Obstetric Myths and Realities

Myths About Caesareans

"Caesareans Safe Mothers Lives".

It is true that in some extremely life threatening cases, a C section may save the life of a mother and her baby. However, a large percentage of caesareans are done for non-life threatening reasons such as:

Breech presentation
Multiple pregnancy
Fearing the baby will be large
High blood pressure in the mother which is not necessarily pre-eclampsia
Fetal heart rate dropping which is not necessarily a sign of distress
Placenta praevia
Maternal choice in the absence of medical need

The operation is NOT safer for the mother in these circumstances and has a three times higher maternal death rate than vaginal childbirth.

Vaginal childbirth causes the death of 1 woman every 10,000 and caesarean causes the death of 4 women in every 10,000.

Death rates from:

Enkin, M., Keirse, M.J.N.C., Neilson, J., Crowther, C., Duley, L., Hodnett, E. and Hofmeyr, J. (2000) A guide to effective care in pregnancy and childbirth Oxford University Press, 3rd Edition.

Vaginal Breech Birth is More Dangerous

A medical study compared breech babies born vaginally with those born by C section and found that there were more baby deaths in the vaginal group, HOWEVER, they only looked at vaginal breech babies born with an extremely high level of intervention, and not breech babies born naturally without intervention.

The hospital model for a vaginal breech birth includes:

1. Lying flat on your back with continuous monitoring. This position reduces the amount of space in the pelvis, making it harder for the baby to be born. You also do not have gravity to help you birth the baby, slowing the birth which could be dangerous in a breech delivery.

2. Episiotomy (female genital mutilation) either with forceps, which can cause injuries to the baby as well as the mother, or a breech extraction where the OB puts his hand in the vagina and literally yanks the baby out. This can cause a reflex reaction and the cervix closes around the baby's head, preventing him from being born and potentially suffocating him. This is a life threatening emergency.

Only babies born by these methods were studied.

If a natural, active breech birth is done, the mother would stay active, walk around etc during labour.

During delivery she would be in an upright position so that gravity can assist the birth, and during the birth, any medical attendents would NOT touch the baby as he came out, to avoid him becoming stuck. The NCT say:

'Some births are ‘managed’ or ‘assisted’ with epidural anaesthesia, episiotomy (a cut to enlarge the vagina) and forceps. Others are ‘natural’ or ‘physiological’ in which the woman is free to move about and change position; monitoring of the baby’s heartbeat allows the mother to be upright and mobile; neither an epidural or opiates are used; the midwife or doctor does not touch the baby’s body as it is being born unless there is a clear reason to do so; the baby is born entirely through the unaided, expulsive efforts of the mother. Providing all goes well, the midwife avoids touching the mother or baby during the birth and holds her hands ready to receive the baby once it has completely emerged.'

http://www.nct.org.uk/info-centre/information/view-41

No research has been done on breech babies who are born by hands-off natural birth, so the study advising C sections was poor science.

'Breech babies do better after Caesareans than Vaginal Birth'

This isn't true except in very life threatening cases where the baby will die without it.

Babies born by caesarean are more than twice as likely to die before they leave the hospital than babies born vaginally.

The neonatal death rate after vaginal delivery is 0.63% per 1000. The death rate for babies born via caesarean is 1.77% per 1000.

Researchers excluded babies born by emergency caesarean and those suffering from fetal distress and other conditions requiring a caesarean which could explain their death, and they just concentrated on low risk women who had been offered a caesarean. Because of this, they were concerned by the results of the study.

They thought that babies born by C section may be dying due to:

1. Lack of hormones from the mother. Being in labour causes hormones from the mother to go to her baby which help to mature his lungs.

2. Being squeezed in the birth canal expells fluid from the lungs - C section babies don't have this advantage.

3. Physical injury to the baby - some babies are accidently cut during surgery as it isn't possible to avoid it 100% of the time.

