When is a caesarean really necessary?

Which of the following circumstances necessitate a caesarean delivery over attempting vaginal delivery?

  1. The baby is in the breech position – presenting bottom down rather than head down
  2. Mum is carrying twins – both twins are presenting head down
  3. Mum has HIV – with a viral load of less than 400 copies per ml
  4. Mum has had a caesarean previously
  5. Mum’s labour is failing to progress
  6. The baby is in the transverse position – lying across mum’s body

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Only No. 6. and even then, only after attempts to manoeuvrer baby into a head down (or breech) position have not worked.

In all other instances, a caesarean may be recommended but it is not required. That said, it is worth listening to the fine detail of why a caesarean may be being recommended in a specific case.

For example, over the last few decades the number of breech babies delivered vaginally at home has decreased, so if you are planning a home birth and your midwifery team are recommending a hospital birth, this could be because they feel less experienced in home breech births. Investigating the possibility of an experienced, independent midwife may mean this is still possible for, or moving the plan to a birthing centre within the local hospital may help move towards a birth plan which supports both parties.

Similarly, twins do not have to be delivered vaginally, but where one twin is lying in a more complex position i.e. not head down, then a caesarean may be preferrable to mitigate against situations where cords become entangled or prolapse as the first twin is delivered.

At the end of the day, it is about being informed and checking you have all the facts. If you are at all unsure that the advice you are being given is the whole picture, it is your right (in the UK at least) to ask for a second opinion.

Sort the fact from the fiction

There are many myths about caesarean birth, and the popular press often perpetuate these to achieve sensational headlines.

It can also be the case that as women talk to each about birth experiences, incomplete or inaccurate information can be inadvertently passed on. One person’s negative experience can so easily paint this important procedure in a terrible, light.

It is so incredibly important to check information, ask questions and challenge responses before making a decision about the way in which you prefer to give birth. Taking on board second-hand information without questioning it, means some women face birth knowing next to nothing about caesarean birth. As a result they risk missing out on opportunities to make their experience a positive one.

  • Did you know, putting your gown on backwards means you can try holding baby skin-to-skin during surgery?
  • Did you know a breech position does not mean you must automatically have a caesarean delivery?

Caesarean Birth: A positive approach to preparation and recovery blows the myths out of the water. It also dedicates entire chapters to the preparation for and recovery from caesarean birth. There are even whole appendices on the risks and benefits of both vaginal and caesarean birth to help in your decisionmaking. All data has been reviewed by a team of midwives and obstetricians and we are confident the information is accurate and reflects the latest research.

Finally! No caesarean rate targets in England

NHS England have finally admitted that the idea of an ideal caesarean rate is absurd. In fact, they have gone so far as to admit it is potentially “unsafe and clinically inappropriate”. No doubt influenced in no small part by the inquiry into the excessive number of baby deaths at Shrewsbury and Telford hospital NHS trusts. (Note – Shrewsbury NHS trust had one of the highest rates of vaginal delivery in the country during the review period!)

The letter from Jacqueline Dunkley-Bent NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity directs:

“all maternity services to stop using total caesarean section rates as a means of performance management…We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases.”

In response RCOG (Royal College of Obstetricians and Gynaecologists), said:

“We welcome this clarification from NHS England. These targets are not appropriate in individual circumstances. Both vaginal and caesarean births carry certain benefits and risks, which should be discussed with women as they choose how they wish to give birth.”

Along with other birth groups, we have been campaigning for this change for years and are very relieved such unnecessary, unethical targets have been removed.

Vaginal birth and caesarean delivery both have benefits as well as risks for mum and baby. NICE guidelines have made it clear since 2011 that it is reasonable for women to make an informed choice in either direction. However, target rates imposed by NHS England have made it very difficult for women to make use of this change to the guidance. Some hospitals sticking rigidly to the targets, others ignoring them and being penalised.

Fundamentally, we should be able to trust our Doctors to have our best interests at heart when making decisions about the progress of our pregnancy. Targets based on economics and hosptial policies has never put the women first and we welcome the NHS’ recognition of their mistake.

This letter means a mother’s right to make an informed choice for one mode over the other is now more possible. That doesn’t mean it will always be straightforward. Some practitioners stil believe “normal” (vaginal) is best and will strongly encourage you away from a caesarean. However with the hospitals no longer pressured by unrealistic targets women are in a much stronger position to argue their case. This does mean being able to demonstrate clear reasons for your choice is still very important. Knowing what is a necessary route to delivery versus just a suggestion is paramount. Caesarean Birth: A positive approach to preparation and recovery, covers everything you need to know to put your case forward effectively.

What are my options after a caesarean birth?

This is quite a common question. Unfortunately, the answer is not straightforward.

Hospital policies continue to influence things both overtly in terms of whether there are written (or unspoken) caesarean targets, but also more subtly through common practises such as induction guidelines / tolerance for the length of 2nd stage labour etc.

