Trial of labour: Is a caesarean safe?by Joanna Wane
Medical technology has revolutionised childbirth, with the number of caesareans being performed “on demand” at a record high. But what evidence is there to answer the question every pregnant woman wants to know: will a caesarean be safer for me and my baby?
But get a ticket marked with “C” and pull out your diary to schedule it in, because your baby is destined to be born under a halo of surgical lights, lifted from a slice through your abdominal muscle just below the bikini line.
It’s a social experiment that could transform our understanding of childbirth and whether the method of delivery, by push or by cut, has lifelong consequences for both mother and baby. But would you take that gamble? And how ethical would it be to select a pregnant woman to have a caesarean, in the absence of anything on her file that suggests it’s the best way to go?
Actually, that’s already happening. One in four babies in New Zealand is born by caesarean, up from less than 10 per cent in 1980. Almost half are elective (or planned) caesareans, on the advice of a specialist concerned there might be problems with a vaginal birth. But a growing number are being performed on “maternal request”, often without any medical red flags at all.
At Auckland City Hospital, where a third of babies are delivered surgically, staff are now required to record the primary reason why. In elective c-sections, having had a prior caesarean is the most common factor; the second is that the mother-to-be wanted one.
Fear of childbirth plays a “huge” part in that, says consultant obstetrician Michelle Wise. “Fear of pain, fear of the outcome for the baby. Women have a lessening faith in their own bodies that they’re able to birth normally.”
And there’s the paradox. Childbirth has never been safer, yet it remains one of the most dangerous times in life for both the mother and her newborn. In the US, it’s the sixth most-common cause of death among women aged 20-34.
"If a doctor suggested a caesarean, you knew you were on the way to the morgue.”
A century ago, the main purpose of a caesarean was to extract a baby from a dying woman, notes medical writer Randi Hutter Epstein in her book Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank. “Caesarean sections were death rituals, not lifesaving procedures. If a doctor suggested a caesarean, you knew you were on the way to the morgue.”
Today, c-sections are considered one of the great advances of 20th-century healthcare. But while the initial fall in maternal and infant death has stabilised, caesarean rates are still rising – despite efforts by district health boards to reverse that trend because of the pressure it places on strained resources, from theatre capacity to hospital beds needed for longer post-natal stays.
Wise’s two children arrived the traditional way, but several of her colleagues have chosen to give birth by caesarean. When a medical specialist makes that call, it sends a powerful message, in a culture that associates technology with safety and is increasingly risk-averse. Whether all pregnant women should be offered a caesarean, says Wise, is “a complex issue for society to debate”.
“Personally, I don’t think that’s the way to go. At the end of the day, the safest thing for the mother and her baby is a vaginal birth. I’d still maintain that, because I have yet to see any good evidence to the contrary. But we’re human, and sometimes things do go wrong.”
Of course, surgery can be unpredictable, too. One woman told North & South she spent a week in hospital “in really bad shape” after her planned caesarean and struggled to breastfeed. “If you think it’s the easy option, you’re dreaming.”
Says Wise: “There’s a perception an elective caesarean is very much a controlled environment, which it is. You can get your toenails done and be there for 10am. But a general obstetrician like me has seen enough women haemorrhage who could have died; we’ve had bladder injuries, sepsis [a life-threatening complication caused by infection], heart attacks... Caesareans are not without risk.”
In the UK, maternity guidelines now recommend women considering a caesarean be given evidence-based advice on the relative risks and benefits, based on an analysis of international research by NICE, the National Institute for Health and Care Excellence. However, the quality of many of the studies that advice is based on is rated by NICE itself as “low” or “very low” – in part because so little research has been done on elective caesareans.
Flipping conventional wisdom on its head, New Scientist reported in July that doctors in the UK are now considering whether pregnant women should be officially warned about the danger of leaving it all up to nature.
“Medical evidence is on their side,” the magazine claimed. “Planned c-sections are the safest option for the baby, because they avoid any chance of brain damage from a vaginal birth and the not-insignificant risk of stillbirth after 39 weeks.
