Response to Should You Choose A Caesarean Section? article as posted on www.canoe.ca, in the Toronto Sun and in the Winnipeg Free Press.

April 4, 2001

C-Health and Dr. Gifford-Jones,

I am dismayed to find that even Canadian doctors are providing misinformation to the public regarding caesarean section births. It is rampant in the US thanks in no small part to the recommendation by ACOG to have an obstetrician or surgeon immediately available at a VBAC (vaginal birth after caesarean) trial of labour. The subsequent rise of caesarean births, the decrease of VBAC's and the dismal news that midwives are losing backup for VBAC clients, doctors are refusing to provide women the right to a VBAC and whole hospitals are not allowing VBAC trial of labour in US facilities is appalling.

Yes you are very correct in saying that surgical techniques, anaethesia and antibiotics are improving every day, to the extent that a caesarean section is relatively safe, and thank goodness for those who truly need this life-saving operation. As the president of the International Caesarean Awareness Network (ICAN) Inc., I can affirm, however, that a caesarean section is NOT as safe as a vaginal delivery. A caesarean section is major abdominal surgery and should never be taken lightly.

Dr. Gifford-Jones declares, "There are several benefits to caesarean delivery. There's no pain during birth and less discomfort following surgery than with labour. And there's little chance of being troubled by either urinary or fecal incontinence, which may occur after vaginal birth." Having had three caesarean sections myself and having talked to thousands of women who have also experienced a caesarean birth, I can attest to the fallacy of both statements. There is almost always discomfort during a cesarean birth where the mother has either an intrathecal or epidural and is awake for the birth. The tugging and pushing needed to extract the baby from the uterus without the aid of contractions are not only uncomfortable, but can even be painful. Especially if the anaesthesia is not adequate, which is not an uncommon occurrence in either a general or an epidural/intrathecal caesarean delivery.

In contrast to the claims of Dr. Gifford-Jones, all women who have had a caesarean section will experience pain and discomfort after the surgery. How can they not? Their skin, muscle, uterus... 7 layers in total, are cut through and they are left with relatively few stomach muscles, making maneuvering difficult at best, and often very painful as they heal. I have personally seen many women get up shortly after delivering their baby vaginally and be able to shower, care for their baby and go about life as normal compared to the debilitation of recovering from major abdominal surgery that takes at least several days and often weeks to fully recover from. I have yet to see any woman who has had a casearean birth recover as quickly as a woman who has had a vaginal delivery, obstetrics aside, of course.

And as for the myth surrounding urinary and fecal incontinence based solely on a vaginal birth, a recent South Australian study published in the December 2000 edition of the British Journal of Obstetrics and Gynaecology states, "...elective caesarean section is apparently not an effective way to reduce the prevalence of most subsequent pelvic floor disorders, except when instrumental vaginal delivery can be avoided. Pregnancy (more than 20 weeks) REGARDLESS OF MODE OF BIRTH, greatly increased major pelvic floor dysfunction - defined as any type of incontinence, symptoms of prolapse or previous pelvic floor surgery. The difference between caesarean and forceps was significant, but not between caesarean and a natural birth." (43)

Henci Goer, who's life work is evaluating synthesizing obstetric research and is the author of Obstetric Myths vs Research Realities (1995) and The Thinking Woman's Guide to a Better Birth (1999), adds, "vaginal birth probably has some adverse effects, as does pregnancy, in that some women develop urinary incontinence during pregnancy. However, the main source of problems is obstetric management, principally the largely unnecessary, but still common, practice of episiotomy. None of the justifications for its routine or frequent use are supported by the medical research (9,12,14,37,42), and women with no episiotomy have the strongest pelvic floors after childbirth (23). This should not come as a surprise. Logic dictates that cutting muscles would weaken them... Forceps delivery can also do considerable genital damage and anal sphincter injury, as, to a lesser degree, can vacuum extraction (6,19-20,38,41)."

Henci Goer also affirms the risks of caesarean surgery. "The surgery itself, as opposed to medical problems that might lead to a cesarean, increases the risk of maternal death, hysterectomy, hemorrhage, surgical injury to other organs, infection, blood clots, and rehospitalization for complications (16,24,33-34,39). Potential chronic complications from scar tissue adhesions include pelvic pain, bowel problems, and pain during sexual intercourse. Scar tissue makes subsequent cesareans more difficult to perform, increasing the risk of injury to other organs and the risk of chronic problems from adhesions. The surgery itself also increases the risk of the baby being born in poor condition or having trouble breathing after planned cesarean or cesareans done for reasons other than the baby's condition (2,8,18). Also, because of scar tissue, the incidence of placenta previa (the placenta overlays the cervix) and placenta accreta (the placenta grows into or through the uterine muscular wall), complications that kill babies and mothers, soars with each successive cesarean (1,3,10,17,28,36). Infertility and ectopic pregnancy (the embryo implants outside the uterus) associate with previous cesarean section as well (17). Finally, the uterine scar raises the specter of uterine rupture during a subsequent pregnancy or birth, a danger not removed by planned repeat cesarean (15,30). Compared with vaginal birth, cesarean section causes pain and debility, sometimes for weeks (26)."

