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To push or not to push? Choosing to deliver by caesarean section.

Research published this week in the British Medical Journal shows that babies born by elective caesarean section are more likely to have breathing trouble after birth. This is especially the case for babies who are mildly premature (1 to 3 weeks early).

These results are important, since the rates of elective caesarean sections are high in the UK (as in many countries). These rates are higher in middle class mothers, a group  that has been labelled “too posh to push”.  But how should doctors respond to a request for a caesarean section by a mother (where there is no medical indication)? Do the increased risks of caesarean section justify placing restrictions on maternal choice?

The results of the Danish study come as no surprise to those who work with mothers and with newborn infants. It is common for infants born by caesarean section to breathe fast for some hours after birth. Maternal hormones (including stress hormones) that are produced during labour help babies to remove the water that fills their lungs before birth. But as we have developed ways of relieving mothers of the physical and emotional stress of delivery, one consequence is that this affects babies’ ability to adjust to life outside the womb.

The absolute risks to infants are small. In the BMJ study the risk of “serious” breathing trouble for infants who were born by elective caesarean section at 37 weeks (3 weeks early) was 2%, compared to 0.4% in babies where mothers had chosen to deliver vaginally. It is important to note that this sort of breathing problem is still largely treatable without long term problems (at least in countries where there is access to newborn intensive care). The chance of a baby suffering permanent problems or dying because a mother had chosen to deliver by caesarean rather than vaginally is very small indeed. (Too small to be able to be determined by this study).

So should mothers be restricted in their choice of how to deliver their baby? Should it be a decision of doctors that in the absence of a medical reason, surgical delivery is not an option? Alternatively should mothers be urged (or “pushed”) to choose to deliver vaginally if possible?

Clearly mothers should be fully informed about the risks and benefits of choices that they make about giving birth. So this research is important in that it may help ensure that mothers are given all the information that they need before making a decision. But perhaps there are ways of respecting the autonomy of mothers, while also maximising the welfare of infants. One option would be to restrict the timing of elective caesarean section, for example so that it would only be performed after 39 or 40 weeks. Alternatively further research may demonstrate ways of reducing the risks of caesarean section for infants. One intriguing extension to the above argument is the following: If advances in medicine mean that we get to the stage where the risks of surgical birth for infants (and mothers) are lower than for vaginal delivery, there may be an ethical obligation to deliver by caesarean.

Further reading
Risks to babies from caesarean section
News report in the Times
News report on BBC
Risks to mothers from caesarean section
Report in the Telegraph
BMJ article November 2007

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