When asked: “Can I have a Caesarean section?” I always answer: “YES”.
There is an increasing number of women who choose to have an elective Caesarean section as the mode of delivery, rather than a vaginal delivery.
The request is usually made at the first antenatal visit and usually of the first pregnancy. It is usually made without there being any obvious medical, past surgical, previous pregnancy reasons why a Caesarean section is necessary and why she would not be successful in having a vaginal delivery.
Often the choice for a Caesarean section is motivated by a fear of labour and vaginal delivery, often it is a concern about perineal trauma or be not wanting the stretching of the vagina and vaginal introitus (entrance) which happens with a vaginal delivery. Often the decision relates to adverse labour and vaginal delivery experiences of friends or family member or knowing people who needed emergency Caesarean sections. It could be: “both my mum and sister had to have Caesarean sections”. There could be a concern about prolapse in the future, which is more associated with vaginal deliveries. There could be fear of needing an operative vaginal delivery, and especially of a forceps vaginal delivery. There can be other reasons. But whatever the reason for the question is I am always happy to oblige, and I always say: “yes” to the request.
Today Caesarean sections are a lot safer than the past. While the ‘mechanics’ of the surgery are the same, we have improved suture material and better surgical techniques. This, and my attention to detail with the operation and making sure I close all layers correctly, underpins my patients having good post delivery recovery. Often my patients go home on just paracetamol or no analgesics.
Anaesthetics for Caesarean section have changed over the years. Now it is usually either a spinal anaesthetic or a combined spinal-epidural regional anaesthetic. Spinal needles have been improved so now it is unlikely to get a ‘spinal tap’ headache. Anaesthetic drugs have improved so they are more effective than in the past. The regional anaesthetic today is quick to work and has a more predictable effective block and is safer than general anaesthetics.
When asked: “What is safer – a vaginal delivery or a Caesarean section?” I reply: “A Caesarean section is safer for the baby as you can avoid all the risks to baby of labour and vaginal childbirth. For the mother a straightforward vaginal delivery would be safer but there is always the uncertainty whether this will happen. A Caesarean section is often safer than a more complicated vaginal delivery.”
When a patient asks: “Will I need a Caesarean section?” that is very different question to: “Can I have Caesarean section”. If there are factors that increase her likelihood of needing a Caesarean section then I will discuss them, and she can decide as to the mode of delivery. But if there are no such factors then I advise her I anticipate a good labour and normal vaginal delivery. But I also say labour and childbirth are totally unpredictable and I have no certainty of what will happen in her case. She may end up needing an emergency Caesarean section or operative vaginal delivery (such as for foetal distress in labour or lack of progress in labour). She needs to decide as to the mode of delivery.
There are times I advise the patient it would be safer to have a Caesarean section delivery. This could be because she is very short which implies a small pelvis (but she can elect to have a ‘trial of labour’ instead), a previous Caesarean section for an obstructed labour (implies considerable risk of uterine rupture in labour), the unborn baby is excessively large, past health issues where a specialist doctor has advised her that labour and vaginal delivery are too dangerous. A Caesarean section is also recommended if she has had fourth degree tear or 3b or 3c third degree tears. I don’t recall ever having managed a delivery where the patient has sustained such injuries. Sometimes after a difficult vaginal delivery with tearing a woman is emotionally traumatised and fearful of another vaginal delivery. Most such women have been public patients or under the care another obstetrician in their previous pregnancy. I would recommend an elective Caesarean section. There can be other reasons for suggesting an elective Caesarean section.
Finally, there can be developments in a pregnancy that prompt me to recommend a Caesarean section. These include placenta praevia, severe pre-eclampsia or intrauterine foetal growth retardation requiring delivery at an early gestation, active genital herpes at the end of pregnancy. Breech presentation babies were historically almost always delivered vaginally. But now with Caesarean sections being safer than in the past and with a Caesarean section delivery being safer for breech presentation babies than a breech vaginal delivery, most breech presentation babies are delivered by Caesarean section. There may be other reasons that become apparent in the pregnancy to recommend a Caesarean section rather than labour and a vaginal delivery. All such developments, their risks and benefits, are discussed in detail with the patient as I want ‘to be on the same page’ as the patient in making the delivery mode and timing decision.