Elective Cesarean Section

The Babble Staff

C-sections are safer than ever, and women are having them in growing numbers (they accounted for twenty-nine percent of American births in 2004). Many of these were performed on healthy women with low-risk pregnancies. A scheduled C-section certainly makes life easier for doctors, as births are quick and on time. Some women prefer C-sections too; there is no grunting, no pushing, and you can plan the hospital visit. (Though the NIH notes that maternal request cesareans are in fact very rare.) There's nothing risk-free about a vaginal delivery, but a C-section is a major surgical procedure. Dr. John Zweifler, chief of the University of California , San Francisco-Fresno Family and Community Medicine Department, points out that while your C-section may be faster and easier than a vaginal delivery, you will need more time to heal. Some women believe avoiding labor will keep their vaginas in better shape, but studies suggest that women who have undergone C-sections may not be at less risk for pelvic floor-dysfunction. C-sections are also likely to complicate future pregnancies and multiple C-sections bring risks of complications, including bladder and bowel problems.

August 17, 2006

C-Section Rate at All-Time High in U.S.

While Caesarean births are sometimes medically necessary, factors such as convenience are driving the rate too high, some experts contend. And the delivery method carries with it risks that aren't acceptable if a C-section isn't necessary to preserve the health of the mother or baby, doctors say.

Patient preference is one, with some women requesting them for convenience — they can schedule the birth and plan time away from work and set up child care for other family members, for instance. "In our society, everything is on demand," Zweifler said, adding, C-sections can be "convenient for our lifestyle — the doctor's and the patient's."

A C-section is considered major surgery, as the physician cuts into a women's abdomen to remove the baby. Infection is a risk, as is increased blood loss and decreased bowel function. And recovery time is typically longer following a C-section, Zweifler said: "It can take four to six weeks to heal tissue."

Those who have a C-section tend to take longer — sometimes up to six weeks — due to soreness and pain.

Both Zweifler and Leeman suggest that women not consider a C-section just for convenience, especially if they plan to have more children. Repeat C-sections increase the risk of bladder or bowel problems.

"Birth is a very empowering process for women," Zweifler said. Having a C-section "is taking it out of the hands of women and putting it in the hands of a surgeon in a very sterile environment. If you have a life-threatening condition or a fetus in distress, a C-section can be life-preserving. But to do it on a routine basis when there is no risk to the mother and baby, you may be causing harm, and you need to be very cautious."

C-Sections are on the rise and moms are getting blamed, but is it really the woman's fault? "Some of the increase in elective cesareans is due to mother request, but I personally believe that group is a very small, very affluent subset of women and does not represent the desires or needs of most mothers," says Peter Bernstein, MD.

Doctors say that while advances in C-section delivery have increased its safety profile considerably, risks still remain higher than for a vaginal delivery, and rise still higher with every C-section a woman has.

The first study to examine risks to babies born via elective cesarean, published in this month's edition of Birth, reported that in 6 million births, the risk of death to newborns delivered vaginally was 0.62 per thousand live births versus 1.77 for those delivered by elective C-section. In a recent news statement Stanley Zinberg, MD, deputy executive vice president of the American College of Obstetricians and Gynecology said, "At this time, our position is that cesareans should be performed for medical reasons." ????

One study showed that women who had cesarean deliveries were almost twice as likely to be re-hospitalized than women who had vaginal deliveries. Other studies have shown elective cesarean won't prevent pelvic-floor dysfunction and accompanying laxity in vaginal muscles and future urinary incontinence. There's evidence that cesarean birth may also lead to significant problems immediately after delivery and beyond. While it may seem that a baby lifted from the uterus would be nearly perfect, having suffered few consequences of the treacherous trip through the birth canal, such babies actually experience lower Apgar scores, accidental wounds, more respiratory distress and a higher rate of breastfeeding difficulties, colic and overall fussiness in the postpartum period. Mothers may experience increased risk of prematurity in a subsequent birth.

