Caesarean surgery is lifesaving for some mothers and babies, and avoids problems for others. But in many cases it is not clear that the benefits outweigh the risks, particularly if the risks to any future pregnancies and births are taken into consideration. Across the country more than 1 in 4 babies are born by caesarean, and is some hospitals it is more like 1 in 3 women who will have surgery for the birth of their baby.
Most women do not want a caesarean unless it is clear that their baby really needs to be born that way, but other women know that a caesarean birth is best for them. Our national guidelines make it very clear that women’s preferences need to be taken into account when a caesarean is being recommended to, or requested by, a pregnant woman.
Caesareans may be planned before labour starts and these can be referred to as planned or elective caesareans. Elective does not mean that the women has chosen or wants the caesarean; just that it is planned surgery.
Other caesareans may be unplanned. Unplanned caesarean are often also called emergency caesareans, this is because they had not been planned and the reason for them ‘emerged’ before or during labour. Only a small number of emergency caesareans are urgent and the term ‘crash section’ may be used to describe this urgent surgery. Most emergency caesarean are not urgent and there is time to agree what you want for the birth of your baby.
As very few caesarean need to be done in a rush and many are planned well before the birth, there is usually time to consider what you want to happen when your baby is born. Most obstetricians are happy to work with women to make a caesarean birth a positive experience. It is usual for the baby’s father and/or a birth supporter to be in theatre for the birth and for the parents to be able to greet their baby and have skin to skin contact, providing the baby is well.
Other options for the birth might include:
If you are having a planned caesarean and are not being supported with your birth plan you have a right to be referred to someone else who will. For more idea of what you might like for the birth see http://caesarean.org.uk/caesareanBirthPlan.html
Some women feel strongly that their baby should be born by caesarean and usually have a very good reason for why they feel this is best for them. Reasons may be psychological or physical, and both should be recognised as medical reasons for requesting the surgery. The NICE guidelines provide recommendations on how women who want a caesarean should be supported, including being referred for psychological support where there is a fear of birth, but ultimately being booked for a caesarean or referred to someone else who will. If you are struggling to get your needs for a caesarean respected then please see the page on {your right to specific treatment}, but you may also find this Birthrights fact sheet useful http://www.birthrights.org.uk/library/factsheets/Right-to-C-Section.pdf
Some reasons for caesarean to be suggested before labour are (and there are many others):
With the exception of placenta previa, which usually (although not always) means that a caesarean is the safest way to give birth, none of the above situations means that a caesarean is inevitable, and you do have the option to decline. This is the case for many situations where a caesarean is suggested. If you would prefer to explore your options, you are free to do so. The decision to accept the offer of a caesarean is always yours, and yours alone.
When a planned caesarean is recommended there is time to consider whether this is the best decision for you and your baby. This will be a very personal decision. Most women need not only to think about why the caesarean is being recommended, but also about the risk of the surgery and about what their personal priorities are for the birth of their baby. For some women a caesarean birth will be something they can accept happily, but for other they will need to explore every other option before they can agree to surgery.
A caesarean may be recommended before or during labour if an issue arises such as:
Although you may have less time to consider your options when an issue of this sort arises you still have the right to make an informed decision. In order to give or decline consent, you should still be provided with information about:
When a caesarean is suggested or requested information about the risks must be provided in order that you can give consent for surgery, just as it would be for any other surgery. Signing a consent form without this information makes that consent invalid, and there could be legal case to answer from any surgeon who has not obtained valid consent to carry out surgery. People will consider different risks or benefit to be more or less important when making their decision.
Caesarean surgery has risks that would be expected of any surgery such as:
In addition, caesarean births have other risks specific to a baby being born this way. Common post surgical problems include wound infections and adhesions. Less common ones include permanent nerve damage, bladder damage and hysterectomy.
When babies are born by caesarean they miss out on the journey through the birth canal. Often it is suggested that this is an advantage, but we now know that important things happen for the baby during this part of birth, including helping to prepare the baby to breathe and seeding the baby’s gut with beneficial bacteria. Research has confirmed that babies born by caesarean are at greater risk of:
All of these issues seem to be related to missing this part of the birth process.
