The first few weeks after having a baby often feel like a bit of a blur, a muddle of feeding changing and sleeping. During this time, when your baby cries it is a good idea to presume hunger and to feed her. By doing this you achieve two things: your baby learns that when she cries, her needs are met, and by feeding frequently you are able to establish a good milk supply.
Once you have established your milk supply, you can look at spacing feeds a bit. Milk supply takes btw 6weeks and 3 months to establish.This routine is a basic suggestion of how you can make your day a bit easier for yourself. Try not to be too rigid and be aware that you will have to customize it to suit your baby. All babies are different and with a little tweek here and there you should find your own way with your baby.

The main reason this routine follows a sleep, feed, awake pattern is to avoid feeding a baby to sleep, which is handy to start with but gets to be a bit of a bind when your child is a year old and you are still the only one that can put her to sleep. During the first few weeks babies are quite hungry when they wake up and aren’t too willing to wait for a feed. Another reason is that it is easier to space feeds by using this order as babies sleep for the last part of the cycle and somehow manage to wait longer asleep than awake. If you feed a baby to sleep, you will  probably have to feed again when she wakes up as well, which won’t give you much time to do anything other than feed, feed, feed.

7am-ish        FEED offer 1 breast till had enough /comes off /starts fussing
Offer same breast again
If not interested, but you think she is still hungry offer other breast.
When she comes off feed is finished
Change nappy if dirty, if not wait and change later before she goes to sleep.

Until niggly, that means after having tried everything: lying here and there, and carrying around a bit.

8.30/9ish    SLEEP i.e. Change nappy if you need to, swaddle if she likes to be wrapped up,
give a dummy if you use one,or a musical toy that suggests sleeptime.can take for a short walk
hold till calm and quiet and put into bed(a dark, quiet room will help)
If she fusses., try to settle in bed, change position, sit her up and wind her, and if calm lie her back down. If doesn’t settle try holding for a bit till calm, then back into bed. BE PATIENT AND PERSISTANT, babies love repetition

Remember the SNOOZE BUTTON if she wakes soon after she went to sleep, presume tiredness and press the snooze button. Ie dummy or pat back to sleep, if possible keep her in bed, change her position in case she’s uncomfortable. Soft crooning `’now its sleep time type noises” and out you go again. If she insists then its feed time again.

10-11ish     FEED when she wakes up,

Repeat  above

12/12.30ish    BIG SLEEP (NB to be in her bed for at least one sleep, to let it be a proper sleep)

2-3pm        FEED when she wakes up

Btw 4-5pm    SHORT SLEEP (Not very important, can nap anywhere)

Evening: 2 options I can offer and I’m sure there are many more…

5pm FEED

6pm BATH when starts to get niggly and FEED in dark and quiet place
AWAKE If she is happy to wait FEED just before bath and then again after bath. FEED in dark and quietInto BED round about 7pm-ish if that suits                       your lifestyle and your baby.

Most babies will wake up to feed once or twice during the night. Other things to consider if your baby is waking up often at night:
Too cold / too hot
Clothes wet if nappy has leaked
Dirty nappy
Uncomfortable (change position/ try winding)
Blocked nose if s/he has a cold (elevate head of bed with pillow under mattress, try Nasenol drops by Natura)

Expect to FEED if she wakes at around 10/11ish and change nappy if dirty
(some books recommend waking up a baby for this feed, personally, I think babies feed better when they wake up themselves because they are hungry.

If you wake her, she will more than likely have a half-asleepy, half-hearted feed and still wake up again hungry later so that means you still end up feeding in the night AND you are tired from waiting up late to feed)

And early morning FEED if she wakes up, don’t change unless dirty.

Regardless of when she fed during the night always start morning feed around the same time-ish, 7-7.30 seems like a civilized time for the day to start, see what works for you. Another helpful routine is to bath your baby in the morning after a feed and then feed again after bath and then let her have a sleep. Baths are amazingly exhausting. Again, the routine rythm is what babies like. This also can help to get a rythm for yourself as after bathing your baby you can then have a shower and get your own day started.

That way each day starts at the same time and you can keep a pattern going.


Try to keep feed times quiet times – that way feeds will be proper and longer and that means it will be easier to space feeds.
Be flexible, some days things WILL go pear-shaped, so what? That’s just one day, tomorrow will probably work just fine.

NB HONOUR THE GROWTH SPURTS!!!!, these come almost weekly for the first couple of months and in order to keep up a good milk supply you will have to allow more frequent feeding at these times, they should only last 24-48 hours but some , like week 3, can last up to a week. Honour this restocking up of milk and then after breasts are fuller,  you can get back to “normal”
Be patient
Some days won’t work too well, especially in the beginning. But babies DO love repetition– so keep repeating a pattern and she WILL fall into a routine
Try to keep a sense of humour about it all. When its tough remember this too will pass. It WILL get easier. The birth of a mother is more difficult than the birth of a child and it takes much longer.

EVENTUAL  AIM:  I repeat this is the EVENTUAL aim, not all babies will ever get to this bit  just see what kind of babe you’ve got. Remember keep it flexible, if you get too rigid it just makes you tense and babies never respond well to tense parents.

FEEDS: 7am    11am    3pm    5/6pm (snack)    7pm    11pm  (and maybe once during the early morning)
SLEEPS: 9-10/11pm    12-2/3pm    4-4.45/5pm

After a while, as your baby gets a bit older, the 11pm and early morning feed will merge into one feed and later still, that feed will be done away with. This takes time and all babies are different, so don’t rush your baby. Babies seem to co-operate more if we let the night feeds disappear at their pace rather than at ours.


Research has repeatedly shown the safety and benefits of midwife care. Statistics show that births attended by midwives have:

  • lower infection rates
  • lower C-section rates
  • fewer complications
  • healthier outcomes
  • lower overall medical costs – than doctor-attended hospital births.

In addition, there is no difference in infant mortality between midwife-attended and doctor-attended births for low-risk women. Countries such as the Netherlands, Sweden, and New Zealand, which have the best birth outcome statistics in the world, use midwives as their main maternity care providers.(

Care with a modern midwife is truly an art form. Not only do you get a careful attendant that is nurturing and trustworthy – you also get a professional who is aware of the latest research, and knows when technology is necessary, when to use it and when not to.