4. Being born before he is due. There is evidence to suggest that even babies born at 38 weeks have a disadvantage compared with those at term and they have more breathing difficulties.

5. Delayed breast feeding. Milk takes longer to come in after you've had a caesarean because there are no labour hormones to tell your body you've had a baby, therefore you might not have any milk for several days or longer.

The study said:

The percentage of United States' births delivered by cesarean section has increased rapidly in recent years, even for women considered to be at low risk for a cesarean section. The purpose of this paper is to examine infant and neonatal mortality risks associated with primary cesarean section compared with vaginal delivery for singleton full-term (37–41 weeks' gestation) women with no indicated medical risks or complications. Methods: National linked birth and infant death data for the 1998–2001 birth cohorts (5,762,037 live births and 11,897 infant deaths) were analyzed to assess the risk of infant and neonatal mortality for women with no indicated risk by method of delivery and cause of death. Multivariable logistic regression was used to model neonatal survival probabilities as a function of delivery method, and sociodemographic and medical risk factors. Results: Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62). The magnitude of this difference was reduced only moderately on statistical adjustment for demographic and medical factors, and when deaths due to congenital malformations and events with Apgar scores less than 4 were excluded. The cesarean/vaginal mortality differential was widespread, and not confined to a few causes of death. Conclusions: Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication.'

Source: Birth, Volume 33 Page 175 - September 2006.

Other Complications For Babies Born By Caesarean

Immune System Impairment Through C Section

A messy birth could be good for the baby's digestion. So say researchers in Germany, who have found evidence that baby mice squeezing through the birth canal swallow bacterial molecules that help their gut grow healthily. The finding suggests that kids born by caesarean might miss out.

The researchers think that bacterial scraps naturally slopping around in the birth canal and mother's faeces are swallowed by the baby mice as they make their entry into the world. These molecules pass down into the gut, where they stimulate the gut cells; a single exposure is enough to teach the cells to tolerate friendly bugs in the future.
Gut reaction

To show this, Hornef's team looked at the responses of gut cells of baby mice born both naturally and by caesarean. Those born through the vagina fired up an inflammatory response in the two hours after birth, a sign that their cells had been stimulated by bacterial molecules. In contrast, babies born by caesarean did not show signs of such activation.

Source: http://www.bioedonline.org/news/news.cfm?art=2477

Poor Lung Function in Caesarean Babies

Lung function tests were carried out in the first 6 hours of life on 26 babies born by vaginal delivery and 10 born by caesarean section. The babies born by caesarean section had a mean thoracic gas volume of only 19.7 ml/kg body weight compared with 32.7 ml/kg for the babies born vaginally. We conclude that this is owing to an excess of lung fluid in the babies born by caesarean section.

Source: Arch Dis Child 1978 Jul;53(7):545-8.

Respiratory Diseases are Five Times Higher in C Section Babies

OBJECTIVE: To determine whether there is an increased incidence of persistent pulmonary hypertension in neonates delivered by cesarean, with or without labor, compared with those delivered vaginally. METHODS: We did a computerized retrospective review of 29,669 consecutive deliveries over 7 years (1992-1999). The incidences of persistent pulmonary hypertension of the newborn, transient tachypnea of the newborn, and respiratory distress syndrome (RDS) were tabulated for each delivery mode. Cases of persistent pulmonary hypertension were reviewed individually to determine delivery method and whether labor had occurred. The three groups defined were all cesarean deliveries, all elective cesareans, and all vaginal deliveries. RESULTS: Among 4301 cesareans done, 17 neonates had persistent pulmonary hypertension (four per 1000 live births). Among 1889 elective cesarean deliveries, seven neonates had persistent pulmonary hypertension (3.7 per 1000 live births). Among 21,017 vaginal deliveries, 17 neonates had persistent pulmonary hypertension (0.8 per 1000 live births). chi2 analysis showed an odds ratio 4.6 and P <.001 for comparison of elective cesarean and vaginal delivery for that outcome. CONCLUSION: The incidence of persistent pulmonary hypertension of the newborn was approximately 0.37% among neonates delivered by elective cesarean, almost fivefold higher than those delivered vaginally. The findings have implications for informed consent before cesarean and increased surveillance of neonates after cesarean.

