After decades of the medicalisation of childbirth, recent years have seen the momentum gained by the 'natural childbirth movement' help to broaden the choices available to expectant mothers and encourage them to consider childbirth and its setting much more actively. This is a largely positive phenomenon, however, in some quarters medical intervention is now so disparaged that many women feel that they have somehow failed if they end up giving birth by caesarean. Yet a caesarean is far from the 'easy way out' that some people believe, and there are times when it is the best option for ensuring the safety of you and your baby.

Planned caesareans
Certain pregnancy complications or circumstances may lead your doctor to advise you to have a caesarean delivery before labour starts - a planned caesarean. In some cases it will be clear that the chances of a successful vaginal delivery are slim, other cases may be less clear-cut and the question will be whether you're prepared to run the risk of an extended, and possibly difficult, labour and an emergency caesarean should things not go well.

  • Placenta praevia - If the placenta partly or completely covers the cervix towards the end of your pregnancy then you will usually need a caesarean as there is a risk of excessive bleeding during a vaginal delivery. In the case of marginal placenta praevia, where the placenta lies very close to the cervix, a vaginal birth may be possible. If you have been diagnosed with placenta praevia early in pregnancy then try not to worry: in most cases the placenta moves out of the way as the womb grows.
  • Placental abruption - A serious condition in which the placenta separates partially or completely from the wall of the uterus before birth. The condition can lead to severe bleeding, posing risks to both you and your baby, and compromises the functioning of the placenta, meaning your baby may be deprived of essential oxygen and nutrients and increasing the risk of a stillbirth. With a minor placental abruption you may have a chance of a vaginal delivery as long as both you and your baby are doing well, you will be closely monitored for any changes. If the abruption is anything more than minor then you'll most likely need a caesarean.
  • You are suffering from pre-eclampsia or have very high blood pressure - Pre-eclampsia prevents the placenta from working properly, limiting the supply of food and oxygen to baby and may also affect the mother's kidneys, liver, lungs, brain and blood clotting system. The only cure is delivery of the baby and placenta, so an early delivery by induction or caesarean may be necessary, depending on how serious the condition is. A vaginal delivery is usually possible, but factors such as the position and condition of the baby and the dilatation and effacement of the cervix may make a caesarean a preferable. If the condition suddenly worsens then a rapid delivery by caesarean is likely.
  • The baby is too big for your pelvis - Modern scanning equipment can give an accurate reading of your baby's size and highlight when s/he may be too big for your pelvis. Because the ligaments in your pelvis soften and allow a degree of flexibility during labour, it's rare that a doctor will be able to tell you that your baby definitely won't be able to fit through your pelvis, but if s/he feels that a successful vaginal birth is unlikely they will recommend a caesarean.
  • Multiple births - Where one or more of the the babies' positioning is awkward a caesarean may be recommended: About 50% of twins are born by caesarean and when there are three or more babies to be delivered a caesarean is almost always the delivery method. In the case of twins, some doctors are more willing than others to attempt vaginal delivery if the first baby is breech, so if an attempted vaginal birth is important to you may want to look for a doctor with the relevant experience.
  • The baby's position is breech (bottom first) or transverse (sideways) - A breech position is a common cause of planned caesareans but it is worth getting a second opinion or looking for help to try and turn the baby if you don't want a section.

Emergency caesarean section
Before labour commences naturally an emergency caesarean section may be necessary if you have a medical condition, such as pre-eclampsia or placental abruption, that rapidly deteriorates and threatens either your, or your baby's, health. An emergency section may also be necessary once labour has actually started and common reasons include:

  • Slow progress and exhaustion - If progress in labour is unduly slow and either mother or baby are becoming very tired a caesarean may be wise. Not only are things more likely to go wrong as you and the baby tire, but you may exhaust yourself to the point of illness and be in no fit shape to care for your baby in the days after birth.
  • Fetal distress - If the baby becomes distressed in the course of labour, with a repeatedly dropping or low heartbeat, and birth is not imminent, there is a danger that the baby's condition may rapidly deteriorate.
  • Meconium in the waters - If meconium was found in the amniotic fluid when the waters broke there is a danger of infection to both mother and baby. If more than 24 hours have elapsed since waters broke or there are any signs of infection then you will probably need a caesarean.
  • High blood pressure - If the mother's blood pressure becomes high and doesn't respond to drugs you may need a caesarean to curtail the risk of seizures.
  • If there is abnormal bleeding - Abnormal bleeding can have numerous causes and pose a serious risk to both mother and baby.
  • Umbilibal cord abnormalities - If the umbilical cord becomes wrapped around the baby's neck and there is a risk of strangulation at birth and a caesarean will be necessary if the cord can't be freed manually. A prolapsed umbilical cord, where the umbilical cord emerges through the cervix before the baby is fully out, may be constrained by the emerging baby, so cutting off the baby's oxygen supply - if the baby's heartbeat slows a caesarian will be necessary.

When a caesarean is suggested
Depending on the severity of the above complications, a caesarean may be the only safe way to deliver your baby. In many cases doctors will be keen to err on the side of caution in order to be sure of delivering healthy babies to healthy mums. If avoiding a caesarean is important to you, then let your doctor know that you don't want a caesarean unless it is really necessary. If you aren't convinced that a caesarean is the best thing for you and your baby then don't be afraid to ask for a second opinion when it is recommended.

However, do try not to close your mind to a caesarean completely. Even when a caesarean isn't strictly medically necessary it still may be the best option for you and your baby if you are going through a tough and extended labour that isn't progressing. Above all, remember that a safely born baby to a healthy mother is more important than the details of your birth experience.