EXPLORE PAST ISSUES
Controversies
Vol. 16 No 4 | Summer 2014
Feature
Caesarean on request
Dr Dereck Souter
FRCOG FRANZCOG DDU


This article is 5 years old and may no longer reflect current clinical practice.

Elective caesarean section for maternal request remains a contentious issue, with many women wishing to avoid a vaginal birth and many hospital administrators, clinical directors and patient advocate groups continuing to push for a lower caesarean section rate. Elective caesarean section for maternal request remains a contentious issue, with many women wishing to avoid a vaginal birth and many hospital administrators, clinical directors and patient advocate groups continuing to push for a lower caesarean section rate.

Benefits

Pelvic floor

A 2013 study by Gyhagen et al followed up 5000 Swedish women over a period of 20 years, who had only one child either vaginally or by elective caesarean section2, found that primary caesarean section was significantly protective against both urinary incontinence and symptomatic pelvic organ prolapse. The prevalence of urinary incontinence of more than ten years duration was 2.75 times greater after vaginal birth at 10.1 per cent, compared with 3.9 per cent after caesarean section. Urinary incontinence was also more common 20 years after vaginal birth (40 per cent) than after caesarean section (28.8 per cent).

Of the same 5000 women, those who delivered vaginally had a significantly higher prevalence of symptomatic pelvic organ prolapse at 14.6 per cent, compared to 6.3 per cent in those delivering by caesarean section. Interestingly, this study also found a three per cent increase in symptomatic pelvic organ prolapse for every 100g increase in birthweight over 3000g.

The 2013, 12-year follow-up of 10 000 women by the ProLong Study group reported similar benefits of caesarean section, with 29 per cent of women delivering vaginally having prolapse to the hymen or beyond, compared with only five per cent of women delivering exclusively by caesarean section.3

Faecal incontinence may have a more multifactorial origin than we think, as the 12-year follow-up revealed a 3.7 per cent incidence in women delivering exclusively by caesarean section and four per cent in women having a normal vaginal delivery (NVD).4

In summary, a woman can more than halve her chances of pelvic organ prolapse or urinary incontinence for more than ten years duration by delivering her babies exclusively by caesarean section.

Early postpartum haemorrhage

In their summary of the available evidence, the NICE group quoted a comparison of planned vaginal birth (which includes instrumental vaginal deliveries and emergency caesarean section) with elective caesarean section and found that the elective caesarean group had a lower incidence of postpartum haemorrhage (PPH) (1.1–3.9 per cent) compared with 6–6.2 per cent in other births. Obstetric shock was also three-fold lower at 0.006 per cent versus 0.018 per cent.

These findings are supported by the 2013 blood transfusion rates at National Women’s Hospital (NWH) in Auckland, where transfusion in elective caesarean section was required in 1.2 per cent of cases, less than half of that of planned vaginal birth (2.7 per cent).5 For actual vaginal birth the transfusion rate was still higher than elective caesarean section at 2.1 per cent. This is despite planned caesarean sections including indications associated with high intra-operative blood loss, such as placenta praevia and accreta.

Predictability and safety

A planned caesarean section offers a more predictable birth than a planned vaginal delivery. An elective caesarean section at NWH for a first baby will avoid: the 25 per cent chance of an emergency caesarean section; the 20 per cent chance of an instrumental vaginal birth; the 25 per cent chance of an episiotomy; the three per cent chance of a third-degree tear; and the possibility of having to go to theatre after a normal birth for manual removal of the placenta.6

The NICE appendix includes one report that found elective caesarean delivery at 39 weeks reduced perinatal mortality by one per thousand births, presumably by avoiding an at term stillbirth. However, another report in the same appendix showed an increase in neonatal mortality in the caesarean section group. I believe this is likely to be owing to not controlling for high-risk pregnancies and fetal abnormalities, as the majority of term stillbirths in NWH are still related to congenital abnormality.

Psychological

Some patients are referred to our private practice having been so traumatised by previous vaginal birth experiences that they have only planned another pregnancy after establishing it is possible to have an elective caesarean section. These women invariably find caesarean section a very positive birth experience. Other reasons for requesting a caesarean section include a past history of sexual abuse and a fear of childbirth. For some women, the mode of birth is negotiable with appropriate psychological support and the promise of an early epidural. Other women, regardless of support will still request a caesarean.

While almost all of my patients will acknowledge the convenience of knowing the date and approximate timing of their baby’s arrival, in my experience this has rarely been an indication on its own.

The risks

Recovery

Recovery is longer than after a normal vaginal birth, with NICE reporting an average postnatal stay 0.6–1.4 days longer. There are no data given on return to normal daily activities, such as lifting or driving, but experience and anecdotal evidence would support a longer recovery time from caesarean section overall. Of interest, many of my patients with a bad vaginal birth experience (such as third-degree tears) find their recovery significantly easier after an elective caesarean section.

The doubling of hysterectomy for PPH and the five-fold increase in cardiac arrest in the elective caesarean group reported in the NICE guidelines are unlikely to affect a low-risk patient without a praevia, accreta or cardiac condition. However, repeated caesarean section is likely to increase the risk of both a placenta praevia and accreta. The background risk of accreta has been reported to be 1:400 and this increases to 1:300 after two caesareans, 1:200 after three, 1:50 after four, 1:40 after five and 1:15 after six caesareans.6

Clearly, there is an increasing likelihood of complications with subsequent caesarean sections and my patients tell me that apart from the quicker recovery after elective compared to emergency caesarean section, the recovery is no easier with subsequent caesareans. This is unlike vaginal birth, where the second and subsequent births are almost invariably easier and less complicated than the first birth. The practical implications of having to deal with a toddler while recovering from a caesarean have prompted many of my patients to request a trial of labour for subsequent pregnancies.

