The Sunday Times MediScene - WHEN TO CUT, WHEN NOT TO!

In modern medicine, most patients are well aware of their right to say a firm 'no' to serious surgery. Less clear, however, is one's right to ask for it, especially when the pros and cons of the procedure are a little hazy. The elective caesarean or c-section is a perfect example. Despite the fact that a c-section qualifies as a major abdominal surgery, expectant mothers are increasingly asking for caesareans…presenting their doctors with a dilemma. To cut or not to cut? That is the question.

Here Mediscene speaks with Dr. Nithya Jayawickrama, senior consultant obstetrician and gynaecologist at Apollo Hospital on the pros and cons of getting a caesarean.

A c-section is a surgical procedure that involves making an incision in the abdomen and uterus through which the baby is delivered. In certain circumstances, a caesarean is a planned one or an elective caesarean which is carried out before labour can begin; in others, it's done when an unforeseen complication arises during labour.

Now, many first-time mothers are opting to have the operation without there being any specific medical reason behind it. Fear of pain and the desire to bypass a long drawn-out labour are common motives. However, an elective c-section is often not scheduled for simple convenience. Instead, there can be a number of reasons why your obstetrician recommends you have one. Some are:

* Your baby is in the breech position - lying bottom first or transverse (sideways).

* You are expecting more than one child - twins, triplets or quadruplets.

* The placenta is positioned across the neck of your womb, making it impossible for your baby to be born vaginally (a condition known as placenta previa.)

* Your baby is big; especially if you are diabetic or if you had a previous baby of the same size or smaller who suffered serious trauma during a vaginal birth.

* You have serious preeclampsia (a hypertensive disorder) or some other medical condition is threatening the wellbeing of both your child and yourself.

* If you have genital herpes, delivering your baby via c-section will help protect him or her from the infection.

* Your baby's heartbeat is slowing - an indication that he or she is not coping well with contractions. This condition is known as foetal distress.

* The cervix stops dilating or dilates slowly so that both mother and baby are tired and ready to give up.

* The umbilical cord slips through your cervix (this is called a prolapsed cord). If that happens your baby needs to be delivered immediately, because a prolapsed cord can cut off his or her oxygen supply.

* The placenta starts to come away from the wall of the uterus and there is a risk of haemorrhage or excessive bleeding and oxygen deprivation for the baby.

* The baby does not move down into the pelvis because the pelvis is too small for the baby to get through.

Rapid advances in technology have resulted in dramatic increases in the safety of the procedure. Skilled obstetricians, easy, safe blood transfusions, clean, sterile surgical environments, and modern drugs all ensure that the procedure is relatively safe and easy on both mother and baby. Delivering your baby through a slit in your stomach means no vaginal stretching or episiotomies (a surgical incision through the perineum made to enlarge the vagina and assist childbirth.) This comes as a relief, even though episiotomies are fairly common, especially in first-time mothers. Aside from the pain, the sutures used to close it may also get infected, requiring a long healing period.

Normal vaginal birth is sometimes thought to strain or damage the pelvic floor - the network of muscles, ligaments, and tissues that act like a hammock to support the organs of the pelvis: the uterus, bladder, and rectum. In a worst case scenario, this may result in the pelvic organs dropping down and protruding into the wall of the vagina.

Some obstetricians hold that a caesarean will allow you to have a baby while maintaining a sound pelvic floor and avoiding urinary or fecal incontinence. (Incontinence is the lack of voluntary control of excretory functions.) Plus you walk away with your vagina in much the same shape, something which in turn results in better sexual experiences.

In addition, simple things like knowing the date of your baby's birth gives you time to prepare every last detail. If you're a working mother, you can plan your time off from work and arrange proper care for other children and dependents you might be leaving at home. Last but not least, the much discussed labour pains are also done away with.

Caesarean section is a major abdominal surgery and so it exposes the mother to all the risks of major surgery. The list is intimidating and includes the chances of infection, haemorrhage, complications of anaesthesia and damage to internal organs. The scars remain both on the outside and on the inside. The one on your womb makes it likely that you go in for a c-section in your next pregnancy instead of risking rupturing the old wound and losing the child.

This procedure is not only more expensive (it can cost up to four times the price of a normal birth), it also means the mother take longer to recover, spending more time in hospital. The pain might last for more than a month. The effects on the baby are less well understood, though clear complications arise if the child is premature. There is an increased risk of infant respiratory distress, injuries from the surgery, a higher rate of breastfeeding difficulties, colic and overall fussiness.

It has even been suggested that caesarean section alters or delays normal bacterial growth in the gut, which in turn impacts on development of the immune system so that babies develop diarrhoea and sensitization to food allergens such as cow's milk.

Women having been giving birth the natural way for thousands of years and advocates say it should continue that way. The World Health Organisation states that no region in the world is justified in having a caesarean rate greater than 10 to 15 percent, yet almost everywhere it is on the rise. In the end, it is the woman and her doctor who must come to a common consensus on what is best for her and her child.