Nearly one out of three pregnant woman deliver via cesarean section. With numbers like these, expectant moms ought to know the procedure, risks and reasons for this surgery. Here are expert opinions about its place in obstetrics. 

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Why Are C-Sections So Common?

We don't tend to think of childbirth as dangerous, but it's never been risk free. "Just a relatively short time ago, women and babies died in labor due to infection or prolonged, dysfunctional labor," says Angela King, MD, an ob-gyn in Fort Collins, Colorado. "Thankfully, medicine has improved to where that very rarely happens in the U.S." The option of a c-section is part of that improvement.

If problems arise during labor, your doctor might decide that an emergency c-section (one that's unplanned) would be safer than a vaginal birth. For instance, the baby's oxygen supply might be in jeopardy due to pressure on the umbilical cord. Maybe the fetal monitor signals trouble with the baby's heart rate. Or perhaps the baby just isn't budging, which puts the mother at risk for infection.

When facing a difficult delivery, doctors have traditionally resorted to extracting the baby with forceps or a vacuum. But many younger physicians don't have the same experience with these techniques as previous generations of ob's have, so they consider them to be riskier than surgery.

For another range of reasons, scheduled c-sections are on the rise as well. An ultrasound might show that the baby is breech (bottom first), and efforts to turn her in the womb aren't working. Prior health issues (such as hypertension or diabetes) can also lead to pregnancy complications that require a c-section. And if a woman has had a previous uterine operation, she may opt for surgery to avoid the risk of rupturing her uterus during a vaginal birth.

An increase in multiple births has also inched up the c-section rate, especially for women expecting triplets. "With 40 percent of twins, labor is not a problem, as long as their heads are down," says John P. Elliott, MD, director of maternal fetal medicine at Banner Good Samaritan Medical Center, in Phoenix. When Courtney Hall, of Fort Worth, went into preterm labor at 33 weeks, she welcomed the option of delivering her twins by c-section. "I was glad that it happened that way," she says. "I trusted that it would be okay because doctors perform so many c-sections."

Finally, as c-sections become more common, there's a small but growing trend to choose this form of childbirth. Some women want to avoid the possibility of prolonged labor pain or vaginal tearing. Others like the convenience of scheduling the birth. "I call them designer deliveries," says Dr. Elliott. "A woman will say, 'I'd like to deliver my baby next Tuesday. My mother is flying in.'" So she'll opt either to induce labor (which raises the odds of emergency c-section) or to schedule an elective c-section (one performed without a medical reason). The surgery is generally done at or shortly after 39 weeks' gestation, which is the earliest time sanctioned by the American College of Obstetricians and Gynecologists.

Elective c-sections also give doctors a measure of control. Obstetrics, in general, is unpredictable, and can require that an ob is on call for 24 to 48 hours at the hospital, says Kenneth Johnson, a doctor of osteopathic medicine who practices obstetrics in Fort Lauderdale. A scheduled 25-minute c-section, on the other hand, is more predictable.

What Are the Risks?

The trend is not without its critics. "It's still a major operation," says Dr. Elliott, and surgery puts the mom at a greater risk for complications such as infection, blood clots, or excessive bleeding. "Mother Nature has been doing this way longer than I have," says Dr. King. "I need a very good reason to intervene -- not just a tee time."

Scheduling the c-section before 39 weeks might jeopardize the baby's health too. Premature babies have a greater risk of having breathing difficulties, due to underdeveloped lungs, as well as delayed brain development.

Women who want to try a vaginal birth after a c-section (VBAC) run the risk of bursting their incision during labor. In subsequent pregnancies, a woman with a cesarean scar on her uterus also runs a higher risk for a condition called placenta accreta; the placenta implants low in the uterus and grows into the scar where the previous incision was made. The risk rises with each c-section, and it can be life-threatening for the mother.

On the other hand, Dr. Elliott says, the baby is better off in a c-section than in a vaginal delivery, under most circumstances. Your child could avoid potential trauma from a vacuum or forceps or the loss of oxygen from a compressed umbilical cord. And the majority of mothers do make it through their c-sections just fine.

Is There a Right Way to Have a Baby?

Many women feel disappointed about having an "irregular" birth experience. "I tell my patients who are upset about having a c-section that it's my job to deliver a healthy baby and to get Mom through the process healthy and well too," says Dr. King. "Whether it happens by a vaginal delivery, by forceps, or by c-section doesn't matter to me."

Betsy Brown, of Raleigh, North Carolina, was initially upset about her c-section, but when she thinks of her daughter, Miller, now, she feels differently: "No matter how she got here, she's a wonder. And I should just pipe down and love her, no matter how she got out."

What Is the C-Section Procedure?

A c-section generally starts with a visit from an anesthesiologist, who discusses your pain-relief options. In most cases, you'll have either an epidural (a catheter inserted in your spine, which delivers a steady stream of anesthesia) or a spinal block (a single injection of anesthesia).

The physician begins by making a 5- to 6-inch incision in the skin above your pubic bone. Cutting through the underlying tissue, he then makes a horizontal incision through the lower part of the uterus, just above the bladder. Generally, you're alert but numb, and a curtain is draped across your chest, blocking your view of the surgery.

The doctor then reaches in and pulls the baby out. "My ob said, 'It's a girl,' and held her up in the air for me to see," says Anne Negrin Reis, of Queens, New York, when her daughter, Lindsey Stella, was born. "My husband got to hold her, and then they weighed her and took her to the nursery." Meanwhile, the doctor continues the surgery, removing the placenta and stitching up the incisions, layer by layer. The surgery lasts about 25 to 60 minutes.

When it's over, you're wheeled into a recovery room where you're reunited with your infant, provided you're both well. "Within an hour after she was born, I was nursing her," says Trista Blouin of Pensacola, Florida, whose first child, Sophia, was born via a planned c-section.

While many women share this experience, c-section moms are statistically less likely to breastfeed their babies than women with vaginal deliveries. A number of factors, such as pain from the incision, keep these moms from establishing a breastfeeding routine early on.

Your hospital stay typically lasts three to four days, as opposed to two days for a vaginal birth. Once you leave the hospital, reduce activity for about six weeks, Dr. King recommends. "I limit my patients to carrying only the baby, nothing heavier," she says. "Stairs and walking are fine. No baths for at least two weeks, but showers are okay."

How painful is the recovery? That's hard to predict because different moms experience different levels of postoperative soreness.

Originally published in the December 2008 issue of American Baby magazine.

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