NICE report some studies showing fewer deep vein thromboses(DVTs) associated with elective caesarean section than NVD. However, other studies still show an increased thromboembolic risk with caesarean section, rendering these trends inconclusive.

Costs

The most expensive birth is an after-hours, in-labour emergency caesarean section, where both delivery unit and on-call theatre staff and facilities are used. Indicative costs for birth in the USA in 2011 were7:

  • Normal Vaginal Delivery (NVD) $10 657
  • Assisted Vaginal Delivery (AVD) $13 749
  • Planned CS $17 859
  • Emergency CS $23 923

Based on the NWH rates of NVD (55 per cent), a 20 per cent AVD rate, and a 25 per cent emergency LSCS rate, 100 planned vaginal births would cost $1,399,000 and 100 planned caesareans would cost $1,785,900. Comparing planned vaginal births, rather than actual vaginal births, with elective caesarean section there is only a 28 per cent increase in costs compared to the 78 per cent extra cost if a simple crude comparison is made.

Effects on the neonate

When comparing planned vaginal birth with elective caesarean section, the results from a study reported in the NICE guidelines shows a significant increase in the NICU admission rates at 6.3 per cent and 14 per cent, respectively. This is compared to the NWH 2013 annual clinical report findings that showed the NICU admission rate for planned term vaginal births was 5.5 per cent compared to 8.2 per cent for elective caesarean section. Surprisingly, the NICE study showed no significant difference in neonatal respiratory morbidity between the two groups (RR 1.04).

Differences in neonatal gut flora between babies born by caesarean and vaginally have been shown.8 There are postulated benefits of reductions in asthma, type 1 diabetes mellitus, obesity and allergies with exposure to and acquisition of the maternal vaginal flora.9 Caesarean section has also been shown to affect early breastfeeding success, but there is no difference in breastfeeding rates at six months when comparing modes
of delivery.10

Summary

The majority of women who have a normal vaginal birth will not have either prolapse or incontinence and will have a quicker recovery than women who have a caesarean. However, for the 40 per cent of women experiencing urinary incontinence 20 years after childbirth, one in four of them would not have their symptoms if they had had a caesarean.

In an ideal world, birth would either be an uncomplicated vaginal birth and or an elective caesarean, this would result in optimum outcomes for both individual women and the health budget. The challenge for us as clinicians is being able to assess whether a woman is likely to have an uncomplicated normal vaginal birth or would be better suited to an elective caesarean section.

Although there is no evidence in the literature to suggest we can predict successful vaginal birth, we should take note of the importance of birthweight in predicting prolapse, with each 100g over 3000g increasing the risk of prolapse by three per cent. Perhaps we obstetricians are better than we think at predicting uncomplicated vaginal birth, as the third- and fourth-degree tear rate for private specialists of 1.4 per cent is half the overall rate of 2.9 per cent at National Women’s Hospital, where 48 per cent of the births are booked with a private midwife.

If a woman is planning on having three or more children, I believe she would be wise to try to give birth vaginally. However, for one or two children then a very serious case for delivery by elective caesarean section can be made. Ultimately, the woman should make an informed decision that she is comfortable living with for the rest of her life.

References

  1. NICE. Intrapartum care: caesarean section (update). www.nice.org.uk/
    guidance/cg132/chapter/Appendix-C-Planned-CS-compared-withplanned-
    vaginal-birth, 2011.
  2. Gyhagen M, Bullarbo M, Nielsen T, Milsom I. The prevalence of
    urinary incontinence 20 years after childbirth: a national cohort study
    in singleton primiparae after vaginal or caesarean delivery. BJOG.
    2013;120:144-151.
  3. Glazener C, Elders A, MacArthur C et al. Childbirth and Prolapse:
    long term associations with the symptoms and objective measurement
    of pelvic organ prolapse. BJOG. 2013;120:161-168.
  4. MacArthur C, Wilson D, Herbison P et al. Faecal incontinence
    persisting after childbirth: a 12 year longitudinal study BJOG.
    2013;120:169-179.
  5. National Women’s Health. 2013 Annual Clinical Report. http://
    nationalwomenshealth.adhb.govt.nz/health-professionals/annualclinical-
    report.
  6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Caesarean delivery on maternal request (CDMR):
    2013 statement. www.ranzcog.edu.au/component/docman/doc_
    view/972-c-obs-39-caesarean-delivery-on-maternal-request-cdmr.
    html?itemid=341.
  7. U.S. Agency for Healthcare Research and Quality, HCUPnet, Healthcare cost and utilization project. Rockville, MD: AHRQ.
  8. Jakobsson HE, Abrahamsson TR, Jenmalm MC, Harris K, Quince
    C, Jernberg C, Björkstén, Engstrand L, Andersson AF. Decreased
    gut microbiota diversity, delayed bacteroidetes colonisation and
    reduced Th1 responses in infants delivered by caesarean section. Gut.
    2013;63:559-566.
  9. Dominguez-Bello MG, Costello EK, Contreras M, Magris M, Hidalgo
    G, Fierer N, Knight R. Delivery modes shapes the acquisition and
    structure of the initial microbiota across multiple body habitats in
    newborns. PNAS. 2010;107(26):11971-11975.
  10. Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ.
    Breastfeeding after cesarean delivery: a systematic review and metaanalysis
    of world literature. Am J Clin Nutr. 2012;95(5):1113-1135.

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