Health: Don't let fear drive mothers to the scalpel

Are women who opt for Caesarean section labouring under a delusion?
WHEN LUCY Turner found herself pregnant with her first child three years ago her thoughts, like those of most mothers-to-be, turned to the birth itself. As a midwife, Turner knew more than most about what lay ahead. Which is why, she says, she had no hesitation in going to see her obstetrician at the earliest opportunity to request an elective Caesarean.

"There was no medical reason why I was putting myself forward for a Caesarean - all I knew was, I definitely didn't want to go through labour," says Turner, who is now 36. "I was worried about the pain, I was concerned about the possible damage to my pelvic floor, I was concerned about the chance of an instrumental delivery. A Caesarean seemed the perfect answer." Some obstetricians would have tried to talk a woman out of such a decision, but Turner's didn't - and her daughter Annabelle was duly delivered by section.

The decision was, she says, absolutely right for her - and when Annabelle's brother Jack came along four months ago, Lucy had no reservations at all in opting once more for a surgical delivery. "To be honest, I can't think why anyone wants to do it any other way," she explains. "You know in advance when it's going to happen, it was a lovely experience for both me and my husband, and pain relief after the delivery was very good indeed. It didn't even mean an over-long hospital stay - I was in on a Monday and back home by Wednesday.

"Worries have been raised about whether you bond with your child so well if you have a section, but that's absolute codswallop. In fact, if you have to go through a long-drawn-out labour I think that's more likely to interrupt bonding than a planned Caesarean."

Turner's choice is an unusual one - particularly for a midwife - but, according to a recent report in the British Medical Journal, it's one that more women should be given the chance to make. That's the view of Sara Paterson-Brown, consultant obstetrician at Queen Charlotte's and Chelsea Hospital in London - and Turner agrees wholeheartedly. "After all, women have choices about prenatal diagnosis and about whether to go for a home or hospital delivery," she says. "Why shouldn't they have the chance to opt for a surgical delivery as well?"

Over recent years the number of Caesarean sections in Britain, as in the United States, has been rising steeply; one in six deliveries is now carried out this way. The rise has been linked to an increasing tendency on the part of doctors to jump in with the scalpel rather than wait to see the course a labour takes - if anything indicates a baby is in distress, a Caesarean is believed by many obstetricians to be the quickest and safest way of ensuring the baby's safety.

But while the majority of sections are so-called "emergencies", opted for after labour has already started and when a vaginal delivery seems dangerous or impossible, a proportion are "electives", opted for before the event by the parents in consultation with their doctor. It's not known exactly how many Caesareans in Britain are electives, although most of them are decided on because of some medical indication that labour may not progress normally - typically, because a previous delivery ended in an emergency section.

That's how it was for Julia Pollard, 36, of Farnham, Surrey, whose first son, George, was born by Caesarean. "It was a scary experience," she remembers. "George got stuck in the birth canal, and they decided they'd have to operate. One minute the delivery was calm and collected - the next the room was full of people ripping bags open and scrubbing up. I had panic attacks for some time afterwards.

"When I got pregnant again with Joe, who's now 18 months old, I was keen to avoid that kind of experience again. The doctor said I could have what they call a "trial of labour", in which we could go ahead with a normal birth and see what happened, but I was terrified it would end the same way as with George. So I opted for an elective section, so we at least knew what was going to happen and could plan ahead."

Pollard says she wouldn't have chosen a section without strong medical evidence that a vaginal delivery would be difficult. "Even though I knew what was going to happen with Joe, it was a scary experience. Given the choice, I'd have had a normal delivery - you're up and about so much more quickly; [after a Caesarean] you can't drive for six weeks afterwards. And the pain is bad - I could only just walk, with difficulty, five days after my sections."

Yvonne Williams, who runs the Caesarean Support Network, says most women who elect for a surgical delivery do so for reasons like Pollard's - she believes the number of women who would choose a section for convenience, or because of worries about damage to their bodies from a vaginal delivery, are few and far between. "It's four times safer to have a normal delivery than a section, and the length of time of recovery is longer," she says. "The effects of the anaesthetic can drag on for some time, and I don't believe it should ever be a woman's first option. I think women who want to make this kind of choice are often motivated by fear, which to me seems a shame."

And electing for a section to avoid pelvic damage doesn't always pay off, according to Jane Newman, an obstetric physiotherapist at the John Radcliffe Hospital in Oxford. "The most important thing as far as long- term damage is concerned is the management of the delivery, and the management of the patient afterwards," she says. "We see just as many complications attached to Caesarean deliveries as to vaginal ones - it doesn't follow that you'll always avoid problems if you have surgery."

That doesn't, though, seem to be the prevailing information getting through to pregnant women. Tracey Johnston, an obstetrician at St Mary's Hospital in Manchester, says more and more women are now requesting a section for non-medical reasons. "It's a trend that's coming in from the US, where women are often offered a Caesarean to keep themselves `honeymoon fresh'," she explains. "What's vital, though, is that obstetricians talk the whole thing through carefully with the woman concerned. Often there's an irrational fear that can be overcome through counselling, and she will go on to have a normal delivery and be perfectly happy with it."

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