Caesarean section: a life-saving option


PARENTING:CAESAREAN sections have had a bad press of late. From the recent Economic and Social Research Institute (ESRI) report looking at why the Caesarean section rate here increased by almost 25 per cent between 1999 and 2007, to a recent article in this newspaper which spoke of how medical monitoring of labour increased the “risk” of having “the ultimate intervention in the natural birth process”, it would seem a section is among the worse things that can happen to a mother, writes KITTY HOLLAND

To read the ESRI report, Recent Trends in the Caesarean Section Rate in Ireland 1999-2006, one could believe nothing good could come of a Caesarean birth.

It speaks of “a range of social and emotional harms of Caesarean sections to mothers”, “increased postpartum use of antibiotics and greater severe maternal morbidity and mortality” and an increased risk of a hysterectomy after a section.

C-section babies risk breathing problems, surgical cuts, non-establishment of breastfeeding and later adulthood trauma. Furthermore, babies delivered by section cost the health service more than the vaginally delivered babies.

At no point is there a reference to the fact that in most cases, a Caesarean section is a life-saving intervention for the baby, and in many cases for the mother too.

Nor to the fact that, as the World Health Organisation points out (WHO), the countries with the lowest Caesarean section rates – 0.4 per cent in Chad, 6 per cent in Cape Verde – also have the highest infant and maternal mortality rates.

The section rate in Ireland is about 25 per cent of all births.

The ESRI cites a WHO recommendation made in 1985 that a country’s section rate should not exceed 15 per cent. It does not refer to WHO’s most recent pronouncement on the issue, Monitoring Emergency Obstetric Care.

Published this year it says: “Both very low and very high rates of Caesarean section can be dangerous, but the optimum rate is unknown” and that “there is no empirical evidence for an optimum percentage”.

It comments later: “Without a Caesarean section, most women with obstructed labour will either die or be severely maimed.”

The ESRI report concludes the data it examined suggests “changes in physician behaviour over the period may well play a significant role” in the increase here.

Several obstetricians have questioned how the institute could extrapolate so generally from data which lacks details on why any of the sections were carried out.

There is no doubt that there is pressure from some quarters on expectant mothers to view Caesarean sections as “bad”.

Some discourse suggests women are being duped and manipulated by male obstetricians and a medicalised system, and that women “lack confidence” to insist on “natural birth”.

One woman who felt the pressure is Sandra Adams, from Dublin, whose son Liam was delivered by section in March.

“About a week before he was due the obstetrician told me there was a possibility I would have to have a Caesarean,” she says.

Her baby was lying oblique in the womb – neither transverse nor longitudinally, with his shoulder effectively positioned in her pelvis. A vaginal birth could have resulted in his death and her being maimed.

The news, she said, “really upset” her. “I went for a swim after the appointment and bawled my eyes out. I had been to antenatal classes with Cuidiú and was all geared up for a natural birth. They really give you the confidence to feel you can do it.

“About a a week later my waters broke at home and in we went to the Rotunda.”

A midwife examined her and said Liam was not in position, a diagnosis her obstetrician confirmed, and she was brought into theatre minutes later, at about 5pm. “And Liam was born at 5.50pm.”

She was glad of the preparation from Cuidiú about what to expect. “There were about eight people in the theatre – it was crowded, and it was very, very quiet.

“The staff kept talking to us, telling us at every stage what was happening, what they were going to do. All the way they were communicating.”

Baby Liam was taken to be checked over and quickly Sandra’s husband was holding him, skin to skin as he and Sandra had requested. “They went out of their way to make sure our wishes were respected.”

Asked how she was afterwards, Sandra says she had done a lot of reading and knew women could feel disappointed.

“But I realised though that I had done a tremendous job carrying Liam for nine months and the section was for the best. If we hadn’t had that option, the outcome could have been very grim, for both of us.”

When people heard she had had a section some pitied her. “And I know they didn’t mean any harm. But you have to get over this desire to have a ‘perfect birth’.

“I would be very pointed in saying I had a very good experience, if having major surgery can be described as ‘good’.”

Her recovery in the days and weeks after went well. “There were no complications and the midwives were magnificent. I was five nights in hospital and it was wonderful to have that time.”

Niamh Healy, antenatal spokeswoman for Cuidiú, says new mothers she sees generally accept having had a section, if it was necessary.

“It’s the mothers who feel their section may not have been necessary who feel very disappointed.

“I do worry sometimes that our classes, where we promote the desirability of a natural birth, sets women up to be upset when in the end they have to have a section.”

The most important thing for women who do have to, she says, is that they are fully informed of why they can’t deliver vaginally this time.

A number of obstetricians who have spoken to The Irish Timesagree the C-section rate has increased beyond desirable levels, but say the ESRI report tells them nothing new.

They point to the absence in the report of the fact that sections are usually highly necessary, and necessity must be behind much of the increase.

Spokesman for the Institute of Obstetricians and Gynaecologists, Dr Michael O’Connell, says the report extrapolates interpretations from data which does not record the reasons for the C-sections.

“What we need is something like the UK’s Sentinel survey where over, say a three-month period, every C-section carried out is clearly recorded, including the reasons for it. Only then, with a clear audit, will we find out why more sections are happening.”

Dr Gerry Burke, obstetrician at St Munchin’s Maternity Hospital in Limerick where the section rate is 27 per cent, says the major changes he has seen are older and bigger mothers.

“Women are deferring fertility and that has to have consequences,” he says.

Older women, he points out, have bigger babies due to the decreasing efficiency in the way they metabolise carbohydrates as they age.

“The patients are a lot heavier than they used to be. They are older and heavier and having bigger babies, but their pelvises are the same size.”

First-time labours, which are accounting for a higher proportion of births, take longer. Longer births increase the chances of distress to and even life-lasting injuries to the babies, he says.

Indeed, a study by obstetrician Dr Rhona Mahony of the National Maternity Hospital, published in last month’s Irish Medical Journal, underlines this.

It finds the rate of cerebral palsy in babies, associated with seizures in the immediate aftermath of birth, was nine times higher among first babies than it was among second and subsequent babies.

This, says Mahony, is associated with longer labours for first-time mothers.

All of which, says Burke, may indeed be contributing to a lower threshold among obstetricians for performing sections.

“The increased medico-legal environment may be influencing obstetricians’ behaviour, but their priority, I can tell you, is to have a good outcome.”

He doesn’t sense strong pressure on mothers to have or not to have a section.

“Whichever way the baby is born is a tremendous achievement. Ninety-nine per cent of mums just want a healthy baby and nothing else matters.

“I am constantly impressed at women and what they will put themselves through. They will go through anything to achieve that goal.”

Sandra Adams agrees. While some mothers, particularly those who may have been in labour for hours before finally having a section, may feel very disappointed, she feels there should be more balance. A section is not a failure to “have the baby yourself”.

“There is no ‘perfect birth’. Birth is messy, it’s visceral. The most difficult things are getting pregnant and the pregnancy.

“The birth should just be about getting a healthy baby and mother, and it doesn’t really matter how that’s achieved.”