The National Center for Health Statistics reported last month that the cesarean or c-section rate hit an all-time high in 2007, with a rate of 31.8 percent, up 2 percent from 2006.
When a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. However, a vaginal birth is still considered the safest birth for a woman and her baby. Marygrace Elson, MD, director of general gynecology in the Women's Health Center at University of Iowa Hospitals and Clinics, talks about c-sections:
What type of surgery is a cesarean section?
A c-section is abdominal surgery. It's usually done under regional anesthesia, which could be a spinal or epidural, but it's sometimes done under general anesthesia. The skin incision can be up and down or crosswise. What's more important is where the incision is in the uterus, and usually that incision is crosswise in the lower part of the uterus, which we call a transverse incision. However, there are unusual situations where the incision will be in the upper, more active part of the uterus, and situations such as extreme prematurity would be possible indications for that.
Are there risks involved for both mother and baby during a cesarean section?
Certainly, there are risks to any surgery. Risks of a cesarean birth include bleeding during surgery; infections which can include wound infections, bladder infections, or pneumonia after surgery; and there also can be complications of anesthesia.
How does recovery differ if a woman has a cesarean section?
Recovery is quite a bit slower from a cesarean birth then a vaginal birth. Since it's abdominal surgery, it takes a little while for normal bowel function to return and women aren't up and around quite as rapidly after a cesarean birth. It's harder for them to establish breast feeding with their baby. They stay in the hospital longer—usually three to four days after surgery, rather than one to two days after a vaginal birth. Even after they go home, it's not back to life as usual. Since it's abdominal surgery, women aren't able to drive for a bit or do heavy lifting. And women will be aware of the incision for up to a year, as with any abdominal surgery.
Is a c-section baby more at risk to develop complications?
Babies that are born vaginally get a big squeeze as they come out and that helps their transition to breathing the air around us. Babies born by cesarean just don't get that big squeeze, so their lungs can be a little wet and this causes them to have a little more effort trying to breathe. And they will breathe faster, so these babies often need just a little extra observation in the newborn period to make sure they will make the transition without any problems.
Are complicated or difficult births more common today than past decades?
That's a somewhat difficult question to answer. I can tell you that assisted reproductive technology has increased the rate of multiples, such as twins or higher order multiples—triplets, quads—and these are definitely more complicated births.
The obesity epidemic in the United States has increased obstetric complications in general; including babies that can't fit through the birth canal. There are also women with significant medical problems who in prior generations would not have been able to even become pregnant—or survive pregnancy. Due to medical advances, these women are now having babies and these are much more complicated pregnancies and births.
If a woman has a c-section with her first baby, do all subsequent babies need to be delivered by cesarean section?
No. Whether or not a woman can choose a trial of labor after having a cesarean birth depends mainly on the type of incision in the uterus and how many cesareans she has had. It also depends on the resources available at her hospital.
The American College of OB and Gynecologists has identified that a woman is a possible candidate for trial labor after cesarean if she's had one prior cesarean, a pelvis that seems adequate, and no other scar in her uterus.
Further, a physician capable of performing an emergency cesarean delivery, anesthesia and operating room personnel must be immediately available throughout active labor; usually that means in the hospital. Many smaller hospitals just plain can't do this. At UI Hospitals and Clinics, we have a moderate number of patients who are being co-managed with their local obstetric provider. They see their local provider for their routine care, but they come here for their labor and their birth.
Most cesareans at term are crosswise incisions in the lower part of the uterus, which we call the lower uterine segment, and this area has relatively less blood supply, so that's why we can allow a trial labor after cesarean. About two-thirds of women who choose a trial labor after cesarean will have a successful vaginal birth, which is called VBAC or vaginal birth after cesarean.
At UI Hospitals and Clinics, our successful VBAC rate for the last year was just at that national average of 68 percent. There is a slightly increased risk of labor for a woman who has had a cesarean, compared to one who has not. It's usually about 2 percent—it's the risk of that prior scar opening up—but usually that doesn't result in significant problems because of that decreased blood supply to that part of the uterus. But sometimes if that scar opens, it can be accompanied by massive hemorrhage. This can be rapidly catastrophic for mom and baby and that's why the need for immediate capability to do an emergency cesarean.
If a woman's prior incision is in that upper, more active part of the uterus, then she cannot labor in the future because that area has an abundant blood supply so those women always need to be delivered by cesarean before they labor.
Why are the number of caesarian births on the rise?
As you mentioned, the total cesarean rate in the U.S. is now at about 32 percent. That's about doubled over the last 20 years. Operative deliveries have stayed right at about 9 percent. Here at UI Hospitals and Clinics, our rate is right at the national average, right around 32 percent.
These rates are impacted by several factors. The medical-legal climate in the United States certainly looms large for anyone providing obstetric care, because if there's a poor outcome with the baby, the plaintiff's attorney will argue that either one should have done a c-section, or, if you did, they will argue it should have been done sooner.
We're also starting to see women request elective cesarean births. It's estimated that about 2.5 percent of all births in the United States now are c-sections on maternal request. There are lots of motivations for this request. Sometimes families simply like the idea of picking a day for logistical reasons. The only real medical reason to consider elective cesarean has to do with pelvic support.
There's absolutely no question that having a baby weakens a woman's pelvic floor and this can lead to later problems with urinary incontinence or prolapse. Aside from a longer hospital stay and the other things we've already discussed, elective cesarean birth after 39 completed weeks is not a very big deal the first time around. The real issue of elected cesarean birth shows up with the next pregnancy because any time there's a scar in the uterus, the placenta may implant in the wrong place; for example, in front of the baby and this sets women up for hemorrhage and possible need for hysterectomy.
What bottom line advice would you give to pregnant women who are considering their birthing options?
Women should discuss their questions and concerns with the provider taking care of them during the pregnancy, including pain relief in labor and what the provider's philosophy is about interventions in labor and birth.
Together, they should discuss her risk factors and what the provider's recommendations are for birth route. This discussion should take into account the woman's age, her history, her future pregnancy plans. Both the woman and the provider should be on the same page. If a woman has had a prior cesarean birth and wants a trial labor, and if she's a good candidate but her local hospital cannot offer her this option, we would always be happy to see her in consultation in University of Iowa Hospitals and consider co-managing with her local provider. |
