By Dr Rae Watson Jones, Obstetrician and Gynaecologist, Mount Lawley

Clinicians can be polarised on this question. Most private obstetricians will readily agree, and women often choose a private obstetrician to have this option easily available.  In the public system, there are generally more hoops to jump through.

Dr Rae Watson Jones

What are the typical reasons for the request?

For first-time mothers, these include:

  • fear of labour (tocophobia),
  • family pressure e.g. my mother and my sisters all had Caesareans, I don’t believe I can have a successful vaginal birth,
  • previous trauma or surgery to bony pelvis or hips (belief that she cannot extend her hips or tolerate lithotomy position),
  • chronic back pain (fear that labour will exacerbate symptoms)
  • believing Caesarean section is “more dignified” and controlled

For women not having their first baby, a common reason is a previous successful vaginal birth perceived as traumatic but with no ongoing physical complications.

Is there any problem with this request? One third of babies born in Australia are born by Caesarean section, above the OECD average and well above the WHO recommendation of 15%. This figure predominantly consists of women with a previous Caesarean section so efforts to reduce the rate are usually targeted towards improving the vaginal birth after Caesarean (VBAC) rate or preventing index Caesarean section. Proponents for reducing this figure argue there are long-term costs to women, the health system and the economy.

Advantages of a Caesarean section:

  • Risk of ending up with a Caesarean section after attempting labour and an elective Caesarean has less risk of complications than emergency Caesarean
  • Less chance of pelvic organ prolapse and urinary incontinence
  • No risk of perineal trauma
  • Planned procedure and controlled birth experience

Disadvantages of a Caesarean section:

  • Surgical complications (e.g. haemorrhage, bladder, bowel or urinary injury, wound infection)
  • Limit to family size (increased risk of complications with each Caesarean)
  • Slightly increased risk of stillbirth in future pregnancy compared with never having had a Caesarean
  • Risks of placenta praevia accreta in future pregnancy
  • Neonatal risks – transient tachypnoea of the newborn
  • An association with delayed cognitive development and childhood asthma compared with children born vaginally

A suggested approach to women requesting a Caesarean is to explore the reason for the request and have a frank discussion about the pros and cons.  Involving other clinicians (e.g. the GP, a second obstetrician), once the reason for the request has been elicited, is useful.   A midwife providing continuity of care during the antenatal period and labour may ease fears regarding labour.  A clinical psychologist can be consulted if there is a history of anxiety or depression or to determine if there is true tocophobia that may have a detrimental effect on the woman’s mental state during the antenatal or postnatal period.

By going through this process, the woman will be empowered in her decision-making and the obstetrician will have truly met the requirements of informed consent.

Key messages

  • Requests for non-medical Caesarean sections are more common today.
  • Women should be thoroughly informed of the pros and cons.

Author competing interests – nil relevant disclosures

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