More Australian women are opting for a caesarean delivery and one specialist has even predicted that by the end of the decade, more than half of all Western women will choose to give birth that way. However it's a risky procedure. Peta Newbold reports.

Giving birth is an extraordinary experience that's unique to every woman, every time. Some women labour long and painfully, while others just seem to 'pop them out'. To a certain extent each woman's body determines the kind of birth she'll have but there are still choices she can make. There's public versus the private health system, pain relief or none, vaginal delivery and increasingly, elective caesarean.

Back in the dark ages

Historically there was no choice in childbirth. Babies were born vaginally and caesareans were only performed when the mother was dead or dying. However one popular myth traces the origin of the caesarean back to the surgical birth of Julius Caesar. Nice story except that his mother Aurelia is reputed to have lived to hear of her son's invasion of Britain!

In the early years of this century, caesarean sections were still very risky, but today with better anaesthetics and antibiotics, they're being performed in as many as 20 per cent of Australian births.

Too many caesareans?

To put that into perspective, the World Health Organisation (WHO) states that no region in the world is justified in having a caesarean rate greater than 10 to 15 per cent and many countries including Australia are now actively trying to bring their spiralling figures into line.

Reasons for elective caesareans

• Breech births Babies born bottom first are at greater risk than those born in the normal position of head first. Australia's Cochrane Collaboration reviews medical evidence to discover the most effective medical practices. It has just published a systematic review that found that planned caesarean deliveries for breech babies greatly reduce the risk of death for the baby but slightly increase the risk for the mother.
• Older mothers Sydney obstetrician Dr Keith Hartman told the ABC's 'Lateline' programme, that he believes Australia's high rate of caesareans is due to women giving birth later in life, and wanting more medical intervention to avoid any risks.
• Repeat Caesarean One of the risks of having a baby when you've had a caesarean section in the past is that the uterus may tear so many women believe it's safer to opt for a second surgical delivery. Now a US study published in the New England Journal of Medicine (2001 vol 345 pp 3-8) has come up with some facts that may help women decide.

It followed 20,000 women who had a caesarean the first time to see what happened during their next birth. It found that the risks of having a subsequent baby normally is very low with up to 3000 women needing to have an elective caesarean to protect one baby.

Interestingly, even women who didn't go into labour and had another caesarean section had a risk of a uterus rupture. It wasn't much though - about two women per thousand and just going into labour naturally raised the risks a little - to five women per thousand.

One of the key factors that emerged is whether the labour is being induced, and with what drug. Being induced with the commonest drug used in Australia - oxytocin - raised the risk a little more, to nearly 8 per thousand.

But the biggest risk of all - 24 women per thousand - was with the use of prostaglandins. So the message is that if you are being induced, ask what's in the drip.

• Busy lives Senator Rosemary Crowley, Chair of a Senate Inquiry into Childbirth Procedures said that women were demanding 'caesars' to fit in with their busy lifestyles. Also:
• Doctor's convenience She added that sometimes doctors were doing caesarean sections because "you could be clearer about the timing of them."

Risks of vaginal delivery vs. caesarean section

Caesarean birth is major abdominal surgery and there are risks are involved but the figures vary greatly. Some show that the estimated risk of a woman dying after a caesarean birth is less than 1 in 2,500 compared with the risk of dying after vaginal birth of less than 1 in 10,000.

However a leading UK specialist, Nicholas Fisk, Professor of Foetal and Maternal Medicine at London's Queen Charlotte's and Chelsea Hospital, disagrees.

According to news reports he told delegates at the Perinatal Society of Australia and New Zealand's Annual Congress in Canberra last year that for many women, the risk of Caesarean versus vaginal delivery was finely balanced.

He said that vaginal delivery is:

• The major cause of incontinence and prolapse in women.
• Also associated with stillbirth before labour and delivery, death of the foetus during labour and delivery and cerebral palsy.

He added that such risks have traditionally been considered acceptable, but are arguably greater than other risks society rejects such as drink driving or riding a motorbike without a helmet.

"Patient choice is all important in maternity care and, given this, I believe efforts to reduce Caesarean deliveries are doomed,' Professor Fisk added.

However, Associate Professor Alastair MacLennan, Director of Obstetrics and Gynaecology at the Women's and Children's Hospital in Adelaide, at the same conference, said their research showed that Caesareans did little to protect women from post-pregnancy problems, such as prolapse and incontinence.

Caesarean delivery: other risks

• Infections, haemorrhage, transfusion, injury to other organs,
• Anaesthesia complications
• An elective caesarean section increases the risk to the infant of respiratory distress syndrome, and multiple complications, leading to intensive care and heavy financial costs.
• Longer hospital stays.
• Even mature babies, the absence of labour increases the risk of breathing problems and other complications.
• Delayed breastfeeding and bonding.
• Post natal depression.

In the end the decision about a vaginal or surgical birth should rest with each woman and her doctor.

One mum's experience

Sydney mum, Isobel Brown has two children, a 10 year old born by vaginal delivery and a 7 year old born by emergency caesarean section. She said that if she had any more children she would choose to give birth by caesarean section.

"My first labour was more than 36 hours long and it was without doubt the darkest time of my life," she said. "The second labour seemed to be dragging on in exactly the same way when the baby became distressed. It was an enormous relief when I was offered a caesarean and I found the whole experience was brilliant.

The baby was very big but healthy, I was home in three days, we bonded well and I breastfed him for five months. After that I'd say a caesar's the way to go."

That's worlds apart from Senator Rosemary Crowley's view however. She is also a GP and she told ABC Radio's PM programme, "This is becoming a culture, a practice that people expect to have this high rate of caesarean section.

We believe it's an expensive, misappropriate use of very scarce resources and importantly not the best way for a baby to be born. On medical evidence provided to the Committee, it's better if the baby can be born vaginally."

_____________________________________________________________ References:

ABC Online

Cochrane Collaboration

Childbirth.org