While doctors’ fears seem to be that a lower rate of cesarean surgery will mean greater mortality and morbidity for mothers and babies, the statistics indicate this fear is not well-founded. There really is no data showing that higher cesarean rates equate with lower rates of maternal or neonatal mortality (Lake, 2012). Many circumstances where a cesarean is clearly indicated such as placenta previa or severe preeclampsia should be clear to any competent obstetrician as they will be accompanied by symptoms of a life-threatening emergency like vaginal bleeding and hemorrhage, seizures, blood pressure changes, and vision disturbances. In the case of transverse lie, a simple ultrasound will show the position of the baby. In cases such as maternal infection with HIV or hepatitis B where a cesarean section is indicated to prevent transmission of the infection to the baby, testing can be done to ascertain the mother’s infection status. Other circumstances for a cesarean surgery need to be more clearly outlined by hospitals and even in medical school curriculum and practice.

Helping both doctors and patients understand the actual risks and benefits of a cesarean surgery will be crucial in decreasing the overall rates of cesareans. Patients need to understand that a cesarean section is a major surgery and not a benign procedure. While vaginal birth entails risks, so do cesarean sections and the choice between a vaginal birth and cesarean is not a choice between a dangerous option and a risk free option, but rather weighing the actual risks and benefits in each patient’s specific case.

The risks and benefits of vaginal birth after cesarean may not be fully understood by many women. The risk of uterine rupture is frequently cited as a a reason that a VBAC could be too dangerous, but the actual risk of uterine rupture and even the actual risks to the baby are not necessarily well communicated to mothers. The ACOG’s 2010 bulletin on VBAC shows that the risk of uterine rupture is 0.4 to 0.5 percent for planned, elective cesarean, 0.7 to 0.8 percent for a trial of labor after one cesarean and between 0.9 and 1.8 percent for a trial of labor after two cesareans. Ironically enough, it is statistically more likely that a baby will be injured during a cesarean section than suffer from a uterine rupture- especially with a trial of labor after one cesarean.

ACOG’s 2010 bulletin further explains that many risks associated with VBAC are negligible when compared with those of elective repeat cesarean section. The risk of neonatal death during a trial of labor after cesarean is 0.05 percent for elective cesareans and 0.08 percent for a trial of labor after cesarean (TOLAC). The rate of perinatal death due to hypoxia was greater for TOLAC than elective repeat cesarean mothers at 0.13 percent versus 0.01 percent, though still extremely rare. Helping more women to accurately weigh the risks and benefits for their pregnancy and achieve a successful VBAC will help with reducing cesarean rates and the accompanying costs and risks.

The usage of cesarean surgery has been controversial, but based on data about the risks to mothers and infants and the accompanying costs associated with cesarean rates, it would be in the best interest of women, infants and healthcare costs to reduce the rate of cesarean sections. This will require doctors and expectant parents to adjust some of their perceptions about vaginal birth and cesarean birth, but a reduction in cesarean rates is possible and desirable. Reducing cesarean sections does not have to mean that cesareans are withheld from women who need them or that doctors should be reluctant to perform them when medically indicated. Instead, care should be taken to establish the circumstances when a cesarean is actually necessary and reserve the usage of cesarean surgery for instances when it is truly needed. A cesarean section is major surgery and should never be performed for the comfort and convenience of the physician. Women should also be fully aware of the real risks and benefits when they decide to have an elective cesarean.

References

Alexander, James M., Leveno, Kevin J., Hauth, John, Landon, Mark B., Thom, Elizabeth, Spong, Catherine Y., Varner, Michael W., Moawad, Atef H., Caritis, Steve N., Harper, Margaret, Wapner, Ronald J., Sorokin, Yoram, Miodovnik, Menachem, O’Sullivan, Mary J., Sibai, Baha M., Langer, Oded, and Gabbe, Steven G. (2006). Fetal Injury Associated with cesarean delivery. American College of Obstetricians and Gynecologists 108(4). Retrieved from http://content.lib.utah.edu/utils/getfile/collection/uspace/id/395/filename/3560.pdf

American College of Obstetricians and Gynecologists (2010). Vaginal birth after previous cesarean delivery. Practice Bulletin- Clinical Management Guidelines for Obstetrician-Gynecologists, no. 115. Retrieved from http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery

Gorman, Anna (2015, May 13). How one hospital reduced unnecessary C-sections. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2015/05/how-one-hospital-reduced-unnecessary-c-sections/392924/

Grivell, Rosalie M. and Dodd, Jodie M. (2011). Short- and long-term outcomes after cesarean section. Expert Review of Obstetrics and Gynecology, 6(2). Retrieved from http://www.medscape.com/viewarticle/739458_1

Harvard School of Public Health (2013, March 19). Pregnant women’s likelihood of cesarean delivery in Massachusetts linked to choice of hospitals. Retrieved from http://www.hsph.harvard.edu/news/press-releases/pregnant-womens-likelihood-of-cesarean-delivery-in-massachusetts-linked-to-choice-of-hospitals/

Kozhimannil, Katy Backes, Law, Michael R. Virnig, Beth A. (2013). Cesarean delivery rates Vary 10-fold among US hospitals; reducing variation may address quality, cost issues. Health Affairs 32(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/

Lake, Nell (2012, November). Labor, interrupted. Harvard Magazine. Retrieved from http://harvardmagazine.com/2012/11/labor-interrupted

Laroia, Nirupama (2015). Birth trauma. Retrieved from http://emedicine.medscape.com/article/980112-overview#a1

Marasco, Lisa and West, Diana (2005). How to get your milk supply off to a good start. New Beginnings, 22(4). Retrieved from http://www.lalecheleague.org/nb/nbjulaug05p142.html

Stanford University (2015, December 1). Optimal C-section rate may be as high as 19 percent to save lives of mothers and infants. Stanford Medicine News Center. Retrieved from chttps://med.stanford.edu/news/all-news/2015/12/optimal-c-section-rate-may-be-as-high-as-19-percent-to-save-lives.html

Warner, Lawrence W., (2013). Arriving at the appropriate cesarean delivery rate. American Congress of Obstetrician-Gynecologists. Retrieved from http://www.acog.org/About-ACOG/ACOG-Departments/District-Newsletters/District-VIII/July-2013/Cesarean-delivery-rate

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