Sydney Pelvic Floor Health

Elective Caesarean

Elective Caesarean Section on maternal request

If you are reading this text you’re probably interested in an up to date medical viewpoint on whether it can be reasonable for a woman to request a Caesarean Section (CS) even if there is no clear medical indication, such as a Breech presentation, twins, toxemia, a very big baby or certain medical complication of pregnancy. You may already know Magnus Murphy’s Pauline Hull’s book ‘Choosing Caesarean: A Natural Birth Plan’ which probably is currently the best mass market book on the topic. Here I’ll summarise some of the medical arguments in favour of elective Caesarean. There are disadvantages, but they get so much airplay already that I won’t mention them here. It may be enough to state that I have never, in my entire professional career of 30 years, seen someone who suffered major permanent disability due to an elective Caesarean. I do see women with permanent disabilities due to vaginal birth just about every day, between 5 and 10 a week. 

What I’m writing here refers to the first birth. That’s an important point to make. If someone has had a difficult or traumatic first birth she may want to avoid any similar experience for the next baby- but any damage that can occur with vaginal birth very likely has occurred already. We have published several studies that suggest that a second of third vaginal birth doesn’t seem to cause additional damage. This means that most of the benefit of elective CS is due to avoiding the first (or any) vaginal birth. It also means that having a second baby normally after a first CS (vaginal birth after Caesarean or VBAC, also called TOLAC) gives you the worst of both worlds- but VBAC/ TOLAC is covered elsewhere on this web site (VBAC link)

A lot of doctors choose elective CS. In a piece for our local O/G magazine in Australia the author confessed that she had had two elective CS in private, even though she still feels that requests for elective CS should be denied. If you think that’s a weird position to hold- I agree. It illustrates the degree to which we have been confused and misled by the ideology of natural childbirth. The effects of this ideology on modern maternity care is covered in details elsewhere on this web site (Antenatal Info link). Here it should be enough to say that there is so much self- censorship amongst obstetric colleagues, so much denial of scientific fact, that you should not be surprised at anything, even in the medical literature. In this case the consequence is disabled, sick or dead babies and mums. If you think this is alarmist please read a recent UK government report on events at Furness General Hospital, which has now led to a nationwide review of maternity services in the UK.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_
v0.1.pdf
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From a purely medical point of view, Elective C/S has a number of indisputable benefits, which are rarely disclosed to patients and are commonly ignored by obstetricians and midwives. In fact, many obstetricians in public hospitals actively try not to think about those benefits in order to suppress their gut feeling that we’re often bullied into doing the wrong thing. 

1.) Elective CS is associated with reduced perinatal mortality (fewer dead babies) compared to a planned vaginal birth, simply due to the fact that elective CS results in an earlier delivery. Every day spent in the womb carries a risk of unexplained stillbirth- that is, the baby dying inside the uterus without us knowing why and how. The woman typically presents with absent baby movements, we put a scanner on, and the heart is still. It’s just about the most terrible thing to happen in an obstetric service, and every obstetrician in Australia has had to give such news to a patient and her family. Because of this basic fact of pregnancy, known for centuries, between one in 500 and one in 2000 babies will die if an elective CS is denied. I’d be very surprised if this fact was ever mentioned in antenatal clinic. 

2.) Elective C/S prevents 100% of tears of the anal sphincter (‘major’ perineal tears or OASIS), which are much more common than previously known at 10-20% of all women who have given birth vaginally. These tears are the main factor in the causation of fecal incontinence in women, which requires about 10,000 surgical procedures p.a. in the US alone. 

3.) Elective C/S prevents 100% of levator tears (major tears of the pelvic floor muscle or ‘avulsion’) and over-stretching of the pelvic floor muscle opening (the ‘hiatus’), which affect 12-35% of women after a first vaginal birth. These forms of damage are the main cause of female pelvic organ prolapse (that is, a hernia of bladder, womb or bowel through the vagina). This likely is the strongest public health argument for elective CS, with an estimated 100,000 procedures p.a. in the US directly or indirectly due to such trauma. 

There are many other less obvious benefits, such as the avoidance of psychological trauma up to and including posttraumatic stress disorder, psychosexual issues and partnership problems due to traumatic childbirth. Those we’ll cover in another location on this web site (Tokophobia link)

Hence, there can be little doubt that elective CS can be a sensible, rational option for someone who is about to have her first baby. Not inevitable, surely, given that this choice has substantial downsides, but entirely rational. The older the woman is at the time of her first birth, the lower the number of kids she is planning, the more rational it is. There is certainly no medical or scientific reason to deny a CS on maternal request. 

There remains the argument that elective CS is more expensive, and that we need to spend the money elsewhere because it is needed for hip replacements or immunisations. This is a fallacy. The difference in short- to medium term cost has been estimated at - lo and behold!- GBP 84 by the National Institute of Clinical Excellence (NICE) in the UK in 2011 That’s without accounting for prolapse, fecal incontinence or stillbirth. If one were to account for all those, elective CS is most obviously cheaper for society than an attempt at ‘natural’ childbirth.  

Finally, let’s consider the interests of the obstetrician. After all, I am concerned not just with women getting accurate, up to date information and optimal treatment, but also with colleagues being bullied and coerced into doing the wrong thing. They’re actually often hurting their own interests by taking actions that could see them end up in court. The UK Supreme Court has recently delivered a decision that very much strengthens the rights of pregnant women vis-à-vis their healthcare providers. This is probably at least partly due to the Supreme Court nw having a female judge, the first ever, and she’s said to be a feminist! 

The Montgomery vs Lanarkshire judgment https://www.supremecourt.uk/decided-cases/docs/UKSC_2013_0136_Judgment.pdf the text reads as follows: ‘Where either mother or child is at heightened risk from vaginal delivery, doctors should volunteer the pros and cons of that option compared to a Caesarean’. Not just agree to a maternal wish- to voluntarily offer it! And do I really have to mention the universal principle of patient autonomy to affirm the right of every pregnant woman to decide on her treatment? We’re pro- choice, aren’t we? 

In at least half of our antenatal patients- most first time mothers, anybody at age 30 or above, any gestational diabetic, anyone with a very big (‘macrosomic’) child, anyone who is obese, anyone going over term, anyone in whom it looks as if the baby is not going to come easily, obstetricians will in future have to discuss the option of elective CS. Your doctor will have to bring it up, and of course he/ she will have to agree to an elective CS if you want it. 

Not doing that may well see the obstetrician in court and may cost him/ her their livelihood. And of course that would happen as a consequence of someone, mother or baby, having suffered entirely avoidable complications, some resulting in longterm disability or even death. 

HP Dietz

Sydney