Wednesday, February 6, 2013

Elective C-Section - Would You Do It?

It's the latest thing. As fashionable as Kabbalah, without all the studying. Madonna did it. So did Elizabeth Hurley. Cesarean section by choice has become almost a fad of sorts. Do Yoga at 8 a.m. Have your baby at 10 a.m. It not only fits your schedule, but your doctors and you get the added benefit of avoiding anything remotely like a labor pain.

Sandy, 34, had an elective Cesarean section and frequently encourages other women to do the same.

"It is so exciting to finally hear other women and members of the obstetric community saying what I have said for the last six years," she said. "I had an elective Cesarean section with my first pregnancy because I had a wonderful female OB who respected my desire to avoid vaginal and pelvic floor trauma. My section was awesome - wide awake and no pain, I was up walking in less than 8 hours."

Diverse attitudes between doctors and mothers about the "right" way to deliver a baby are not only causing confusion for new mothers who are frightened about their first labor and delivery experience, but divisiveness among feminists. For many years feminists fought for the right to take control of their bodies once again and deliver babies naturally without the unnecessary medical intervention that women throughout much of the twentieth century were subjected to. Now, a new generation of feminists assert that it is also their right to choose to deliver their baby without pain. But how safe is an elective Cesarean section?

Some studies and doctors claim that elective Cesarean is just as safe if not more so than a vaginal delivery and that the possible side effects of a vaginal delivery make c-section even more attractive.

Dr. Jennifer Berman, a urologist, author and television personality, said that she elected to have a Cesarean section with her second child and wished she had done so with her first.

"I had a very difficult time with the delivery of my son, Max in December, 1999. I was in labor for 18 hours, which was made more difficult by the fact that I had an epidural too early, which in turn caused the birth process to slow down.

"Max was supposed to have been a seven-pound baby, but was actually nine pounds, eight ounces. His head and shoulders got stuck in the birth canal and he suffered fetal distress. Given my body habitus, he should have been delivered c-section, but I persevered and delivered vaginally.

"My second reason for choosing c-section stems from the work I've done as a urologist. During a reconstructive surgery fellowship last year, I saw women who suffered the effects of incontinence and prolapse. These effects are directly related to vaginal delivery.

"In cases where women are predisposed to incontinence and prolapse, doctors are willing to perform c-section. I experienced incontinence for seven months after Max's birth and it began to recur during this pregnancy.

"Had I seen patients with such problems before Max was born, I would have elected to have a c-section with him, too. I decided that I didn't want to risk more incontinence or prolapse in the future."

A study performed by H. P. Dietz, MD (Heidelberg) and M. J. Bennett, MD (UCT) and published in the August 2003 issue of Obstetrics and Gynecology, the journal of the American College of Obstetricians and Gynecologists, concluded that: Vaginal birth, in particular operative delivery, negatively affects pelvic organ support. This appears to be true for all three vaginal compartments. All forms of cesarean delivery were associated with relatively less pelvic organ descent. These findings may partly explain the protective effect of elective cesarean delivery for future symptoms of pelvic floor disorders."

Dietz and Bennett studied a total of 200 women, recruited early in their first pregnancy, and examined them during the first and early second trimester, the late third trimester and between two and five months postpartum. A total of 169 women or 84.5 percent showed highly significant increases in organ mobility. In addition, the length of the second stage of labor correlated with an increase in pelvic organ descent, suggesting that vaginal delivery is a major contributor to pelvic organ prolapse.

However, what many advocates of elective Cesarean section do not mention is the fact that the same study also states that the most significant pelvic floor damage occurred in women who experienced an operative vaginal delivery.In particular, women whose babies were delivered with the help of forceps or vacuum extraction experienced the highest degree of damage. In addition, Dr. W. Benson Harer, Jr., president of the American College of Obstetricians and Gynecologists, while maintaining that every woman should have the right to choose between a Cesarean section and a vaginal delivery, also concedes that many pelvic floor issues (urinary incontinence, uterine and bladder prolapse) can be prevented by improved labor and birth techniques.

Episiotomies are also associated with pelvic floor damage and long-term complications. They have been proven to be unnecessary and harmful in most births, yet the majority of American women are still subjected to this surgical procedure during a vaginal birth.

The belief that Cesarean section is much safer for the baby is also contentious. In fact, the risks to the baby can be substantial. Cesarean section is major surgery and brings with it many risks to both mother and child. Babies born by Cesarean section do not receive the natural stimulation that comes from moving down the birth canal, and therefore must often be given oxygen or a rub down to help them breathe. They also miss out on the natural hormones that are released during vaginal birth to help the baby during his first moments of life.

According to the Mayo Clinic's Complete Book of Pregnancy & Baby's First Year the risks of Cesarean section are substantial for mother and child:

1. Premature birth. If the due date was not accurately calculated, the baby could be delivered too early.

2. Breathing problems. Babies born by Cesarean are more likely to develop breathing problems such as transient tachypnea [abnormally fast breathing during the first few days after birth].

3. Low Apgar scores. Babies born by Cesarean sometimes have low Apgar scores. The low score can be an effect of the anesthesia and Cesarean birth, or the baby may have been in distress to begin with. Or perhaps the baby was not stimulated as he or she would have been by vaginal birth.

