Mothers Choosing Caesareans
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I work (as a midwife) for a UK website answering women’s email questions. I would like to ask for your help with one particular subject, which I’m frequently asked about – choosing/requesting an elective CS.
The most common reason given by my correspondents is fear of labour and its physical effects. Some messages hint at other reasons, including emotional and psychological (but, so far, not social).
I write back at great length, trying to address specific fears, emphasising the value of preparation for labour and supportive and skilled care during labour, citing statistics relating to relative safety, and so and so on. Finally, I suggest how they may wish to approach health professionals with their request, and I maybe suggest further reading or sources of support. Some of the women write back along the lines of “I hadn’t thought it through properly, and now I realise it isn’t the easy option”. Others are clearly well-informed and very focused on what they want.
I would really, really appreciate hearing your experiences and views!
Do you, as clinically active midwives, hear many such requests? (Or do they go no further than anxious thoughts, late at night, in front of the computer?!)
How do you deal with them?
How do obstetricians deal with them?
How do groups such – such as AIMS – deal with these issues?
Interestingly, one woman recently posted her wish for an elective CS on a parents’ discussion group – and was immediately shot down in flames by other women – all insisting on the superiority of labour, how misguided she was to think this way, how it wouldn’t be so bad as she feared and so on. I would like to feel that we, as midwives, could and should be more supportive – but how best to do this?
Two key articles to start you off:
“It is every woman’s right to choose to be delivered by elective caesarean section.” (Summary of a live debate) International Journal Obstetric Anaesthesia. 1999. vol. 8. p.43-48.
Two articles – first by Erskine, KJ (proposer of the motion), second by McGrady, E (opposer)
Caesarean Section for Maternal Choice by Sara McAleese, From MIDWIFERY MATTERS, Spring 2000, Issue No. 84
Are Caesarean Births Really The Answer For Worried Mums?
By Pat Hagan, WebMD Medical News
I think the more people read about elective caesareans, the more demand increases. I have had two people ask me this week. One trained as a midwife but never practised and said she thought she could “never see herself going through that” and one, at 4 foot 11, a primip, quite forcefully told me that she was “far too small” and there would be no point in her suffering hours of labour only to have an emergency section at the end of it. I quite forcefully told her that my mother is four foot ten and had short easy labours and births.
Where will we all end up if women are genuinely led to believe that it is a consumer choice? I had never known of anyone having an elective for maternal request and no other reason before all this hoo-ha in the press about it started a couple of years ago. I truly believe that it was a deliberate effort by obstetricians to obfuscate the facts about the disgraceful CS rate, but it has become a self-fulfilling prophecy. Or did they mean that to happen?
…well of course it doesn’t help when the media trumpet the information that a majority of female Obs would opt for a CS to ‘save their perineum’.
Shame is that it was not publicised quite so widely that Midwives would, in the majority, opt for a normal birth.
I too have noticed an increasing trend in classes of women asking if they can ‘opt’ for a CS and avoid all the ‘pain, discomfort and inconvenience’ of a vaginal birth. Six years ago, when I began teaching, I was rarely asked this.
I recently showed two videos in class, one of a CS and one of normal birth. The class polarised on their views of each – at one extreme feeling that CS looked more ‘normal’ and ‘civilised’ and at the other end seeing it as ‘cold’ and ‘clinical’. It made for some interesting discussion!
The sad truth is that many women do not see CS as an operation. Let’s face it, we give it a nice sanitised name like ‘caesarean section’ and not ‘ a surgical cut into the lower abdomen and uterus to manually remove the baby.’
Don’t get me wrong. I feel there is a definite place for CS in maintaining the safety of women and babies. But it scares me rigid that CS might become the norm.
Does anyone have any concrete, first hand evidence that increasing numbers of women are requesting CS without any clinical reason, (that is, purely for convenience or personal preference?) or is this simply an attempt to divert attention from the real reasons for the increase in CS rate nationally?
I have never had any woman ask for CS unless she has had a sound rationale for this choice. Reasons I’ve been given recently include a vaginal birth experience so bad that it left her with post-traumatic stress disorder, multiple fibroids which stood a good chance of obstructing the outlet, and 2 labours which had previously ended in CS for obstructed labour (woman tiny, babies over 10lb).
Just personal experience, but two women I know personally had C/S on request at term. One of them purely because her mother had a bad pelvic floor. And I don’t think she had any problem getting her request met.
I have some problems with the statement that it is “every woman’s right to choose to be delivered by caesarean section”. Primarily because, while the woman has a common law right to decide what to do to her body, an obstetrician cannot be forced to undertake a caesarean section which s/he feels is clinically unwarranted.
So, as long as women do not get the impression that they can walk in and demand that one is done I suppose I am content, if content is quite the right word.
Although AIMS will fight equally hard for a woman who has every reason to ask for a caesarean as we do for women who want to avoid them, I do have anxieties about the propaganda that portrays a caesarean as an easy option from which one instantly recovers and rushes off the next day to go skiing….
