From the minute she found out she was pregnant, 31-year-old Beth Nightingale knew how she wanted to give birth. ‘On my first midwife appointment, I asked for a caesarean,’ she says. ‘I struggle with anxiety and I knew I’d be a complete state doing it the natural way.’
But the reaction from her midwife was not exactly encouraging. ‘She immediately ruled it out,’ says Beth, a marketing manager from Essex. ‘I was told caesareans weren’t for first-time mums like me – they were only for people who’d had previous traumatic births. So I thought I just wasn’t allowed one.’
Beth’s due date came and went. Two weeks late, doctors decided to induce the labour by breaking her waters. Still her baby wouldn’t budge. They tried forceps, and an epidural was needed.
Anxious about the failed attempts to help her give birth this way, Beth repeatedly asked if she could have a caesarean – but her obstetrician wasn’t willing.
‘They kept saying it was safer to continue to try to have the baby normally, which I never quite understood,’ she says.
During the marathon 36-hour labour, Beth developed a potentially lethal infection. And when forceps failed to work, she was rushed into an operating theatre where, finally, she gave birth… by caesarean section.
But instead of it being a routine, planned procedure – one that’s generally low-risk – it was an emergency. Without it, mother and child may well have died.
But during the frantic rush to get her baby out, Beth’s womb ruptured due to internal damage caused by the forceps.
Beth Nightingale and her baby daughter (no name given) who suffered a traumatic natural birth and ended up having an emergency caesarean
She was transferred to a high-dependency unit where she then developed sepsis, a life-threatening immune-system reaction.
‘It was just one nightmare after another,’ she says. ‘I remember asking the doctors, ‘Am I going to die?’ ‘
Beth was in hospital for a week, and it was months before she was strong enough to resume a normal life. Thankfully, her daughter Raina, now ten months old, was fine and unscathed.
The same cannot be said of Beth. Physically, she says she’s no longer in pain. Psychologically, though, the trauma is unshakable. ‘I am terrified about having another child,’ she says.
In Britain in the 1950s, just three per cent of babies were born by caesarean section.
‘I don’t know if I’ll be able to carry it to term or if I’ll be able to give birth again safely.’
She admits that her initial anxiety about giving birth, which led her to ask for a caesarean, and the way in which her labour turned into a disaster, were unconnected. She was healthy, and her pregnancy was straightforward. The fact that it went so badly was just ‘one of those things’.
But she has been left with a deep sense of frustration. ‘It all could have been avoided if they’d have just let me have the caesarean that I wanted,’ she explains.
According to experts, Beth is far from the only mother to be denied her choice – and suffer the gruesome consequences. Despite concerns about a rising number of caesarean sections – and mothers deemed ‘too posh to push’ – top gynaecologists have warned that thousands of women are in fact not allowed a caesarean birth, when it might be the best option, and suffer life-changing injuries as a result.
‘Serious pelvic-floor disorders involving incontinence and other debilitating symptoms are sadly becoming more common among our patients after birth, with many needing several further operations,’ says Dr Robert Freeman, an NHS consultant gynaecologist working in the West of England.
According to guidance set by the National Institute for Health and Care Excellence, all women should be allowed to choose a caesarean, as long as the risks and benefits of both methods of birth are communicated, enabling mums-to-be to ‘make an informed decision’.
The cost of a routine caesarean delivery to the NHS is roughly £3,000 – twice that of a vaginal birth. However, some research has suggested it’s cheaper to offer caesareans, as there are fewer complications requiring additional treatment, and fewer claims for compensation afterwards.
Despite this, NHS data obtained in 2018 by the charity BirthRights found that 15 per cent of the 146 NHS trusts approached did not offer planned caesareans for those without medical conditions.
The cost of a routine caesarean delivery to the NHS is roughly £3,000 – twice that of a vaginal birth. However, some research has suggested it’s cheaper to offer caesareans, as there are fewer complications requiring additional treatment, and fewer claims for compensation afterwards
And vaginal deliveries are the default option offered by most NHS trusts, even when a caesarean might be a better option.
The new warnings come six months after an independent inquiry ruled that a ‘lethal reluctance to conduct caesarean sections’ was partly to blame for a spate of tragic maternity deaths at the Shrewsbury and Telford Hospital NHS Trust between 2000 and 2019.
Dr Freeman says: ‘Women are not being warned about the risks of vaginal delivery and spoken to about other options, like caesareans. This is especially true for those at high risk. Instead, they think these injuries are a normal part of childbirth, when they needn’t be.’
Jen Hall, from the childbirth injury charity MASIC, says her organisation has seen a significant rise in the number of women seeking their support over the past two years. ‘We used to have a handful of mothers contact us a month, but these days we’re getting requests every day from women who are in desperate need of help.’
The term ‘caesarean’ is thought to derive from the Latin word caedare, which means ‘to cut’.
Clive Spence-Jones, consultant obstetrician and gynaecologist at the Whittington Hospital in North London, says: ‘In many cases, a caesarean section is the most common-sense form of delivery.
‘If you have a woman with no risk factors and a smallish baby, a vaginal birth is great and unlikely to cause much long-term damage.
‘But these days there are thousands of women who don’t fit into this category because they are older, and maybe bigger, and are at a higher risk of serious tears and damage to the pelvic organs during a vaginal birth.’
A recent analysis of NHS hospital data by researchers from the London School of Hygiene and Tropical Medicine showed a three-fold increase in the incidence of childbirth-related pelvic injuries, as a result of vaginal births, since 2000.