A midwife’s care is based on the idea that the woman is the central decision maker in matters regarding her birth and her child. Midwives respond to mothers as a caring and collaborative partner, highly trained to work with each unique situation individually. Her goal is the health and well being of mother and baby. She has the resources, wisdom and professional training to safely guide the journey of pregnancy.

A qualified midwife is a specialist in natural birth. She is skilled in monitoring women and their babies through pregnancy, labor, birth and into motherhood.
As well as her clinical expertise, she shares with you the desire for a healthy and empowering birth experience and uses her knowledge and experience to guide you towards this goal. During pre and postnatal visits that are three to ten times longer than standard doctor visits, the midwife listens to what is needed at each step of the process. She can then offer appropriate information, physical, emotional or clinical support, and discuss options of care.



ANTENATAL VISITS (each) (30MIN-1HR): R300-R750
LABOR AND BIRTH: R8000.00-R12000.00
POST NATAL VISITS (each): R500-R800

What needs to be done quickly when you come to theatre for an unplanned (non-elective) ceasarian operation.
If you are having a planned (elective) Ceasarian the same things are done but in a much more leisurely manner
If it is unplanned it may all may seem overwhelming to you, with people milling about, but this is what is happening (not necessarily in this order).
The baby’s heartbeat is listened to get a baseline and to ensure that it is satisfactory. This is usually done with a continuous CTG machine, which is really useful in these circumstances. If you are having a CS because of concern about the baby, listening to it will help to ascertain the degree of urgency.

The anaesthetist will be asking you about your history of having operations and anaesthetics, and about allergies. A spinal, epidural, or general anaesthetic will be advised, and an intravenous drip started in a vein in your arm, if one is not already in place.

If you have not already done so, you will be asked to sign a form of consent to the operation. Ideally this should be done with time for you to ask questions. However, if time is important, it may seem that we are hurrying you. But if we asked you to consent to anything before the need is apparent, that could be criticised. Could we do this better? But how?? Any ideas??

A blood pressure cuff will be put on your upper arm so that your blood pressure can easily be checked by a machine.

A clasp rather like a large clothes peg may be put on one of your fingers. This helps monitor the amount of oxygen in your blood

Little sticky plasters with wires attached will be put on your chest to keep a check on your heart beat.

Somebody will be taking blood from one of your veins to cross match with donated blood to make sure that compatible blood is available if needed. A test of your blood quality (a full blood count) will also be done on this specimen.

Some rather tight white elastic stockings will be put on your legs. These are to prevent any clots forming in your leg veins during the operation. In some hospitals inflatable sort of boots, rather like snow boots are used for the same purpose.

Somebody else will be putting a soft plastic tube, called a catheter, into your bladder to empty it. This is left in, and attached to a plastic bag to make sure your bladder stays empty during the operation, and for a day or so after, so that you do not need to get out of bed to go to the loo. If you would prefer it, this can be done once you are anaesthetised either by general anaesthetic or once the spinal or epidural anaesthetic is working.

A sort of bandage called a diathermy will be wrapped round your upper left leg. This is connected to apparatus which seals blood vessels during the operation, so that blood loss can be kept to a minimum.

Somebody will be asking you to remove any loose jewellery, earrings, watch, bracelets, necklaces, etc. so that they cannot become detached. Fixed jewellery, like rings will be covered by sticking plaster to avoid static electricity building up. The family diamonds and your Rolex should really have been left at home, but if you have any valuable jewellery please make sure it is given into your partner’s care

Somebody else will be shaving the hair at the bottom of your bump (your pubic hair). We do not shave the hair between your legs, just the bit where the stitches will be, so that hairs do not get caught in the stitches.

You may be asked to drink some salty tasting medicine. This is sodium citrate, and it is to make your stomach juices less acid, so that if you vomit it will not be acidic.

A name band is put on your wrist, if one is not already there, so that if you do need a general anaesthetic, your name can be checked. If you are allergic to anything another wristband usually a red one will be attached with an allergy warning printed on it. Don’t forget to tell us about any allergies.

All the people in theatre have to wear special sort of footwear usually clogs, or boots that have special antistatic soles to avoid static electricity building up. The clogs are noisy. We also wear clean closely woven cotton clothes, cover our hair and sometimes our mouths, to help avoid infection.

A very large and bright light will be positioned overhead to enable the surgeon to have a very good light to work under this light is quite hot.

The surgeon will probably want to do a final check on your abdomen to feel how the baby is lying, it may be necessary to examine you internally.
While all of this is happening to you, other people are getting other things ready. The person who will be passing instruments and equipment to the surgeon is setting out on trolleys everything likely to be needed, so that it is ready to hand. They count and check with another person how many instruments, swabs, stitches they have, so that during the operation they can keep track, and ensure that you don’t leave theatre with more than you came in with! These two people may just seem to be chatting, but they are counting out loud to each other.
The paediatrician (baby doctor) will come in, prepare and check the resuscitation equipment, in case your baby needs help after it is born.
We use suction equipment during the operation and check it before we start. This makes a hissing noise.
There is a lot to be done, if it has all to be done quickly, it must seem like everyone is scurrying around in a chaotic fashion. But it is organised chaos, and very necessary. We do check and cross check, that it is all done before we start.
In addition to all this, at least four people will be “scrubbing up” and putting on sterile clothes. They will be:
The person in charge of the instruments as mentioned previously, she or he will have scrubbed up first, and everybody else has to avoid touching this person as they move around.
The surgeon
Another doctor or midwife to assist the surgeon
The midwife who will take the baby to the paediatician, and assist with the resuscitation of the baby if necessary.
Other people who may be in theatre
If there is serious concern about the baby there may be a specialist baby nurse present as well.
A nurse or midwife who is “running” This is someone who is fetching and carrying and generally assisting, but who is not “scrubbed up” They will check the swabs used and the instruments used with the scrubbed, instrument person.
An operating department assistant. This is a person with special training whose role is to assist the anaesthetist.
Your own midwife to give you support, though she may have been asked to scrub to assist, or to take the baby.
Your partner or other relative or friend of your choice, who will be asked to wear the special theatre clothes.
Even though birth by Ceasarian Section is not without risks and is marginally not as safe as a normal birth, everything that is being done to and for you is being done to make the operative birth of your baby as safe for you and your baby as possible.
If you are having an epidural or spinal anaesthetic the anaesthetist will check very carefully that you will not feel any pain during the operation, though it will be explained that you will feel the movements of the baby being delivered through the incision in your abdomen. Many anaesthetists check the effectiveness of the numbness of your abdomen by rubbing a block of ice over your abdomen and possibly your breasts. Research has shown that the ice is a better method of ascertaining a complete numbness that using a pinprick. The anaesthetist will explain exactly what s/he is doing and that if you have chosen an epidural or spinal anaesthetic it is very occasionally necessary to give you a general anaesthetic i.e. put you to sleep. Please do not hesitate to ask the anaesthetist or surgeon any questions you wish.

