Labor and delivery

Is cesarean a safe option?

By Jennifer Vanderlaan

In 2003, for the first time since 1977, the US maternal death rate rose above 10 deaths per 100,000. In 2004, the maternal death rate rose again to its highest level in decades. Though the total number of deaths is small, the increase has many experts concerned. As researchers begin to look at information about why more women are dying, an increase in the number of cesarean surgeries is a prime suspect.

Though American women have grown accustomed to cesarean as a normal way to give birth, the fact remains that it is major abdominal surgery. Until fairly recent history, cutting open a woman's abdomen was reserved for times when a woman was obviously dying or had already died. Although it might have produced a living baby, the mother's death was almost certain. With the creation of safer anesthetics and an understanding of the causes of infection, the death rate for cesarean surgery is now remarkably low. However, the death rate from cesarean is four times higher than vaginal birth even when the surgery is elective.

Healing from a cesarean can be difficult. As many as 30% of women have a post-surgical infection. The blood loss from a cesarean is at least twice as much as a vaginal birth during a normal surgery, and 4% of women who undergo cesarean have a major complication such as hemorrhage, blood clotting, pelvic infection, or pneumonia. Two weeks after the surgery, 15% of women still have trouble with everyday activities.

After having a cesarean, the risk for infertility and ectopic pregnancy increases. Though the uterus heals without scar from a vaginal birth, cesarean surgery leaves a scar that increases the risk for placenta previa, placenta accrete, and placental abruption. As the cut heals, other organs near the uterus, such as the bowel or bladder, can become adhered to the scar, causing pain and making a repeat cesarean more difficult. These risks increase with each cesarean a woman has.

Babies born by cesarean surgery are more likely to have breathing problems than babies of the same age who are born vaginally. The hormones of labor help prepare babies for the sudden change from intrauterine life to the outside world. Without those hormones, your baby may be at a disadvantage for the first hours or days. Miscalculation of dates for planned cesarean can also cause your baby to be born prematurely, increasing the risks to his health.

Even with the risks, cesarean is sometimes the safest way for a baby to be born. Unfortunately, there is disagreement about when that may be. Most reasons for a cesarean surgery do not have a clearly defined diagnosis, but instead rely on a judgment call made by a doctor or midwife. What one doctor may label "failure to progress", another might consider a slower than average labor. It can be frustrating for a woman recovering from major surgery to know that a different doctor might have worked with her to achieve a vaginal birth.

About 30% of births in the United States are by cesarean surgery, but in some hospitals, as many as 45% of births are by cesarean. Cesarean rates in Canada range from 17% to 36%, giving an average of 26% throughout the country. Private hospitals have higher rates of cesarean than public hospitals. Obstetricians attending labor have higher rates of cesarean than midwives, with male obstetricians having a 40% higher rate of cesarean than female obstetricians. This means where you give birth and who is hired to attend you in labor may have more influence on whether or not you have a cesarean than anything to do with your pregnancy. To help avoid an unplanned cesarean, select a caregiver with a low cesarean rate.

Some women become concerned that giving birth vaginally after a cesarean may cause the uterine scar to tear. Although it is a possibility, it is a very rare occurrence. Only about 2% of women have any of separation of the scar tissue, most of which does not cause any problem or need any assistance to heal. Interestingly, about 2% of women who have elective repeat cesarean are found to have a slight separation of the scar tissue, which means some separation must happen during pregnancy. The type of incision used on your uterus can affect your risk of a true rupture, so be sure to ask what type of scar you have. Other women are worried that planning for a vaginal birth will end up in another unplanned cesarean and disappointment. Overall, 80% of women who attempt a vaginal birth after a cesarean are successful at vaginal birth, regardless of the reason for previous cesarean.

If you are considering a planned cesarean, get a second opinion about your and your baby's health. If possible, ask a doula or childbirth educator for the name of doctor or midwife in your area known to have a low cesarean rate. Discuss the risks related to your pregnancy, and how the risks of both vaginal birth and cesarean may be reduced. Consider other options that may be available to you, and the risks those options may entail. In this way, you can be confident the decision you make is the safest way for your baby to be born.