Caesar versus vaginal
Vaginal delivery is associated with the risk of urinary and faecal incontinence. Urinary stress incontinence affects up to 33% of women three months after delivery, with most cases resolving spontaneously. But one study from Australia showed no difference in stress incontinence in women undergoing an elective c-section or a vaginal birth. It is not clear if it is the pregnancy itself or the birth process that leads to the pelvic floor dysfunction. Relaxin, a pregnancy hormone, may cause excessive relaxation and remodelling of the tissues and subsequent incontinence.

Faecal incontinence however is a very significant problem and is strongly associated with a vaginal delivery. Most studies show that faecal incontinence and anal sphincter damage is related to a prolonged second stage, instrumental deliveries, especially a forceps delivery, increased maternal age, a second vaginal delivery and a large birth weight of more than 4kg. Vaginal delivery, especially if there has been a tear or episiotomy, is more frequently associated with painful sex post-delivery. However this problem may also be due to hormonal changes causing vaginal dryness.

The other patient – the foetus – must also be considered. Having an elective c-section will prevent the small risk of a foetus dying during labour (1 in 1 561). The risk of foetal injury is also much less with an elective c-section than a vaginal birth, especially if an instrumental delivery is needed. On the other hand, having a c-section is linked to an increased incidence of placenta praevia (low lying placenta) and placenta accreta (adherent placenta) in future pregnancies, with the incidence rising with the increasing number of c-sections performed.

In babies born by elective c-section, there is an increased risk of neonatal respiratory distress syndrome. This may be due to the baby being denied the physiological stresses of labour or the lungs may be immature. Studies show that all truly elective c/sections should be performed at 39 weeks to avoid neonatal respiratory complications.

Giving women the choice
"Is it appropriate to perform a caesarean section on request without a medical indication?" The answer is yes, provided the couple are properly and fully informed of all the benefits and risks associated with each delivery method. Women who feel in control of their childbirth are more satisfied and have a greater emotional well being postpartum. Those delivered by an elective c/section have less negative feelings towards their birth than those delivered by an emergency c-section. Thus women who have an elective c-section appear to be better counselled and prepared for the birth.

The evidence, although incomplete, shows that both vaginal and caesarean births are not without risks. Our challenge therefore is to provide the best data available regarding the potential risks, benefits and consequences of the various delivery methods to help women make the best choice for themselves. We need to be able to predict which labours will have an adverse outcome and thus reduce the need for emergency caesarean sections. We need to listen to what informed women want. There must be an interactive partnership between doctors and patients and maximum maternal satisfaction for the least risk.

Once a caesarean always a caesarean?
This should be replaced by "Once a caesarean, always a hospital delivery". For many reasons, some women will attempt a VBAC (vaginal birth after caesarean section) and 50-70% will have a successful vaginal birth. However there are risks that every woman must be fully aware of.

A recent study by Lyndon-Rochelle of over 20 000 women in Washington who had a previous caesar showed that, in these patients, the overall risk of rupture of the uterus was 4.5 per 1000. For women not in labour the risk of rupture was 1.6 per 1000 and for women in spontaneous labour the risk increased to 5.2 per 1000 (3.3 times higher). In the event of induction with prostaglandins, the risk was 15 times higher. Foetal mortality was 10 times higher.

So if a woman wants a VBAC she needs to be fully informed of these complications and even sign an informed consent document. Some women will not be prepared to take any risk whatsoever and others will say that having a vaginal birth outweighs the small absolute risks of a uterine rupture. Protocols should be in place to deal with any emergency. There must be facilities to deliver the baby within 15-20 minutes to avoid neonatal neurological problems. There must therefore always be an obstetrician and an anaethetist present in the labour ward at all times. Because of these requirements and the fear of litigation, the incidence of VBAC is steadily declining.