Source: Obstet Gynecol. 2001 Mar;97(3):439-42.

Fetal laceration injury at cesarean delivery is not rare

OBJECTIVE: To investigate the incidence of fetal laceration injury in cesarean delivery.

METHODS: A retrospective review was conducted using a computer-based data coding system. All neonatal records were reviewed for infants delivered by cesarean during a 2-year period. Maternal records were reviewed in those cases of documented fetal laceration injury. The Fisher exact test was used when indicated.

RESULTS: There were 904 cesarean deliveries performed during the study period; of these, 896 neonatal records (98.4%) were available for review. Seventeen laceration injuries were recorded (1.9%). The incidence of laceration appeared higher when the indication for cesarean was nonvertex (6.0% versus 1.4%, P = .02). One of 17 (5.9%) maternal records indicated the presence of the laceration of the fetus.

CONCLUSION: Fetal laceration injury at cesarean delivery is not rare, especially when it is performed for nonvertex presentation. The minority of obstetric records show documentation of such lacerations, suggesting that this complication often may not be recognized by obstetricians.

Source: Obstet Gynecol 1997 Sep;90(3):344-346

According to the Royal College of Obstetricians and Gynaecologists, 2% of babies born by caesarean suffer injuries during their birth, that's 2 babies in every 100, meaning around 3,000 infants are injured every year in the UK due to C-sections.

One mum recalled

'When they eventually brought my baby over to me, I was shocked to see he had a plaster across his cheek, almost up to his eye.

'Initially I was told it was just a nick from when the doctors had cut through the final layer to get Lucius out. But a week later the plaster came off and I saw a huge cut. I was heartbroken.

'When I finally got through to one of the senior midwives at the hospital, she told me: "You took the risk by wanting to have a C-section."

'Then she reminded me that I had signed a consent form - as if I had signed away all my rights. The main priority seemed to be to fend off lawsuits.

Source: http://www.dailymail.co.uk/health/article-1201049/With-thousands-infants-injured-year-Caesarean-births-mothers-warned-risks.html#ixzz0dTUP3V9z

Risk of Schizophrenia in People Born By C-section Due to General Anesthesia

Schizophrenia is associated with both increased dopaminergic activity and perinatal complications. To test whether dopamine-mediated behavior can be altered by birth complications, we investigated effects of amphetamine (AMPT) on activity levels in adult rats that had been born vaginally or by Caesarean section (C-section) from isoflurane-anesthetized dams with or without addition of 10 min global anoxia. For comparison with our previous results, we also included rats born by C-section from decapitated dams.

The main finding is that rats born by C-section from isoflurane-anesthetized dams, either with or without added anoxia, showed greater AMPT-induced activity as adults compared to vaginally born controls. C-section from decapitated dams also enhanced AMPT-induced activity, however the time course differed from that following maternal anesthesia. Thus subtle alterations in birth procedure can produce long-lasting increases in dopamine-mediated behavior, supporting a role for birth complications in the pathophysiology of schizophrenia.

Source: Neuroreport 1998 Sep 14;9(13):2953-9

Food Allergies in Caesarean Babies

Researchers at Munich's Ludwig-Maximilians University studied 865 babies all breast fed for the first four months of life. Of these, 147 babies had been born by C section. They were monitored at one, four, eight and 12 months of age for allergies to cows milk, soy protein and eggs.

At 12 months of age they were given a blood test to check for allergic response and they found that the C section babies were more likely to suffer from diarrhoea and food allergies than babies born vaginally.

Source: http://news.bbc.co.uk/1/hi/health/3758730.stm

Higher Risk of Asthma in Caesarean Babies

A study found that children born by caesarean had nearly twice the risk of developing asthma by age 8 than children born vaginally.

