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 was in the same position as you a few years ago. I felt the ELCS was probably a better choice for me (35, first baby) but didn't have the nerve to push it. When I got to 41+6 and an induction was on the cards I was lucky to be seen in the labour ward (having been kicked out of the birth centre, where I hoped to have my happy vaginal delivery, for being post-dates) by a specialist in urinary incontinence and bladder damage who was visiting / observing for a few days. He had a more detailed look at me, observed that I wasn't at all effaced or dilated (Emily Oster's book has good stats on this - predictive of normal vaginal delivery or not) and recommended a c-section. The baby turned out to be 9 1/2 lbs and awkwardly positioned, and there were also undiagnosed problems with the placenta that could have led to a very difficult delivery/ emergency section. This after the event. My recovery was very easy. However, the same situation two years later led to an easy choice of ELCS but that did not go so well -- even bigger baby, massive haemorrhage. I think the first surgeon was quite skilful and the second a trainee. But still rather difficult to say. I felt somewhat envious of friends who'd had a vaginal delivery the first time (often long and tricky) but who breezed through a short labour for the second.

If you might want to have a large family, I would probably try for the vaginal birth. If you're completely sure about keeping it to one or two then I think the risk-averse and prudent option is a c-section. And that's just thinking about you. My babies had Apgars of 10 and 10 (apparently quite rare) and 9 and 10 and were very calm, alert and breastfed well. Neither has any allergies. From their point of view a vaginal birth couldn't have gone better. From mine, a good one would have been better, a bad one much worse.

@canyoutoleratethis

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

Absolutely this!

Women who have active pregnancies and labours, where they keep mobile and aren't stuck on a bed with an epidural often have better outcomes. Again, is only my experiences caring for women in labour and delivering babies.

If I was you OP I'd get a consultant appointment booked in before 36 weeks to discuss birth options.

Personally I'd make a plan to go to term, plan for a NVD, if no baby by 41 weeks, instead of induction go for an ELCS.

If you are labouring and everything's going well, it's not very often than things suddenly change for the worse. For example if baby isn't coping well we can see this before things become an emergency, often hours before, but we tend to take a watch and wait approach where safe.

Explain to your midwife you want a section at the first signs of abnormality rather than waiting until you're fully, having a trial for forceps and EMCS. Speak to the consultant about how this could work. There's obviously no guarantees.

Wow, this has generated some interesting discussion. I think it is quite fascinating that the people who have shared my concerns and have looked into the outcomes have come to the same conclusion as I have.

I will try to respond to the issues and questions raised...

Just planning 1 or 2 children max. I have had a discussion with the obstetric consultant whos care I am under, this was very straightforward to arrange. She has left the decision in my hands. Definitely not for induction. If I go into spontaneous labour and all is progressing well, with the baby in a suitable position I may consider carrying on down that pathway. Otherwise planned section in the 39th week.

I realise a lot of the information on here is anecdotal. Interestingly, I have been asking my post partum friends if they have any long lasting effects and it seems the vb ones largely have urinary symptoms while the CS ones do not. Not v scientific, and I am aware pregnancy in its self can cause pelvic floor issues regardless of delivery mode. Again anecdotal but the VAST majority on this forum that have has a vb then elective section have preferred the section and have recovered well.

Risk factors for age- more likely to need instrumental delivery.

Sorry to hear of the difficult recoveries from Em CS and associated trauma. I think the trauma surrounding childbirth can be quite significant. This organisation appears to offer considerable support to those that need it www.birthtraumaassociation.org.uk/

I take the point that a vb "complication" may be something relatively insignificant eg a minor tear. There was a paper I came across though that suggested vb increased the chance of having needed pelvic floor surgery by aged 80 and a risk factor was previous tears.

I am glad I am not the only on to be cynical about the motivations for promoting vaginal births! I have never come across anyone who had even thought of this factor.

I have not come across the fact that female gynecologists opt for elective sections- very telling!

It does seem reasonable that preparation can help- eg being physically fit, being psychologically prepared and having a calm environment can help. I suppose it would be hard to quantify the benefits of this statistically.

There do seem to be a lot of inductions, I am not sure if these people are catagorised separately. Would be great to see that information.

I do not have any information on elective sections that turn into a more emergency situation. I suppose there are still differences including the woman has not laboured and not dilated etc. I suspect those patients are included in the elective numbers.

