Choosing Cesarean: A Natural Birth Plan

Choosing Cesarean: A Natural Birth Plan

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by Magnus Murphy, Pauline McDonagh Hull

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Obstetrician and gynecologist Magnus Murphy, MD, and journalist/advocate Pauline McDonagh Hull offer a compelling case for surgical delivery as a legitimate birth choice for informed women. By offering a wealth of medical evidence from around the world and thoughtfully countering the many objections detractors have lodged against it, the authors convincingly


Obstetrician and gynecologist Magnus Murphy, MD, and journalist/advocate Pauline McDonagh Hull offer a compelling case for surgical delivery as a legitimate birth choice for informed women. By offering a wealth of medical evidence from around the world and thoughtfully countering the many objections detractors have lodged against it, the authors convincingly demonstrate that a planned cesarean birth at thirty-nine- plus weeks is a safe and often preferred alternative to a planned vaginal delivery. An indispensable guide for women, their families, and medical professionals.

Editorial Reviews

From the Publisher
"A must-read for all women."
—Dr. Jennifer R. Berman

"An excellent presentation of the complex issues surrounding maternal request cesarean delivery. . . .
The authors have addressed the most common and most debated pros and cons in such detail as to allow the individual patient and her physician to make a truly informed decision."
—Ralph W. Hale, MD, Executive vice president, American College of Obstetricians and Gynecologists

"A must-read for all women. Women need to be informed with all information related to elective c-section versus vaginal birth. This book arms women with the information needed to make the choice that suits them best."
—Dr. Jennifer R. Berman, Urologist and sexual health expert, Berman Women’s Wellness Center

"As a global maternal health advocate, I hope that all women will someday have more birth options to choose from—and that once a woman has had access to information about her options and makes an informed decision about her birth, the rest of us will stand behind her to support that choice."
—Christy Turlington Burns, Director/producer No Woman, No Cry; founder, Every Mother Counts

"At last a sensible and ‘easy-to-read’ book about the pros and cons of cesarean at the mother’s request. It reviews the scientific evidence thoroughly enough to satisfy professionals but also explains it in straightforward language for the nonmedical reader."
—Phil Steer, MD, frcog, Emeritus professor, Imperial College London; editor in chief, BJOG, An International Journal of Obstetrics and Gynaecology

"A thoroughly readable book, beautifully written and well researched. The authors offer a supportive approach with informed decision making. . . . A compelling book I can thoroughly recommend."
—Dr. Peter De Jong, Consultant obstetrician and gynecologist, University of Cape Town

Library Journal
In this title, physician Murphy (obstetrics & gynecology, Univ. of Calgary; coauthor, Pelvic Health and Childbirth: What Every Woman Needs To Know) and former BBC journalist Hull (editor, argue for one particular method of childbirth they think should be available to all women: elective Cesarean sections (C-sections). They are quick to point out that they are not advocating for all women to have C-sections; rather, they want women to be aware of the risks and benefits of vaginal vs. C-section births and make evidence-based choices. Despite the authors' apparent sincerity in their argument and the extensive references they offer to support their case, many readers are unlikely to be swayed. VERDICT This book is unique in its willingness to openly address the risks of vaginal delivery, making it a valuable addition to any pregnancy- and childbirth-related shelf. Expectant mothers should keep the authors' obvious preference toward elective C-sections in mind as they process its information. While this title may not change readers' views of childbirth, it presents an idea worth exploring.—Mindy Rhiger, Mackin Educational Resources, Minneapolis

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Prometheus Books
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Read an Excerpt

Choosing Cesarean

By Magnus Murphy Pauline McDonagh Hull

Prometheus Books

Copyright © 2012 Magnus Murphy, MD, and Pauline McDonagh Hull
All right reserved.

ISBN: 978-1-61614-511-8

Chapter One

A Cut above the Rest: My Own Informed Decision

By Pauline M. Hull

First they ignore you, then they ridicule you, then they fight you and then you win. —Attributed to Mahatma Gandhi (1869–1948)

Probably the most frequent question that I am asked by journalists, and also by friends and family, is "Why did you choose to have a cesarean?" So here, for the record, is my answer.


The onset of puberty spurred some of my earliest conflicts with Mother Nature and all things natural, and funnily enough (depending on your sense of humor), a sharp-edged blade was involved in one of these too. The first example was when I made the apparently contentious decision to introduce the hair on my legs to a nice sharp razor, against the sternest advice from an aunt.

