Elective Cesarean Section
The Pros and Cons
Thanks in part to celebrity culture as well as a mindset of convenience, a number of pregnant women are opting for electively scheduled Cesarean sections (Cesarean Delivery on Maternal Request or CDMR). This group is comprised of women who have had previous Cesarean sections as well as those choosing a Cesarean section for their first pregnancy without attempting a trial of labor. The Cesarean section rate in the U.S. has skyrocketed from a low of 4.5% in 1965, the first year these statistics were recorded, to a high of 34% in 2009. In the last decade alone, the Cesarean section rate in the United States increased by 50%. Around the world, the Cesarean section rate is even higher; the rate in Brazil is 75%. The growing section rate is due to multiple factors; however, CDMR only accounts for 2.5% of the increase.
Before a woman considers CDMR she should be apprised of the pros and cons as they relate to her and her baby. There are physical, mental, emotional and practical arguments relating to her and her baby that can be made for and against CDMR.
The Pros
Convenience
Having an electively scheduled Cesarean can certainly be more convenient. It allows the woman to arrange her work schedule and maternity leave. It also can aid in the planning for childcare if the couple have other children. Other family members can also formulate plans for visits and assistance.
Reduction of Anxiety
CDMR can assuage a first time mother's anxiety associated with labor and vaginal delivery. She may be frightened by the anticipated pain of labor or the pain of a vaginal delivery. She may be worried about tearing or an episiotomy. She may be concerned about how her partner will perceive her after observing her in labor and delivery. The mother may be anxious about the potential for "something happening to the baby" during the attempt of a vaginal delivery. Another concern may be the possible need of an emergency Cesarean section.
Risk to Baby
If a Cesarean section is scheduled, it is less likely that the baby will become oxygen deprived. There is a decreased risk of birth trauma such as that associated with a forceps or vacuum delivery. There is decreased chance that the baby would suffer permanent neurological damage such as that associated with a shoulder dystocia (the baby's shoulder becoming stuck) during a vaginal delivery. There is a lower associated neonatal infection rate as well as lower risk of neonatal death.
The Cons
Longer Hospital Stays
After a Cesarean section the usual length of stay is four days as opposed to two days for a vaginal delivery.
Longer Recuperation and Increased Pain
Major Surgery
Although downplayed, a Cesarean section is considered major surgery. There are surgical and anesthetic risks. The risks associated with surgery include infection, hemorrhage, injury to other structures in the abdomen and blood clots in the leg and/or lungs. Infection can occur either in the incision, the uterus, or the bladder. Prior to performing a Cesarean, a catheter is placed in the bladder for the purposes of draining it for surgery as well as to keep track of the patient's urinary output. Catheterizing the bladder places the woman at risk for a urinary tract infection. With surgery there is increased blood loss compared to a vaginal delivery and therefore there is a potential need for blood transfusion and its associated risks. Damage to internal organs such as the bladder or bowels can occur. Scar tissue or adhesion formation is another consequence of Cesarean section, which at a later date can cause bowel obstruction, infertility or ectopic or tubal pregnancy as a result of blocked fallopian tubes. Adhesions may also be responsible for pain syndromes. Anesthetic complications are also a related risk of surgery. Risks from either regional or general anesthesia include low blood pressure, headache or pneumonia.
Later Consequences
Cesarean section is known to increase the risks of uterine rupture, placenta previa (the placenta implants over the cervix) as well as placenta accreta (abnormally deep attachment of the placenta). All of these place a patient at risk for an emergency hysterectomy (removal of the uterus).
Baby Outcomes
Babies born by Cesarean have lower Apgar scores. Accidental injuries can happen such as skin laceration. There is an increased risk of breathing problems especially if the due date is not accurate and the baby is inadvertently delivered prematurely as the lungs may not be fully matured. Babies that have been delivered by Cesarean may have increased allergies and diarrhea. Their immune systems may be affected. There also may be problems breast feeding the baby.
Studies have not shown that having a Cesarean section decreases the risks of stress urinary incontinence or pelvic organ prolapse or affects sexual functioning.
In 2006 a symposium of experts at the National Institutes of Health State of the Science Conference on CDMR reviewed 1,406 articles involving existing studies and concluded that the information presented did not support a recommendation for either CDMR or planned vaginal delivery.
Whatever a woman's reasons for CDMR, whether they are based on emotional, practical or psychological factors, the decision to opt for CDMR should only be undertaken after extensive counseling between a woman and her obstetrician. According to the American College of Obstetricians and Gynecologists recommendations, if a woman chooses CDMR it should not be performed before 39 weeks of gestational age, based on lack of availability of effective pain management, nor is it recommended for women planning on having future pregnancies.