The Great Debate - Vaginal Versus Caesarean Birth
There are many different options and many different paths that a woman can choose, and these decisions can be overwhelming – private versus public hospital, the option of home birth, whether to use a doula, and perhaps most importantly, whether to attempt a vaginal birth or to opt for an elective Caesarean.
We have to stop shaming women for the birth choices that they make, whatever they may be, and start accepting that the most important thing is for women to feel relaxed and confident in the choice they have ended up making. Women deserve to feel empowered and to never, ever look back and say ‘I wish I had known this before my delivery’ or ‘Why didn’t anyone warn me that this was a possible outcome?’ In this day and age, women are slowly but surely fighting for their rights in a variety of other aspects of their lives, all the while attempting to stamp out any cattiness and guilt from other women (especially in the new realm of online information sharing). We need to ensure that this follows into our birthing practices as well, and that we do not let what happens during childbirth, on this single day in our lives (give or take a few days…), feel like it will define who we are as a mother or a woman into the future. We need to accept that, of course, everyone only wants the best for their unborn children.
Some women prefer the thought of giving birth in a hospital, perhaps feeling safer in a medical environment. They might find the knowledge that they will be surrounded by health professionals who do this every day helps to calm any anxiety and take the burden of choice out of their hands. If something were to go wrong, and they needed the next level of medical intervention, they are already in the right place without needing an ambulance trip to get there. Some women may appreciate being able to stay away from home (and toddlers…) and be looked after in hospital for a number of days after the baby is born.
Other women find the thought of giving birth in such sterile, medical surroundings completely unnatural and a source of anxiety and discomfort in itself. They might prefer the thought of birthing their baby in their own home, surrounded by only a few trusted people that they have already built a relationship with, and then to be able to stay at home with their new baby even from that first day.
A midwife friend of mine made a comment recently, which I think hit the nail on the head. For all women, being comfortable in their surroundings and trusting the people that they are birthing with, means that they feel they can ‘let go’ enough to deliver the baby. Anxiety and feeling uneasy about one’s surroundings can only act to make you ‘hold on’ and would not be helpful to the process at all, especially in the situation of a vaginal birth.
Some women will prefer the ‘less is best’ approach to knowledge surrounding childbirth, and will avoid reading too much information in the lead up to their due date and instead putting the trust in the birth professionals that they have chosen to make the right decision for them on the day. This is a valid approach – after all, these health professionals help women to birth every day, and sometimes all of this research and information can just act to increase anxiety. If you honestly feel that you would rather not hear the pros and cons of different birthing options that’s fine – just choose not to read on. But please be aware that those of us who work with women in the postnatal period do often hear women lamenting the fact that they didn’t arm themselves with the knowledge they needed to ask the right questions and make informed decisions throughout the birth process.
Then some women go down the complete opposite path, and have a very definite idea about what they want out of their birth experience. These women want to birth in a very exact way (usually as naturally as possible) with a very strict birth plan. This is fair enough too – you have the right to birth your baby as you would like to. However, a word of warning - all of us working in obstetrics have met women who feel a sense of failure because their birth plan has not gone as expected. Childbirth is one of those rare times in our lives where so much of what happens is out of our control, and although there is nothing wrong with a birth plan, for these women I would highly recommend discussing with a trusted birthing professional all of the potential outcomes, not just your ideal one. This is to make sure in advance that you are emotionally prepared for the fact that one of your less desirable birth outcomes might be the only way to deliver your baby safely into this world, and there is nothing about that scenario which indicates failure.
I advise that women should all try and sit somewhere between these two extremes – you need enough knowledge to be able to question your health professionals about the evidence behind certain accepted birthing practices, you need reassurance about how certain unfavourable scenarios are going to be avoided, and you need to be aware of the facts regarding the short and long term outcomes that could affect you and your baby depending on how the birth ends up progressing.
So, if you would like to be as informed as possible, here is a summary from the available literature on the possible positives, negatives and considerations associated with vaginal birth versus Caesarean delivery on maternal request.
