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Who decides whether you have a caesarean section?

Whether you're totally set against a caesarean or keen on avoiding vaginal birth, who makes the decision on whether you have the operation

Posted: 27 February 2009
by Maria Muennich

When a caesarean is recommended
When your obstetrician recommends that you should have your baby by caesarean section you aren't under any obligation to follow their advice, however forcefully she presents her case: You need to consent to the procedure before doctors can procede with it, and in that sense the person who ultimately decides whether you have a caesarean is you.

However, the decision-making process is usually a little muddier than this as, unless you are an obstetrician or midwife yourself - or unless you object to caesareans on religious grounds, you'll probably be basing your decision on the advice of your doctor and midwife and their reading of the situation.

There are certain situations when a caesarean will be the only safe way to deliver your baby, in which case a caesarean will be presented to you as the only option. In many other cases a caesarean may be the best option for the health of you and your child. In these circumstances your doctor will probably advise you very strongly to have the operation.

These days caesarean section is seen as a quite low-risk operation by doctors (although it certainly isn't risk-free) and so in many cases doctors may err on the side of caution in recommending a caesarean out of their desire to deliver healthy babies to healthy mums. You may even have the feeling that a caesarean is being suggested because it's more convenient for the medical team. If you're not convinced that a caesarean is really necessary then ask plenty of questions about why the section is being recommended, and what would happen if labour were allowed to continue. If you're not happy with the responses you are being given then you can ask for a second opinion.

One of the roles of your birth partner is to help you assess these recommendations, ask the right questions and support you if you're not convinced a section is really necessary. If you're lucky enough to have a midwife present who has looked after you through pregnancy and with whom you've developed a good rapport, then you might feel happier discussing the situation with her and assessing the pros and cons of having a section, or not.

Can I be forced to have a caesarean?
Your right to refuse a caesarean section is protected by law. This means that even if your decision will probably result in the death of you or your baby, you are legally entitled to refuse the advised treatment, as long as you are deemed 'competent' or fit to make that decision.

There have been instances of women being declared mentally unfit to make this decision for themselves - not always a difficult argument to present for a woman in the throes of labour - and so being forced to have a caesarean, however this isn't common.

You should also be aware that in refusing a caesarean you may be putting the life of you and/or your baby at high risk, or exposing one or the other of you to long-term health risks. If this is the case then your obstetrician will present the case for caesarean in no uncertain terms.

What if I want a caesarean regardless of medical necessity?
As an expectant mother you don't have the right under the NHS to a caesarean section if there's not clear medical reason for one, but that doesn't mean that you definitely can't have one. If you would prefer a caesarean section to a vaginal delivery then you can ask for an elective caesarian, but it would help your case if you had good reasons. Caesarean isn't a risk-free operation; it is major abdominal surgery from which you will usually need six weeks to completely recover. There is some evidence that babies born by caesarean are more likely to suffer breathing difficulties and need specialist neonatal care. Mothers meanwhile, can experience problems such as scarring, haemorrhaging, deep vein thrombosis and damage to the bowel, bladder, uterus, ovaries or fallopian tubes. Figures from the NHS present c-section as three times more likely to result in a fatality for the mother than a vaginal birth although the numbers are still very low.

The numbers of caesarians performed by the request of the mother on the NHS are very small and would probably need to show your doctor that you were aware of the risks - and the implications for your post-natal recovery for your case to be considered. One strong argument that can be presented as medical grounds for an elective caesarean is when you have a very strong fear of childbirth and this threatens your mental health. In such a scenario you should usually be given counselling to see if the fears could be overcome before your doctor agrees to a caesarean.

If your doctor doesn't agree to a caesarean then s/he is obliged to refer you for a second opinion to another consultant who may agree to the operation. If you feel strongly about having a caesarean then make sure that you aren't referred to a hospital which has a policy of refusing all c-sections that aren't based on medical grounds. If all else fails then you do have the option of paying for a caesarean in a private hospital.

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