To go natural or have a caesarian section?

When in March 2010, Sharon Natukunda a fiirst time mother then, passed her due date by three weeks, she started to worry. There was no sign of labour. Together with her doctor, they agreed that she be induced into labour using drugs.

“I was sure that I would push the baby once the drugs were administered. But after 14 hours of intense labour pains, my cervix failed to open and the baby was big. When the doctor told me that I had no choice but to agree to a C-section, I complied but that did not take away my disappointment,” Natukunda narrates. She says: “It had not occurred to me that I would have my child by C-section. That was not what I wanted. But because it was an emergency I agreed although it took me time to get over it.”

Natukunda gave birth to a baby boy weighing 4.8kgs. However, what she has failed to forgive herself for, is the fact that she was unable to hold and breastfeed her baby after birth. It took another day and even when she finally met him, she could not hold him as she was recovering from the operation. “And my baby had been fed on formula. I did not agree with that either but had no choice. The dos and don’ts were just too many and that’s when I made my mind that I will never do another C-section unless it’s a matter of life and death,” says the 27-year-old mother of two.

A year after, Natukunda got pregnant with her second child. Even when it was considered too soon by her doctors bearing in my mind that she had delivered by C-section, she decided that she would go natural.

Early antenatal visits
“I started going for antenatal visits early, partly to check my scar to ensure that it had healed properly. This went on until the last week of my pregnancy. When I ascertained that the scar had healed properly, I set my mind to do everything possible to have my baby delivered through the normal birth canal.”

While Natukunda had made her choice, the doctors constantly reminded her that it was very risky and that she was likely going to have more complications if she insisted on the natural birth method, reason being that she was having another baby too soon after the first one.

Medically, it’s recommended that a mother takes a break of at least three years before they can have another baby if the previous one was delivered by C-section. And if it’s less than that period, the next baby should also be delivered by the same method to avoid complications. Natukunda, a revenue assistant at Civil Aviation Authority was not going to take any of that.

“I wanted the doctors to give a clear reason. Maybe that my blood pressure was too high, that I was diabetic, that my pelvic bones had not fully developed or that the baby was lying in a wrong position; maybe I would have listened. I just didn’t like this “it’s risky” response because I didn’t think that the circumstances that led me to be operated during the first pregnancy would be the same.”

She went on to consult different doctors about the possibility of having a normal delivery. She dreaded having a scar on another scar. She got even more hope when one of the doctors she consulted told her that she would be given a chance to try. “I wanted to go to the labour suit – not the theatre, not again,” she says. When her expected date of delivery came and passed, Natukunda’s doctor called and asked her to go to the hospital but she did not do that. She asked him for another week, after assuring him that if she got any strange feeling or complication, she would run to the hospital.

The week passed and there was no sign. She says that at that point she started losing hope of “pushing” her baby so she packed her bags and headed to the hospital.

Four hours later, a doctor came to her room and told her that the best thing for her to do at that point was to go for C-section. She debated on whether to sign the form but decided against it and rather called the midwife who had been monitoring her. “I asked her to check my cervix for any signs of progress. Usually, they do this at particular times so I had to practically beg and she agreed. She gave me good news when she said that the cervix was opening and assured me that I would give birth normally. I became stronger,” she recollects.

When the doctors came to take her to the theatre, she insisted on a natural birth. So, about four doctors and midwives decided to monitor her until she finally gave birth to her second baby boy.

Natukunda says that she cannot compare the joy she felt when the baby was placed in her arms immediately to what she felt when she woke up from anaesthesia following the birth of her first born.

To date, while she loves both her sons, Natukunda says she feels a special bond for the child she birthed normally saying that the bond was established at birth unlike her first. “I was able to hold and breastfeed him. Even when he was taken to the nursery for special care, I could easily walk there and spend more time with him – just because I was able.”

Natukunda is now eight months pregnant with her third child and she is convinced that she will deliver her baby normally even when the doctors have told her that the baby is lying in a wrong position. “I’m simply positive that by the time I go into labour, the baby will be in the right position. I cannot trade natural birth method for anything,” she reaffirmingly says.

Advantages of natural birth

According to Dr Paul Muwanguzi, a gynaecologist, it is cheap for the family. In Kampala, most private hospitals offer C-section at Shs1.5m and above, as opposed to normal births which usually cost between Shs200,000 to Shs800,000. So in terms of cost, it is definitely cheaper.

“The contractions associated with labour help prepare the baby to breathe when it finally comes out. This may sound ridiculous but when the uterus contracts, it presses the baby’s chest therefore helping the baby to exercise its breathing,” he says.

It often times does not require very highly skilled medical personnel. Most normal births in Uganda are carried out by traditional birth attendants, than by skilled midwives. No need to have a person trained in surgical skills to attend a normal birth.

After birth, the mother very quickly bonds with the baby and is advised to initiate breastfeeding as soon as possible; this may not be possible if a mother has had an operation.

