Elective Cesarean Section. Part 1: the Mother
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Elective Cesarean Section. Part 1: the Mother.

Date: January 29th, 2015

Cesarean on Request, right or wrong?

Twenty-seven years ago when my wife found out that she is pregnant with our first child she told me that she wants to have a cesarean section. She was nurse at the time, and her experience with labor ward at the time of her training put her off the idea of vaginal birth forever. My wife is not alone in her choice, and elective cesarean – also called cesarean delivery on maternal request (CDMR), is a fairly common occurrence.

Choosing an operation instead of what is supposed to be a natural process, such as childbirth, to many seems outrageous. But, as it often happens, things are not what they look like on the surface. Surgery carries with it potential complications. On the other hand, vaginal delivery is not an innocuous process either, and has its own risks and complications, and cesarean section can prevent many of them. This article will give a brief overview of risks and benefits of cesarean section by request for the mother.

The actual frequency of cesarean on request is difficult to estimate. Some studies estimate it at between 1 – 2% of all cesareans. However, because the estimates are largely based on the absence of certain diagnostic codes in the databases these estimates cannot be accepted as reliable. It is also my personal experience cesarean on request is considerably more common than the data suggests.

In a survey published in 2006 by the American College of Obstetricians and Gynecologists 18% of obstetricians indicated that they would prefer planned cesarean if they or their spouse were delivering a baby after an uncomplicated pregnancy at term. Similar survey from Britain indicates that 10% of midwives, 21% of obstetricians, 50% of urogynecologists (doctors who deal with the diagnosis and treatment of urinary incontinence and female pelvic floor disorders), and 50% of colorectal surgeons would also choose planned cesarean over vaginal delivery.

Why Cesarean?

There are quite a few reasons why women choose cesarean for their childbirth, as listed below.

  • The desire to avoid elements of vaginal delivery, such as pain and trauma to the pelvic floor.
  • Desire to plan and/or time delivery
  • Desire to avoid unplanned cesarean and complications related to it
  • Desire to avoid possible complications of vaginal delivery: incontinence and pelvic organ prolapse
  • Desire to avoid complications related to the newborn: death during labor, cerebral palsy related to lack of oxygen during labor, birth trauma, infection in the newborn
  • Fear of labor
  • How valid are these reasons? This part of the article will present risks and benefits of elective cesarean section for the mother.

Pelvic Organ Prolapse and Urinary Incontinence.

In 2006 the panel of experts from various fields reviewed the existing data and came up with the National Institutes of Health State-of-the-Science Conference Statement. Synthesizing the data from many other studies, the NIH state-of-the-science panel came to conclusions that planned cesarean may be associated with a lower risk of trauma or organ injury. It included both trauma to the perineum and injury to internal organs as the result of cesarean.

The Term Breech Trial has found that three months after delivery urinary incontinence was significantly higher in vaginal delivery group compared to planned cesarean (7.3% vs. 4.5%). However, two years after delivery there were no differences between those who planned cesarean delivery and those who planned vaginal breech delivery when patients were questioned about symptoms.

A study conducted in Baltimore area and published in 2011 compared outcomes 5 – 10 years after childbirth between women who had had cesarean deliveries and those who had had various types of vaginal delivery. Vaginal delivery was associated with almost three times higher incidence of urinary incontinence and more than four times increase in pelvic organ prolapse, compared to cesarean section without labor. The risk of complication was most dramatic when forceps or vacuum had been used during labor. The same authors confirmed their findings in the 2012 review that included over 60 published studies.

Complications of Cesarean Section

Cesarean section is a surgical procedure and, without a doubt, can cause harm, both to the mother and the baby.

Immediate complications of cesarean section are similar to those in other types of abdominal surgery and include bleeding, wound infection, inadvertent injury to the abdominal organs, ileus (temporary paralysis of the bowel), nausea, vomiting, deep vein thrombosis and possible pulmonary embolism. It is important to remember, that there is a significant difference in complications between emergency cesarean and elective, or planned. Emergency procedures are often performed in a hurry, at late hours and have higher risk of complications. Elective cesarean, on the other hand, practically eliminates the need for the emergency and is done in more controlled conditions during day hours.

