Elective C-section: yes or no?

[Gennz]

So I have the option of choosing a ELCS. I'm only 8 weeks so I have a long time to decide! This is my first child. I would really liek to hear your experiences of ELCS vs natural birth.

As I see it, the options from best to worst are:

1. Straightforward natural delivery, no complications;
2. Elective C section;
3. Complicated natural birth resulting in emergency C section;
4. Complicated natural birth resulting in other intervention for delivery.

(Numbers 3 & 4 may be interchangeable, this is a guess). The problem with weighing up the stats is that all we know is that 25% of births end in a C-section, and that a straightforward natural delivery is the preferable option.

However, we don't know:
(a) of the 25% of C sections, how many are emergencies and how many are elective. I think this is important because electives are vastly preferable to emergencies. With emergencies, my guess is that most of the damage and the recovery time results from the unsuccessful effort to push the baby out before the call is made to go for a EMCS, not the actual CS operation. Given elective C-sections are not widely available, my guess is that most of the 25% of birth resulting in CS are emergency CS.

(b) of natural births, how many were really natural & straightforward (textbook labour, delivery with minimal damage & no interventions) vs how many were complicated i.e. required forceps or worse e.g. sustained damage leading to surgery. (I'm assuming by the time you require forceps, you have had a long and painful labour?)

Because there are no stats available, I thought of all my friends who have given birth and collated their various stats. The outcomes from 18 births were:

• 6 straightforward, no complications
• 5 natural birth requiring interventions or surgery (meaning they were v long & painful and/or there was damage sustained)
• 7 c-sections (EMCS & ELCS)

The highly unscientific anecdotal evidence, then, suggests that chance of straightforward delivery with no intervention and not resulting in emergency C-section is 33%. Bear in mind that, even of the 6 births representing the 33% stat, I have no idea about the state of their bits after birth! They could be irretrievably altered or damaged for all I know.

Do I want to take my chances on 33% uncomplicated birth, or would it be better to go straight for the next-best option of elective C-section which presents more of a "known" risk. My biggest fear, even bigger than surgery (which I'm not really scared of, have had quite a few surgeries in my time so it holds no terrors for me) is lasting damage downstairs, resulting in problems with sex or with bladder. C-section would seem to remove this risk. I also like the idea that a CS "cleans you out" and reduces the lochia time.

However I would like 2 or maybe 3 kids so I know choosing a C section isn't ideal from this perspective.

(No doubt I am totally overthinking this. My job involves a lot of trying to mitigate risk (& controlling outcomes which I gather can be a bit futile when it comes to childbirth & parenting!!))

And VV for me, but are we discussing anecdata? We could discuss correlation and causation too I guess.

I'll just do anecdata for now - I'm long term disabled and I've been told the worst thing I could have done was have the first CS. Sadly it was a crash with GA so it was unavoidable, knowing that a big part of my disability was saving my daughter's life helps me get through it.

Pregnancy rather than birth DOES cause problems with urinary continence (and the pelvic floor in general). CS are shown to reduce the number of women who have problems with muscle control and their bladder but having a CS does not eliminate the risk, it merely reduces it.

However there are other dangers associated with having a CS in terms of your bladder - namely risks associated with use of a catheter and risks of cutting into the bladder during surgery (though the later is much more common in EMCS rather than ELCS because of the effect of a contracting uterus).

It is not quite as straightforward as it is often made out to be unfortunately. However, people may have a preference based on their circumstances and think that on balance one is less risky than the other for them.

I've had 5 sections. 1st was an emergency after a long labour, not progressing well and an 11lb baby. The second was planned as the consultant thought the baby would be large again and advised that a planned elcs was preferable to a second failed labour and emergency section. I took his advice and had a planned section. 3 more babies followed each born by elcs.
I enjoyed all of my planned sections. They were calm peaceful experiences and I recovered well from each one. I felt like part if the process by asking for the screen to be lowered at the point of birth and requesting skin to skin asap. I'm glad I've not had to endure any vaginal trauma or tears but I have paid for that with my abdomen being ruined!

I've had 3 sections. First due to breech, straightforward recovery. second vbac that failed to progress (officially emergency but actually there was no rush but I laboured quite a long time), recovery was a bit tougher as I was tired and had had lots of contraction, but ok. Third breech again. I was going to attempt vba2c with the third but didn't due to presentation. Just as well as the surgeon discovered my uterine scar was so thin that she did not need her scalpel, it opened by itself. If I had laboured it would almost certainly have ruptured with disasterous consequences. I have been told that another pregnancy would be vety risky and ill advised. Luckily we don't want more.

