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Frequently Asked Questions

What are the risks?

Caesarean versus vaginal delivery

Planning a caesarean

Effect of a caesarean on subsequent births

The caesarean proceedure

After the operation

Caesarean statistics

What are the risks?

If I end up having a caesarean, what are the risks to me?

There are a number of risks with having a caesarean. Some of these are the same as for a vaginal delivery and others are specific to having a caesarean.

What are the dangers to my baby if I have a caesarean?

If you have a caesarean for medical reasons it is because there is already a level of risk associated with the birth of your baby. A caesarean will remove some of these risks but will introduce other risks through the course of the procedure.

Is my baby likely to develop asthma as a result of my having a caesarean?

Research connecting the likelihood of developing asthma to having been delivered by caesarean is contradictory and specialists in the field reveal that far more research is required before any firm conclusions can be drawn.

Links have been made with premature babies but not with full term babies (where delivery is anything from 37weeks onward). Though it has been suggested that women who themselves have asthma have a greater likelihood of giving birth prematurely suggesting that there may be a pre-disposition for asthma rather than it being caused by a caesarean delivery in itself 66.

A number of studies have identified an increased likelihood of asthma when a baby is born already exhibiting respiratory and other pre-natal problems. And more than a quarter of caesarean births occur more than 3 weeks prior to term and the reasons for the early birth may have more to do with the symptoms than the caesarean birth itself 67 68, while other studies have found no significant connection at all 69. There is also a study suggesting that there is a possible link between whooping cough vaccinations and asthma, also suggesting that the BCG (TB vaccine) might protect whooping cough vaccinated children against the risk of asthma. It is significant that in the countries where the routine use of BCG has been abandoned (UK, New Zealand, Australia, Ireland, USA, etc) the rates of childhood asthma are the highest. A Brazilian team is currently exploring the possible protective effect of BCG against asthma.

It is also worth noting that there are many other behaviours and treatments also thought to contribute to the likelihood of developing asthma in childhood: increased intake of trans fatty acids (processed oils which are found in a great variety of food i.e. cakes, biscuits, french fries and fast food in general); exposure to antibiotics as a foetus; antibiotic treatment in the first 6 months of life and the absence of the BCG vaccination (where the prior administration of the Whooping cough vaccination has occurred) 70.

In the UK, a caesarean (where there are no prior medical indictors) cannot be scheduled more than 10 days prior to the recognised due date of your baby. This means that at the time of birth your baby is 39 weeks and therefore the lungs are considered to be "fully mature". If your baby has to be born prematurely (prior to 37 weeks) for medical reasons, the risk of respiratory difficulties does increase. Research is suggesting however that breastfeeding your infant and requesting the BCG vaccination in their early years may be a means of reducing the possible effects of a premature caesarean birth 70.

Will a caesarean impact the development of beneficial gut bacteria? What's New

Research suggests that the colonisation of the gut with 'good' bacteria occurs in the first week after birth and that for babies born by caesarean this process may take slightly longer. This may result in an increase in the number of bouts of diarrhoea. In families where there is a history of allergies, research indicates that there is an increase in the likelihood of developing egg and nut allergies 71. However, more than a quarter of caesarean births occur more than 3 weeks prior to term and the reasons for the early birth may have more to do with the symptoms than the caesarean birth itself.

As with asthma, research suggests that breastfeeding can play an important role in the immune system and the introduction of these important bacteria to the gut 73.

Caesareans versus vaginal delivery

Will I feel I have missed out if I don't have a "normal" (vaginal) birth?

Most women naturally have particular ideas about how they would like to give birth. If your birth does not meet your expectations it is possible that you will feel disappointment and in the case of having a caesarean may have feel you have "missed out".

