Cesarean Section

Cesarean Section

What Every Woman
Should Know

You've been in labor since 5:00 a.m. and it's now 11:00 p.m. Your cervix is stalled at eight centimeters. Contractions are zapping your uterus. You're freezing cold, nauseated and about to pass out from exhaustion.

Your husband wants to rub your back. Your nurse wants to take your blood pressure. And your obstetrician wants to do a cesarean section.

Your response?

"Fine! Yes! Anything!"

It is not your most rational moment. That's why any discussion about having a cesarean--such as defining the circumstances, outlining the possibilities, weighing the alternatives, scoping out your doctor's attitude--should take place before you ever set foot in a labor room, says Bruce Flamm, M.D., associate clinical professor of obstetrics and gynecology at the University of California at Irvine and research chairman at the Kaiser Permanente Medical Center in Riverside, California.

This is especially true since cesarean sections are the most frequently done operation in the United States. Of the more than four million babies born every year, it's estimated that about one million are delivered by cesarean section, according to data gathered by the Centers for Disease Control and Prevention in Atlanta.

Studies show that in a typical year, about 35 percent are done because the woman delivered a previous baby by cesarean. Thirty percent are done because, for one reason or another, labor does not progress. Twelve percent are done because the baby is in a breech--that is, feet- or buttocks-first--position, 9 percent because the baby is in distress and 14 percent for various miscellaneous reasons such as the mother's herpes infection or diabetes.

But according to a report from the Public Citizens Health Research Group in Washington, D.C., many of the cesareans done each year are unnecessary. Based on estimates by Edward Quilligan, M.D., co-editor-in-chief of the American Journal of Obstetrics and Gynecology, the public citizen group estimates that cesarean sections should account for 12 to 14 percent of total births. The actual number of cesareans is closer to 23 percent of all live births. In other words, about half of all cesareans are probably unnecessary.

The Effects of Age

A cesarean section is a major abdominal operation in which a pregnant woman is given either a local or general anesthetic and the baby is surgically removed from the uterus. Although rare, maternal death occurs two to four times more frequently than with a vaginal birth, while rates for complications such as hemorrhage and infection are five to ten times higher. The procedure also requires an extra couple of days in the hospital, costs more and takes about three times longer to recover from than a vaginal birth.

Common reasons for a cesarean section are situations in which the baby is in danger, is too big to fit through the mother's pelvis or is in a poor position for delivery; there's bleeding; there are multiple fetuses such as twins or triplets; the placenta has torn or separated from the mother before birth; there are large fibroids in the lower part of the uterus that might obstruct the baby's delivery; or the mother has complications such as uncontrolled high blood pressure, says Helen Kay, M.D., a specialist in maternal/fetal medicine and associate professor of obstetrics and gynecology at Duke University in Durham, North Carolina.

Nowhere on that list is either maternal age or the fact that a woman has had a previous cesarean section. Yet a study of more than 700 women at Brown University School of Medicine in Providence, Rhode Island, and Yale University School of Medicine found that women 30 to 34 were 63 percent more likely to have a cesarean than women in their twenties, while women over age 35 were twice as likely to have a cesarean. On the other side of the country, a study of women who delivered single babies in civilian hospitals in the state of Washington from 1987 through 1990 revealed that women in the 30-to-34 age range had nearly double the cesarean rate of women 15 to 19.

Why are post-30 women more likely to have a cesarean? "It may have a lot to do with nonmedical things like the fact that women who have their babies when they're 38 may be attorneys or Ph.D.'s," says Dr. Flamm. It's what's called the premium baby concept, he explains. Some doctors think that because a woman put off childbearing, her "last chance" baby has to be perfect. "And the only way a doctor feels he can assure that is to perform a cesarean section at the first hint of trouble," he says.

Given the number of things that can go wrong as a baby makes that rough-and-tumble trip down the birth canal--like the umbilical cord becoming looped around the baby's neck, for example--some doctors feel that a cesarean tips the scales in the baby's favor.

