Caesarean versus vaginal birth

If you are researching your childbirth options, this section tries to provide a balanced high level list of the positive and negative aspects of both forms of delivery. The two methods are very different and carry some identical risks and some very different risks. It is your feelings associated with the positives and negatives that should inform your choice, not pressure from other people.

A study reported in the Obstetrics and Gynaecology journal reports that "The risks of CS [caesarean section] and labour are real but different, and if fully explained to the woman, she should be allowed to accept one set of risks over the other - after all she is the person who has to live with the consequences. An elective CS in a fit healthy woman is neither unsafe nor bad practice if she truly understands the risks involved and is adamant that she cannot accept the risks of labour or vaginal delivery." 45

We recommend that you search out real experiences too as this will provide you with more concrete examples of these factors. Our connect you to other people who have had or are thinking about caesareans. Talk to your family and friends but always bear in mind the following:

• The recency of the birth experience (practises even 10 years ago can differ radically from the norm found today)
• The amount of support the friend had during and after their experience
• The extent to which they were open minded about the course their birth would take, prior to the onset of labour (i.e. if they were adamant about having a water birth at home and ended up being rushed into hospital for an emergency caesarean, their perceptions of the birth are likely to be far more negative than someone who hoped for a water birth but was aware that complications might require a change of plan)

Caesarean births

Positive aspects of caesareans

• When medical indications suggest that you or your baby are at risk if you attempt (or are attempting) a vaginal delivery a caesarean can be the fastest or safest way to delivery your baby
• You will be fully conscious - you are awake and capable of welcoming your baby into the world; you do not miss out on your baby's first cry, or even necessarily that first cuddle. The exception to this is if you have a general anaesthetic but a general anaesthetic is not standard procedure. You are certainly able to breastfeed as soon as the surgery is complete (in rare instances women have been known to hold and breastfeed their baby while surgery is completed).
• Known experience - much more is known about the way your birth will proceed. In an elective caesarean particularly you will know when and how everything is going to happen to you; your baby should be with you as soon as he / she is born (assuming the baby is responding well); you will not labour for hours and face discussions about what you might do next when you feel least capable of having them
• Avoidance of labour - if you have an intense fear of childbirth, an elective caesarean avoids all the uncertainty and pain typical of labour
• Protection of your pelvic floor - reduces the risk of stress incontinence caused by stretching of these muscles 3. With natural childbirth this is quite common and can be difficult to overcome, causing inconvenient leakage of urine when coughing, sneezing, laughing or crying 18. Persistent problems are less common but in these cases treatment can be arduous and disappointing once the condition is established. Beware that if this is your sole reason for requesting a caesarean you may be accused of being somewhat selfish in wanting to keep yourself 'honeymoon fresh'
• Timing - both in terms of timing and duration, surgeons can work out when your baby is due so that a delivery date can be arranged appropriately. This means that the surgery can be expertly planned, so that work and private life can be managed and manipulated i.e. childcare arrangements for existing children can be made and you can prepare yourself fully for what is to come. You will know what day and time the surgery will take place - very helpful if family or friends are needed to provide immediate home support round the clock. This can be an important factor if, for example, you are a single mother with little support
• Speed - a caesarean section takes less than an hour in the operating theatre. Your birth partner can be there too (unless you have a general anaesthetic). Many women are up and about and going home within three days of the surgery
• Damage - in most cases this is minimal and temporary, the horizontal incision site soon heals to leave a neat, barely-visible bikini line scar within a matter of weeks and unlike vaginal damage it is highly unlikely to affect your sex life