However in a recent study in the British Medical Journal, involving more than 14,000 women "Professor Deidre Murphy of Dundee University, working with colleagues from Bath University, found no evidence of an increased risk of depression and this type of [caesarean] delivery… Prof Shaughn O'Brien, of the Royal College of Obstetricians and Gynaecologists, said the study gave "clear and conclusive evidence that caesareans were not in any way linked to postnatal depression." 11

The more flexible your birth plan and the more relaxed you can be about the possibilities of your birth changing direction as you progress through labour, the less likely you are to suffer caesarean related depression and disappointment. Post-natal depression is an entirely different thing and this is not thought to be related to the manner in which you give birth. If you have at least investigated your rights and the classifications of the stages leading to a caesarean then you know more about what is going on and can be involved in the discussions about whether or not a caesarean (or indeed forceps, episiotomy etc.) is really necessary.

I am carrying twins and have been told that I have to have a caesarean. Is this true?

Not necessarily, however there may be very good medical reasons why you should and you should ask your health professionals to explain these to you. The position of the babies will play a significant part in determining how they are born. According to American figures around 40% of twins are both head down at term, with another 30% with the first baby head down and the second breech. Where there are no other complications (i.e. positions of umbilical cords, identical twins sharing a placenta and amniotic sac etc.) both of these positions should be considered acceptable for a vaginal birth. Where the first twin is breech or indeed one or more is in the transverse position (lying across the uterus) a caesarean is far more likely to be encouraged by your health professionals.

"While having twins does increase the likelihood of you having a caesarean, fewer than half of twins are born this way" 64.

In some instances you may find that you can manage to deliver the first twin vaginally but for some reason (i.e. foetal distress or prolapsed umbilical cord etc.) the second twin may need to be delivered by caesarean. This occurs in only about 3-4% of all twin births 65. But given this possibility it is advisable to prepare for this eventuality by discussing your caesarean requirements in your birth plan. In particular it is worth talking to your hospital in advance to determine what their policy is about twin births. Some hospitals require all twin mothers to give birth in the operating room, even if they have a vaginal birth. Some hospitals might also insist on the insertion of an epidural anaesthesia needle even if no medications are used, this allows immediate anaesthesia should surgery become necessary.

Research reported in the British Medical Journal (BMJ) from studies evaluating over 4,500 sets of twins born between 1992 and 1997 found that during vaginal childbirth, the second twin is up to eight times more likely to die, compared to twins delivered through a caesarean. In total, one in every 270 second twin died during natural childbirth, which is a significantly higher death rate than babies who are not twins. The majority of these deaths were due to a lack of oxygen. When the researchers looked at over 450 twins born by caesarean, none of the second babies died 44.

I am worried about my sex life after a vaginal delivery. Is there any evidence to suggest that a caesarean will mean my sex life is less likely to be interrupted? What's New

The reaction of each woman to sexual contact during pregnancy differs. Some women become increasingly interested in sex and others lose interest all together. The same is true for postnatal reactions. Varying hormone levels are thought to play a significant role in this. Add to this the fact that tiredness experienced by both parties in the weeks and months following the birth of their baby will also impact interest in sex and you can see that damage due to mode of delivery is just another factor.

That said, where a woman has experienced trauma, either physical or mental, then the knock on effect to her sex life may increase. In the case of physical damage to the vagina, the healing process may naturally reduce her willingness to participate in sex for a time. But on the same front recovering from a caesarean may produce similar results. While the vaginal area is undamaged the abdomen can be very sensitive to pressure and twisting actions. However in this instance it may simply mean trying less active positions for a time i.e. spoons. We know of at least one instance where a woman experienced an emergency caesarean and significant baby-blues (not postnatal depression) and who found that in the early weeks "being close" to her partner i.e. resuming sexual contact, was the only thing that helped keep her head above water "at least one part of our lives could return to normal".

In the case of mental trauma this can arise from either mode of delivery and is difficult to guard against. A woman's reaction to her birth can have knock on effects far wider reaching than her sex life i.e. her ability to bond with her baby. Where severe mental trauma has occurred it is worth seeking professional counselling.