4. Fetal injury. Although rare, the surgeon can accidentally nick the baby while making the uterine incision.

Risks to the mother are more common and include:

* 1. Infection. The uterus or nearby pelvic organs such as the bladder or kidneys can become infected.

* 2. Increased blood loss. Blood loss on the average is about twice as much with Cesarean birth as with vaginal birth. However, blood transfusions are rarely needed during a Cesarean.

* 3. Decreased bowel function. The bowel sometimes slows down for several days after surgery, resulting in distention, bloating and discomfort.

* 4.Respiratory complications. General anesthesia can sometimes lead to pneumonia.

* 5. Longer hospital stay and recovery time. Three to five days in the hospital is the common length of stay, whereas it is less than one to three days for a vaginal birth.

* 6. Reactions to anesthesia. The mother's health could be endangered by unexpected responses (such as blood pressure that drops quickly) to anesthesia or other medications during the surgery.

* 7. Risk of additional surgeries. For example, hysterectomy and bladder repair.Researchers at the Wake Forest University School of Medicine also studied the effects of Cesarean section and the results were alarming. After a seven year, population-based, case-control study in North Carolina, the researchers concluded that Cesarean sections cause two to four times more women to die as a result of childbirth than in vaginal deliveries.The authors looked at many factors: demographics, medical risk factor, pre-term delivery, use of prenatal care and health care services, including mode of delivery, to determine what factors were associated with maternal mortality. Style of birth (Cesarean or vaginal) was the most significant factor related to maternal mortality, although whether or not the mother sought prenatal care also had an effect. The study found that the pregnancy-related mortality rate among women with Cesarean deliveries was 35.9 deaths per 100,000 Cesarean deliveries with a live-birth outcome compared to 9.8 deaths per 100,000 vaginal deliveries without complications. The mortality rate for the population presumed to have had elective Cesareans was 18.4 per 100,000 Cesarean deliveries.They concluded, "Removing barriers to and actively promoting use of prenatal care services and decreasing the rate of Cesarean deliveries could decrease the number of pregnancy-related deaths."

The increase in Cesarean section births, whether electively or by doctor's order, in the United States is staggering. The World Health Organization (WHO) states, No region in the world is justified in having a Cesarean rate greater than 10 to 15 percent. However, more than one fourth of all children born in the United States in 2002 were delivered by Cesarean; the total Cesarean delivery rate of 26.1 percent was the highest level ever reported in the United States. While the Cesarean delivery rate declined during the late 1980s through the mid-1990s, it has been on the rise since 1996. In addition, the number of Cesarean births to women with no previous Cesarean birth jumped 7 percent and the rate of vaginal births after previous Cesarean delivery (VBACs) dropped 23 percent.

Despite all of the efforts to convince mothers that Cesarean section is just as safe if not more safe for mother and child than vaginal delivery, the United States still ranks 8 in infant mortality among industrialized nations (behind the Czech Republic and Cuba) as of the world for maternal death. However the Centers for Disease Control (CDC) estimates that maternal deaths are underreported by one half to two thirds, and that half of US maternal deaths are preventable. The rate of death due to childbirth has not decreased since 1982, and increased in 1999.

In an editorial for Obstetrics and Gynecology, Dr. Ingrid Nygaard and Dr. Dwight Cruickshank argue that while they believe offering healthy women who plan small families an elective Cesarean section is justifiable, they do not condone such a recommendation on a routine basis.

"There are many unanswered questions regarding elective Cesarean delivery at term, and it is important that we try to answer them before making this part of the informed consent process. How should we manage the woman who goes into labor before 39 weeks? Is there a point in labor (dilatation and descent) at which time it is too late for Cesarean delivery to benefit the pelvic floor? At least in terms of anorectal physiology, the protective effect of Cesarean delivery is pronounced only if delivery is affected before a cervical dilatation of 8 cm. Is there a fetal size or gestational age below which vaginal delivery is not deleterious to the pelvic floor? As more US women become obese, will the risks of elective Cesarean delivery be greater than anticipated? Obesity itself is a risk factor for urinary incontinence, which may further decrease the value of preventive Cesarean delivery in this population. Given that some racial and ethnic groups are more predisposed to prolapse and incontinence than others, do we manage all patients similarly, or do we take such considerations into account? How should we analyze the economics of Cesarean delivery on demand? Projecting future cost should not rely on the arbitrary charge structure in place today. How do we balance the cost of elective Cesarean delivery with that of treatments for pelvic floor disorders?

"Given the absence of rigorous scientific evidence, we believe that it is currently ill advised to routinely give all prenatal patients the choice of their desired mode of delivery. What appears to be a fairly low-risk proposition in non-obese healthy women having only one or two children is likely not inconsequential in obese women, women with poor nutritional states or medical illnesses, or women who will have several Cesarean deliveries."

What most obstetricians and midwives do agree on, whether for or against elective Cesarean section, is that mothers need to be informed about all of their options and the benefits and risks of both. Childbirth, even in the 21st century, is still risky business and having all of the information available is the only way mothers can be certain they are receiving the best care.

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