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Jul 23

Vaginal birth vs Caesarian Section – there’s a debate?

A very interesting article from New Scientist has been doing the rounds and stirring up a lot of controversy in Women’s Health and Midwifery circles.

Have a read of it, and then we can discuss it ….

 

 

All good? Now, I have a few issues with this article. It is written in extremely emotive language. It described vaginal birth as being ‘in vogue’. Really? It’s fashionable to birth vaginally? You’re not keeping up with current trends if you require a Caesarian (CS)?  Is it just a clickbait article?

Statistics quoted in the article appear to be poorly substantiated . When we look at Cochrane data (current best practice guidelines), the stats are woefully misrepresented. The author, Clare Wilson, says that 9 in every 10 women sustain a vaginal tear when they deliver vaginally, citing a smaller study in SE England. The Cochrane research says that episiotomy rates when they do them only when it seems necessary is around 28%, compared to policies in some places where an episiotomy is routine, so occurs in 75% of deliveries. A recent report from the NHS (given the article was written about the British system, I’ll reference the British system to keep the argument sound) showed ‘perineal laceration during delivery’ rates of 40.2%. This includes any stitching at all – a single stitch, up to many stitches. Tearing / laceration was the most common complication of a vaginal delivery in the NHS. ‘Maternal care for known or suspected abnormality of pelvic organs’ (53.2%) was the most common complication of CS. They also quote an 8% episiotomy rate for spontaneous labour.

She goes on to suggest that a small vaginal tear through mucosa only (no muscle) is worse than a surgical incision through skin, fat, 4 layers of muscle, fascia, uterus and then stitching through all of those layers. Don’t get me wrong, I am exceedingly glad that we live in a time and a place where CS is an option, and where the medical risks of birthing can be managed. But is it inherently a medical condition?

Pregnancy is a risky state.  There can be significant weakening of the pelvic floor musculature and stretching of the other soft tissues through pregnancy itself.  A CS does not protect 100% against later pelvic floor dysfunction such as incontinence or pelvic organ prolapse, as evidenced by the authors statistic of a 29% rate 20 years after a CS compared to a 40% rate for vaginal deliveries.  Rates of these are higher amongst women who have a vaginal delivery, moreso if it has been a long second (pushing) stage, the baby is larger than 4000g or if instruments (ventouse or forceps) are required to delivery the baby.

 

I think what bothers me the most, is that this is an opinion piece published in a scientific magazine, that does not appear to have much scientific basis. Pregnancy and labour can be a fairly stressful time for many women, especially in this age of so much contradictory information, so I consider this piece to be quite irresponsible.  In the first couple of sentences, she refers to birth as a medical event, which I find unsettling.  It seems to take any decision making away from the woman – leave it to the wiser doctors.

I completely agree that better informed consent should be occurring in many settings. Many women are not aware of the risks, and are collating much of their information from the internet, with out necessarily appreciating how accurate the information presented is. It is the role of all care providers to inform our patients of any risks, to discuss those risks with reference to current statistics, to the best of our knowledge. Birth is a wonderful, wonderful experience. Meeting your child for the first time, adding to your family unit – it’s wonderful. And we have been doing it for millennia. There are risks with everything we do – walking down the street, driving, having an Xray, being vaccinated, falling pregnant. It is important that we do understand and accept those risks, and then make the best decisions we can.

 

What do you think?