March 8, 2010

To Cesarean or Not To Cesarean, That is the Question!

A few weeks ago after a morning prenatal yoga class, three students were left talking about birth options. One student was expressing her strong desire to have a VBAC (Vaginal Birth After Cesarean”) with her second child, while another, who was also on her second pregnancy, was hoping to have a vaginal twin birth. The third student, a first-time mother with a twin pregnancy, was contemplating having an elective cesarean instead of trying for labor and a vaginal birth.

The conversation went as followed: the first-time mother said she was leaning towards the elective cesarean because she is overwhelmed by the idea of labor and the pain involved. (With vaginal twin births, there is a slightly higher risk of birth complications and many doctors will offer their patients the option of going straight to surgery). This mother feels a cesarean will allow her to bypass the undesired experience of labor. The VBAC mother strongly disagreed and offered her opinion, saying that in her experience, a C-section should not be taken lightly – it is major abdominal surgery and for her, it was painful and timely to recover from. The second-time twin mom, who is also hoping for a vaginal birth, agreed and added that if the twin babies are in a good position to be birthed vaginally, that is the route she thinks is best for her. She suggested to the other twin mother that if the pain gets to be too much, she can always use an epidural and still have a chance at birthing vaginally, avoiding the risks and recovery process of a cesarean.

For some women, a planned, elective cesarean is the right choice. While it is true to say that cesarean delivery has gotten safer in the last 50 years, it is still not without risks. In making that choice, I believe it is best to be fully informed about the risks associated with this, as any, major surgery. As with all our choices, there are risks, benefits, and consequences to take into consideration. This is not meant to scare anyone. My true objective is to be impartial and offer the facts about this topic.

Risks Associated With An Elective Cesarean Without An Accepted “Medical Indication”
(Please feel free to view Medical Indications for A Cesarean Section, Facts vs Myths)

*Emergency hysterectomy – Certain complications, such as excessive bleeding, placental problems or uterine atony (loss of muscle tone), may require the removal of the uterus – a hysterectomy. The chance for this procedure is greater from a cesarean birth than from a vaginal birth.

*Greater blood loss and hemorrhaging – Cesarean surgeries requires two incisions: the abdominal and the uterine. During pregnancy, the uterus has one of the greatest blood supplies of any organ in the body, which can result in greater blood loss upon cutting. The chance for blood loss with a c-section is twice as likely as with a vaginal delivery.

*Mortality – The mortality risk with elective cesarean (no emergency present) has recently been reported as almost 3 times the risk of a vaginal delivery.

*Accidental Cuts – Increased risk of damage by accidental cuts to internal organs, including the bladder, the uterus, intestines and uterus.

*Infection –Infections occur in approximately 7% of women after having a C-section. The most common sites for infection post-cesarean are the incision site, the tissue lining the uterus, and the urinary track.

*Incision site – Chance of reopening up of the incision site.

*Blood clots in the legs and pelvis – This is a potentially serious complication, since the clot could travel to the lungs and cause pulmonary embolism. Luckily, there are warning signs that this is occurring, including the area surrounding the clot being swollen and hot to the touch. Hospitals often have thick leggings or compression devices for the leg after surgery to keep blood flowing and prevent a clot from forming. Getting out of bed to move around is also a preventative measure.

*Anesthesia complications – Three types of anesthesia are used for cesarean sections: spinal, epidural and general. The spinal and epidural are most commonly used for elective cesareans. They are generally low in risks and complications, but do have some common side effects such as headaches, shaking, itchiness, nausea, vomiting, decreased blood pressure with the potential for nerve damage and residual back pain. General anesthesia, due to carrying greater risks, is rarely used.

*Adhesion – Scar tissue can form a connection between tissue or organs that are not normally connected. Abdominal adhesions are a common outcome of any pelvic or abdominal surgery. In fact, they develop in 93% of people who have undergone pelvic surgery. They are especially common after cesarean sections. Possible locations of adhesions after a cesarean birth are the fallopian tubes, ovaries, bowels and bladder.

*Residual pelvic pain – The International Journal of Gynecology and Obstetrics featured a study out of Brazil – a country that has a 93% cesarean rate for private hospitals and 30-50% for public hospitals – that reported results stating “In women with chronic pelvic pain, a history of cesarean section was observed in 67.2% of cases, adhesions in 51.7%, endometriosis in 33.6%, sequelae of pelvic inflammatory disease in 31.9%, leiomyoma in 6.9% and pelvic varices in 11.2% The result of this pelvic pain could lead to the need for future surgery and pain medication.