Dr. Marsden Wagner, formerly Director of Women’s and Children’s Health for the World Health Organization for fifteen years, states, "There is no evidence that a cesarean rate higher than 10% (actually 7%) yields any benefit to mothers or babies. There is ample data that cesarean surgery, especially done electively (without benefit of any labor) hinders the development of mother and baby and places each of them at immediate and long-term risk of numerous problems." In his article in The Lancet, Vol. 356, he also outlines the risks to the baby of a caesarean birth. "The first danger to the baby is the 1-9% chance that the surgeon's knife will accidentally lacerate the fetus (6% with non-vertex position)."(44,46) This was not even mentioned by Dr. Gifford-Jones. Transient Tachypnoea or the baby breathing faster than normal is also a risk, though not life threatening, it does mean that the baby will be observed closely for the first few hours, and is often mistaken as an early sign of infection, so the baby is more likely to be treated with unnecessary prophylactic antibiotics.(47) These coupled with respiratory distress syndrome (RDS) and prematurity which are both major causes of neonatal morbidity and mortality, which is greatly reduced if the woman is allowed to go into labour before the cesarean section.(45,48,49) Henci Goer adds, "let's not overlook the potentially deadly complication called persistent pulmonary hypertension."(50) The risks are not to be taken lightly for babies as well as mothers.

Dr. Gifford-Jones predicts using his "crystal ball" that elective caesarean section will rise and unfortunately I will have to agree, at first anyway. As long as doctors are advising women fallaciously that caesarean birth is as safe, or safer, than vaginal birth, will women continue to allow caesarean and elective caesarean, believing it is the best choice.

Finally, Dr. Gifford-Jones questions who is best to ask regarding elective caesarean birth. I would recommend discussing the question with midwives, who are the experts on normal birth, rather than female obstetricians if you want a true answer to your question on elective caesarean section. Obstetrics is a sub-specialty of surgery and as such many obstetricians learn to fear birth because they tend to work with high-risk women. I have yet to ever meet a midwife who would recommend any elective caesarean unless medically necessary. Even if it was deemed necessary, labour before the surgery would be the next best choice because of the benefits to both mother and baby. And as for asking men if they would choose caesarean, ask any husband whose wife has been unnecessarily subjected to this invasive surgery and I think your answer will be found.

Connie Banack

President of the International Caesarean Awareness Network (ICAN) Inc.

Program Director, Global Birth Institute (GBI)

[email protected]

780/962-1846

REFERENCES

1 Ananth CV, Smulian JC, and Vintzileos AM. The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. Am J Obstet Gynecol 1997;177(5):1071-8.

2 Annibale DJ et al. Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med 1995;149(8):862-7.

3 Asakura H and Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol 1995;85(6):924-9.

4 Berghmans LC et al. Conservative treatment of stress incontinence in women: a systematic review of randomized clinical trials. Br J Urol 1998;82(2:181-91.

5 Blair E and Stanley FJ. Intrapartum asphyxia: a rare cause of cerebral palsy. J Pediatr 1988;112(4):515-519.

6 Bofill JA et al. A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor. Am J Obstet Gynecol 1996;175:1325-30.

7 Bump RC and Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25(4):723-46.

8 Burt RD, Vaughan TL, and Daling JR. Evaluating the risks of cesarean section: low Apgar score in repeat c-section and vaginal deliveries. Am J Public Health 1988;78:1312-4.

9 Carroli G and Belizan J. Episiotomy for vaginal birth. In: The Cochrane Library, 1999. Oxford: Update Software.

10 Clark SL, Koonings PP, and Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985;66(1):89-92.

11 Cosner KR, Dougherty MC, and Bishop KR. Dynamic characteristics of the circumvaginal muscles during pregnancy and the postpartum. J Nurse Midwifery 1991;36(4):221-5.