It is possible to avoid automatically having another caesarean, always assuming of course the reason for the first caesarean is not likely to recur in each pregnancy. Hospitals are being increasingly encouraged to support VBACs (Vaginal Births After Caesarean) and NICE guidelines state that:

“Women have the right to choose VBAC… Therefore, this model would support a woman being able to choose her preferred mode of birth in consultation with the healthcare professionals responsible for her care.” NICE guideline

Some hospitals offer special clinics aimed at encouraging just this. If this is your aim, it is worth asking what is available at your hospital and your local doctor surgery as these classes can provide lots of information and support about how to manage your pregnancy and labour to help increase your chances of achieving a vaginal birth.

For those women preferring another caesarean this will, in many cases, be dependent upon the opinion or policy of those responsible your care. Some hospitals do not encourage a planned caesareans (even after a previous one) if there is no medical need. A previous caesarean no longer constitutes a ‘medical need’, unless, as already mentioned, your first caesarean was for reasons which are likely to recur in a later pregnancy.

“Know your rights Calmly discussing your options, knowing what can and cannot be insisted upon and the difference between a required and suggested caesarean, puts you in a strong negotiating position. From Chapter 3 of Caesarean Birth: A positive approach to preparation and recovery.

For example: Where a caesarean request is being refused you have the right to a second opinion.

“Recommendation 39: An obstetrician has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.” NICE guideline

There is a lot of detail in Caesarean Birth: A positive approach to preparation and recovery about ways to manage these discussions, whether your aim is to avoid or indeed plan a caesarean. Either way, there are quite a lot of things you can do to help you case.

Why prepare for the possibility of caesarean birth?

Like it or not, whatever your birth plan says, the fact is a third of UK births will be caesareans. As I have worked with practitioners and women preparing for birth over the years, it has become very apparent that fear and stigma can still be very much a part of caesarean experience for many. Unfortunately, in being unprepared for a caesarean outcome, when it happens some women in their sleep deprived, stressed and postnatal hormonal state, are unable to rationalise the experience describing it as “disappointing” or worse “highly traumatic”.

Understandably, many women take their adventure into motherhood very seriously, attending antenatal classes, buying book after book or, if neither of these, at least talking to family and friends about their options. Sadly in many cases despite the best of intentions many can remain quite in the dark about caesarean birth, inadvertently taking on board the negative opinions and media hype surrounding this mode of birth. And while some practitioners do try to talk about caesareans in a positive way, women often reflect they found it difficult to find the positive messages and that preparation advice was typically woefully insufficient.

One woman once wrote to me:

“I was actually on the table and surgery had started when it occurred to me to ask what the difference was between an epidural and a spinal anaesthetic,¦I should have known and it was too late to participate in any discussion.”

In the UK nearly 1 in 3 births are caesarean, and over 1 in 3 in the US with similar rates in many countries. Yet all too often the two phrases heard in connection are:

“major surgery” and

“it will affect your ability to bond with your baby”

While both can have an element of truth to them (for some women), the tone in which they are typically delivered and the total absence of any explanation, support or clarification makes them two of the most irresponsible phrases used in antenatal discussions.

That said it is becoming more acceptable to ask questions and a quick Google search will produce websites talking about how to improve your caesarean experience. But incredibly in 2021, the number of books which treat caesarean delivery as a valid and incredibly positive birth experience can still be counted on one hand.

I wrote the first edition of Caesarean Birth: A positive approach to preparation and recovery to redress this imbalance back in 2011 and it has since gone to a second edition (2018). As a complete caesarean ‘manual’ it covers:

  • Why one might be suggested
  • Why we should prepare
  • How to make the most of a caesarean (preparation and recovery guidance)
  • A detailed risk / benefit comparison with vaginal delivery
  • Implications for future births
  • A description of procedure itself and crucially how women can participate in and influence that process

The book blows apart the myths we hear about caesareans and women have reported feeling more confident and able to make informed decisions about their births as a result. Crucially it gives lots of ideas on how to prepare for and express preferences about the experience, radically improving the chances of perceiving it positively should a caesarean become necessary.

For example, knowing to ask to put your gown on backwards (opening at the front) prior to surgery means, assuming there is no emergency, you can easily hold your baby skin-to-skin and possibly even breastfeed while still in theatre. Such a seemingly simple thing is so incredibly important to so many and is actually totally achievable in many caesareans.

Asking questions and being better informed places us in a far stronger position to negotiate and actively manage the direction and experience of our birth whether it is a vaginal or a caesarean outcome, why leave out knowledge of a whole birth experience and risk being disappointed or traumatised unnecessarily.

“I am so glad I read this book before my birth. I didn’t intend having a caesarean but when it happened I wasn’t at all frightened and I fed ‘S’ in the recovery room. This book thoroughly demystified caesarean birth for me.” Vicki (35)