Negative aspects of caesareans with regional anaesthetic

• Physical discomfort - in the first few days there is likely to be some discomfort around the caesarean incision site and walking will be slow and painful for a couple of days. It will also seem difficult to get out of bed and turn over. However you will be given adequate pain relief both in hospital and to take home to help deal with this and for many, this discomfort rapidly disappears. It may mean that you need a little support the first few times you try to get into position for breastfeeding
• Abdominal muscles can weaken in the longer term and this can restrict your activity for a time, but careful exercise can remove this effect
• Haemorrhage or sudden heavy bleeding - on average, you will lose about twice as much blood during a caesarean as during vaginal birth. However, blood transfusions are rarely needed and you are closely monitored during and after the surgery. Sometimes bleeding occurs because of an internal tear, in this case the tear can normally be repaired and the bleeding stopped. Sometimes blood loss is from the placental site, which may be controlled by drugs, (if this is not possible then surgical techniques are used). In the most serious (and rare) cases of haemorrhage a hysterectomy may have to be performed
• There is a risk of surgical damage to the bladder and bowel - these are rare and are repaired at the time of the caesarean surgery. Taking no food and restricting water consumption prior to the procedure can reduce the chances of this occurring as the surgeon has a clearer surgery site
• Surgical nicks to your baby are rare (in around 2% of caesareans - most commonly breech presentation 27) and the risk is reduced further by ensuring your baby is in a good position prior to surgery
• Baby's breathing - a baby born by caesarean before the 39th week of pregnancy is at higher risk of mild to serious lung and breathing problems. The Sunday Times reported "It can make a huge difference having a caesarean at 39 weeks instead of 37, as each extra week halves the risk of respiratory morbidity." 37 In the UK an elective caesarean will not be performed more than 10 days prior to the due date unless there are already other medical issues arising that indicate that a caesarean is necessary. Therefore unless other medical indications arise your baby will be born full term with negligible risk to the respiratory system. In the case of a premature birth, whether the birth is caesarean or vaginal your baby may have some respiratory difficulties and need to wear an oxygen mask in order to receive extra oxygen
• Infection - a risk, which is often preventable. Prior to surgery you will be given some antibiotics to help counteract any infection. If there is a major concern about infection you may be given a course of antibiotics over a number of days. In serious cases you may need to return to theatre, though this is very rare

• Mortality - Mortality rates are very low but should not be ignored. In a recent government report by the Department of Health 2000-02 "Confidential Enquiries into Maternal Deaths" research revealed that the categorisation of maternal deaths varies from one hospital to the next 95. The integrity of the data is such that the Enquiry has decided to caveat the results so heavily as to only make general statements rather than produce hard facts at this time. They have called for rigorous classification across the UK to redress this gap.

  A summary of the enquiries findings are as follows:

  In the majority of cases where death followed a caesarean section there were serious prenatal complications or illness that, in many cases, dictated the need for a caesarean section in any case. While, there are occasional deaths from anaesthesia or haemorrhage that result directly from the procedure, "it is important to note that, during this triennium, no women died from the direct effects of anaesthesia for a caesarean section undertaken at her request and for which there was no clinical indication" 95.

• Clots - Deep Vein Thrombosis (DVT) can occur. Pre-emptive measures are taken in all caesarean cases. If you have a planned caesarean it is likely that you will be given anti-embolic, elasticated stockings to wear (this is not standard policy in all hospitals unless you are considered to be high risk). If you deliver by an emergency procedure these stockings will be put on afterwards. You should continue to wear these stockings for the duration of your stay in hospital. You will also be given injections to help thin your blood a little to prevent clot formation
• Anaesthesia - it is possible to react to a general anaesthetic, however such reactions are very rare. However these drugs do cross into your baby's bloodstream and your baby may be more sleepy than normal and occasionally may be slow to start breathing when born. If this is the case, the midwife or paediatrician will give your baby a drug called narcan (naloxone) to reverse the effects of the anaesthetic
• Constipation - can arise as a result of the anaesthetic. In many cases, medication is prescribed automatically to counteract this. Taking a supply of fruit and extra fluids can help to reduce the effects
• Trapped wind - this is wind trapped in the abdomen cavity during the procedure. It can cause temporary discomfort. Drinking peppermint tea can significantly reduce this
• Emotional response - if you had not planned to have a caesarean, an emergency caesarean may come as a shock, affecting your overall perception of your birth. A negative birth attitude can impact your ability to breastfeed. A positive attitude 20 about the need for the caesarean can go a long way to reducing this effect
• Cost to the NHS - the cost is greater for a caesarean (approximately £750 more). "In the UK every 1% rise in the CSR [caesarean section rate] has been estimated to cost the NHS over £5,000,000 per annum" 40 However in the USA it has been calculated that an increase in intervention in vaginal deliveries, in particular the administering of oxytocin and epidurals, can exceed the cost of an elective caesarean by almost 10% 40

Negative aspects of caesareans with general anaesthetics

An emergency caesarean with a general anaesthetic is different to regional anaesthesia (Spinal or Epidural) In addition to the risks already outlined you should bear in mind the following:

