Why do medics argue for VB over CS?

[EmeraldIsle81]

Just reading so many threads where medical teams really argue with patients to do vaginal birth over Caesarean section when the patient wants a CS. Can anyone tell us why that is?

The uncertainty of vb, the risk of distress and damage to baby if vb doesn't go well, damage to mother, length of time in delivery, pain management. Midwives having to go to find a specialist if complications arise.

I just don't understand why all of that is so preferable to a patient wanting a CS where everything is prepped, planned, no surprises, quick procedure with the right people there in the room just in case, recovery is monitored and managed.

Thanks all!

Has anyone read Adam Kays (ex dr) book about his time as an obstetrician?

He made a comment in there about how 60% of female obstetricians choose a non-medical c-section for their own births (over half!) and said he feels it isn’t fair how normal patients aren’t generally given this option or given balanced information if they try to request it.

So I don’t think it’s as straightforward as ‘c-sections are way more dangerous’ if the drs who deliver babies actually choose them more often than not. There are pros and cons to both.

A CS is not by nature an ‘easier’ way of giving birth. Recovery from a CS compared to a normal VB is much harder and longer.

I agree with this, had a very quick VB with gas & air & found recovery easy. Semi elective CS with dd2 & I honestly was surprised how painful the first few days were. I expected it to be super easy.

He made a comment in there about how 60% of female obstetricians choose a non-medical c-section for their own births (over half!) and said he feels it isn’t fair how normal patients aren’t generally given this option or given balanced information if they try to request it.

That makes sense. Obstetricians are likely to see far more complications related to VBs so are likely to have a bias. Aren't midwives more likely to choose VBs? My uncle works with brain injuries & never let his kids ski or horse ride & the kids were wearing helmets in the 80s for cycling which was rare. It was the same for us as his warnings rubbed off on my parents.

A succesful VB with no intervention and just needing a trebor mint to suck on to deal with pain is an ideal. If you compare an ELCS to this then of course an ELCS will look like the worse option. But this isnt the choice being made

Well, exactly. The risks of a VB are not made clear to women. It is a very risk process. Even women who have on the face of it uncomplicated births are often left with prolapse, incontinence, altered or damaged vaginas. These symptoms are minimised and trivialised as though they don’t even matter. They do fucking matter and women are fobbed off with “do pelvic floors”.

No one is going to tell a woman whose baby has suffered a hypoxic brain injury during a VB, or a woman who has been left doubly incontinent for life, that it’s great she didn’t have a caesarean because she wouldn’t have been able to drive for 6 weeks. When VB goes wrong, it can be catastrophic. Yes it is rare, but so is dying from a section. 3 times higher maybe, but the actual risk is about 20 in 100,000 or something.

Likewise women who end up having EMCS.

Plenty of women who have a VB would have, with hindsight, been far better off with a caesarean. No one can have this hindsight so it is perfectly reasonable to weigh up the differing risks and decide which you’re more comfortable with, and plenty of medics prefer the risks of a caesarean.

In the clinical negligence cases I deal with, the negligence is basically always failing to offer a caesarean quickly enough or at all. This focus on VB is dangerous.

Yes I’m pretty sure midwives are more likely to choose VB as they do see a more balanced picture... but still, if other experts in childbirth choose non-medical c-sections at such a high rate (60% is pretty astonishing when you think 10% of ‘normal’ patient birth are ELCS and that’s mainly medically needed ones) then it does show it isn’t really as straightforward as saying planned sections are way riskier. Obstetricians will still know the risks/benefits and are obviously intelligent people yet frequently will opt for a non medically needed c-section for themselves.

Even women who have on the face of it uncomplicated births are often left with prolapse, incontinence, altered or damaged vaginas. These symptoms are minimised and trivialised as though they don’t even matter.

I completely agree that women's issues are not given enough respect & for some women CSs should be the first option. I have French family & their after care seems much better. However CS will not always prevent incontinence & prolapse, the effects of pregnancy alone damages the pelvic floor.

That is true cokehoke but the risks are greater with a VB than a CS.

He made a comment in there about how 60% of female obstetricians choose a non-medical c-section for their own births (over half!) and said he feels it isn’t fair how normal patients aren’t generally given this option or given balanced information if they try to request it.