Background: Cesarean section might be a risk factor for asthma due to a delayed microbial colonization, but the association remains controversial.

Objective: To investigate prospectively whether children born by cesarean section are more at risk of having asthma in childhood, and sensitization at the age of 8 years taking into account the parental allergic status.

Methods: We studied 2,917 children, who participated in a birth cohort study and followed for 8 years. The definition of asthma included wheeze, dyspnea and prescription of inhaled steroids. In a subgroup (n=1,454), serum IgE antibodies for inhalant and food allergens were measured at 8 years.

Results: In the total study population, 12.4% (362) of the children had asthma at the age of 8 years. Cesarean section, with a total prevalence of 8.5%, was associated with an increased risk of asthma (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.27-2.51). This association was stronger among predisposed children (with two allergic parents: OR, 2.91; 95% CI, 1.20-7.05; with only one: OR, 1.86; 95% CI, 1.12-3.09) than in children with non-allergic parents (OR, 1.36; 95% CI, 0.77-2.42). The association between cesarean section and sensitization at the age of 8 years was significant only in children of non-allergic parents (OR, 2.14; 95% CI, 1.16-3.98).

Conclusions: Children born by cesarean section have a higher risk of asthma than those born by vaginal delivery, particularly children of allergic parents. Cesarean section increases the risk for sensitization to common allergens, in children with non-allergic parents only.

Source: Roduit C, et al "Asthma at 8 years of age in children born by caesarean section," Thorax 2008; DOI:10.1136/thx.2008.100875.

Asthma, Diabetes and Leukaemia in Caesarean Babies

Another study of 37 newborn babies and found that the C section babies had changes in their white blood cells, compared with babies born vaginally.

Prof Mikael Norman, a paediatric specialist, from the Karolinska Institute, in Stockholm, said: "Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks.

"Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before."

Source: http://www.telegraph.co.uk/health/healthnews/5686941/Babies-born-by-caesarean-more-prone-to-asthma-study-finds.html

Celiac Disease Associated with Caesarean

Methods A retrospective, multicenter, case-control study that included 1950 children was performed in cooperation with 26 university and 16 nonacademic children's hospitals. Information on intestinal disease manifestation, together with mode of delivery and gestational age at birth, postnatal complications, and breastfeeding, was collected by the attending physician from children and their parents who were visiting a gastrointestinal outpatient clinic for Crohn disease (CD; 516 cases), ulcerative colitis (250 cases), celiac disease (157 cases), and other gastrointestinal diseases (165 cases) and control subjects who were visiting ophthalmologic, orthodontic, and dental outpatient clinics (862 cases).

Results Whereas the rate of cesarean delivery of children with Crohn disease or ulcerative colitis was similar to that of control subjects, a significantly enhanced likelihood of being born by cesarean delivery was found in children with celiac disease compared with control subjects (odds ratio: 1.8 [95% confidence interval: 1.13–2.88]; P = .014).

Conclusions The mode of delivery and associated alterations in the development of the enteric homeostasis during the neonatal period might influence the incidence of celiac disease.

Source: PEDIATRICS (doi:10.1542/peds.2009-2260)

Complications For Mother

Aside from tripling her risk of death in childbirth, there are also additional complications for mothers undergoing a caesarean section:

Hysterectomy Occurs 1 in Every 5,000 Vaginal Births and 1 in Every 313 Caesareans

