In the past 20 years, the cesarean section rates have nearly quintupled in the United States. Marygrace Elson, MD, division director of general obstetrics at University of Iowa Hospitals and Clinics, talks about cesarean births:
For those who do not know, what is a cesarean?
A cesarean birth is delivering the baby through a surgical incision in the uterus. It's a little unclear where the word comes from, although the popular myth is Julius Caesar was delivered by cesarean. In those times, the mother would have been near death or dying, so since his mother went with him on his campaigns, we're reasonably certain that he was not delivered by a cesarean.
When is a cesarean birth necessary?
There are a few emergency situations where we perform cesareans. One of those would be if the placenta is lying across the cervical opening, that's called a previa, and if a woman labors and the placenta is in front of the baby, she could suffer profuse bleeding that could threaten both her life, as well as the life of the baby.
Sometimes the umbilical cord falls down through the cervix ahead of the baby. We call that prolapse and the baby's blood supply can be cut off, so again this is an emergent reason to perform an emergency cesarean.
More commonly we do cesareans because there's no progress in labor, either the cervix doesn't dilate or when the mom is pushing, the baby just doesn't come down; some times the baby's too big; sometimes the baby's just not positioned optimally; sometimes the uterine muscle just doesn't contract right. If the baby is breech, or butt first, then we would usually do a cesarean these days. And another reason would be if the fetal heart rate tracing is non-reassuring, if the monitor tracing does not reassure us that the baby is doing well, then we might recommend a cesarean. But actually a lot of cesareans today are done because the mom has had a prior cesarean.
Why are cesarean birth rates on the rise?
Around 1970, the cesarean rate in this country was about 5 percent, but a lot of things have happened in the last 30 years. First of all, we've given up doing vaginal breech deliveries in this country. We also have quit doing midforcep deliveries because of studies that show that babies didn't do so well after those kinds of births.
Another thing is the advent of electronic fetal monitoring. This was introduced and quickly became the standard of care back in the '70s and we have relied on electronic monitoring to try to tell us how babies are doing in labor. What's interesting is that despite these huge increases in the numbers of cesarean sections, we haven't really seen a decrease in cerebral palsy.
If a woman has a complication that leads to a cesarean, will her next baby also need to be a cesarean delivery?
No, whether she can labor again after cesarean depends on the kind of incision that's made in her uterus, and the vast majority of cesareans are what we call lower segment transfer cesareans.
These are incisions where there's a crosswise incision made in the lower part of the uterus, which does not have a big blood supply. So these women, if there aren't any complicating factors, can be offered a trial of labor, and about two-thirds of them will make it regardless of why the first one was done. The risk of separation of that scar is estimated at about 1 percent, but again, because there's not a big blood supply to that area, this usually does not cause any kind of emergency situation.
However, to offer that trial of labor after cesarean, it's recommended that the hospital have the ability to perform an immediate cesarean, which pretty much means in-house anesthesia and in-house obstetrics. This isn't usually true in smaller hospitals. Here at the University we often share care with some of our local providers in the surrounding communities so that these women can be offered a trial of labor; the woman receives most of her care from her local doctor, but then comes here for her labor and delivery.
The other kind of incision is called a classical incision, and these women cannot labor because they have an incision that goes up into the muscular part of the uterus, which has a much greater blood supply. Fortunately, these types of incisions are usually restricted to extreme prematures, or a few other unusual situations, so this is not the kind of incision most women have.
Are cesarean rates influenced by non-medical factors, like insurance, the mother's age, education level, or higher socio-economic bracket?
That's kind of an interesting question because actually extremes of maternal age are a medical risk factor in pregnancy, and that includes teens as well as older, first-time moms. Both teens and older first-time moms have just sort of a generically increased risk of pregnancy complications. There is a definite increase in the chance of having a cesarean for your first baby if you're an older mom. The rate for first births in young women, let's say women under 30, is about 20 percent, but it's more than double that for women who are in their 40s.
