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Ideal gap between caesareans – new research

A new study by Soroka University indicates that there may be reasons, other than risk of scar rupture, why a longer interval between caesarean births is ideal. Up to now recommendations have suggested that a gap of 15-18 months or more be planned to reduce the likelihood of scar rupture during subsequent pregnancies. However Kessous et al discovered during their review of 3176 births between 1988 and 2010 that in fact scar rupture was no more likely in any of their groupings (less than 12 months, 13-18 months and more than 18 months gaps).

However they did find an increased likelihood of premature birth in the group of women who had a second caesarean within 12 months of the first. This risk was 12%  whereas those who waited longer had only a 5% risk.

Premature birth has significant implications for baby in particular. Low birth weight and the immaturity of baby’s lungs are just two of the complications that can occur and the earlier the baby arrives the more likley they will need assistance in a SCU (Special Care Unit).

No connection between caesarean delivery and obesity in later life

In the past studies have suggested there may be a link between being born by caesarean section and being obese in later life. The hypothesis is that caesarean babies may not be exposed to useful bacteria during birth causing weight problems in later life

This latest study from Mamun et al  finds no such connection. The study carried out an assessment of all mothers and their babies born between 1981-3 in a Brisbane hospital. Researchers found that on reaching 21 years of age, 21.5% of all the babies were over weight (12.4% obese). However there was no relationship between this group and the manner in which they were delivered.

This is an important study for women. The guilt felt by some women when their planned vaginal birth concludes with a caesarean delivery can be profound. The reasons for their feelings of guilt are varied, but the on-going impact of a caesarean delivery on the health of their child is one that is sometimes reported after the fact. This study could go a long way to reducing such fears and guilt.

Urinary Incontinence guideline issued

NICE have issued an update to the Urinary Incontinence guideline. “Since the publication of the 2006 guideline, new methods of managing urinary incontinence have become available on the NHS…Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. While rarely life-threatening, incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and carers of women with UI may be profound, and the resource implications for the health service considerable.”

Instrumental deliveries are associated with increased risk of bowel problems, urinary and anal incontinence. The amount of damage can be perceived as greater than a caesarean and certainly more than a straightforward vaginal birth,[i] affecting movement and causing significant pain during recovery. Ventouse seem to cause less damage and pain than forceps,[ii] with forceps particularly linked to increased incidence of pelvic floor issues. There is some suggestion that women should be counselled to consider a caesarean rather than forceps intervention when experiencing a birth that requires instrumental assistance[iii]

Bear in mind when assessing childbirth risks that while vaginal birth seems to increase the likelihood of pelvic floor problems, particularly where forceps are involved, it is not the only factor. Obesity, smoking, HRT and hysterectomies are also thought to be factors, as is the extra weight of pregnancy itself exerting pressure on these muscles. McDonagh Hull talks in more detail about this issue.

[i] S. Paterson-Brown, ‘Elective Caesarean Section: A Woman’s Right to Choose?’ Progress in Obstetrics and Gynaecology J Studd, Ed. (2000)14:202-15

[iii] S.A. Farrell, ‘Cesarean Section Versus Forceps Assisted Vaginal Birth: It’s Time to Include Pelvic Injury in the Risk–Benefit Equation’ CMAJ, 166/3 (2002)

AIMs review Caesarean Birth: A positive approach to preparation and recovery

Chloe Bayfield an AIMS midwife recently reviewed Caesarean Birth: A positive approach to preparation and recovery.

“The book is easy to follow and explores almost every aspect of the thought processes you are likely to go through when making decisions about your birth…Using this chapter, [“How Can I Improve My Recovery”] along with Appendix A (“The caesarean procedure”), will go a long way towards preparing you for your operation.”

Thank you for your supportive words.

(AIMS -Association for Improvements in the Maternity Services objectives are: working towards normal birth, providing independent support and information about maternity choices, raising awareness of current research on childbirth and related issues.)

Dads struggle through birth too!

Professor Marian Knight from Oxford University speaking about her new research reveals that “pregnancy complications…can have long-term effects on mental and physical health, as well as on family relationships.”

Of course Mum experiences the pain and worry of childbirth, but it would be incredibly naive to assume that it is a walk in the park for the partner. The birth partner (often the father to be) witnesses the person they love in pain and are powerless to stop it. Yes they may be given ideas of how to help during labour but they cannot stop the pain and they have to watch hour upon hour of it without any idea of when it will end or indeed how it will end … and those are just the straightforward births.

Add to this those practitioners who treat partners with impatience, indifference and/or a general lack of respect and you have individuals feeling totally inadequate and traumatised by the whole experience. For those suddenly excluded from theatre if an emergency arises requiring a caesarean (it is not uncommon for the partner to be left in the corridor alone with no news of mum and baby for considerable time periods) there is a particular risk of trauma and flashbacks.

When I interviewed dads for the book Caesarean Birth: A positive approach to preparation and recovery I repeatedly came across descriptions of events where they felt completely out of control, horrified and unprepared. Some described months of nightmares afterwards, others confessed they hoped not to have more children and still others revealed that they were relieved their wife had a caesarean. One father contacted me begging me to convince his wife to have a caesarean as he could not face a third natural birth.

It is wonderful that partners are encouraged to participate in birth but they too require support and understanding in order to remain effective during the birth and beyond.

While I believe that it is entirely reasonable for Mum to be focused inward during pregnancy and particularly birth this should not be to the total exclusion of the partner and their feelings.

In an ideal world antenatal education would encourage families to recognise the needs of everyone involved in the birth. For the sake of family relationships going forward it is crucial both parties are helped to recognise the long term effect on relationships where partners have been excluded, emasculated and traumatised. For these families far greater support is needed postnatally than is currently available.