it. Labour is not perceived as being a trial, the pain is more like that experienced by athletes when they are giving their all and trying their hardest. Labour and birth are often the hardest physical work a modern woman ever has to do, but can also be the most rewarding.
A mother who has experienced a natural birth can generally walk unaided after the birth and can begin caring for her baby straightaway.
A mother who has experienced a natural birth is usually able to become involved in family life within hours of the birth and can get back to normal daily life within just a few days. Diary appointments can generally be attended, albeit with a baby present!
Mothers who have experienced natural birth are often able to drive very soon after the birth. It has been known for mothers to drive the same day of the birth and most feel fully confident after just a couple of days.
When the birth has gone well, the baby is often peaceful, quiet and relaxed.
When the birth has gone well mothers feel stronger, both physically and emotionally. There is a wonderful sense of achievement and peace, of strength and control, of health and completeness, of being able to cope and get on with life in general. It is a very positive life-changing experience.
That women are prepared to opt for major surgery in preference to undergoing labour and birth in our hospitals is an indictment of the maternity services. Normal, healthy women carrying healthy, term babies no longer feel safe and confident about giving birth under the current model of care. Until such time when true midwifery can come to the fore and women are given the emotional support that they need, then it is likely that numbers of women needing to opt out by requesting surgery will continue to rise.
In this 21st century there are two routes of birth, one is abdominally via caesarean section and the other is vaginally through the birth canal. As long as vaginal birth remains an unacceptable option women will continue to need the only other possibility available to them.
There are many very good reasons for having a caesarean section and with a little forethought and planning the operation can indeed be a wonderful experience. There is also no denying that a positive caesarean section is infinitely preferable to a traumatic vaginal delivery.
But what too many have lost sight of, is that even the best caesarean can never hold a candle to a good experience of giving birth to your baby yourself.
Gina Lowdon and Debbie Chippington Derrick
First published in the AIMS Journal, Vol 14, No 1, 2002