Source: This article is from Mary Cronk’s Website.

Birth, a highly respected, peer-reviewed multi-disciplinary journal, just published findings of research on the more-than-twofold increase in neonatal mortality with cesarean birth over vaginal birth in low-risk women. These significant findings should be presented to women who are considering an elective cesarean section.

August 29, 2006 – For mothers at low risk, infant and neonatal mortality rates are higher among infants delivered by cesarean section than for those delivered vaginally in the United States, according to recent research published in the latest issue of Birth: Issues in Perinatal Care. Researchers at the Centers for Disease Control and Prevention analyzed over 5.7 million live births and nearly 12,000 infant deaths over a four-year period. In general, neonatal (andlt;28 days of age) deaths were rare for infants of low-risk women (about 1 death per 1,000 live births). However, neonatal mortality rates among infants delivered by cesarean section were more than twice those for vaginal deliveries, even after adjustment for socio-demographic and medical risk factors.

The overall rate of babies delivered by cesarean increased by 41% between 1996 and 2004, while the rate among women with no indicated risk for cesarean delivery (term births with no indicated medical risk factors or complications of labor and delivery) nearly doubled.

“These findings should be of concern for clinicians and policy makers who are observing the rapid growth in the number of primary cesareans to mothers without a medical indication,” says lead researcher Marian MacDorman. While timely cesareans in response to medical conditions have proven to be life-saving interventions for countless mothers and babies, we are currently witnessing a different phenomenon- a growing number of primary cesareans without a reported medical indication. Although the neonatal mortality rate for this group of low-risk women remains low regardless of the method of delivery, the resulting increase in the cesarean rate may inadvertently be putting a larger population of babies at risk for neonatal mortality.

In the past it was assumed that babies were delivered by cesarean because of a medical risk, thereby explaining the higher infant and neonatal mortality rates typically associated with cesarean births. In this study, only women with no identified medical risk or labor and delivery complication were included in the analysis and a substantial neonatal mortality rate differential was still found, according to MacDorman’s research.

This paper is published in the journal Birth: Issues in Perinatal Care.
Media wishing to receive a PDF of the any of the articles should contact:

Marian F. MacDorman, Ph.D., has been a Statistician and Senior Social Scientist in the Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, for the past 18 years. She received her Ph.D. in Demography from the Australian National University in 1987, and an M.A. in Population Geography from the University of Hawaii, Manoa, in 1981. She is currently co-chair of the SIDS and Infant Mortality Committee for the American Public Health Association (MCH section). For inquires, please call: 301-458-4800

Birth: Issues in Perinatal Care , edited by Diony Young, is a multidisciplinary, refereed journal devoted to issues and practices in the care of childbearing women, infants, and families. It is written by and for professionals in maternal and neonatal health, nurses, midwives, physicians, public health workers, doulas, psychologists, social scientists, childbirth educators, lactation counselors, epidemiologists, and other health caregivers and policymakers in perinatal care.For more information, please visit:

Vaginal bleeding can occur frequently in the first trimester of pregnancy and may not be a sign of problems. But bleeding that occurs in the second and third trimester of pregnancy can often be a sign of a possible complication. Bleeding can be caused by a number of reasons.

Some basic things to know about bleeding are:

  • If you are bleeding, you should always wear a pad or panty liner so that you can monitor how much you are bleeding and what type of bleeding you are experiencing.
  •  You should never wear a tampon or introduce anything else into the vaginal area such as douche or have sexual intercourse if you are currently experiencing bleeding.
  • If you are also experiencing any of the other symptoms mentioned below in connection with a possible complication, you should contact your midwife or doctor immediately.

First Half of Pregnancy:

Threatened Miscarriage:

Typically this begins with bleeding, which may or maqy not be followed by accompanying cramps and lower backache within the next few hours or days. Bleeding can be a sign of miscarriage but does not mean that miscarriage is imminent.Bleeding alone even though heavy, is often transitory and frequently does not end in miscarriage. Studies show that 1 out of every 5 women experience some  bleeding (including spotting) in the first half of pregnancy. If ultra sound or doppler has confirmed that you have a live baby, your chances of carrying your baby to a verifiable age are 90%.

Options for treatment: Rest in bed, make sure you are getting enough protein, salt and calories in your diet and drink plenty of fluids. Taking 500g of Vitamin C with Bioflavanoids can help to strengtthen the placental bed.

To reassure yourself you could have an ultrasound performed, Ultrasound can confirm a pregnancy as early as 6 weeks. The fetal heart can only be heard with a doppler from between 10-12 weeks gestation onwards, earlier than this you will require an ultrasound to see the heartbeat.

Blood tests are another way of determining whether your pregnancy is continuing, these can be performed at most blood pathology laboratory and could be taken by a midwife, G.P, obstetrician, or at the laboratory itself. 2 tests need to be done 5 days apart  to determineif the pregnancy is still viable. This is an accurate and minimally invasive test. The test is known as a Quantitative Beta- hCG test and tests the amount of hCG hormone that is circulating in the blood. 5 days later when this test is repeated,

Inevitable Misscarriage: 

If bleeding steadily increases and is joined by cramps and pain, and especially if accompanied by cervical softening and dilation, the inevitable loss of the pregnancy is much more likely. If the miscarriage is inevitable, you still have some options . Some women choose to go in to hospital immediately and have their uterus emptied by having a D+C ( ie dilation of the cervix and scraping of the uterine wall to empty the uterus) or for a vacuum procedure, others will want to avoid surgical intervention  and let nature take its course.

