Natural birth vs caesarean section: What’s better?

DR DAVID N EMVULA FOR decades, the World Health Organisation (WHO) has specified 10 to 15% as the ideal caesarean section rate, yet rates around the world keep rising.

As a result, the C-section rate in 2021 was over 50% in Egypt, Turkey, and Brazil, just to name a few.

Modern refinements in C-section technique, the use of antibiotics and regional anaesthesia, have improved C-section safety. The procedure is now so safe that some women are being offered and are seeking elective C-sections.

The downstream effects of this is increased maternal morbidity and mortality and it’s these ‘non-medical’ reasons for choosing a C-section that spark so much controversy.

A caesarean section was used almost solely to save the life of a mother in whom vaginal delivery was extremely dangerous or to save the life of a foetus when a vaginal delivery is not imminent, or was deemed risky.

Some of the indications for a C-section include: the afterbirth too close to the opening of the womb – called a placenta previa, and vaginal delivery that would lead to life-threatening bleeding.

Others include a dangerous drop in the foetal heart rate, heavy vaginal bleeding from a torn afterbirth, breech babies, big babies, babies that are in an awkward position in the uterus (for example, sideways) or arrested labour – where the woman only dilates to a certain amount then stops.

Maternal mortality and morbidity are more than three times greater with C-sections compared to vaginal delivery: specifically, the risks of heavy bleeding during or after a C-section, infection, damage to the bladder or intestines, forming blood clots around the uterus or in the leg veins and amniotic fluid embolism.

In subsequent pregnancies, the risk of abnormally lying or abnormally attached placenta and uterine rupture is increased. Depending on the cut on the uterus, a repeat C-section may be the only option of mode of delivery in some patients. A side-to-side cut on the uterus, called a ‘low transverse uterine incision’, carries a low chance of the incision breaking open during pregnancy or labour and it’s safe to try for a normal vaginal delivery. This is called a vaginal birth after caesarean or VBAC.

An up-and-down uterine cut, in contrast, has a much higher chance of breaking open with a subsequent pregnancy, which can cause heavy internal bleeding or even stillbirth, so it is considered unsafe to try for a vaginal delivery.

A higher rate of unexplained stillbirth in pregnancies after a C-section also contributes to an increase in perinatal mortality. In addition to the greater risks, a C-section costs more than a vaginal birth.

A caesarean section has a modest protective effect against urinary stress incontinence (the inability to control the release of urine from the bladder) and pelvic organs prolapse (pelvis organs drop from their original position in the pelvis) later in life, compared to a vaginal birth.

Babies also require special attention during a C-section as their lungs have a little extra fluid due to failure to be compressed by the vagina.

Contact with the maternal vagina during a normal vaginal delivery and maternal skin postpartum exposes the foetus to the normal maternal microbial flora. Microbial exposure and the stress of labour also lead to marked activation of the immune system of the newborn.

A caesarean section interferes with neonatal exposure to the maternal vaginal and skin flora, leading to colonisation with other environmental microbes and an altered microbiome. Routine antibiotic exposure with a C-section likely alters this further. As a result, immunological diseases including asthma, atopic dermatitis and coeliac disease are more common in children born by a pre-labour C-section compared with those exposed to labour.

Conversely, advantages of a successful vaginal delivery are numerous to both the baby and the mother. With a vaginal delivery, there is a higher chance of successful breastfeeding shortly after delivery, decreased hospital stay after childbirth, rapid recovery physically and psychologically, and increased mother-child bond and attachment.

There are numerous complications associated with a vaginal delivery; these complications vary by stages of labour and are dependent on numerous factors.

Complications can be generalised into the following categories: failure of labour to progress, abnormal foetal heart rate, vaginal tears, and bleeding during or after delivery.

One of the major limitations of a normal natural birth is labour pain. Pain is one of the most common medical problems, which adversely affects an individual’s abilities and leads to fear and anxiety. Attitudes towards labour pain are associated with physical, psychological, environmental, and supporting factors.

Modern obstetrics advocates support or companionship during labour and childbirth and adequate analgesia, including an epidural analgesia for a ‘positive childbirth experience’. However, today, a C-section is perceived as an escape from labour pain and a common belief that caesarean delivery is less painful, safer, and healthier than vaginal delivery.

Caesarean section can be lifesaving and is recommended when the life of the mother or the foetus is at risk. Compared with vaginal delivery, c-section involves increased maternal risk, financial cost, and sometimes foetal risk.

Individuals’ views and attitudes significantly influence the choice of delivery. These views are based on different information sources, which may vary in terms of accuracy and reliability, therefore, it’s important to discuss the modes of delivery with your obstetrician to make an informed decision.

* Dr David N Emvula is a specialist obstetrician and gynecologist at OB-GYN Practice.

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