"Don't!" she warned. "Your hair will grow back twice as thick as it is now, and you'll regret it forever."

Needless to say, I haven't regretted my decision to live with fuzz-free shins since that day forward (although I did wait a few weeks before shaving my whole leg, just in case), and indeed, other areas of depilatory care were to follow without further ado. Next up was my desire to buy a bra. The natural look just wasn't cutting it anymore inside the thin white cotton shirt of my school uniform, so I decided to intervene.

"You don't need to measure me," I insisted in the shop. "I can tell just by looking at all the bras which size I'll need." But as it turned out, I couldn't. My youthful impatience and ignorance of this new set of ABCs created such angry red marks around my chest and back that barely a week later I had to make a rather sheepish return to the store for a proper fitting. What's the point of these childhood anecdotes?

First, they illustrate that from a very early age, so much of what women choose to do with their bodies is not natural. In our attempts to make ourselves prettier, smarter, younger, thinner, happier, or whatever it may be ( you name it, there's an artificial method available), we often employ un natural means to facilitate our own perceived satisfaction. Yet while we're busy trying to make these choices, there are external influences telling us what choices we should or shouldn't make and putting constant pressure on us to rethink our natural instincts or desires. And perhaps nowhere is this more prevalent than when it comes to having children. For example:

• Birth control (pills, condoms, injections, diaphragms, coils, etc.) helps us manipulate when or if we get pregnant, which for increasing numbers of women means delaying motherhood long after the alarm on their naturally ticking clock has gone off. We simply hit the snooze button to buy ourselves a little more time, and then another month or even year passes before the alarm bells begin to ring once more.

• Abortion offers us an alternative to carrying our babies to term, and whether it's legal, ethical, moral, or otherwise, the fact remains that it is medically possible and widely available.

• In vitro fertilization (IVF) and surrogacy provide us with an alternative means of starting a family (or the chance of having one, at least) if we, or our partners, are infertile or struggling to conceive.

• Ultrasound technology, blood tests, urine samples, and other regular medical monitoring (some or all of which are employed throughout pregnancy) give us a special preview of life formation and alert us to potential problems at a level that is just not available naturally.

My childhood anecdotes also highlight the importance of making an informed decision. For example, my decision to wear a bra was one born of personal size, comfort, and timing more than it was a symbolic step into womanhood, but even so, in choosing to strap a (wo-)manmade contraption to my body, I should have done my homework first.

And so this is precisely what I did when it came to my birth plan. I realized that some women feel a natural pull toward vaginal birth and that others feel entirely ambivalent about delivery type, and I also knew that I felt differently. For me, there was a choice to be made, and again, initially at least, this choice was purely instinctive.

But with more than just a few red bra strap marks at stake this time, I made sure that my decision about which birth plan would fit me best was an informed one, and after careful consideration, research, and planning, I chose a cesarean, and these are my reasons why.


Truthfully, ever since I understood that it was a possibility, I knew I wanted a cesarean. Even as a young woman, it seemed a perfectly logical and natural choice to me: a planned, controlled birth with the aid of a competent surgeon in favor of an unpredictable, potentially painful birth plan dependent on the vagaries of Mother Nature. I never felt an urge or desire to pursue the physical rite of passage into motherhood that I'd heard other women describing, and indeed, I felt the exact opposite of eagerness when they would talk excitedly about the drama of waters breaking; contractions starting; Hollywood-style car races to the hospital; and the number of hours, days, and perineal stitches they could chalk up to their children's births. To my ears, it all sounded like the most barbaric initiation ceremony for membership into a paradoxically competitive club that I had no intention of joining. I might want a baby, but I certainly didn't want one the traditional way.

That said, by the time I began thinking seriously about becoming pregnant in my early thirties, there was much more involved than an instinctive desire to avoid pain and trauma for myself. I'd done a great deal of research and decided that without doubt, my baby would be safer if I took a planned surgical route rather than a trial of labor. Ironically, after everything I'd read, I now had some fears about a cesarean birth in terms of my own risk and discomfort, but not my baby's. For example, I hated the idea of spinal anesthesia (which is partly why promises of an epidural did nothing to entice me toward a trial of labor—I was worried enough about someone sticking a needle into my spine without adding the force of a labor contraction into the mix), and I wondered how difficult the recovery might be as a new mom. But these were things I decided I could tolerate because to my mind, I was 100 percent convinced that the least traumatic outcome for my baby would be cesarean delivery at thirty-nine-plus weeks into my pregnancy.

