Exhaust or sun roof?

Such was the query from my friend Mark who having recently had a baby himself (well his wife had) was well versed in the various escape route options for babies from their mothers. And just in case his analogy was too subtle – the question was whether I was planning to have a vaginal birth or caesarean!
An American friend was blindsided that there was even a choice in the matter and that it wasn’t something determined by the obstetrician or dictated by the cost restrictions of the NHS (vaginal birth is £800 cheaper than caesarean birth). But a choice it is per the latest NICE guidelines and the reason for that seemed to boil down to there not being enough evidence that the costs involved in supporting the mother’s mental health if denied a caesarean would not outweigh the £800 saving, and that one study showed that women who had an elective c-section had a significantly higher satisfaction score with their birth experience birth two days and three months after the birth. Elective c-section also provides the mother with a degree of control over when her birth happens, involves less if any labour pain and obviously vaginal injury is highly unlikely, so there are benefits to it.

Despite the choice, the numbers for elective c-section remain low. The rate of preference for caesarean in the UK, Australia and Sweden ranging from 6-8%.

There is another category of women – those offered a planned c-section because it will be less risky than vaginal birth. The cases that NICE recommend offering a planned c-section for are:
– the baby is breech and external cephalic version has failed or is contraindicated
– placenta praevia, where the placenta fully or partially covers the cervix (cutting off the exit for the baby)
– twin pregnancy where the first twin is breech
– mothers who have a primary genital herpes simplex virus infection in their third trimester
– mothers with HIV who are not receiving retroviral therapy, have hepatitus C, or a viral load greater or equal to 400 copies per ml

As babycentre explains, caesarean births tend to be higher risk than vaginal births, largely because it’s a major abdominal surgery, with longer recovery time, higher risk of infection, blood clots, adhesion (scar tissue which makes your organs stick together or to the abdominal cavity, affecting about half of women who have caesareans), side effects from the anaesthetic, as well as more serious complications requiring intensive care, hysterectomy, further surgery, or bladder injury. There are also risks to the baby, as explained by the American Pregnancy Association, such as breathing difficulties, premature birth (if the birth date has been miscalculated), and injury (e.g. a nick from a scalpel). And there are further risks as they grow up, with studies showing “increased risk of asthma, food allergies, celiac disease and type 1 diabetes” that a recent study believes is due to babies born by caesarean missing out on crucial bacteria (bacteroides for the science geeks) injested during the journey down the birth canal.

Despite this, the rate of caesarean in the UK is 25%, up from 9% in 1980. The difference in these numbers causes a lot of consternation and commentary about women being “too posh to push” and the medicalisation of birth, which may be true but, as Kirstie Allsop argues (slowly becoming Britain’s Martha Stewart without the jail sentence), this should be balanced against the increased likelihood of c-section that results from women generally being older and fatter when they give birth than they were in 1980, and more likely to have had medical intervention in the pregnancy, such as IVF that increases the likelihood of multiple births.

Another unexpected choice for the mother is the right to refuse a c-section even when recommended by their medical team. If the alien remains breech and I don’t want a c-section then I can elect to have a breech vaginal birth, so long as the medics have explained the risks to myself and the baby and I have determined that even knowing these I still want to proceed with a vaginal birth. Personally, I think this level of choice is a good thing – it’s my body and my baby, I should have the right to determine what happens to it, however foolish the decision might be.

At this stage, I’m keeping an open mind – the important thing is a healthy mother and baby at the other end, and I suspect I will make whatever choice I need to to increase the likelihood of that happening, even if it means a c-section.

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