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27 Sep

Caesarean section or Vaginal Delivery?

Many women look forward to the moment of conception. Being shown the ultrasound scan and seeing that tiny heartbeat pulsating, finally means the start of a new life, literally! As the tiny embryo grows to take human form, decisions also take serious shape-one of which is the method of delivery. So, how does one get to decide how to usher their baby into this world? Does it even matter? Well, yes. It does matter. So many things need to be considered. Usually this conversation is best had in the consultation room with one’s GP or obstetrician in depth. It can take that one piece of information to switch on the lightbulb that directs you to a clearer path best suited for you. Allow me to guide you into a few handy tips to aid your conversation when the time finally comes.

What are the benefits of a vaginal route?
Well, besides the quicker healing that comes with delivering a baby vaginally, the immunological stimulation to the baby unique to vaginal deliveries remains one of the undisputed benefits. As the baby passes through the bacteria-filled vagina, exposure to these organisms has been shown to stimulate and activate the baby’s immune system.

More advantages include:
– Early bonding within one hour of delivery and breastfeeding has been proven to create a stronger and better bond between baby and mother..
– Less breathing difficulties such as Transient Tachypnoeic of the neonate (TTN) which is lessened by the labour contractions helping to squeeze fluid out of the baby’s lungs
– Faster recovery time and thus less hospital stay (same day discharge if with no complications).
– Better post-partum experience for mom (more tolerable pain as uterus gradually reduces to normal size)
– Less future fertility problems and pregnancy complications (that come with a c-section scar)

Vaginal birth can be the easiest and simplest choice provided, there are no indications for a caesarean delivery. This reminds me of my experience; I was in labour for 12 hours so when the moment of truth finally arrived, I was in so much agony I twisted my arm without notice until I had delivered as suddenly, once popped, all the labour pains went away…instantly! It was only then that I noticed a painful deformity on my wrist and could recall rolling on the bed with wide arms like a belly dancer in the final countdown knocking the steel bed with my hand. Now obviously, that wrist pain was not my first priority at that moment, due to the far-exceeding-excruciating labour pains. Giving analgesia closer to delivery is bad idea as it suppresses the baby’s breathing.

What could go wrong during vaginal delivery?
The baby could go into fetal distress which is an emergency indication for a caesarean section to be done to prevent brain injury and in worse cases, the death of the baby.

Perineal tears. The baby stretches the vaginal canal on its way out causing the muscles on the floor of the pelvis to stretch to maximum and thus tear if the floor is not properly supported or safely cut to ease way for the baby. Long term, one could experience urinary incontinence resulting from over-stretching of the pelvic muscles and distortion of the structures surrounding the birth canal during delivery. This is where the importance of midwives comes in for full support of the perineum during the pushing process. [Your full cooperation and participation as a soon-to-be-mother
cannot be emphasized enough for your and baby’s safety!]

Uterine prolapse is much more common in older women who have given birth multiple times and have thus weakened pelvic floor and uterine structures keeping the womb in place. The womb or bladder could protrude through the vagina as collagen loses its integrity with age.
How does one prevent or minimize this?
The midwife or doctor can do an episiotomy if the opening is too small for baby to come out by cutting through the pelvic muscles in a linear, safer way before the muscles disproportionately tear. It is easier to repair and heals faster than an unmonitored tear.
Pelvic floor exercises like Kegels are excellent for restoring muscle memory and integrity. These exercises improve urinary control and sexual experience as they tighten the vaginal wall muscles as well as the pelvic floor back to their original state quicker.
Caesarean section benefits for mommy?
If it is a planned delivery, it will be much quicker than a normal vaginal delivery (usually 30 mins-1 hour depending on surgical skill and patient).
One knows exactly when to expect baby arrival and thus affords better planning around the expected date of delivery.
Reduced risk of urinary incontinence and pelvic floor weakness as no stretching of pelvic structures and muscles occurs.

What are the disadvantages of a caesarean section?
That mother and baby bond is delayed as the mother is in recovery needing close monitoring; whilst baby is with the neonatal unit staff doctors being monitored too.
Unlike a normal vaginal delivery where one is discharged 4-6 hours after delivery if no complications, the minimum hospital stay is 3 days. This is to closely monitor the mother for any complications such as bleeding, anaesthetic or nerve related complications, urinary problems, pain management, close blood pressure monitoring and ensuring mobility to name a few.
Prior to signing the consent form for the operation, these complications are explained by the doctor.
The complication scope is very wide for a caesarean section and can be categorized into immediate, short-term, mid-term and long-term.

Those that occur commonly however are:

– Bleeding during and after the operation which may require a blood transfusion, partial or total removal of the uterus to prevent death in extreme
cases both during or after the operation.
– Anaesthetic complications such as a spinal block or failed spinal which might require general anaesthesia meaning, you are completely put to deep sleep for the operation (this has its own set of risks and complications depending on the mode and medication used to achieve this).
– Injury to structures such as the bowel, bladder etcetera during the operation.
– Prolonged hospital stay (Hospitals and staff have procedural measures in place to minimize adverse events such as infections and other complications from occurring in the ward and theatre. For example, in the ward antibiotics and medicine to prevent vomiting which might lead to aspiration during the operation and thus pneumonia further prolonging hospital stay are given to prevent infections and reduce risks; counting of swabs and instruments in theatre to ensure no foreign material is forgotten in the abdomen during the procedure) and so on.
– Future fertility is reduced.
– Abnormal placental implantation risks increase.
Both methods have extensive benefits and critical points to consider for the baby and mother.

What are the expected costs?
In public hospitals in South Africa, the only cost one can expect to pay is the administration fee which varies depending on one’s salary scale, but free for women who are unemployed. Most women deliver for free or only pay between the range of R30-R200 maximum for all services, including food and medication provided.
In private, it depends on one’s cover plan and service provider. It is important to notethat most costs go to the private hospital. For example, if you are covered by Medical Aid X, the cost for vaginal delivery may be R20 000, wherein R18 000 goes to the hospital, R500 to the doctor, R700 for the anaesthetist, R200 for medication, R150 for assistants, R600 administration, R1200 miscellaneous costs leaving the patient with additional costs to cover.

Of course, covers vary and specialist costs vary owing to experience, skillset and qualifications. Doctors are extremely underpaid for their
services in private as most funds are channeled towards medical aids. Operating on a cash basis, thus makes sense for doctors to recoup for their skills. This unfortunately impacts on the patient.

Whichever mode one opts for, it is important to do thorough research. Ask as many questions as possible from your healthcare provider. Do pick up the phone to enquire at various hospitals what their procedure entails, costs and read public reviews. This assists to create realistic expectations for a more fulfilling experience in one’s step towards a lifelong journey.
Having a baby is an exciting milestone for most women. Doing what we can to protect ourselves and little ones from complications is but the beginning of our contribution to their future. Honouring clinic check-ups and doctor’s appointments, leading healthy-balanced lives (cutting off alcohol, smoking and unhealthy lifestyle), protecting our mental health, screening for illnesses and treating and controlling those already present makes a huge difference in improving health outcomes of babies delivered. We all have a responsibility toward channeling these precious babies into the world in a healthy and safe manner. You can do it, whether by push, or surgical shove. All the best!

Dr Asafika Mbangata is a Family Medicine specialist who holds 2 post graduate diplomas in Obstetrics (2017) and HIV Management (2019). She is currently finalising her Masters in Medicine (MMed) with the University of Pretoria whilst transitioning into the Clinical Research space. She obtained her MBChB at Walter Sisulu University in 2013.

Twitter: @asafikambangat 

IG: dr_asafika

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