Cut and run
An increasing number of American women are choosing C-sections. Is this trend a risky indulgence, or a sign of female empowerment?
By Dana Hudepohl

The debate over elective cesareans started publicly in the spring of 2000 when then-president of the American College of Obstetricians and Gynecologists (ACOG), Dr. W. Benson Harer Jr., argued for "maternal-choice cesarean" in an editorial printed in the association's journal. Doctors were forced to pick a side as more patients entered their offices with requests. From 1999 through 2002, the number of elective C-sections provided to women with no previous C-section rose almost 42 percent, accounting for more than 2 percent of more than 4 million deliveries. If more women start getting their way, that number could skyrocket.

In an online survey at Newshe.com, a Web site put out by sexual health experts Drs. Laura and Jennifer Berman, when nearly 2,500 women were asked, "Would you opt for a C-section over a vaginal delivery if you had the choice?" 37 percent answered "Yes"; another 9 percent answered "Not sure."

Proponents point to evidence showing that when healthy women choose to have C-sections, the risks, benefits and costs are balanced between C-sections and vaginal delivery. They conclude that the choice should be the mother's. Critics — doctors, midwives and women among them — answer back that a C-section is major surgery with risk of complications, longer recovery and potential problems with future deliveries.

After more than a year of deliberation, the group concluded that it is ethical to provide an elective C-section if the doctor believes it is in the best interest of the woman and her fetus and if he has advised her of the risks involved. If the doctor believes a C-section would be detrimental to the health and welfare of the woman and her fetus, he is ethically obliged to refrain from performing the surgery. If the patient and doctor cannot agree on a method of delivery, he should refer the woman to another doctor. The ACOG cautioned that evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. In other words, the jury is still out.

It's no wonder: A recent Gallup survey of 301 female OB/GYNs showed that even women who take care of other women are sharply split. Thirty-six percent said they would not perform a C-section if a woman asked for it, 32 percent said they would, and 28 percent said it would depend on the woman's circumstances.

"C-sections are incredibly safe, but bad things can happen during medical procedures," says Dr. Jerome Yankowitz, director of the division of maternal and fetal medicine at University of Iowa College of Medicine, who is against elective C-sections unless a patient has been thoroughly counseled. "It can be unnecessary surgery analogous to liposuction. Most people have no complications, but then there are a few who do. Afterwards people think, 'Why did they do that? They weren't that heavy!'" Yankowitz says he knows of many cases of bladder damage in the mother, bad wound infections and bowel injury as a result of C-sections. Many doctors advise against elective C-section if a woman plans on having more than two children since subsequent surgeries become riskier. "

Her organization issued a statement last fall against elective C-sections, stating that "purported benefits of cesarean section on demand are unproven and the known risks place the woman's life and reproductive future on the line."

The fact that no large-scale studies have been done to compare apples to apples is what concerns nurse-midwife McCartney. "Before physicians jump in and say there are no problems with C-sections, I'd like to see a study comparing a healthy vaginal delivery to a healthy C-section," she says. "Most people think the study has been done already and it hasn't. Women think they're having an opportunity to make a choice, but what they're really getting is their provider's opinion."

Stephanie Higgins, 24, had planned to have a drug-free natural delivery, but when her baby was three weeks late and estimated to be over 11 pounds, her doctor recommended that she schedule a C-section. "I feel like I missed out on an easier, more natural process," says Higgins, who couldn't get out of bed or pick up her newborn — who, it turned out, only weighed in at 8 pounds, 15 ounces — for days because of the pain from her cut stomach muscles. More distressing than the soreness was that she had difficulty nursing. "Since my body had not gone through labor, it took longer for my milk to come in," she says. "My baby was hungry and I had nothing for her for a good five days. It was a really difficult experience." While Higgins believes that women should have a choice how they deliver, she wishes she had been able to stick to her original birthing plan. "People say, 'I wouldn't want to go through the pain of childbirth,' but there's a lot of pain with a C-section — and I had an uncomplicated one. The recovery was much more difficult than anyone I knew who had a vaginal delivery."

Proponents of elective C-section are more interested in talking about the mother's long-term health than the weeks after the baby is born. "The first few weeks after you have the baby is a lot different than the rest of your life," says Bost. Studies have associated vaginal delivery with higher risk of lasting consequences, including pelvic organ prolapse and urinary or fecal incontinence.