I am almost 47 and my 2nd child, now almost 22 was born by LSCS (lower-segment caesarean section) due to an abruptio placentae and undiagnosed breech presentation. I was in transition at surgery and denied the strong urge to push. Daughter had very bruised ankles and was physiologically jaundiced for many weeks post delivery. 3rd baby was SVD 19 years ago, but not after a long struggle with the obstetrician who wanted to induce me, give me an epidural (so that he could feel inside my uterus for dehiscence), etc. My compromise was to agree to the induction. Babe born with apgars of 9 & 9 after a 45 minute labour, whilst doctor attempting to apply FSE due to 2nd stage dips – fool!
Anyway, even though I am to be a granny in September, the whole point of this is to relate that, having had 2 lovely spontaneous deliveries and a section, I know what I would opt for any day – a normal delivery!!!!! If I could deliver a baby tomorrow, I wouldn’t hesitate to opt for a normal delivery. If a section is unavoidable, so be it, and I am so sorry if I am upsetting anybody with a less than optimal prospect – but why CHOOSE to have a section?
Many women ‘choose’ caesarean sections because of: fear, misinformation, previous sexual abuse,a belief that it is the only option or a belief that it is the better of two evils. If anyone can add any other categories I would very much like to hear about it. ..
I suspect they ‘choose’ because the propaganda trivialises this major surgery and they think it is just a little cut and they will be skiing at Cloisters the following week. It would be fascinating to do a study of those women who ‘choose’ and see how happy they are with the result – I have spoken one woman who determinedly chose a caesarean and was very proud and happy with her choice and her ‘intact perineum’.
AIMS is receiving more calls from women wishing to book a caesarean section, but I must stress the calls are very few and far between and far less than the calls from women trying to argue against having a caesarean section.
The women wanting caesareans appear to fall into two categories:
1. Their previous birth experience was so horrific that they are terrified of a repetition.
2. They are expecting their first baby and most of their friends or relatives have had awful experiences and they want to avoid joining the club.
We have only had two cases where the women wanted to protect their perineums and sex lives (rational argument about the risks of caesareans to their sex lives fell on stony ground – they were absolutely determined).
Do we understand what ‘normal birth’ is?
I believe that the constant media diet of painful, traumatic ghastly birth experiences has resulted in a generation of women who are fearful of birth (not that there were not women who were fearful of birth before), but women (and many midwives) have little understanding of normal birth.
Time and again, I hear women describe their ‘normal’ births as: breaking the waters, setting up a drip because they did not progress, epidural, long periods of electronic fetal monitoring, episiotomy and because they delivered vaginally, and the midwives wrote normal delivery on the notes, the women see their very painful births (often stranded on a bed) as ‘normal’. I always explain that they did not have a normal birth they had an obstetric delivery, and we really need a concerted campaign to reclaim the definition of normal. What happens in the majority of our large, centralised, obstetric units is not normal but it is a common experience.
By AIMS’ definition of normal birth less than 10% of women under obstetric care achieve a normal birth (and I suspect the figure is far less among primigravidas). The present system of data collection does not easily allow us to identify normal birth, but a fairly accurate assessment can be made.
AIMS has recommended that the statistics are collected in the following form:
- Artificial Rupture of membranes YES/NO
- Induction of labour YES/NO
- Acceleration of labour YES/NO
- Epidural anaesthesia YES/NO
- Episiotomy YES/NO
(Note: if the response to any of the above is YES, then the birth should be recorded as an obstetric delivery)
Type of delivery:
Normal birth YES/NO
Obstetric delivery YES/NO
Perhaps by this means we will be able to impress upon both midwives and mothers the difference between a normal labour and the actively managed technological births experienced by the majority of women in UK hospitals?
Beverley Lawrence Beech
One of our consultants who told me this week that as an advocate of choice in childbirth he is of the opinion that women should be honestly informed of the risk of perineum and vagina trauma that he associates with vaginal deliveries … and … wait for it sisters …….. that women should be entitled to elective CS to protect them from future corrective surgery.
My jaw hit my chest with an audible thud.
yours in sisterhood
Don’t tell me he says c/s are safe and not a single hysterectomy has ever been undertaken in his hospital (as a result of a c/s) and that (as a result of these never-undertaken hysterectomies) no corrective surgery has ever been required …
Oh and there are isn’t any psychological upset as a result either, and the fact you miss skin to skin contact and you may never bear children again…
(who had an unwanted hysterectomy after an elective caesarean)
A woman I know in Oxfordshire wanted her second baby to be delivered by a midwife that she knew, and who knew her history (due to a very traumatic first delivery). Despite her best efforts (and she is quite assertive!) the Trust couldn’t see its way to arranging this, but were happy for her to have an elective CS – which she chose and they were happy to pay for. This cannot be unusual and it is a SCANDAL.
The latest great entry in our message book at work is a real show-stopper. It gives the woman’s name and the comment ‘elective caesarean section — maternal request — needle phobia’. The mind boggles. I wonder if anyone has told her about all the needles this will entail? As opposed to a normal delivery where she needn’t have any needles if she doesn’t want to.
