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!!))

Gennz - do midwives working in the way you describe have worse outcomes than births managed by obstetricians in obstetric settings.

Because in the UK first time healthy mums who opt to labour in freestanding birth centres are just as likely to take home a healthy baby as a similar mum who opts for an obstetric led birth in a hospital setting. She's also more than twice as likely to emerge either her abdomen and vagina intact.

I haven't seen similar research from NZ. Have you looked at the evidence on safety of the different models of care in NZ?

I don't know if I've seen stats on that mini. Also I don't there are stats kept on birth injuries in NZ.

I know that people have good experiences of birthing in birthcentres or midwife-led births, but it's not for me, for the reasons listed above.

mini I'll try to address as many of the interesting points you raise as possible, apologies if I miss out on something:

1. The Birthplace study doesn't make the claims you seemed to make earlier on its behalf (apologies if I misunderstood what you claimed). All it says is that low risk pregnancies remain low risk in non-obstetric settings (more so 2nd and 3rd pregnancies, less so 1st pregnancies). Obstetric settings see more complications, but there is no accounting for why that is - the obvious answer is because mid and high risk pregnancies are routed there in the first place.

1. If one wanted to conduct a proper study on this, audit is not sufficient (which is what the Birthplace study is). You'd need at least to: a) set out criteria for judging low, mid and high risk pregnancies, b) assign an independent investigator to categorise pregnancies low mid high, c) randomnly route some low risk to non-onstetric settings and some low risk to obstetric settings (you'd probably get REC approval for this) to see if either setting has a statistically significant effect on outcomes, d) randomnly route some mid and high risk to non-obstetric settings and some mid and high risk to obstetric settings (I can't see a REC approving this) to see if either setting has a statistically signigicant effect on outcomes. Only this would give you some indication on whether obstetric settings impact on risk actuation.

1. The relationship between abnormal placentation is complicated. The risk increases after 2 or more CS but is also related to maternal age and previa. This is a matter on which women must obtain qualified medical advice, but see here for a survey of risks: www.ajog.org/article/S0002-9378(05)00050-5/abstract

OK DD has run out of patience, so I'll try to return to this later!

Gennz I find it interesting what you say about the NZ midwife system. I have had two children in the UK and one in NZ, and am now pregnant with my 4th here in NZ. I found the NZ system to be far better than the UK one, and a big part of that was due to the midwife care. Are you aware that you get to choose your own midwife here? So you can interview lots, get recommendations etc. and then choose the one you are most happy with? So it is not a lottery as to who you end up with - that midwife will be with you the whole way through and at the birth itself, unlike in the UK where you just get whoever is on shift at the time.

I had two vb in the UK, one very long, with intervention etc and one very short, but both ended up with shoulder dystocia (although I didn't have any lasting damage with either despite 1 episiotomy and 1 bad tear and had very quick recovery). The consultant I saw in the UK when I became pregnant with dc3 was very blasé about my past births and just told me they always try for natural births no matter what, however we emigrated to NZ when I was 27 weeks and the consultant I saw here was absolutely shocked at this and said that they would never recommend a vb after two shoulder dystocia and they would definitely advise a elcs which I had. That same consultant did my elcs (which was very relaxed, couldn't fault the care I had) and dc3 was actually stuck in my pelvis and it took a long time to get him out, with a lot of bruising - they said after that if I hadn't gone for an elcs I would have ended up with an emcs and could have had a very different ending. BUT two cases of shoulder dystocia is considered very rare, so I wouldn't necessarily factor this into your decision at all.

The midwife I chose here was amazing, and she had no issues at all about passing over my care for an elcs, she said she always went with what was best for the woman. I know they get paid slightly less for an elcs, but considering the amount of women they care for in a year, and a fairly low elcs rate I don't think it is a major factor at all. My midwife was there for the whole of my elcs, took photos for us, weighed the baby etc, visited me several times in hospital. I have chosen her to be my midwife again this time and she was the one who said of course you'll want to have a elcs again as she wouldn't recommend even considering a vb, has organised my consultant appointments etc. It is such a friendly system here, so, so much better than my experiences in the UK.

I would say though that I would have chosen a natural birth again if I had been able to as the recovery was just so much quicker with it than the elcs. I am also glad I got to experience a natural birth (although I would really have loved to not have emergency situations at the end of each birth which were really distressing).

