As a midwife I have reflected on why I feel sad when I hear of, see and care for women who have elected, when there is no clinical indication, to have a caesarean section.
In Midwifery Today magazine, a group of traditional midwives came together to write their declarations about midwifery and birth and they stated, ‘As human beings we are all one.’ If this is the case then we are all affected by the experience of these new souls being born into this world by a surgical operation.
My main concern with the increase in caesarean rates in Australia and New Zealand (one in five babies have a caesarean birth) is how many of these women have been fully informed? I am not alone in my concerns. Many midwives all over the world are debating whether a woman has the right to choose a caesarean section in the absence of clinical indications and when she is not fully informed. At the recent 2004 International Conference of Midwives many midwives felt that the women could not be making an informed decision, while others argued that women should be charged for the surgery, aligning it with elective cosmetic surgery, desired by some but not necessary.
Michel Odent, in his book The Caesarean, considers the long-term effects of the caesarean birth and how this type of birth ‘from above’ can interfere with the capacity of love to develop in the baby (either love of oneself or love of others).
As a student midwife I was given definite and undisputable indications for caesarean section:
- Cord prolapse — where the cord slips through the cervix and becomes vulnerable to compression and the supply of blood can be cut off.
- Placenta previa — the baby’s placenta is covering the cervix so the baby’s exit is blocked.
- Placenta abruption — placenta separation from the uterus wall occurs before the baby is born.
- Brow presentation — the largest diameter of the foetal head (from the back of the baby’s head to its chin) is the presenting portion.
- Transverse lie — the baby is lying horizontally.
These situations represent a tiny proportion of all births.
Many more reasons are now given to women so that they view a caesarean section as the safest way to birth their babies. One of the main reasons given by doctors for women to automatically require a caesarean section is when their last birth was by caesarean.
‘Once a caesarean, always a caesarean’ — this statement was made back in 1916 due to a fear of uterine rupture. It is important to note that the risk of uterine rupture or dehiscence (i.e. partial separation of uterine wall which has little or no symptoms and minimal, if any, maternal or foetal morbidity) combined is up to 2%, whether women choose a VBAC (Vaginal Birth after Caesarean) or planned repeat caesarean section.
Women have every right to make an informed decision to have a VBAC. Statistics show that women have up to an 80% success rate of having a vaginal birth after having had a caesarean. When birth is left to unfold and not interfered with, I believe this percentage could be much higher. The Association for Improvements to Maternity Services states ‘that the care of a woman in labour after a previous lower-segment caesarean section should be little different from that of any woman in labour’.
Some hospitals persist in placing management protocols that inhibit the birth process, such as:
- Induction at 39 weeks
- Early admission as soon as labour starts
- Continuous electronic fetal monitoring
- Siting of an intravenous drip or a cannula
- Restriction of the length of first stage of labour
- Restriction of the length of second stage of labour.
Women need to be aware of and become fully informed regarding these policies. They have a choice and are not obliged to abide by them, especially when evidence suggests their interference in the birth process.
It is also becoming common knowledge that women are electing to have caesarean sections to save their pelvic floor. If women are choosing to have a caesarean section to birth their babies based on available research they should also know that the research showed no attempt to avoid intervention practices that can cause pelvic floor problems. Interventions that can increase pelvic floor damage are outlined in the International Caesarean Awareness network list. They are as follows: episiotomies, vacuum extractions, forceps, birthing while lying on your back, using care-giver directed pushing, pressing against the opening to the vagina as the baby’s head is born.
When becoming informed about the option of a caesarean birth the whole picture must be considered. To help in the decision-making journey, Birthchoice UK (5) provides valuable information. They state that following a caesarean, women are more at risk of health problems such as wound or uterine infection, haemorrhage, blood clots, damage to the bowel or bladder resulting from the operation and possible infertility. The overall research shows women are four times safer having a vaginal birth than having a caesarean birth. ‘Birthchoice’ also mentions that the major risk for the baby is difficulty breathing which is four times as likely in a baby born by caesarean.
I have written this article with love and for the empowerment of women because through knowledge comes empowerment. Sheila Kitzinger says that, ‘Unless women can obtain accurate information then they are not free to give not only informed consent but informed refusal.’
- The Caesarean. Michel Odent (2004).
- Caesarean Birth. (2001) Making Informed Choices, an initiative of BIRTHRITES.
- VBAC — On Whose terms? Association for Improvements to Maternity Services (2002).
- What Every Women Needs to Know About Caesarean Section (2004). The International Caesarean Awareness network.
- Birthchoice UK. (2004). Research Summary — Caesarean Birth.
Published in Byronchild/Kindred, Issue 13