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Choosing Cesarean: Are
Elective C-Sections Safe?
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As an expectant mother for the
first time, I am constantly surprised by how eager
well-meaning family, friends and baby-loving strangers are
to tell me labor and delivery stories. A woman at a
volunteer event who patted my belly and breathlessly
confided that nothing was more amazing then her vaginal
birth. An acquaintance whose vaginal delivery resulted in
her baby’s shoulder being broken with forceps. My brother,
who supplied every detail of his wife’s four cesarean
sections. But what’s surprised me most is the question
almost everyone ends his or her stories with: “So, are you
going to have a c-section or a vaginal birth?”
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“Do I actually have a choice?” I
wondered. With a healthy pregnancy, I assumed that I would
be expected to have a vaginal delivery unless something went
wrong. That’s when a friend pointed out that I could elect
to have a c-section—even if it wasn’t medically necessary. A
quick Google search showed me that the subject of first-time
mothers choosing to have a “cesarean delivery on maternal
request” is the center of an unresolved national debate. Are
these elective c-sections safe? Why are more women
requesting them? What are the short-term and long-term
effects? Armed with questions, I turned to
Carla Ortique, M.D., an obstetrician and
gynecologist at The Austin Diagnostic Clinic, for answers.
Rise in Requests
“I have begun to see some requests for c-sections that
aren’t medically necessary,” says Dr. Ortique. “Many women
have a fear of labor pain, as well as a fear of injury to
their infant because of a difficult delivery or instruments
used. A small subset of people is looking at convenience and
the desire to have more control than a labor situation
allows. You can pick a day, you know what’s going to happen
and you can plan ahead.”
Some women also fear urinary incontinence and uterine
prolapse (when the uterus drops or protrudes into the
vagina), risks that are higher with vaginal deliveries than
with c-sections, Ortique explains.
While there are no hard and fast numbers, the National
Institutes of Health estimates that in the United States and
internationally, requests from first-time expectant mothers
for medically unnecessary c-sections ranges from 4 percent
to 18 percent of all cesarean sections. Because cesarean
section is a common procedure, many women assume that it’s
safe. And for the most part, risk of complication to the
mother and infant are low. But, says Ortique, it’s still
surgery.
“Some people assume that a c-section is the best and safest
way to go without understanding the risks of the procedure,”
she explains. “C-sections and vaginal deliveries both have
risks, and a woman considering a c-section that is not
medically needed should weigh them all.”
Considering Cesarean
For a c-section, the medical risks are greater for the
mother than the infant. Compared to a vaginal delivery, a
woman undergoing a c-section faces a higher risk of
bleeding, infection, blood clots and damage to other organs,
such as the bladder or bowel, even though those risks are
low. In addition, recovery time is longer for a c-section
than for a vaginal birth.
Possible long-term complications also need to be considered.
Each time a woman has a c-section, her risk increases for
placenta previa (when the placenta implants too low in the
uterus) and placenta accreta (when the placenta attaches too
deeply to the wall of the uterus). Both of these conditions
can endanger the lives of mother and baby. While many women
have first pregnancies that end in c-section due to medical
necessity and have safe c-sections after that, many
physicians don’t recommend a medically unnecessary c-section
for women who want several children.
“Some proponents of elective c-sections argue that if a
woman only want one or two kids, and they’ve been counseled
by their doctor, that’s fine,” Ortique says. “But
realistically most women don’t know how many kids they’re
going to have—an inadvertent pregnancy may occur. And the
more c-sections you have the higher the risks.”
Another long-term issue women should consider is whether
they would like the option of a vaginal delivery in the
future. Vaginal birth after cesarean section (commonly
called a VBAC) can be challenging. If you’ve had a
c-section, the risk of a ruptured uterus during a VBAC is
half a percent to two percent, explains Ortique. A ruptured
uterus can cause death to the baby or a loss of blood flow
that can result in neurological problems. For the mother,
the result could also be a hysterectomy.
“When we say ‘there is a 1 percent chance,’ the odds are
clearly in your favor,” says Ortqiue. “But unless you are
for some reason significantly wedded to the idea that you
would like a VBAC, women today, because of how doctors are
counseling them, aren’t choosing to do so as often,” says
Ortique. “It doesn’t mean that we think it’s any less safe
than it was 10 years ago when we were actively encouraging
VBAC, it’s just that medically, legally and ethically, we
are now counseling in a way that is causing women to not
choose that route because of potential risks.”
C-sections can also pose risks to the baby. For example,
newborns are more likely to have respiratory problems if
born by c-section, regardless of the reason for the surgery,
according to the NIH. In 2006, a panel of national experts
convened by NIH on medically unnecessary c-sections
recommended that doctors perform elective c-sections only if
they’re sure the baby has reached at least 39 weeks, when
the baby’s lungs are fully mature.
An Individualized Decision
The medical community itself is divided on whether or not
c-sections that aren’t medically necessary should be honored
by physicians. The NIH panel on elective c-sections
concluded that there is not enough evidence to evaluate the
benefits and risks of a medically unnecessary c-section
compared to a vaginal delivery and that more studies are
needed.
While the American College of Obstetricians and
Gynecologists (ACOG) “continues to review the issue,” its
current position is that “cesareans should be performed for
medical reasons.” If a woman requests a medically
unnecessary c-section, ACOG stresses that she should be
thoroughly and accurately counseled on all of the associated
risks.
“Many OBGYNs are concerned that we’re going to start to see
more labor complications that used to be extremely rare as
we start honoring elective c-sections,” says Dr. Ortique.
“In general, most physicians are going to counsel someone
who has never had a baby before against doing a truly
elective c-section if it’s a normal pregnancy.”
In the end, childbirth is a unique experience for every
woman and factors such as age, overall health, fetus health,
cultural and social beliefs and future childbirth goals all
influence delivery decisions.
“The most important thing you need to do if you’re
considering an elective c-section is to talk to your
physician about the short-term and long-term risks so that
you can make an individualized, informed decision,” says
Ortique.
Carla Ortique, M.D.,
an obstetrician and gynecologist at The Austin Diagnostic
Clinic, is board certified by the American Board of Obstetrics
and Gynecology and has more than 20 years of medical experience.
Sonja Weisel-Jones is an Austin-based writer due to give birth
on July 26.
The Austin Diagnostic
Clinic (ADC) is a multi-specialty clinic with physicians
representing 24 medical specialties at more than 10 locations.
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