• You are not awake when your baby is born
• Both you and your baby will be quite drowsy from the anaesthetic for a number of hours
• Emotional negativity. Some women report having difficulty bonding with their baby initially. It may help to ask for someone to visit you after the surgery to tell you about your specific operation in detail or have photographs taken of your baby being cleaned and checked and then over the course of his / her first hour (Requesting this in advance as part of your birth plan is essential)
• Your birth partner is very unlikely to be able to be present at the birth. If your birth partner wants to be present to observe the birth and report to you or wants to be able to hold your baby the moment he/she is born then request it in advance. Some hospitals are becoming more positive about such requests. However you should not underestimate the stress your birth partner might experience seeing you asleep and undergoing surgery

Subsequent pregnancies

• Risk of rupture involving the uterus and possibly other tissues in subsequent pregnancies - of a horizontal lower segment scar (i.e. from a previous caesarean) is generally considered to be around 0.5% (which is one in 200 women). This is considered a serious complication
• Vaginal Birth after Caesarean - A previous caesarean does not mean that your next birth must also be a caesarean. 33% of women go on to have a vaginal delivery 14. Vaginal Birth After Caesarean (VBAC) organisations provide a lot of information for mothers wanting to have a vaginal birth after a caesarean. There are some circumstances where a vaginal birth will not be advisable and you should seek clarification from your consultant after your first caesarean to check whether you are in this group. Midwives and doctors do tend to be a bit more cautious during a labour if the woman has had a caesarean previously because of a small risk, usually estimated at 0.35% 14, of the uterine scar tearing during contractions. The risk of an infant death during the birth process (following an earlier caesarean) is small for women who have a planned vaginal birth (10 per 10,000), but this is even lower with a planned, repeat caesarean (1 per 10,000) 27
• Subsequent ectopic pregnancies - where the embryo has implanted outside the uterus. It is not clear whether a caesarean can increase the likelihood of developing an ectopic pregnancy, however in the case of such a pregnancy it would need to be terminated and there is a risk to the mother of severe bleeding and surgery (which in rare instances includes a hysterectomy) 22
• Placenta Previa (low placement of the placenta) and Placent Accreta (an abnormally firm attachment of the placenta to or through the uterine wall). Placenta Accreta is rare outside of cases of Placenta Previa. Placenta Accreta is difficult to diagnose prior to delivery (though a transvaginal ultrasound may detect this). And it can result in a premature birth typically at 34-35 weeks. A possible link has been identified between the incidence of Placenta Previa and previous caesarean, previous D&Cs (Dilation and curettage), maternal age and multiple pregnancies. It is relatively rare however - average incidence of approx. 1 in 7,000. If there is a risk of Placenta Accreta an elective caesarean may be recommended as separation of the placenta from the uterus makes it difficult to control bleeding when uterine contractions occur to deliver the placenta. 50% of patients in this scenario require blood transfusions. There is a risk of a hysterectomy associated with dealing with this situation. In some cases alternatives can be found but this is only possible where the mother is 'stable'. 38

Vaginal births

Positive aspects of a vaginal birth

• Pain relief - you can limit this as much as you like, opting to keep both you and your baby totally drug free for the duration of the birth. Most anaesthesia cross the placenta to a greater or lesser extent and may make you and your baby drowsy after birth. Gas and air have no major side effects for you or your baby and with the correct technique, good pain relief can be achieved, though this is more difficult if you are induced. There are numerous other methods for helping to control the pain during labour such as those taught by the Active Birth Centre
• Born to your baby's schedule - unless you have to be induced, your baby will be born when it is good and ready. This means that both you and your baby have the necessary hormones (oxytocin etc.) to help you cope with the situation
• Birthing through the birth canal stimulates your baby's lungs preparing his/her body to breath
• You can hold your baby the moment he/she is born and, if there is no anaesthetic in your system, your baby is likely to be more alert and able to see, hear, smell, taste and feel you
• Sense of achievement - by following your human instinct through to its natural conclusion women can feel a tremendous sense of achievement at having given birth this way
• Shared experience - going through the pain and jubilation of labour and birth may give you an empathic understanding of what your baby has just been through

