Repeat caesareans under spotlight

Allowing women to make a more informed choice for their second birth might help reduce unnecessary surgery, writes Christine Catling-Paull.

In the developed world the topic of caesarean section often gives rise to an emotional debate. Some view the caesarean section with disdain and fear, whereas many women have caesarean sections as a matter of necessity.

Health professionals have a polarity of views on the subject. In truth, caesareans can be life-saving operations for many mothers and babies. However, never have the rates of a surgical technique increased so quickly in such a short time span than the caesarean section operation.

A third of women have caesarean sections in Australia. More than half of these are repeat operations, sometimes performed with no medical indication. Are women choosing to have caesareans to have their babies when, given appropriate care, they could avoid major surgery? It seems so, although like most things in life, there are other factors that influence these women's choices - some of which need addressing.

One of the main drivers of the increasing caesarean section rate is repeat caesareans. The alternative to repeat caesarean section is vaginal birth after caesarean.  However, some hospitals simply do not give women this option. Other hospitals present the risks of vaginal birth after caesarean in such a way that women are frightened of choosing this option.

Often women are terrified of labour because their previous experience may have been long and exhausting resulting in an emergency caesarean. These women need time and counselling to unpick their fears and truly make an informed decision about their next birth. They are simply not catered for in busy antenatal clinics.

It is easy to imagine that a lot of women believe an elective, planned caesarean section can sound like an easy, ordered and less stressful way of having a baby. However, it is unlikely women are given complete information about the risks regarding caesarean versus vaginal birth. It is likely that women are told about the risks of wound infection, thromboembolism, chest infections and that it can take six weeks to feel almost back to normal.

How many women are told that they are at increased risk of having babies with respiratory distress, having a subsequent stillbirth, may be less likely to conceive in the future or have a higher risk of placenta accreta or placenta percreta that can cause significant intra- and post-partum haemorrhage?

In addition, breastfeeding and bonding with their babies can be affected. Recent research would also suggest that mothers who had caesareans were less responsive to their babies. These issues are not often discussed with the women who think it is "easier" to have babies this way.

Many clinicians are wary of uterine rupture in women having a vaginal birth after caesarean. A recent Australian retrospective study of 21,389 women showed 0.02 per cent of participants suffered a uterine rupture. It is known that augmentation and induction of labour increases this rate. Because of this rare possibility, it is recommended that women undergoing vaginal birth after caesarean have IV cannulation, continuous fetal monitoring, and artificial rupture of the membranes, all of which can lead to a further cascade of intervention that can cause negative outcomes, including repeat caesarean section.

Some studies suggest women having a vaginal birth after a caesarean should be cared for like any other woman, and not undergo the stress of interventions - which would likely raise the vaginal birth after caesarean success rates. Rates for vaginal delivery after a C-section vary widely between institutions, but given the appropriate care, rates can be as high as 70 per cent. It is important to be aware of the factors that promote vaginal birth after caesarean, and also those that do little to help.

Clinical and non-clinical interventions that promote the uptake and success of vaginal birth after caesarean have been studied in our systematic review that included more than 700,000 participants. These found that non-clinical interventions such as guidelines, audit and feedback, and characteristics of clinicians can have a positive impact on rates.

Local guidelines that are owned by the institution and driven by clinicians also have a good effect on vaginal birth after caesarean uptake and success rates. Conversely, clinical interventions such as induction of labour using artificial rupture of membranes, prostaglandins and oxytocin infusions are often associated with lower rates. Similarly, X-ray pelvimetry and scoring systems should not be used in isolation to predict success rates.

It is vital that further work is undertaken to lower the rates of caesarean section around the world.

Given the potential adverse health risks to both mothers and babies, this should be a priority for all health institutions.

Christine Catling-Paull is a lecturer in midwifery at the University of Technology, Sydney.