In the already mentioned Term Breech Trial there was no differences in mortality or serious morbidity between vaginal birth and cesarean section groups. Similarly, the mentioned

The National Institutes of Health State-of-the-Science Conference Statement of 2006 had conclusions slightly different from those of the Term Breech Trial and indicated that planned cesarean may be associated with a lower risk of bleeding or need for transfusion. It is important to note that the panel did not consider outcomes in future pregnancies in which prior cesarean delivery may lead to increased complication rates.

Pathological Attachment of Placenta

Placenta is an organ that connects the developing fetus to the uterine wall and allows the transfer of nutrients and oxygen, and elimination of waste via the mother’s blood supply. It is attached to the internal surface of the uterine wall and is expelled by the uterus after the baby is born. In some cases placenta can develop pathological attachment to the deeper layers of the uterine wall. This complication is known as placenta accreta. When it happens an attempt to remove placenta after the baby is born can result in severe bleeding, which may require blood transfusion, surgery and, in severe cases, emergency hysterectomy. Risk factors for placenta accreta include age over 35 years, multiple pregnancies, previous abortion and/or uterine curettage, placenta previa and – the strongest – previous cesarean section.

Prospective study of 2006 that followed 30,132 women found that incidence of placenta accreta gradually rose from 0.24% of those undergoing first cesarean section to 6.74% in those who had their sixth cesarean. Significant jump in the rate of this complication was apparent after the third cesarean. Respectively, the risk of emergency hysterectomy rose from 0.65% to 8.9% for the first and sixth cesarean respectively.

Danish study that analyzed the data from the Danish National Birth Cohort demonstrated the most dramatic increase in risks of serious complications after previous cesarean section. According to its results the risk of placental abruption was 2.3 times, uterine rupture 268 times (!), hysterectomy 29 times and anemia 2.8 times higher in future pregnancies among women whose first birth was via cesarean section. Personally, I find the increase in uterine rupture surprising: the actual incidence was 1.86%, which is three times higher than in the developing African countries. (Worldwide, from 1976-2012, 25 peer-reviewed publications described the incidence of uterine rupture, and these reported an overall uterine rupture rate of 1 in 1,146 pregnancies, or 0.07%). Nevertheless, the risk of complications in subsequent deliveries is higher with every subsequent cesarean section, particularly after third time.

There is some research that suggests that previous cesarean section can slightly increase the risk of stillbirth and ectopic pregnancy in the future. However, given the fact that all of these studies are observational we cannot say with certainty that this is true. Once again, because there are no properly conducted trials on elective cesareans and the data is drawn from patients who have higher risk of complications – they had emergency cesarean after all – the magnitude of the increase is not sufficient to draw definite conclusions.

The Verdict

To summarize the facts regarding cesarean section on maternal request we can state the following.

Elective cesarean eliminates the risk of emergency cesarean section. The latter often has to be performed in a hurry and at odd hours of the day. Because of this emergency surgery is associated with higher risk of complications and is stressful for the woman and her partner. Elective cesarean is generally scheduled on a day convenient for the people involved (granddad can arrive from the country), is done during day hours and is generally safer.

Planned cesarean allows avoidance of vaginal delivery and its complications. In particular, the risk of urinary incontinence and organ prolapse is reduced, and some research indicates that this protective effect is still evident 5 – 10 years after giving birth.

Data suggests that immediate complications of elective cesarean are not very different from those of vaginal delivery. However, the catch is in the longer-term problems. Cesarean section increases the risk of abnormal placement of the placenta during future pregnancies, and this risk jumps up considerably after the third surgery. Therefore, if you are planning to have more than three children this risk should be carefully considered and discussed with the obstetrician.

Photo from: http://www.freedigitalphotos.net/images/

Dr. Eugene Smetannikov is a practicing anesthesiologist with the interest in obstetric anesthesia. He is the author of the most comprehensive book on the subject, The Truth About Labor Epidural

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