Cesarean Sections
Are They Risk-Free?
In the United States, cesarean (si-‘zar-E-an) sections are one of the most common surgeries for women. With 31.8% of women delivering babies via cesarean, it is easy to assume the surgery is risk-free. What women are often told after a cesarean is that a healthy baby was the most important outcome. However, the cesarean can sometimes be at a cost to the mother's emotional and physical well-being.
When a cesarean is necessary, it can be a lifesaving procedure for both mother and baby. A cesarean section is major abdominal surgery used for the delivery of an infant through an incision in the mother’s abdomen and uterus. The incision may be made across the bottom of the abdomen above the pubic area (transverse) or in rare instances, in a line from the belly button to the pubic area (vertical).
There are specific times when a cesarean becomes truly necessary. A cesarean section is indicated in the following situations:
- Complete placenta previa at term
- Transverse lie at complete dilation
- Prolapsed cord
- Abrupted placenta
- Eclampsia or HELLP with failed labor induction
- Large uterine tumor that blocks the cervix at complete dilation (Most fibroids will move upwards as the cervix opens, moving out of baby’s path.)
- True fetal distress confirmed with a fetal scalp sampling or biophysical profile
- True absolute cephalopelvic disproportion or CPD (baby too large for pelvis) This is extremely rare and only associated with a pelvic deformity (or an incorrectly healed pelvic break).
- Initial outbreak of active herpes at the onset of labor
- Uterine rupture
Many reasons given for cesarean, especially prior to labor, can be questioned. This includes macrosomia (large baby), maternal age and parity, assisted reproductive technology, CPD, dystocia, failure to progress, breech, fetal distress or even prolonged second stage. Fetal positioning during labor and maternal positioning during second stage, most notably when women are in a semi-sitting position, causes most CPD diagnosed in current obstetrics. There are very few true indications for a cesarean section where the risks of surgery outweigh the risks of vaginal birth.
The risks of cesarean surgery are mental and physical affecting both mother and baby. Psychological outcomes such as negative feelings, fear, guilt, anger and postpartum depression are common consequences of both emergent and elective cesarean sections.
A cesarean poses documented medical risks to the mother’s health. These risks include infection, blood loss and hemorrhage, hysterectomy, transfusions, bladder and bowel injury, incisional endometriosis, heart and lung complications, blood clots in the legs, anesthesia complications, and rehospitalization due to surgical complications.
Scar tissue makes subsequent cesareans more difficult, increasing the risk of injury to other organs and the risk of chronic problems from adhesions. Potential chronic complications from adhesions include pelvic pain, bowel problems, and pain during intercourse. The mortality rate is at least two to four times that of women with vaginal births. One-half of women who undergo a cesarean section suffer complications.
Each successive cesarean increases risks for future pregnancies. The more cesareans a mother undergoes, the greater the risk of placenta previa, placenta accreta and placental abruption in subsequent pregnancies. These complications can be life-threatening to mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy.
A cesarean poses documented medical risks to the baby’s health, as well. Risks include respiratory distress syndrome (RDS), iatrogenic prematurity (surgery performed too early due to an error in determining due date), persistent pulmonary hypertension (PPH), and surgery-related fetal injuries such as lacerations, An elective cesarean section significantly increases the risk of premature birth and respiratory distress syndrome, both associated with multiple complications, intensive care and burdensome financial cost. Additionally, cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding, and the establishment of family bonds.
The best approach for a mother to reduce her chances of a cesarean is to become educated. Education can include attending birth education classes in and out of the hospital environment. Additionally, mothers can research risks and benefits of routine and emergency procedures before they are faced with them. When faced with any procedure, mothers are entitled to have informed consent outlining the short and long term effects on the mother, baby, and the labor process. Are there other options to the procedure?
Another strategy for mothers is to choose a care provider and a birth facility wisely. Cesarean rates are often influenced by non-medical factors. These include: individual care provider philosophy and training, convenience of doctor or patient, the patient’s socioeconomic status, peer pressure, fear of litigation, and financial gain.
When choosing a care provider, mothers benefit from interviewing more than one provider. Some interview questions are the following: Do they have a set time limit for labor and second stage pushing? What does the provider feel can interfere with the normal process of labor? Under what circumstances do they use medical interventions such as labor inductions? Are post date pregnancies a problem? It is helpful for the mother to educate herself ahead of time and determine if the answers are evidence -based. As with care providers, it is important to tour more than one birth facility –note the differences, find out the cesarean rate, etc.
Additionally, research shows that labor support such as a doula reduces the need for a cesarean. When selecting a doula, number of births, and experiences with normal, non-interventive birth are factors to consider.
In our society, educated consumers shop around for quality merchandise. First time parents spend time filling out baby shower registries to ensure they get just the right items. Even more essential for families, is to take, at a minimum, the same amount of care to choose a care provider and birth facility. Although there are no guarantees, the anticipated outcome of a pregnancy is a healthy baby. However, the real goal to work towards is a physically and emotionally healthy mother and baby. Pregnancy, labor, and birth are the critical beginnings that shape the essential mother/child bond for life.
