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Myths and misconceptions about caesareans

By Caroline McCullough ©
Originally published in the Bub Hub September, 2006 Newsletter.

In Australia today, approximately one in three women give birth by caesarean section. National Caesarean Awareness Day (September 11^th) was established to help raise awareness about the impact of caesareans on women and families, to honour the journeys of women who have given birth by caesarean and to dispel myths and misconceptions about caesareans and vaginal birth after caesarean (VBAC).

Caesarean surgery, like any major surgery, carries risks for both mother and baby and also any future babies the mother has. Despite this, many people view caesareans as the safest and easiest way to have a baby. Women’s magazine stories of Hollywood celebrities who have booked in for caesarean births have helped normalise the idea that a caesarean is a desirable way to have a baby rather than a life saving operation to be used in extreme circumstances.

So what’s having a caesarean really like? Does a mother really have more control over the birth and her baby’s wellbeing by having a caesarean? Is it a neat, dignified experience? Are caesareans really pain free? And why do so many women give birth by Caesarean?

Caesarean realities

Women’s experiences of caesareans vary a great deal. Some women feel empowered by them stating that they have more control based on the false beliefs that caesareans guarantee a healthy baby, are pain free or that caesareans avoid pelvic floor damage. In this technological age, it may be true that some women feel more at ease with the clinical, the scheduled and the routine of caesareans. A few women have a pathological fear of childbirth, perhaps due to horror stories they’ve heard or seen on TV, or sexual assault during their childhood. Despite these views, very few women ask for a caesarean without a medical reason. A recent study done by the Childbirth Connection in the US (2006) found that less than 1 percent of women requested an elective caesarean for no medical reason.

The reality for most women is that their obstetrician advises them to have a caesarean. The reasons vary but with some obstetricians having caesarean rates of 50 percent or more, you can bet that not all caesareans are necessary or even beneficial. The same study by Childbirth Connection stated that 10% of women felt they’d been pressured into a repeat caesarean by a health professional. Anecdotal evidence by women supports this.

Gold Coast mother of three, Deirdrie had her first baby by elective caesarean at a private hospital.

“During my pregnancy, I was thinking everything was going well until the week she was to be born when I was told that my baby was getting too big and my pelvis was too small....I had another round of scans, including a pelvimetry showing she would be at least 9lbs and it also showed my pelvis wouldn't birth a baby over 8lbs. So under a lot of pressure and information based on fear, I decided to go ahead with a planned c/s.

“I now have three children and my last was my biggest baby at 9lb 6oz, with a head circumference of 37cm. She was born beautifully at home in the water vaginally.”

Brisbane mother of two, Megan was planning a VBAC and was at the end of her pregnancy when the pressure was put on: “Dr D said we need to get this baby out as you are 15 days overdue and your baby could die if we don’t get it out…I really believe I was pressured because the next few days were booked solid with caesars due to the $3000 payment [new maternity payment by the Federeal Government that came into effect in 2004]. I believe they pressured me so they could get me out of the way. I knew my baby was ok. I had seen the scan and CTG the day before [that showed he was healthy].”

Even though caesareans are touted as safe, neat operations, the reality is that many women feel that caesareans are one of the most disempowering and undignified experiences a woman can endure. Experiences like this can compromise a mother’s emotional safety. The impact on mental health outcomes of these experiences has not been accounted for to any large extent despite the fact that 15 percent of women in this country suffer from postnatal depression and about 1 in 3 women find childbirth traumatic.

The simple truth is, during a caesarean the woman has no control over what is being done to her. She is incapacitated and sometimes unable to move at all depending on the strength of the epidural. In rare cases the epidural may not work effectively to block the pain of the operation and the mother may be rendered unconscious with general anaesthetic. Some mothers feel ignored while medical staff are deep in conversation at the operating table and some mothers feel their need to bond with their baby is usurped by common hospital policies to send babies to special care nursery for several hours after surgery.

Jo, a mother from Adelaide said this of her caesarean: “They were discussing football results and didn’t notice the epidural wasn’t working until the anaesthetist noticed that when they touched me my screams were coinciding!”

After the birth, the mother is dependent on pain killing drugs, may have difficulty in picking up, caring for or feeding her newborn and moving about unassisted. Post operative infections, which are reasonably common, may cause severe cramping and fevour for several days after the birth.

For several weeks after the birth a mother is not supposed to drive or lift anything heavy including emotionally distraught toddlers who are trying to adjust to a new brother or sister in the house.

All this is a lot to go through for anyone having surgery let alone a woman making the transition to motherhood with sleepless nights and the demands of newborns and toddlers to deal with. Most women who have had a caesarean would agree that a caesarean birth is not the easiest way to have a baby and many feel insulted when someone suggests they took the easy way out.

There are ways in which women can take more of an active role in how their caesareans are performed. For those women who feel they need to have a caesarean birth it can be helpful to negotiate a caesarean birth plan with the attending obstetrician and pediatrician. In this way you can ensure your needs are met and the operation is carried out in a respectful manner. It can also help you implement strategies to kick-in your natural hormonal response to help you bond with your baby after the operation and establish breastfeeding. Skin-to-skin contact with the baby on your chest straight after he or she has been taken out can be very helpful for the mother and baby. A blanket can be placed over the baby to keep him or her warm while you say “hello” to each other for the first time. Delayed chord clamping can be helpful in providing more oxygen to the newborn after the shock of being taken out of the womb so suddenly. It also helps to have a professional birth support person there for you and your partner, someone who can make sure that your needs are met and your wishes respected, someone who can help you establish breastfeeding in recovery if you desire to or get hold of your placenta if you want to see it.