*Child/Mother bonding time and skin to skin time eliminated – While the mother can view her baby or have her baby brought to her face, skin to skin contact is limited in the operating room. However, it is a good idea for the father to initiate skin to skin contact with the baby as soon as possible. (For more information about the benefits of skin to skin contact, please read Study Finds Benefits For Skin to Skin contact with Newborn)

*Placental development for subsequent pregnancies – Each successive cesarean greatly increases the risk of developing placenta previa, placenta accreta and placental abruption in subsequent pregnancies. These conditions are fortunately rare, and involve a malfunction in the placenta’s normal growth and placement.

*Breastfeeding difficulty – Women can successfully breastfeed after a cesarean birth. However, there are a few obstacles they may encounter on the way, the first being prolonged separation from their baby. (I would advise checking into the hospital’s protocol to see whether the baby goes to the nursery after delivery or the recovery room with mom.) The second issue that arises is finding a comfortable position to nurse in. Placing the baby on the mother’s abdomen may result in painful pressure on the mother’s incision. The “football hold” may be a better option immediately following surgery. Third, due to the increased pain and risk of infection, the mother is given painkillers and antibiotics. These medications may have an effect on the milk, leaving the baby a bit lethargic. Finally, there is an increased chance of developing a yeast infection due to the antibiotics. This could lead to thrush in the baby’s mouth or diaper area, as well as on the nipples.

*Longer recovery time – Due to the nature of any sort of surgical procedure, there is a recovery time that needs to be honored. With vaginal births, most women are mobile and recovering from birth within one or two days. With a cesarean birth, it can take up to 6 weeks to feel fully recovered.

*Extended hospital stay – Women that have cesareans will stay in the hospital for an average of 2 days longer than a vaginal birth. During these days the mother will receive post-operative care and observation.

*Respiratory distress for the infant – In a recent study of 1000 women, (500 cesarean births and 500 vaginal births) states, “The incidence of respiratory distress was reported in 6% of newborns delivered by ECS,5 versus 1% in Infants born vaginally.6 The presence of labor preceding cesarean section reduces the risk of respiratory morbidity in the neonatal period.”

*Surgery-related fetal injuries – There is 1.9% chance the surgeon’s knife will accidentally lacerate the fetus (6.0% when there is a non-vertex fetal position). (5) Obstetricians may be less aware of this risk–in one study only one of the 17 documented fetal lacerations was recorded by the obstetrician doing the surgery.

*Future stillbirth and fertility issues – There has been evidence linking fertility issues and stillbirth with previous cesarean section. This is attributed to greater risk of post-operative infection, pelvic adhesions, and placenta developmental issues. A recent study has reported that the risk of unexplained stillbirth in a second pregnancy is somewhat increased if the first birth was by cesarean rather than by vaginal delivery (1.2 per 1000 v. 0.5 per 1000)

Benefits Of An Elective Cesarean Without An Accepted “Medical Indication

*Avoid Urinary Incontinence – This can be a common postpartum problem with vaginal birth. In one study of primiparous women, 26% had urinary incontinence at 6 months postpartum, the rate being lowest with elective cesarean (5%), higher with cesarean during labor (12%), higher still following a spontaneous vaginal birth (22%) and highest following a vaginal forceps delivery (33%)

*Avoid Fecal Incontinence – This situation is much less common than urinary incontinence as a result of a vaginal birth, with only 4% of women encountering this issue.

*Lower risk of birth injury –
The rates of birth injuries such as fractures and nerve injuries are reduced by more than 50 percent among neonates delivered by cesarean. However, the rates of such injuries among the neonates of women who are at low risk (women without diabetes who have neonates without macrosomia) are extremely low even with vaginal delivery.

* Avoid the risk of emergency cesarean – In rare cases when a mother needs an emergency cesarean, this is defined as an immediate risk for the mother and baby. Such scenarios would include; cord prolapse which occurs in 1 out of every 400 births, placental abruption (a premature separation of the placenta from the uterine wall) which happens in 1% of pregnancies, or “fetal distress”. This last reason cannot easily be quantified, since there are many different interpretations of what fetal distress means and when it is an emergency situation.

*Avoid the risk of an unplanned cesarean – This category is different then the emergency C-section, which indicates that the mother or child’s life is endangered. An “unplanned cesarean” can be advised for reasons such as “failure to progress”, CPD (Cephalic Pelvic Disproportion, aka “the baby is too big”), or time restraints for either labor or pushing.

*Timing – For those that feel it is important to plan when their baby is born, an elective cesarean gives the parents the opportunity to choice the baby’s birth day.

*Fear – If the mother cannot get past the fear of labor, a cesarean might eliminate this stress factor.

Hopefully, these facts will offer the mother deciding between a vaginal birth and elective cesarean some clarity when weighing risks verses benefits.



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