Elective C-sections: A risky choice?

Experts question new surgical delivery trend


Merry Mayer and Susy Schultz

Should a woman be able to choose to have a Caesarean even when there may not be a medical reason?

This controversy has been growing for the past three years at the same time the number of Caesarean sections has been on the rise.

Everyone seems to agree more women are having Caesareans—about three women in 10 now have one, according to 2004 numbers from the New York-based Maternity Center Association.

When the procedure is medically required, there is no issue: The best delivery is one that ensures the mother and the baby are safe.

The problem comes when it is a Caesarean on demand.

In fact, the increases in C-sections prompted the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists to issue reports in 2000 expressing concern about the number of C-sections among healthy women. Both said the United States can and should reduce the number.

Locally, BlueCross BlueShield of Illinois says the number of C-sections among 120,000 insured members rose from about 26 percent in 2003 to 30 percent in 2004.

And elective C-sections are growing as well, albeit not by as much.

A study released last year by Health Grades, a Colorado health care research company, found the number of elective C-sections rose from 1.77 percent of all deliveries to 2.21—an increase of 25 percent from 2000 to 2002. And a survey of female obstetricians by the Gallup Organization—its first ever—found that 22 percent of C-sections were elective.

Birth is a natural process that has been going on for thousands of years and surgery—no matter how routine—always carries risks, which can be as extreme as death.

Yet, urogynecologists, who care for women with pelvic floor dysfunction but do not deliver babies, argue that surgical advances make C-sections safe. And, they say, C-sections prevent women from developing pelvic problems later in life.

So, women are requesting C-sections. Some because they have heard vaginal birth will lead to pelvic dysfunction. Others because they fear the pain of vaginal delivery. And others because they want to know exactly when their baby will be born.

"It has become a fad that is being fueled by fear and by promises that are way too tempting," says Deanne Williams, executive director of the American College of Nurse Midwives.

Risks for convenience

C-section risks include bladder injury and placenta accreta, a potentially life-threatening condition that can require an emergency hysterectomy, says Dr. Ann Warren, an obstetrician and gynecologist in Barrington.

Warren says there should be a good reason for doing a C-section—not just avoiding pain. "I won’t tell them they don’t have the option, but I have some concerns about it. I need to have them vocalize to me their reasons for it."

And the risks can have long-term consequences.

"You need to look at the risk of the decision vs. the complications of that procedure," says Williams. "This is not a single procedure decision. It is one that will affect subsequent births. And the risk after subsequent Caesareans goes up exponentially for you and your baby."

Williams recommends reading the brochure "What Should I Know About Caesarean Section?" found at www.maternitywise.org.

Other risks include the formation of scar tissue, hemorrhaging, infection and uterine damage. Evidence also suggests that women who have had a Caesarean have a higher risk of ectopic pregnancy.

"I run into [some patients who request a C-section]. It’s their first pregnancy and they have heard the buzz about it," says Dr. Maryam Siddiqui, an obstetrician and gynecologist at Mount Sinai Hospital in Chicago. "I try to talk them out of it. It’s major surgery."

The American College of Obstetricians and Gynecologists’ ethics committee determined that the evidence to support "the benefit of elective Caesarean is still incomplete."

But there is no blanket rule. Sometimes surgery is called for. It should be a discussion between patient and doctor.

Dr. Jennifer Berman, co-director of the Female Sexual Medicine Center at UCLA Medical Center and co-host of Discovery Health Channel’s "Berman & Berman," chose a C-section for her second child. "I had a very traumatic, long labor [the first time]," Berman says. "Women should choose how to deliver, assuming we understand the risks involved."

The controversy

Yet, some doctors believe C-sections are a better option even when not medically necessary.

"Vaginal delivery is the single biggest risk factor in developing pelvic floor dysfunction," says Dr. Brett Vassallo, a Park Ridge urogynecologist.

Pelvic floor dysfunction can cause urinary and fecal incontinence and pelvic organ prolapse, where organs such as the uterus are no longer supported and begin to drop down, causing blockages and pressure.

These problems are not as rare as you might think—many women who haven’t even given birth experience urinary incontinence, says Williams.

"By age 40 about one-third of women will report some degree of problem," says Dr. Roger Goldberg, director of urogynecology research at Evanston Continence Center. But Goldberg claims this results from how women give birth. "[It doesn’t matter] how many babies they had, the birth mode was the important factor."

Goldberg studied 542 identical twin sisters and found those who had elective Caesareans were less likely to have bladder and rectal problems.

Williams says this one study is too small to draw a definitive conclusion. The one systematic review of the medical literature shows a Caesarean is not an indicator one way or another for pelvic dysfunction.

"All of these women who are being promised that a C-section is going to prevent incontinence later in life are being sold a bill of goods," Williams says. "We do not know."

"More research has to be done on the risks and benefits," says Dr. Sherman Elias, obstetrics and gynecology chair at Northwestern Memorial Hospital. "I don’t feel dogmatic [against] it, but there must be true informed consent."

Exercise can help

Still, there are things women can do before and after giving birth to prevent later physical problems.

"Women go into childbirth with very little understanding of how it will affect their bodies. They are about to run the Boston Marathon—who would run a marathon unprepared?" Goldberg says.

Perineal massage, which stretches the skin between the anus and vagina, and Kegel exercises, which strengthen pelvic floor muscles, can help, adds Vassallo.

Goldberg says women who regularly do Kegel exercises during pregnancy prevent a loss of muscle strength and actually emerge with stronger pelvic muscles than before pregnancy, he says.

Williams agrees. "Kegeling is an old-fashioned intervention," she says, "but it works."

Merry Mayer is a Chicago-based writer with two children. Susy Schultz is associate publisher and editor of Chicago Parent.

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