INDEPTH: CAESAREAN BIRTHS
Too posh to push?
CBC News Online | March 4, 2004
Dr. Jan
Christilaw
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It's becoming known as the "too posh to push" phenomenon thanks to recent media stories, but the reality is, the rate of caesarean births (C-section) in industrialized countries is rising. In Canada, there has been "a jump of almost three per cent in the last two years," said Dr. Jan Christilaw, an obstetrician at B.C. Women's Hospital in Vancouver.
The Canadian medical community is widely debating the subject. The ethics committee of the Society of Obstetricians and Gynecologists of Canada (SOGC) is struggling with its policy on a guideline for health-care professionals and their patients. It plans to release its position in the spring 2004.
At the moment, SOGC says that vaginal birth is the preferred option for most women and that C-section births are reserved for medical reasons. "Health-care professionals strive for the lowest possible risk to the pregnant woman and as such, patient-physician discussion and informed consent are extremely important in order for patients to understand the risks of such an operation," SOGC said in a release in early March.
It's difficult to determine the risks and benefits of elective caesareans because current studies are based on non-elective C-sections involving women with medical or obstetric problems. Random studies are underway on elective caesarean births, but the results won't be available for several years.
Some, but definitely not all, experts feel the risks and benefits for health are the same for either method, and hospitals say the costs to the health-care system are about equal.
Cesarean rates in Canada fell from 20 per cent of live births in 1986 to 15 per cent in 1994, but rose again to 19.6 per cent in 1997. In the United States, the rate of caesarean delivery reached an all-time high of 26.1 per cent in 2002.
The World Health Organization stated that a caesarean section rate of over 15 per cent indicates "inappropriate usage."
The International Caesarean Awareness Network lists caesarean rates in Brazil at 40 per cent (1999), Australia at 21.1 (1998) per cent and Bolivia at five per cent (1997).
The following risks and benefits of elective caesarean birth have been gathered from various medical reports:
Benefits:
- No labour pain.
- Alleviation of fear and anxiety related to childbirth and health of baby.
- Possible reduced risk of urinary incontinence, which is a common postpartum problem.
- Possible reduced risk of fecal incontinence, which is not as common as urinary incontinence in postpartum, but happens to about four per cent of women giving birth.
- No tearing of the anal sphincter, which can cause fecal incontinence.
- Convenience of control over delivery date and circumstances.
- For women with a small or immature baby, C-section delivery might reduce the chance of fetal or neonatal death, but it might also increase the risk of maternal morbidity.
- Possible reduced unexplained or unexpected stillbirth.
- Possible reduced complications in labour.
Risks:
- Maternal mortality is higher than with vaginal birth.
- Longer hospital stay and recovery time.
- Operative complications such as lacerations and bleeding.
- Removes the benefit, through vaginal delivery, of allowing the fluid in the baby's lungs to be squeezed out as the infant passes through the birth canal.
- Breathing problems. Babies born by caesarean section are more likely to develop breathing problems such as transient tachypnea (abnormally fast breathing during the first few days after birth). Possible low Apgar* scores caused by the effect of the anesthesia or lack of stimulation.
- Reactions to anesthesia. The mother's health could be endangered by unexpected responses (such as blood pressure that drops quickly) to anesthesia or other medications during the surgery.
- Risk of additional surgeries. For example, hysterectomy, bladder repair, etc.
- Increased risk of major bleeding in a subsequent pregnancy.
- Among term babies, the risk of neonatal respiratory distress necessitating oxygen therapy is higher.
- If the exact due date isn't known, a woman may need amniocentesis to check fetal lung maturity so a premature baby isn't delivered accidentally.
- Complications such as bladder, bowel, or blood vessel injury and infection.
- Multiple caesarean deliveries increase the risk of surgical complications. A fourth or fifth cesarean has more risk than the first or second.
- Increased blood loss, on average, twice as much with caesarean birth as with vaginal birth. (However, blood transfusions are rarely needed during a caesarean.)
- Respiratory complications. General anesthesia can sometimes lead to pneumonia.
- Fetal injury. Although rare, the surgeon can accidentally nick the baby while making the uterine incision.
*Apgar score is an evaluation of a newborn's heart rate, breathing effort, muscle tone, colour and response to stimulation.
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Commentary by Mary Hannah, Department of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre in Toronto
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