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?!

I had a VB with ventouse, one stitch afterwards. Recovery was quick, walking about next day, back to exercise quickly. CS next time and was more than 6 months before I felt I could do vigorous exercise like running. My abdominal muscles took a long time to heal from the surgery.

There is a slightly higher risk of needing a transfusion (these are most likely to be emergency sections)

I lost a lot more blood with a planned c section than emergency.

And I don’t think planned vs emergency would make much difference to risk of infection for most people. I know plenty of people who have have planned sections and gone on to develop an infection.

One piece of research that influenced me was that female gynaecologists tend to opt for ELCS

Surely this is because they see the worst cases. Because midwives favour VBs themselves?

Is it really only 50% chance of an uncomplicated birth?

What counts as an uncomplicated birth?

I was induced with a pessary which worked & that was it, no other intervention. I had a very mild if that's the right word 2nd degree tear, weren't sure I needed stitches. No discomfort or pain healing. Would that class as complicated or uncomplicated?

I think a straight forward induction with no assistance would be an uncomplicated birth. I mentioned above that RCOG states on their website that 1 in 3 first time mothers need an assisted vaginal delivery, on top of that would be those having EMCS so you can see how they get to 50%.

I had first time ELCS due to breech baby followed by a VB. Currently pregnant and if it goes to term I'll probably opt for a VB again if I can. I'm think I might be one of the lucky ones from the stats with a VB, short labour and a small episiotomy. Recovery was infinitely easier than CS. I really loved being able to get up and walk, felt light as air straight away without weight of a baby. With the CS the worst thing was just feeling so helpless the first night but I do think things have changed now, I think they want you up and walking again asap. I had a whole night with a catheter when I couldn't move. Antenatal wards are quite busy so I much preferred being able to take care of myself, go to the loo, get a new pad. With CS we didn't have a bedside crib so I had to buzz every time I wanted to get to the baby. It also meant the private rooms the hospital had available weren't an option as needed the extra help and the ward was loud. (Tbf they weren't with the second as full that time!) It might all be different in your hospital, especially as I think I'm some places your partner can stay and help but just some things I experienced.

A huge number of FTMs are now induced, that must have a sizeable impact on the outcome stats.

To give some contrast to other posts I had a home birth with my first and so far only DC, went swimmingly. I had some tearing and stitches but it’s all back to normal now. Doesn’t even look any different and I didn’t notice it happen at the time.

I did the same research as you OP and looked in great depth at the statistics etc and I opted for an ELCS.

Apart from physical injuries, 10% of women are diagnosed with ptsd following labour, and it is thought that a further 10% may have undiagnosed ptsd. That is shocking.

My ELCS was a lovely experience and I healed wonderfully. EBF from the first hour. I was so happy with my choice (The only downside being 4 nights in hospital which is standard for CS in my area. Next time I will insist on going home much earlier).

I also did pelvic floor exercises 3 times a day religiously in pregnancy and never so much as a hint of issues post partum. The squeezy app is good for this.

Any replies you get here are going to be anecdotal, so not sure how helpful this is. I’m 36 and my first birth four years ago was a three day labour, with induction, ending in trial of forceps delivery and then an emergency C - Section. Recovery was hard, wound got infected, and breastfeeding was tricky to establish. This time round (6 weeks ago) I had an elective C section and managed to breastfeed really easily, milk came in within 2 days, wound healed really quickly and was driving and up and about within 3 weeks. Not sure if that was due to being an elective, but if I had another I would definitely go for the elective c section again rather than risk labour. However, this is just my experience and I’m sure there are loads of great stories about successful vaginal births and horror stories about c sections 🤷‍♀️

