March 2, 2010
When I hear women debate whether it's better to have a vaginal birth or a Cesarean section, I'm able to offer a rare perspective: I experienced both—in the same delivery.
I popped out my first twin, Toby, the old-fashioned way. But my second little guy, Ian, was delivered by emergency C-section after his umbilical cord dropped down before he did, potentially compromising his oxygen supply.
Needless to say, I'm grateful to have had that C-section; but in the absence of an emergency situation like mine, I'd choose a vaginal delivery any day.
It's true, as comedian Carol Burnett said, that "giving birth is like taking your lower lip and forcing it over your head." But if you ask me, it sure beats staples in your belly, a catheter in your bladder, intense gas pains, a longer hospital stay and recovery, and double the risk that you'll land back in the hospital with an infection.
If you're having a repeat C-section (you'll probably need to if your first delivery was via Cesarean) or if your baby is being delivered before 39 weeks, the chance that your baby will have to spend time in the neonatal intensive care unit (NICU) also doubles.
Once a rarity reserved for obstetric emergencies, C-sections have become commonplace, now accounting for nearly 32 percent of all U.S. deliveries (up from 20.7 percent in 1996). As a result, giving birth surgically is often perceived as easier and safer than labor and vaginal delivery, even for low-risk pregnancies. But in most cases, it's not.
"For mothers who don't have a risk condition, a Cesarean is actually less safe for mom and baby than a vaginal birth," says childbirth researcher Eugene Declercq, Ph.D., assistant dean for doctoral education at the Boston University School of Public Health.
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To be sure, C-sections are safer now than in decades past. This is largely because of improved surgical techniques and better antibiotics to protect against post-operative infection, and because regional (local) rather than general anesthesia can usually be used. Yet compared to women who deliver vaginally, those who deliver by planned Cesarean are 2.3 times more likely to be re-hospitalized within 30 days (19.2 out of 1,000 women for Csections, compared with 7.5 for vaginal births).
The risk of death is extremely low for babies who are delivered via planned Cesarean to low-risk mothers with no labor complications—about 0.75 deaths per 1,000 live births. Yet according to a 2008 study of more than 8 million U.S. births over a three-year period, this rate is 69 percent higher than the neo natal death rate for planned vaginal deliveries.
A much more common concern is respiratory distress. Newborns delivered via Cesarean before 39 weeks gestation (about one-third of all scheduled C-sections) and babies delivered via repeat Cesarean are twice as likely to be admitted to the NICU for breathing problems. C-section babies also have higher rates of childhood asthma.
"Being pushed through the birth canal squeezes fluid from their lungs, so babies delivered vaginally tend to have fewer respiratory issues," explains OB-GYN Bonnie Wise, M.D., an associate professor at the Northwestern University Feinberg School of Medicine in Chicago.
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Perhaps the best reason to avoid a nonessential C-section for your first baby is so you aren't forced to have a second—or third—surgery. The potential risks associated with pregnancy after a C-section and with repeat Cesareans are serious.
For example, uterine scarring from a previous C-section leads to a much higher risk of placenta previa (when the placenta partially or entirely covers the cervix) and placenta accreta (when the placenta burrows into the uterine muscle rather than simply attaching to the lining). Both conditions can trigger lifethreatening hemorrhage in the mother, either during labor or after giving birth.
These and other risks increase substantially with each successive C-section, no small concern given that the adage "once a Cesarean, always a Cesarean" is still a reality in the United States today. Some 91 percent of moms who delivered via C-section the first time end up having a Cesarean again rather than a VBAC (vaginal birth after Cesarean).
"I think we've minimized how advantageous it is for mothers and families to have an initial vaginal birth," says John M. Thorp, Jr., M.D., a professor of OB-GYN at the University of North Carolina at Chapel Hill School of Medicine.
"It used to be that C-sections were done to save the life of the mother or baby. But the standards for doing them are being lowered, and malpractice has a lot to do with it," says Maureen Corry, M.P.H., executive director of Childbirth Connection, a nonprofit childbirth advocacy organization.
Many doctors agree. "The threat of a lawsuit is in the front of my mind," says Miami obstetrician Randy Fink, M.D. "If something goes wrong with a vaginal birth, the first question you're going to be asked is: 'Why didn't you do a C-section?' " Our litigious environment, he says, means that "some women have C-sections that may be a quick jump to the knife."
RELATED: How Many C-Sections Can You Have?
These days, doctors are also much more likely than in the past to turn to C-section for breech babies, twins and cases of lengthy labors. The trend, Thorp suggests, is partly due to a profession- wide "loss of skill and confidence." When doctors aren't accustomed to delivering vaginally in all but the easiest situations, the C-section cycle perpetuates itself.
As even Declercq, a vaginal-birth advocate, points out: If your doctor isn't confident and experienced with vaginal births, "you don't want this person delivering your baby vaginally."
Also contributing to the high C-section rate is the near-universal use of electronic fetal monitoring. Monitors measure the fetal heart rate during labor to detect signs of distress, but they have a high false-positive rate. Says Fink: "Until there is some better way, it's our only tool to assess the baby's safety, but it ultimately results in a lot more C-sections than are probably necessary." Declercq considers the commonplace use of fetal monitoring "part of our general affection for technology" and says there's "no evidence that fetal monitoring as a universal practice saves lives."
A secondary factor in the rising C-section rate is the sharp decline in VBACs, from 28 percent in 1996 to about 9 percent now. In roughly 1 percent of attempted VBACs, the woman's uterine scar ruptures, and in rare cases, the rupture results in severe blood loss in the mother and/or brain damage or death of the baby.
"Not every hospital or health-care system can offer the anesthesia and operatingroom availability that VBAC requires," North Carolina's Thorp says. The overall VBAC success rate is about 70 percent, but in many parts of the U.S., there are no hospitals that allow VBACs or doctors willing to attempt them.
No accurate formula exists to predict whose uterus will rupture, but there are numerous established criteria for which women make the best VBAC candidates. For example, your success rate may be as high as 85 percent if you have had a previous vaginal birth, if your uterine scar (not the visible scar on your belly) is from a "low transverse" incision, if you're younger than 40 and not overweight, if your C-section was more than two years earlier, and if you arrive at the hospital during labor rather than being induced.
"It's rare to see these women now," says Wise, who performs VBACs. "But when we do, it works beautifully."
Some obstetricians predict the pendulum will soon start swinging back in favor of vaginal births. "Everything in my specialty is driven by fad and consumerism," says Thorp. "I imagine there will be a backlash and that families will start valuing vaginal delivery and seek out the doctors who likewise value it."
Circumstances beyond your control may cause you to deliver by Cesarean, but you can take these steps to increase your odds of delivering vaginally.
Cesarean section rates vary dramatically across the U.S. and even among hospitals and medical practices in the same city. The C-section rate in New Jersey is about 38 percent; in Utah, it's 22 percent—only slightly higher than that of Sweden, one of the industrialized world's lowest. (Because Utah's birth rate is the nation's highest, doctors there have great incentive to keep the primary C-section rate low in order to prevent repeat C-sections.) Rates in California hospitals average 31 percent.