Breastfeeding - had real trouble with dc1, mastitis twice, bleeding nipples etc but ended up feeding her for 13 months, dc2 established really quickly, but interestingly enough dc3 was the easiest to breastfeed by far, he latched himself on before we had even left theatre

Let me know if you want any more info about my elcs in NZ :)

thanks so much dontevenblink

I know there are some fab midwives out there - my sister had a great one for both her labours. Conversely I have had friends who have had absolutely terrible experiences: for one friend the midwife never showed (kept texting saying "I'll be there in 5 minutes" - an hour and a half later friend almost birthed alone in hospital room, had to go straight to surgery after delivery with 4th degree tear) another the midwife delayed handing over care, ended up with baby in distress and EMCS; and another was misguidedly encouraged to go for a VBAC although should have been classed as high risk & ended up with EMCS and uterine damage. So I do have my reservations about the system and I do think that the midwives behaviour in the latter two cases were influenced by $$.

(I know some are really good though, and if I do try to go VB I will have the midwife associated with my ob helping me labour at the hospital).

Whereabouts in NZ are you? The views from the birthing unit at AK Hospital are pretty fantastic!

I'm in Christchurch, the views are pretty awesome from the women's hospital here - postnatal care is on the 5th floor, couldn't believe it when took me to my private ensuite room with views over the hills, it was better than most hotels I've stayed in

To be honest I've only ever heard positive stories about the midwives here, all my friends seem to have had great midwives and a lot are still in touch with them. I think it is probably a system where you have to be very careful about who you choose, I just love the fact you know who is going to be with you at your birth and the fact they know you and your history beforehand - I had 4 different midwives at the hospital with dc1 and nobody seemed to pass any info on and I felt I wasn't listened to at all. I do have friends here who work at the women's hospital who say it is well known who the good and bad midwives are... probably why they say word of mouth is so important. I'm just glad we get a choice :)

"1. The Birthplace study doesn't make the claims you seemed to make earlier on its behalf (apologies if I misunderstood what you claimed). All it says is that low risk pregnancies remain low risk in non-obstetric settings (more so 2nd and 3rd pregnancies, less so 1st pregnancies). Obstetric settings see more complications, but there is no accounting for why that is - the obvious answer is because mid and high risk pregnancies are routed there in the first place."

No Boo - YOU have misunderstood. You have not read the details of the study.

The figures I have given on this thread are outcomes ONLY for mothers deemed low risk at the start of labour.

The study examines outcomes according to PLANNED place of birth and not actual place of birth.

Low risk women who are deemed low risk when they arrive to give birth in an obstetric setting have an unplanned c/s rate of nearly double that of similar similar low risk women presenting in labour at birth centres - whether in hospital or free-standing, with no significant difference in neonatal outcomes.

You can see that the women were categorised as low risk according to current NICE clinical guidelines - which are used across all trusts and which are very comprehensive. here (page 13)

As for the insistence on randomising - you cannot randomise women in this type of trial. You know that. Dismissing this study because of a lack of randomisation is silly.

The plain English summary of the study is here: here

From the British Medical Journal:

Thanks rosalie It does seem v unfair that here I can opt for an ELCS if I'm willing to pay, but some candidates like you with very valid reasons for wanting one have to fight for them (and can still be turned down).

Mini does that study track birth injuries to mother or outcomes for the baby? As those two are my big concerns re a VB (the former especially). My sense is that with VBs there can be some very negative after effects but the prevailing attitude seems to be "well you have a healthy baby, that's the main thing."

Of course a healthy baby is VERY important, but having an intact vagina, resumption of an enjoyable sex life and continence are important to me too. I don't think women should be derided for wanting to "stay honeymoon fresh" for placing value on these things. (Not that you said that I hasten to add ... you just see that phrase sneerily bandied about in the media).

mini I can't access the actual study as I'd have to pay for it, but the summary seems to be all about the slightly increased risk of first time home births. Where it does mention CS, if you add the statistics from the three non-obstetric settings they come up to 10.7% CS as compared to 11.1% CS in obstetric units which does not seem like a statistically significant difference.

"Where it does mention CS, if you add the statistics from the three non-obstetric settings they come up to 10.7% CS as compared to 11.1%"

What?

Sorry - I don't get the logic at all of adding the percentages of emergency c/s from out of hospital settings, and then comparing it to the percentage of women having c/s in out of hospital settings.