There are good reasons for women who are not bleeding excessively to adopt a wait and see approach, as lonbg as problems do not arise that make a watch and wait plan unwise. Surgical intervention can damage the cervix or perforate the uterus, may introduce infection and is often a traumatic experience.

If you choose to wait and let things happen naturally, keep in touch with your caregiver. Do not try to manage a miscarriage yourself without any support people present. Keep warm, monitor the bleeding closely, Drink lots of fluids to keep yourself hydrated

Some reasonable guidelines regarding miscarriage are:

  • expect bleeding and cramping to increase until the bleeding is very heavy (soaking a pad every 30 minutes to an hour) and cramping is severe (usually worse than any menstrual cramps)
  • in most cases severe symptoms (as above) should not last more than an hour to an hour and a half, almost all women will have a complete miscarriage in this amount of time. If symptoms are less severe, a miscarriage can take longer, sometimes the fetus will be passed at one point and the placenta a few days later.The amount of bleeding and mother’s overall condition and signs of infection should be monitored throughout a prolonged miscarriage. If signs of infection become apparent or symptoms increase in severity without completing the miscarriage, you will need to go to hospital.
  • If bleeding continues and is more than slight or if pain is prolonged or severe, it is advisable to see a doctor The doctor will then need to determine whether the miscarriage is complete or incomplete. This is often determined by performing an ultrasound and an internal examination.
  • Generally three hours after it appears that everything has passed  the bleeding has slowed down. Pain and cramps will steadily decrease or cease, but slight tenderness may persist for as few days. If tenderness is more than slight or accompanied a fever or foul smelling discharge, further assessment for a possible infection is needed. Bleeding may continue as it would after a birth, however the placental site is small at this point, it should only be a light flow.

Ectopic Pregnancies:

Ectopic pregnancies are pregnancies that implant somewhere outside the uterus. The fallopian tube accounts for the majority of ectopic pregnancies. Ectopic pregnancies are less common than miscarriages, occurring in 1 of 60 pregnancies.

Signs of Ectopic Pregnancies:

  • Cramping pain felt low in the stomach (usually stronger than menstrual cramps)
  • Sharp pain in the abdominal area
  • Low levels of hCG
  • Vaginal bleeding

Women are at a higher risk if they have had:

  • An infection in the tubes
  • A previous ectopic pregnancy
  • Previous pelvic surgery

Molar Pregnancies:

Molar pregnancies are a rare cause of early bleeding. Often referred to as a “mole”, a molar pregnancy involves the growth of abnormal tissue instead of an embryo. It is also referred to as gestational trophoblastic disease (GTD).
Signs of a Molar Pregnancy:

  • Vaginal bleeding
  • Blood tests reveal unusually high hCG levels
  • Absent fetal heart tones
  • Grape-like clusters are seen in the uterus by an ultrasound

What are common reasons for bleeding in the first half of pregnancy?

Since bleeding that occurs in the first half of pregnancy is so common (20-40%), many wonder what the causes are besides some of the complications already mentioned. Bleeding can occur in early pregnancy due to the following factors, aside from the above mentioned complications:

  • Implantation bleeding is one of many normal pregnancy symptoms and can occur anywhere from 6-12 days after possible conception. Every woman will experience implantation bleeding differently—some will lightly spot for a few hours, while others may have some light spotting for a couple of days.
  • Some type of infection in the pelvic cavity or urinary tract may cause bleeding.
  • After intercourse (known as post-coital bleeding)some women may bleed because the cervix is very tender and sensitive. You should discontinue intercourse until you have been seen by your doctor. This is to prevent any further irritation—this can feel quite frightening, although having sexual intercourse does not cause miscarriage, it is advisable to let bleeding settle.

Second Half of Pregnancy:

Common conditions of minor bleeding include an inflamed cervix or growths on the cervix. Late bleeding may pose a threat to the health of the woman or the fetus. Contact your health care provider if you experience any type of bleeding in the second or third trimester of your pregnancy.

Placental Abruption:

Vaginal bleeding may be caused by the placenta detaching from the uterine wall before or during labour. Only 1% of pregnant women have this problem, and it usually occurs during the last 12 weeks of pregnancy.

Signs of Placental Abruption:

  • Bleeding
  • Stomach pain

Women who are at higher risks for this condition include:

  •  Having already had children
  • Are age 35 or older
  • Have had abruption before
  • Have sickle cell anemia
  • High blood pressure
  • Trauma or injuries to the stomach
  • Cocaine use

Placenta Previa:

Placenta previa occurs when the placenta lies low in the uterus partly or completely covering the cervix. It is serious and requires immediate care. It occurs in 1 in 200 pregnancies. Bleeding usually occurs without pain.
Women who are at higher risks for this condition include:

  • Having already had children
  • Previous cesarean birth
  • Other surgery on the uterus
  • Carrying twins or triplets

Preterm Labor:

Vaginal bleeding may be a sign of labour. Up to a few weeks before labour begins, the mucus plug may pass. This is normally made up of a small amount of mucus and blood. If it occurs earlier, you could be entering preterm labour and should see your midwife or doctor immediately.
Signs of Preterm Labor include these symptoms that occur before the 37th week of pregnancy:

  • Vaginal discharge (watery, mucus, or bloody)
  • Pelvic or lower abdominal pressure
  • Low, dull backache
  • Stomach cramps, with or without diarrhea
  • Regular contractions or uterine tightening

Sources :
Anne Frye : Holistic Midwifery

Sara McAleese

“Let us ensure that in improving maternity care, the natural process of birth is upheld with a knowledge that medical care is there to aid women when there are complications, not to prevent litigation or to salve a midwife’s lack of confidence in her practice and skills, or in women’s ability to give birth naturally”

Magill-Cuerden, 1996

ACCORDING to Sultan and Stanton (1996): `there is an increasing awareness among obstetricians of requests for delivery by elective caesarean section.’ The suggestion that every woman should have the right to demand that her baby be delivered by caesarean section is an emotive and contentious issue. While certainly some women with a relative rather than an absolute indication for caesarean section are involved in decision making about their preferred mode of delivery (Mould et al, 1996), for example, women with a breech presentation or having had a previous caesarean, the idea that a woman with no medical, obstetric or psychological risk factors can demand that her child be delivered surgically, at increased risk to herself and her fetus and increased cost to the NHS has no parallel in any other area of medical or surgical care. Johnson et al (1986) found that 10% of obstetricians surveyed would perform a caesarean section for no other reason than that the woman requested it, and this figure may well have increased in the intervening decade.

