Some stats- is a planned C section better?

[FirstTimeMama848484]

I am due to deliver in the next few weeks and after a lifetime of assuming I would proceed to labour and a straightforward delivery, I have started exploring the pros and cons of a vaginal birth. I’m 37, 32/40 just now, first pregnancy.

I understand that no option can be guaranteed to be risk free, however looking at the scientific evidence I wonder if an elective section may have the best long term out comes.

The chance of an uncomplicated delivery for a first delivery looks like it is about 50%. For the lucky 50%, the benefits include less respiratory issues for baby, sooner skin to skin, quicker recovery and same day discharge. Embarking on a normal vaginal delivery results in around 50% of with no risk factors, having complications such as the use of forceps or vacuum device, emergency caesarean delivery, obstetric anal sphincter injury, postpartum haemorrhage, or neonate born with an Apgar score of 7 or less at five minutes.

The unfortunate 50% in the latter group are potentially going to forgo their rapid recovery and other benefits. They may end up with injuries with a substantial recovery time, longer than that of a planned section. Admittedly a rare situation but, a 4th degree tear or significant pelvic floor injury may result in lifelong issues.

When looking at risks of an elective section, it is difficult as most articles have not separated out elective from emergency sections. My local unit quotes the risk of bladder or bowel injuries to be about 0.1% in women with no previous abdominal surgery and a normal BMI. There is a slightly higher risk of needing a transfusion (these are most likely to be emergency sections) and slightly higher risk of the baby needing NICU input (again, likely the emergency sections). Risks of abnormal placentation or uterine rupture in subsequent pregnancies are significant issues, however the risks mainly increase from the 3rd section onwards. Anecdotally, recovery time also appears to be quicker for Elective vs Emergency sections. There are many planned section units aiming for discharge within 24-48 hours, with only simple pain killers given for discharge.

I am really interested in the long-term pelvic consequences of both modes of delivery as I am very athletic normally and would like to get back to this at my previous level. Like any reasonable person, I am keen to avoid pelvic organ prolapse and incontinence issues. Another paper I found discussed the association of delivery mode with pelvic floor dysfunction (urinary incontinence, faecal incontinence, overactive bladder, pelvic organ prolapse) after first delivery. This paper quotes an uncomplicated SVD 15 year incidence of pelvic floor dysfunction at around 30%, operative vaginal delivery 40% and Caesarean delivery 17%.

Overall, it looks like a first time labourer attempting a vaginal delivery has a 50% chance of achieving this with no complications (although longer term risk of increased pelvic floor dysfunction) and any complications making the immediate and long-term situation worse. The best long term pelvic floor function seems to be those having a planned section.

So, assuming one has an uncomplicated elective section (odds seem to favour this) and could deal with the immediate recovery, is the way to go to ensure most optimal long-term outcome?!

Caesarean sections are not without risk as you’ve mentioned - infection, bleeding, blood clots, problems in subsequent pregnancies - but I do think that the risks of vaginal delivery are understated (especially for women aged 35+) and the risks of (at least planned) caesareans are overstated.

My personal experience is that I’ve had a difficult vaginal delivery with a third degree tear that necessitated further surgery a few months down the line; I was fortunate enough to recover ok, but I was advised to go for a section the second time. The recovery from the caesarean was 1000 times easier. I lost a fraction of the amount of blood I lost during my vaginal birth. I was mobile again much faster. My mental health was shot to shit after the trauma of my first birth but my c-section was absolutely beautiful - I bonded with my baby so much better.

Obviously that’s just anecdata - there will be plenty of women who’ve experienced both caesareans and vaginal deliveries and vastly preferred their vaginal deliveries, or found their caesareans very traumatic. But from my experience I would say that a planned c-section is generally worse than a straightforward vaginal birth but significantly better than a traumatic one. But I think women aren’t given enough information to realistically evaluate their chances of getting a straightforward one.

How many children are you planning? At your age etc, if one or max two I would strongly request an ELCS and not stop until I got it.
Personally I had a section and recovered extremely quickly and well. I know my NCT friend had a vb and she was far worse off - recovery took months!
I think your OP is very evidence based so I would write it out like that and ask for some very compelling arguments to agree to vb.

Does going into spontaneous labour affect outcomes? Could you say that you will try a vb if you go into labour before 40 weeks but will want a booked section for that date? To avoid induction which may lead to a cascade of intervention?