Babies born via elective section are at risk of needing SCBU for resp support. This is for transient tachypnoea of the newborn. Fortunately, as the name suggests, this is transient.

I think its a good point to raise that a planed CS occurs during working hours, with a consultant present, a full theatre team. Its not 3am with the most junior staff who are likely to be tired.

Agree completely that the data for emergency and elective sections should be separated. Perhaps it is, I'll do some more digging!

Thanks again everyone for contributing! Would still love to hear more thoughts or experiences....

I had a very straightforward vaginal birth for DC1, DC2 was an ELCS as she was breech and it went very wrong (won't go into detail). Almost ended in a hysterectomy and my stomach was black and blue for weeks.

I understand most ELCS go well (and I did subsequently have a positive one in which they carried out repair work) but they aren't completely risk free as most seem to think.

I would also say that I felt no pressure to have a VB with either birth. It was left up to me entirely. I was told no horror stories or horror stats about CS. I heard many more horror stories about VB and actually my VB was absolutely fine despite not being straightforward. No ongoing issues for either of us. My ability to hold pee is significantly better than my sister's and she doesn't have any children and has never been pregnant.

So, just to offer balance. I think my experience of being convinced one way or the other was the complete opposite to what is suggested in the op. If anything, I felt pressure not to go for VB based on 'horror stories'. I know I was very lucky btw with my recovery in particular, and that the horror stories aren't made up! They do happen, of course. But I heard so much about the agony I'd be in, the 'frankenfanny' etc and it just wasn't my experience at all.

And I was shocked at my ELCS recovery not veing a complete breeze based on stories. I had heard nothing about it being as hard as mine was at all, from Hcps or anyone really.

Not that it would have made a difference tbh, as it would have been riskier for dc2 for us to have attempted another VB as there was risk of another shoulder dystocia, which is elevated after you've had it once already as I did. So, the shit recover was worth it for us

Before giving birth I was terrified of the thought of tearing or having an episiotomy. Thought I would reject any attempt to give me an episiotomy.

In the end I had an episiotomy and a second degree tear. I needed a lot of stitches.

However...it just wasn't that bad. It was nowhere near as bad as I had feared. Not in the slightest. I didn't require a jug of warm water to soothe my 'bits' whilst using the loo, for instance.

Things were a bit painful for a few weeks post-birth, but I imagine a C-section wound would be painful as well.

What I'm trying to say is that while I'm one of those women who required interventions during childbirth, in the end those interventions just weren't a big deal.

All I will say is that if they start to discuss induction, just got for a ELCS. "Normal" deliveries work well in under 30s, but in over 30s, the risk of complications does go up. Of my NCT group of 4 mums, we all have 2 children each and 6/8 were c sections (all planned) and 2/8 were vaginal but both were instrumental. The 2/8 did not recover well and one still has complications, and they both went on to have their second children via ELCS.

Depends on what the unfortunate 50% are enduring, if lots of these are grade II tears for example or having an epidural then much less than 50% are actually having a traumatic birth. If the 50% are third degree tears plus or needing instrumental delivery then I can understand preferring an elective c-section.

Tbh, I'd always go for a vaginal delivery, however an elective c-section is never going to have the same outcomes as an emergency one and I can well understand why someone would opt for it.

I should add, totally put off a c-section as I can't tolerate opiates, so much as a small dose codeine as pain relief would have me vomiting profusely and I don't think paracetamol right after surgery would cut it for me. I would consider maybe it I could take opiate analgesia.

Just wanted to say thanks so much for this thread as I’m at 31 weeks and have been having exactly the same thoughts. I’ve kept very active during pregnancy and practiced hypnobirthing and used the squeeze app. About to start perineal massage too.

I’ve struggled to find reliable stats broken down in a way that’s useful for me but anecdotally my friends who have had c-sections have all recovered well (both emergency and planned).

Of my friends who have had vaginal births, about half had dream water births with no after effects, whilst the other half have had horror stories with ongoing issues, PTSD, trouble feeding, prolapses that required surgery etc. This is my absolute worst fear as I’m very sporty and it would kill me to have to give all that up.

Inductions seem to cause a lot of the problems, so I’ve decided to ask to book an elective c-section as close to due date as possible. If I go into spontaneous labour beforehand I have hopefully done enough prep to be in the lucky 50%

@Movingsoon21
You sound similar to me in that a bad tear/ pelvic floor issues that impact on sport in the long term would be an absolute disaster.
I still waver but, for the short term potentially longer recovery time for a section there seems to be some protection in the longer term when it comes to pelvic floor/prolapse problems. Of course, there is a small risk of complications even with a planned section done by a consultant in day time hours, but this seems smaller than an Em section in the middle of the night.

