Natural Caesarean section is safe, popular and feasible and is not encouraging maternal requests for C-section births

Dr Felicity Plaat, a Consultant Anaesthetist at Imperial College Healthcare NHS Trust London, UK, also says the technique is associated with increased breastfeeding rates, although she says more evidence is needed.

Some 20-25% of pregnant women in the UK give birth by Caesarean section. It was in 2008 that Dr Plaat, along with colleagues midwife Jenny Smith and Professor of fetal medicine Nick Fisk described a technique for natural Caesarean section, that together they had developed in their unit at Queen Charlotte's Hospital in London.

During a natural CS, the way the baby is removed more slowly from the abdomen mimics normal birth more. Crucially, the parents' role is central rather than reduced to a passive patient role. The drapes are lowered so they can actually see their baby being born. Whenever possible their wishes are granted (lower lighting, choice of music, no unnecessary talking in theatre). "As an anaesthetist I need to give an anaesthetic that allows mum to freely interact with her baby immediately, whilst ensuring both are safe," explains Dr Plaat.

Natural CS incorporates evidence based elements used during vaginal birth that promote bonding, breast feeding and enhanced maternal satisfaction, that are absent from conventional CS. "Reaction to the publication of our paper was immediate and initially hostile: the lack of scientific trial evidence for the efficacy or safety of the technique and the potential to encourage women to ask for CS delivery were major concerns," says Dr Plaat. "However, most women who have CS are advised to do so -- there is a medical indication. In the UK at least, with the emphasis on normal (vaginal) birth, many women requiring CS have a feeling of inadequacy or even failure. The natural CS appears to mitigate this, by increasing bonding opportunities between mother and baby, rather than immediately taking away the baby to be cleaned and weighed and measured, as happens in conventional CS."

A survey carried out in the UK by the Obstetric Anaesthetists' Association at the end of 2010 showed that the full natural CS was offered by only 2.5% of maternity units but one or more elements of the technique were offered by 55%. Almost half of respondents were aware of the Natural CS. "Anecdotally a lot more units are offering versions of natural CS in the UK in 2017," explains Dr Plaat. She adds: "The only randomised controlled trial of natural CS compared to conventional CS was carried out in a unit in Germany. This trial found improved breastfeeding rates, no increase in any complications and a much better patient experience. However we need to investigate further where the technique is being used in Europe."

She adds that originally, Natural CS was only offered to women having pre-planned C-sections who are healthy with healthy babies, but were indicated for C-section because of their babies being in wrong position or other obstetric causes. This would account for some 30- 35% of all C-sections. But she adds that in the USA a group at Rhode Island Memorial Hospital (see link to USA paper below) has begun offering natural CS to women having unplanned emergency CS.

The German study of natural CS found there was no increase in the rate of the so-called CS on demand or maternal request during the duration of the study at the Charité University Hospital, Berlin. Nor is there any evidence that natural CS has increased 'maternal request' CS in the UK. This is a contentious subject in the UK. Currently fewer than 1 in 20 CS births in the UK are requested by the mother with no medical reason.

However the official positon of the UK's National Institute for Health and Care Excellence is that, quote, "if a woman is fully informed and has been counselled about risks they should be allowed to request CS without medical indication 'as not agreeing to a request for a CS could have a negative impact on a woman's mental health and potentially lead to a long-term need for psychological support postnatally'."*

Dr Plaat also points to legal action that recently took place in the UK that ruled that patients should be told about reasonable alternatives to any treatment offered by their doctor. To quote the judge in this case [Montgomery v Lanarkshire Health Board [2015] UKSC11]: "a patient is entitled to take into account her own values, her own assessment of the comparative merits of giving birth in the "natural" and traditional way of giving birth by Caesarean section, whatever medical opinion may say, alongside the medical evaluation of the risks to herself and her baby."

She concludes: "I believe natural CS makes the experience of birth much more satisfying for the increasing number of women who require CS. Denying women this in order to discourage them from considering this mode of delivery is in my personal opinion, completely unethical."