Cesarean Sections
Women have always had to make a number of important decisions in preparation for labor and birth:
- Where will I have my baby?
- Who will be my healthcare provider?
- Who will be with me to support me during labor and delivery?
- How will I deal with the pain in labor?
But choosing in advance whether you want a vaginal birth or a cesarean birth was not one of the options - until now.
Previously, the decision to perform a cesarean section was made only at the recommendation of your healthcare provider, based on medical conditions and critical issues of safety for you and your baby.
Some physicians now offer the new option of an "elective cesarean section" or a "cesarean on demand." This means that some doctors permit a mother with a healthy, full-term pregnancy to schedule a C-section rather than go into labor and have a vaginal birth-even if the mother has had no prior cesarean deliveries and has no current medical indications.
What's the justification? Proponents of elective cesareans suggest that the operation is as safe for the mother and the baby as a vaginal birth. Furthermore, some proponents reason that vaginal birth damages a woman's pelvic-floor muscles, which could lead to incontinence later in life. By choosing surgery, the argument goes, a woman might avoid the problem in her future.
Even the most informed mother-to-be could be confused. Isn't a C-section a major abdominal surgery reserved for urgent medical situations? Isn't giving birth vaginally nature's way-and therefore the safest method for both the mother and her baby? The problem is that most of what is being said about elective cesareans is speculative at best and inaccurate at worst.
An appropriately performed C-section can be a life-saving procedure for both a woman and her baby. Vaginal births are the norm, but sometimes a cesarean is the best way to have the healthiest birth possible when medical issues are present.
But cesareans on demand? Is that like movies on demand? Will this be the era of fast-food healthcare? Drive-through deliveries?
What we don't know. Changes in standard medical practice should be made only after studying the results of well-planned, controlled research studies. When thinking about elective cesareans, it's important to understand that we just don't have the scientific studies on which to base an informed decision. Here's why:
Until recently, C-sections were mainly performed for medical reasons, such as arrest in the progress of labor, serious medical conditions that would preclude starting labor, or medical problems that developed during labor or delivery. The current information we have is derived from studies of these types of cesareans. You can't just apply those findings about risks and outcomes to this new use of the surgery, in which none of those conditions are present. It's like comparing apples and oranges.
Also, most of the information we have about vaginal birth is derived from a mix of different kinds of vaginal deliveries. Studies that evaluate the impact of vaginal birth on longterm bowel and bladder incontinence involve researching women who birthed 20 or more years ago, when medical practices such as forced pushing, episiotomies, and the use of forceps were common. All such practices have been shown to significantly increase the risks for damage to the pelvic floor muscles. To date, there are almost no studies of vaginal births done without these practices, making the existing data very limited in its usefulness. Again, it's a mixed-fruit basket.
And here's a twist: There have been well-documented studies that show that a C-section doesn't protect women from these complications. In comparisons of women over age 50 who had cesareans (or had no children at all) to women who had vaginal births, the rates of incontinence problems were the same.
What we do know. It's simplistic and misleading to just list the risks of a C-section compared with a vaginal birth, because the risks described below - although well documented - generally derive from studies of all types of cesareans and almost never from first-time, elective cesareans. What we can do is divide the risks into two categories:
1. Risks that are likely to be present regardless of the reason the cesarean was done. These risks are applicable, even in an elective cesarean.
Risks that exist for all cesareans, including elective:
- Longer hospitalization than for vaginal births
- More pain than with vaginal birth
Injury to the mother from surgery, such as accidental cuts to the bladder or the uterus
- Injury to the baby from the surgery, such as accidental cuts to the baby's head
- Higher risk of the baby developing asthma
- Unexplained stillbirth in subsequent pregnancies
- Catastrophic complications such as an ectopic pregnancy (tubal pregnancy) and uterine rupture in the next pregnancy
- Placental problems that can threaten both the mother's life and the baby's life in the next pregnancy
- Problems with getting pregnant again and possibly an increased risk of miscarriage
2. Risks that can be related to, or made worse by, the medical reasons for which the cesareans were performed. An elective cesarean done without medical reasons might have decreased risks for these factors, but the risks remain to an unknown degree.
Known risks of medically indicated cesareans:
- Maternal death
- Excessive bleeding or hemorrhage
- The need for an emergency hysterectomy (surgical removal of the uterus)
- Infection after birth o Problems with blood clots such as stroke or pulmonary embolism, which can be life-threatening
- Hospital re-admission for problems
- Respiratory problems for the baby
- Premature babies
Other concerns. When thinking about an elective cesarean, some women consider other factors, such as convenience, pain avoidance, and future sexual satisfaction. But again, the answers are not black and white.
Convenience and satisfaction: Having a baby in any fashion is an interruption in a woman's life. Being able to choose the timing of your birth is likely to prove to be a small benefit in the larger scheme of things. Ultimately it is a trade-off. Are the risks of elective abdominal surgery versus a spontaneous nature-mediated event worth the convenience factor?