“A planned c-section is also the only guaranteed way to avoid a risky emergency c-section. And they are cheaper in the long run once the costs of caring for injured mothers and children are taken into account… Sometimes medicalisation is best.”
"If there’s no informed consent, a forceps delivery could be seen as a criminal act, an assault.”
Dietz, formerly an obstetrician who worked in New Zealand in the 1990s, told North & South elective caesareans should be routinely offered to women aged 35-plus who are having their first baby. Older women labour less effectively, problems with the placenta are more common, and their pelvic floor muscles and connective tissues are stiffer.
“The older someone is at first birth, the likelihood of just about every complication in the book goes up,” he says. “The longer the gestation lasts – which is important because the baby grows bigger and harder to push out – the higher the risk of stillbirth.”
Dietz also thinks caesareans should be offered to women with high blood pressure or who are carrying a large baby, likely to weigh more than 4kg.
He puts the chances of a woman having her first baby at the age of 20 by a normal delivery without major trauma at about 70-80 per cent; by the age of 40, the likelihood of a normal birth without major tissue tears drops to 20 to 30 per cent.
“And no one gets told this. You may well not go into labour spontaneously and the likelihood of being overdue is much higher than at age 18. And every day overdue, there is a cumulative risk of stillbirth. That risk is minimised by an elective caesarean.”
In New Zealand, the mean age of first delivery is now more than 30, up from 22-23 two generations ago. Dietz says older women are much more likely to require an emergency caesarean, which (unlike a planned c-section) increases the risk of infection, post-partum haemorrhage and other complications. The need for an assisted birth with a ventouse or forceps is higher in older women, too. “And if there’s no informed consent, a forceps delivery could be seen as a criminal act, an assault.”
Dietz says the outcome of an appeal in the British Supreme Court last year emphasised the importance of spelling out the risks. In that case, a diabetic woman whose baby was born with serious disabilities after complications during labour had raised concerns about a vaginal delivery but wasn’t told about the danger of a large baby becoming stuck by its shoulders in the birth canal.
Her doctor’s policy was not to routinely advise women of the risks because she believed they were likely to opt for a caesarean, which was not in the interests of the mother. The mother won the appeal, after losing two earlier court hearings where it was found the risk to the baby didn’t in itself require the mother to be warned.
Waikato mother Jenn Hooper, founder of Action to Improve Maternity (Aim), which supports families whose children were damaged or killed by poor birth care, says it can be difficult to differentiate between a cascade of contributing factors that lead to a tragedy.
“We’re told over and over about the benefits of vaginal birth and the risks of caesareans and nothing of the opposite for both. When it comes to Aim families, I’m yet to meet a family unnecessarily harmed by a caesarean, but there are those who could have benefited from one.”
She was discharged two days later, with no complications. Within a fortnight, she’d recovered enough to walk down to the neighbourhood shops; within a month, she was swimming laps at the Parnell pools. Her son, a lively toddler who turns two in December, was breastfed for 10 months and “we seem to get on okay”.
That might sound a bit flippant, Louise says, “but I honestly don’t think it affected any bonding. For what it’s worth, I still think having a purely elective c-section was an excellent idea and I will definitely do the same again when I bite the bullet and have another child.”
Like any good lawyer, she’d done her research first, and it was the NICE analysis that swayed her decision. But while UK neonatal expert Professor Neena Modi describes those guidelines as “very thorough indeed”, she warns they may have a serious flaw. “What the literature doesn’t cover is the possibility – and I’m using that word very deliberately – that there may be long-term impacts on the baby.”
"Normal labour is a very complex process that’s been honed by billions of years of evolution."
Numerous international studies have linked being born by caesarean to an increased risk of chronic health problems, including obesity, asthma, type 1 diabetes, coeliac disease, allergies and even childhood myeloid leukaemia. Modi, who heads the Neonatal Medicine Research Group at Imperial College London, says the odds of a baby developing some of these conditions go up by 20 per cent if born by c-section.
“A medically indicated caesarean section can be lifesaving for both mother and baby. But normal labour is a very complex process that’s been honed by billions of years of evolution and yet we’ve introduced a new treatment, which is an elective caesarean where there is no medical indication but maternal choice, without thinking what the consequences might be.
