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Is Caesarean the right choice?

When I was expecting my first child, I did not really have a birth plan. I didn’t know if I wanted a Caesarean-section (C-section), a drug-free labour or one aided by as many anaesthetic options as a woman in labour can have. I thought, When the time comes, doesn’t your body just do what it has to? And if it doesn’t, won’t the doctor do what he has to? In November 2009, I delivered a healthy 3.5-kilogram baby boy with epidural and vacuum assistance after almost 16 hours in labour. To me, the vaginal delivery was just what I expected. Of course, not every expectant mother can have a natural birth. There are many conditions that may warrant a C-section: prolonged and ineffective labour, placenta previa (when the placenta is abnormally low in the cervix), abnormal presentation (when the baby is not in right position), pro-lapsed cord (when the umbilical cord precedes the baby in the birth canal), and medical problems such as diabetes, hypertension, cardiac disease or ovarian and uterine cysts. In such cases, the obstetrician may call for a C-section in order to save the mother and her child. An elective C-section is when there are no compelling medical or health issues faced by mother or baby. While it’s generally accepted that C-sections are now safer – and more significantly, better techniques and monitoring of anaesthesia have made serious risks and complications somewhat rare – it remains a major abdominal surgery that comes with all the associated risks. There are many reasons cited by mothers who opt to give birth by C-section. According to Dr Ho Hon Kok, Consultant Obstetrician and Gynaecologist at Mount Alvernia Hospital, Singapore, it ranges from the psychological – fear of child-birth, to the physical – concern with pelvic floor trauma and later problems of prolapse and incontinence, and fear of reduction or loss of sexual enjoyment. Some may also schedule a C-section for the sake of an auspicious date, time and horoscope for the child. In some cases, doctors are the ones who prefer and recommend a Caesarean section delivery as the procedure can be planned in advance and also it avoids unforeseen circum-stances that may take place during natural delivery. These are some of the reasons that have contributed to the high C-section rates in Asia and around the world. According to the World Health Organization (WHO), almost half of all births in China are by C-section, of which 25 percent were not medically necessary. The WHO survey, which reviewed over 100,000 births across Asia, found that countries like Vietnam and Thailand are also seeing increasing rates of Caesarean births. Pros and Cons

Pros and Cons

Elective C-sections afford convenience – mothers have greater control to plan childcare and work leave and it is relatively quick compared with vaginal birth. Mothers are likely to be less stressed, as there is no labour pain and no fear of an episiotomy (incision on the perineum). The disadvantages, however, are unsettling. Mothers bear the risk of surgical complications that may damage the bowel and the bladder and cause chronic pain, increased maternal blood loss that may require blood transfusion, infection of the uterus and pain at the incision site that may persist beyond six months, internal scar tissue that may affect future fertility, discomfort that may hinder successful breastfeeding and a possible increased likelihood of postpartum depression. Caesarean babies also bear the risk of preterm delivery, as it is difficult to determine exactly the date of conception. C-sections are likely to take place around 34 to 36 weeks of gestation, and though it’s generally safe to deliver by then, these babies are more likely to have medical problems than babies delivered at full term (37 to 42 weeks). Health issues may include breathing difficulties, problems feeding and maintaining body temperature. They also risk lower Apgar scores (a scoring system to evaluate a newborn’s physical condition) and have a slightly greater risk of respiratory problems like transient tachypnea (type II respiratory stress syndrome). Medical journal, The Lancet, says the reduced risk in C-section births were only if they were medically recommended. Elective C-sections are more likely to result in greater risks for both mother and child.

Nature’s Way

While I can understand the concept of a more liberal patient centred choice when it comes to method of delivery – or any medical procedure for that matter – the pertinent issue here is whether or not mothers know enough to make an informed decision. There are continuous studies on the advantages of natural birth and some reveal interesting findings. Babies delivered naturally travel through the birth canal and acquire about 100 species of microbes like Lactobacillus, known to help milk digestion. These important microbes are transferred to the baby during delivery and match those of the mother’s vagina. The comparison study showed that the skin, noses, mouths and rectums of babies born via C-section had strikingly different bacteria than babies delivered naturally. The report adds to the evidence that C-section babies may be missing out on beneficial bacteria passed on by their mothers via the birth canal. What the research team from the University of Puerto Rico, the University of Colorado in Boulder and two Venezuelan institutes found instead was potentially nasty bacteria such as Staphylococcus and Acinetobacter, typically found on the skin and in hospitals, in C-section babies. While recognising the fact that C-sections can be lifesaving in some cases, the procedure does affect a baby’s first bacterial community, which may affect future health. Research has suggested that babies delivered by C-section are more likely to develop allergies, asthma and immune system-related problems than babies born the natural way.

Bonding Matters

A study by Yale University compared the brain scans of mothers who’ve had vaginal delivery against those who elected Caesarean births, and showed the latter had lesser activity in brain centres related to mother-baby bonding. A possible explanation could be that C-section mothers could be missing out on the hormonal ‘priming’ for motherhood. During the process of natural delivery, the hormone oxytocin is released and is responsible for prepping the mother for bonding with the baby. The absence of the hormone in C-section mothers may provide clues to the possible increased risk of post-natal depression. However, James Swain, leader of the Yale study, said that the study is not aimed at discrediting C-section births, and expectant mothers who need the procedure for medical reasons need not panic because of the findings. The study, however, could help identify mothers who may be more predisposed to low maternal ‘priming’ so they can get the relevant help in preparing for the baby and preventing possible depression.

“My advice for expectant mothers contemplating elective Caesarean section is to plan a frank discussion with their obstetrician early in their antenatal care. This way the risks and benefits of anaesthesia and surgery, lactation and neonatal considerations can be properly deliberated before the intended C-section,” says Dr Ho. Mothers-to-be should evaluate all the information in order to decide on the best birth plan. While we should be thankful that medical advancement in childbirth can save lives, let’s not forget that pregnancy is a natural thing and unless medically recommended, it’s best to have it as nature intended.

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