Negative aspects of a vaginal birth

• Labour pain - this is, for most women, a very painful experience especially in the final stages. The extent to which this pain is experienced will vary from person to person. Breathing techniques, labour positions learned in antenatal classes and Yoga can make early labour less stressful. However fear and tension can alter hormonal states, physically increasing levels of pain often to a point where women can no longer cope without some form of pain relief
• Pelvic floor dysfunction - it is not uncommon for this to appear at the time of birth and/or later in life. 3 Pelvic floor problems arise when coughing, sneezing, laughing or crying and include leaking urine (urinary incontinence), leaking gas or, more rarely, faeces (bowel incontinence). Sexual dissatisfaction and a sagging / dropping of the inner organs (also known as uterine and other pelvic organ prolapse) - are rare but can occur
• Studies suggest that a caesarean may be preferable to the use of forceps in order to "protect the pelvic floor, avoid perineal pain [pain between the vulva and the anus], dyspareunia [pain in the vagina during sex], uterovaginal prolapse [collapsing of the uterus] and incontinence of urine, flatus and/or faeces" 18. Studies also imply that converting to a caesarean after you have progressed through the second stage of labour will not help to protect the pelvic floor from such damage. Possible ways to help avoid the problem are to insist that the health professional does not press against the opening to your vagina as the baby's head is born and dictating the pushing yourself rather than following your health professionals direction as this can be more forceful than needed. According to one article it is ok, once dilated, to wait for up to 2 hours before pushing if you do not feel ready to do so. 22 Finally try to avoid giving birth on your back. In all cases it is a good idea to exercise these important muscles while pregnant as simply carrying your baby up to the point of delivery places some stress on your pelvic floor
• Medical intervention, be this forceps or ventouse, occurs in a significant number of births. Currently in England only 10% of vaginal deliveries are entirely natural (i.e. no medical intervention of any kind including epidurals, forceps, ventous etc.) 42 The Association for Improvements in Maternity Services (AIMS) reinforce this finding stating that only 1 in 6 first time mothers achieved a spontaneous vaginal birth 34. Instrumental vaginal delivery can cause noticeable damage to the mother and the potential for short-term pain and restricted function caused by such injuries should not be underestimated 36 55. The ventouse is now being favoured over forceps 14 as damage is typically less severe 43 and episiotomies are only used to expedite delivery if the baby is distressed. A ventouse delivery can, in some instances, be performed without an episiotomy. However such measures, devised to help the small minority of mothers and babies who needed assistance during labour, may be applied when not strictly necessary. Unless you are in a birthing centre or have been particularly outspoken in your birth plan, it is possible that you will find these procedures being applied to you.
• An episiotomy alone can make sitting and walking very difficult for a week or more and the impact on your sex life may be much longer than this. Unpleasant or painful sensations and invasion of privacy, often by strangers are frequently associated with episiotomies.
• Possibility of a caesarean - according to current UK figures, 1 in 4 women will have a caesarean whether they planned to or not. The Association for Improvements in Maternity Services (AIMS) has found that by its definition of a normal birth (no medical intervention of any sort), only 1 in 6 first time mothers achieved a spontaneous vaginal birth. Medical intervention (including one or more of the following: induction, artificial rupture of membranes, a caesarean section, general anaesthesia, forceps and/or ventouse, epidural anaesthesia or an episiotomy) occurred in the other 5 34
• Tears in the vagina or perineum - these can occur to varying degrees and may need stitching. Dissolvable stitches are used so they do not need to be removed, however the tears can cause pain and discomfort when sitting and going to the toilet (particularly if you develop haemorrhoids). On rare occasions infections may require further surgery, for which most women will be given some local anaesthesia in the perineum and in the vagina or some other form of anaesthetic, before receiving stitches. Such interventions can significantly impact on your retrospective perception of your birth. The impact upon your sex life can be significant for weeks if not months, aggravating postnatal depression and in some cases triggering it
• Tears to the anal sphincter - a few women will experience their anal sphincter tearing during childbirth. This may occur if your baby is very big, but sometimes it can also be torn if the doctor uses forceps or a ventouse. According to AH Sultan reporting in 1997 as many as 35% of first time mothers are likely to suffer some degree of anal sphincter disruption after delivery. The sphincter will be stitched up by a doctor and this is usually performed under a spinal, epidural or general anaesthetic, as it can be very painful 4. (Such minor surgery may mean that you are still taken into theatre, away from your baby). Forceps deliveries and episiotomies seem to be the major culprits, but even spontaneous delivery is associated with increased risk. Furthermore, general pelvic support may be compromised by muscles stretching 5. A decrease in the number of routine episiotomies with forceps deliveries is reducing the number of women suffering tears to the anal sphincter
• Anaesthesia -side effects from an epidural can occur though this is rare. However these drugs do cross into your baby's bloodstream and your baby may be more sleepy than normal and occasionally may be slow to start breathing when born. If this is the case, the midwife or paediatrician will give your baby a drug called narcan (naloxone) to reverse the effects of the anaesthetic
• Nerve damage - if you baby is born vaginally it is more likely to have a nerve injury that affects the shoulder, arm or hand than with a caesarean. Pressure to the face, arms and shoulders can result in temporary weakness (paralysis) of the face or hands etc. Occasionally, the nerve going to the diaphragm can be damaged which may mean that the baby may have difficulty breathing. Such injuries usually clear up completely within a few weeks and no treatment is necessary. Very rarely, the arm and possibly the diaphragm remain weak after several months. In this case, surgery may be needed to re-attach torn nerves. Injuries to the spinal cord due to overstretching during delivery are extremely rare. These injuries can result in paralysis below where the injury occurred. Damage to the spinal cord is often permanent.
• Tiredness - labour will take as long as it takes. The timescales will vary from one woman to the next. Depending on the length of your labour this may result in a level of exhaustion that in itself can result in medical interventions to assist your delivery. Some women who have borderline indications for caesarean sometimes opt to go straight for a caesarean to ensure that they are less exhausted when their baby arrives. You can negotiate a switch to a caesarean during labour if you feel that you are no longer coping, though timing this can be quite difficult as theatre space or an anaesthetist may not be available
• Invasion of privacy - vaginal examinations can be necessary and may be carried out by different people, none of whom may be familiar to you. However you can request not to have these, though they may become necessary in an emergency situation
• Lack of midwives - you may well spend significant periods of time labouring alone. A midwife may have more than one labouring woman to look after at any one time. Figures released in December 2004 by the Royal College of Midwives show that two thirds of heads of midwifery in the UK do not believe they have enough staff 17. While recommendations are that the ratio of midwives to labouring women is 1 to 1.15 49. There are now frequent reports of midwives running between three and five women in labour 17