12 Eason E et al. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000;95(3):464-71.

13 Gordon H and Logue M. Perineal muscle function after childbirth. Lancet 1985;2:123-5.

14 Graham ID. Episiotomy: Challenging Obstetric Interventions. Oxford: Blackwell Science Ltd., 1997.

15 Gregory KD et al. Vaginal birth after cesarean and uterine rupture rates in California. Obstet Gynecol 1999;94(6):985-9.

16 Hall MH. Commentary: confidential enquiry into maternal death. Br J Obstet Gynaecol 1990;97:752-3.

17 Hemminki E and Merilainen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996;174(5):1569-74.

18 Hook B et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997;100(3):348-53.

19 Johanson R et al. North Staffordshire/Wigan assisted delivery trial. Br J Obstet Gynaecol 1989;96:537-44.

20 Johanson RB et al. A randomized prospective study comparing the new vacuum extractor policy with forceps delivery. Br J Obstet Gynaecol 1993;100(6):524-30.

21 Jolleys JV. Reported prevalence of urinary incontinence in women in a general practice. Br Med J 1988;296:1300-2.

22 Klein MC et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Clin Trials 1992;1(Document 10).

23 Klein MC et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 1994;171(3):591-8.

24 Lydon-Rochelle M et al. Association between method of delivery and maternal rehospitalization. JAMA 2000;283(18):2411-6.

25 MacDonald D. Cerebral palsy and intrapartum fetal monitoring. N Engl J Med 1996;334(10):659-60.

26 Miovich SM et al. Major concerns of women after cesarean delivery. J Obstet Gynecol Neonatal Nurs 1994;23(1):53-9.

27 Nygaard IE, Rao SSC, and Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol 1997;89(6):896-901.

28 O'Brien JM, Barton JR, and Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;175(6):1632-8.

29 Phelan JP and Ock Ahn M. Perinatal observations in forty-eight neurologically impaired term infants. Am J Obstet Gynecol 1994;171(2):424-31.

30 Rageth JC, Juzi C, and Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions. Obstet Gynecol 1999;93(3):332-7.

31 Richmond S et al. The obstetric management of fetal distress and its association with cerebral palsy. Obstet Gynecol 1994;83(5 Pt 1):643-6.

32 Sampselle CM. behavioral intervention for urinary incontinence in women: evidence for practice. J Nurse Midwifery 2000;45(2):94-103.

33 Schuitemaker N et al. Maternal mortality after cesarean in The Netherlands. Acta Obstet Gynecol Scand 1997;76(4):332-4.

34 Shearer EL. Cesaran section: medical benefits and costs. Soc Sci Med 1993;37(10):1223-31.

35 Signorello LB et al. Midline episiotomy and incontinence. BMJ 320(7227):86-90.

36 Taylor VM et al. Placenta previa and prior cesarean delivery: how strong is the association? Obstet Gynecol 1994;84(1):55-7.

37 Thacker SB and Banta HD. Benefits and risks of episiotomy: an interpretive review of the English language literature. 1860-1980. Obstet Gynecol Surv 1983;38(6):322-38.

38 Vacca A et al. Portsmouth operative delivery trial: a comparison vacuum extraction and forceps delivery. Br J Obstet Gynaecol 1983;90(12):1107-12.

39 van Ham MA, van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of cesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997;74(1):1-6.

40 Viktrup L et al. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992;79(6):945-9.

41 Williams MC et al. A randomized comparison of assisted vaginal delivery by obstetric forceps and polyethylene vacuum cup. Obstet Gynecol 1991;78(5 Pt 1):789-94.

42 Woolley RJ. Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part I. Obstet Gynecol Surv 1995;50(11):806-20.

43 MacLennan AH et al. The prevalence of pelvic floor disorders and their relationship to gender age, parity and mode of delivery. BJOG 2000;107:1460-70.

44 Wagner M. Choosing caesarean section. The Lancet, Vol 356, Nov. 11, 2000, 1667-1680.

45 Wagner M. Pursuing the birth machine; the search for appropriate birth technology. Sydney: ACE Graphics, 1994.

46 Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997; 90: 344-46.

47 Barrett J, Pitman T. Pregnancy and Birth; The Best Evidence. Toronto, ON: Key Porter Books, 1999.

48 Annibale DJ et al. Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med 1995;149(8):862-7.

49 Hook B et al. Neonatal morbidity after elective repeat cesarean and trial of labor. Pediatrics 1997;100(3):348-53.

50 Levine EM et al. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97:439-42.

Copyright © 1997-2006 Mother Care. All photos © Mother Care & Terri McKinney Photography. All rights reserved. Revised: Wednesday, January 04, 2006.