The bottom line is this: if you are a healthy women having a normal, spontaneous onset labour, you are much more likely to need medical input in the form of surgery if you choose to have your baby in an obstetric led setting than in a midwife led setting. How hard is that to understand? 56% of healthy women who choose to give birth on the labour ward will have a normal birth. Over 80% of similar women who plan to give birth in an FMU will have a normal birth. Nearly 70% of similar women who give birth in an AMU will have a completely normal birth. Over 85% of women who give birth at home will have a completely normal birth. Are you then going to add up these percentages and compare them to the outcomes for a CLU? Why not? Doesn't the same logic apply?

If I said that 30% of people with ingrowing toenails ended up needing further surgery to their feet if they went to have their toenails treated in hospital, compared to only 15% of people having their similarly dysfunctional toenails treated at their local doctor's surgery, with no gains in the hospital group in long term foot health, you'd wonder why on earth so many people were going to have their toenails treated at the hospital and what was causing the problems with foot care there.

here Scroll down to the bottom - you can download a read-only presentation on how the study was constructed, and an analysis of the results.

Can I also add, that the study didn't find that out of hospital birth per-se was associated with poorer outcomes for the babies of first time mothers. The free standing birth centres included in the study have access to any obstetric input without transfer by ambulance to hospital. No doctors, no operating theatres, no neonatal facilities. The average transfer distance for the birth centres in the study was 17 miles, and yet the neonatal outcomes for first time mothers were as good as those of obstetric setting. This suggests to me that it's not out of hospital birth per se that poses particular risks to the babies of first time mothers, but issues surrounding the experience of practitioners working in a home setting and issues surrounding how transfers are organised. Some parts of the UK have high homebirth rates (10%). In other areas it is vanishingly rare. Some practitioners who are called out to births at home have very little experience of providing care in an out of hospital setting, and IMO this is very dangerous. Bringing some obstetric practices into the home environment can make birth more dangerous, and midwives whose main experience has been in a highly medicalised setting may well not be the most appropriate or safest care giver for a mother giving birth at home. The safest form of care for homebirth mothers is caseload care, which is associated with better outcomes for both mothers and babies. On the NHS this is available in some areas and not others. I suspect this also contributes to the poorer outcomes for first time mothers in the study who were giving birth at home.

I question any stats on birth experiences and problems.

I have spoken to too many women, far too many who have been left traumatised, damaged and so on, by their labour's but they did not complain, they were scared, timid, didn't want to make a fuss. thought it was too late and no one would care...left with medical issues below not immediately apparent after the birth and so on.

How can you possibly get any clear picture when there is no proper feed back system and women are not encouraged to give feedback>

How many people come here with issues and complaints and have never even heard of PALS?

What I do know is, the largest cost to Maternity is medical compensation where things have gone wrong and they often need to cover life time costs from baby starved of oxygen at birth ( left with life time disabilities) and so on.

Is is in the interests of MEDICS too, be honest and encourage feedback about birth and labour?

NO.

Also another huge monumental floor in all these stats is that they tend to focus on the physical aspects of birth and labour.

Quite a number of women had physically good labours, but have been left mentally traumatised for various reasons.

I don't expect MW to pay much attention to this aspect of birth as its not really their job.

Now there are comparisons to some births leaving the mother as traumatised as someone in war though, its a very valid aspect of CB that is not taken into account.

Eh? Preventing birth trauma of no interest to midwives?

What planet are you on?

It's a topic that is repeatedly raised by midwives - as individuals and professionally in midwifery journals, conferences etc.

Gennz
My best to worst scenario list looked exactly like yours!
I think you need to gather as much information as possible to make a decision but you know this already.
This was my first baby so have no previous birth experience to refer to.

I had a CS for maternal request- went via my GP who wrote a generic letter to the local hospital obstetric consultants.
Had to be seen by 2 consultants and also see a psychiatrist, although I got the impression this bit was a formality, as part of their process to enable the request.

Baby was actually breech in the end but was counted as 'maternal request'- I didn't care either way!
The birth was a wonderful experience, all the team were great...the post natal ward was shit but I think that's the norm!

I breastfed for the first couple of weeks, eventually gave up due to very sore and cracked nipples...was happy to move onto mixed feeding. My milk came in around day 4.
People told me I wouldn't be able to BF due to the CS but this wasn't the case.

Another friend had a totally natural birth in a pool in a birth centre and her milk never came in so she bottle fed pretty much from the start.

One thing I've learnt throughout the whole process- research, take advice from people but at the end of the day you've got to do what feels right for you and your baby.
People will always say this or that is the right way or the best way, but in the end it's you who will go through the experience and have to live with whatever happens.

Good luck!