One study reveals that with the exception of a reduction in painful sex-related problems it may actually be a myth that a caesarean birth will mean your sex life resumes more quickly. "Of the women surveyed 50% had natural births, 25% had a forceps or ventouse assisted delivery and 25% gave birth by caesarean section. The majority of new mothers resumed sexual intercourse in the postnatal period and there were no significant differences in the timing of resumption by type of birth". However it did find that on issues around sexual response, post coital problems and painful sex related problems women who had a caesarean faired better. This was most significant in issues relating to pain during sex 80. The comparison of painful sex-related problems, sexual response-related symptoms and post coital problems in the first three months after birth according to the type of birth, did suggest that women with caesarean sections were less likely to experience problems on each of these three groups of symptoms, however only the problems relating to painful sex were significantly less."

The pain of childbirth frightens me. Can I have a caesarean?

Yes, though it is worth researching the various other approaches you can take to combating this fear 12. Some women have found that they feel "cheated" if they have not been able to give birth naturally. But at the end of the day, it is you who will go through this and if you would rather opt for a caesarean, the hospital is obliged to discuss your birth plan. They may readily agree or ask you to undergo counselling for your fear and then carry out the caesarean. Some hospitals have a policy of only allowing caesareans for clear medical indications in which case they may refuse. But if they do, they are obliged to refer you to another hospital that will support your decision to have a caesarean.

Tokophobia is a recognised medical condition and is starting to be recognised by some health professionals. Fear of childbirth is a very real and frightening condition and should not be treated lightly by your health professionals.

If my baby's head is too large to be delivered vaginally will I have to have a caesarean?

It is very difficult to reliably determine whether a baby's head is too large to deliver. This is because it is very difficult to reliably assess the size of your pelvic girdle or the position of your baby's head. It is certainly not the case that if your previous pregnancy ended in a caesarean as a result of a large head that your next pregnancy will too. According to the Association for Improvements in Maternity Services (AIMS) there have been many documented cases where women have gone on to deliver vaginally a larger infant than the one that was delivered surgically 34.

Planning a caesarean

If I want to request a caesarean, how should I go about it? What's New

If you want to have a caesarean the first thing to do is formally agree this with your midwife and ensure that it goes on your notes. If your midwife is in agreement then they should then put the process in motion to ensure that around week 34 you receive an appointment with a consultant at your hospital. The purpose of this meeting is to discuss the caesarean in more detail, decide upon the type of anaesthetic that you want to have and agree the delivery date. If you haven't heard from your hospital regarding such a meeting by this time it would be worth checking that they are aware you are having a planned caesarean.

If however your midwife does not agree to the caesarean, you can ask to be referred to a consultant to discuss your specific case. The consultant may agree at this stage and the process outlined above commences. If however this consultant does not agree to your request your hospital is obliged to refer you to another consultant. Your hospital cannot refuse your choice and also refuse to refer you for a second opinion. But in the UK you can still be refused a caesarean if your reasons are non-medical.

However there are a number of things you can do to try and affect this decision:

"If you request a caesarean section - 1. Your doctor or midwife should explore and discuss your reasons with you and make a note of this; they will not automatically agree to arrange for a caesarean section if you ask for one. They should discuss the overall benefits and risks of caesarean section compared with a vaginal birth and make a note of this. 2. If you ask for a caesarean section because you have fears about giving birth, your midwife or doctor should offer you the chance to discuss your fears with a counsellor. 3. If your doctor doesn't think a caesarean section will benefit the health of you or your baby, he or she has the right to decline your request for one. However, they should offer to refer you to another doctor." Page 98

Can I have my caesareans in a private hospital? What's New

It is entirely possible to have your baby in a private hospital and there are definite advantages concerning privacy, single rooms and an increased likelihood of having met your care team prior to your caesarean.

However it is worth noting that it is highly unlikely that your health insurance will cover caesarean births, particularly in instances where there is no recognised medical need for the caesarean. More importantly the facilities available to you in the private hospital of your choice might not meet all your requirements on the day. It is unfortunately the case that some private hospitals are not equipped to cope with situations where things go wrong for either you or the baby. So you could find yourself separated (i.e. in a different hospital) from your baby if one of you has to go into a special care unit.

BUPA holds a list of all private hospitals in the UK. Contacting them directly through one of the three methods shown on their homepage should also be able to provide you with a list specific to your area.

Effect of a caesarean on subsequent births

If I have previously had a caesarean, can I have a home birth subsequently?