Abstract

Objective: To review 10 years' experience of obstetric hysterectomy in a university teaching hospital. Study Design: A retrospective study of all cases of caesarean or postpartum hysterectomy between 1984–1994. Demographic data and clinical details including indications for operation, nature of surgical management and complications were analysed. Results: The incidence of obstetric hysterectomy was 1 in 1420 deliveries. Overall, 0.32% of caesarean sections and 0.02% of vaginal deliveries were complicated by emergency obstetric hysterectomy. Morbidly adherent placenta (32.7%) was the most common cause of uncontrollable haemorrhage. Prior caesarean delivery and placenta praevia were the main risk factors for its development. Operative complications included intra-operative hypotension (33.3%), urinary tract injury (22.2%) and re-exploration for persistent haemorrhage (12.5%). There was one maternal death due to suspected air embolism. Conclusions: Emergency obstetric hysterectomy, though uncommon, remains a potentially life-saving procedure which every obstetrician must be familiar with. It is extremely important to have early surgical intervention, prompt resuscitation and management by experienced medical staff to minimise morbidity and mortality.

Source: European Journal of Obstetrics and Gynaecology and Reproductive Biology, Volume 74, Issue 2, Pages 133-137 (August 1997).

Wound Infection and Re-Admission to Hospital

Wound infections occured in 25.3% of the 428 women having caesareans and 36% of those infections were diagnosed AFTER she left the hospital.

2 women had to be re-admitted to hospital.

Although the majority of wound infections diagnosed after discharge from hospital were not 'major', with only 2 patients requiring readmission, there was significant morbidity amongst this group and considerable cost to the health services. General practitioners saw and treated 12 of the 30 (40%), and there was also an increase in the workload for the Home Care Midwifery service with 49% of all visits to Caesarean section women being to the 30% that were infected (figure 1). Thus, these nonmajor wound infections would appear to be important for both the woman with her delay in returning to normal activities, and for our already overstretched Home Care Midwives, with an increase in demand for their services.

Summary: A prospective study was performed between April 1,1991 and April 30,1992 to determine factors involved in the development of post-Caesarean section wound infection. During this period there were 4,857 deliveries, 428 by Caesarean section (8.8%). Complete data were available on 328 (76.6%) patients. Wound infection occurred in 25.3% of women and was confirmed by positive bacteriology in 77.1%; 36% of wound infections were diagnosed following the patients' discharge from hospital. A negative correlation was found between maternal age and development of wound infection up to age 40 (p = 0.03). Maternal weight was a highly significant indicator of subsequent wound infection development (p = 0.0001), the relationship between increasing maternal weight and infection appearing linear. Antibiotic prophylaxis was found to be the most significant protective factor (p = 0.0007) in the reduction of postoperative wound infection. This relationship was independent of maternal weight.

Source: Australian and New Zealand Journal of Obstetrics and Gynaecology, Volume 34 Issue 4, Pages 398 - 402

Rates of Re-Admission, Gall Bladder Problems and Appendicitis

Caesarean mothers have twice the risk of being readmitted to hospital with complications, than vaginal birth mothers.

17 out of every 1000 C section mothers need to be re-admitted.

There was an 80% increase in hospitalisations for C section mums and a 30% increase for mums who had an 'assisted' birth (forceps, ventouse).

Researchers also found an increase in gall bladder problems and appendicitis in C section mums.

Source:Lydon-Rochell, M. et al, Association between method of delivery and maternal rehospitalization, JAMA, 2000; 283 2411-6

Five Fold Increase in Placenta Praevia in Subsequent Pregnancies of C Section Mothers

Having a caesarean can cause placenta praevia, where the placenta is low lying or covers the cervix, obstructing the baby's exit. This is because the placenta cannot grow in scarred tissue so it chooses an area that is free of scarring in order to grow:

A prospective study was undertaken to determine the relationship between previous caesarean section (CS), placenta praevia and placenta praevia accreta. Of 41,206 consecutive deliveries 1851 had had previous caesarean section and 222 had placenta praevia. Of the cases of placenta praevia, 175 occurred in the uterus and 47 occurred after previous CS. Placenta praevia complicated 2.54% of cases with a previous caesarean section compared with 0.44% of cases with no scar--a 5-fold increase. In patients with placenta praevia occurring with a previous scar, 18 were complicated by placenta accreta (38.2%) compared with only 8 (4.5%) in unscarred uteri. After one caesarean section, placenta praevia was complicated by accreta in 10% of cases and after two or more this was 59.2%. The risk of hysterectomy with placenta praevia and uterine scar was 10% but with placenta praevia accreta it was 66%. There was one maternal death in the placenta praevia accreta group.

