Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too!

CHAPTER 24. Elective cesarean birth

Some women who are enjoying a healthy pregnancy will request a cesarean delivery — even when there are no pregnancy complications or problems with the baby. Some of these women want the convenience of scheduling the birth. If you tend to plan everything in your life down to the minute, waiting for an unknown date for your baby’s birth may seem impossible. For other women, their preference for a cesarean birth (C-section) is driven by fear:

 Fear of labor and delivery and the pain associated with both

 Fear of damage to the pelvic floor

 Fear of sexual problems after birth

If this is your first baby, labor and delivery is an unknown, and that can be scary. You may have heard horror stories about labor and delivery, or about women leaking urine when they laugh or cough after childbirth. If you had a previous vaginal delivery and it didn’t go well, you may be afraid of a repeat experience.

If you’re considering an elective C-section, talk candidly with your care provider. If fear is your major motivation, a frank discussion of what to expect might help along with childbirth education classes. When someone starts to tell you about a terrible birth experience, politely but firmly say that you’ll be glad to listen after your baby is born.

If your previous vaginal delivery was truly one of those horrible stories, remind yourself that no two labors are alike and that giving birth this time may be a much different experience. Examine what made the last birth so bad, and then discuss it with your care provider or a support person. There may be things you can do to help ensure a more positive birth experience this time.

If your care provider supports your request for an elective C-section, the decision is up to you. If your provider is not able to support your request — he or she will not perform an elective C-section — your provider may refer you to another medical professional who will do the procedure. Educate yourself about the risks and benefits of both ways of delivery, and discuss the pros and cons with your health care team — but don’t let fear be the deciding factor.

ISSUES TO CONSIDER

Elective cesarean birth is controversial. Those in favor of it say that a woman has a right to choose how she wants to deliver her child. Those against it say that the risks of cesarean birth outweigh any potential benefits. To date, there’s no convincing evidence in the medical literature indicating an advantage to elective cesarean deliveries. Good medical practice generally resists doing procedures — especially surgical ones — that have no clear advantage to the patient. In addition, there are only a few studies have addressed the issue.

Because the procedure is controversial, you might find that care providers’ opinions on this subject are quite varied. Some are willing to consider it. Others will not perform the procedure, believing that an elective cesarean birth could potentially be harmful and, therefore, against their medical pledge to do no harm.

The best way to make a decision is to be as informed as possible. Ask yourself why this approach is attractive to you. Research the issue thoroughly, talk to your health care team, and carefully weigh the pros and cons of the procedure.

BENEFITS VS. RISKS

Most health professionals believe that with the advances in surgical techniques, elective cesarean births are virtually as safe as vaginal deliveries if this is your first child. The same is not true in the case of a third delivery. In this situation, elective cesarean deliveries carry the risk of more complications than do vaginal births. Here is a listing of the benefits and risks of the procedure:

Maternal benefits Some of the suggested benefits that could come with an elective C-section include:

Protection against urinary incontinence Some women fear that the effort involved in pushing a baby through the birth canal may cause fecal or urinary incontinence, damage pelvic muscles or injure pelvic nerves. Medical evidence has shown that women who undergo a C-section have a decreased risk of urinary incontinence in the months shortly after delivery. However, medical evidence doesn’t show that an elective C-section decreases the risk of urinary or fecal incontinence two to five years later. Some women are also concerned that a vaginal delivery may lead to pelvic organ prolapse, a condition where organs such as the bladder and uterus protrude into the vaginal canal. At this time, medical evidence studying the relationship between elective cesarean section and decreased pelvic organ prolapse isn’t completely clear. But having an elective C-section doesn’t guarantee that problems with incontinence or prolapse won’t occur. The weight of the baby during pregnancy, pregnancy hormones and genetic factors may weaken pelvic muscles. Even women who’ve never had babies can develop incontinence or prolapse problems.

Avoidance of an emergency C-section An emergency C-section, which is usually performed during a difficult labor, has higher risks than both an elective C-section or a vaginal birth. Risks associated with an emergency C-section include infection, a greater chance of injury to organs in the abdomen and pelvis, and bleeding complications.

Avoidance of difficult labor Sometimes, a difficult labor may lead to a forceps or vacuum-assisted delivery. These methods usually don’t pose a problem. Just like C-sections, their safety is dependent on the skill of the individual performing the procedure.

