National Caesarean Awareness Day (September 11) was established to help raise awareness about the impact of caesareans on women and families, to honour the journeys of women who have given birth by caesarean and to dispel myths and misconceptions about caesareans and vaginal birth after caesarean (VBAC).

Caesarean surgery, like any major surgery, carries risks for both mother and baby and also any future babies the mother has. Despite this, the wider community views caesareans as the safest and easiest way to have a baby. Women's magazines - and their celebrity c-section stories - have helped cement this view.

Many women who have had a caesarean would agree that a caesarean birth is not the easiest way to have a baby and many feel insulted when someone suggests they took the easy way out.

So what's having a caesarean really like?

Caesarean realities

Very few women ask for a caesarean without a medical reason. A recent study done by the Childbirth Connection in the US (2006) found that less than 1 per cent of women requested an elective caesarean for no medical reason.

The reality for most women is that their obstetrician advises them to have a caesarean. The reasons vary but with some obstetricians having caesarean rates of 50 per cent or more, you can bet that not all are necessary. The same study by Childbirth Connection stated that 10% of women felt they'd been pressured into a repeat caesarean by a health professional.

Some women feel their c-section experience was disempowering and undignified. Experiences like this can compromise a mother's emotional safety. The impact on mental health outcomes of these experiences has not been accounted for to any large extent despite the fact that 15 percent of women in this country suffer from postnatal depression and about 1 in 3 women find childbirth traumatic.

During a caesarean the woman is incapacitated and sometimes unable to move at all depending on the strength of the epidural. In rare cases the epidural may not work effectively to block the pain of the operation and the mother may be rendered unconscious with general anaesthetic. Some mothers feel ignored while medical staff are deep in conversation at the operating table and some mothers feel their need to bond with their baby is usurped by common hospital policies to send babies to special care nursery for several hours after surgery.

After the birth, the mother is dependent on pain-killing drugs, may have difficulty in picking up, caring for or feeding her newborn and moving about unassisted.

For several weeks after the birth a mother is not supposed to drive or lift anything heavy including emotionally distraught toddlers who are trying to adjust to a new brother or sister in the house.

All this is a lot to go through for anyone having surgery let alone a woman making the transition to motherhood with sleepless nights and the demands of newborns and toddlers to deal with.

Taking an active role in your caesarean

There are ways in which women can take more of an active role in how their caesareans are performed.

It can be helpful to negotiate a caesarean birth plan with the attending obstetrician and pediatrician. In this way you can ensure your needs are met and the operation is carried out in a respectful manner. It can also help you implement strategies to kick-in your natural hormonal response to help you bond with your baby after the operation and establish breastfeeding.

• Skin-to-skin contact with the baby on your chest straight after he or she has been taken out can be very helpful for the mother and baby.
• A blanket can be placed over the baby to keep him or her warm while you say "hello" to each other for the first time.
• Delayed cord clamping can be helpful in providing more oxygen to the newborn after the shock of being taken out of the womb so suddenly.
• It also helps to have a professional birth support person there for you and your partner, someone who can make sure that your needs are met and your wishes respected, someone who can help you establish breastfeeding in recovery if you desire to or get hold of your placenta if you want to see it.

Caesarean risks

Childbirth Connection (2004) provides the following list of increased risks of caesareans (as opposed to vaginal birth) from their comprehensive systematic review of the research on caesareans. 

Physical Risks for the Mother:

• maternal death as a direct result of caesarean surgery
• emergency hysterectomy
• blood clots and stroke
• injuries from surgery to the uterus and other organs such as bladder and bowel
• injuries from anaesthesia
• longer time in hospital
• going back into the hospital
• post-operative infection
• longer-lasting and more intense pain
• ongoing pelvic pain due to scarring and/or adhesions
• bowel obstruction and twisted intestines in the years after surgery as
• result of scarring and/or adhesions

Psychological Risks:

• negative feelings about the birth
• less early contact with her baby
• unfavourable early reaction to her baby
• depression
• psychological trauma including Post-Traumatic Stress Disorder (PTSD)
• poor overall mental health and self-esteem
• poor overall functioning in daily life in the early weeks after birth

Risks for the baby:

• Cut by scalpel (usually in the face) during the surgery
• Breathing problems
• Intensive care admission
• Breast feeding problems
• Asthma in childhood or adulthood

Many of the longer-term impacts of caesareans are little understood but the effect on future pregnancies is beginning to gain more recognition.

In future pregnancies there is greater risk of unexplained still birth, greater risk of all of the above complications if a repeat caesarean is performed and greater risk of life-threatening placenta-related complications, infertility, ectopic pregnancy and uterine rupture. The risks of premature birth, low birth weight and respiratory problems also increases.

Some of these risks are rare but it is important to understand that with the increase in our caesarean rate the incidence of death or injury related to caesareans also increases. This fact has been confirmed by recent research by the World Health Organisation (2006).

Every woman should be fully aware of the risks before deciding what is best for them and their babies.

VBAC realities

Once you've had a caesarean it is harder to gain support for a natural birth after caesarean.

In their Listening to Mothers survey on caesareans (2006), Childbirth Connection found that only 12 percent of women in the survey had a vaginal birth after caesarean (VBAC) and of the 45 percent of women who were interested in VBAC, more than half were denied this option, not because of their individual circumstances but because the care provider or hospital was unwilling to support VBAC under any circumstance.

For any woman having a baby regardless of whether she has had a previous caesarean or not, the risk of the baby dying from Congenital defects, prematurity and low birthweight, SIDS and placenta complications are all greater than the risk of a baby dying from a uterine rupture. All of the above risks are extremely rare but do happen so a woman needs to make a decision on what is the best way to have her baby based on her own individual needs and circumstances.

One of the greatest risk factors for a uterine rupture is inappropriate management of VBAC labour. Despite the fact that inducing and speeding up labour using oxytocic drugs have been proven to significantly increase the risk of uterine rupture whether you've had a previous caesarean or not, many obstetricians still routinely use these drugs to make the length of a labour more predictable.

Another risk factor is the quality of the surgery from a previous caesarean. Some surgical techniques may offer short term benefits but may increase the risks for future pregnancies. 

Many obstetricians have a policy of continuous monitoring and epidurals for VBAC labours and these too can increase the risks of complications. Epidurals can mask abnormal pain which may result from a uterine separation and continuous external monitoring does not necessarily pick up abnormal uterine activity but may result in a woman having a long labour due to being confined to a bed with restricted movement. Recent studies have shown that continuous monitoring does not improve outcomes.

There are strategies women can use to help optimise their chances of an uncomplicated birth. Learning about optimal foetal positioning and active birth, hiring a doula or a private midwife for labour support, declining unnecessary interventions, learning about non-medical techniques to relieve pain, exercising and eating well can all reduce the likelihood of a complicated birth or a repeat emergency caesarean.

Further information and support

If you have negative feelings about your baby's caesarean birth, you are not alone and support is available. The Maternity Coalition has produced a Births After Caesareans infosheet which you can download for free. Childbirth Connection also have a comprehensive booklet on the risks of caesareans and vaginal birth (including VBAC) which you can down load for free. Australian support organisations include Birthrites: Healing After Caesarean (WA-based) and Birthtalk: Support, Education and Celebration of Birth (QLD-based).

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