First of all, a definition – a ‘Caesarean Delivery on Maternal Request’ (or ‘On Demand’) is an elective Caesarean delivery performed because the mother requests this mode of delivery, even though there are no traditional medical reasons to avoid vaginal birth. The rate of this type of birth ranges from a crude estimate of up to 18% of all Caesarean deliveries in the US and is possibly correlated to increasing affluence. Surveys of some obstetricians, urogynaecologists and colorectal surgeons have reported a preference for this type of Caesarean section for themselves or their family members.
So let’s discuss the reasons why some women choose this option. Why would someone choose major abdominal surgery over something that their body is designed to do?
There are a number of reasons that women make this choice, not least of which is the convenience of a scheduled delivery, and the ability for busy women (potentially with little family or community support) to fit childbirth in around work, childcare, and the want to have a certain doctor present to deliver the baby.
Also, we need to consider that for some women, the fear of vaginal childbirth, and the perceived lack of control associated with this, is very real and can be crippling (of course, for some women the fear of a Caesarean delivery and/or hospitals may be just as crippling). This fear may be of pain, or fear of complications from labour and vaginal birth, such as the higher risk of early postpartum haemorrhage after a vaginal birth rather than a planned Caesarean. This fear may be to do with a previous obstetric experience – never underestimate the trauma that a prior birth experience can have on a woman. Post-traumatic stress and postnatal depression are real (and not uncommon) consequences of some birth experiences. This may be able to be overcome with finding the right support people and vaginal birthing situation, but it may be another valid reason for a woman to consider birthing via Caesarean delivery, which they may feel gives them an increased sense of being in control.
There may also be concerns about harm to the baby from labour and vaginal birth, such as stretching injury to the nerves of their arm and neck causing damage and long term disability (brachial plexus injury), trauma to the baby’s bones, lack of oxygen during birth due to umbilical cord compression or placental rupture. All very uncommon, but possible, and therefore worth discussing with a health professional.
Another common fear with vaginal birth is to do with the need and risk for intervention during delivery – forceps, vacuum delivery and emergency Caesarean are not uncommon sequelae of an attempted ‘natural' birth, and women should be counseled on these possible outcomes and what will be done to avoid them. An emergency Caesarean is often described as a traumatic experience and, as mentioned previously, can be associated with postnatal depression and post-traumatic stress. Some women may feel that there is less risk of unknown scenarios with an elective Caesarean delivery.
Fear and concerns can also exist around pelvic floor muscle injury, and subsequently developing anal and/or urinary incontinence and vaginal prolapse. I must add here that for those of us who spend our whole careers working with women with pelvic floor muscle dysfunction in the short and long term after childbirth, the high rate and potentially distressing nature of these issues is something that we can’t ignore! Many other health professionals working in obstetrics don’t necessarily see the longer-term issues that some women are left with after childbirth injuries, and the reality is that pelvic floor muscle dysfunction, especially if a woman is expected to be caring for one or more young children, can be quite debilitating.
Most evidence points towards an increase risk of pelvic floor muscle dysfunction after a vaginal birth versus a Caesarean delivery, with a recent good quality trial showing approximately a 70% increase in bladder and bowel incontinence in the short to medium term. There has been some startling research done recently by Professor Peter Dietz and his team on pelvic floor muscle trauma – they found that approximately 20% of women have part of their pelvic floor muscle tear away from the bone (‘levator avulsion’) during a first vaginal birth, and that this number raises to 50% of women having a first vaginal birth over age 40. Having part of this very important muscle permanently detached from the bone of course means that vaginal prolapse and bladder and bowel incontinence would be much more likely. It is amazing how much some bodies can compensate with exercise and practice, but the research has found that it is often not until menopausal age (when decreasing oestrogen can negatively affect the health of the vaginal and surrounding tissues) that small issues with bladder and bowel control, or vaginal prolapse, become significant problems.