Yes, agree with pp that this is due to obstetricians seeing the high risk cases, the vaginal births that have gone wrong the minority of women who have problems afterwards due to a vaginal birth and are seen for follow up in gynae clinic with ongoing pain, etc. However the majority of women who have vaginal births don’t have such problems.....but the doctors don’t see them.

I’m a midwife. My midwife friends have every single one of them (and there’s been a lot) done everything they can to avoid a section. A friend of mine who’s a consultant obstetrician had a vaginal birth. I’ve known a few doctors who had been SHOs elect for a section.

My first baby fucking ruined me physically during a vb. My recovery took months.

I elected for a Cs the next time and had to get a mental health team involved to vouch for me. Even my family were shocked I'd chose one. Honestly, the recovery from my planned Cs was a breeze compared to my vb. Maybe it'd have been OK second time around but I'm glad I'll never know!!!

It us major surgery and it's expensive and can cause issues but it's down to the individual I think and what experiences they may have had. For example, as well as my bad vb I also can't stand being examined down there due to a sexual assault so I don't see how I could've had a good vb when I was already so distressed at the thought of one.

I think obstetricians (even SHOs!) are perfectly capable of looking at evidence regarding the outcomes of VBs, including uncomplicated ones.

It is perfectly legitimate to want to take the risks of a section over the risks of having a VB like the obstetricians are more likely to see.

Saying that a VB is better gambles on what kind of VB you will have. A section is a major surgery but it is routine and far more of a known quantity.

Even women who have on the face of it uncomplicated births are often left with prolapse, incontinence, altered or damaged vaginas. These symptoms are minimised and trivialised as though they don’t even matter.

Is the problem that the medical profession doesnt feel responsible for these problems? They didnt cause them as they are just consequences of VB which is natural.

It’s cost. Simple as that. Having one midwife sit with you is a whole lot cheaper than a whole surgical team, and they have targets to hit.

If you somehow made the two the same cost; there would be a whole lot less persuading of women to have VBs.

Also I'm assuming obstetricians are likely to give birth later in life & have less than 4 children so a CS makes sense in that context.

the risks are greater with a VB than a CS.

Yes, but there does seem to be a lack of knowledge that pregnancy alone is damaging. Also other factors influence it eg the gap between babies, health of the mother etc.

As a CS baby myself & having also had one I do find the link between allergies, gut bacteria & CS birth interesting.

Thanks @aurynne. The study of women over 35 is of particular interest to me (I'm 37). The conclusion that when comparing elective CS to planned vaginal delivery (remaining deliveries), only moderate blood loss, transfer to NICU and neonatal infections differed between the planned modes, and the neonatal risks were lower in elective CS is what I had expected really. I have bookmarked it to discuss with the midwife/doctor when the time comes

Because vb is generally much safer than a CS! Do your research.

If you actually believe this, it's not OP who needs to do her research. NICE and RCOG, who have done quite a lot of research on the matter, take a different position to yours.

There are risks and benefits to both attempted VB and ELCS. There are also two people involved, sometimes with competing interests.
It isn't as straightforward as one is risker than the other because you're weighing up different risks that some people will feel differently about to others.

So eg the greater risk of placental problems in a future pregnancy after CS is irrelevant for a woman who knows she doesn't want more children, but potentially very important for one who wants several more (and note that attempted VB certainly doesn't prevent the risk of CS). These women would both weigh that particular risk very differently and would not be helped by generalisations.

But they don't all necessarily advise for VB over CS. There is a huge cultural element in this which suggests that not every doctor is offering evidence based advice. For example, Brazil has an overwhelmingly CS rate of births, China has more than half CS and statistics from the US suggest that doctors chose CS for themselves.

In the UK I think there is a (perhaps even unconscious) assumption that harm caused directly by a medical professional is worse than harm that happens naturally. This kind of thinking governs practices around allowing patients to die of natural causes while keeping in place legal and moral prohibitions against direct euthanasia. I think that something similar is happening with CS and VB. Doctors are more concerned with causing harm because of CS, than harm happening because of VB, after all the baby has to come out somehow.