Source: Eur J Obstet Gynecol Reprod Biol. 1993 Dec 30;52(3):151-6.

Most Cases of Uterine Rupture are in Women With Previous Caesarean - 36 out of 39 Cases Were in C/S Mums

Uterine rupture is rare, these 39 cases occured over a 10 year period, but nonetheless, the majority of them are caused by a scarred uterus:

OBJECTIVE: To review the incidence, associated factors, methods of diagnosis, and maternal and perinatal morbidity and mortality associated with uterine rupture in one Canadian province. METHODS: Using a perinatal database, all cases of uterine rupture in the province of Nova Scotia for the 10-year period 1988-1997 were identified and the maternal and perinatal mortality and morbidity reviewed in detail. RESULTS: Over the 10 years, there were 114,933 deliveries with 39 cases of uterine rupture: 18 complete and 21 incomplete (dehiscence). Thirty-six women had a previous cesarean delivery: 33 low transverse, two classic, one low vertical. Of the 114,933 deliveries, 11,585 (10%) were in women with a previous cesarean delivery. Uterine rupture in those undergoing a trial for vaginal delivery (4516) was complete rupture in 2.4 per 1000 and dehiscence in 2.4 per 1000. There were no maternal deaths, and maternal morbidity was low in patients with dehiscence. In comparison, 44% of those with complete uterine rupture received blood transfusion (odds ratio 7.60, 95% confidence interval 1.14, 82.14, P =.025). Two perinatal deaths were attributable to complete uterine rupture, one after previous cesarean delivery. Compared with dehiscence, infants born after uterine rupture had significantly lower 5-minute Apgar scores (P <.001) and asphyxia, needing ventilation for more than 1 minute (P <.01). CONCLUSION: In 92% of cases, uterine rupture was associated with previous cesarean delivery. Uterine dehiscence was associated with minimal maternal and perinatal morbidity. In contrast, complete uterine rupture was associated with significantly more maternal blood transfusion and neonatal asphyxia.

Source: Obstet Gynecol. 2002 Oct;100(4):749-53.

Chronic Long-Term Pain and Nerve Entrapment

According to Dr. Dimitri Leschinskiy, Consultant in Chronic Pain Management at the Queen Elizabeth Hospital, UK:

Chronic pain after Caesarean section seems to be a significant problem in at least 5.9% of patients and may result from the nerve entrapment in the scar tissue.

Source: http://www.painclinic4u.co.uk/conditions-treated.htm

Surgical Accidents

Okay, this is rare, but it does happen rarely after any surgical procedure:

A 26 year old woman has had to undergo surgery to remove a swab left inside her during her Caesarean.

Sahar Asma Sarfaraz from South London, gave birth to her first child Sabrina at Princess Royal University Hospital in Orpington. She complained of severe pain afterwards and three days later an X-ray revealed the hankerchief-like swab which had been left behind!

Mrs Sarfaraz's husband Shaz Sarfaraz said his wife had been complaining of a constant pain since the birth. He said: "She felt like something was really burning and it was not pleasant. But they [doctors] just kept saying that this is natural after a Caesarean." Mr Sarfaraz added that his wife continued to take painkillers to deal with the pain until she went in for an X-ray.

A statement from the trust that runs the hospital said: "Bromley NHS Trust can confirm that a sterile swab was left inside a patient during her emergency Caesarean section. A full investigation into the causes of what happened has been launched."

