C-Section: What are the risks, and What Can you do to Avoid it?

Hi! I'm back!
Caesarean section is a major abdominal surgery that is performed to extract a baby's from it's mother's uterus, when natural birth becomes impossible or if the life of mother or child is in danger.

However, it is used so widely nowadays that it went from being a very last resort to bieng considered as a normal way of being born, and even as a option in childbirh that the mother can actually choose. But this life-saving surgery also has it's risks.

The World Health Organisation stipulates that the ideal c-section rate in any given population should be between 5 and 15%. At this rate, we are saving lives. However, when the c-section rates rises above this line, we are putting mothers and babies at risk. Nowadays, the c-section rate is around 26% in Canada, and 33% (sometimes up to 45% in some hospitals) in the United States. Countries like China, India and Brasil have very worrying cesarean rates, sometimes as high as 80% in some ptivate hospitals. Another interesting fact it that the countries with the lowest cesarean section rates (Sweden(16,8%), Norway (16,8%), Nederlands (14,8%) and Finland( 16,1%)) Are all countries where midwifery is the main model of care...

Caesarian section is major abdominal surgery. It is not to be taken lightly, and it poses risks to both the mother and baby. Here are a few examples:

Risks to the mother:
- Risk of nfection
- Risk of Haemorrhaging
- Risk of complications in future pregnancies and births
- Risks with the anesthesia
- General recuperation harder and longer than for a natural birth
- Augmentation of the risk of developping post-partum depression
- Risk to have attachment difficulties with the baby
- Risk of death (4x higher than with natural birth)
- Augmentation of breastfeeding difficulties ( generally because of anesthesia that can make the baby sleepy and less inclined to suckle, and to the separation of mother and child that affects the hormones of breastfeeding)

Risks to the child (they are for the most part long-term risks):
- Risk of breathing complications at birth
- Risk of suffering a scalper lasceration (1 to 2%)
- Hightened risk of death at birth or during the first year (compared to babies born vaginally)
- Risk of developping allergies, asthma, diabetes and obesity
- Risk or developping issues with the immune system

Despite all of this, there are situations where without c-section, the mother, child of both would be lost. In these cases, we are grateful to have acces to this technique.
Here are some cases where a caesarean section is unavoidable:
- Severe complications of the placenta, such as placenta abruptio (placenta sepatating from the utering wall before birth) or placenta praevia (placenta covering the cervix)
- HIV infected mother
- A first episode of herpes at the end of pregnancy
- Foetal distress
- Cord prolapse (when the umbilical cord is presenting befor the baby's head)
- Severe complications of childbirth
- Bad presentation of the baby making vaginal birth impossible

There are also situations where a caesarean section will be suggested (sometimes very strongly), but where a natural birth is possible with the presence of an experienced doctor or midwife, and in the presence of certain favorable conditions. In these cases, it it for the mother to inform herself and to make the choice she feels it the right one for her.

- When a woman has had a previous caesarean section:
It is possible to give birth vaginally after a caesarean section. it is called VBAC (Vaginal Birth after Cesarean). There are a couple of risks factor that the provider has to watch carefully during birth, and a few interventions to avoid, but, in general, it has been proven that there are less risks in attempting a VBAC than for a repeat cearean. As a matter of fact, midwives in Quebec can handle VBACS, even in an out-of-hospital setting.

- If the baby is breech:
About 3 to 5% of full term babies will be breech, meaning that the presenting part is either the buttocks ot the feet. In most hospitals today, a breech presentation will be an automatic cesarean section. But when some elements are in order, and that the baby is presenting in the correct way (there are a couple of things to check), giving birth to a breech baby vaginally is entirely possible. More and more doctors are starting to offer this possiblilty to mothers. Midwives of Quebec do not handle breech birth, but this could change someday. If you want to know more about breech birth, you can read a previous article I wrote about that subject on my french blog here (translation to come).

-Multiple birth:
More there are babies, more there are risks, that is well known. But a multiple pregnancy doesn't necessarily mean a caesarean every time. During a multiple pregnancy, there will most likely be a lot of pressure to schadule a cesarean. But natural birth is possible, when we know what to check and that some elements are verified. To know more on this subject, please read a previous article I wrote on this subject: Birthing Twins and Triplets Naturally? Why Not!