So although the ops were fine, recovery ok, no overhang, breastfeeding fine etc etc I would say if you want more than 1 or two think carefully about risks for those subsequent births.

OP, if it helps these are the intervention figures for healthy first time mums: (place of birth study 2011)

Forceps Delivery

OU 9.8%
Home 6.3%
FMU 5.3%
AMU 7.8%
Total 9.3%
Unplanned caesarean section
OU 13.0
Home 7.7%
FMU 6.1%
AMU 7.1%
Total 11.9%
Normal Birth
OU 46.4%
Home 69.3%
FMU 71.1%
AMU 62.9%
Total 49.7%
3rd or 4th degree perineal trauma
OU 4.6%
Home 4.4%%
FMU 4.1%
AMU 4.9%
Total 4.6%
Epidural
OU 37.9%
Home 21.1%
FMU 18.1%
AMU 23.6%
Total 35.2%
Admission to a higher level of care
OU 0.8%
Home 0.5%
FMU 0.2%
AMU 1.0%
Total 0.8%

OU = Obstetric led unit/labour ward/consultant led unit (in the uk 95% of births take place on the labour ward)
FMU = Free standing midwife led unit (not attached to a hospital)
AMU = Alongside midwife led unit.

here

page 244

This guidance above compares planned c/s with planned v/b (which will factor in the fact that a percentage of planned vb's end in emergency c/s)

It's worth remembering that these figures are shaped by the fact that 95% of births take place in CLU's/OU, which have a low normal birth rate compared to other birth settings. If you did another analysis of the outcomes associated with planned c/s vs planned v/b where all the low risk women planned births in low tech midwife-led settings, you'd get a very different comparisons, as much fewer of these women end up needing emergency surgery.

Thanks everyone for the data and stats - it's definitely food for thought.

To be clear I have a private obstetrician and through him I can elect the CS at no additional cost. So I know I can definitely have one, it's not a matter of convincing anyone. I'm not in the UK although I think our health system here (in NZ) is fairly similar. The maternity system is midwife/natural birth focussed. Midwives are fully funded by the govt and if you want a private ob you have to pay.

I chose a private ob because I wasn't confident in the midwife system as IMO the quality of care you get is variable. There are some excellent midwives out there, but equally there are some appalling ones, and as far as I can see it is a bit of a gamble as to what you'll get. It also doesn't help that the way the system is funded here the midwives are financially incentivised not to hand over care if something goes wrong (for example if a baby is delivered by C section they don't get $500 of their fee from the govt - about 250 quid). Of course many or most midwives will do what's right for the patient regardless of the fee but the way the system is structured bothers me. Anyway that's a bit of a red herring, but it does inform my birthing choice - for me I will either attempt to labour naturally in a hospital with a midwife appointed by my obstetrician attending me & the ob delivering, or I will get an ELCS.

I definitely won't be labouring at home or at a birthing centre, and there definitely won't be a doula. I totally get that some people prefer those options and that's fine, but for me, I want the medical angle rather than the natural one. I'm a lawyer so I suspect my obsession with risk management has fed through from my professional life!

I also know that anecdote aren't data, and that mumsnet and my friends aren't necessarily relevant to how things will play out for me, but I'm researching as much as I can so hearing the anecdotes are helpful to considering the numbers. (Interestingly when I told my sister I was considering an ELCS - she is of similar build to me and has had 2 reasonably straightforward midwife-led births in a hospital - her immediate reaction was "you lucky bitch! why wouldn't you?" Food for thought!!)

At this stage the main reason I would err towards a natural birth is subsequent children & potential risk. For me, all the other factors lean in favour of the ELCS. That said I' still very much on the fence.

I'd wait to make the decision based on your baby's size and position when you get closer to delivery. I had a vaginal birth with an epidural and some tearing. But I was able to walk and move around the next day, and was out and about 3 days later (granted I walked a little slower). I was able to leave the hospital the next day if I wanted, they just kept me around one more day because I was a first time mom and they wanted to make sure everything was going smoothly.