And how did I reach this controversial conclusion? Due to the nature of my website, which I began work on back in 2004 while still working as a BBC journalist, I had knowledge of numerous medical studies from around the world that demonstrated very positive outcomes with planned cesarean birth that had never really received the wider attention they deserved, in news media, mainstream books, and websites, or by medical professionals providing prenatal information. After reading these and essentially conducting a personal risk-benefit analysis that culminated in a supportive and individualized consultation with my obstetrician (a process every woman is advised to carry out, whatever her birth preference), I felt confident I was able to make a truly informed decision about how to give birth.


It is true that the majority of babies born vaginally arrive safe and healthy, but it is also true that natural birth is fraught with complications and trauma that can lead to moderate or severe injuries and even death. And while many experts point to various statistics and data to demonstrate that these frightening incidences are relatively rare in the developed world or that the percentage of babies actually affected is relatively low, I would always think of the words of a doctor I'd heard speak at a birth conference. The gist of what he said was exactly how I had always felt about risk: "Whatever the statistics say, when it's your birth, and your baby, the only number that matters to you in the end is 'number one' [you], and if anything bad does happen, it's happening to you and your baby 100 percent."


When I asked myself which type of birth pain I could tolerate best, the answer was simple. I had read the evidence on postpartum pain, injury, and discomfort in women following both vaginal births and cesarean births, and I concluded I would be better able to tolerate and live with those described by women in the latter group. Obviously, I was aware of examples of women with spontaneous vaginal births who had escaped any perineal laceration or episiotomy, but with around half of all mothers experiencing at least one of these, I didn't see this as an insignificant risk. As for the cesarean, I understood that there would be a surgical incision and multiple layers of bruised and torn internal tissue to contend with, but I still felt confident that I'd be able to manage this pain.


We've dedicated a whole chapter to this very controversial reason for choosing a planned cesarean ("Cesarean for Sex: The Ultimate Birth Taboo?"), and I must admit that it was a factor I considered. Quite simply, I valued my sex life and didn't want to take any unnecessary risks with the birth of my child that might endanger it. Does that make me a bad mother? I don't believe so. Again, it seemed to me to be a question of tolerance. I knew a number of women who'd had stitches following their vaginal births, and the lucky ones completely accepted any changes in their perineal area as normal; some even joked about receiving an "extra stitch" for their husband (also known as "the husband's knot") or described to me through laughter the new harmless "knobbly bits" they could feel that weren't there before. But others described how their sex life was altered due to ongoing pain and discomfort in and around their vagina. Meanwhile, what I found incredible when discussing and researching this particular risk was that while I wasn't really supposed to be thinking about post-birth sex, the possibility of women experiencing an orgasm during vaginal birth seemed far more acceptable. And I remember thinking, "It's a funny old world."


When I became pregnant, my husband and I agreed that whatever could be known, we wanted to know. For example, when my fetal nuchal translucency and blood tests showed our baby to be at high risk of a chromosomal condition (such as Down syndrome), we chose to have an amniocentesis and find out for sure. And when we were asked whether we wanted to know the sex of our child, we replied with an emphatic yes in both pregnancies. For the birth itself, we liked the fact that with a cesarean, the baby would be delivered very quickly and taken away for a thorough health check while I was being stitched back up. No waiting around for contractions to start, no lottery ticket as to who would be taking care of me when I arrived at the hospital. No debate among the medical team halfway through about what to do or when to do it, or even whether the necessary staff and resources would be available. That's not to say I didn't appreciate that a cesarean plan could be unpredictable too (quite naturally, I imagined all sorts of worst-case scenarios); I just felt that it was more predictable than labor. And should anything go wrong, I couldn't think of a better place to be than in the operating room with my trusted doctor and her team. Also, on a purely practical level, it was beneficial being able to plan the time and date of my births, particularly for arranging the care of our daughter during our son's birth and managing packers for our house moves. However, I would stress that our schedule did not dictate our birth choice; rather, our birth choice facilitated our schedule.


