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C-sections done when a woman is already in labour or for unplanned reasons such as injury, trauma, or severe bleeding are considered emergency caesareans. In contrast, elective caesarean sections are planned. An elective caesarean might be needed if the baby is positioned abnormally, there are active infections such as HIV or herpes or problems with the placenta. A previous caesarean may lead some women to choose an elective caesarean for the next birth.
In Canada, some women request a caesarean for a variety of personal reasons not considered valid in the past. In some societies such as upper-class Brazil, these requests have resulted in a caesarean rate close to 90 per cent. The term ‘too posh to push’ has been used to describe this type of elective caesarean.
The best results for mothers and babies occur with a normal labour and vaginal birth. More complications, particularly bleeding and infection, occur with emergency caesareans. Between these two methods are operative vaginal births (vacuum or forceps) and elective caesareans. It would be simpler to make decisions if doctors could guarantee ahead of time who will need a caesarean.
There are many pros and cons of a request caesarean. Clearly, we don’t have all the answers to the questions and issues raised. As a result, this remains a difficult problem for women and their caregivers.
| PROS OF CAESAREAN BY REQUEST |
CONS OF CAESAREAN BY REQUEST |
| Freedom of Choice | Common Sense |
| Today, women can choose to have a career or stay at home to raise children.They can also choose many surgical procedures such as plastic surgery to their breasts or liposuction to their hips if they wish to pay the cost themselves. Shouldn’t a woman be permitted to decide which method of birth she wants for her baby? | Labour and vaginal delivery are the normal end result of pregnancy. It just doesn’t make sense to perform a technical procedure to replace a normal process when nothing is wrong. Past history has shown us that to embrace technology for technology’s sake has been a mistake. Assumptions have been made before in regard to labour, delivery and newborn care. At one time episiotomies (a cut into the perineum, which is the area between the vagina and the anus) were done routinely. The cut was thought to protect the perineum from worse damage associated with vaginal delivery. Routine episiotomies have since been proven to increase the chance of significant injury. Baby formula was advertised as an ideal replacement for breast feeding. It has since been shown to be an inferior method of feeding babies. Is there any reason to think that doing elective caesareans is any different from these and other past mistakes? |
| Convenience | Convenience |
| Many women want to know when their delivery is going to occur. If it is booked ahead of time, they will be able to plan for work leave and arrange care for other children. Their mothers can come in from out of town in time for the delivery. Their partners can book off work for the day. For some women, certain dates are important for their child’s birthday. Or, they would like to avoid birthdays on dates such as Friday the 13th for superstitious reasons. Women who do not wish any future pregnancies may believe that by booking a caesarean, they can also have a tubal ligation done at the same time. (A tubal ligation is a permanent form of birth control.) They believe this will save them another operation later. | Believe it or not, birthing and raising children can rarely be considered ‘convenient.’ Certainly, recovering from a caesarean birth cannot be considered convenient. Labour and birth may just prepare women for the unpredictable nature of their lives for the next couple of decades.Booking a caesarean does not guarantee that labour will not occur earlier. As well, it is very common for the activity in labour and delivery units to cause repeated delays of the caesarean. A tubal ligation is a minor surgical procedure when compared to a caesarean section. It does not make sense to have a major surgery to avoid booking a minor surgery later. The procedure is also more likely to fail when it is done at the time of delivery. (This means more likelihood of future unplanned pregnancy.) |
| Safety for Mother and Baby | Safety for Mother and Baby |
| Women may feel the ‘sacrifice’ of having a c-section instead of vaginal birth ensures their babies are exposed to the lowest risk possible. Doctors have a hard time refusing to do a caesarean for women who insist on it. There is always some risk in childbirth and delivery. If a problem happens in a vaginal birth, and a doctor has refused to do a caesarean, then there is a risk of being sued. If the problem happens during the caesarean, the risk of a lawsuit is less because the patient demanded the more risky procedure. | Babies born by elective caesarean are more likely to have short-term breathing difficulties. This often means extra treatment and separation from their mothers. This happens because they do not get the benefit of being exposed to the normal hormones and agents produced in a normal labour. There is more likely to be a delay in starting breastfeeding after caesarean. Choosing a delivery time before the natural start of labour is more likely to lead to problems associated with premature birth.Caesareans are also associated with increased risks of infection, blood loss, scarring and blood clotting disorders. Once a caesarean has been done, there are risks to future pregnancies. Recent information shows that the risk of stillbirth is doubled in the next pregnancy. As well, there is a known risk of rupture of the uterus and problems with the placenta. |