There are factors that put you more at risk of pelvic floor muscle damage (not just tearing but also stretching and nerve damage), including giving birth to a baby heavier than 4kg, having a ‘pushing stage’ longer than 90 minutes, having a large perineal tear (3rd or 4th degree, where the tearing extends to the anus, are the most at risk, with a reported rate of 39% of these women suffering from faecal incontinence in the short or long term) or the use of forceps. Forceps use in childbirth is a very hot topic right now! There are some important people in obstetrics in Australia who are advocating that women should view the use of forceps during delivery as assault– it is definitely the factor that has been most highly correlated with levator avulsion, and the only one of those risk factors that is avoidable. Other modifiable factors that have been proven to reduce the rate of pelvic floor muscle trauma include the avoidance of giving birth lying on your back (sidelying or more upright positions are likely to have better outcomes), avoiding ‘coached pushing’ (and instead letting a woman’s body push naturally), perineal massage and stretching in the weeks leading up to delivery and the use of a warm compress on the perineum during the pushing stage of labour. Perhaps some topics that would warrant further discussion in advance with your obstetrician or midwife…?
To flip the coin on pelvic floor muscle dysfunction, however, there are some studies that are inconclusive that after the first few years postpartum there is any significant difference in the rate of bladder or bowel incontinence between women who birth by vaginal delivery or Caesarean delivery, and some authors suggest that it is much more to do with being pregnant one or more times, rather than the mode of delivery. And we can’t go past the fact that, even bigger than these obstetric risk factors, obesity is actually the main cause of pelvic floor muscle dysfunction and something that is definitely modifiable. In summary, an argument could be made that if you undergo correct pelvic floor muscle training before, during and after childbirth, avoid forceps use, get any pelvic floor muscle dysfunction diagnosed and managed early, and control other modifiable risk factors like obesity, maybe pelvic floor muscle dysfunction is avoidable and manageable.
An elective Caesarean means that you can give birth on or before your due date, meaning that there is not risk of going over term. Some women will prefer this, and may wish to discuss with their health professional the fact that post-term deliveries are associated with larger birth weights and higher rates of morbidity and mortality during childbirth. Remember though, that these rates are still very low in developed, first world countries, and there is conjecture in the literature as to whether or not delivering a baby by it’s due date is a good practice or not. Also important to note is that for many women the due date is an estimate, not an exact science, plus the fact that an induction of labour leading to a vaginal birth is another possible scenario to avoiding a baby going past their due date.
Lastly, we can’t look past the factor of a baby dying during childbirth, even though this is such a low risk scenario in first world countries. There are some doctors and pregnant women who choose an elective Caesarean to avoid a late stillbirth. The literature suggests 1 in 500 to 1 in 1750 foetuses reach maturity in utero and then something goes wrong during labour leading to near death or disability, and 1 in 5000 die. Good quality evidence shows that one stillbirth would be prevented per approximately 1200 elective Caesareans at 39 weeks of gestation.
Let’s look at the other side of the situation now - what things could go wrong during a planned Caesarean delivery? Why might it be best for a woman to at least try to have a vaginal birth?
A big factor that needs to be taken into consideration is the increased risk of abnormal placental attachment (issues such as placenta previa and placenta accreta) in future pregnancies. These placental problems can lead to miscarriage and stillbirth, and the risk of one of these occurring increases with the number of Caesarean deliveries that a woman has had. This is why it is absolutely necessary to counsel a woman who is considering an elective Caesarean delivery for the birth of her first child that this choice would not be recommended if she is planning to have more than two children in the future.
Of course, there are always risks with major abdominal surgery, and let’s not kid ourselves, although Caesarean deliveries are very common, they are still major abdominal surgery. Associated with this is an increased risk of anaesthetic complications, cardiac arrest, organ injury, wound infection, DVT (deep vein thrombosis) and intra-abdominal adhesions (adhesions can cause bowel and bladder pain and/or obstruction in the future). The likelihood of these events, however, was very low in all studies done in first world countries (1.6 per 1000 births), and was much less likely with a planned Caesarean rather than an emergency one.