“How can we impose this really quite major change in the way babies are born and not study it scientifically?”
A large-scale clinical trial such as the one described at the start of this article, where pregnant women are randomly allocated to a surgical or natural delivery, is exactly what Modi has in mind.
In what would be an enormously complex undertaking, the study would follow mother and child throughout their life course. Her team, which is collaborating with the University of Manchester, has already begun holding focus groups with pregnant women and their partners to see if they’d be willing, in principle, to take part.
Modi isn’t too concerned by ethical dilemmas; she points to the growing number of women already choosing c-sections based on personal preference, and says the NICE guidelines concluded there was no substantial difference in the risk of maternal complications.
“It’s now socially acceptable to have an elective caesarean, with no medical indication for mother or baby. We need to be honest and say we really don’t know what all the risks and benefits are, but we’re seeing these epidemiological associations with long-term adverse outcomes in babies.”
What’s been identified so far is a statistical correlation, not evidence that being born by caesarean is a direct cause. Modi says the most promising theory is that the process of labour and birth programmes biological pathways by colonising the baby with its mother’s gut bacteria, which play a crucial role in the development of a newborn’s metabolic and immune systems. “A whole raft of experimental literature points to the plausibility of that.”
Antibiotics, routinely administered for a caesarean, also alter a baby’s gut bacteria, and Modi says some women are asking for their babies to be inoculated with vaginal swabs. “I think that’s not at all to be recommended outside of a research study,” she cautions. “That’s jumping ahead far too quickly.”
Dr Wayne Cutfield, a professor in paediatric endocrinology at Auckland’s Liggins Institute, says the composition of gut bacteria laid down at birth is thought to influence the risk not only of certain diseases but also behavioural problems and conditions such as autism. In obesity, the focus of his own research, being born by caesarean is one of the contributing factors.
“The effect is probably small, but when it affects a large number of people it’s not necessarily insignificant,” he says. “It raises the flag that events in pregnancy or right at birth can have long-term consequences beyond the immediate outcomes for mother and baby, and we do need to think about them when decisions are made.”
One of the more curious downstream ripples of that “halo effect” was highlighted by another Liggins study, which found significantly higher levels of stress hormones in the breastmilk of women who’d delivered by caesarean, three to four months after the birth.
At the Malaghan Institute in Wellington, scientists are exploring ways to modify gut bacteria to make them more protective, through changes in diet, for example. While the data to date suggests children born by c-section have an increased risk of non-communicable diseases, lead investigator Dr Liz Forbes-Blom stresses that needs to be kept in perspective. “It doesn’t guarantee that risk, and not all vaginally born children are protected,” she says.
“So rather than thinking of caesareans as good or bad, we should change the narrative, because they are [in many cases] a lifesaving measure. Can we work out what is good to educate the immune system to make these kids healthy throughout their life? That’s what we need to focus on.”
More clues may be found in the Growing Up in New Zealand study, which is tracking the development of almost 7000 children whose mothers were recruited during pregnancy seven or so years ago. About 26 per cent were born by caesarean (in line with the national average) and one research strand will look for a link between mode of delivery and early behaviour, as well as growth trajectories and obesity rates.
Research director Dr Susan Morton says it’s possible women in a position to request a caesarean may come from a more advantaged background, and that may be “somewhat protective” for their baby. “It’s all about reaching maximal potential, isn’t it?” she says. “What we don’t quite know is what that particular intervention [a caesarean birth] might do in terms of what may have been possible for that child.”
For clinicians, says Morton, one of the biggest challenges is understanding what population statistics mean for the pregnant woman in front of you.
“If you can give birth when the baby is ready, you’re in good condition and everything is set to go, then the natural timing of things is probably best. I’m very pleased a caesarean is there when it’s needed, but we don’t have good evidence on what it means long-term. That’s where our knowledge is missing.”
One patient, who’s in her mid-30s, is incontinent after tearing badly during the delivery. “She can’t exercise, she can’t do her job properly, she has no sex life. Her esteem is in her boots.”