Is is uncommon for babies to be injured, but about 1 in 100 babies will be cut during a caesarean birth. Most these cuts are minor, though rarely babies have been seriously injured.
When a caesarean is carried out the uterus will be damaged. Usually a small incision is made which is extended by tearing as tissue that has been torn apart and is a bit ragged heals better than a straight cut when it is stitched back together.
The scar on the uterus does not cause a problem for the majority of women, but it does increase the chance of some problems. It has been shown that it takes women longer to conceive another baby than women who have had vaginal births, and that more women will fail to conceive another baby.
Pregnancies following a caesarean have higher rates of placental problems such as placenta previa and an abnormally adherent placenta (placenta accreta, percreta and increta). These are serious issue increasing the risk for the baby and the women, and if an abnormally adherent placenta occurs then a highly skilled medical team will be required in order to minimise risk of bleeding and to try to avoid the need for a hysterectomy.
Uterine rupture is extremely rare when a woman’s uterus has not been damaged, but after a caesarean a rupture occurs in about 1 in 500 [VBAC] labours.
It is very rare today for a caesarean to be carried out under general anaesthetic and most are done using an epidural or spinal, or a combination of the two. You should be provided with printed information by your hospital about these anesthetics and what to expect. The following page gives information from the Obstetric Anaesthetists’ Association about anesthetics used for caesareans http://www.labourpains.com/UI/Content/Content.aspx?ID=44
There are several different sorts of stitches used to close skin wounds. Dissolving and removal stitches or staples may be used, but the most common way caesarean scars are closed is with a single running stitch with a bead at each end. This is easily removed, usually about 5 days after the operation, by cutting a bead off one and pulling the stitch out in one piece. A midwife should be checking your wound until the stitches are removed and for longer if it has not healed completely when the stitches are removed. You wound should gradually feel less painful, but if it should become more red, sore or oozing, then you may have an infection and need to contact a doctor, as infections after a caesarean can become serious quickly. The following page has a collection of caesarean scar pictures http://www.caesarean.org.uk/ScarPics.html
There will also be internal stitches that have been used to repair your uterus and the tissue around it, these will dissolve in time and rarely cause women a problem, although some women may find that a stitch comes out in the lochia.
How quickly women recover from a caesarean varies enormously and you are going to be the best judge of what you are ready to do. This will include when you are ready to leave hospital. Many women are very keen to get home, but other feel that they are being rushed to free up a bed. If you do not feel ready to go home then make sure that the staff know this whether it is because you are still in pain, feel unwell or have no one to help you when you get home.
Over the weeks after a caesarean you should gradually find you have less pain and are able to do more. However, it is quite common to find that bleeding or pain may increase following a sudden increase in how much you are doing. If you do not feel you are recovering properly then you have a right to see the midwife or your obstetrician even if it is weeks or months after the birth.
Most women struggle a bit emotionally after a caesarean even if they are very happy to have had a caesarean birth, but many women are left struggling with trauma or grief about the birth which can be very hard to reconcile with the delight with their new baby. Understanding what happened, why it happened to them, and what they might or might not have been able to do differently are often key to recovering. Postnatal depression is more common after a caesarean, and some {women suffer with PTSD}. You have a right to help from your health professionals, but women often find the women’s support group are helpful in their recovery.
Women who have had an unplanned caesarean or a problem during the surgery may want talk to someone about what happened. You can make an appointment to see your obstetrician or one of the senior midwives. You may want to get a copy of your notes and if you are unhappy with your care then it is probably a good idea to do this before arranging a meeting. Some women prefer to talk through their birth with someone from outside the Trust, perhaps an independent midwife. AIMS will help to support you if you wish.
Journal Vol. 22, No. 2 Caesarean Birth
Caesarean Birth: Your Questions Answered
Written by: Debbie Chippington Derrick
Reviewed by: Emma Ashworth
Reviewed on: 19/08/2017
Next review needed: 19/08/2019
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