We have a secret in our culture...

and it's not that birth is painful. It's that women are strong. - Laura Stavoe Harm

ICAN

Position Statement: Elective Cesarean Sections Riskier than Vaginal Birth for Babies and Mothers

by Jill MacCorkle, ICAN Clarion Editor

 

Recently, a few physicians have claimed that elective primary cesareans and elective repeat cesareans are safer for babies, and even for mothers, than vaginal birth.1,2 While selective use of the medical literature might seem to back up this claim, a review of the studies which consider short- and long-term risks of cesareans does not. Elective cesareans put babies and mothers at risk, use valuable and limited healthcare resources, have negative psychological and financial consequences for families, and substantially increase serious risks in subsequent pregnancies. The high rate of cesarean in the United States has not resulted in improved outcomes for babies or mothers. Additionally, vaginal birth after cesarean (VBAC) is still less risky for mothers and babies than cesarean section, despite recent claims to the contrary. ICAN is opposed to cesarean sections performed without true medical indication.

 

Risks to the baby from elective cesarean section:

  • Babies delivered by elective cesarean have an increased risk of neonatal respiratory distress syndrome (RDS), a life-threatening condition,3-7 and other respiratory problems that may require NICU care.
  • Babies delivered by elective cesarean have a five-fold increase in persistent pulmonary hypertension (PPH) over those born vaginally.6
  • Babies delivered by elective cesarean are at increased risk of iatrogenic (physician-caused) prematurity, usually related to failure to conform to protocols for determining gestational age prior to delivery, or errors in estimating weeks of gestation even with the use of clinical data.7,8 Prematurity can have life-long effects on health and well-being, and even mild to moderate preterm births have serious health consequences.9
  • Babies delivered by elective cesarean are cut by the surgeon’s scalpel from two to six percent of the time.10 Researchers believe these risks to be underreported.

 

Risks to the mother from elective cesarean section:

  • Up to 30% of women who have a cesarean acquire a postpartum infection. Infections are the most common maternal complication after cesarean section and account for substantial postnatal morbidity and prolonged hospital stay.11
  • Other serious complications for women undergoing cesarean include massive hemorrhage,12 transfusions,13 ureter injury,14 injury to bowels,15 and incisional endometriosis.16,17
  • Women who undergo cesarean report much lower levels of health and well-being at seven weeks postpartum than women who have vaginal births.18
  • Women who undergo cesarean section have twice the risk of rehospitalization for reasons such as infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions, and appendicitis. Rehospitalization has a negative social and financial effect on the family.19
  • Women who undergo cesarean section report less satisfaction than women having vaginal births.20,21
  • Women undergoing cesarean are at increased risk of hysterectomy in both the current and future pregnancies.22,23
  • The maternal death rate is twice as high for elective cesarean as for vaginal birth.24
  • In subsequent pregnancies, women with a prior cesarean have higher rates of serious placental abnormalities which endanger the life and health of the baby and the mother.25-27 Women are rarely told that a cesarean places future babies at higher risk.
  • After cesarean section, women face higher rates of secondary infertility as well as higher rates of miscarriage and ectopic pregnancy.28,29

 

References:
1 Harer WB Jr. Patient choice cesarean. ACOG Clinical Rev 2000; 5(2).
2 Greene MF. Vaginal delivery after cesarean section - Is the risk acceptable? N Engl J Med 2001; 345(1): 54-5.
3 Bowers SK, MacDonald HM, Shapiro ED. Prevention of iatrogenic neonatal respiratory distress syndrome: Elective repeat cesarean section and spontaneous labor. Am J Obstet Gynecol 1982;143(2):186-9.
4 Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: Influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
5 Hales KA, Morgan MA, Thurnau GR. Influence of labor and route of delivery on the frequency of respiratory morbidity in term neonates. Int J Gynaecol Obstet 1993; 43(1):35-40.
6 Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97(3):439-42.
7 Parilla BV, Dooley SL, Jansen RD, and Socol ML. Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery. Obstet Gynecol 1993; 81(3):392-5.
8 Hook, B et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997; 100(3):348-53.
9 Kramer MS, Demissie K, Yang H, Platt RW, Sauve R, Liston R. The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. J Amer Med Assoc 2000; 284(7):843-9.
10 Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997; 90(3): 344-6.
11 Henderson EJ & Love EJ. Incidence of hospital-acquired infections associated with cesarean section. J Hosp Infect 1995; 29: 245-255.
12 van Ham MA, van Dongen PW & Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74: 1-6.
13 Naef RW III, Washburne JF, Martin RW et al. Hemorrhage associated with cesarean delivery: When is transfusion needed? J Perinatol 1995; 15: 32-35.
14 Eisenkop SM, Richman R, Platt LD & Paul RH. Urinary tract injury during cesarean section. Obstet Gynecol 1982; 60: 591-596.
15 Davis JD. Management of injuries to the urinary and gastrointestinal tract during cesarean section. Obstet Gynecol Clin North Am 1999; 26: 469-480.
16 Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. Endometriosis in abdominal scars: A diagnostic pitfall. Am Surg 1996; 62(12):1042-4.
17 Wolf GC, Singh KB. Cesarean scar endometriosis: A review. Obstet Gynecol Surv 1989; 44(2):89-95.
18 Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):241-2.
19 Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. J Amer Med Assoc 2000; 283(18):2411-2416.
20 Fawcett J, Pollio N & Tully A. Women’s perceptions of cesarean and vaginal delivery: Another look. Res Nurs Health 1992; 15: 439-446.
21 Waldenstroem U. Experience of labor and birth in 1111 women. J Psychosom Res 1999;47: 471-482.
22 Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol 1993; 168(3 Pt 1):879-83.
23 Bakshi S, Meyer BA. Indications for and outcomes of emergency peripartum hysterectomy. A five-year review. J Reprod Med 2000; 45(9):733-7.
24 Bewley S. Maternal mortality and mode of delivery. Lancet 1999; 354: 776.
25 Zaideh, SM et al. Placenta praevia and accreta: Analysis of a two-year experience. Gynecol Obstet Invest 1998; 46(2):96-8.
26 Ananth, CV et al. The association of placenta previa with history of cesarean delivery and abortion: A meta-analysis. Am J Obstet Gynecol 1997; 177(5):1071-78.
27 Miller DA, Chollet JA & Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997; 177: 210-214.
28 Hemminki, E and Merilainen, J. Long-term effects of cesarean sections: Ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996; 174(5):1569-74.
29 Hall MH, Campbell DM, Fraser C & Lemon J. Mode of delivery and future fertility. Brit J Obstet Gynecol 1989; 96: 1297-1303.

