I cried when I was told I had to have a C-section. It wasn’t in my delivery plan. Even though I had been massaging my perineum with almond oil to prepare it for the inevitable stretching, it was not meant to be. As an OB/GYN the change in birth plan was easier to understand than someone without the medical background who may feel their right to choose had been taken away from them.
Which brings me to the question, what rights do women have when it comes to a delivery plan? To cut or not to cut, to push or not to push?
Vaginal delivery is a normal physiological process of birthing the baby through the vaginal canal. Normal vaginal delivery accounts for most deliveries in centres in both developing and developed countries. Just like anything in life, it has its pros and cons. Regarding the transition from intrauterine to extrauterine life, several changes occur within the foetus. It has been shown that babies born via the vaginal route have a lower rate of respiratory morbidity (risk of respiratory illnesses) compared to those delivered by C-section before the onset of labour and after (5.3 vs 35.5 vs 12.2 per 1 000 deliveries). Normal vaginal delivery allows for shorter hospital stay bar any complications.
The normal physiological processes of labour and vaginal birth as a mode of delivery have been shown to be favourable for the foetus. As labour is a natural process, unless a woman is being induced, with normal vaginal delivery you may have an idea of when the baby is going to come, but this is not necessarily certain.
“A normal vaginal delivery may be your desire, but remember that there will always be a possibility of a C-section […] surgery may be your preferred method of delivery but you may end up having a spontaneous vaginal delivery.”
Normal vaginal delivery does come with the risk of perineal trauma (such as tearing) and an element of incontinence. You might also need to have an assisted delivery either by vacuum or forceps should your midwife or obstetrician deem it necessary.
C-sections are becoming increasingly popular in the public and private sector and involves the delivery of a baby via surgery. An explanation for the increasing popularity varies between the two sectors and can be for maternal or foetal reasons. The recommended C-section rate by the World Health Organisation is 10-15%. In South Africa, it is higher than that and even higher in countries such as Brazil.
A study conducted between 1998 and 2000 in South Africa found that the C-section rate was 57% at six private hospitals compared to 28% and 19% in a teaching hospital and 20 public hospitals respectively.
What if you just want a C-section?
The easy answer is that you may have a Caesar upon request in the private sector. This is usually done at around 38 or 39 weeks’ gestation as there is evidence to suggest that C-sections performed during this time show no difference in foetal outcome to if it’s done when a baby is at full term.
Caesars done earlier than 38 weeks are usually due to obstetric reasons/risks, which are discussed with the patient. Along with an increased risk of respiratory morbidity, there is also the risk of maternal morbidities such as bleeding, infection and clots in the legs and lungs. Elective Caesareans allow you to plan more when it comes to the arrival of the baby and help avoid perineal trauma.
How about a VBAC?
The dictum of “once a caesarean always a caesarean” by Cragin (1916) is no longer the case. The way surgery is done has improved, e.g. a low segment C-section versus a classical C-section, therefore having a vaginal birth after a surgical delivery is possible and you can talk to your doctor about this. If there are no contra-indications to a vaginal delivery, then there is no reason why you shouldn’t have one.
The best predictor of a successful vaginal birth after a C-section is a previous successful vaginal birth after a C-section. The biggest concern when it comes to a vaginal birth after a surgical delivery is possible uterine rupture, the risk of which increases if the interval between babies is shorter – there is a 2.3% risk of rupture where the interval between deliveries is less than 18 months compared to a 1% risk when the interval is more than 18 months. Although the incidence may be low, the outcome of uterine rupture is generally dire for baby and may result in a stillborn baby or a hysterectomy.
I often get asked why I chose to have C-sections and my answer is simple: my first C-section chose me and thereafter I exercised my right to have another C-section. Regardless of the centre, you choose to have your baby, your delivery plan must be discussed with your health practitioner. A vaginal delivery may be your desire, but remember that there will always be the possibility of a C-section.
The converse is also true: surgery may be your preferred method of delivery but you may end up having a spontaneous vaginal delivery. Whatever your choice and situation, however, you have the right to a safe and successful delivery.