Currently, most insurance companies do reimburse more for a cesarean birth than a vaginal birth, and certainly that could offer a profit incentive to push obstetricians toward cesarean. Blue Cross Blue Shield pays more for a cesarean than for a successful vaginal birth and pays a little bit more for a trial at a vaginal birth ending with a cesarean. Medicaid also pays more for a cesarean than a successful vaginal birth and offers no incentive. So, obviously for busy obstetricians in private practice, it might be a little bit more attractive to schedule these deliveries around the office and surgeries, especially if there's no incentive. There are some older studies that are mainly in the mid-wifery literature that suggest that women with private health insurance delivering in U.S. private hospitals have a higher cesarean rate.
When a woman chooses an elective cesarean, do the risks for premature birth and respiratory problems heighten for her baby?
Yes they do. When we talk about an elective cesarean, we're talking about a scheduled surgery in the absence of labor, so this would include scheduled repeat cesareans, as well as primary cesareans. It doesn't mean the cesarean's not indicated, it just means there's no labor. So when a woman is delivered by an elective cesarean, there are increased risks for respiratory problems in the baby. Babies who are born by cesarean just don't get the fluid squeezed out of their lungs like babies that make the trip through the birth canal, and so these babies sometimes breathe fairly rapidly for a while. We have a name for it, it's called transient tachypnea of the newborn, and it's just that--it's short lived, the babies need to be observed for a little while, but they usually do fine.
But there does seem to be an increased risk of some other, more significant lung problems, as well, for babies that are born by a scheduled cesarean. Now the other risk, which has pretty much gone away, is the risk of scheduling a cesarean--you think the woman is at term, you schedule the surgery, you deliver the baby, and it's actually premature. Fortunately, with increased use of early pregnancy ultrasound dating, we don't see too much of that any more, but it certainly was a problem in the past.
Are there other issues associated with elective cesarean birth?
Oh there sure are. There's actually a really hot controversy in obstetrics right now about cesarean delivery on request, or so-called patient choice cesarean. There was a really interesting survey of women obstetricians in London in the mid-1990s that showed that about a third of them would opt for an elective cesarean rather than labor and deliver vaginally, even if they had no specific risk factors, and this mainly had to do with what's called pelvic floor considerations. If a woman labors and delivers vaginally, there can be some damage to the nerves of the pelvic floor and this can result in incontinence--incontinence of urine, incontinence of gas, incontinence of stool, and obviously this is very distressing and these women obstetricians knew about this. So there is this increasing move toward just opting for a cesarean.
The other thing is that the baby is much less likely to suffer birth trauma with a cesarean than a vaginal birth. Now on the other hand, if you have a cesarean and a subsequent pregnancy, the placenta may not implant properly, it may be in the wrong place, it may be abnormally stuck to the uterus, and the risk of that goes up with increasing cesareans, so it's not like it's all on the bright side. But this is kind of a hot area and something that we see a lot in the press about.
Why is it important for a woman with a complicated pregnancy, who may need to consider a cesarean birth, to receive her prenatal care and deliver her baby at a place like UI Hospitals and Clinics?
Well, if a woman has a complicated or high risk pregnancy, she optimally should receive some of her care and deliver at a tertiary center like UI Hospitals and Clinics. We have sub-specialists in high-risk obstetrics, we have sub-specialists in neonatology, a fine NICU that is nationally known. Our neonatal intensive care unit is backed up by all sorts of other sub-specialists that can care for a complicated newborn. We have obstetricians, anesthesiologists, and pediatricians in-house, 24/7, so we can provide that round-the-clock care for women who are laboring, as well as to the newborn. The other thing is that as a research hospital, our very tiniest newborns can benefit from research protocols and trials that may not be available elsewhere, and these babies tend to do better if they're delivered here, if they're in-born, than if they are transferred in from outside. |
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