Source: http://www.thebabywebsite.com/article.1248.Swab_Left_Inside_Mum_After_Caesarean.htm

Twice the Risk of Developing Post-Natal Depression in Caesarean Mothers

Abstract:
Aim:

To identify whether women having emergency delivery are at increased risk of developing postnatal depression (PND). Methods:

This is a retrospective comparative cohort study design. Two hundred and fifty Malaysian women were part of a previous study examining the prevalence of PND in a multiracial country and the effects of postnatal rituals. All women were at least 6 weeks post-partum when asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Sociodemographic and birth data were obtained. Results:

Data collected were divided into two groups: 55 emergency delivery and 191 non-emergency delivery. There were four missing data. There was no significant difference in the mean age, parity, gestational period, baby birthweight, 5 min baby Apgar score and EPDS scores of the two groups. However, the analysis of PND indicated that women with emergency delivery had a relative risk of 1.81 compared with women with non-emergency delivery. The comparison of the two groups using khgr2 indicated a significant (khgr2= 3.94, d.f. = 1, P= 0.04) increase in the presence of PND in the emergency delivery.

Conclusion:

When compared with women having non-emergency delivery, women having emergency delivery had about twice the risk of developing PND. Special attention to this group appears warranted.

Source: The Journal of Obstetrics and Gynaecology Research, Volume 29, Number 4, August 2003 , pp. 246-250(5)

Anesthetic Awareness and Recall

Surgeons don't tell you but there is a high risk of anesthetic awareness (being conscious in spite of anesthetic) with emergency caesareans, the reason being that they give you less anesthetic than is normal, for the safety of the baby and sometimes it isn't enough to put you to sleep but you will be paralysed so unable to tell doctors that you are conscious.

Out of 763 emergency C sections between the years 2005-2006, there were two cases of anesthetic awareness and a further three possible cases, amounting to 1 case of anesthetic awareness per 382 women.

'Background

The obstetric population is considered at high risk of awareness and recall when undergoing general anaesthesia for caesarean section. In recent years the incidence may have been altered by developments in obstetric anaesthesia.
Methods

A prospective observational study of general anaesthesia for caesarean section was conducted during 2005 and 2006 in 13 maternity hospitals dealing with approximately 49 500 deliveries per annum in Australia and New Zealand. As a component of this study the frequency of recall of intraoperative events was examined using a structured postoperative interview on two occasions.
Results

There were 1095 general anaesthetics surveyed with 47% being performed for urgent fetal delivery. Thiopental was the most common induction agent (83%) with sevoflurane being used for maintenance in 63%. In 32% of cases a depth-of-anaesthesia monitor was used. In 763 cases (70%) there was least one postoperative interview enquiring into dreaming and awareness. There were two cases deemed to be consistent with awareness (incidence 0.26%, CI 0.03-0.9%, or 1 in 382) and three cases of possible awareness.
Conclusion

Awareness with recall of intraoperative events remains a significant complication of obstetric general anaesthesia but was potentially avoidable in all cases detected in this study.

Source: International Journal of Obstetric Anesthesia, Volume 17, Issue 4, October 2008, Pages 298-303.

VAN UK's Comment:

When doctors say the benefits of caesarean outweigh the risks, particularly for malpositioned babies, they are comparing only with high intervention, surgical vaginal deliveries and not with natural, active birth.

They also only look at the immediate risk and never consider ongoing health issues of the mother or her baby. It's a quick fix attitude. Any consequences 5 or 10 years down the line are not even thought of.

When weighing up all of the known and long-term consequences of C/S and comparing that to natural, active breech birth, it is clearly evident that in the majority of cases, the benefits of caesareans for breech babies do not outweigh the risks.

Breech presentation accounts for about 4% of all caesareans so by supporting vaginal breech birth, doctors would be lowering the caesarean rate quite significantly already. This is particularly important as it has a three times higher death rate for women and a twice as high death rate for babies.

The Society of Obstetricians and Gynecologists of Canada are Taking A Stand and No Longer Recommend Routine C/S For Breech Presentation

Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada.

the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first. Normally, the infant descends head first.

“Our primary purpose is to offer choice to women,” said André Lalonde, executive vice-president of the SOGC.

