Caesareans and all their potential side effects can be avoided. However, since all the evidence points to the relative lack of effectiveness of practitioners in reducing the number of surgical deliveries, mothers may have to be extra vigilant. Here are the steps which can help:

Avoid Active Management

When active management is applied in labour, caesarean may be genuinely necessary to rescue women and their babies from the side effects of unnecessary interventions such as induction, electronic fetal monitoring (EFM) and pain relieving drugs. Syntocinon, when used on women with scarred uteri, has been shown to increase the caesarean rate for failure to progress (J Ob Gyn, 1994; 14: 420-2). When used in conjunction with an epidural it increases the likelihood of rupture, leading to a repeat caesarean (BMJ, 1987; 294: 1645-6). In an unscarred uterus, induction can lead to hyperstimulation, producing erratic and eventually ineffective contractions and depriving the baby of oxygen for longer periods of time.

Not surprisingly, induction is associated with higher caesarean rates for fetal distress and increased incidents of dystocia (Ob Gyn, 1992; 80: 111-6).

Induction can lead to further interventions, most commonly EFM. Continuous monitoring has been shown to have no effect on perinatal outcomes (Lancet, 1987; 2: 1375-7), and in a random sample of British obstetricians (Caesarean Birth in Britain, Middlesex University Press, 1995) 19 per cent said they would perform a caesarean "because of fetal monitoring", confirming data from other reports that EFM leads to increased caesarean rates (New Eng J Med, Mar 1, 1990).

Epidural anesthesia is known to slow the first and second stages of labour (Lancet, 1989; 69: 1250-2) and make limp and ineffective the pelvic muscles necessary to rotate the baby into optimum position for birth. Epidurals have been associated with an up to 10 times greater risk of caesarean than other form of pain relief (Am J Ob Gyn, 1993; 169: 851-8).

Stay Upright and Mobile

Walking has no known side effects and is as effective as syntocinon for augmenting labour (Am J Ob Gyn, 1981; 139: 669-72). Women who walk, stand or sit upright during labour have shorter labours, use less pain relief and less augmentation than those who are supine and immobile (Effective Care In Pregnancy and Childbirth, Oxford University Press).

Choose Midwifery Care

Studies show that midwifery care equals low caesarean rates. One survey of 84 free standing birth centres, staffed by midwives, in the US reported a overall caesarean rate of 4.4 per cent (New Eng J Med, 1989; 321: 1804-11). Equally, the presence of a doula (or trained birth companion) has been shown to cut the average length of labour by half from 19.3 to 8.8 hours (New Eng J Med, 1980; 303: 597-600). Factors influencing low caesarean rates among midwives may include greater continuity of care. The more confident and familiar a woman is with her practitioner, the greater confidence she will have in herself.

Be Patient

Some labours, especially first labours, simply are long. Women with a previous caesarean, especially one performed before 4 cm dilation may have long labours comparable to those of women having their first baby (Ob Gyn, 1990; 75: 45-7).

Consider a Home Birth

This may be the surest way of achieving all the prerequisites listed above. For healthy women and their babies, home birth may well be the safest option (J Nurse Midwifery, 1991; 34: 95-103; BMJ, 1991; 303: 1517-9; J Rep Med, 1977; 19: 281-290).