For women with a complicated pregnancy, a caesarean section (C-section) may be necessary for the health of either the mother or child, or both.
However, for a variety of reasons, some women choose to have their baby by a ‘planned’ or ‘intended’ caesarean section even when there is no medical need to do so.
Take Justine Mukawera, for example; when she was expecting her first child three years ago, she made the decision to have a caesarean section because she ‘wanted to avoid the agonising contractions that come with natural birth’.
As a first-time mother, she wanted everything to go as smoothly as possible — nothing like the horrifying tales of natural child birth she’d heard about.
"I was going to have a baby and the experience was new to me. Pregnancy itself was hard and I couldn’t bring myself to endure more suffering during delivery. So I chose to have my baby through a C-section and though it was painful and the recovery was a little bit slower as compared to those who give birth the natural way, I will choose it again,” she says.
Today, more and more women are opting for C-section deliveries, and though the reasons vary from one woman to another, many have expressed fear of unbearable labour.
Dr Kenneth Ruzindana, a consultant gynaecologist at Kibagabaga Hospital in Kigali, says some women nowadays opt for caesarean delivery for a number of reasons; like the convenience of a scheduled delivery; fear of pain or the process, and or complications of labour and vaginal birth.
Some women also have concerns about harming the baby during labour and giving birth. Others have concerns about trauma to the pelvic floor from labour and vaginal birth, and subsequent development of symptoms associated with pelvic organ prolapse, he says.
"Others have concerns about the need for and risks of emergent caesarean or instrument-assisted vaginal delivery, and argue that they don’t want to undergo excruciating pain and in the end have a caesarean section,” Ruzindana says.
Dr Gerard Mbabazi, a medical doctor at Masaka Hospital, agrees with Ruzindana and says that some women choose a C-section because they don’t want to undergo the painful contractions during the process of delivering a baby, even if there is no need for a C-section. This, he says, is termed ‘maternal request’.
Mbabazi, however, warns that there are certain observations women need to weigh before they choose to have a C-section. Normal labour progresses well and leads to a normal vaginal delivery; it is only when labour is not progressing as well as it should that a woman ends up having a C-section.
"C-section is major surgery; therefore, like any other operation, it has its risks and complications. For example, bleeding that could lead to the removal of the uterus, infections within the uterus or at the incision site, different reactions to anaesthesia and of course, longer hospital stays as compared to a normal delivery,” he says.
Mbabazi adds that there could also be injuries to the intestines and the bladder (leading to fistula). There is also risk of uterine rupture on the previous scar during her next pregnancy from which both the mother and the baby could die. Usually, a woman is told all about these risks before undergoing or choosing a caesarean delivery.
Reasons for an operation, Mbabazi says, could be that the baby is in a bad position or is too large for a vaginal birth, there is arrested or prolonged labour, inadequate contractions despite augmentation (giving medication to increase contractions), and when the baby or mother’s health is at risk.
Vaginal bleeding due to detachment of the placenta or when the placenta lies in the birth canal blocking the baby’s head could all lead to a caesarean delivery.
Do not be afraid to push
Dr Ruzindana says that women need not be afraid of having a natural birth, pointing out that the method is associated with a number of advantages.
"A successful vaginal delivery has a number of benefits; no abdominal surgery, shorter recovery period, lower risk of infection and less blood loss.”
The medic also says that for women planning to have more children, a vaginal birth may help them avoid certain health problems linked to multiple caesarean deliveries.
These problems can include bowel or bladder injury, hysterectomy, and problems with the placenta in future pregnancies.
Understanding delayed labour
At times, it’s the fear of prolonged labour that pushes women to opt for a C-section.
Dr Ruzindana explains that the length and experience of labour is different for every woman and every pregnancy, depending on a variety of factors. For example, if a woman has had a baby before, the pelvis (shape and size), the baby’s position, contraction strength and timing, if the labour started spontaneously (naturally or induction was done) and the age of the mother, should all be considered.
"The length of labour depends on many factors, like first-time mothers were reported to generally experience 6 to 12 hours in the first stage of labour (from the time they are dilated four centimetres) with an average length of 7.7 hours.
"Many people count labour very differently. Some people consider both early labour and active labour as one and the same, while hospitals will record data for active labour only. Early labour is really something not done in the hospital for many women, so it isn’t really counted in many of the averages when looking at the length of labour,” says Ruzindana.
Vaginal birth vs caesarean
Karen Barasa, a mother of two, had her first child normally but for her second, she had to undergo a caesarean section when a worrying situation occurred during labour.
"I was in labour for two days, and so the doctor carried out a sonography and found out that I had no amniotic fluid, he said I was to have a C-section. I had not planned for it as I knew I would deliver normally, just like it was with my first child,” she says.
Comparing her two experiences, Barasa says she would never opt for a caesarean section.
"The experience was terrible; the pain after the operation was too much, compared to when I delivered normally. I had a serious headache and had to go back to hospital twice for drips to ease the pain,” she recalls.
She says that for her, the safer and better method is to deliver normally, unless if one has complications.
"I wouldn’t advise anyone to opt for C-section if they have no complications,” Barasa says.
Clementine Rutayisire begs to differ, and believes that the easier way to deliver with minimal pain is through a C-section.
"I understand there are complications that come with an operation, but this is the same even with natural delivery. Having a C-section is easier and the pain is minimal, and I would rather have this than those painful contractions that can go on for days,” the mother-of-three says.
Epidural administration
In an epidural, a local anaesthetic is injected into the epidural space (the space around the tough coverings that protect the spinal cord). Epidurals block nerve signals from both the sensory and motor nerves, which provides effective pain relief but immobilises the lower part of the recipient’s body.
While epidurals are very effective at alleviating the pain of the mother in labour, Ruzindana cautions about the risks involved.
They lengthen labour and may increase the risk of a caesarean section. They magnify the chances a baby will be persistently posterior (POP, face up) in the final stages of labour, which in turn decreases the chances of a spontaneous vaginal birth.
"They increase the chances of complications from instrumental delivery. They increase the risk of pelvic floor problems (urinary, anal and sexual disorders) in mothers after birth, which rarely resolves spontaneously,” he adds.
Epidurals pose their fair share of risks to the baby too, for example, similar levels of epidural drugs are found in the baby’s blood stream, but the baby takes longer to eliminate the drugs because the immune system is still developing.
Epidural anaesthesia is widely available in some private clinics in Kigali. However, public hospitals at the moment do not offer epidural anaesthesia albeit there are plans to introduce the service to expectant women, Ruzindana says.
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VAGINAL BIRTH OR C-SECTION?
Penina Umutesi, administrator I think intended C-sections should be discouraged because the risks that come with the operation are way too many. There are cases of infections or even excessive bleeding that could lead to loss of life.
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Matthew Kagabo, businessman Doctors should discourage women who choose to have a caesarean section when they can have the baby normally. Child birth should be natural, apart from when there are difficult circumstances. The natural method helps create a bond for the mother and the baby.
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Derrick Kabanda, student C-sections are safer nowadays I believe, with the evolution of technology. So if a woman decides she wants an operation then she should go ahead. However, they should not forget that there are risks that could occur like it is with any other operation. Weighing options is very important.
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