There is also an increased risk of uterine rupture in future pregnancies if there is already a scar in the uterus from a previous Caesarean Section. It is important to note that although this is very serious (life threatening in fact) and needs to be considered, it is very uncommon, and almost always related to a trial of vaginal birth after a caesarean (VBAC), rather than during a subsequent elective Caesarean delivery.
Another reason that women may want to avoid a Caesarean delivery if possible is the likelihood of a longer recovery period. The likely pain and relative immobility after major abdominal surgery could interfere with early mother-baby bonding. Women and their families also need to consider the amount of physical help and support they have available to them at home, not just after the first delivery, but also after subsequent Caesarean deliveries when there also may be a toddler or two to look after during this recovery period. However, it is also important to note that many women find that their recovery from a vaginal birth, especially if it involved stitches, swelling, bruising etc to the perineum, may also require a large amount of extra help and support in the early weeks after delivery. Research has shown that by three months post birth, any difference in postnatal recovery has evened out between the types of delivery.
Women might be concerned about how a Caesarean delivery may negatively impact their newborn baby. There is an increased risk of neonatal respiratory conditions in babies born via elective Caesarean (35.5/1000 babies, versus 12.2 from emergency Caesarean and 5.3 from Vaginal birth). It is suggested that labour (even if it leads to an emergency Caesarean) could help to reabsorb lung fluid, or perhaps babies born by elective Caesarean might be less likely to have reached full maturity in utero. Although this needs consideration, it is very likely that any respiratory distress is resolved within the first couple of days as the newborn baby brings up any excess mucous from their chest, and no long term effects are noted. This may, however, have a negative effect on early breastfeeding in those first few days.
What about the cost of a Caesarean delivery? While an uncomplicated vaginal birth might only have one birth attendant (usually a midwife), a Caesarean birth is likely to have at least 8-10 medical attendants there to look after you and the baby, including a midwife, an obstetrician, an anaesthetist, a paediatrician and other theatre nurses and assistants. Then there is the cost of the theatre and surgical equipment too. This cost has to be passed on to someone, and that depends on whether you are in a private or a public hospital, and what level of cover you have with your insurance company. You can see, however, that the public system may go out of business very quickly if they had to pay for every woman to have a Caesarean section and will not necessarily be keen to allow elective surgeries if they feel that they are not medically required. To play devil’s advocate, I have also seen articles that compare the cost of a Caesarean delivery versus the potential saved cost of ongoing incontinence and prolapse issues for that woman and the health system down the track, which is very hypothetical but an interesting point nonetheless!
A point needs to be made about the argument that babies born via vaginal birth may have better long-term immune responses and less long-term health issues than babies born via Caesarean delivery. The theory is that a baby born via Caesarean delivery does not experience labour-related stress (for example compression of their lungs coming out of the birth canal), nor immune activation from exposure to maternal vaginal flora. There were definitely articles published in the past that seemed to back this up, but more recent Australian studies with large numbers seem to suggest that there were other factors, like the mother’s obesity, that were found to be the common cause of any discrepancies in the groups rather than the mode of delivery. I have seen some interesting recent articles about combatting any potential negative difference between groups by giving the baby’s chest some level of compression as it is born through the abdominal incision of a Caesarean section, and taking swabs of the mother’s vaginal flora to put onto the baby immediately after a Caesarean birth, but I couldn’t find good quality evidence one way or the other for either of these suggestions. I think it is also worth having the conversation pre-birth with your obstetrician about the possibility of immediate skin-to-skin contact after a Caesarean birth (as would almost always happen after a vaginal birth) to optimize this transmission of the mother’s natural flora to the baby.