Previous and current history do not, in fact, alter your right to try to have a home delivery, though if there are medical indications such as multiple births, breech presentation etc. it is likely that you will be strongly encouraged to deliver in hospital.

Arguably if you really want a home delivery and you are brought into hospital, your labour is less likely to proceed as you would wish. According to the National Childbirth Trust (NCT) "CFM [Continuous Fetal Monitoring] has been shown by many research studies not to improve the outcomes for either babies or mothers, that is to say no benefits to life or health have been shown, but it has been shown to increase caesarean rates. That is caesareans are thought to be advisable when they aren't needed." 60 So if you really want a vaginal delivery it is a good idea to think about having most if not all of your labour at home. Some hospitals (inc. Guy's and St Thomas' in London) do admit that if you try for a vaginal birth following a previous caesarean and it transpires during your labour that you may need a caesarean, it is likely to be "done earlier than in the first labour, [they] do not try so long with a scar" 74. Health authorities have a legal obligation to provide a competent midwife at your home. Your GP and midwife are obliged to provide obstetric services in the event of an emergency. A home booking does not prevent you from transferring to hospital at any time during your labour should you need or wish to do so.

Vaginal Birth After Caesarean (VBAC) organisations can provide a lot more information about the possibilities of a vaginal delivery after a caesarean. The concern often described to women in this situation is that there is an increased risk of the previous caesarean scar tearing during labour. A reporter writing in the the National Childbirth Trust magazine - New Generation Digest quoted that "The risk of rupture of a transverse [horizontal] lower segment scar is generally considered to be around 0.5% (which is one in 200 women). The majority of these cases result in minimal adverse effects on either mother or baby. The occurrence of poor outcome is considerably lower. In a review of all the VBAC studies carried out worldwide and documented in the International Childbirth Education Association (ICEA) Review published in August 1990 it was found that "in over 21,000 planned labours after caesarean only five babies were reported to have died in association with scar rupture". This is less than one in 4,200 (0.02%). In the same sample "twelve mothers lost their uterus due to scar rupture (0.06%)." 9

Does a vertical incision in a previous caesarean means that I cannot try for a vaginal birth?

According to the National Childbirth Trust "It is generally accepted that after a classical caesarean (a vertical incision) you are not eligible for future vaginal delivery. This is because of the slightly higher risk of uterine rupture." 61 It is worth discussing this with your health professionals and Vaginal Birth After Caesarean (VBAC) organisations may be able to offer you more specific advice.

How many caesareans can I have?

There is no set limit on the number of caesareans that can be carried out on an individual woman. The Caesarean Birth and VBAC Information Organisation are aware of at least one women in this country (UK), that has had a seventh caesarean fairly recently 58. However in general subsequent caesareans are not as easy or predictable as a first caesarean. This is due to the scar tissue that may remain from previous surgeries. Damage to the bladder or bowel may be more difficult to avoid during subsequent surgery and women can be unaware that they have had such damage repaired during an earlier caesarean. If you are hoping to have a large family you may wish to try for a number of vaginal deliveries rather than having four or five caesareans.

I have already had a caesarean. When is it safe to plan my next baby?

Child spacing is a very personal decision and one that is far more complex than simply considering caesarean scar rupture statistics. Much of the research available on this subject reveals that socially there is really no such thing as the idea gap between children. Family circumstances seem to play the most significant part in the decision making process i.e. how difficult was it to conceive last time, how old is Mum, how many children make up the family already and in particular the financial capabilities of the family, particularly if childcare is needed. However you will find that health professionals will often quote two years as the ideal gap. Various family specialists have looked at a variety of gaps between births (from as small as 9 months up to 2 years) and have found that while the risk of scar rupture is greatest in small gaps, it is incredibly rare and there is very little difference between the various gaps in terms of the level of risk.

In relation to you health, if you put on a lot of weight during your first pregnancy it may feel important to be back in shape before trying for another baby. Certainly if you are wanting to try for a vaginal birth next time round then the more overweight you are the greater the likelihood of needing a caesarean.