Quite frankly, for me the contractions before the epidural were much more painful than the healing process of the tear. If I could do it again, I'd do it the same way. An unmedicated birth is no prevention for tearing, tearing happens quite commonly with any first time mother.

And.. 3 weeks later everything seems to feel the same. Haven't tried penetrative sex yet because I don't want to cause an infection, but from what I can tell everything is in working order down there. ;)

"I'm a lawyer so I suspect my obsession with risk management has fed through from my professional life!"

In which case I don't understand why you would chose a model of care (obstetric led) which every good quality bit of large scale research in the UK/Australia/Netherlands (ie, all countries which have a similar model of care) links to poorer outcomes for low risk women, and no improvement in fetal outcomes.

In particular, healthy women who plan vaginal births under a private obstetrician (ie, outside of the public health system) as a group have significantly worse outcomes - more forceps, more unplanned c/s, more inductions, more perineal damage, without any proven gains for their baby.

here

From another study:

"Among primiparas at low risk, 34% of private patients in private hospitals had a forceps or vacuum delivery compared with 17% of public patients."

34% of low risk first time mums needing forceps or ventouse deliveries? That's shocking. Really, really poor.

Have you asked your Obs. what his/her spontaneous vaginal birth rate is?

Gennz, if you aren't in the UK bare in mind that risks differ from country to country.

This is because the demographics of different countries vary; a typical woman in the UK may be a different average age and their bmi may be different for example so even the most generalised information for low risk women may be very different to the characteristics of a low risk woman in NZ. (The demographic of women having children in the UK is very different to many other European countries - we have more teenage and older mothers for example - which is impacting on figures. There is a lot of comparison between European countries yet these differences are rarely even mentioned much less given much attention).

The skills and practices of health care providers may differ considerably. This may be down to training differences or finances (and the level of litigation).

The cultural attitudes to birth vary widely from country to country too, and this shouldn't be underestimated.

It does mean that data from the UK, may not be as relevant as you might think as its not comparable due to all these differences. Whilst there may be common similarities, there are likely to be huge differences too.

I would encourage you to focus on data available for NZ rather than the UK primarily for this reason. Data from elsewhere may be helpful, provided you understand the differences between countries and the potential flaws in using this data for your own circumstances. Caution is very much needed though. There is no international pattern in whether ELCS are ultimately better than VBs and the differences actually raise far more questions than answers in that respect unfortunately.

It is a real minefield, and I'm not convinced you'll find the guidance you ultimately are looking for on MN because its British based for that reason unfortunately either. I don't believe its really going to be as reflective of the NZ system as you need it to be. It might offer you good background information, but its not necessarily relevant to you.

Minifingers Rest assured I've done plenty of research and I'm comfortable with my decision to choose an obstetrician. I won't be labouring in a private hospital, I will be in a public hospital with my private ob as my lead maternity carer.

I'm not really interested in an ideological debate - to each their own, and this is the process I'm most comfortable with.

Hi ReedToothBrush - I'm definitely focussing on NZ birth stats. There's no similar website to MN here and I think people's experiences of ELCS particularly will be similar, so it's def been helpful. I have lived in both countries and have had friends and relatives give birth in the Uk so I have a general idea of how it all works.

• Red!

Which is why I've linked to studies from Australia.

And actually there are fewer differences between uk populations and those of NZ and Aus than between the UK and other European countries. In particular rates of obesity are almost identical and age of first birth is not massively different.

Personally I think that the maternity system is NZ is more similar to the UK than it is to Australia.

Median age of childbrith here is 30. I'll be 33 when I give birth so not high risk, but not exactly a spring chicken either!

Just to stick my tuppence in.... many mums agonise about the birth but seem to forget, or not do quite as much research, into what happens next ie how to look after the baby.

I had an ELCS with DD1 due to full placenta praevia and seemed to be the only one in the NCT classes that asked about bathing baby, dressing, feeding, sleeping etc. we just didn't have time to cover that.

I do understand the need to plan everything but these babies do have a habit of doing there own thing, both in the way they arrive and how they are when they're finally here. I'd say hanging out with real life mums, hoiking up your judgeypants now on all the things they're doing wrong and how you'll do it all differently might be more useful time spent

For what it's worth I did have a VBAC with DD2, technically with a bit of interference from syntocinin drip but had a fantastic birth day and really felt an overwhelming sense of empowerment from it

On the other hand I felt the recovery from the ELCS was easier, everyone in the family helped out and the drugs were great. The natural birth left me very tired out but I was also looking after a 3yr old and didn't have the drugs! I feel I could do the VB again any day but not the whole pregnancy thing. I could also think of ways to improve an ELCS and think it could also be a great birth

It really won't matter how they got there once they're here

Good luck and enjoy the crazy roller coaster of unpredictable life coming!!