Indications for Caesarean section

Women are almost three times more likely to have a caesarean birth now than they were twenty years ago (Francome et al, 1993). This rise is attributable to many factors, not least the vastly improved safety of the operation itself and of anaesthetic techniques, but including also fear of litigation (Savage and Francome, 1993). Absolute indications for caesarean birth include cephalopelvic disproportion, transverse or oblique lie of the fetus, placenta praevia, major placental abruption, prolapse of the umbilical cord and severe pre-eclampsia, and these conditions, in which mother or fetus or both would die without surgical intervention, account for between 5.8% and 8.5% of all births (Francome et al, 1993). A 1993 study found that the overall caesarean rate for England was 12.1% (Savage and Francome, 1993), suggesting that not all caesareans are absolutely indicated.
Relative indications include `fetal distress’ and `failure to progress’ in labour (both loosely defined conditions), multiple births, particularly large and particularly small babies, breech babies and women who have had a previous caesarean (Francome et al, 1993). Non-physical indications are less well documented but may include fear of vaginal delivery, fear of pelvic floor damage or previous bad experience of vaginal delivery (Ryding, 1991). Some women may feel that a caesarean section is the `best way’ to have a baby – a view that `is being created by some obstetricians’ according to Hemminki (1997). Whether an obstetrician, faced with a woman demanding delivery by caesarean in the absence of any indication, should be able to accede to her request is the focus of this debate. Although midwives do not make decisions regarding caesarean sections, they have a pivotal role in giving women clear and unbiased information regarding choices for labour and delivery, and are also influenced by changes in the caesarean section rate, as will be demonstrated.

Maternal mortality

Decision making in obstetrics, as in any other area of health care, must be influenced by the perceived risks of a procedure. Elective lower segment caesarean section has been demonstrated to carry a greatly increased risk of maternal death – mortality is approximately 4.5 times as high after elective caesarean than vaginal delivery (Hall,1994) even after controlling for pre-existing medical problems or obstetric complications (Lilford et al, 1990). In fact it is estimated that approximately 140 women die every year in the United States following caesarean sections which were not medically indicated (Savage and Francome, 1993).

Maternal morbidity

Maternal morbidity is also increased by surgical delivery. Postoperative complications include wound infection, pain, uterine infection, urinary tract infection, deep vein thrombosis, chest infection, pyrexia, the need for urinary catheterisation and the need for blood transfusion, and only 9.5% of women in one study had no postoperative problems (Hillan, 1995). Long term problems can include formation of adhesions, intestinal obstructions and bladder injury, and increased risk of placenta accreta and scar dehiscence in subsequent pregnancies (Sultan and Stanton). Psychosocial complications of caesarean birth can include increased hospital stay causing separation from family and other children, separation from the newborn at birth, lengthy physical recovery periods interfering with the relationship with the child (Treffers, 1993) and feeling `too ill’ to breastfeed despite having previously wished to do so (Francome et al, 1993).

Neonatal morbidity

Neonatal morbidity is also significant following elective caesarean section, with the incidence of respiratory distress syndrome and transient tachypnoea of the newborn significantly increased after caesarean section, particularly where the woman has not laboured at all (Morrison et al, 1995). This risk is greatly increased in caesarean sections before 39 completed weeks gestation and, related to this, where the estimated date of delivery has been in dispute (Parilla et al, 1993). The neonate may also sustain injuries at caesarean delivery such as scalpel lacerations and joint dislocation (Sultan and Stanton).

Risks of vaginal birth

Vaginal delivery, however, is not without risk for all women. Sultan and Stanton list possible sequelae to vaginal delivery as emotional and psychological trauma, inadequate perineal repair leading to perineal discomfort or dyspareunia and extension of an episiotomy or perineal tear into the anal sphincter, although this is most likely to be associated with a forceps delivery (Sultan et al, 1994). However, as Magill-Cuerden (1996) points out, `if childbirth results in long-term [pelvic floor] problems, why are we not researching methods of prevention and treatment at the time of birth?’ It is not so long ago that compulsory episiotomy was regarded as a universal preventative for pelvic floor damage, and now prevention of potential problems with incontinence and dyspareunia may increasingly be seen as justification for caesarean section.

Financial cost

Another factor related to decision making must be the cost of a procedure in relation to its benefits. Caesarean sections in the UK cost the NHS approximately £760 more than a vaginal delivery, and it is estimated that every 1% decrease in the caesarean rate nationally would save the NHS five million pounds (Audit Commission, 1997). Five million pounds would pay for approximately 167 more midwives. Caesarean birth on average trebles the amount of time a woman spends in hospital during the postnatal period (7 days compared to 2.5 days) and so results in a greatly increased outlay of midwifery time (Audit Commission, 1997). While expense alone cannot be used to justify the refusal of treatment, it must surely be a factor if morbidity and mortality are shown to be increased rather than reduced by that treatment.