I'd add, if you decide to go for a vaginal birth look for a care-giver who has a high normal birth rate among patients. All health professionals keep records. If they've got a very low normal birth rate for healthy primiparous mums (ie below 50%) then I'd really consider whether it would be a good experience trying for a vaginal birth under their supervision.

BeyondRepair Fri 25-Apr-14 11:05:34
Quite a number of women had physically good labours, but have been left mentally traumatised for various reasons.
I don't expect MW to pay much attention to this aspect of birth as its not really their job.

Minifingers Fri 25-Apr-14 14:34:26
Eh? Preventing birth trauma of no interest to midwives?
What planet are you on?
It's a topic that is repeatedly raised by midwives - as individuals and professionally in midwifery journals, conferences etc.

I would tend to agree with Minifingers to be perfectly honest. It was recommended in 2004 at a Common's Select Committee that more information gathering and standardisation of information regarding reasons for ELCS (with particular focus on the reasons behind maternal requests) be done nationally to further our understanding of why ELCS were on the increase. To date there have been no moves to do this.

Then in 2011 when the NICE guidelines on CS were updated several hospital Trusts preempted them by announcing several months beforehand that they had a blanket ban on maternal requests. This completely ignored the information on why women were asking for ELCS that had prompted the change in the guidance (and why).

Its worth noting that virtually all the research used in the guidance was from outside the UK and very little was UK based. The key UK piece of research was dated 2000 and was very small in scope (though has been very influential). So between 2004 and 2011 despite the problem being flagged, and there being a government recommendation to investigate the issue next to no research was done and nothing really followed up on this previous research.

Is this down to midwives? I would strongly suggest that this is not the case. I think you have to look much further up the decision making chain.

Indeed I have seen numerous midwives speak about the problem and challenge the lingering myth of "too posh to push". I can pull up maybe a dozen articles published in the press prior to 2011 which senior midwives have contributed to, trying to debunk the ignorance and draw attention to the subject. And why when you think about it, were the NICE changes made when there was this apparent 'lack of evidence'. The panel of obstetricians and midwives acknowledged the issue despite this. I can only feel this must have been in part in response to their own personal experience and their awareness of the problem on the ground.

Since 2011, there does seem to have been progress in changing the landscape with regard to birth trauma. This is against a background of cuts and lack of resources. Again, I ask, who is pushing this forward? Its not the government nor is its not the NHS who continue to judge hospitals on CS rates and put pressure on hospital to reduce them without any consideration whatsoever for why they are being done.

No there are really only two groups who can have done anything positive and thats the front line staff - both midwives and consultants and women themselves pushing the issue.

And fortunately and finally, a few places are taking the plunge and the research is starting to be done... whilst others still resist even acknowledging the issue.

Strangely enough there was an article in The Telegraph yesterday in which the RCM claimed that hospital chiefs are deliberately ignoring staff shortages and not reviewing staffing levels, because if they do, they would be forced to do something about it.

And that just attitude just about sums it up for me.

Sorry Mini,

Just going on personal experience, and what I see on here which is usually pushing a birth with no medical help, cascade of intervention evangelism and general distaste for ELC as the body can birth perfectly fine.

BeyondRepair - yup, it's true that many people here get animated about the very high rates of preventable birth injuries women are experiencing in UK hospitals. I suppose this is what you mean by 'evangelical' ?

ELCS is a different issue altogether. I think it's quite rational that so many women consider it a safer and less frightening option than a badly managed vaginal birth with a high chance of ending in emergency surgery.

The problems with all the VB birth stats is that none tell you with any accuracy how the women fare afterwards. Successful VB could mean anything from feeling fab with in days to on-going issues for years. My mum keeps rolling her eyes at me "you do too much research! In my day we just got on with it! I had 4 straightforward VBs!" Yes but she also had a badly managed miscarriage for her 5th pregnancy which resulted in uterine tumours and a hysterectomy.

It is a really hard decision and sometimes I wish I didn't have the ELCS option so I could just cross my fingers and get on with it! (First world problems eh.)

Obviously I have a lot of time and more factors may come into play over the pregnancy which will tip the risk balance one way or the other.

About 5% of first time mothers end up with a severe perineal wound that requires specialist repair in theatre. Most won't experience any ongoing problems after repair. Hope that helps.

I'm afraid I also fall into the 'have faith in a benign universe and a skilled midwife' camp. I've found my experiences of labour to be opportunities for personal growth - yes scary, hideously painful, and a bit frightening at times, but they have left me feeling confident of my own strength and self sufficiency, which has been good for me as a mother. I will always have the feeling - if I can do that I can do anything. I appreciate that other people feel fearful and disempowered by their labours so I know that feeling isn't universal.