It's not an ideological debate - I'm only discussing clinical outcomes for different models of care. You have implied that you are risk averse. I don't understand why in that case you would chose a model of care which is linked with poorer maternal outcomes - more birth injuries and emergency surgery.

But I appreciate your obstetrician may have a record of success in facilitating normal births for healthy women as well as being a competent surgeon, should you chose a planned c/s. I don't mean to be rude - I'm a skin flint personally and if I was paying a great deal of money to a doctor I'd hope for the best possible outcome, which in my book is a healthy baby and preferably (when opting to try for a normal birth) a high chance of emerging from the birth with vagina/abdomen intact. (Or as near as).

I have had two complicated labours. My first, I was induced, and ended up having a ventouse and an episiotomy, involving approx 30 stitches. My second, I had a caesarian section. I personally preferred the first one.

Hi Chocolate - I totally agree! In fact that was one of the first things my ob said "parents to be focus so much on the birth when usually that's the easy part - it's weeks and months that come after whcih are really hard." We are one of the last of our friends and family to have kids so I have spent a lot of time with my friends babies and toddlers and my sister's children but I am under no illusions that I know what I'm doing!

Of course I do have some ideas about what I would do. At this stage I'm thinking I'll be a routine, baby in own cot, sleep-training kind of mother but come back to me in a year! Odds are I'll be co-sleeping, sling wearing, breastfeeding til 18. There's nothing worse than a parenting know-it-all with no kids!

Mini I appreciate your response. Totally get where you are coming from but maybe I'm unusual in that I'm not bothered about having a natural birth. I only want one if it's totally uncomplicated and I know I can't guarantee that.

My local hospital has the following stats:

unassisted vaginal births 53%
induced labours 12%
instrument assisted births 11%
elective CS 10% (this being the UK, these will all be for medical reasons like pre-eclampsia)
EMCS 12%

My experience of my friends (all older than the OP) is that the vast majority of them have had vaginal births so this ties in with the above stats. Agree with the PP that says you need to look at the stats for your local hospital and the OP you are talking to. I'd not choose a CS without medical reasons, the recovery time is much longer than a VB. And while that might not be a problem with a PFB, if you go on to have 3 then it will be incredibly hard to be out of action for several weeks when you have 2 older children to look after. I did the school run with DD1 2 days after DS was born prematurely, when you have older kids you have to there for them as well as for the baby.

Yes that's my main concern fisherprice

Would be great to get stats on recovery time for genuine ELCS only as my gut feeling is that these are a geninely different kettle of fish from EMCS or ELCS for medical reasons but all c-sections are lumped in together.

Also - I'll probably get flamed for this - but I wuld have thought that all the factors which make me a good candidate for VB: age, health weight, reasonably fit, non-smoker etc etc - would seem to me to point towards being a good candidate for ELCS: higher likelihood of faster recovery etc. I've had surgery a few times over my life for various non-health issues (teeth extractions, tonsils, foot injury) under local and GA, and I've always recovered quickly from surgery.

If I was having a private birth and so some control over my care I think I'd opt for natural birth (with pain relief!) but sadly my mw was rubbish so dd1 was in my arms 25 minutes after mw told me I was in early stages, the pain was going to get a lot, lot worse and I needed to toughen up. dh asked for a second opinion and it turned out I was 10cm and had been refused pain relief and told I was making too much fuss. Staff went into panic mode and dd was born soon after leaving me feeling totally let down, not listened to and in shock. Technically birth was fine and dd arrived in 2hours 5 minutes start to finish. Due to my care I requested the option for a cs(before ttc #2) and after reading my notes the consultant agreed and apologised (first time my feelings had been validated that my birth was not as it should have been). I always said that if through my pg I felt confident in the mws I would try natural birth but I wanted to have the say and be listened to.
2 months after meeting consultant and having his written agreement I fell pg.... with ID twins who were breech so all choice was removed and CS it was. In the end it was emcs as I went into labour prematurely and due to first birth being so fast they couldn't take the risk of waiting. CS was the most amazingly calm experience and I recovered a lot quicker both physically and mentally.
But that was me and I also know terrible cs experiences exist. You don't know what will happen or how you will feel.
My advice is keep your options open and listen to your gut/heart and go with what feels right.