Why women ask

Women’s reasons for requesting caesarean section must be examined closely when deciding whether to accede to their request. Ryding (1991), in a study of women asking for caesarean section on psychosocial grounds, found that among the primiparous women, reasons for the request ranged from three women with unwanted pregnancies who planned to have their child adopted at birth and wished to have a caesarean under general anaesthetic, to two women who were themselves doctors who were convinced (despite their obstetrician’s advice to the contrary) that vaginal delivery was unsafe for their child.
This is similar to the findings of Al-Mufti et al (1996) who surveyed obstetricians and their partners and found that 31% of female obstetricians would request caesarean section for an uncomplicated pregnancy. The other women cited `fear of giving birth’ as the reason for their request. Among the multiparous women, reasons given were previous emergency caesarean, previous perinatal death, previous labour and delivery with obstetric complications and the development of serious health problems following a previous pregnancy. At that clinic, women requesting caesarean on psychosocial grounds were then offered counselling by a psycho-therapeutically trained member of the obstetric staff, following which about half of them decided to choose a vaginal birth (Ryding, 1991). `Labour debriefing’ of women who have had previous traumatic deliveries may also be helpful (Robinson, 1995).

This approach – treating a psychological problem with psychological care, rather then unnecessary surgery, appears to be useful and cost-effective, and there may be a role for midwives in providing labour debriefing and counselling following proper training. Chamberlain (1994) comments that women requesting a caesarean section are `making a cry for help,’ but then goes on to say that he would agree to their request – surely counselling or therapy would be a preferable first option?

Sociocultural reasons

There may be sociocultural reasons why women request caesarean section. Souza (1994) describes how in Brazil some obstetricians have caesarean rates of up to 75% and Sultan and Stanton comment on the: “vicious circle of cultural phenomena and economic influence, enhanced by convenience for the obstetrician,” which has led to vaginal delivery being regarded as: “archaic, painful, disfiguring and a cause of diminished sexual performance.”

Conversely, caesarean delivery, despite being major surgery involving severe pain and permanent scarring, is sometimes seen as the `easy’ way to give birth. Oakley and Richards (1990) discuss how the operation is now conceptualised very differently that other forms of surgery, euphemistically called a `section’ rather than an `operation’ and how it is not expected to carry any of the physical and psychological morbidity associated with surgery (despite evidence to the contrary). Francome et al (1993) point out that obstetricians’ lack of concern about the after-effects of caesareans may reflect the fact that they spend very little time postnatally with women who have had them. Hemminki (1997), referring to the study by Al-Mufti et al in which 31% of female obstetricians stated they would prefer caesarean birth, comments that: “if this view of caesarean section as a good alternative… a view in contradiction with scientific literature… spreads to lay people, the demand for caesarean deliveries is likely to explode at this time of emphasising patient choice.”

Should obstetricians accede?

If women are indeed choosing to request caesarean over vaginal delivery in the absence of any recognised indication, should their wishes be met, particularly now that maternal choice is emphasised in the maternity services as never before? Changes in social policy over the last few years, particularly the Winterton Report and Changing Childbirth, have now embraced women’s right to be at the centre of decisions about their maternity care, and it was on these grounds that the idea that: “it is every woman’s right to demand a caesarean section” became accepted.

However, it can be argued that if women choose caesarean over vaginal delivery, obstetricians and midwives may not be giving them enough information about maternal and neonatal morbidity and mortality following surgical delivery (Viccars, 1997). Sultan and Stanton point out that: “unfortunately, maternal freedom of choice does not always equate with a logical decision in terms of neonatal outcome or maternal well-being.” It is illogical to allow some women to choose surgical delivery at increased risk to themselves and their babies while forcing others to have caesarean sections against their wishes, sometimes by court injunction. Ryding (1991) comments that: “a serious complication or a young mother’s death is felt to be an even greater tragedy if the indications for surgery were not indisputable” and maternal choice cannot be regarded as an indisputable indication.

Losing the ability to give birth vaginally

Savage (1992) has stated that: “as the developed world becomes more and more dependent on technology, there is a danger that people will cease to believe that women can give birth naturally,” and comments that she believes that a reduction in the caesarean section rate can only be achieved by making midwives independent practitioners, mostly based outside hospitals, and allowing them to become the guardians of normal birth again. This view is echoed by Treffers and Pel (1993) who argue that midwives, `dedicated to protecting physiology,’ working in teams with their own caseloads of women, can reduce unnecessarily high levels of intervention. While it is indisputable that lack of intervention in childbirth can have disastrous consequences for women, midwives must seek ways of supporting labouring women and auditing our work so that complications can be reduced without recourse to surgical intervention (Magill-Cuerden) and must believe in women’s ability to give birth and promote that belief, so that our society does not develop such a fear of normal birth that surgery is seen to be preferable.

Sara McAleese


Al-Mufti R, McCarthy A and Fisk N M (1996). ‘Obstetricians’ personal choice and mode of delivery’, The Lancet 347, 9000, 544.

Audit Commission (1997) First Class Delivery: improving maternity services in England and Wales Stationery Office, London.

Chamberlain G (1994.) ‘Balancing risks and choice: discussion’, in: Chamberlain G and Patel N (eds) The future of the maternity services, RCOG Press, London.

Francome C, Savage W, Churchill H and Lewison H (1993). Caesarean Birth in Britain, Middlesex University Press, London.

Hall M H (1994). ‘Mortality associated with elective caesarean section’, British Medical Journal, 308, 6943, 1572.

Hemminki E (1997). ‘Caesarean sections: Women’s choice for giving birth?’ Birth, 24, 2, 124-125.

Hillan E M (1995). ‘Postoperative morbidity following caesarean delivery’, Journal of Advanced Nursing, 22, 1035-1042.

Johnson S R, Elkins T E, Strong C and Phelan J P (1986). ‘Obstetric decision making: responses to patients who request caesarean delivery’, Obstetrics and Gynaecology, 67, 847-850.

Lilford R J, Van Coeverden De Groot H A, Moore P J and Bingham P (1990). ‘The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances’, British Journal of Obstetrics and Gynaecology, 97, 883-892.

Magill-Cuerden J (1996). ‘Intervention in a natural process?’ Modern Midwife, 6, 5, 4.
Morrison J J, Rennie J M and Milton PJ (1995). ‘Neonatal respiratory morbidity and mode of delivery at term : influence of timing of elective caesarean section’, British Journal of Obstetrics and Gynaecology, 102, 101-106.

Mould T A J, Chong S, Spencer J A D and Gallivan S (1996). ‘Women’s involvement with the decision preceding their caesarean section and their degree of satisfaction’, British Journal of Obstetrics and Gynaecology, 103, 1074-1077.

