Unfortunately not all births go to plan. Many women require a caesarean on medical grounds after labour has commenced—either because the baby is “stuck” or because baby is stressed by the labour process. Sometimes, a caesarean is planned to occur prior to labour beginning for the safety of either baby or mum.
For women who have a choice with regards to whether they have a caesarean or a vaginal birth—know that it is your decision.
It is your body, it is your birth and, as long as you understand the risks and benefits of both modes of delivery and you’ve had a detailed discussion with your health care provider—then really it is up to you.
Benefits and risks of a vaginal birth
In broad terms, having a vaginal birth may be associated with a quicker recovery, a shorter hospital stay and reduced risks in any subsequent pregnancies for those babies and their deliveries.
But there are still some risks including:
Needing an emergency caesarean
The risk of needing an emergency caesarean in labour is about 20 per cent. Most emergency caesarean sections do not involve lights and sirens or teams of people shouting. Most emergency caesareans are planned to occur within an hour of making that decision and are performed in quite a relaxed manner.
If you need a caesarean in labour, it is more risky than having an elective c-section, but only marginally. It’s associated with an increased risk of infection and bleeding for the mother as well as an increased risk of damage to internal organs which is rare.
Needing a vacuum or a forceps delivery
Around 15 percent of women require an “instrumental delivery” which means the use of a vacuum or forceps at the end of labour. Instrumental deliveries are recommended when babies get stuck or stressed just prior to them being born when a woman’s cervix is completely dilated.
For baby, having an instrumental delivery is generally very safe. Most babies born this way will have temporary marks from the device used, however a very small amount may experience more significant bruising, hemorrhage or nerve injuries—most of which are temporary but may require further monitoring in the nursery.
For mum, having an instrumental delivery increases the chance of having a larger tear that may extend to the bottom muscles (see below). It is for this reason that an episiotomy is recommended for first-time mums having an instrumental delivery. The episiotomy in this instance is performed to reduce the risk of damage to the bottom muscles.
An instrumental delivery may also increase the risk of long-term pelvic floor problems like prolapse or incontinence.
So around 65 per cent of women will get exactly what they want when they go into labour—that is, a vaginal birth without assistance.
It would be lovely to be able to predict which women will enter labour and deliver without the use of instruments or an emergency caesarean. Unfortunately, there is no good formula to figure out prior to labour which mums will need these procedures.
A tear in the muscles around the vagina
Of the first-time mums who deliver vaginally without instruments, seventy per cent will have a second degree tear, which is a tear into the muscles around the vagina. This type of tear generally heals quickly and without long-term pain.
Stitches are placed that dissolve away within one to two weeks so you don’t have to have them taken out. Icepacks and simple analgesia like paracetamol and ibuprofen work very well for any discomfort.
Three to five per cent of new mums will sustain a third or fourth degree tear. This is where you have damage to the muscles surrounding the anus. In this instance most women do well, but a good repair (usually in the operating theatre) is required to reduce the risk of long-term anal incontinence. Follow-up physiotherapy is recommended after this kind of repair, and for some women, referral to, and further treatment, by a colorectal surgeon may be required.
It is important to know that there are ways we can reduce tears and it’s important to ask your health care provider about your individual risk.
Risks to the baby
Some babies born vaginally experience minor injuries such as bruising, hemorrhage, abrasions or temporary nerve injury.
The risk of vaginal birth causing long-term injury to a baby is very rare though—three in one thousand.
Around 5000 caesareans would need to be performed to avoid one case of cerebral palsy caused by birth.
What are the risks of an elective caesarean
Women who choose to have—or medically need to have—a caesarean before labour begins, should know that it’s generally a very safe procedure.
There is a slight increase in the risk of bleeding at the time of delivery however only about 1 in 50 women will need a blood transfusion.
There is a small increased risk of infection and therefore antibiotics are given at the start of the procedure to reduce this to about 3 in 100 women.
Risks to the baby
The most common risk to baby from a planned elective caesarean is having some retained lung fluid.
While babies are in the womb their lungs are like sponges—they are full of amniotic fluid. When babies are born they need to take a big deep breath in and start crying to push all of that fluid out of their lungs so their lungs can bring in air.
Around 3 in 100 babies that have not been through a labour and are born by caesarean section will have difficulty removing that lung fluid. The risk of retained lung fluid increase with every week earlier that we deliver babies via caesarean.
For mum, there is a slightly higher risk of having period problems after a caesarean because of the scar of uterus. They may be more heavy, prolonged or painful. Some mums may have a slight reduction in fertility after a caesarean section.
The most serious risk for mums after a caesarean is that they may experience a rare condition in the next pregnancy called placenta accreta. Placenta accreta is a very serious condition that can occur in a subsequent pregnancy. It is where the placenta sticks down over the old caesarean section scar on the uterus and become stuck to the uterine muscle. It means that the placenta will not be able to be removed from the womb after delivery of the baby, and this can cause life-threatening bleeding.
Women who have a placenta accrete need early delivery—most around 35-36 weeks and need to have a hysterectomy (removal of the uterus) at the time the baby is born. Thankfully placenta accreta is rare. The risk of this happening is about 1 in 300 if you’ve had one previous caesarean and that increases for every caesarean you have.
So if you’re planning to have a whole football team of children—5, 6 or even 10 babies—then it makes sense to try to avoid a caesarean section in the first instance. If you are planning a family size of two to three then it probably is not going to make too much of a difference in terms of your long-term family plans.
Whichever mode of delivery you need, or choose to have, remember that this is just one day in yours and your new baby’s life. What comes after birth is even more incredible—watching a little human grow into someone with personality and independence is such an amazing experience. Whilst the “birth day” is a very important day, the end goal for birth should always be that the parents feel informed about their birth choices, that they feel supported, and that they feel—and are—safe.
As always, women should ask lots of questions of their health providers. A personalised discussion of the risks and benefits of both kinds of birth should be given so an informed choice can be made.