I was very satisfied with each of my cesarean birth experiences (and I say this gratefully, not smugly). I came home with two healthy babies, my obstetrician was wonderful, I recovered well, and I have never suffered flashbacks or any other psychological trauma related to the births. My husband was happy with how the births went, too, and I mention this because sometimes the birth experience of men is downplayed or forgotten. Interestingly, my husband had no notion of birth preferences at all when we discussed having children. He says that back then, he would have gone along with whatever I wanted, natural or surgical. But now, after years of hearing stories from his peers about their more traditional birth events, my husband says he appreciates how different his more relaxed experience was from many of their realities: for example, one colleague's hour-long emergency transfer from a birthing center thinking he was going to miss the birth because he wasn't allowed to go with his wife when she was sent ahead in an ambulance, another whose wife has just had a second surgery for prolapse in her early forties, and a friend's etched memory of blood on the labor ward floor and a doctor's stark warning to prepare himself because his wife might not make it.


Finally, I feel that motherhood is a very personal journey for every woman right from the start. We each have a unique perspective and approach, and we all feel differently about raising our children—just as we do about birth. I viewed birth merely as a means to an end and had no expectation or desire that it should be personally fulfilling or special in itself. In fact, I'd probably never have thought much of it again except for the nature of my work, and I have sometimes wondered whether this could be one of the reasons maternal request has earned itself an almost mythical reputation. Perhaps women choosing cesareans just don't consider their birth experience as something worth talking, writing, or shouting about once it's over, and consequently, their silence is misconstrued as nonexistence. But even though their birth stories are not necessarily being heard in a public forum, it's highly likely that they are being heard by a very large audience indeed: their daughters, the next generation of mothers. And if I'm right, and this is the case, surely the time has finally come to stop denying that women like me exist, and as a society, to accept that the phenomenon of maternal request cesareans is not going away anytime soon. On the contrary, if our daughters have anything to do with it it's simply an inevitable feature of our birthing future.


Excerpted from Choosing Cesarean by Magnus Murphy Pauline McDonagh Hull Copyright © 2012 by Magnus Murphy, MD, and Pauline McDonagh Hull. Excerpted by permission of Prometheus Books. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Meet the Author

Magnus Murphy, MD (Calgary, Alberta, Canada), is the author (with Carol L. Wasson) of Pelvic Health and Childbirth: What Every Woman Needs to Know. He is an assistant clinical professor in the Department of Obstetrics and Gynecology at the University of Calgary. He is also in a private practice specializing in pelvic floor disorders and at the Pelvic Floor Clinic at the Calgary Regional Health Authority. He created the website, which provides information on these disorders.

Pauline McDonagh Hull (Farnham, Surrey, UK) is editor of, a Web site that provides specific information on elective cesareans and offers support to women with this birth plan. She also campaigns for recognition of the legitimacy of planned cesareans via her blog Formerly, she worked as a BBC News broadcast journalist and producer in London.

From the Trade Paperback edition.

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Choosing Cesarean: A Natural Birth Plan 3 out of 5 based on 0 ratings. 2 reviews.
AwaitingJuno More than 1 year ago
I bought this book when I was expecting my second child and only wish it was available when I was expecting my first! It is a very well researched book - it does not advocate cesareans for all, but does advocate that women make informed decisions regarding their birth plans. It provides an overview of the risks and benefits of vaginal births (too often those risks are ignored or given little attention) as well as the risks and benefits of planned cesarean. It also provides the risks and benefits of cesarean delivery. Planned cesarean can be a good choice for women who are planning small families and/or those who are at high risk of needing an emergent cesarean. It is about time the fairy tale of vaginal deliveries being good for all women was debunked, and this book does that with evidence based information. A valuable resource for any woman interested in making a truly informed decision regarding her options for delivery of her child. The planned cesarean I experienced for the birth of my second child was far better (emotionally and physically) than the unplanned vaginal deliver I experienced with my first child and this book provided me with a very clear understanding of what I could expect from a cesarean birth plan.
Anonymous More than 1 year ago
This book is incredibly dangerous to women! Cesarean is major surgery and there is major risk involved. To say that it is the safest option for ALL women is a ludicrous statement that even the most intervention-happy OB would shy away from. Yes, cesareans have a place. That place is with high-risk women who need the surgery to save themselves or their baby!