The other is a single woman who became pregnant with donor sperm at the age of 42 and suffered damage to her anal sphincter during a difficult birth.
“She’s a busy, professional woman who has to wear a nappy when she goes out because she’s can’t control her bowel motions. Had anyone stopped to think, ‘Okay, here’s a 40-something woman who’s only planning to have one baby and doesn’t have a springy pelvis because of her age… she’d be much better off having a caesar’, it would have been a no-brainer. But no one ever discussed it with her.”
One international study describes pelvic floor dysfunction (almost exclusively caused by pregnancy and childbirth) as reaching almost epidemic proportions in later life, often requiring surgery and causing huge costs to the health system.
North & South spoke to a woman facing a hysterectomy and surgery to repair a bladder prolapse after being “torn to shreds” when her daughter, who weighed 4.5kg, became wedged during a 26-hour labour. Another mother of two suffered permanent nerve damage from a forceps delivery.
“I can’t walk fast or down stairs very well without leaking,” she says. “I can’t run, which is hard with young boys. That’s probably what gets me down the most – watching other mums run. And it’s ongoing, for the rest of my life.”
“It might be that you have a birth plan and if all goes well, okay. But if there’s any sign of obstructed labour, early recourse to a caesarean is a good option.”
Like Peter Dietz, Smalldridge thinks women deserve to be warned about the dangers of natural childbirth, especially older, first-time mothers carrying a large baby who are more likely to have a prolonged labour and end up needing an instrumental delivery. She says a levator avulsion, where the pelvic floor muscles are pulled off the pubic bone as the baby passes through the birth canal, happens in up to 12 per cent of normal births, putting the mother at risk of prolapse, where the pelvic floor muscles are too weak to hold the organs in place. If forceps are used, the likelihood of damage doubles.
Smalldridge, who was an obstetrician for 15 years, has run workshops teaching midwives how to identify and repair perineal trauma. One of her presentations features the results of the ProLong Study, which recruited almost 8000 new mothers in Dunedin, Aberdeen and Birmingham in the early 1990s. Co-led by Otago University’s Professor Don Wilson, it found c-sections lower the risk of urinary incontinence and prolapse, and prevent third- and fourth-degree anal sphincter tears.
“I’ve see many women have lovely normal births – but it shouldn’t be a vaginal birth at all costs,” she says. “It might be that you have a birth plan and if all goes well, okay. But if there’s any sign of obstructed labour, early recourse to a caesarean is a good option.”
The way a vaginal delivery is managed can also dramatically lower the risks of long-term damage to the pelvic floor. In Norway, tears to the anal sphincter during childbirth were reduced by 65 per cent after a multicentre intervention programme that promoted a more liberal use of lateral episiotomies and a “hands-on” delivery, where pressure is applied to the baby’s head to control its delivery during crowning, a policy that’s been widely adopted in hospitals here.
Wilson is part of a group collaborating with the Cleveland Clinic in Ohio, which has developed a predictive modelling program that uses an online calculator to predict the risk of pelvic floor injury, based on factors such as family history, the size of the baby, and the mother’s age, BMI and ethnicity (Asian and European women tend to have poor-quality collagen).
Called UR-CHOICE, it’s designed to help counsel women considering an elective caesarean but also to reassure those likely to cope well with a normal birth. A paper on the breakthrough is about to be published and Wilson hopes the scoring system will be available for trial by the end of the year. “But don’t forget, you get more pelvic floor dysfunction as soon as you get pregnant, however you give birth.”
At the Auckland Bioengineering Institute at Auckland University, computational (mathematical) modelling is being used to develop “simulations of childbirth”, where personal information, including MRI or CT scans, could be run through a program to predict how labour may unfold.
Former midwife Dr Jenny Kruger, who heads the institute’s pelvic-floor research team, says much of the existing advice given to women is based on statistical associations. “Imagine if you could take someone’s own geometry, put it up on a laptop in your office and plug in a whole lot of other variables – how that muscle will behave [under stress], the position of the baby, the size of its head – and then look at potential outcomes.”
