In this 21st century there are two routes of birth, one is abdominally via caesarean section and the other is vaginally through the birth canal. As long as vaginal birth remains an unacceptable option women will continue to need the only other possibility available to them.

Why bother going through the process of giving birth vaginally when you can have a planned caesarean section? Increasing numbers of women today appear to be subscribing to this view. Maternal request for delivery by caesarean section is reportedly on the increase and has been blamed, in part, for the continuing rise in the caesarean section rate.

photo credit: maria mono

The level of maternal request is a controversial issue. The National Sentinel Caesarean Section Audit report notes that studies report rates of maternal request ranging from 1.5 per cent to 48 per cent. Much of the variation is due to unclear definitions of ‘maternal request’ and whether there was also a supporting clinical indication.

But the use of ‘maternal request’ as a reason for carrying out surgery is a nonsense, since it simply indicates who instigated the decision. Clinical indications are not, after all, lumped together under ‘obstetric preference’. Until audits standardise the terminology and sub-divide ‘maternal request’ into the underlying reasons why women prefer to undergo surgery, serious debate of the issue will be hampered.

Regardless as to the actual level of maternal request and the methods used to quantify it, there is no denying it is very much an issue of our time. The amount of media coverage and the frequency with which ‘maternal request’ is cited as a barrier to the reduction of caesarean rates, demonstrate that this issue is of concern to a great many, both in the childbirth world and our society as a whole.

Why has caesarean delivery apparently become more popular?

Some women consider caesarean delivery more advantageous and more in keeping with the 21st century because:

• A caesarean is a modern way to have a baby, involving the use of technology. Modern technology features highly in our daily lives. We are at ease with it and find it reassuring. The latest and most up-to-date technological equipment is much prized and sought after in all areas of our lives.
• A caesarean is a medical operation. Birth is currently seen as a medical event as it usually takes place in hospital. Is a caesarean operation not therefore a logical conclusion to pregnancy for women of this millennium?
• A caesarean can be scheduled. Few of us can get through a day in our modern world without a watch and a diary. Our daily lives are ruled by time and by carefully planned appointments. Choosing the date of the baby’s birthday has considerable appeal in this context for some women. We have become accustomed to leading our daily lives in a way that pays little heed to the natural flow of events. For example, modern technology allows us, in many respects, to disregard the divisions of night and day or the seasons of the year.
• A caesarean is quick in comparison to most labours. We live in an age when the quicker something can be achieved the more advantageous it is perceived to be - whether this is making a cup of instant coffee, washing the laundry, travelling from a to b, or sending a communication. In our society time is money.
• A caesarean is perceived as pain-free. The operation is carried out under anaesthetic and therefore there are no pains of labour to be endured. The “wake me up when it’s all over” scenario appeals to many women.
• A caesarean avoids the need for a baby to make the journey through the birth canal. Many women worry about how something as large as a baby could possibly fit through such a small opening. Some women fear the baby may be ’squashed’ and damaged in the process.
• A caesarean is clean. The antiseptic nature of the operating theatre is very different from the physical exertion of labour. No sweat and tears. The mess of amniotic fluid and blood is dealt with out of sight. Urine is catheterised. There are no lumps of poo emerging from the rectum, pushed out by the baby’s head as it journeys down the vagina. Is this not more in keeping with our aseptic society?
• A caesarean is clinical - and therein perhaps lies its biggest attraction. Planned caesarean birth avoids the necessity for the many probings of the vagina, which have become routine during what is termed ‘normal’ birth today. A woman can more easily maintain a degree of professionalism and detachment in her relationship with her carers since the private areas of her body are left unmolested and unsullied.

With these advantages in mind, does caesarean delivery not fit rather well with the ethos of our society in this new millennium? The problem is, however quick, clean and convenient caesarean delivery may be considered, it also has its disadvantages:

• The most obvious being the post- operative recovery period. Contrary to popular perception, delivery by caesarean section is far from an ‘easy’ option. Caesarean mothers are never able to jump off the operating table and get straight back to normal.
• The operation itself may be completely pain free but the post-operative recovery period rarely continues to be so. There is, of course, a range of painkillers to help mothers through the first few days, but even so moving around, handling the baby and going to the toilet, all present their own difficulties and have to be tackled slowly and carefully. Those diary appointments have to wait.
• Caesarean mothers can also find they need to break wind more often. Post- operative wind may also cause discomfort and pain in the abdomen and elsewhere in the body - even in the shoulders - due to pockets of air being trapped.
• There is also the scar; usually a horizontal cut of about 5-6 inches (12- 15cms) is made just below the pubic hairline. The upper portion of pubic hair is shaved and can often be itchy as it grows back. Not an easy area to scratch, especially with the presence of a tender scar!
• In our society many of us are dependent upon our cars for transport. Insurance companies may not cover caesarean mothers for up to six weeks following the operation. Mothers may not, in any case, feel physically strong enough to control a vehicle, especially in an emergency situation.
• Many household chores may be difficult or impossible for caesarean mothers for some weeks after the birth. These can include: changing duvet covers; vacuuming; lifting heavier objects (laundry baskets, toddlers); carrying something as light as a newborn baby up and down stairs; stretching up to reach high cupboards or peg out washing.
• If this is not a first baby, a caesarean mother will find it difficult to pick up or cuddle her other children. There is also a longer hospital stay, commonly around five days, meaning a longer separation from her family, which can be problematic.
• Some unlucky caesarean mothers suffer post-operative infections (In UK hospitals around 20 per cent of mothers en dup with totally new infections - for caesarean mothers the risk is even higher). Depending on the type, severity and response to treatment, these can sometimes be quite distressing and can slow the recovery rate quite considerably.
• And then of course there are the risks. Caesarean section is major surgery and complications can occur. Mothers die very rarely these days, but the risk of maternal death is higher with caesarean section than with vaginal birth, as is the risk of needing a hysterectomy. Scar tissue or adhesions may cause long- term pain, bowel obstruction, infertility or miscarriage and may make repeat surgery more difficult. Caesarean mothers are also at increased risk of ectopic pregnancy, placenta previa and placenta accreta in subsequent pregnancies.
• A caesarean is not without risk to the baby either. Babies are occasionally cut by the surgeon’s scalpel. Babies who are born by caesarean section have a higher incidence of respiratory problems both at birth and in adult life.
• Perhaps a caesarean is not quite as practical a solution to the problem of bringing a baby into the world as it might at first seem. But even women who are well informed of the realities of caesarean birth maintain a preference for this form of delivery. Why have we reached the point where women are prepared to face the risks and inconveniences of major abdominal surgery in order to avoid giving birth to their own babies?

There are many very good reasons for having a caesarean section and with a little forethought and planning the operation can indeed be a wonderful experience. There is also no denying that a positive caesarean section is infinitely preferable to a traumatic vaginal delivery.

But what too many have lost sight of, is that even the best caesarean can never hold a candle to a good experience of giving birth to your baby yourself!