Yes, there's significant global variation here. We seem to have a worse problem with the natural fallacy in the UK than in some places too. Some of the posts on this thread show that, comments about us being designed to give birth for example. Clear nonsense.

We do seem to make a certain amount of policy based on quite idealised assumptions too. So for example we have freestanding birth centres in the UK, rightly so as this is an option many women want, but there are a number of them that are very underutilised. While at the same time, there are hospital based obstetric units having to close and turn patients away because they're so full. Freestanding MLUs are only for low risk women, no complaints there as I understand there are good reasons for that. But that's not the way the birthing population is going: we are getting older and fatter and thus more likely to be risked out of freestanding MLU usage. Our provision doesn't reflect that.

I've had a VB with a third degree tear for DC1 and an ELCS as DC2 was extended breech (and massive) and the doctors advised that a vaginal birth would be too risky. I had been desperate to avoid a c section because I didn't want another spinal - I had to have one while they repaired my tear and it was difficult, took multiple attempts and resulted in a dural puncture.

The spinal went ok for the ELCS but I'd still take a VB over CS any day. The third degree tear was a breeze to heal from in comparison. With the ELCS the recovery was longer and much more painful, my milk was delayed, I was discharged without any painkillers, I had to sleep propped up for ages and struggled to get up and down from bed, I got an infection, my abdomen is still numb above my scar. I also have a little lump in my belly button.

I was discharged without any painkillers

I definitely found this odd particularly as some yrs before I had abdominal surgery & was kept in for a week on morphine.

I was discharged after 24 hours but was offered paracetamol which I didn't take as had some at home. The shuffle to the car was really hard! Obviously I was naive (or dumb) but I didn't expect to be painful.

Oh god I almost wish I hadn't read this, I am facing the decision of ELCS or VBAC. Ofcourse I'd rather the facts, just hard to process.

I was really hoping for a vaginal birth first time round but now 2nd time round the thought of it petrifies me. I think this has something to do with my previous induction tbh which quite frankly was traumatic!

Sorry @aurynne - having looked at the rest of those links I realise I wasn't being clear. What I mean was studies showing the difference in risk between choosing a vaginal birth (encompassing unassisted and assisted deliveries, and emergency cesareans) vs risks of going for an ELCS from the start. The study of over 35 year olds does that perfectly. If you (or anyone else reading) know of any other studies like that I'd be really interested to read them.

I had a vb with dc1 and an elcs with dc2. Recovery from the cs was so so so much easier, I still can't believe it. I had it 10 weeks ago and I feel great- totally myself, no pain, baby weight is falling off as I'm fully mobile. After my vb at this stage I was still in pain, struggled to walk far and couldn't sit on hard surfaces - even the car was a trial. I know that I was unlucky and that vb should be more straightforward but for those who suffered complications from it the first time, I highly recommend a cs for number 2. Luckily I didn't have to fight for mine - every medical professional I spoke to agreed it was definitely the best choice for me.

I've had an EMCS and an ELCS

Not a walk in the park by any stretch.

Recovery was long- especially second time round.

I’ve had two CS due to medical grounds - I am to high risk for VB. I wish I had the choice I would have liked to have tried VB but wasn’t allowed.

I hate my scar and the tummy apron I’m now left with :( my first CS I was more mobile after wards and recovery seemed quicker. 2nd one I was in a lot more pain recovery was so much slower, was very sick and vomited after the operation, my scar got infected and took forever to be pain free easily 3 months to be fully no longer in pain. Then a fair few months to even have any core strength! 10 years later my scar still not right :(

But I have two healthy children and I’m alive. There are balanced reasons for both but I don’t think anyone thinks CS is an easier option - even a ECS like my 2nd one which I thought was going to be like my 1st was completely different!

Aurynne, that is really really interesting, thank you for your contribution.
I think I also read that CS babies are also more likely to be obese, also due to the natural gut organisms they collect on their route to being born naturally but miss out of with a CS. Fascinating stuff.
I think that more and more stuff will emerge about our gut/microorganisms and general health.
Anyway from a personal POV, I had 2 natural births with absolutely no complications and then an emergency CS with weeks of recovery and hated it, although obviously thankful to have a live baby who was so tangled in the cord they struggled with the CS too! Youngest is now 13 and I still get some itching and dry skin on the scar site.