With a vb, you roll the dice and you could have a great outcome or a total horror story with long term consequences! It’s the impossible task of trying to make a decision without knowing what the outcome would be if you took the other choice.

@FirstTimeMama848484 agreed! Will let you know what my midwife / the consultant says after I speak to them later this week.

Best of luck with your decision, fingers crossed we both come out the other side with no damage!

[quote FirstTimeMama848484]@Movingsoon21
You sound similar to me in that a bad tear/ pelvic floor issues that impact on sport in the long term would be an absolute disaster.
I still waver but, for the short term potentially longer recovery time for a section there seems to be some protection in the longer term when it comes to pelvic floor/prolapse problems. Of course, there is a small risk of complications even with a planned section done by a consultant in day time hours, but this seems smaller than an Em section in the middle of the night.

With a vb, you roll the dice and you could have a great outcome or a total horror story with long term consequences! It’s the impossible task of trying to make a decision without knowing what the outcome would be if you took the other choice.[/quote]
With a first baby you roll the dice with a c section as well.

I've got a friend who's had 2 sections (one was a twin pregnancy) and 3 years on still has pelvic issues. Cannot sit for long without serious amounts of pain.

2 other friends who've had planned c sections have issues with holding urine.

Of those 2 one wasn't able to even step over the threshold of her flat without pain for 3 months. She dreaded her second planned section recovery because she had moved to a place with stairs.

One friend couldn't have sex for 9 months after their planned c section.

3 friends got infections after their c sections.

2 had to have generals for their sections. 1 still has issues with headaches after her section (not sure if epidural or spinal or if they are the same thing)

All our kids range from 8 years to 4 months

Me? Two vaginal deliveries and a third degree tear - no pelvic issues, no wee issues, no long term pain or damage. Big into spin and yoga and can do both with no issue.

A c section is no guarantee against long term complications.

You sound similar to me in that a bad tear/ pelvic floor issues that impact on sport in the long term would be an absolute disaster.

If impact on athletic ability is a huge factor - which is absolutely reasonable - then you seem to be underweighing the impact of having your core muscles sliced through in your calculation?

@Movingsoon21 @FirstTimeMama848484 I could have written both of your posts.

I’m having pregnancy physio with a lady who specialises in post-birth injury. She has confirmed my suspicions - avoid an induction at my age (late 30s) as the cascade of interventions is so risky. She spends her days helping postnatal ladies so I suspect she knows what the outcomes actually are across the board, not n=1 personal experiences.

My plan is to schedule a c-section close to my due date and hope she comes naturally beforehand.

@lolololloo

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.

I had a very similar experience. With hindsight I wish I'd pushed for a caesarean first time round.

@TrippinEdBalls just from the people I know (although I do know a lot of women who have given birth), none have had any issues at all with a c-section recovery. None have even had the “small” issues you hear about; like not being able to walk far or lift things. They’ve all been back to normal within a few days. But maybe my friends and relatives are in an abnormal sub-group for this?

I don’t know.
I had a large baby (8lb8), and I’m small. He was born with arm above head. I had small episiotomy which didn’t hurt during or after. No issues since.

3 friends or family have have c sections in the last 18 ish months. All issues. My sil had baby 2 weeks after me ( 20 ish months ago), and still can’t lift anything as says her stomach core muscles are just shot. She can’t walk up more than a slight slope without muscle pain from where she was cut.

A c section is a necessity often, but it is major surgery. I would have though more issues with c section and then major sport fitness

I opted for ELCS for many similar reasons as you OP. The best outcome is a straightforward VB but nobody can guarantee you that. The second best outcomes are from ELCS. I didn’t want to take the unknown chance of not being in the former.
It’s true that many obstetricians also have ELCS but it is a biased cohort as they normally deal with complicated births which can have a profound impact on them emotionally and mentally.

What I would caution with what you’ve said is having ELCS by a consultant in the day and an exhausted junior at night for EMCS. That is certainly not the case. In many instances, you won’t get a consultant day or night, but you will get a senior registrar. The consultant will do the surgery if the registrar is unavailable, day or night.

No issues with my CS, pelvic floor totally normal as pre-birth, recovery was great and I’m choosing it again for DC2.