Some women would decide the risks weren’t worth taking and opt for a caesarean, says Kruger. “But if you had someone who was anxious and felt they couldn’t deliver vaginally, you could say, ‘Actually, all these things point to a completely normal delivery.’ It’s nowhere near the point where it can be implemented yet, but it’s not nearly as science fiction as it used to be.”
“Respect for the microbiome is one example of the evolution in thinking that can occur when science begins to appreciate nature’s design.”
Sarah Ballard, also a midwifery lecturer at AUT, believes the progression of labour and the natural timing of birth may be far more important than many people think, involving an intricate interaction of maternal and fetal hormones that ensure both mother and baby are physically and psychologically ready. “There are effects if we bypass the babies’ decision-making around their optimal time to be born.” Most notable, she says, is that their lungs are less primed to inflate at the critical moment of birth, leading to a higher rate of neonatal intensive care admissions for respiratory distress.
Farry is involved in international research looking at fear of childbirth prior to pregnancy. Among the New Zealand women interviewed, 90 per cent intend to give birth vaginally, but “if current trends continue, fewer than half of them will end up achieving that”.
She’d prefer to see taxpayer dollars which are being spent on non-medical elective caesareans redirected into freestanding midwifery-led birthing units, where international studies show better outcomes for both mother and baby.
Midwife Adrienne Priday works with a South Auckland health centre where many of the women under her care have health issues and an elevated risk of childbirth complications, yet have a high rate of normal births and less intervention. She believes that reflects a community where childbirth is seen as a normal, healthy process “both for their bodies and for the women, who get a lot of mana from a normal birth”.
Farry says caesareans go deeper than the visible line of sutures just below the bikini line: as multiple layers of internal wounds heal, they can form adhesions and distort the pelvic organs, ligaments or musculature. Some women also don’t realise they’ll be given medication, including opiates and antibiotics, and the impact this may have on breastfeeding and mother-baby attachment, especially given the increased likelihood of admission to neonatal intensive care.
“When women need a c-section, and a number definitely do, the last thing we want is for them to feel they have failed or that they haven’t given their baby the best start. We don’t want women to be labouring under the illusion that there’s a right way and a wrong way, but it’s important to help women understand that birth is complex, regardless of how one chooses to have their baby.”
In New Zealand, there’s no cost for an elective caesarean through the public health system, although many women opt for a private specialist. Whether c-sections are officially available on request depends on where you live and who you ask. In a recent news report on the rise in caesareans at Tauranga Hospital, the district health board’s midwifery leader, Margret Norris, told the Bay of Plenty Times they were not performed for “social reasons”.
In her experience, most women who request a caesarean are motivated by the fear of losing control and uncertainty around the outcome of natural childbirth – despite the increased risk of complications in any future pregnancies.
“Do we still lose some babies in pregnancy? Do we still lose some babies in labour? Of course we do,” says Belgrave, who chairs the Perinatal and Maternal Mortality Review Committee. “There will always be some negative outcomes, no matter what we do. But the problem when you’re looking for data is the vast majority of outcomes will be normal. I don’t believe we have evidence that [a caesarean] is safer for babies.”
Yet, by 2025, the caesarean rate in Auckland is projected to hit 40 per cent. Auckland City Hospital already has two dedicated caesarean theatres: one for elective surgery from Monday to Friday; the other on call for emergencies 24-7. Spill-over means some planned c-sections end up on the acute list, says obstetrician Michelle Wise.
“We’ve seen the rate go up every single year. And with the number of women coming back for repeat caesareans, it will suddenly feel like everyone’s having one. There’s no doubt at some point the whole system has to rejig.”
As science weighs the advances of technology against the will of nature, inevitably the goalposts will continue to shift. It’s now standard practice to offer a surgical delivery to women with twins or breech babies, for example.
Can Wise imagine a time when caesareans become routine? “I couldn’t fathom the social change that would be required, after the whole movement of women taking the birth experience away from doctors and hospitals. I think it would be a disaster,” she says.
“But at an individual level, for a woman who is informed and makes a clear, well-documented choice, I think it’s something we should be offering in a way that’s equitable for all women.
This article was first published in the October, 2016 issue of North & South.
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