Paradoxically, during the same period, the number of caesareans carried out has risen too – from one in five births to one in four. In one 2018 report published in The Lancet medical journal, researchers called the increase ‘alarming’, warning of links between caesareans and immune- system disorders such as asthma in children.
There are significant risks associated with the surgery – blood clots, potentially lethal infections and increased chance of hysterectomy.
And once a mother has one caesarean, all future births are likely to be delivered by caesarean section. The womb, once cut, will never be as strong again. Despite this, Ranee Thakar, NHS consultant gynaecologist and obstetrician working in a South London hospital, says: ‘I wouldn’t describe the rise in caesareans as alarming. There is no ideal number of caesareans.’
She adds: ‘We need to move away from concepts of an ‘ideal’ birth and lean towards personalised care – there are risks and benefits with both methods.’
‘Serious pelvic-floor disorders involving incontinence and other debilitating symptoms are sadly becoming more common among our patients after birth, with many needing several further operations,’ says Dr Robert Freeman (pictured), an NHS consultant gynaecologist working in the West of England
The rise in severe injuries is also linked to increasing numbers of higher-risk women giving birth. Age and obesity mean women’s bodies are less naturally resilient to the stresses of complications such as prolonged labour, making damage to the area more likely.
And today, more pregnant women on average are older than ever before – aged nearly 31 when they first give birth, compared with 24 in the previous generation. Meanwhile, a 2019 study showed that the number of obese mothers has doubled in a decade, from 22 per cent to 44 per cent.
During our investigation, we heard from more than 20 women who said they were not given caesareans, despite requesting them.
One mother told us that she was given a forceps delivery ‘against my will’. The forceps failed, but during the process the mother suffered nerve damage to her legs and hips, and her daughter was left with facial injuries.
Another woman asked for a caesarean, concerned that her 5ft, 7½-st frame would not be able to cope with childbirth, but was told just to have an epidural if she couldn’t stand the pain.
Now, 13 years on from the vaginal delivery, which required the use of forceps, the nerves near her bowel remain damaged, compromising her ability to detect when she needs to go to the toilet.
Another woman, 37-year-old Amy Ranjbar from Plymouth, was told to continue pushing for ten hours, resulting in a fourth-degree tear from the vagina to the back passage. Roughly 40,000 women suffer this every year, resulting in recurrent infections, acute pain during sex and, sometimes, faecal incontinence, according to the Royal College of Gynaecologists and Obstetricians.
Nine years on, Amy still suffers incontinence and severe pain during sex and has a suspected organ prolapse. ‘I remember friends being so judgmental about caesarean sections, saying it was taking the easy option and I should try to do it the natural way,’ she says. ‘But why should any woman have to go through what I did if they don’t want to?’
Forty per cent who give birth vaginally will suffer a pelvic-floor condition lasting at least a decade after birth, and one in three will have urinary incontinence.
One in ten have a pelvic-organ prolapse – where one or more of the organs in the pelvis slip down and bulge into the vagina.
A recent survey by MASIC found that nearly half of those who sustained these injuries suffered post-natal depression as a result, while a quarter regretted having a child because of the trauma.
The idea that women who ask for a caesarean are ‘too posh to push’ is simply untrue, says gynaecologist Dr Freeman.
‘The most common reasons women ask for caesareans is because of terrible problems first time round and mental health issues like anxiety. Most women want to have a vaginal delivery.’
Experts also say that some of the supposed risks posed by caesar_eans to babies have been ‘exaggerated’, with a wealth of research showing no long-term consequences for children.
Research also shows that the majority of caesarean sections carried out are performed as an emergency, which is riskier than a planned one.
There are a number of reasons why this may happen, most commonly due to the position of the baby, pre-eclampsia, or if it is presumed the baby is in distress.
Doctors may recommend a caesarean at the beginning of pregnancy if the mother has underlying health conditions, if the baby is developing abnormally, or in the case of multiple births.
But Mr Spence-Jones says there are other women who would benefit from a caesarean.
‘Some who are very small and have a newborn with a large head circumference could suffer debilitating injuries with a vaginal birth, and a caesarean may well be the less risky option,’ he says.
‘People who have hypermobility, where joints are unusually stretchy, are also at increased risks of serious tears and pelvic damage, because the tissues in the area are weaker.’
Research by Dr Freeman found that very short women – such as those under 5ft – were at high risk of a difficult labour and pelvic-floor damage.
In 2016, the Royal College of Gynaecologists and Obstetricians held a consultation on whether to routinely warn all pregnant women of the risks of vaginal birth, in the same way they must with a caesarean. It followed a landmark legal case in which the Lanarkshire health board was forced to pay out for failing to warn a new mother – whose baby got stuck during delivery and suffered brain injury – of the risks of vaginal birth.
The Supreme Court judge ruled that the problem would have been avoided if a pre-labour caesarean section had been performed.
But, after deliberating, there was no change in the guidance.
Experts say guidelines must change and that women should now be told of potentially life-changing injuries that a ‘natural’ labour can cause.
‘Many of my patients who have been left injured by their vaginal delivery say they wish they had known there was a risk this might happen,’ says Ranee Thakar.
‘It doesn’t necessarily mean they would have chosen a C-section instead, but at least they’d have had realistic expectations.
‘We talk to pregnant women about everything else – such as breastfeeding and what to do with the baby – but we don’t talk about the fact you might be left with a prolapse or incontinence.
‘We have to start being frank and honest, and empowering women to make their own informed choice, whatever choice that might be.’