If you have a pre-schooler it is particularly important to consider the impact of a second caesarean in the immediate period following the surgery. You are likely to require more support at home, this is particularly the case where the child is a toddler still being lifted in and out of cots and highchairs etc.

There are a few studies that suggest that getting pregnant within 6 months of a previous birth may result in the second baby being born prematurely. One particular study showing this finding looked at 89,000 women having second births in Scotland between1992-8 and these findings were irrespective of whether a first pregnancy had complications or not 81. However in relation to intervals between caesareans, we have been unable to locate any studies which state any specific risks to a subsequent caesarean of having too small a gap from an earlier caesarean.

In terms of risk, the likelihood of an infant death during a VBAC (vaginal birth following an earlier caesarean) is very small for these women (10 per 10,000), but this is even lower with a planned, repeat caesarean (1 per 10,000) 27. Rather the Caesarean Birth and VBAC Information Organisation state that their research shows that rupture rates are increased by the use of induction 58. The evidence suggests that the uterine scar will naturally become stronger with time but that the risk of a rupture remains very small. In addition there are plenty of women who have had perfectly straightforward vaginal deliveries when the gap between pregnancies has been very short.

Vaginal Birth After Caesarean (VBAC) organisations provide a wealth of information and support for you if you have had a caesarean and want your next birth to be vaginal. It is not unusual to be told that if you have already had two or more caesareans, that future babies will need to be delivered by repeat caesarean. This need not be the case. 33% of women go on to have a successful vaginal delivery 14. The National Institute for Health and Clinical Excellence (NICE) guideline 27 quotes a rate of rupture during VBAC as 0.5% (which is one in 200 women) which is taken from an audit carried out in 2000. This audit also found the rate of rupture at a repeat caesarean to be 0.12%. Even in the serious cases, the woman's uterus is usually repaired and her baby unharmed.

The caesarean proceedure

Do I have to be asleep for the surgery?

Usually this is not the case, unless you really want to be. A general anaesthetic tends only to be used in cases of absolute emergency. The anaesthetics used in the UK are either a regional spinal or epidural (or both) and you are awake the whole time. This is better for both you and the baby as the associated risks are lower.

What If I start to feel the operation?

If you are one of the rare few whose anaesthetic begins to wear off during surgery, let your anaesthetist know immediately. The surgeon can stop their work and the anaesthetist can top up your epidural and improve your situation within minutes. As a last resort you can be placed under general anaesthetic (which works almost immediately) if you really cannot stand it. If possible it is worth waiting till the baby is delivered (this is usually in the first 5-10 minutes of the procedure) and it means that your baby will not be affected by the anaesthetic.

Will my arms be strapped down during the procedure?

There is no reason for your arms to be strapped down or restrained in any way. The tilt of the operating table (15 degrees) is so slight that there is no risk of you sliding off. If you are worried that you might be strapped down ask in advance and specify you do not want to be. It is also worth speaking again to the staff as you go into theatre if you are really worried.

I have heard that I might be very breathless during the caesarean, is this true? What's New

When the epidural/spinal is administered the anaesthetist will calculate the amount you need in order to achieve a full 'block'. The amount you are given is based on several few factors (your weight being just one of these). Everyone reacts slightly differently and this is normal, but this means it is difficult to ensure that they get the amount exactly right. They would rather give you too much than too little. They are hoping to achieve a 'block' up to your upper chest. However sometimes it will rise a little higher and this is why you will no longer be able to feel yourself breathing even though you are (and why it can rise to your face in rare instances).

With an epidural/spinal you are awake and this is a very good thing for both you and your baby, but it also means that you are aware of your surroundings and what is going on. For those women who are not prepared for a caesarean this can be rather daunting. If you are feeling nervous and breathless tell your anaesthetist. One of the advantages of being awake during the procedure is that you can talk and provide them with feedback and they can reassure you.

Some women experience breathlessness during the actual moment of birth. This is because sometimes it is necessary to help push the baby out and this involves someone (usually a nurse) applying pressure behind the baby (i.e. on your upper chest) and this will restrict (but not stop) your breathing momentarily. It is normal for this to happen and should last no more than a minute or so. If you are worried about this ask them to warn you when they are about to do this.