Fewer childbirth problems Theoretically, a planned cesarean birth may reduce rare childbirth problems. It might reduce labor-related infant death, shoulder dystocia, birth injury — which is a particular concern for high-risk women who have large babies — and breathing in of meconium, which occurs when a baby has a bowel movement prior to delivery and inhales fecal material. The events of labor also carry a very small risk of cerebral palsy. It’s important to remember that the risk of these complications is low with a vaginal delivery, and having an elective cesarean birth is not a guarantee that these problems won’t occur.

Reduced risk of transmitting infectious disease With an elective C-section, there may be a reduction in mother-to-child transmission of infectious diseases such as AIDS, hepatitis B, hepatitis C, herpes and human papillomavirus.

Scheduling of the birth Knowing when you’re going to have your baby may allow you to be better prepared for childbirth. Scheduling may also ease demands on your medical caregiving team.

Maternal risks, short-term There are risks and disadvantages associated with an elective cesarean birth. They include longer hospital stays. The average hospital stay following a cesarean birth is three days, compared with two days for a vaginal birth.

Higher infection rate Because surgery is involved, risk of infection following delivery is higher with a C-section than with a vaginal delivery.

Complications of surgery Because cesarean birth is major surgery, it carries associated surgical risks, such as infection, wound complication, bleeding, damage to neighboring organs, and formation of blood clots. Anesthetic risks are greater with a cesarean delivery, as well.

Reduced initial infant bonding and breast-feeding Within the first few hours after delivery, you may not be able to breast-feed or do much with your newborn. But this is temporary. You’ll have time to feed and bond with your child when you’ve recovered.

Insurance coverage An elective cesarean delivery may not be covered by your insurance, and it may be more expensive than a vaginal delivery. Before making your decision, check with your insurance company to see if your insurance covers elective cesarean births.

Maternal risks, long-term Long-term risks that can accompany an elective cesarean birth include:

Future complications Numerous pregnancies tend to increase the risk of complications with each successive pregnancy. Multiple cesarean births increase your risk even more. Most women can safely have up to three C-sections. Each repeat C-section is generally more complicated than the last, however. For some women, the risk of surgical complications, such as infection or heavy bleeding, increases only slightly from one C-section to the next. For other women, such as those who have significant internal scarring, the risk of complications increases substantially with each repeat C-section.

Uterine rupture in subsequent pregnancies A previous cesarean birth may increase your risk of uterine rupture, especially if you decide to try a vaginal birth after a cesarean birth. These risks are small, but should be discussed with your care provider.

Placental problems Women who’ve had a previous cesarean birth are at an increased risk of placental problems in subsequent pregnancies, such as placenta previa discussed in Chapter 27. Placenta previa occurs when the placenta covers the opening of the cervix, and often results in preterm delivery. Placenta previa and other placental complications enhanced by cesarean delivery greatly increase the risk of bleeding in the mother.

Increased hysterectomy risk Some placenta problems, such as placenta accreta in which the placenta is attached too deeply and firmly to the uterine wall, require the removal of the uterus (hysterectomy) at the time of delivery or shortly thereafter.

Injury to bowel or bladder Inadvertent injury to the bowel or bladder during cesarean delivery is rare but is much more likely in repeat operations. Placental complications also can lead to bladder injury.

Fetal risks Some possible risks to baby associated with cesarean birth include:

Respiratory problems One of the more common risks to a baby after a cesarean birth is a mild respiratory condition called transient tachypnea. It occurs when the baby’s lungs have too much fluid. While your baby is in the uterus, his or her lungs are normally filled with fluid. During a vaginal birth, movement through the birth canal naturally squeezes the baby’s chest and pushes the fluid out of the lungs. During a cesarean birth, the squeezing effect isn’t present, so your baby’s lungs may still contain fluid after birth. This results in rapid breathing and usually requires additional oxygen delivered under pressure to get the fluid out.

Prematurity Even mild prematurity can have significant adverse effects on a newborn. If the timing of baby’s due date is not accurate and the C-section is performed too early, the baby may experience prematurity-related complications.

Cuts A baby may be cut during a cesarean delivery, but this is rare.

MAKING YOUR DECISION

If your care provider doesn’t at least challenge your request for an elective cesarean delivery you should ask yourself why. Physicians and surgeons are duty bound to avoid unnecessary medical interventions, especially those interventions that carry risk. The lack of scientific evidence to support elective cesarean delivery makes such a procedure unnecessary. While scheduling, efficiency and financial reward favor an elective cesarean from a physician’s point of view, a care provider you can trust should at least discuss the topic with serious reservations.