Thanks to the above 2 posters for their replies.
Only thinking 1-2 babies max and definitely keen to avoid an induction.
With my cynical hat on… I found something that says a vb costs £1500 and a section £2500. I wonder if that’s why the risks of vb are understated and section overstated

This is only my personal experience, so counts for bugger all really, and it varies so much.

But, I was in the unlucky 50%. Dc1 was a ventouse delivery, with macroberts manoeuvre due to shoulder dystocia and we had the teeniest of cuts to help her out. I think I had one stitch or something very minor like that. Dd did have a low APGAR at birth as well. Recovery was significantly better than anticipated for me. The midwives in postnatal kept offering me painkillers and I didn't need them. I was back to normal within about a week. Sex with the teeniest bit of discomfort within a few weeks. After the first time it was completely normal again. I used something called an epi no in the run up to the birth and I do think it helped

Dc2 was measuring big and due to the previous shoulder dystocia, we went for ELCS. The CS was great! So calm etc. But my recovery was awful. I'd lost quite a lot of blood, I didn't need the loo for ages and they were a bit worried. Not anywhere near enough help on the ward. This was pre covid but even still it was impossible to get help. I really struggled with bfing and dc2 was not feeding properly. Ended up with a stay in NICU, then jaundice etc.

I don't regret the CS, as it was probably the best for us in the circumstances, but I definitely preferred the recovery from the VB.

Sex after ELCS was extremely uncomfortable for months. Think dc2's quite big head was really jammed into my pelvis and they had to really wriggle him about to get him out. Very nearly needed forceps for the CS delivery, but didn't at the last minute

I suffer from tokophobia and met with a consultant obstetrician and expert in pregnancy mental health before even trying to get pregnant to discuss options and risk profile of each mode of delivery. DM if you want to chat more but basically she advised me that there's not much in it on a first baby in terms of risk. If you could guarantee a so called lottery winner VB i.e. no complications, no tearing, cutting etc then that would be statistically a bit safer. But only about 5-10% get those...

Just my experience- I have no medical qualifications or anything like that.

DC1: induced, had a very long labour. Baby got stuck and had breathing issues when born. Had a very traumatic birth and was in a lot of pain afterwards. It took me quite a while to recover and also took my DM contacting the midwife to ask for medicine once I was sent home.

DC2: because of the complications I had suffered with DC1 I was offered an elective C Section. This was brought forward to 36 weeks due to complications but it was a brilliant experience from start to finish. So calm and baby didn't need any extra help (but we were kept in for a week due to her low birth weight and establishing feeding). I had a nurse whose only role was to look after me and keep me calm and she took some amazing candid photos. It took me a couple of days to regain mobility but once up and about I felt so much better then after my natural birth.

Not planning any more but if I did fall pregnant again I would undoubtedly have enough section.

The other positive re the cs was that there was nothing too unexpected. That can make a huge difference psychologically imo. Trauma is when it's unexpected isn't it? So can definitely see why VBs have potential to be more traumatic

Have you also looked at the statistics around age for risk factors as I’m sure I’ve read about this coming into it too although I might be wrong there.

Yes, I should say that my VB was when I was 31 and my CS was when I was 34

I have had an EMCS and a ELCS and I would say my recovery was equal for both. The initial first couple of days were harder after my second CS but once over that I was almost back to normal after a week! And I never needed more than paracetamol/ibuprofen. Whereas after the EMCS it was a little longer recovery, but not much. I lost a lot of blood with the EMCS, but not much at all after the ELCS. My pelvic floor is fine but I’m sure I’ve read pregnancy can affect it anyway so won’t always be linked to delivery method. I’m also sure I’ve read somewhere that age is a factor, so the older the mother the more chance of assistance needed etc. something my consultant mentioned was that you don’t know in the future what surgeries you might have, and having a CS might make any future abdominal surgeries trickier and harder to recover from, and also there could be adhesions which are difficult to fix. My sections haven’t affected my babies (as far as I’m aware) and both were EBF. Just one thing I wanted to mention though is that CS doesn’t automatically mean baby comes out easily, with my ELCS forceps still needed to be used to get the baby out (though no damage to me or baby). Comparing to some of my friends recovery stories I am glad I had sections, both my babies were massive though so I doubt I’d have been one of the lucky ones if I’d have had VB’s 😂

I am keen to avoid pelvic organ prolapse and incontinence issues.