You write as if you being in the ‘lucky 50%’ is purely random, when a lot of factors are in play that could help you to get into the 50%, such as your fitness levels, your general health, your weight (both pre-conception and in pregnancy), the methods you use in early labour (how active you are and how much you stay on your feet/bouncing on a ball - basically not laying on a bed for hours), etc. I know there are a lot of unknowns when it comes to labour and there appears to be an element of luck, but there is also a lot I believe you can control to give yourself the best chance of getting into that 50%. I was ‘lucky’ and my DD was born at home in a lovely waterbirth, she is my first and I laboured very quickly with zero issues. I was also incredibly active and fit during my pregnancy and stayed active during labour. I did a lot of hypnobirthing studying and classes and followed that approach throughout. I do count myself lucky, but I also think I did everything I could to get that birth. This isn’t to say others who have had problems haven’t also done everything they could, they were just in the unlucky 50%. So, what I’m trying to say is that there is some luck, and it’s true to say anything could happen, including some pretty horrible things, but there is plenty you can do to improve your odds

ELCS without a doubt. I too share your cynicism that the only real benefit of a VB is a cost saving to the NHS and it's actually disgusting how the figures for ELCS are mixed up with EMCS.

DD turned breech so I was offered an ELCS and it was a dream, compared to the noises I heard from the poor women on the ward during their 'natural births'. If you check out csection rates across the world you'll see that the obsession with natural births is very much a UK thing and most other countries have the attitude of what is safest and simplist is the best option, and in most cases that is a ELCS.

Recovery in no time and no complications, and the same was said by all the mum's I know who had the same. The stories from several of those who were 'encouraged' to try for a natural birth really are horrific with either themselves or baby being put needlessly at risk just so we could save some money/midwives could feel like they're still useful. I'm cynical though..

I basically came to the same conclusion as you. The conflation of EMCS and ELCS is a crock of shit.

I am a “1-2er” and 36 weeks with my first.

I have my ELCS booked (I was prepared to fight and also to pay for private if i needed to) and am delighted with my choice…
let’s see if I feel the same way in 6 weeks

This was me 6 months ago, I did the same research and requested a section. As it happened, baby had reduces growth so the consultant advised an induction at 38 weeks. I agreed, as long as I could request a section if an assisted delivery was looking likely.

I wish I had pushed for the section. I stopped the induction at about 30 hours in (no progress at all, baby back to back in awkward position) and requested a section. Midwife said no, that I'd be "putting my baby at risk needlessly". I requested to speak to the consultant who agreed immediately.

Baby was born the next day via section. He was very much stuck in there and they had to use forceps (only lightly) to get him out! I reckon if I had continued with the induction I would have ended up with an EMCS anyway.

Good luck whatever you decide!

I had an emcs after a long long labour as DS was too big to exit and an unplanned vbac.
Disadvantages of the CS. Sex was agony for months, especially the orgasms. We had sex twice in the year after DS was born.
My scar is still numb. Recovery was easy for major surgery but I still got stuck in chairs, couldn’t lift for weeks, had to take painkillers.
Had a couple of incontinence episodes in the first few months. Wet the bed, had to take change of clothes out with me incase. It did resolve its self.

Disadvantages of the vbac. It was really painful during the pushing stage and I’d run out of painkiller options. Had an episostomy (sp) as I couldn’t get dd out with out one. It healed really quick but the doctor spent ages sewing it up after the birth. Was a bit sore after so did take the odd painkiller. Pushing gave me one pile that occasionally flares up but no bladder issues.

I’d take a vb over a CS any day.

I think what @canyoutoleratethis says is very fair and its good to weight these elements up.

Have you looked at the statistics for those elective CSs that turn into emergencies during surgery? Are they included in the elective statistics?

Wow you've done a lot of reading.

I was in the lucky 50%. I had a third degree tear with my first but no pelvic complications arising from pregnancy or labour. My second birth was a beautiful relaxed water birth with no tear at all.

For me, an elective c section would have been a stupid idea. I'd have gone through a lot more pain and risk more long term consequences than having my vaginal births.

The thing about birth though is you have no idea what birth you'll have until you have it. Even a straight forward c section could result in infections or bad scaring etc.

Personally, unless there's a medical reason to go for a c section, Id try a vaginal birth but if it helps have a clear stopping point for you to request a c section. That could be a few stopping points, e.g induction or labour over x hours or pain level making you want an epidural etc.