Oakley A and Richards M (1990). ‘Women’s experiences of Caesarean delivery’, in: Garcia J, Kilpatrick R and Richards M (eds) The Politics of Maternity Care, Clarendon Press, Oxford.

Parilla B V, Dooley S L, Jansen R D and Socol M L (1993). ‘Iatrogenic respiratory distress syndrome following elective repeat caesarean delivery’, Obstetrics and Gynaecology, 81, 3. 392-395.

Robinson J (1995). ‘I want a caesarean’, AIMS Journal, 7, 2, 15.

Ryding EL (1991). ‘Psychosocial indications for caesarean section’, Acta Obstetrica et Gynecologica Scandinavica, 70, 1, 47-49.

Savage W (1992). ‘The rise in caesarean section – anxiety or science?’ in: Chard T and Richards M P (eds) Obstetrics in the 1990s: Current Controversies, Blackwell Scientific Publications Ltd, Oxford.

Savage W and Francome C (1993). ‘British caesarean rates : have we reached a plateau?’ British Journal of Obstetrics and Gynaecology, 100, 493-496.

Souza C D M E (1994). ‘C-sections as ideal births: the cultural constructions of benificence and patient’s rights in Brazil’, Cambridge Quarterly Healthcare Ethics, 3, 358-366, cited in Sultan A and Stanton S (1996) ‘Preserving the pelvic floor and perineum during childbirth – elective caesarean section?’ British Journal of Obstetrics and Gynaecology, 103, 731-734.

Sultan A H, Kamm M A, Hudson C N, Thomas Bartram C I (1993). ‘Anal sphincter disruption during vaginal delivery’, New England Journal of Medicine, 329, 1905-1911.

Sultan A and Stanton S (1996). ‘Preserving the pelvic floor and perineum during childbirth – elective caesarean section?’ British Journal of Obstetrics and Gynaecology, 103, 731-734.
Treffers P E and Pel M (1993). ‘The rising trend for caesarean birth’, British Medical Journal , 307, 1017-1018.

Viccars A (1997). ‘Women’s involvement with the decision preceding their caesarean section and their degree of satisfaction’, MIDIRS Midwifery Digest, 7, 2 208.
AH updated 22 July 2001

This article was originally published in MIDWIFERY MATTERS, Spring 2000, Issue No. 84 and was obtained online from Radical Midwives’ Homepage –

The U.S. c-section rate jumped to 29.1% in 2004. This record-setting preliminary figure from the Centers for Disease Control and Prevention represents a sharp increase of more than 40% over 8 years (Hamilton 2005).

In addition to this alert, please see the at-a-glance chart – vaginal birth and cesarean birth: how do the risks compare? (PDF)

Why is the c-section rate rising?

Many factors are driving cesarean rates up, including:

  • providers’ fear of lawsuits: given the way our legal system works, even when scientific evidence supports vaginal birth, providers may feel that performing a cesarean reduces their risk of being sued or losing a lawsuit
  • forced cesareans: more and more women who have had a previous cesarean or whose babies are in a breech rather than head-first position are unable to find doctors and hospitals willing to offer vaginal birth due to fear of lawsuits
  • casual attitudes about surgery: our society is more tolerant than ever of surgical procedures, even when not medically needed
  • growing belief that c-section is “safe” and vaginal birth is “harmful”: these opinions began to form before a careful look at the relevant research, and the research does not support them (see “What are the health costs…”, below).
  • side effects of other common procedures: attempts to start labor artificially (labor induction) and use of electronic fetal monitoring to see how a baby responds to labor interventions are on the rise, and both increase the likelihood that a woman will have a c-section
  • failure to support normal physiologic labor: care that promotes normal vaginal birth processes – such as continuous labor support from a doula, or use of hand movements to turn a breech baby to a head-first position (external version) – greatly lowers the likelihood of c-section.

With more favorable conditions and more appropriate care, a very large proportion of c-sections that are performed in the U.S. could be avoided.

Why are healthy mothers and babies experiencing surgical birth when there is no medical reason?

Birth certificates are the primary source of national data on cesarean births. A recent analysis found that more and more U.S. women who have c-sections have no sign of any medical need for this surgery on their birth certificate (Declercq 2005).

What is driving these surgical procedures? Many policy, research and media reports assume that “elective” cesareans (with no medical rationale) are “maternal request” or “patient choice” cesareans. Because birth certificates and most other data sources provide no information about decision making processes and the motivation of participants, it is wrong and irresponsible to equate c-sections that had no apparent medical cause with “patient choice” cesareans.

One report that looked at this question found that most cesareans with no medical rationale were proposed by doctors, not mothers (Kalish 2004). When mothers ask for such surgery, it is important to understand their motivation, including whether they had access to balanced accurate information on harms and benefits of cesarean versus vaginal birth, access to choices and support for their choices. We need to better understand why women request a c-section with no medical reason, but this should not divert attention from physician and hospital led influences on escalating cesarean rates (Gamble 2000).

Many obstetricians have begun to support “patient choice” cesarean, but do not support women’s right to choose vaginal birth after cesarean (VBAC), vaginal breech birth, and out-of-hospital birth, although the best research suggests that these would be reasonable choices for many women.

This selective support for women’s right to choose surgical birth raises important questions about motivation and conflicts of interest. Cesareans may be attractive to providers who feel that the surgical procedures reduce their risk of being sued or help them better schedule and control their professional and personal lives. They may be attractive to hospitals due to increased revenue relative to vaginal birth (see “What are the financial implications…”, below). An independent investigation is urgently needed to clarify whether these conflicts of interest are driving cesarean rates up and jeopardizing the health of mothers and babies.

What are the health costs of c-sections with little or no benefit?

To provide evidence-based guidance to women and other stakeholders, Maternity Center Association carried out the first and only systematic review to identify the full range of harms that may be worse with c-section or vaginal birth.

Many adverse effects did differ, and nearly all favored vaginal birth. Here is the main conclusion:

Unless there is a clear, compelling and well-supported justification for cesarean section or assisted vaginal birth, a spontaneous vaginal birth minimizing use of interventions that may be injurious to mothers and babies is the safest way for women to give birth and babies to be born.