Thanks motherofdragons

(How good was GoT the other night!)

Hi OP

I've not read all of your thread (so sorry if any of this is repeated!) but I thought I'd chime in a little anyway.

One thing with a CS is that it automatically puts you into the high risk category for any subsequent pregnancies. This can effect your model of care and/or delivery. Or even the no of children you have.

First time around I had an induced labour and hyper stimulated immediately (after one prostaglandin pessary) and ended up with a crash section. A scary experience, but still ultimately positive as DS arrived safely. The recovery was pretty brutal though - I have had a ruptured appendix and therefore emergency surgery, as well as elective surgery (tonsillectomy) as well as wisdom teeth removal and always recovered well and quickly. I 'recovered well' from the section (ie no infections or cellulitis - my SIL with one EMCS and two ELCS under her belt, had cellulitis with her first ELCS) but still found it very hard (it is major surgery!). It was at least 4 weeks before I felt properly decent ie able to walk further than around the block without a rest, able to lie down or sit comfortably.

I imagine that NZ (or at the very least your private OB) does not use prostaglandin pessaries. I now live in the US and my midwives were not surprised to hear of my experience since they don't use them here for that reason (f you hyperstimulate on the drip you can dial it down/switch it off but once the pessary works there's no going back!).

One of my NCT friends chose an ELCS instead of induction and found the recovery also very hard. She is now 37 weeks with her second and wants a vbac.

Second time around (still in the UK) I had a vbac - I had a sweep on my due date and DD arrived less than 48 hours later, after a lovely labour. But her actual delivery was hairy, in that again it was fetal distress and they were about to use the ventouse, so I had an episiotomy, but managed to push her out myself. I had lots of stitches but still found the recovery far easier than the section. I was walking within minutes of birth, home within a night and out and about with my newborn and 2 year old straight away. I felt like I'd climbed a mountain (in the best sense of achievement!) rather than been hit by a bus (like the first time).

I now live in the US, so a completely different system of care, and due with no 3 in Oct. I'm with a midwife practice, as OBs here tend to 'strongly recommend' ELCS if you've had an EMCS, mainly due to litigation risks/their professional indemnity due to the risk of uterine rupture. While a CS if I have no other choice is fine (preeclampsia or breech), I will do all I can to avoid anther one since I will have a 2 year old and 4 year old who will also need me!

I had a doula second time around and totally recommend them. I'll be having one again despite having private care, so knowing who will be with me during labour and delivery. They have nothing to do with the birth really (they are not medical professionals), they take care of you (and your DP). A doula would support you how ever you choose to deliver. Little things our doula did were things like making sure I (and DH) had water and snacks (especially important for DH since I was in the zone!), took pictures and generally kept a calm bubble around us, which was particularly useful when still labouring at home! I think DH found the doula better than me, since I zoned out for large chunks of it but do remember the two of them chatting happily. He recommends them more than I do in fact. The post natal visits were also lovely.

Sorry for the ramble! If you want some ELCS experiences then you could try posting on a US site, or even an Irish one (since the Irish system also has a large private component with many OB led births & more ELCS). You could also try the Living Overseas section of MN to get some NZ mumsnetters' experiences.

Good luck with it all. At 8 weeks, it's all still so hypothetical and lots of good stuff to come (my favourite is once you start to feel kicks!). I definitely think educating yourself about your options/risks is a good approach but there is also a lot you can't plan for. However your birth goes, you will have a lovely baby and it's the start of a great adventure! Just remember the MN mantra of TTSP (this too shall pass).

For me, unless I could have a homebirth I would go straight for c/section as the second safest option.

Thanks Flip that was a lovely post. At this stage I am favouring VB unless a reason arises to go ELCS. Plenty of time to mull over it!

One interesting feature about the NZ system (in contrast to the UK, Australia and the US particularly) is that there is no personal injury law here. All personal injury claims are covered under the statutory Accident Compensation system, and this includes injuries caused by medical misadventure. In general I think this is a good thing as it means we don't have a culture of ambulance chasing lawyers, but it does mean that if soemthing goes wrong the only recourse against the medical professional is disciplinary action.