I think CS reduces the risk but do not eliminate it. Pregnancy alone does damage, my 2nd was an elective & my bladder is much weaker than after my VB. My mum only had CSs & had a prolapse.

The CS was 100% the right choice for dc2 but I hated it & apparently had a textbook recovery. I had expected no discomfort which was clearly unrealistic.

As pp said they needed a ventouse for my dc with the CS

I was 37, had a failed induction & emcs. If I was you I would definitely refuse induction & go straight to Cs & also not stay in labour too long before converting to emcs because there is nothing worse than being sleep deprived having been in labour for over 24 hours & then having to face emcs. I would also try to avoid an epidural or spinal because it can lead to more interventions.

It took a good couple of months for me to heal after my emcs.

I had stitches that should have dissolved not dissolve, I had the ends of my wound burst open (I wasn't overdoing it), I had cellulitis it was hell. I'll never have another child after going through the hellish induction and then a horrible recovery.

It's only 7 months later I'm begining to realise I have trauma from the experience.

Interesting discussion OP. One of the things that would concern me about a section is the thinking about CS babies having more allergies etc - although I don’t recall the stats and the range of babies’ outcomes compared. Maybe I’m sucked in by the ‘natural birth’ narrative but there have to be benefits to babies coming out in the way that they do vaginally?

I’ve had 2 VBs and had a mild prolapse after the second. Physio said the likelihood is that the first baby did much of the damage due to a very long labour, then second labour finished it off by being v quick but v large baby. However with physio support and me losing weight and improving my fitness, it’s really not a big deal. I could never have called myself athletic like you but my fitness is better now than it has ever been, so I’d imagine with your prior fitness, barring serious birth injury (how many of the 50% would be considered serious I wonder?), you’d have a good chance of returning to it.

I have had two straight forward spontaneous vaginal deliveries. Easy recovery, no complications. I tore both times, 2nd degree, needed stitches. That was all. Aged 35 and 40.
I agree with PP who said that induction generally leads to interventions.
As you gather the stats it would be very important to establish how many spontaneous labours ended in emergency C-section vs how many inductions ended in emergency C-section.
If I was to be induced I would want to go straight to c section and skip the induction. If spontaneous I would be happy to go ahead with vaginal delivery. (just my personal opinion)

Can I recommend Ina May Gaskin's "Guide to Childbirth" , she discusses interventions and their consequences in a balanced fashion.

I did the same research and calcs as you and came to the ELCS conclusion. It was the 30% long term pelvic floor issues stat (from my consultant) that swung it for me. The ELCS recovery was hard going for the first couple of days, but now I’m a few months out and my body feels totally back to normal.

Your point about relative costs isn’t cynical, it’s accurate. It’s well documented that NHS is incentivised to encourage vaginal birth for this reason. At a population level, it makes sense.

I’ve been doing the same sort of research and calculations recently as I’m also a geriatric first time mother. I have the added complication of previous pelvic surgeries for endometriosis.

The RCOG say that 1 in 3 first time mothers have an assisted vaginal birth. This is across all age groups. To me, that risk is pretty high and in particular I’m not willing to be induced under any circumstances.

What I’ve settled on is a planned c-section with the proviso that if I go into labour naturally at any earlier stage, I’m happy to try.

This is interesting. Do the FTM vaginal delivery stats include induced labours or are they all spontaneous?

One piece of research that influenced me was that female gynaecologists tend to opt for ELCS. Then a kind friend pointed out to me that as we age our pelvis starts to fuse. My consultant (was already consultant led as old & monitoring DS) didn't put try to dissuade me when I brought the subject up. No regrets.

Is it really only 50% chance of an uncomplicated birth? I'm glad I didn't know that statistic before my first.

I know this might sound a bit hippy dippy, but have you considered how factors like birth environment and support might help to reduce your risk of certain interventions or complications? I planned a home birth with my first baby and although I transferred into hospital fairly early in labour I was told that statistically just by booking one I'd halved my chances of an emergency c-section. There are also really good stats that come out of situations where women are allowed to labour in a way that respects their bodily processes etc. Obviously that can't account for all risks and possibilities but if you're concerned about recovery then it probably does make sense to look at options which maximise the chance of a lower risk birth. And then potentially opt for a section at the first sign of anything being not quite right. That was always my broad strategy anyway, and it seemed to work well for me three times over. When DS3 went breech at 36 weeks I signed the consent forms for caeserean immediately, but he turned around again so I didn't need one.