The following adverse effects were more likely with c-sections:

  • shorter term harms to mothers, such as infection, blood clots and stroke, emergency hysterectomy, surgical injury, more severe and longer lasting pain, poorer overall functioning
  • ongoing harms to mothers, such as pelvic pain and twisted, blocked bowels
  • harms for babies, including surgical injury, difficulty getting breastfeeding going, breathing problems at birth, asthma in childhood and adulthood
  • future reproductive harms for mothers, including infertility, ectopic pregnancy, and serious problems with placentas such as growing into the cesarean scar (placenta accreta) or separating too early from the uterus (placental abruption)
  • harms for babies in future pregnancies, including stillbirth or newborn death, low birthweight, physical malformation.

In addition to painful perineum, just two adverse effects were more likely in mothers with vaginal birth: leaking urine (urinary incontinence) and leaking gas or stool (bowel incontinence). Unfortunately, we can’t make good sense of this research for 2 reasons:

  • effects of common, harmful, unnecessary obstetrical practices: incontinence problems may not be due to “vaginal birth” per se but could be the result of widely used practices such as cuts to enlarge the opening of the vagina (episiotomy), forceful staff-directed pushing and pushing while lying on the back
  • measurement problems, such as investigating too early during the recovery period and using very inclusive definitions that are not based on women’s concerns.

As only about 3% of women who give birth vaginally have any degree of new urinary or bowel incontinence problem, respectively, a year after birth, it is essential to improve the quality of vaginal birth practice and help women resolve any problems by non-invasive measures (for example, “Kegel” pelvic floor muscle exercises) rather than tolerating major abdominal surgery for healthy mothers and babies.

In short, unnecessary c-sections pose plenty of risk to mothers and babies, and offer no clear benefit.

What are the financial implications of a runaway c-section rate?

There is another cesarean-related cost. On average, hospitals charge many thousands of dollars more for a c-section than for vaginal birth. And among the hundreds of procedures performed in U.S. hospitals, c-section is the most common one.

In 2003, U.S. hospitals charged an average of

  • $15,519 for a c-section with complications
  • $11,524 for a c-section with no complications
  • $8,177 for a vaginal birth with complications
  • $6,239 for a vaginal birth with no complications.

The most common reason for hospitalization in the U.S. is a woman having a baby, and there are over 4 million births every year. Avoidable cesarean surgery adds billions of dollars to the burden of health care costs for governments, employers and individuals in the U.S. Access to health care coverage is jeopardized, and health care costs threaten the economic stability of governments, businesses and families. We cannot afford to tolerate costly, avoidable surgical procedures.

What is the ideal c-section rate?

As c-sections have troubling health and financial downsides, they should only be used when they offer a clear, established health benefit. Although needs vary from woman to woman, very low c-section rates are possible for the majority of mothers and babies who are healthy. Both the largest ever study of women giving birth in birth centers (Rooks 1989) and the largest ever study of women giving birth at home (Johnson 2005) found that just 4% of those who began labor in those settings had a c-section. Moreover, neither study found evidence that these low rates and this type of care posed extra risk for mothers and babies when compared to similar healthy mothers and babies experiencing hospital birth. However, as the Johnson report points out, 19% of low-risk mothers end up with c-sections in U.S. hospitals.

“Practice style” (and thus, the likelihood of using cesareans and other maternity interventions) can vary greatly from one maternity provider to another and one place of birth to another. The largest birth center and home birth studies underscore the value of careful choice of maternity caregiver and place of birth.

Variation in practice style also has major cost implications in comparison with average hospital charges of $6,239 (plus charges for newborn care and anesthesiology services) for an uncomplicated vaginal birth, the average birth center charge was $1,624 (with no extra newborn or anesthesia charges) in 2003.

Our in-depth Maternity Topics provide more information on these and related issues:

  • What should I know about cesarean section?
  • Should I choose VBAC or repeat c-section?
  • How can I prevent pelvic floor problems when giving birth?

Declercq E, Menacker F, MacDorman M. Rise in “no indicated risk” primary caesareans in the United States, 1991-2001: Cross-sectional analysis. BMJ 2005;330:71-2.

Gamble JA, Creedy DK. Women’s request for a cesarean section: a critique of the literature. Birth 2000;27:256-63.

Hamilton BE, Ventura SJ, Martin JA, Sutton PD. Preliminary births for 2004: infant and maternal health. Health E-stats. Released November 15, 2005.

Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416.

Kalish, R.B., McCullough, L, Gupta, M., Thaler, H.T., and Chervenak, F.A. (2004). Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol, 103, 1137-1141.

Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen E, Rosenfield A. Outcomes of care in birth centers: The National Birth Center Study. N Engl J Med 1989 321:1804-11.

U.S. Agency for Healthcare Research and Quality. HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ, 2005. [DRGs 370-373.]

©2005 Maternity Center Association. All Rights Reserved.

Los Angeles – A Caesarean delivery more than triples a woman’s risk of dying in childbirth compared to a vaginal birth, according to a new study from France.

The risk is still quite small, but many developed countries have seen a dramatic rise in the number of Caesareans performed each year as more women elect to avoid a vaginal delivery.

Researchers, led by Catherine Deneux-Tharaux of the Maternite Hopital Tenon in Paris, looked at 65 maternal deaths recorded in the French National Perinatal Survey from 1996 to 2000.

All of the deaths followed births of a single child and were not due to conditions existing prior to delivery. The women had also not been hospitalised during pregnancy.

The researchers found that the risk of death – from blood clots, infection or complications from anaesthesia – was 3,6 times higher for women who had Caesareans.

The risk of death after childbirth was increased whether or not the Caesarean was performed before the onset of labour or during labour.

The study was published in the September issue of Obstetrics and Gynecology.

Although rates of maternal death in most developed countries are relatively low – United States women have a 1 in 3 500 chance of pregnancy-related death – the incidence of maternal mortality has not significantly decreased in the last two decades, according to American College of Obstetricians and Gynecologists.

Source: IOL
(September 01 2006 at 07:05AM)