1. Catalinotto, Ellen RN, CNM


If it's unnecessary, why is it still performed?


Article Content

Does scheduling a medically unnecessary cesarean section guarantee an easy delivery and a perfect baby? Data on elective cesareans are sparse; according to Births: Preliminary Data for 2005 from the National Center for Health Statistics, the cesarean delivery rate in that year reached 30.2% of births in the United States. That's 46% more than in 1996, although risk factors that lead to surgical deliveries remain virtually unchanged.


Health care providers and hospital administrators are under intense pressure to raise profits and improve efficiency, and because elective cesareans can be more cost-effective than labor and vaginal birth, they may be attractive. But are they safer? A National Institutes of Health conference, Cesarean Delivery on Maternal Request, held March 27 to 29, 2006, explored this issue.


When it comes to sexual function after delivery, pelvic organ prolapse, and urinary incontinence in mothers, and stillbirth, intracranial hemorrhage, and neonatal asphyxia in infants, the evidence favors neither mode of delivery.


Regarding the risk of hemorrhage, evidence rated as "moderate" favored planned cesarean over vaginal or unplanned cesarean delivery. But several attendees criticized that conclusion because the methodology used to compare risk included in the vaginal-delivery group women who had a cesarean after difficult labor, skewing the results in favor of planned cesareans. Evidence showing that women who have cesareans have longer hospitalizations and recoveries than those who have vaginal delivery and that the risk of newborn breathing problems is higher with cesarean delivery was rated as moderate.


The conference report recommends that women who plan to have several children be advised against elective cesarean delivery because they will face a higher risk of placenta previa, placenta accreta, decreased fertility, stillbirth, and uterine rupture in future pregnancies.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Some conference attendees raised concerns about the findings. They pointed out that outdated but common practices that contribute to the morbidity of vaginal delivery, such as limited ambulation, closed-glottis pushing, supine positioning, and episiotomy, should be changed and evidence-based practices evaluated before cesarean delivery is judged equivalent or preferable to vaginal birth.


Attendees also objected to the reliance on studies comparing vaginal breech deliveries with planned cesareans because it overstates the risks of vaginal birth and minimizes those of cesarean. Furthermore, these results should not be extrapolated to the 96% of births in which the baby is in the normal vertex position.


Women's health advocates were frustrated by "patient choice" and "autonomy" being used to defend medically unnecessary surgery, while the right to choose vaginal birth after cesarean is increasingly denied.


In the September 2006 issue of Birth, MacDorman and colleagues' analysis of nearly 6 million U.S. births between 1998 and 2001 found that in full-term pregnancies without complications or medical risk, cesarean delivery nearly tripled neonatal mortality rates, even when deaths from congenital malformations and infants with low Apgar scores were excluded. According to a study by Deneux-Tharaux and colleagues published in Obstetrics and Gynecology in September 2006, maternal mortality rates in healthy women more than tripled after elective cesarean section.


Treating normal female reproductive functions as pathologies and promoting "improvements" that later prove harmful is not new. Substituting formula for breast milk raises infant death rates. Episiotomy worsens perineal trauma. Let's not make the same mistake with medically unnecessary cesareans. Social and emotional support, upright positioning, spontaneous pushing, and avoiding episiotomy: these evidence-based techniques increase the chance of a vaginal birth and minimize the risks. Let's trust the evidence and stop frightening women into unnecessary surgery.