Evidence 1, Fear 1... It's a Tie!

So way back when, I discussed elective cesarean section as a reasonable birthing alternative. In women who are adequately informed regarding the risks and benefits of both vaginal and cesarean, elective c-section should be perceived as no less valid a choice than home birth, drug-free birth, unassisted home birth, birthing centre birth, or any other option currently available to pregnant women. Then, in a seeming 180, I posted a few months later regarding my interest in being delivered by a midwife in a hospital setting. Again, all of this remains hypothetical since as far as I know, I remain fetus-free. But it never hurts to be prepared.

My personal views on the subject are pretty predictable to anyone who has been reading my blog for awhile-- as long as women are informed regarding the risks and benefits to both mother and baby, they should be allowed to make the decision that is best for them. As I mentioned before, my only problem with this situation are the increased costs to the health care system if one opts for an elective c-section. But for simplicity, I'm going to overlook that little detail for the purposes of this particular discussion.

I am no stranger to obstetrics. I completed one rotation as a medical student in a relatively small academic centre. My next two month block was also spent in an academic centre, although in a much larger city. During my time in family medicine over the past two years, uncomplicated obstetrics has been a big part of my practice-- I have followed many women through from their initial positive pregnancy tests through to their deliveries and beyond. Now that I'm nearing the end of my 8 months of full-time family practice, I'm seeing several women whose babies I delivered coming back with positive pregnancy tests once again. Sharing such an incredible moment in a family's life still feels like such an honour. And as much as I complain about the effect it has on my free time, I still love the fact that my family practice has such a significant obstetrics component.

From my end, though, I'm still torn. I have seen so many of the worst-case-scenarios it seems like a normal vaginal delivery with good outcomes for both mom and baby are the exception to the rule. I am very aware that my perceptions are heavily influenced by my experiences in high risk obstetrics. I had hoped that my experiences in uncomplicated obstetrics through my family practice would help to give me a more balanced viewpoint when it came time to make birthing choices for myself.

I am uncomfortable with uncertainty. Aside from the odd sports injury, I have never experienced pain. And as one of my friends at work put it, I have an 'internal locus of control'-- I think that's a nice way of saying that I'm a control freak. What scares me about giving birth is the unpredictability of it all. I can plan and prepare for a vaginal birth all I want but may still end up with an emergency c-section. Vaginal births are sometimes uncomplicated and beautiful, but other times-- forceps, tearing, incontinence, sexual dysfunction, uterine prolapse... and that's just the maternal outcomes. The number of things that could potentially go wrong with baby is staggering.

I'm not sure when I started to think this way, but I began to view elective c-sections as a way of maintaining some degree of control and predictability over the whole birthing process. Although the concept of entirely elective c-sections hasn't been completely accepted by the medical community (let alone society in general) it's not something I've talked about very much. But there is plenty of evidence to support the idea. Although none of the data is completely undisputed, studies have suggested that elective c-section may reduce the risk of post-partum urinary incontinence, fecal incontinence, uterine prolapse and sexual dysfunction.* And that's just on mom's end. From the baby's side, studies suggest a reduced risk of unexplained stillbirth, chorioamnionitis and cord prolapse. These possible benefits must be weighed with the increased risks, particularly those associated with post-operative complications for mom and increased incidence of breathing difficulties in newborns.

Unfortunately, the decision to opt for primary elective c-section over vaginal delivery isn't so straightforward as just weighing the risks and benefits of each option. If it were so simple, I'd be first in line for for my uncomplicated, low intervention vaginal delivery. But no one can guarantee anybody that their planned vaginal delivery won't evolve into more-- operative vaginal deliveries (meaning a vaginal delivery that is vacuum or forceps-assisted) increase the risk of complications to mom and baby considerably. If an emergency c-section is required, the risks are increased even more. Each of these scenarios carries a greater risk than if an elective c-section had been undertaken initially.

And that's where I'm stuck. I want one of two scenarios-- a low intervention vaginal birth attended by a midwife in the secure environment of the hospital, or a planned, controlled, elective c-section. Ideally, the former plan would be the ideal one. But again, there is no guarantee that plan won't evolve into something more risky. And that's what scares me, because that's the part I have very little control over.

I am a primip, so by definition I have an 'untested' pelvis. I don't know if I'll be able to give birth vaginally, and I won't know until I try. I am healthy, which is in my favour. I am older than ideal, although still a couple of years away from being considered 'advanced maternal age'. My mother gave birth to three children vaginally with no major complications. But it's still that uncertainty that makes me unwilling to completely discount the elective section option.

A month ago I would have said that my plan would have been to have a midwife-assisted delivery in a hospital. And then the Canadian Medical Association Journal published Maternal Mortality and Severe Morbidity Associated with Low Risk Planned Caesarean Delivery Versus Planned Vaginal Delivery at Term. It wasn't a perfect study, but added more information to the information already out there. And now I'm undecided yet again. And around here, midwives book up fast. So if I want to have a midwife-assisted delivery as an option, I'd better make the decision before I even pee on a stick.

Bah. With my luck, mini-Couz will end up breech and the decision will be made for me.

*Interestingly, more recent studies have actually found no difference in urinary incontinence between c-sections and vaginal births. And they've found that method of delivery is not a significant predictor of sexual dysfunction one year after delivery. So even the 'evidence' isn't set in stone.