My anti-natal class is not really talking to me about what a caesarean will involve in their hospital. Should they be?

Researchers from Emory university in Atlanta, Georgia, looked at the psychological aftermath of childbirth in 103 women 20. They concluded that many factors contributed to the perception a woman develops of her birth. But that giving women more information about what to expect was the key to reducing the trauma they experienced. The researchers found that the likelihood of experiencing trauma after the birth increased "by having more medical intervention, more pain, a longer labour, negative experiences, a caesarean section, feelings of powerlessness, inadequate information and not having expectations met...they were particularly likely to feel birth was traumatic if pain was different from what they had expected." It is interesting to note that only one of the long list of factors blamed for contributing to this depression is a caesarean. The research recommended that "childbirth classes give women realistic ideas of the experience of birth and hospital procedures. Doctors should aim for good communication and excellent pain control, including allowing the woman to have a sense of control by giving her options."

It may be worth reminding those running your anti-natal classes that, in the UK at present, statistics show that 1 in 4 women will have a caesarean birth, whether they originally chose to or not. And that given such high odds you would find it helpful if they provided more information about the procedure, recovery and ways in which you can make a caesarean a more positive experience.

Can I be sterilised during a caesarean if I wish?

This is known as Tubal Ligation At Caesarean. The National Institute for Health and Clinical Excellence (NICE) guideline 27 states that if a woman requests sterilisation it should be agreed and documented at least a week before the caesarean is performed - this gives the woman time to reconsider should she need to.

Do I have to have a catheter?

No you don't but you should be aware that the surgeon is not obliged to continue if he thinks such a decision will jeopardise the surgery. More particularly there are very good reasons for ensuring your bladder stays empty for the duration of the surgery - it makes it far easier for the surgeon to avoid nicking the bladder (nicks are likely to result in bladder repair operations). The catheter can be inserted once you are anaesthetised and so there is no need for any discomfort and it should be removed no later than 12 hours after the surgery, a process that is also usually painless 27.

After the operation

How soon after a caesarean will I be able to pick up my baby?

Picking up your baby is entirely possible immediately after a caesarean. Some mothers have difficulties in getting out of bed in order to reach their baby the first day after the caesarean, but once at the cot there is no reason why you should not be able to pick up your baby. Staff are on hand to pass babies to caesarean mothers in the first couple of days, but you may like to ask for assistance building a safe area on your bed where your baby can stay with you instead.

What will my scars be like and will a caesarean cause internal scars (adhesions) as well as an external scar? What's New

A caesarean scar tends to be approximately 20cm in length and initially be red or pink and slightly raised. The incision site will vary from person to person. Typically it is a slightly curved horizontal incision along the bikini line. You will be shaved prior to the surgery - it might be worth asking your partner to do this before going to hospital as otherwise it is likely to be done "dry" by a nurse with a Bic razor. As you recover from the surgery the colour becomes increasingly muted and should eventually turn into a fine white line along your bikini line. Where complications arise due to infection etc. this line may take longer to heal and may remain red and inflamed for longer. However in most cases the scar line should be the fine white ine you would expect with any skin incision within a year of the surgery. On rare occasions a vertical caesarean incision will be required, but the colouration pattern will follow similar lines. Homeopaths can recommend treatments for the scar area.

Some women experience slight puffiness around the scar area for some time. This generally disappears. The puffiness is associated with water retention rather than damaged muscle and the degree of puffiness can increase slightly with exertion (hence the importance of moderate rather than rigorous exercise in the months following a caesarean). This puffiness usually disappears over time.

Diet can significantly enhance the health of skin in general so your diet, before, during and after pregnancy can impact your skins recovery.

In addition to the external scar, fibrous bands of scar tissue develop internally as part of the natural healing process (known as scar tissue). These can sometimes be felt around the scar area as slight raised patches, but they are not visible externally. In many cases this scar tissue is harmless. However in some cases it may adhere to other internal organs and cause pain and may also cause complications for subsequent pregnancies and caesarean sections. For example a second baby delivered by caesarean can expect to take 5.2 minutes longer to be delivered and a third and fourth might be as much as 8.4 and 18 minutes longer respectively due to the care required to cut through previous scar tissue.