“More women are feeling disappointed when there is no one who is trained to assist in breech vaginal delivery,” he adds.

Since 2000, C-sections have been the preferred method of delivery in breech births. Studies suggested that breached births were associated with an increased rate of complication when performed vaginally.

As a result, many medical schools have stopped training their physicians in breech vaginal delivery.

The problem now, according to Dr. Lalonde, is that there is a serious shortage of doctors to teach and perform these deliveries.

With the release of the new guidelines, the SOGC will launch a nationwide training program to ensure that doctors will be adequately prepared to offer vaginal breech births .

The new approach was prompted by a reassessment of earlier trials. It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births.

The SOGC stresses that because of complications that may arise, many breech deliveries will still require a cesarean section.

Breech presentations occur in 3-4 per cent of pregnant women who reach term. That translates to approximately 11,000 to 14,500 breech deliveries a year in Canada.

The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth – spontaneous labour, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.

“The safest way to deliver has always been the natural way,” said Dr. Lalonde.

“Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”

Cesarean sections, in which incisions are made through a mother's abdomen and uterus to deliver the baby, can lead to increased chance of bleeding and infections and can cause further complications for pregnancies later on.

“There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so,” said Dr. Lalonde.

“It is the general principle in medicine to not make having a cesarean section trivial.”

The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally.

The national average for babies delivered via cesarean section in Canada is 25 per cent.

Source: The Globe and Mail, 17 June 2009.

Justifable Reasons to Have A Caesarean

There are some cases in which caesareans are truly needed:

1. Placental abruption, where the placenta tears away from the wall of the uterus, cutting off baby's oxygen supply and causing internal bleeding.

2. Transverse lie baby that cannot be turned (this is a baby lying sideways across the womb). This occurs in about 1 in every 2,500 babies.

3. Extreme fetal distress which is life threatening.

4. Cord prolapse where the cord comes down before the baby, cutting off his oxygen supply (sometimes it is possible for an experienced midwife to move the cord out of the way as the head is being born).

5. Complete placenta praevia where the placenta totally covers the cervix, blocking the baby's exit.

6. Footling breech baby that does not descend. The safest form of breech baby is bottom first and the bottom is wider than a foot and dilates the cervix more easily. Although there are successful vaginal births with a footling breech, occassionally the foot will be born and then the cervix fails to dilate, leaving the rest of the baby trapped inside.

7. Pre-eclampsia/eclampsia of pregnancy. A lot of OB's perform a C/S just because of high blood pressure and protein in the urine, but these two symptoms alone are not necessarily pre-eclampsia. If you are also having these symptoms: headache, major swelling of the legs, dizziness, disorientation, seeing bright lights or other visual disturbances then you likely have pre-eclampsia and if your baby isn't born immediately, then you could go on to have a seizure, stroke or in extreme cases, coma and death.

8. A malformed uterus or abnormally small pelvis in the mother that would prevent vaginal birth. OB's are increasing ordering C-sections for mothers just because their babies are estimated to be 9lbs. It is perfectly normal for a woman to have a 9lbs baby and the majority of pelvises, even in first time mums, will accomodate that. I had a 9lbs 1oz baby at home in just over 2 hours and I know other women who've had 9lbs and even 10lbs or 11lbs babies at home with no problems.

The pelvis should have to be medically diagnosed as being abnormal or the baby get stuck in the birth canal before this is a true emergency.

Personally, if my baby was stuck I (Joanna) would opt for a C section instead of episiotomy because episiotomy is female genital mutilation and causes long-term pain and can affect the person's sex life. I still get pain from my scar after 14 years and my personal feeling is that the genitals are more sensitive than the abdomen. The pain of a C/S is also taken more seriously by medical staff with mothers being given morphine pumps etc, whereas I was only offered paracetamol when my pain scale was 200 out of 10!

But it's every woman's personal choice which I believe she has the right to make if she understands all the risks and benefits.