I think your assumption is wrong. Babies born by ELCS are more likely to be admitted to SCBU for respiratory support due to their lungs being unprepared for birth and not having undergone the physiological changes which occur during labour. If a labour results in an EMCS then baby’s lungs have been prepared for breathing due to the labour homes. This does not happen for ELCS. Babies born by LSCS have not have the fluid squeeze out of their lungs which happens as baby passes through the birth canal so they are at significantly higher risk of transient tachypnoeia of the newborn

I had ELCS for the reasons you state, op.

Good places for stats are the Birthplace study, which has outcomes broken down by age, and the NICE guidance on maternal request c section (health economic section)

Be aware that some hospitals make it (extremely) difficult to access a maternal request section - see the webpages of Birthrights for more info

@Treacletoots

ELCS without a doubt. I too share your cynicism that the only real benefit of a VB is a cost saving to the NHS and it's actually disgusting how the figures for ELCS are mixed up with EMCS.

DD turned breech so I was offered an ELCS and it was a dream, compared to the noises I heard from the poor women on the ward during their 'natural births'. If you check out csection rates across the world you'll see that the obsession with natural births is very much a UK thing and most other countries have the attitude of what is safest and simplist is the best option, and in most cases that is a ELCS.

Recovery in no time and no complications, and the same was said by all the mum's I know who had the same. The stories from several of those who were 'encouraged' to try for a natural birth really are horrific with either themselves or baby being put needlessly at risk just so we could save some money/midwives could feel like they're still useful. I'm cynical though..

Obsession with natural birth - a few points on that.

First c sections are life saving operations. Nothing against them at all.

BUT as women living in the UK we have to check our privilege a bit here. We live in one of the safest countries in the world in which to give birth. Our maternal and infant mortality rates are very low. Add to that, however we give birth, we leave hospital without a bill. No woman here has to factor cost to herself when deciding how to give birth.

So ... other countries without the 'natural birth obsession'. Don't kid yourself that they have higher rates of c sections because it's always in the woman's best interest.

It can be because of shortages of qualified midwives / doctors. It can be because parents have successfully sued doctors for massive damages after autism diagnosis and claims it was due to a vaginal birth, this pushes up insurance premiums and makes doctors fearful of assisting a natural birth. Don't forget that scheduling all your mothers to deliver Mon- Fri 9-5 helps the work life balance too.

If a woman in the UK wants a c section she can have one. The point of the consultant appointment is to ensure she is fully aware of the risks before undergoing major surgery. Same as any other type of surgery.

Purely anecdotal here as well but I had 1 EMCS and then 2 electives. Absolutely zero issues with recovery. Of all my friends it is the ones with natural births who have had longer term issues and pelvic floor problems.

Why does so much of the information conflate EMCS and ELCS together?

Women considering an ELCS will most likely be avoiding an EMCS all-together so emergency c-section risk is actually more applicable to those opting to attempt vaginal birth.

Surely it’s in the best interests of women to have clearer and relevant information when they’re making such a big decision? If I’m considering a ELCS for my first baby the risks of a third or fourth c-section or of an emergency c-section aren’t particularly relevant. It’s a shame, especially when you hear of women being given these mixed-up statistics at actual in-person discussions with doctors.

This is why I'm having a private elective !

Had a CS, amazing birth experience. No pain after, easily picked up my baby, breastfeed in the delivery room straight away. Was walking with my baby a few days after. Sex about 2/3 weeks after, slightly painful at the beginning but think that was due to nerves as thought it would be painful but wasn’t! Minimal bleeding after the section, no ural/gastric issues. 100% would have it again.

I had an EMCS for my first and am having an elective for second. I could technically try for a VBAC but I found my section actually very easy and have been left with no issues, so it feels more of a known quantity I suppose. I was sure I would have a vaginal birth for first but now I'm quite glad I didn't.

I'm also very nervy about baby getting stuck. A friend's baby was deprived of oxygen during birth and ended up with fairly severe cerebral palsy, and the thought of that terrifies me, that a healthy baby could become badly disabled just as a result of the birthing process. I know there's always a risk with a section too, but it feels far more controlled in terms to actually getting them out.