Like you OP I did all my research on types of birth.

I came to the conclusion that I absolutely could not do a VB as the risks involved were unacceptable to me personally.

My personal experience of two ELCSs are that I absolutely made the right decision and I wouldn't change a thing. Incidentally both were eventually deemed medically necessary, DD1 turned breech a few days before my planned date and DD2 was resolutely breech at every growth scan from 28 weeks.

I had some extra factors in choosing elcs over vb, type 1 diabetic so already classed as high risk, induction by 38 weeks was standard and I was very much against induction, high risk of emcs, high risk of intervention due to my condition, induction etc etc and most of all a risk to babies born to diabetic mothers of shoulder dystocia which can severely disable and kill otherwise healthy babies due to lack of oxygen.

DD1: ELCS became EMCS as I went into labour two days before my planned date, I still don't think of it as an emergency as it was performed during very early labour and was still a very calm experience. Lost less than 500ml of blood, up and in the shower less than 12 hours after, slowly plodding about the ward and caring for baby myself. Had to stay in 4 nights as she had jaundice (common in babies with diabetic mums especially when born before term). Out for coffee and lunch when we registered her at 6 days old, walked to and from registry office. Minimal post operative pain, well managed with paracetamol and ibuprofen. Took lactulose in hospital as I was terrified of the first bowel movement, i didn't need to be. Sent home with blood thinning injections to use until 10 days post op. No infection, scar healed well. Minimal bleeding/lochia. Waited the advised 6 weeks to resume sex to reduce potential risk of infection at the wound site left by the placenta. No discomfort or any other problems.

DD2: ELCS, less than 500ml blood loss (surgeon laughed when I said that was my aim for this op as that was my last blood loss, she told me it wasn't possible, had to eat her words after 😁), up and showered within 12 hours, slowly plodding about the ward and looking after baby by myself. Discharged within 24 hours. Minimal pain, managed well by OTC painkillers. Blood thinning injection for 10 days again. No infection, scar healed well. Minimal bleeding/lochia. Again waited the six weeks before sex and again no discomfort and because this baby sleeps sex life was back to pre pregnancy from then. Out for lunch on day 4, driving on day 13. Back to Pilates within the 6 week time frame and rock climbing (indoor wall) by week 7. My legs did swell up like tree trunks but that was my own fault for not wearing the compression stockings, so in fairness there is one thing I'd change and it's that.

Neither of my girls required help with breathing and both were born with an apgar score of 7 at minute 1 which was a score of 10 by minute 5.

I had really crap pregnancies so think the universe did me a favour by giving me fantastic births. I know I'm very lucky.

I wouldn't hesitate to recommend ELCS and my DM who suffered awfully after two difficult VBs thinks despite having major abdominal surgery that I got off easier with recovery than she did. She had to have corrective surgery for incontinence after suffering in silence for years.

@FirstTimeMama848484 are you any further in your decision-making? My midwife won't discuss birth choices etc until week 36 so I'm in limbo for another 4 weeks...

@Twizbe your post inspired me to do a bit of anecdata on my own friends/close family.

The stats were:

Out of 23 births, 3 were planned c-sections (all for second babies). All 3 of these went really well and recovery was very quick. Back to exercise in a normal amount of time, no lasting impact at all.

Of the other 20 attempted natural deliveries:

• 10 were "good" births with no trauma and limited intervention (one had pessary but then normal labour and two had epidural but otherwise normal labour, no injuries; but rest had water birth or just gas and air). 2 of these just happened to be really quick and relatively easy, and the rest swore by hypnobirthing.

• 7 ended up with EMCS, mostly after induction, or taking too long after waters breaking, failure to progress, etc. All of the c-section impact healed well and recovery was good. However 4 of the births ended up with lasting trauma/injury from trying to push for too long.

• 3 were horror stories, involving induction, forceps, lasting injury, trouble feeding etc.

So from my friends and relatives' experiences, all of the c-sections were good and healed well, quickly. The natural labours were 50% good (which is great for those women!), 35% not great/quite stressful and 25% awful.

@Movingsoon21 do you know for the 20 attempted natural births if they were first babies or not? I think that makes a big difference if a woman has already laboured previously

@Fretfulmum good point, just done the maths and two of the attempted natural births were second babies (these were both “good” births).

All 3 horror stories were first births (two of them then had planned c-sections second time round)