Caesarean risks

So if caesareans are so safe what is risky about them? Childbirth Connection (2004) provides the following list of increased risks of caesareans (as opposed to vaginal birth) from their comprehensive systematic review of the research on caesareans.

Physical Risks for the mother:

· maternal death as a direct result of caesarean surgery.

· emergency hysterectomy:

· blood clots and stroke

· injuries from surgery to the uterus and other organs such as bladder and bowel

· injuries from anaesthesia

· longer time in hospital

· going back into the hospital

· post-operative infection

· longer-lasting and more intense pain

· ongoing pelvic pain due to scarring and/or adhesions

· bowel obstruction and twisted intestines in the years after surgery as a result of scarring and/or adhesions

Psychological Risks:

· negative feelings about the birth

· less early contact with her baby

· unfavorable early reaction to her baby

· depression

· psychological trauma including Post-Traumatic Stress Disorder (PTSD).

· poor overall mental health and self-esteem

· poor overall functioning in daily life in the early weeks after birth.

Risks for the baby:

· Cut by scalpel (usually in the face) during the surgery

· Breathing problems

· Intensive care admission

· Breast feeding problems which may result in increased allergies

· Asthma in childhood or adulthood

Many of the longer-term impacts of caesareans are little understood but the effect on future pregnancies is beginning to gain more recognition.

In future pregnancies there is greater risk of unexplained still birth, greater risk of all of the above complications if a repeat caesarean is performed and greater risk of life-threatening placenta-related complications, infertility, ectopic pregnancy and uterine rupture. The risks of premature birth, low birth weight and respiratory problems also increases.

You may be thinking these risks are highly unlikely. Some of them are rare (and some like surgical injury to the baby are not) but it is important to understand that with the increase in our caesarean rate the incidence of death or injury related to caesareans also increases. This fact has been confirmed by recent research by the World Health Organisation (2006). Every woman should be fully aware of the risks before deciding what is best for them and their babies.

VBAC realities

Once you’ve had a caesarean it is harder to gain support for a natural birth after caesarean. In their Listening to Mothers survey on caesareans (2006), Childbirth Connection found that only 12 percent of women in the survey had a vaginal birth after caesarean (VBAC) and of the 45 percent of women who were interested in VBAC, more than half were denied this option, not because of their individual circumstances but because the care provider or hospital was unwilling to support VBAC under any circumstance.

In Australia, most women who walk into an obstetrician’s office wanting to VBAC walk out 15 minutes later with the bloody image of a torn up uterus imprinted in their minds. Chilling tales of hysterectomies and dead babies are often told and women, quite rightly, are left feeling they are too scared to “take the risk”.

So let’s put this risk into perspective. For any woman having a baby regardless of whether she has had a previous caesarean or not, the risk of the baby dying from Congenital defects, prematurity and low birthweight, SIDS and placenta complications[1] are all greater than the risk of a baby dying from a uterine rupture. All of the above risks are extremely rare but do happen so a woman needs to make a decision on what is the best way to have her baby based on her own individual needs and circumstances.

What women aren’t told is one of the greatest risk factors for a uterine rupture is inappropriate management of VBAC labour. Despite the fact that inducing and speeding up labour using oxytocic drugs have been proven to significantly increase the risk of uterine rupture whether you’ve had a previous caesarean or not, many obstetricians still routinely use these drugs to make the length of a labour more predictable.

Another risk factor is the quality of the surgery from a previous caesarean. Some surgical techniques may offer short term benefits but may increase the risks for future pregnancies..

Many obstetricians have a policy of continuous monitoring and epidurals for VBAC labours and these too can increase the risks of complications. Epidurals can mask abnormal pain which may result from a uterine separation and continuous external monitoring does not necessarily pick up abnormal uterine activity but may result in a woman having a long labour due to being confined to a bed with restricted movement. Recent studies have shown that continuous monitoring does not improve outcomes.

Women are also not told that there are strategies they can use to help optimise their chances of an uncomplicated birth. Learning about optimal foetal positioning and active birth, hiring a doula or a private midwfe for labour support, declining unnecessary interventions, learning about non-medical techniques to relieve pain, exercising and eating well can all reduce the likelihood of a complicated birth or a repeat emergency caesarean.

Further information and support.

If you have negative feelings about your baby’s caesarean birth, you are not alone and support is available. The Maternity Coalition has produced an INFOSHEET on births after caesareans which you can download for free at www.maternitycoalition.org.au. Childbirth Connection also have a comprehensive booklet (see reference below) on the risks of caesareans and vaginal birth (including vaginal birth after caesarean) which you can down load for free at www.childbirthconnection.org. Australian support organisations include CARES-SA (Caesarean Education Recover and Support, South Australia www.cares-sa.org.au), Birthrites: Healing After Caesarean (WA-based www.birthrites.org) and Birthtalk: Support, Education and Celebration of Birth (Qld www.birthtalk.org). In September a new national organisation Caesarean Awareness Network Australia (CANA) is being born to help direct women to evidence-based information and resources about caesareans and birth after caesarean.

References

Listening to Mothers Survey II, Childbirth Connection (2006). www.childbirthconnection.org.

Childbirth Connection (formerly Maternity Center Association) (2004) What every pregnant woman needs to know about caesarean section. www.childbirthconnection.org.

WHO 2005 global survey on maternal and perinatal health research group. (2006).

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet June 3, 2006; vol. 367: 1819–29

[1] [Infant mortality by cause: US/State, 2000-2002 (Source: NVSS) US department of Health and Human Services, Centres for Disease Control and Prevention, National Center for Health Statistics.]

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Myths and misconceptions about caesareans