"Other doctors feel that women who are 32 or 33 aren't as strong and healthy as a 22-year-old, which is why they're not able to have a vaginal birth. My personal feeling is that that's baloney. I've delivered many babies to women who are 38 and 39 who have had vaginal deliveries without any problems," Dr. Flamm says.

The Second Time Around

Even if you had a cesarean section to deliver one baby, you may not need one with the next, doctors agree.

"My personal feeling is that almost every woman who had a prior cesarean is a candidate for a normal birth," says Dr. Flamm. The exception, he says, is the woman who had a "classical" incision during the first section. This is a vertical cut in the uterus that usually begins above the belly button and extends down to the pubic area.

If a woman has a classical incision, there is a 10 percent chance that the uterus will rupture in subsequent pregnancies. That may not sound like a big risk, but if it happens, the results can be catastrophic: significant blood loss for the mother and death for the fetus.

Only about 1 percent of cesareans are done with a classical incision, says Dr. Flamm. Today, most surgeons use a "bikini" incision, in which the initial cut is made horizontally across the uterus. (This incision follows the line where the top of a bikini would lie against the abdomen.)

Statistics indicate that increasing numbers of women who have had prior cesareans are having subsequent babies vaginally, he adds. "The vaginal birth after cesarean--VBAC--rate has gone up about tenfold in the last 20 years," says Dr. Flamm. "In 1970 the rate was about 2.2 percent; in 1990 it was about 20.4."

That still means that 80 percent of women who have had a previous cesarean section are not delivering vaginally. But the increase is enough to cause cesarean rates in general to level off for the first time in decades--a trend that Dr. Flamm hopes will continue.

What You Can Do

Here's how you can reduce your chances of having a cesarean section.

Use a certified nurse-midwife. "Certified nurse-midwives have very low cesarean rates," says Dr. Flamm, who is married to one. "They're nurses to begin with. Then they go through a year-long program and an internship where they work with other midwives. They're very well-trained, and in most cases they work as a team with a physician as backup." About the only thing they can't do that a doctor can is perform major surgery.

The only women who probably shouldn't use a midwife are those who have a medical problem such as diabetes or are on blood pressure medication. To find a certified nurse-midwife near you, write to the American College of Nurse Midwives, 818 Connecticut Avenue NW, Suite 900, Washington, DC 20006.

Get a doula. "You should have somebody with you who can support your point of view about birth and cesarean sections," says Dr. Flamm. "In the midst of labor, it's not easy to keep a focus on what you want to do.

"That's why I believe in doulas, or trained labor support people who have been at hundreds of births. They'll sit with a woman in labor, and they've been down this road so many times before that they're not going to panic when there's a little dip on the fetal monitor." They'll also act as the woman's advocate should the need arise. If a woman has said she doesn't want drugs and a doctor starts to give them, the doula may remind the doctor of the woman's wishes.

"In some cities doulas are listed in the phone book under 'labor support,' " says Dr. Flamm. Any childbirth educator associated with a hospital or Lamaze group can probably refer you to one.

Ask for your doctor's stats. "There are doctors in this country with a cesarean rate of 10 percent and there are doctors with a rate of 80 percent," says Dr. Flamm. "And amazingly, some of those doctors with 80 percent rates are taking care of low-risk women.

"But cesarean rates are a sensitive issue with most doctors," he says. So basic human courtesy dictates that you should ask about your doctor's rates in a sensitive, nonconfrontational way. You might say on your first visit, for example, "You know that I'm interested in a natural vaginal birth and I was just curious as to what your cesarean rate is." "Approached that way, I think most doctors aren't going to get too upset about it," says Dr. Flamm.

A typical obstetrician's rates might hover between 15 and 20 percent, Dr. Flamm says. "If the doctor says the rate is 30, 40 or 50 percent, however, I'd be a little concerned." If that rate seems too high to you, it's probably a good idea to find another doctor.