But a new study of 363 women from Tel Aviv University does show that elective C-section can have a protective effect. The prevalence of urinary incontinence one year after women delivered vaginally was 10.3 percent, but for women who had an elective C-section with no labor, it was only 3.4 percent. (It was 12 percent for women who had a C-section after laboring).

"This is a very touchy topic," she admits. "But in my mind, it should be an individualized decision between a patient and a doctor. When you need treatment for, say, prostate cancer, you have options. I don't understand why delivery of an infant is any different."

In Brazil , the overall cesarean delivery rate is 50 to 60 percent and climbs to 90 percent among wealthy women delivering in private hospitals. South Korea has one of the highest C-section rates in the world, with almost half of Korean women delivering by C-section (up from 6 percent in 1985 and 21.3 percent in 1995). In Denmark , nearly 40 percent of OB/GYNs agree with the woman's right to request a C-section. But recent media coverage of Hollywood 's elective C-section trend with headlines like "Too Posh To Push" (Time) have given the issue a sense of elitism.

On average, C-sections are twice as expensive as vaginal deliveries. Can maternity wards handle a rising demand for elective C-sections? Yes, says Bost, since those numbers don't apply to elective C-sections. His research, published in the Journal of Obstetrics and Gynecology, found that when you factor in nursing, medication, and monitoring during long labor, the costs of vaginal deliveries and elective C-sections balance out. He concluded, "Adopting a policy of cesarean on demand should have little impact on the overall cost of patient care."

Should doctors perform an elective caesarean section on request?

Yes, as long as the woman is fully informed

The view that this procedure is clinically unjustifiable has been challenged, 1-2 and over the past decade or so prophylactic caesarean section has been gaining credence. 1-3, 1-4 The balance of benefit versus harm between caesarean section and vaginal delivery is crucial to this debate; although the evidence is incomplete, it challenges the dogma that vaginal delivery is almost always better.

These are not comparable to the elective procedure, which most practising obstetricians consider safe. Recent evidence of maternal morbidity after caesarean section and normal and instrumental vaginal delivery challenges some deep rooted obstetric and midwifery teachings: normal vaginal deliveries can cause damage to the pelvic floor, 1-7 and instrumental vaginal deliveries are associated with slower recovery 1-8 and greater pelvic floor damage and incontinence 1-9 than normal delivery and caesarean section. Previous caesarean section does compromise future obstetric performance, 1-10 1-11 but evidence is limited and, with reduced family size, this has probably become less important in decision making.

Elective caesarean section cannot guarantee normality, but it avoids the above problems by virtue of avoiding labour and prolonged pregnancy. Short term complications to the neonate of transient tachypnoea and respiratory distress syndrome are reduced by delaying elective caesarean section until 39 weeks of pregnancy have been completed.

We are at a turning point in obstetric thinking, brought about not only by the advances that have made caesarean section safe and the evidence that vaginal delivery can be associated with substantial morbidity but also by the attitudes of our society, which reflect intolerance to risk. We encourage "family planning" and prepregnancy counselling, we routinely perform antenatal screening, and we offer prenatal diagnosis — all of which are "unnatural" and promote a concept of the "designer baby." Can we do all this and then refuse a woman a safe mode of delivery (caesarean section) that removes the gambles associated with labour and which she personally finds unacceptable?

These choices should not be discredited simply because they are not the ones that were expected. We should respect a woman's view and choice if it is fully informed, if she expresses a logical reason for wanting a caesarean section, and if she can demonstrate an understanding of the implications of the procedure. We should not be dictating to women what they should think, nor should we be judgmental of their values if they happen to differ from our own.

This does not mean that obstetricians should become technicians at the mercy of women's choice, but that they should be partners in the process of decision making. There is no room for complacency with such incomplete evidence, and further research is needed; but on the basis of the available evidence the concept of a prophylactic caesarean section being outrageous has been shattered by the fact that almost a third of female obstetricians would choose it for themselves. 1-18 Prophylactic caesarean section can no longer be considered clinically unjustifiable, and it now forms part of accepted medical practice. click to close

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