And lastly, the very important (but very low risk) concern of neonatal or maternal death during Caesarean childbirth – women should have this conversation with the health professionals overseeing their birth. Although it was discussed earlier that elective Caesarean could possibly play a small role in preventing babies being still-born, there is also literature that quotes a 2.84 fold increase in maternal death rate with Caesarean sections rather than vaginal births (note that this data is from the 1990’s). Other studies have shown no difference in maternal mortality, and again it should be noted that this is rare in first world countries regardless of type of delivery.
There are many women that I have spoken to who feel, in retrospect, that they were ‘bullied’ into a Caesarean section when they didn’t truly require it. There are studies showing emergency Caesarean rates increase between the daylight hours on weekdays. Some may consider that an obstetrician in the private system will make more money if he/she performs a Caesarean birth rather than a vaginal delivery, and that a Caesarean birth takes approximately 30 minutes while a vaginal birth could mean being on call for the best part of a day or more. Therefore, if you are going to choose to birth in a hospital with an obstetrician, you have to feel completely comfortable beforehand that you trust this person who is in charge of your well-being, that you know that they will make the right decision for you, and that you are well-informed enough to understand their reasoning if they suggest an elective or emergency Caesarean delivery. And if you don’t necessarily trust them, or don’t know who the health professional will be on the day, have you considered hiring a doula or midwife to be with you during the process and acting as your advocate?
There are also many women that I have spoken to who feel that their vaginal delivery and the consequences of the delivery were not what they expected. The previous statistics should be considered regarding the not-so-unlikely rates of postnatal bladder and bowel incontinence, as well as vaginal and perineal tearing, episiotomies and pain in this area after a vaginal birth. Midwives, doctors, and (very importantly, and often unheard of) Women’s Health & Continence Physiotherapists, are there to help you prevent and manage these common issues. The worst scenario is feeling any sense of failure, or feeling alone in the recovery process. There is always something pro-active you can do and always someone you can talk to about your postnatal issues. Have you considered seeing a Women’s Health Physiotherapist during pregnancy, or attending a Preparation for Labour or Hypno-birthing course? And never forget the importance of a Women’s Health and Continence Physiotherapy check-up at approximately 6-8 weeks postnatally, to make sure that you have optimized your pelvic floor muscles before returning to the rigours of daily life and exercise.
In the obstetric community up to this point in time, it has generally been agreed that it shouldn’t be routine to discuss elective Caesarean delivery with every patient, given the high degree of uncertainty about the clinical benefits and risks. There are very interesting new articles being published, however, about the possibility of pre-birth counseling for women regarding their personal set of risk factors for pelvic floor muscle damage during vaginal delivery. A set of risk factors has been put together with the acronym ‘URCHOICE’:
U – Urinary or faecal incontinence pre-existing before childbirth
R – Race, with women of Asian descent being most at risk
C – Childbearing age, with women in their late 30’s and 40’s being more at risk
H – Height less than 160cm
O – Overweight, with mother’s BMI being greater than the normal range
I – Inheritance, a family history of a mother or sister with pelvic floor muscle dysfunction
C – Children, and whether they are planning on birthing more than two
E – Estimated foetal weight greater than 4kg
Women would be given a low, moderate or high score depending on the presence of these risk factors, and those in the low risk group should be reassured that a vaginal birth is very likely to have the best outcome for them. Women in the high risk group, however, should be given counseling about the pros and cons of their particular set of circumstances, and an informed choice could be made about the mode of delivery, along with addressing any personal emotional and psychological aspects of childbirth that may be worrying them. This may include family pressure, concerns about pain, previous personal trauma or trauma in a previous childbirth experience.
Remember, all women have the right to be well informed about childbirth and their options, and to feel comfortable with whatever decision they make on how to birth their baby. No woman ever ‘fails’ at childbirth, but there are often reasons outside of her control that birth might not go as originally planned, and the community needs to support women in the aftermath of this. We should feel lucky to live in a society where we have multiple different options regarding how to bring new life into this world, and we can rest easy in the knowledge that this will be safe for both mother and baby in the overwhelming majority of cases.