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The Cutting Edge: A C-Section Boom

Surgical knife

Jason Todd

When Terrie Montelongo learned she was expecting, the 26-year-old San Antonio resident did what many first-time moms do -- she chose a color for the nursery, registered for gifts, and dreamed about the day when she would finally hold her baby. But as Montelongo's belly expanded, her mind filled with fear. "I was really worried about labor pain, and the very idea of an episiotomy totally freaked me out," she says. "And the birthing classes didn't help -- the more I learned, the more I was convinced I couldn't handle it." And so Montelongo asked her ob-gyn for a c-section even though it was medically unnecessary. "My doctor was willing to do it, but he made sure I understood the risks and benefits," she says. "Ultimately, the decision was mine." On March 22, 2005, Joseph Michael Montelongo entered the world just as his mother envisioned -- with the help of a scalpel, not a push.

A decade ago, doctors resorted to surgery only if a vaginal birth was deemed too risky for the mother or child. Today, the majority of cesareans are still performed for medical reasons (for instance, the baby is too large or in a breech position, or goes into fetal distress during delivery), but more and more women are requesting to give birth by c-section. Some mothers-to-be, like Montelongo, have qualms about the pain of vaginal delivery; others worry about the risk of urinary incontinence from a vaginal birth, and still others simply like the convenience of scheduling the delivery date. All these women want more control over their childbirth experience.

Labor & Delivery: What to Expect in a C-Section
Labor & Delivery: What to Expect in a C-Section

According to a report from HealthGrades, a healthcare-information company, the number of elective c-sections -- first-time, preplanned c-sections with no medical need -- rose 36 percent between 2001 and 2003. And since l996, our nation's c-section rate has almost doubled to an all-time high of just under 30 percent, which means that nearly one baby in three is born via surgery. Within the obstetrics community, patient-choice cesarean is controversial. Some doctors believe that patients should be able to choose a c-section if they prefer, while others adamantly oppose performing surgery when it isn't necessary. "A c-section is major abdominal surgery with all the risks and complications associated with it," says Bruce Flamm, MD, a clinical professor of obstetrics and gynecology at the University of California, in Irvine. "Without medical cause, I generally wouldn't do it." Critics of elective c-sections point out that the procedures not only put the mother and child at risk, but they also waste medical resources and increase costs. A cesarean delivery can cost approximately $7,000 more than a vaginal one, and c-section moms spend twice as long in the hospital, resulting in higher medical bills. It's estimated that cutting the current cesarean rate from 30 percent to 15 percent could yield an annual medical savings of $1 billion.

In 2003, the American College of Obstetricians and Gynecologists (ACOG) released a statement essentially approving elective c-sections if a doctor believes the procedure is in the best interest of the patient. The debate, however, continued and became so heated that in March 2006, the National Institutes of Health (NIH) convened a panel of experts to examine why more women were having c-section births and what the inherent risks were. In the end, they found no reason to dissuade women from having elective cesareans as long as they don't plan on having more than two children (women who have repeat c-sections increase their risk of developing complications like placenta previa).

Birth Stories: Planned C-section With Twins
Birth Stories: Planned C-section With Twins

Maternal-request cesareans aside, there are many reasons why c-section rates are skyrocketing. The increase in fertility treatments has produced more high-risk multiple births. Also, first-time mothers are older and heavier. Studies show that women over 35 are far more likely to have c-sections than younger women, and overweight moms-to-be are nearly four times as likely to have one.

Ironically, medical advancements that were meant to help with the birthing process have contributed to the spike in cesareans. The likelihood that a woman will need surgical intervention during delivery goes up if: she's taken labor-inducing drugs (these can result in prolonged or difficult labors); she's had an epidural (walking helps labor progress, but an epidural restricts a woman's mobility); or she's hooked up to a fetal-heart-rate monitor (this also restricts mom's movements, plus many doctors consider any heart-rate change to be a sign of fetal distress and immediate cause for surgery).

"There's no clear-cut answer to how long a woman should labor or when exactly a baby is in distress," says Kimberly Gregory, MD, an obstetrician and gynecologist at Cedars-Sinai Medical Center in Los Angeles. "Many doctors err on the side of caution and throw in the towel early." A baby who's in trouble must be delivered as quickly as possible to avoid injury. And doctors are also worried about lawsuits: Failure to perform a cesarean early enough is one of the top reasons obstetricians are sued.

The role of VBACs

Perhaps the most significant change in labor-room practices over the last decade is a reluctance among hospitals and doctors to allow vaginal births after cesareans (VBACs). Repeat cesareans account for 35 percent of all surgical deliveries today. VBAC deliveries were uncommon until the 1980s, because doctors warned that the stress of contractions and pushing would cause the uterine muscle to rupture, a potentially fatal condition for mother or baby. But after studies placed the rupture risk at only about 1 percent, doctors began recommending VBACs if the reason for the prior cesarean was unlikely to happen again -- for example, if your first baby was breech, but your second is head down. In 1996, the country's VBAC rate hit a high of 28 percent. As of 2004, it's dropped to a mere 9 percent.