| Pelvic Floor | Pelvic Floor |
| Some people believe that having a caesarean reduces or eliminates the chance of pelvic nerve damage and bladder control problems later in life. Although bladder problems can happen to anyone, they are certainly more likely to occur in women who have had a vaginal birth. This is especially true for women who have had difficult assisted vaginal births. Some women are also fearful that vaginal delivery may interfere with normal sexual activity after delivery. | There is no question that pregnancy and childbirth can have negative effects on the pelvic floor and bladder function. However, it is not certain whether a caesarean before the start of labour will improve the result. The pregnancy itself may be a factor. Only a few labour practices are more likely to lead to pelvic floor problems. These include prolonged second (pushing) stage of labour, and some forceps and vacuum deliveries.There is the possibility that a very difficult and traumatic vaginal birth could lead to difficulties with sexual activity. However, it is much more likely that the stresses and demands of being new parents are responsible for a change in sexual activity for most couples. It is not usually due to changes to the vagina and perineum. |
| Anxiety about Childbirth | Anxiety about Childbirth |
| Childbirth is known to be strenuous, painful and exhausting. There are no guarantees that a caesarean will not be necessary after hours of labour or that baby and mother will be healthy at the end of the process. Some people are so anxious about the process that they feel a caesarean is a better choice for them. Others fear that a large baby will be too difficult to deliver. | It is important to have realistic expectations for pregnancy and childbirth. Prenatal classes can be very helpful in preparing for birthing and raising a child. If a woman suffers from an anxiety disorder, performing a caesarean will not treat this problem. In fact, a caesarean may worsen the anxieties that can occur in caring for a newborn infant. The answer is to treat the anxiety, and provide a supportive environment in labour. Labour should be managed appropriately with pain relief techniques. The tremendous sense of accomplishment that comes with successfully giving birth can also go a long way to treating an anxiety disorder. It is known that postpartum depression is more likely after a caesarean than after a vaginal birth. |
| Costs to the Health Care System |
Costs to the Health Care System |
| The hospital costs of childbirth are greater in the labour and delivery units than in the postpartum (after birth) or recovery units. A caesarean takes a minimal period of time in the labour and delivery unit. It can be scheduled for daytime when staffing costs are less. | More nursing staff are required for a caesarean than for a vaginal birth, increasing the costs. Also, the length of stay in hospital after a caesarean is usually twice that of a vaginal birth.There are ways to reduce the costs of vaginal births in keeping with better outcomes for mothers and babies. One is not to admit women very early in labour to hospital. Another is to avoid inducing (starting) labours unless medically indicated. This way it is less likely there will be other interventions (and extra costs) in labour. Each additional vaginal delivery a woman has tends to become easier and more efficient. This results in less cost for future deliveries.Perhaps those choosing caesarean without a medical reason should be asked to pay the costs of the surgery, just as they are for cosmetic surgery. |
| Evolution | Evolution |
| Our society is changing over time. Babies are bigger, women are older when having babies and are often more overweight than in the past. The chances of needing a caesarean increase under these circumstances. So, women may choose to have an elective caesarean as they feel their individual risk is too high to try to have a vaginal birth. Anaesthetic and surgery techniques have improved over time. This makes caesareans safer than ever. | Ideally, it would be best if we could advance the health of society. It would help to improve body weights and encourage women not to delay childbirth to the point of increasing their health risks in pregnancy and childbirth. It is possible that knowing a woman’s age or weight or suspecting a large baby will make a doctor more likely to recommend a caesarean. While so much is unknown about what the future will hold for a society where caesarean section rates are higher than ever before, it’s best to be cautious. |
Women have the right to choose the medical option they feel is best. It is also important that they have access to the appropriate information. They need to be truly informed about what is and is not known. There is much that we still don’t know about the long term effects of unnecessary caesareans. We should be very careful about the choices we are making.
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