A Caesarean is a surgical operation, performed under general, epidural or spinal anaesthesia, in which the baby is born through an incision in the abdominal wall and the uterus.59
The Caesarean birth rate has risen in England from 11% in 1990 to 22% in 2002. The situation is the same in the other countries of the UK. The World Health Organisation (WHO) has recommended that no hospital should have a Caesarean rate higher than 10-15%,20 although many hospitals in the UK now have Caesarean rates over 25%.
Necessity of Caesarean operations
Caesarean operations are carried out for many reasons, including pre-eclampsia, fetal distress, delay in progress of labour, multiple pregnancy, placental problems, and previous Caesarean.59. There is divided opinion amongst obstetricians as to when a Caesarean is necessary.60
For detailed research evidence on Caesarean birth in the following circumstances, see "A guide to effective care in pregnancy and childbirth" by Enkin, Keirse et al (Oxford University Press, available from NCT Maternity Sales).
A recent trial61 has concluded that for breech babies, a Caesarean birth is safer. This conclusion has been challenged,62 and the suggestion made that the conclusion of the trial should be that, for breech babies, Caesarean birth is safer than an obstetric vaginal delivery (involving a high level of intervention). The comment is made that no study has yet been done comparing the safety of Caesarean birth for breech babies, with birth where the woman is attended by a practitioner of midwifery care, competent in delivering breech babies vaginally, and with minimal intervention.
Risks of Caesarean operations
The risk of a mother dying as a result of a Caesarean operation is small, but is considered to be four times higher than that associated with a vaginal birth (4 per 10,000 births compared with 1 per 10,000 births).17 One study has suggested that an elective Caesarean is safer than an emergency Caesarean, by a ratio of 1:1.5.63
Most forms of post-natal health problems are higher with Caesarean birth17 including the risks of anaesthesia, infection, haemorrhage, thrombosis and pulmonary embolism.59
Recovery from a Caesarean birth takes longer, and may affect the early post-natal period, particularly where a woman has older children. A woman who has had a Caesarean may need more support at home.60 There may also be psychological effects, including a sense of loss or failure over the birth.59
The major risks of Caesarean birth for the baby relate to the risk of respiratory distress, the incidence being 4 times greater in babies born by elective Caesarean than in those born through the birth canal.59 One study has concluded that this can be reduced by waiting until at least 39 weeks gestation before performing a Caesarean.64
Avoiding a Caesarean
Some of the following may reduce the likelihood of having a Caesarean:
Requesting a Caesarean
Obstetricians do not agree about whether a woman should be able to have a Caesarean on request. One often-quoted survey showed that 31% of 85 female obstetricians in London would have an elective Caesarean rather than give birth vaginally.67. This is used as evidence that choosing a Caesarean is a rational choice for women. On the other side of the debate, 69% of female obstetricians would prefer not to have an elective Caesarean, and in another survey 129 out of 135 female midwives (over 95%) opted for a vaginal birth rather than a Caesarean.68
Some obstetricians believe that, given what is known about the risks, they cannot justify performing major surgery on a woman in the absence of a clinical reason.70 Others believe that opting for an elective Caesarean is a valid maternity choice of women, providing they are fully informed of the risks.69 The debate continues.
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