Category: csections commentary

Urinary Incontinence more likely following vaginal birth

A recent study looking at the likelihood of experiencing urinary incontinence in later life found that the likelihood is far greater following a single vaginal birth than following a single caesarean birth. The study questioned 6148 women and found that the prevalence of urinary incontinence trebled (10.1%) after a vaginal birth compared to caesarean (3.9%).

While the most significant risk factor for symptomatic prolapse was vaginal birth Maria Gyhagen (co-author of the paper) also pointed out that “There are many factors affecting urinary incontinence but obesity and ageing as well as obstetric trauma during childbirth are known to be three of the most important risk factors.”

So what does this mean in terms of birth planning?

While it is certainly an important finding it is just one more piece of information to take into account when evaluating the risks and benefits of both modes of birth. Alone, this increased risk of urinary incontinence should not be a reason to jump at choosing an caesarean birth. There are many other factors to consider and your own circumstances with regards your current (or planned) pregnancy should be taken into account before making any decision either way.

My book Caesarean Birth: A positive approach to preparation and recovery talks a lot about the benefits and risks of both modes of delivery and provides up to date research and statistics which you may wish to use to inform your debate with your practitioners.

Repeat caesarean or VBAC?

There has been a lot of coverage in the media over the last few years quoting research looking at the comparative safety of a repeat caesarean versus a vaginal birth after caesarean (VBAC).

The findings are invariably such that the research can be used both by protagonists wanting to reduce the caesarean rate and those wanting to promote the validity of repeat caesarean birth (particularly maternal request CS). In other words it is still very much a matter of personal opinion.

What is clear is that for women trying to make decisions about their birth plans the risks typcially being discussed (e.g. scar rupture, fetal death and haemorage) are, with either delivery mode, incredibly small.

While findings can be manipulated to make controvercial headlines all current research can really emphasise is that rather than making snap decisions one way or the other women need to evaluate the broader risks of both modes of birth in their specific situation and make their decision based on their preference once fully informed.

So revisiting pre-conceptions and assessing the quality of the information you are given is of paramount importance. For example: Hemorrhage risks are incredibly small (2.3% in planned VBAC and 0.8% in planned caesarean). Despite this some women, who would prefer a vaginal birth, rule out an attempt accepting a potentially ‘unnecessary caesarean’ because they have not been given the full facts. Conversely those women, for whom the risks associated with a planned caesarean feel more acceptable than the risks associated with a failed vaginal attempt, may not consider a prophylactic caesarean because they feel unable to challenge the popular opinion being pushed by the media and natural birth advocates that VBAC is better.

It is important that women feel empowered to make decisions, that they are involved in the decision making process and that they challenge the advice they are given. Afterall they are the ones that have to come to terms with the outcome.

Caesareans, breastfeeding and gut bacteria

Once again the media have gone rather mad about a research paper without assessing the details of paper itself in an attempt to deliver sensational headlines about caesarean birth.

This paper actually describes gut bacteria in 24 infants at 4months of age but the media have rehashed old concerns about links with asthma.

It is entirely possible to make statements about the presence of the various bacteria from reliable tests conducted on the infants fecal matter and the paper should really have stopped there. However, it goes on to suggest links between caesarean birth and lower levels of breastfeeding and an increased likelihood of developing health problems in the long term (as a result of a lack of exposure to certain gut bacteria due to not having passed through the birth canal).

Aside from the media’s poor attempts at reporting on a very small, inconclusive study, I  take issue with the research paper itself:

  • No mention, or assessment of any environmental factors which can also easily influence gut bacteria level, other than use of antibiotics, (it looks purely at birthmode and breastfeeding patterns)
  • Only one assessment of gut bacteria levels are taken (at 4 months of age – no follow up to assess changes due to on-going development and exposure to new environmental factors – yet it is widely acknowledged that “gut profiles vary widely in the first year of life.”)
  • Sample size is laughable small (the total number of babies assessed – 24, of these only 6 were actually caesarean births) “A study of this size is too small to reliably detect any differences between natural and caesarean deliveries, and formula and breastfed babies, and even less so to detect any differences according to type of caesarean delivery (emergency vs. elective) or brand of infant formula, for example”

What is particularly disappointing is that the researchers feel comfortable making vague statements along the following lines “It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births” (which quite clearly shows even they cannot say their study provides conclusive evidence let alone how these bacteria levels relate to later health issues) and yet they are happy to produce a paper suggesting there is a link with caesarean birth specifically. Not only this but they take no account of the impact their statements may have on mothers who ‘need’ a caesarean to avoid serious outcomes. Nor dothey offer any information about how women can redress the bacteria imbalance. In otherwords they scare without offering any hint of a solution.

The NHS have been very quick to denounce the media’s scarmongering and suggest extreme caution when attempting to draw any conclusions from such a small study.

“The study does not provide any evidence that the mode of delivery or feeding pattern was the cause of the bacterial levels measured. Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life”

They go on…

“The researchers say that the development of bacteria in the gut in the early part of a person’s life is poorly understood. However, the design of this study means that it arguably adds little to that understanding. It only examined the gut bacteria of an extremely small sample of babies at one point in their life and can tell us little else about the causes of these bacterial levels, or how they related to longer-term health outcomes.”

And there is more…

“Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life.”

As for the media’s poor attempts at interpreting the paper, they have chosen to re-hash claims suggesting there are links with childhood asthma. This despite the majority of studies investigating such a link having been repeatedly shown to be inconclusive often omitting significant environmental factors, such as the presence of parental smoking.

Actually don’t get me started on the media…

An increase in the UK rate of forceps deliveries

The forceps rate has doubled in the last few years, according to a recent report picked up by the Mail On-line (over 42,000 last year) but is that really a surprise given:

  • The suggestion in 2010 (from within the medical profession) that there be an increase in forceps use if the aim is to reduce the emergency caesarean rate
  • The increased focus on natural birth, seemingly at all costs
  • The drive to reduce the caesarean rate making it ever more difficult to plan a caesarean for border line cases

It would be useful to know how many of these forceps deliveries were performed on women who might actually have been better advised to plan a caesarean? Indeed some of them could well have been advised of this but were so afraid of this ‘unknown evil -the caesarean’ that they actually preferred to take their chances.

Caesareans are regarded as a “last resort, best avoided” and because women are still not given balanced information many will resist a caesarean when it might actually be the safer option for them and their baby. Some of these women will go on to require highly medicalised instrumental births, many of which are truly traumatic, (damaging them both emotionally and physically, not to mention the risks to baby).

Women’s preparation should not simply be driven by the current bias towards natural birth. They need more information across birth modes and their opinions should be respected. Crucially in order to form these opinions in the first place they need to be supported in the development of realistic birth expectations using balanced information. Sadly neither of these can be guaranteed in many antenatal publications and clinics and many women will continue to have traumatic births, some of which could have been better managed, and experienced far more positively, with a planned caesarean.