If you are planning multiple caesareans it may be worth asking your consultant about the possibility of using a product such as "Seprafilm" (though it is far from standard practise in the UK). This is a product increasingly in use in America, the aim of which is to prevent adhesions developing 77. It looks rather like a thin fabric and is wrapped around relevant areas to prevent adhesions occurring. Within a day it turns into a protective gel and within a week the body absorbs it. Similar products are already in use for other types of abdominal surgery.

All major tissue layers are stitched during the surgery. The exception to this is the stitching of the peritoneal layer (the white waxy coating visible on the outside of organs). Debate is on going about whether or not this should be stitched together during caesarean surgery. Until recently it has been thought that allowing this layer to heal naturally reduced the incidence of adhesions, but this hypothesis has been based upon recovery from non-caesarean surgery 78. However a recent study led by Deirdre Lyell, MD, assistant professor of obstetrics and gynaecology at Standford medical school USA) found that patients whose peritoneum was stitched following their first caesarean delivery were significantly less likely to develop adhesions. "closing the peritoneum offered five times as much protection against the formation of adhesions as leaving it open. It also offered three times as much protection against dense adhesions, which are considered the most difficult to treat" 79.

Are the pain relief drugs safe to take if I want to breastfeed?

Yes, breastfeeding is strongly encouraged in the UK so they are specifically prescribed with this in mind.

Is my car insurance invalidated if I drive within 6 weeks of having a caesarean?

Some insurance companies stipulate in the fine print specific situations where you might not be covered by their insurance in the case of an accident. Major surgery, including a caesarean, might be one of these situations. It is worth checking with the insurer.

Caesarean statistics

The number of caesareans is increasing in the UK. Is this really down to an increase in the number of women who are "too posh to push"?

While the overall rate of caesareans in the UK has increased in recent years (see Figure 1 below), the increase cannot really be blamed solely on those women labelled "too posh to push". Many elective caesareans are being carried out at the recommendation of the obstetrician and are based on medical indications. While the overall number has increased the split between elective and emergency rates has remained essentially unchanged for over two decades (see Figure 2 below). Caution, fear of litigation etc. on the part of the health professionals may well be contributing to this overall increase in the caesarean rate. Certainly the Nuffield Study reported that Doctors said "it was very unusual, even unheard of, for obstetricians to be sued for doing unnecessary caesarean sections; therefore pressure was on them to err on the side of caution and do a caesarean section whenever there was any doubt over a situation." 56

UK caesarean rates 1992-2004

Figure 1 - UK caesarean rates 1992-2004

Split of Elective vs Emergency Caesareans

Figure 2 - Split of emergency and elective caesarean rates

A survey of 1315 women in the USA in Jan 2006 found that despite press reports, only 1 woman (0.08%) who might have initiated a planned primary caesarean without medical reason did so 75.

There is little accurate data discussing the issue of those women who are simply "too posh to push". "Who knows what properly informed and assessed women prefer? Caesarean section rates, especially for request, are very variable suggesting that currently women are not given fully unbiased information and so remain susceptible to cultural, media and medical fashion" 76.

What is the rate of caesarean births in the UK?

The following information is quoted directly from a BBC report on a study carried out by the Royal College of Obstetricians and Gynaecologists on behalf of the Department of Health 28. It involved an audit of every maternity unit in England and Wales over a three-month period between May and July of 2001. 30 years ago just 3% of babies were born by caesarean section in the UK, now in England & Wales the average is 21.5%, this rate varies from region to region:

The study found that for all caesareans carried out in England and Wales the main reasons included foetal distress (22%), lack of progression during labour (20%), previous caesarean (14%) and a breech baby (11%).

The National Sentinel Caesarean Section Audit Report 14 collected international rates of caesareans over the last 20 years and show that the USA has the highest rate despite the rate having dropped since the mid 90s with Scotland and England indicating the next highest rates currently (20% and 19% respectively).

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