The vaginal vs caesarean debate: Is it time we changed the default option for childbirth?

Gynaecologists in the UK are set to debate the current view of vaginal birth as the default option for childbirth. Kathy Donaghy asks if it's time we had a similar conversation in Ireland

Kathy Donaghy

When it comes to childbirth, there is no one way that suits everyone. For decades, vaginal delivery has been considered to be the best option, yet some experts may be having a rethink.

News that British obstetricians are to discuss the current view of vaginal birth as the default position could prompt a similar debate here too. In a recent article, obstetrician Mairead Black, who is also a clinical lecturer at the University of Aberdeen, argued that natural birth comes with its own risks, including tearing, haemorrhaging and incontinence for the mother and injuries for the baby during labour.

"So why is it that the vast majority of pregnant women are only being warned about the risks of caesarean sections?" she asked.

Black pointed out that this could now change as the Royal College of Obstetricians and Gynaecologists is to discuss the current view of vaginal birth as the default option for childbirth in the UK. "They will consider whether there is merit in routinely discussing the relative risks and benefits of vaginal birth and caesarean section with pregnant women. Such an approach would ideally provide balanced information for women to inform their birth plans," she said.

The caesarean section rate in Ireland is 26pc, although there are wide variations between different hospitals - from 19pc at Sligo General Hospital to 38pc at St Luke's Hospital in Kilkenny.

Caesarean rates are on the rise in developed countries and Ireland's National Maternity Strategy (2016) identifies a number of possible reasons for this - including "reductions in the risk of caesarean delivery, increasing litigation, increases in first births among older women and the rise in multiple births resulting from assisted reproduction".

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Despite the fact that the World Health Organisation's recommended rates are between 10 and 15pc, many countries, including the US and China, have rising caesarean rates. So, is it time we had a more open debate about all our birth options in Ireland?

Krysia Lynch, spokeswoman for the Association for Improvements in the Maternity Services Ireland (AIMS), believes it is. According to Lynch, the first time a woman gives any thought to what kind of birth she is going to have is when she goes into labour.

"There is no one-size-fits-all birth for all women," she says. "Each case needs to be looked at individually. For some women, the best choice is a caesarean section - and that may be because of a personal choice or due to emotional factors or physical issues."

Lynch gives the example of a mother who has had a very traumatic previous birth who may not wish to go through a vaginal delivery. "Even though, physically, everything might be fine, a woman needs to have that choice," she says.

In some cases, Lynch says women's decisions are influenced by caregivers who would prefer their patient's birth to go a certain way. "We would ask what kind of information these women are being given. And we would say that women should be trusted - give them the information and trust that they know what's best for them."

She adds that women seeking impartial advice should go to the website of Britain's National Institute for Clinical Excellence or the AIMS website.

Lynch's points are echoed by author and midwife Tracy Donegan. She says that while there is no doubt that a straightforward vaginal birth is preferred by most women, their midwives and consultants, for some women, birth isn't straightforward and can result in a life-changing perineal injury.

"My philosophy has always been that a positive birth comes in many forms and is defined by mum - nobody else. There are ways to reduce the risk of severe perineal injury (labouring without an epidural, avoiding forceps and not giving birth on your back), yet these are still common practices in many Irish labour wards.

Pregnant women need to understand the options available to them

"Even in the perfect upright birth, a baby can have his hand on his cheek which may be the cause of injury," she adds.

Donegan, who founded the GentleBirth programme and GentleBirth app to help mothers-to-be prepare for their baby's birth, says it's so important that women are provided with clear information on the risks of both vaginal and caesarean birth, based on their individual risk level so they can make the best decision for themselves and their baby.

"Research suggests that midwifery-led care is associated with less perineal injury, but unfortunately, not all Irish women have access to midwifery-led care through their pregnancies and won't know their midwife on the big day," she explains.

"Making informed decisions doesn't always mean having access to the care mum is requesting. Most hospitals will not support a first-time mum to choose a caesarean birth if she is a public patient so there's a much bigger issue to consider.

"Maternity services are already over-stretched and understaffed, which means policy-makers would also need to provide for an increase in staff and services to manage an increase in planned caesareans to ensure safe care can be provided to all women giving birth in Ireland."

It doesn't help that birth choices are already fraught with anxiety, adds doula and birthing expert Lisa Wilkinson. She believes we need a new language to help build the confidence of women in birth.

"Everyone who works with pregnant women understands that fear and adrenaline stalls or stops labour by reducing oxytocin, the hormone that drives our labours," she says.

"Instead of risk, let's talk about chance. Yes, there are small chances of problems happening in labour, but these chances are minimised with the right kind of care for mothers," says Wilkinson, who founded the Elbow Room, a yoga and pilates centre in Dublin.

"All the evidence points to one midwife with one woman - midwifery-led care is proven to have the best outcome. And all the evidence points to removing the arbitrary time restrictions on both birth and pregnancy. The idea of labelling birth with a "default option" is nonsense. Every woman's birth should be through informed consent," she adds.

Wilkinson says while there are chances of labour not progressing or mothers and babies getting into difficulties that warrant medical intervention, these problems are largely caused by the medical model of active management of labour and routine inductions before babies are ready to be born.

"These procedures, often presented as necessary, are pressurised onto women without explaining the chances of further interventions or the contra-indications of the drugs being used. In this instance, the women do not get the whole picture. Their consent is not given with all the correct information," she continues.

"This brings us into the cascade of intervention - where one procedure often leads to another, all cascading towards a C-section. Where in fact the problem was not a failure on the woman to give birth, but a failure of caregivers to wait and give the right support."

Deciding between vaginal birth and a caesarean is a matter of choice - but women need to be given impartial information that allows them to make the right choice for them.

A gentle introduction

In April of this year, a new approach to caesarean birth was introduced at University Maternity Hospital, Limerick. According to the HSE, the "natural caesarean" - otherwise known as a gentle or slowed-down caesarean - puts maternal choice and control at the heart of the procedure and, critically, allows for earlier and more prolonged contact between the mother and baby in the first moments after birth.

The HSE says the technique attempts to replicate as closely as possible the natural delivery and aims to ensure that it is the mother who is the first person to hold the baby. While research into the natural caesarean is ongoing, the technique is believed to have considerable benefits around easier breastfeeding, calmer infants and greater maternal satisfaction in the short and long-term.

The HSE says one of the strategy's core ambitions is to give women more choice and control over how their pregnancy and delivery is managed. Gentle caesarean involves some simple changes which can make a significant difference for the mother. Heart-monitoring wires are placed on the mother's upper back to allow the obstetrician to place the baby on her chest.

The woman's non-dominant hand is used for IV and bloods so that the dominant hand is free to hold the baby. The screen between the woman and the surgical team is lowered so the woman can see the baby being born.

In a technique called 'walking the baby out', the baby is allowed to clear its lungs by itself and push itself out. And in this way, the mother gets to find out the sex of the baby without having to be told by one of the surgical team. The baby can be placed directly on the mother's chest and skin-to-skin contact is immediately established in those precious moments after birth.