-A large baby:
Another reason that can bring mothers to opt for a caesarean delivery is the discovery of a very large baby ''that may not get through the pelvis''. Know that weight estimations before birth, even with ultrasound are very inreliable, espacially as the term approaches. The margin of error can be of as much as five pounds! On to of this, the pelvis moves, and the frequent change of position during birth can get a big baby through. The possibility of having a big baby, even if it can be scary, is not a medical reason to schedule a caesarean section. And if the birth ends up in a cesarean anyway, even after attempting a natural birth, the baby will still have had the benefit of getting some of the birthing hormones of his mother.

And what to say of normal pregnancies, where everything is looking good? Some women end up with a c-section when everything seemed to be going fine. Sometimes, certain interventions, or certain ways of handling labor can augment the risks of developping complications and ending up with a caesarean section. Here are some tips to put all the chances on your side to avoid a cesarean section:

- Have a doula by your side. Some studies prove that the support and information brought by a doula can lower by 50% the riske of having a caesarean section

- Avoid induction. An induction, or the fact of inducing labor artificially dramatically augments the riske of having various interventions done, and at the same time the possibility that the birth will end up with a cesarean. It you get past your ''due date'', it is possible to encourage the baby to come out by natural and non-pharmacological ways. Induction should be a lsat resort.

- The use of epidural anesthesia, of synthetic oxytocin (pitocin, syntocinon), of Cytotec (misoprostol), and the artifical rupture of membranes are also interventions that can lead to complications that require a cesarean.

- Ask for intermittent monitoring of the foetal heart with a doppler or a feotoscope instad of continuous monitoring. The problem with continuous foetal monitoring is that it is very hard to understand the variations in the foetal heart rate, and sometimes we can think the baby is in distress even if he is not. Being on continuous monitoring also forces the mother to stay in the bed, lying on her back or on her side, which makes the baby's descent harder and can make labor longer, augment pain and augment the risks of having more interventions done (like an epidural or an oxytocin drip). Since the introduction of electronic foetal monitoring in the 1980's, all we can see in an augmentation in the number of c-section, but no change in the neonatal mortality rate or in the general state of babies at birth.

- Other things that can help: Frequent change of position during labor and during the pushing stage, going for the midwife model of care, create a birthing environment where the mother feels safe, chose a place to birth where the cesarean rates are low, chose a doctor who is experienced in physiological birth and whose c-section rate is low, attend quality birthing classes, get informed on your rights as a pregnant and birthing woman and about all the available options.

I hope this article will have helped to clarify some things.

For those who are interested, here is a video of an caesarean surgery, where we see exactly how it happens, from the first cut to the suturing. (beware, we really see EVERYTHING): https://www.youtube.com/watch?v=BgijW3-y8FQ

If you wish to learn more abour the various implications of caesarean section, I suggest you read the book The Caesarean, by Dr. Michel Odent.

Have a nice day!

Sources:
BRABANT, Isabelle, Une naissance heureuse, Fides, Québec,  2013, 576 p.
BUCKLEY, Sarah J., Gentle Birth, Gentle Mothering: A Doctor's Guide to Natural Childbirth and Gentle Early Parenting Choices, Celestial Arts, United States, 2009, 348 p.
GASKIN, Ina May, Birth Matters, Seven Stories Press, New York, 2011, 250 p.
GASKIN, Ina May, Ina May's Guide to Childbirth, Bantam Books, New York, 2003, 348 p.
GIER, Henci, The Thinking Woman's Guide to a Better Birth, Perigee, New York, 1991, 367 p.
ODENT, Michel, Césariennes: questions, effets, enjeux Alerte face à la banalisation, Éditions Le souffle d'or, Londres, 2005, 183 p.
Marshall H. Klaus, John H. Kennell, Phyllis H. Klaus, The Doula Book: How A Trained Labor Companion Can Help YouHave a Shorter, Easier, and Healthier Birth. Perseus Press, 2002, Chapitre V
http://www.cesarine.org/avant/etat_des_lieux.php
http://www.cesareanrates.com/blog/2013/1/8/world-health-organizations-15-percent-cesarean-rate-recommen.html
http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf
http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf
http://www.cesareanrates.com/blog/2012/12/8/world-cesarean-rates-oecd-countries.html
http://uvahealth.com/Plone/ebsco_images/6875.jpg



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