Parenting a child also involved taking risks every day. I recommend you don't google 'balloon accidents' or you will never let your little one go to a friend's party once he or she is born! :-)

Welcome to the parenting world of fear, perpetual risk assessment and the highest stakes imaginable. Try not to let it suck out all your natural joy and optimism!

I'm surprised at that minifingers I had a 3 degree tear repaired in theatre so am part of that 5%. I would have guessed a higher statistic than that.

I had no problems at all since the birth and almost forgot to mention it at my 2nd booking in appointment. It played such a tiny role in my dc's birth. Healed with no problem, no pain at all (although I was routinely taking the pain relief tablets prescribed, so that might have been why).

Stayed in one night only, I wanted to go home as couldn't sleep very well on the ward, so they discharged me.

Saw the physio in the hospital and did my pelvic floor exercises she gave me, saw her once more a month or 2 later and she just asked how I was and went over the exercises again.

Strangely enough I do have more of a fear of tearing less seriously and being stitched by the midwives under gas and air, I think this is part of the fear of the unknown, simply because of my experience in theatre and my healing afterwards was not a problem for me.

People fear different things, so I do understand the op's fear of vaginal injuries. I have more of a fear of being cut open so hope to avoid a cs. But even this fear is minor for me, so I feel lucky that I don't have anxiety surrounding these issues.

genz

There is no way to record a womans experience in birth, or after.

there is no joined up thinking or place to put all information in one place.

for instance a lady with bladder issues, eventually plucks up courage to go to docs...does that info ever get put anywhere back to hospital? no!

Many women suffer in silence.

No mini I mean the brigade who refuse to accept that often labour, no matter what you do before and during will simply be dangerous and life threatening and no matter how many floors you scrubbed before, no matter how mobile you were, no matter how this that and the other you were ...that baby would have still got stuck, come out wrong, the nail sliced the vag on the way out, chin got stuck, and so on.

Some posters on here seem to think problems only occur because the mum did or didn't do something ot they didn't get good care.

Labour and birth is un predictable.

What 'brigade' is this?

I don't know anyone who doesn't acknowledge that things sometimes go shit shaped in labour even with optimal care.

Acknowledging that care isn't always optimal and that much can be done to improve birth outcomes is a completely reasonable stance.

As for 'there is no way of recording' - well that's the point of research into birth outcomes. That's how the RCOG came up with its guidelines on c/s and VB. I get your pint about women not presenting at their gp with problems - but this is just as true for women who have ongoing problems with their c/s wound. I know plenty of people with really negative feelings about their c/s wound - who have a bad overhang, nerve damage, scar lopsided, wound sensitivity, keloid scarring, who have never been back to their GP.

I had my DS, first baby, at Christmas. I had a VB with both ventouse and forceps intervention at the end leading to episiotomy. Sounds bad BUT I have to say, it isn't as bad as it sounds. I was in the birthing pool from 4pm when I was admitted, all the way through until 8pm and managed the contractions with just gas and air, no big drama really. However, the pushing stage was tricky and after 2 hours they concluded that my DS was a little stuck / not progressing and I was out of the pool and across to the labour ward very quickly. 20mins later he was born after both suction and then forceps. Even though those last 20mins were a bit scary (I was worried about my DS being OK) and undoubtedly painful (local anaesthetic only does so much!) I was up and about very quickly afterwards and very well for not having had any pain relief other than G&A. It hurt to sit down and I would say at 17weeks post partum it is still not 100% right, I do think I am well on the way. I have been exercising heavily and resumed both sexual activities and all aspects of normal life (which actually I did at about 6-8weeks). It just doesnt feel 100% normal down there (and I have to drink a lot of prune juice to avoid having to strain!), but I think it will get there.

So, in short, if you had told me I would end up with VB with invention BEFORE the birth, I would have gone for an ELCS. With the benefit of hindsight at 17 weeks post partum, I think I would probably attempt a VB second time round. The experience and the damage are not great BUT I would not swap them for major surgery. It is a very personal choice though - there is no 'easy option' (i.e. I don't think you're likely to get out with everything totally intact - but it's probably all fixable!) so it's about weighing up which has the best pros / cons for you as a person. I am active and didn't want the longer recovery time or the scar, but I can totally sympathise why you wouldn't want an episiotomy!

Good luck!