So what happened? Although the rupture rate didn't change, there were simply more VBAC births occurring, which meant more total deaths -- deaths that made national headlines. In 1999, spurred by these well-publicized reports, ACOG modified its VBAC guidelines, stating that a medical team must be "immediately available," which means that an ob-gyn and anesthesiologist should be standing by and an operating room ready each time a VBAC is attempted. (Previously, the guidelines had suggested that a surgical team be "readily available.") "That one little word -- 'immediately' -- was enough to panic the medical community. Suddenly, surgery, even if it wasn't medically warranted, seemed less risky than the chance of getting sued," says Tonya Jamois, president of the International Cesarean Awareness Network (ICAN). ICAN estimates that more than 300 hospitals nationwide no longer permit VBACs because they're concerned about liability.

"Although it wasn't ACOG's intention, these guidelines have made obstetricians afraid of VBACs," says Sebastian Faro, MD, a Houston obstetrician and gynecologist. As a result, more mothers today choose a second c-section birth, in part because their doctors strongly recommend it.

Still, many women are relieved to repeat the procedure. Alice Ann Howard's first baby was born via emergency c-section after going into fetal distress. When she became pregnant again, the Richmond, Virginia, mom stuck with a cesarean birth despite her doctor's blessing to try a VBAC. "I knew VBAC risks were low, but I'd never forgive myself if something went wrong. A planned c-section felt safer, and I knew what to expect," she says.

Indeed, one of the top reasons women request nonmedical cesareans is uncertainty about what to expect during labor and delivery. And celebrity moms like Britney Spears, who reportedly made her plans to deliver her babies via c-section because the alternative sounded too painful, have somewhat glamorized the procedure. "These celebs give young women a false perception that surgery is an easy and risk-free way to give birth," says Jamois.

Women think, "Why be in labor for 20 hours if I can plan for a 30-minute procedure?" But the truth is that the majority of vaginal births don't entail horrifically long labors or scary complications. "Giving birth is a natural process, and most expectant moms would be able to experience an uncomplicated birth if they -- and their doctors -- had more faith in what women's bodies can do," says Parents advisor Katherine Camacho Carr, PhD, president of the American College of Nurse-Midwives.

A woman's right to choose

Ultimately, moms like Terrie Montelongo argue that a mother has a right to choose her delivery method -- and more and more doctors agree. "An uncomplicated vaginal delivery is ideal, but since we can't accurately predict who will or won't have problems, a cesarean is a reasonable request as long as the patient is educated about the risks," says Mary D'Alton, MD, NIH panel chairperson and chair of the obstetrics and gynecology department at Columbia University Medical Center, in New York.

Certainly, with every pregnant woman facing a 30 percent chance of a cesarean, it's smart to be familiar with both modes of delivery. "What's important is that women are given the right tools to make informed decisions," say Dr. Faro. Of course, in the end, having a healthy baby matters so much more than how your child entered the world.

newborn baby wrapped in a blanket

Jason Todd

Prior to surgery your pubic hair is shaved, and once you're in the operating room, a catheter is inserted into your urethra, an intravenous medication line is inserted into your arm, and you're given a spinal block. Your obstetrician makes a 4- to 5-inch horizontal "bikini" incision just above your pubic bone. Several layers of fat and tissue are cut, and the abdominal muscles are separated. You and your husband won't have to see what's going on, since the doctor puts a screen up at your waist. Finally, the doctor opens your uterus to lift out your baby. You might feel some uncomfortable pulling and tugging sensations during the procedure, but usually there's little or no pain. Although delivery takes about 10 minutes, the subsequent suturing can take up to 30 minutes. During this time you will be able to see but not hold your newborn. "It's too risky to let a medicated mother hold a squirming infant while her internal organs are exposed," explains Dr. Bruce Flamm.

Recovering from a c-section is more difficult than recovering from a vaginal birth. Because almost twice as much blood is lost during a c-section than during a vaginal delivery, medical complications are common. Up to 30 percent of c-section moms develop postpartum infections, and they're twice as likely to be rehospitalized due to surgical tears and blood clots. A study published in the September 2006 issue of Obstetrics & Gynecology found that women who opt for an elective cesarean have three times the risk of dying from complications of anesthesia, infection, and blood clots than those who choose vaginal delivery. Walking, sneezing, laughing, or simply shifting positions can be painful for weeks. And many women find that breastfeeding is especially challenging because the tender incision site makes it difficult to nurse comfortably.