Elective Caesarean Section

First of all let’s clarify what a caesarean delivery or birth is. It has been long thought that the word caesarean originated because the Roman emperor Julius Caesar was the first baby to be born by caesarean section. But there is some disagreement about this – perhaps he was and maybe he wasn’t. This may just be one of those fables which sounds as if it could be true, lending some authority to it.

But what is clear is that the word caesarean is derived from the Latin word caedo which means “to cut”. And this is precisely what happens during a caesarean.

What Exactly is a Caesarean Delivery?

This is an operation which allows a baby to be born through a cut made into their mother’s abdominal wall and uterus. During a normal delivery a baby is born as it comes out through the mother’s vagina, but with a caesarean section delivery the baby is born as it comes through a surgical incision or cut which has been made into the mother’s abdomen.

A caesarean can be either planned, otherwise known as elective; or unplanned, otherwise known as an emergency caesarean. Another name for an elective caesarean delivery may be “on maternal request” as this can also be done in the absence of any maternal or foetal indications.

When is the Decision Made?

If vaginal birth is considered risky and problems are detected early, then a planned/elective caesarean section may be considered. An emergency caesarean section tends to occur when there are problems once labour has already started.

Many reasons contribute to why a caesarean section may be unplanned or an emergency. It’s not uncommon for women who have intended to give birth vaginally to find they need an emergency caesarean delivery once their labour has already started. Their own health or that of their baby’s may become compromised by a vaginal birth.
For some mothers especially, this can become a real disappointment. What was intended and planned for did not eventuate and it can take time and in some cases, even supportive counselling to come to terms with. But this can also be the case with an elective caesarean section delivery. If mothers are advised reasonably early in their pregnancy that a caesarean is likely then they have more time to become used to the idea.

Reasons for an Elective Caesarean

It is important to remember that not all women with the following conditions will need a caesarean delivery. Every woman and her pregnancy are unique and individual circumstances must be considered when considering birth options.

• Personal choice. Some women are just not keen on the idea of having a vaginal delivery.
• The baby is in a position which is not head down e.g. may be lying bottom first or “breech”. Alternately, the baby may be lying in a sideways position known as “transverse”.
• A multiple pregnancy.
• If a woman has had a previous caesarean section delivery then she may choose, in consultation with her maternity care provider, to have a “repeat” caesarean with consequent babies.
• When there are pregnancy complications such as diabetes, pregnancy induced hypertension, placenta praevia or if there is an increased risk to the mother and/or her baby for a vaginal delivery.
• “Social” reasons such as when a woman and her partner in consultation with their obstetrician choose when the baby will be born. This can happen, for example, in cases where partners may otherwise be physically absent for the baby’s birth.
• For maternal mental health or emotional well-being. Some women who have a history of sexual abuse elect to have a caesarean section delivery.
• If a mother has a pre-existing medical condition which adds to her risk of labour and delivery complications.

Reasons for an Emergency Caesarean

• Failure for the labour to progress. This can happen for all sorts of reasons but essentially, if labour does not proceed actively towards a vaginal birth, caesarean section delivery may be the only option.
• Cephalo Pelvic Disproportion (C.P.D.). This is where the baby’s head circumference is too large to fit through the mother’s pelvis.
• If the baby is in distress, otherwise known as foetal distress. If their heart rate is dropping and not returning to a normal rate and rhythm after a uterine contraction then this can mean the baby is becoming distressed.
• Uterine cord prolapse. This is when the cord presents first ahead of the baby. There is a risk that the baby’s oxygen supply may be cut off or compromised as their head (or presenting part) compresses the cord.
• If there is a problem with the mother’s physical health during the labour. If, for example she has a sudden rise in her blood pressure or has a large bleed then a caesarean section may be considered.

But I Don’t Want to Have a Vaginal Birth!

Some women are genuinely scared of having a vaginal delivery. They can be very strong self advocates for having a caesarean although there may not be a physical reason why they cannot have a vaginal birth. In this case many factors need to be carefully weighed up.

Caesarean section is not without risk, and scientific evidence shows that a vaginal delivery is generally the safest mode of childbirth.

Prenatal counselling is sometimes considered necessary for women who are genuinely fearful of having a vaginal birth. Referral to a psychologist or counsellor with specialised skills in obstetrics and maternity care can be very useful.

Writing up a realistic birth plan, ensuring emotional support during labour and delivery and planning for pain relief can make a big difference towards looking forward to childbirth rather than fearing it. Though it is fair to say that for some women, no amount of counselling or ante-natal support can allay anxiety surrounding their baby’s birth.

Issues When Considering an Elective Caesarean

Individual risk factors can add complexity to whether a caesarean section is the safest way for a baby to be born. There is no prescriptive “one size answer” to why and when a caesarean may be necessary.

• Maternal age and obstetric history including past deliveries. The older a woman is the higher her risk of obstetric complications.
• A mother’s size and Body Mass Index (B.M.I.); pregnant women with a high B.M.I. are generally at greater risk of complications for both vaginal and caesarean delivery.
• The baby’s gestational age. Caesarean section delivery may be considered less stressful for a premature baby than being delivered vaginally.
• In consultation with their obstetrician, some women consent to having a tubal ligation at the same time as their caesarean section. If a couple have finished having their family then doing both at the same time can eliminate the need for two lots of surgery.
• Some women who have a history of sexual abuse and trauma elect to have a caesarean birth. There may be cases where women do not wish to disclose their reasons so sensitivity around this elective “choice” is important.
• If there has been a previous history of “poor” obstetric outcomes then a caesarean section delivery may be considered.

Before a Caesarean Birth

It’s important to:

• Be fully informed of the risks and potential complications. A caesarean section delivery is an operation and although the risks may be small it is still important that you are fully informed and understand the process before providing consent.
• Understand that any pre existing health conditions you have may add to the overall risk.
• Be clear about your baby’s gestation.
• Advise your doctor and maternity care providers about any allergies you may have.
• If you have any cultural or religious requests it is important that you share these with your doctor.

Types of Caesarean Sections

Most caesarean section incisions (cuts) are made horizontally in the lower segment of the mother’s uterus. This is known as a “bikini line” cut. This is a preferred incision as it creates fewer problems with subsequent pregnancies and birth.

But sometimes a vertical incision in the mother’s uterus is necessary if the baby needs to be delivered very quickly or the placenta is adhered very low to the uterus. Another name for this is a classical incision.

The cut on the mother’s abdomen may still be horizontal but the cut on the uterus is vertical. If you are unsure then ask the doctor who has done the caesarean. This may be important if you change your maternity care provider for subsequent pregnancies.

Risks and Complications of Caesarean Delivery

Although the risks are considered small, especially with current day surgical techniques, caesarean section delivery does pose different risks when compared with a vaginal birth.

• Excessive bleeding.
• Deep Vein Thrombosis (D.V.T.) this is minimised by movement and wearing surgical stockings.
• Infections which can either be in the wound itself or within the uterus.
• A longer post natal recovery period in hospital.
• More painful than a vaginal birth.
• Anaesthetic complications.
• Potential impact on subsequent pregnancies and deliveries.
• Breathing difficulties for the baby. Uterine contractions help to clear the baby’s lungs of mucous and fluid and when they are born via caesarean section, they may not have the benefits of this.

It is important to remember that many factors contribute to the decision whether a caesarean delivery is needed. Every woman and her baby are unique. If you are in any doubt, speak with your doctor and/or maternity care provider about what is right for you.

Written for Huggies by Jane Barry-Midwife and Child Health Nurse and director of www.mybabybaby.com.au