Vaginal births after a caesarean

If you have a caesarean on a previous delivery, it is quite possible that you can go on to have a successful vaginal birth on your next delivery should you want to. 33% do go on to successfully deliver vaginally 14 but it does carry, when coupled with induction, an increased risk of the uterus rupturing 59. The National Institute for Health and Clinical Excellence (NICE) 27 state that the risk is between 80 and 240 per 10,000 women depending on the type of drugs used to induce labour.

The risk of an infant death during the birth process (following an earlier caesarean) is small for women who have a planned vaginal birth (10 per 10,000), but this is even lower with a planned caesarean (1 per 10,000) 27. Vaginal Birth After Caesarean (VBAC) organisations are an excellent source of help and support in assessing this risk and improving your chances of a vaginal birth, should you want one.

Making a choice

Unless you are in the situation where medical indications make it critical for your baby to be delivered by caesarean, the decision is ultimately yours and yours alone. By researching your options you can make the decision making process (elective or emergency) much easier. If your situation is not black and white we would suggest the following activities to help with your decision-making:

• Understand the positive and negative aspects of both a vaginal birth and a caesarean birth
• Talk to as many people as you can. Take a look at our , they can connect you with other people who have had caesareans or are thinking about them. Ask lots of questions and understand as many different experiences as you can, particularly of women who have used the same hospital / birthing centre in the last couple of years (assuming that you have not opted for a home birth). If possible try to maintain a logical approach to assessing the stories. Women naturally feel very strongly about their own birth experience, good or bad. It is a very personal and intense experience

Be clear about your fears (and those of your birth partner). Ask yourself what you feel about:

• Being in labour for a long time
• Your ability to tolerate pain
• Risks, specific to you and your baby, of becoming distressed during labour
• The idea of a natural birth becoming medically assisted i.e. working through hours of labour to then end in forceps, ventouse or caesarean
• The ability to control the timing of the birth or the surgery

Which experience do you wish for your baby - being squeezed through the birth canal or disturbed and lifted from your abdomen?

Discuss the choices with your birth partner. They are likely to have worries and questions of their own. In most cases they will be involved in the whole process and it is very important that they are in agreement with the choices that are made. Even with a general anaesthetic caesarean they will still have a role in caring for the baby until you wake.

Once you have all the information you will be in a much better place to make the decision.