Oh well — only time will tell.
My 3rd babe was born in a successful VBAC (vaginal birth after caesarean), the previous caesarean performed for abrupted placenta (1st baby SVD (spontaneous vaginal delivery)).
When my youngest was 22 hours old, a representative from my partners firm arrived with a bouquet of flowers to witness a family mealtime – youngest on the boob, and me alternately shovelling food into me and my toddler. He expressed surprise – should I not be in bed? Why? I felt wonderful!! The following day, I had to visit the dentist and my local shops. An acquaintance on seeing me with baby so young asked if I should be out! Why not? Later in the day, we visited town. I was surely not a cripple, but a normal, healthy mum with 3 children.
However, even I could see the difference from the last birth, when I was discharged from hospital post-caesarean, 1 week prior to Christmas, to cope with a young babe, a toddler, a haemoglobin of 9.5, (when my pregnancy norm had been 14), and the run down to Christmas and all that this entailed with a young family – and my partner was BRILLIANT!
I feel that any woman contemplating a ‘social’ caesarean really ought to be able to view women in different ways, i.e. through documentary, no holds barred, and see the full implications of the process.
As I mentioned before, I really enjoyed my 2 normal birthings, and know full well what I prefer. Normal childbirth is bliss in comparison to caesarean delivery!!
Just as a comparision, after my C/S my mother-in-law came to visit me the next day with my husband around 8am to find me up, dressed (in ‘real’ clothes’), having taken out my IDC (indwelling catheter) myself, folding nappies. She wanted to know why I wasn’t in bed, as she had been after her deliveries 30 years ago (vaginal, but that’s not the point). I told her someone had to fold the nappies, and I felt fine.
I truly believe that attitude is a huge factor in recovery from C/S. By the way, this was no ‘small’ incision – 4800g baby, 38cm (albeit unmoulded) head.
After Cherie Blair had her fourth baby by VBAC:
Dr Stuttaford apparently wrote his article before finding out that Mrs Blair was not in fact having an elective repeat caesarean. The article pooh-poohs the idea of a VBAC, and includes a description of what happens during the operation, diagram of the operating theatre.
Electronic Telegraph, Thursday 27 April 2000
“I wouldn’t have them any other way” by Olivia Fane
Article about why elective caesareans are great, by a mother who has had several. She too jumped the gun, saying that “OVER the next few weeks, a great bevy of natural childbirth fanatics will launch their attacks on Cherie Blair for choosing to have her fourth child by elective Caesarean section”
This is a good example of reasons for women requesting a c/s, ie an exhausting first-time labour. In the author’s case this ended in a c/s and she chose to have all future children by elective repeat. It is great that she could explain her feelings so well in her article, but it would have been helpful if she could have looked at why her first labour was so difficult, perhaps.
Love thy labour
Electronic Telegraph, Saturday 4 July 1998
“More and more women are ‘booking in’ to give birth by ‘painless’ Caesarean. It’s a nice idea, says Kate Saunders, but do they realise the risks they’re taking?”
Caesarean Choice Study
I am based at the Centre for Family Research, Cambridge. We have recently received funding from the Nuffield Foundation for a three year study looking at the decision making process when childbearing women choose, or seek to decline, caesarean section.
We intend to use retrospective and prospective, qualitative and quantitative approaches, and to contact professionals as well as childbearing women. We are hoping to involve women from a wide range of social backgrounds. The plan is to explore some of the issues that are less likely to be accessible from the large-scale RCOG (Royal College of Obstetricians and Gynaecologists) audit that is about to start.
We are only at the piloting stage. However, we hope that it will help to throw some light on how and why decisions are made, and on what information women are basing their choices.
On this site:
- Planning a Good Caesarean
- Caesarean Section for Maternal Choice by Sara McAleese
- Forced Caesareans
- Risks of Caesareans
- Vaginal Birth After Caesarean
On other sites:
Transcript of a brief debate from Good Morning America on elective c/s, between Dr. W. Benson Harer, the president of the American College of Obstetricians and Gynecologists, and Dr. Marsden Wagner, former director of Women’s & Children’s Health at the World Health Organization.
UK’s National Sentinel Caesarean Section Audit Report
Cesareans: Are they really a safe option? by Henci Goer
Response to the above debate on elective c/s, with detailed references.
Caesarean pages on US Midwife Archives
British Medical Journal articles:
Should women who elect to have caesareans pay for them?
Letters: Caesarean Section Controversy
Changing attitudes towards caesarean delivery , BMJ 2000;321:33-35 ( 1 July )
Midwives would prefer to have vaginal deliveries
Politically incorrect surgery
Caesareans in Latin America
Survey of obstetricians’ personal preference and discretionary practice.
Al-Mufti R, McCarthy A, Fisk NM
Are Caesarean Births Really The Answer For Worried Mums? By Pat Hagan, WebMD Medical News
Questions for mothers considering elective caesareans(at the bottom of the page)
AH updated 22 February 2002