The disadvantage, however, is that normal labour and delivery is a very distressing time for both mother and family, associated with a lot of pain. Often times, this process could take about 10 hours so this woman needs all the support she can get from her partner.

Caesarean section on the other hand is a major operation. It can be done while the mother is fully anathesised (general anaesthesia) or partially anesthesised (spinal anesthesia; where the anesthetic medicine is injected into her spinal space to block pain).

“Being a major operation, it requires very highly specialised people to carry it out. This includes a doctor, a theatre nurse, a midwife to receive the baby, and an anaesthetist to monitor the woman while the operation is ongoing,” he says, adding that when it is all done, the mother must be monitored every 15 minutes until she is fully awake, and kept on the ward for at least three days receiving post-operative care.

More urban women going for C-section
According to Prof Josephat Byamugisha, the head of the Obstetrics and Gynaecology at Mulago hospital, the number of women opting for C-section in public facilities remains low at the national level although the practice seems concentrated in urban areas and in private facilities.

For instance, out of 350,000 deliveries done at the hospital last year, 26.5 per cent were C-section, indicating an increase by 2.8 per cent over the last three years while at national level; it is less than five per cent.

“In fact, we have an unmet need of C-section method of delivery if we are to prevent maternal deaths as well as reducing some of the permanent damage that comes during birth such as fistula,” he says, adding that in public facilities, people fear C-section even when they get complications. But this is different at private facilities, mostly among the elite class of women because women can ask for it, unlike in public facilities where the decision is made by an expert with a strong reason.

Bobil Williams, the Public Relations Officer at Case Hospital, says the number of women who go to the hospital asking to deliver by C-section is increasing with some choosing dates on which they want their babies delivered. While he declined to give statistics, he says that women today perceive it to be easier and trendy, partly because there has been advancement in medicine. The wounds heal faster, the scar is smaller and they think it’s less painful than going through normal labour.

However, a nurse at the facility who prefers to remain anonymous because she is not authorised to speak says that most doctors in private hospitals do not have time to monitor labour through all the stages, and thus prefer C-section.

Who should go for a C-section?
Dr Evelyn Nabunya, a Consultant Obstetrician/gynaecologist at Mulago hospital, says: “As a hospital, we encourage mothers to deliver normally as much as possible because of the benefits that come with the normal process.” “It’s the best because the mother goes home earlier, the mother and baby get to bond, stimulates breast milk faster and bleeding is less and the uterus goes back into shape faster than a C-section,” she explains. “But for cases where complications are detected, C-section is preferred for instance if a woman presents with a low lying placenta – the placenta comes before the baby, that makes it difficult to deliver the baby and we recommend a C-section,” she says.

Other conditions under which C-section should be done include, if the mother has a high blood pressure; is diabetic; has a history of complications; if there is excessive bleeding during labour; if the baby is less than 34 weeks for fear of damaging the brain; and if the mother is HIV-positive.

Dr Paul Muwanguzi, a gynaecologist, says the indications for a caesarean birth would be either maternal or fetal. Maternal indications would include; two or more previous cesarean sections in the past pregnancies, cephalo pelvic disproportion (baby’s head bigger than mother’s pelvis), obstructed labour, and mal presentation (when the part that comes first is anything other than the head, among others.

“On the other hand, baby indications for C-section include; foetal distress (when the baby is not doing well or tired), cord prolapse -when the cord comes down before the rest of the baby, placenta previa – when the placenta is located lower down in the uterus.”
Other circumstances in which a C-section is preferred are; when mother is 35 years or older; if they have had fibroids before; if they are very short, have had multiple pregnancies; and if they are too young with not fully developed pelvic bones.

However, Dr Nabunya also says that lately, doctors are rather quick to recommend C-section once they detect any complication for fear of litigation – because they are blamed when there is death of baby during delivery. But Dr Muwanguzi says, “Currently we have more women asking their doctors if they can have a caesarean section even when there is no reason for it. This is becoming increasingly more common.

“Usually patients give reasons like; they don’t have the courage to withstand the labour pains, sometimes they have heard stories or even themselves experienced horrible dignity violations by health workers during labour, so they decide that they aren’t going to go through it anymore while other women still just don’t want to experience any complications related with child bearing.”

Dr Joseph Soponyai, an associate professor and Surgeon at Case Hospital, says that more C-sections in private hospitals are driven by money rather than medical ethics. “Some doctors and health facility owners just want to make more money which is not likely if they did more normal deliveries. Others don’t bother explaining to mothers about the likely risks of this,” he says.

Complications that may arise
Dr Muwanguzi says some people may die while still on the operation table because of an adverse reaction to drugs, mostly anaesthetic drugs or blood loss. “Sometimes during the procedure, other organs may be damaged leading to other post-operative complications. A common one is when the urethers or bladder get damaged and this may result in a fistula and yet in other cases, the woman may end up having untimely sterilizsation in cases where the surgeon cannot control the profuse bleeding so the woman’s uterus is taken out in order to save her life.

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