The Real Risk for Cesareans: An Expert Interview

The Real Risk for Cesareans: An Expert Interview

Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical birth has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.

Reasons for this increase have been discussed profusely:

• The surgical focus of obstetrics and the need to train residents;
• The low priority and few practical skills for supporting women’s abilities to labor and give birth naturally;
• A rigid view of the duration of normal labor; and
• A low threshold of definition for ‘labor dystocia’

Surgical birth is also a ‘side effect’ of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring. Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported ‘supply-side’ justifications such as “baby seems large,” also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians’ personalities — specifically their anxiety levels

The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.

Pamela K. Spry, BSN, MS, PhD, the President of Lamaze International, a leading childbirth-advocacy group, spoke with us about the risks for birth by scalpel.

Medscape: Childbirth methods are often trend-driven. In the 1960s and 1970s, there was a big push for natural childbirth. What has driven women away from that method since then?

Dr. Spry: In the 1960s, women were rebelling against twilight sleep — childbirth under heavy narcotics that required being strapped down to the delivery table. There was also the push for fathers to be in the delivery room, which wasn’t allowed, and certainly not during heavily sedated birth. Now we have a widespread availability of local and regional methods of pain relief that let women be awake and aware, share the birth with their families, and basically rely on technology to assist them at birth. I think this drive has been somewhat alleviated, but there is still a push for natural childbirth. This is the reason women are still seeking classes, making birth plans, and choosing home birth and birthing centers.

“Natural childbirth” can mean different things to different people. For Lamaze, it means a birth that’s allowed to happen on its own without the use of unnecessary medical interventions, to provide women the safest and healthiest birth possible.

Medscape: Are rates of surgical delivery being driven up by women or clinicians? Is this the age of Blackberry birth — scheduling everything ahead of time?

Dr. Spry: Actually, there are 2 parts to this question. One is, what has driven up the rate of repeat cesareans, and that answer is easy: there has been a big decrease in the availability of choosing to labor and deliver vaginally (VBAC) after having 1 or 2 previous cesarean births, causing a huge increase in the rate of surgical delivery [for repeat cesareans]. Compared with the early 1990s when VBACs were encouraged and acceptable, many hospitals, insurance companies, and clinicians now refuse to allow women to try laboring after a previous c-section because of perceived medical and legal risks.

The second part of the question is whether women or clinicians are responsible for the increase in the primary c-section rate, and I think that’s more difficult to answer. In a study of more than 1500 women, we tried to determine just that. The research results indicated that only 1 woman in the study actually reported that she requested a cesarean, which leaves the decision for the vast majority of cesarean deliveries up to clinicians. So understanding when cesareans are medically necessary, as well as the risks involved, is important in achieving a safe and healthy birth.

Although it might be convenient, babies who are born before they are ready are at increased risk for major medical problems.

Medscape: What are the main risks these days with c-sections? Are these risks underplayed by obstetricians, and, if so, why?

Dr. Spry: Many of them were covered in the introduction. Any time we schedule a surgery or an induction, we are assuming that we know the baby’s due date. Anything that’s scheduled before a woman’s estimated due date could result in a baby being born before its ready. [And iatrogenic prematurity is a reality with any scheduled birth — that is, due dates may have been calculated wrong and inadvertently, babies are born before they are actually term.] We’re getting more research looking at the near-term preemie. We find that they have breathing and developmental problems and that the risk for death is increased. Certainly, cesarean delivery increases the risk for the baby being injured from the incision. Surgery also carries risks for women, such as blood loss, clotting, infections, severe pain, and adverse anesthesia-related events. This is something that we haven’t focused on, and I’m not certain that informed consent includes this information — that there are complications during future pregnancies and that it does risk future children. There is an increased risk for stillbirth with a second or third c-section, as well as placental problems like percreta and accreta (abnormal growth and attachment of the placenta into the uterus), increasing the risk for hemorrhage. Women may experience dire complications as a result — bladder injury, hysterectomy, and maternal death. I don’t know that I would describe these risks as “underplayed” by obstetricians, but rather that women are not prepared to ask the right questions that lead to informed decision-making.

It would be interesting to read the informed-consent documents for cesarean deliveries, and see what risks are included.

To read the full article please go to http://www.medscape.com/viewarticle/706095