Should Caesarean Delivery be available as mom’s choice?

Jane Brody ~ Science & Health / New York Times 

Tuesday, December 15, 2003

When my twin sons were born 34 years ago, the goal of every woman I know was a vaginal delivery. Alas, for me, that was not to be. The babies were just too big to make it through my narrow pelvis and after a nightlong labor they had to be delivered surgically by Caesarean section.

Such so-called emergency Caesarean will always be with us, the result of labor that fail to progress, fetuses that are too big or in the wrong position, placentas that block the uterine opening, infections, severe hypertension or other complications in the mother and health or life-threatening problems in the fetus.

If surgical birth occurred only for such reason, the Caesarean section rate would be about 10 percent of live births, or 15 percent at most.  But the rate in the United States now exceeds 25%, in part because a growing number of women are requesting “elective caesarean”  -- planned surgical deliveries. The rise in elective Caesareans has created a controversy in obstetrics, with some physicians strongly in favor of letting informed women choose their mode of childbirth and other physicians and nurse-midwives just as strong opposed with no clear-cut medical reason arises.

There are a number of reasons women may request elective cesareans. One is convenience – the ability to fit childbirth into their work schedule, plan for the care of their other children, or have spouses, parents or both be present at the birth.

Another is fear for the baby’s safety. A third factor involves possible pelvic injury that can result in urinary or fecal incontinence, complications that are more likely to follow a vaginal delivery.  And, of course, there are always some women who are so afraid of the pain of labor and delivery that they prefer the major surgery of a Caesarean. 

The most important question – which method of delivery is safer for an otherwise healthy woman with an uncomplicated pregnancy? --- can not be fully answered.  

As with any operation, there is a very small risk of a postoperative pulmonary embolism [bloodclots] but this complication can also occur after a vaginal delivery.

Of course, a planned caesarean would obviate the need for far riskier emergency Caesarean surgery  should a problem arise during labor.

In decades past the main drawback a higher mortality rate. But recent data from Britain and Israel reveal a lower death rate from scheduled Caesarean that from vaginal deliveries.

As for the welfare of the baby, planned Caesareans bring benefits and risks. The risk of stillbirth rises, albeit slightly, when pregnancies go beyond 39 weeks. The risk of birth-related cerebral palsy, also very low, is greater with vaginal deliveries. 

And vaginal births that require instruments (forceps or vacuum extraction) are more likely to result in injuries to the baby, including bleeding, fractures and nerve injury. When mothers are carriers of infectious agents like HIV, hepatitis B or C virus or human papilloma virus, Caesarean delivery can prevent transmission to the baby.

On the other had, if there is any uncertainty about the mother’s due date, an elective Caesarean can result in the birth of a premature baby. Also, there is often a delay in the onset of lactation when babies are born before labor begins, although no ill effects on breastfeeding or mother-infant bonding have been demonstrated.

Any woman considering elective Caesarean should discuss the benefits and risks fully with her physician early in the pregnancy. If the doctor opposes her choice, referral to another physician may be the wisest choice.

Jane Brody writes about health for the New York Times