In Childbirth Connection's landmark study of elective cesareans, mothers were surveyed regarding maternal satisfaction with their birthing experiences. Women who had undergone cesareans were less satisfied (both at the time of birth and later) than mothers who'd had vaginal births.
Pain avoidance: Whether one has labor pain or postoperative pain, the fact remains that childbirth will most always involve some pain, even with the use of narcotics and anesthesia.
The Childbirth Connection survey found that women with cesareans rate themselves as having more pain overall than do mothers with vaginal birth. The pain of labor is limited. The pain of abdominal surgery continues for weeks afterwards.
Bonding and breastfeeding: Cesareans result in delayed contact with the baby in the critical first hours after birth, postponing mother-child bonding. They also can make breastfeeding more difficult to establish and more challenging.
Sexual satisfaction: Some women worry about the impact of vaginal birth on their sex life. While birth certainly impacts intimacy on a temporary basis, no evidence exists to suggest that it is the cause of long-term problems, nor that women who have cesareans face any fewer challenges.
Long-term impact: While not all cesareans are avoidable, it is important to remember that having one cesarean not only affects you and your baby in this pregnancy, but can impact your ability to both get and stay pregnant the next time. Having a C-section can also affect the health of your future children and your own health during your next pregnancy and birth.
For the best and safest birth. While the times have changed, one thing has not: The safest birth is still a vaginal birth that does not include labor and birth practices known to damage your pelvic floor. There is not enough information at this time to ethically say that an elective C-section is as safe or safer than a vaginal birth. And there is no evidence that birth by abdominal surgery protects women against incontinence issues in later life.
Take the time to discuss your questions, concerns, and preferences with your healthcare provider. Ask for what you need. It is, after all, your body, your baby, your birth.
Reducing risks in vaginal births. Certain labor-management and birthing practices have been proven to increase the risk of damage to a woman's pelvic-floor muscles, which in turn could increase her risk of incontinence later in life - although that correlation has not been conclusively proven by current studies.
Labor-management practices.
Pushing: Early pushing, before the baby has descended to the pelvic floor and the woman has a strong urge to push, can increase stress on the pelvic floor muscles and is associated with potential damage to the bladder connective tissue.
"Purple pushing": So-called purple pushing - where the mother is told to hold her breath and push to the count of 10, three times with each contraction - can lead to the woman being too tired to continue pushing. This increases the need for mechanical assistance, such as forceps or a vacuum extractor, both of which are associated with damage to the pelvic floor.
What you can do: The timing and method of pushing in the second stage of labor are critical components to preserving the strength of a woman's pelvic-floor muscles. Don't push until you feel a strong urge to do so. In the case of an epidural, wait until the baby's head is very low (called laboring down). This will decrease the time needed for pushing, reduce stress on the pelvic floor, and increase effectiveness.
Birthing practices.
Episiotomy: Cutting the perineum has been proven to create short-term and long-term damage to the woman's pelvic support structure. Episiotomies often lead to "extension" tears that occur after the initial cut is made as the baby is born. These tears often lead to more serious injury.
What you can do: Discuss your strong preference for no episiotomy with your healthcare provider. It is usually necessary to do one only in an emergency.
Forceps and vacuum extractors: The use of forceps for vaginal birth significantly increases the risk for damage to the pelvic-floor muscles. The use of forceps and vacuum extractors are associated with the use of episiotomies, which also increases the risk of pelvic-floor injury.
What you can do: The best way to avoid the use of forceps and vacuum extractors is to work with care providers who rarely use them.
Birthing positions: Supine positions, where the mother lies on her back, put more stress on the pelvic-floor structure than other positions and can increase the potential for damage from the birth.
What you can do: Try semi-sitting, squatting, side-lying, using a birth stool, hands and knees, or even standing while birthing
What the experts say about elective cesareans
The American College of Nurse-Midwives
"The list of reasons women must not think surgical birth is as safe as a vaginal birth is long and ranges from increased incidence of drug-resistant infections, to the potential for life-threatening complications from blood transfusions. Women risk permanent damage to abdominal and urinary tract organs, longer recovery times, little to no chance for a subsequent vaginal birth, and a premature end to their ability to safely bear children."
Childbirth Connection
What Every Pregnant Woman Needs to Know About Cesarean Section provides the most complete review of what is known about the risks of elective cesarean section and proven techniques for avoiding unnecessary surgery.
The American College of Obstetricians and Gynecologists
"ACOG cautions that 'both sides to this debate' must recognize 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."
The Society of Obstetricians and Gynaecologists of Canada
"The Society of Obstetricians and Gynaecologists of Canada does not promote Caesarean sections on demand. The Society has always promoted natural childbirth and believes that the decision to perform a caesarean section during labor and delivery should be based on medical indications. At this time, there is no indication that a caesarean section carries less risk than a vaginal delivery for mother and baby. The Society is concerned that a natural process would be transformed into a surgical one, and that elective procedures would create added pressure on healthcare resources that are already overextended."
*taken from "Cesareans on Demand?," by Mayri Sagady Leslie, CNM, MSN, Every Baby magazine, Issue Four
