Physician Group Discourages Elective C-sections

March 22, 2013

News Review from Harvard Medical School – Physician Group Discourages Elective C-sections

Without a medical reason for a cesarean section (C-section), doctors should recommend vaginal delivery to pregnant women. This is a new recommendation from the American College of Obstetricians and Gynecologists (ACOG). About 2.5% of pregnant women choose to have a C-section with no medical reason. A C-section involves risks, including bladder injuries, bowel injuries and complications in future pregnancies. Women who have C-sections also have longer hospital stays and recovery times. ACOG notes that voluntary C-section is particularly not recommended for women who want to have more than one child. This is because the risk of complications increases with each C-section. The guideline was published March 22 in the April issue of the journal Obstetrics & Gynecology.

By Mary E. Pickett, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

This week it is my son's birthday. "This is really your day to celebrate, more than his," my husband usually tells me on my kids' birthdays. When he does, makes me think of the days that each of my babies was born, and usually makes me smile a little wryly. What a monumental physical effort it was to deliver each of them, and with such an incredible reward afterwards. How to describe what it is like to go through childbirth? "Labor of love" doesn't sound right. That is too clean and soft a term. No, childbirth is messy, humbling and painful, even though it is a triumph. Giving birth takes true grit, with or without modern-day help from an epidural.

In the United States, 3 out of every 10 babies are delivered by cesarean section (C-section.) This is the highest rate of surgical delivery in history. Most C-sections are done for medical reasons. But in recent years, some mothers have decided ahead of time that without having a medical reason, they too want to have their babies by C-section. In the past several years, this decision was made by mothers for 2.5% of all US births. These deliveries have become known as "maternal-request cesareans."

Why would a woman ask for a C-section if she did not need one? Some of these women fear childbirth pain. Some think they will recover faster if a C-section is done. Some think they will be less likely to have urine leakage or problems with sexual function later.

The American College of Obstetricians and Gynecologists (ACOG) made an announcement today saying that maternal-request cesareans are not safer than vaginal deliveries. They do not help women avoid complications from delivery. After making that statement, this influential expert group also made a recommendation: Vaginal birth is recommended unless there is a medical reason for a C-section.

Hooray for ACOG. We needed this sensible recommendation.

What Changes Can I Make Now?

Don't plan to have a C-section if you don't need one. ACOG also issued two other recommendations. A voluntary C-section is not recommmended for women who are planning to have several children. Also, when they are needed, ACOG said that C-sections should be timed to happen only after 39 weeks gestation, unless there is an emergency.

There are some good reasons to have a C-section:

• If testing close to the time of delivery shows that the baby is not getting enough oxygen.
• If the placenta is attached too deeply in the wall of the uterus to deliver without surgery. This is called placenta accreta.
• If the placenta covers the exit from the uterus. This is called placenta previa. When there is bleeding from placenta previa, a C-section is needed.
• If the baby's head is too big for the pelvic exit.
• If the pregnant woman has either herpes blisters on delivery day, or HIV infection with a large viral load.
• If the baby is in a breech (feet-first) position.

A C-section is also reasonable in the following situations. However, in these cases, doctors are more flexible about your choices:

• If you have had one or two C-sections already. In this case, it is safe in most situations to attempt a vaginal delivery.
• If you are having twins or triplets.
• If you have hepatitis C.
• If you have preeclampsia (high blood pressure and leg swelling—a medical emergency in pregnancy).

What about planning for pain relief?

These days, about 70% of women who deliver babies in hospitals in developed countries receive epidurals if they are available. An epidural is a catheter placed through the skin of the lower back to deliver pain medicine. Epidurals decrease your pain while still allowing you to feel pressure and movement in your uterus. You can still use your legs and pelvic muscles. Labor averages about 15 minutes longer in women who receive epidurals. Having an epidural does not make a woman more likely to need a cesarean.

Be flexible if you think you might want "natural" childbirth. Most people use this term to mean a vaginal delivery without pain medicine or medical procedures. Childbirth is about equally safe for the baby, with and without medicines.

How many women request medicines for pain relief, even if natural childbirth was their original plan? Most do — surveys show that up to 60% of women who plan to deliver naturally end up requesting medicine for pain once they are in labor. Labor pains are especially hard for women who are having a first baby. After labor pains begin, only 29% first-time mothers planning for natural childbirth stick with their original plan. Among women who have delivered a baby before, 68% who plan for natural childbirth stick with the plan.

What Can I Expect Looking to the Future?

In obstetrics there are high stakes: the life and health of the child, the life and health of the mother. Decisions need to happen quickly. With high stakes like these, obstetricians work very strictly with guidelines when they are based on good evidence. ACOG recommendations have a large impact. With the new ACOG recommendation, most doctors will not offer a C-section unless there is a medical need.