Figuring out your birth plan can be fraught with pressures—from relatives and in-laws weighing in, or even friends and colleagues who think they know best. But there shouldn't be pressure from your doctor—just information to help you make an informed choice. That's the conclusion of a new committee opinion on elective Caesarean sections that's been endorsed by the Society of Obstetricians and Gynaecologists of Canada (SOGC). "Reaching a mutual decision on mode of delivery should be done without bias or coercion," says the paper.
The SOGC, which has long supported the idea that doctors shouldn't offer Caesarean sections to women when they aren't medically necessary, has now endorsed the statement that suggests women should be able to request C-sections, and have their doctor counsel them with all of the relevant risks and benefits to help them come to the best decision for their delivery. "Performing a Caesarean delivery on maternal request should not imply that a provider offered a Caesarean delivery, but rather that they engaged in a meaningful discussion, obtained informed consent, and executed an individualized delivery plan for the person," writes the committee.
"The cornerstone of managing these requests is understanding why the patient is making the decision. Exploring the person's values, fears and concerns, and their understanding of both birthing methods is key to successful counselling."
In some cases, a woman's decision may be based on a traumatic vaginal birth experience from the past, a desire to have a predictable delivery time or a fear of pain. (In this last case, a doctor might inform her about epidurals and other options for pain management. And it's important to keep in mind that women who undergo C-sections report experiencing more pain after birth than those who have vaginal births.)
In any event, when a woman expresses a desire to plan a Caesarean section, the committee says that she should be walked through the risks. For example, C-sections involve longer hospitalization than vaginal deliveries, can lead to complications in future pregnancies (such as contributing to placenta previa or placenta accreta) and can increase the chance of complications with future abdominal surgeries. There's evidence that women are more likely to experience postpartum depression after a C-section and breastfeed less. And among babies born via C-section, there are small increases in the risk for asthma, juvenile arthritis, immune deficiencies and obesity.
But there are some benefits, too. For example, there's a reduced chance of urinary incontinence and pelvic prolapse. And there are better outcomes for breech babies.
If, after going through all the information, a woman still wants an elective Caesarean section, the doctor can agree to perform it after 39 weeks or decline if the procedure could present significant health concerns to the mother or child. But the committee notes that any doctor who refuses to perform the procedure has a responsibility to refer the patient for a second opinion.
Having these consultations and taking a woman's choice into account may seem like a given, but it's a novel move. As of 2009, just 42 percent of obstetricians, and a measly 19 percent of family doctors and midwives, supported a person's right to choose a C-section. There's been a long tradition of guilt for women who choose certain birth options, like epidurals and C-sections, but the new statement acknowledges the importance of women being informed and being able to exercise their own autonomy—and that could help make every childbirth a little bit better.