More done than ever before …C-SECTION RISKS: What Every Woman Needs to Know

Cesarean risks for mothers MCA found that women who undergo Cesareans experience more severe and longer-lasting pain than with vaginal birth. Pain was the leading postpartum health concern in the first two months after Cesarean for over 80 percent of women in a recent national survey. Dr. Eugene Declercq, co-author of the resulting report, Listening to Mothers, adds, “Even six months after Cesarean delivery, pain continued to be a problem for one in 14 women who had a Cesarean. Yet many women fear vaginal birth because they worry about the pain.” The survey also revealed that women who had Cesareans were more likely to experience bladder and bowel difficulties, headaches and backaches. Women who have Cesareans are also more likely to be re-admitted to the hospital in the weeks after birth and are much more likely to have an infected uterus than those who deliver vaginally. Between one and nine out of every 1,000 women who give birth by Cesarean are at added risk for an emergency hysterectomy in the early weeks after giving birth.

Cesarean risks for babies A baby born by Cesarean may suffer accidental cuts (usually minor) during the surgery. MCA estimates that this occurs in between one and nine of every 100 Cesareans. Due to the pain, lengthy recovery period, and risk of infection and complications, a mother who has had a Cesarean has less early contact and may have an early negative reaction to her baby, affecting maternal bonding. Cesarean-born babies are less likely to be breastfed, missing important health benefits, and they have a high risk of early respiratory problems and lifelong asthma.

Cesarean risks for future pregnancies Women who undergo Cesareans (versus vaginal birth) have a very high risk of later infertility. For those who do conceive again, between one and nine out of every 1,000 have an increased risk of ectopic pregnancy, placental issues (placenta previa, placenta accrete or placental abruption) or a ruptured uterus. A baby who develops in a uterus with a Cesarean scar appears to have a moderate risk (one to nine of every 1,000) of dying before or shortly after birth.

Concerns for older mothers These findings are particularly important for older women who have postponed childbearing. “Pregnant women over 35 are often automatically classified ‘high risk’ and targeted for Cesareans,” says Dr. Declercq. “Instead, we should look at the medical risk factors of each individual woman. Age alone is not a risk.” If fertility drugs have resulted in a woman carrying twins, triplets or more, physicians typically recommend a Cesarean. “Fewer and fewer doctors have the skills to deliver multiple births vaginally,” says Dr. Declercq. “As those skills are increasingly lost, this will become a self-perpetuating cycle.” Older women who have invested a lot emotionally and financially trying to conceive may be urged to undergo a Cesarean to minimize risks to the baby. “These mothers may feel there is no room for error or uncertainty,” observes Dr. Andrei Rebarber, maternal fetal medicine specialist at NYU School of Medicine. While he acknowledges that a Cesarean gives more control over the fetus, Dr. Rebarber advises women to evaluate all options carefully before making a decision. Tonya Jamois, president of the International Cesarean Awareness Network (ICAN) cautions, “Doctors have their own sets of constraints — their schedule, their liability — that may bias their recommendations. Women need to clearly understand the risks and benefits of both Cesarean and vaginal birth from an unbiased point of view.”

Cesarean rate increasing In 1970, one woman in 20 gave birth by Cesarean. Today, nearly six in 20 do so. The Centers for Disease Control (CDC) have expressed concern about the growing Cesarean rate among healthy, low-risk women. The U.S. Department of Health & Human Services advocates reducing Cesareans for low-risk women to less than 15 percent by the year 2010. The World Health Organization estimates that half of all Cesareans performed in the U.S. are unnecessary. There is no debate that Cesareans are absolutely necessary in the presence of urgent medical concerns. Cesareans can save lives or prevent serious injury to mother and baby if the mother is hemorrhaging or the baby’s oxygen supply is seriously compromised.

VBACs declining The “once a Cesarean, always a Cesarean” debate continues. The rate of vaginal births after Cesarean (VBAC) has plummeted 55 percent since 1996. A 1999 American College of Obstetricians and Gynecologists (ACOG) bulletin urged practitioners to offer VBACS only where facilities, anesthesia and nursing personnel are “immediately available” to perform emergency Cesareans. As a result, many smaller hospitals without 24/7 surgical staffing have adopted a “no VBAC” policy. ICAN provides advice for women faced with forced Cesareans due to such policies. (see Resources).

“Defensive medicine” Medical, legal, social and financial factors contribute to the increasing Cesarean rate. “Lawyers tell OBs that few lawsuits occur if you perform a Cesarean too soon,” says Dr. Rebarber. “Lawsuits occur when you perform a Cesarean too late or not at all.” For New Yorkers, the legal climate in obstetrics led to the closing of the only freestanding birth center in Manhattan. Midwives, as well as MDs, are forced at times to practice defensively, resulting in more interventions. Physicians increasingly use medical interventions that can lead to Cesarean. “The long term trend has been that practices that were developed and appropriately applied to high-risk mothers are slowly but surely being used with more and more mothers, based not on actual medical risk but on potential medical risk,” says Dr. Declercq. “For example, fetal monitoring is beneficial for mothers in a high-risk pregnancy, but it has very little or negligible benefit for low-risk mothers. Yet it’s used in about 93 percent of all pregnancies.” He explains that irregularities sometimes appear on monitoring strips even when nothing is wrong with the baby. “A Cesarean is regularly done if there’s any question about the results,” Dr. Declercq says, “because it’s almost impossible to explain to a courtroom jury in a case with a bad outcome that an irregularity on a fetal monitoring strip was not a definitive sign of a problem.” Dr. Rebarber adds that when labor isn’t progressing, some doctors still use the 1960s Friedman Curve to decide when to induce labor or perform a Cesarean. “Newer criteria indicate that women should be given more time for labor to progress before jumping to a C-section,” says Dr. Rebarber. “If both doctor and patient know these new criteria and are prepared for longer labor, often a Cesarean can be avoided.”