 

This may be copied and distributed with retained copyright.
© International Cesarean Awareness Network, Inc. All Rights Reserved.

 

VBAC

Vaginal Birth After Cesarean Checklist

Read good pregnancy and Vaginal Birth After Cesarean books. Two suggestions are: "The VBAC Companion" by Diana Korte and "Open Season" by Nancy Wainer Cohen.

 

Focus on good nutrition and exercise. Make a daily checklist to ensure you are getting essential nutrients. Engage in daily exercise such as swim, walk, yoga, prenatal fitness class- whatever feels good. For information on diet throughout pregnancy, we recommend reading, "What Every Pregnant Woman Should Know" by Dr. Tom Brewer and Gail Sforza Brewer or The Brewer Diet.

 

Register for VBAC, refresher or another quality, independent prenatal program. Even though you may have taken classes in a previous pregnancy, an evening out together with your partner will help to prepare you both, promoting discussion, giving you ideas on coping with labor and bringing a focus to this baby and its birth.

 

Enlist the encouragement of a supportive care provider. Find a caregiver/hospital who ALREADY provide the options you want. Find someone who believes in VBACs, has a VBAC success rate over 75% and a cesarean rate that is lower than the community average. Consider having a midwife as your primary caregiver. Midwives have a very low rate of cesarean birth. If you are unsure about anything, get a second opinion. Trust your inner strength and knowledge.

 

Hire a doula/labor assistant/support person. It is worth every penny to be reassured during labor by someone who believes birth is a natural function. This person will have supportive non-medical skills to help you through labor for the birth you want. This person will assist you from your first contractions at home right through postpartum. A labor assistant, or doula, takes the pressure off fathers and family members so that the whole family can be supported.

 

Throughout pregnancy practice relaxation and visualization with exercises, tapes, massage, affirmations and touch. Use affirmations such as "Each contraction strengthens my baby and me." Or "I will birth my baby vaginally, naturally, and joyfully."

 

Write a birth plan. Discuss everything that is important to you with your care provider, putting it all into your birth plan. Make extra copies to be put in your chart. Know your hospital’s VBAC policies and negotiate well before the birth for anything different. Things to consider when writing your birth plan are:

 

  • Establish a safe, supportive birth environment to encourage labor.
  • Try a variety of positions. Instead of lying down, try standing or walking. Squatting to push can be most effective. Try the birth ball. Try walking the halls. Try ‘dancing’ with your partner.
  • Continue your calorie and fluid intake. Labor is work and takes energy. Far from eliminating the risk of aspiration with general anesthesia, total fasting (NPO) may increase the risk by raising the acidity of the stomach contents.
  • Avoid medical intervention whenever possible. Continuous electronic fetal monitoring may restrict your movement. Ask for noninvasive options. Ask what will be done with the results.
  • Artificial induction should be avoided, if possible. Medical induction is linked with high rupture rates and many interventions.
  • Ask for time to try non-medical methods to stimulate labor if your labor is not progressing. These include change of position, walking, nipple stimulation, aromatherapy, acupressure. Every labor is different. Unless you dilated to five or six centimeters during a previous labor, consider this one your first labor.
  • Avoiding an epidural may increase your chance for a vaginal birth. An epidural interferes with the baby being optimally lined up and will reduce your ability to push effectively. Try natural pain relief measures, such as: hot/cold compresses, bath/shower (once labor is established), tenns unit, massage, relaxation, guided imagery, birth ball. If you start to think you really need an epidural, give yourself a few more contractions, or request that you be checked one more time. You may be moving quickly into transition without realizing it.

 

Having a birth plan cannot guarantee that your wishes will be followed. Working with a careprovider who believes in birth is easier than fighting one who does not. No amount of demanding or asking nicely will get you the birth you want.

 

Many cesareans are done due to posterior or asynclitic presentation. Avoiding reclining positions prenatally. Read Val el Halta’s "Posterior Presentation - A Pain in the Back" article and "Understanding and Teaching Optimal Fetal Positioning" by Jean Sutton and Pauline Scott.

 

Believe in yourself and the process of birth. Repeat affirmations to yourself constantly. Encourage yourself to believe that you are capable of delivering your baby vaginally. Get in touch with your inner self; your resources and abilities. Forget about your scar and focus on the positive aspects of your pregnancy.

 

Work on leftover negative emotions (guilt, disappointment, anger) from previous cesarean birth(s). Two wonderful books for this are Lynn Madsen’s "Rebounding From Childbirth", and "Ended Beginnings" by Claudia Panuthos.

 

Learn to trust, cooperate with and listen to your body and baby. Listen to your own unique labor pattern.

 

Feel good about yourself and your relationship as a couple and keep a positive outlook.

 

Enlist the support of family and friends. Remember that according to medical studies VBAC is usually safer for both you and your baby than a repeat cesarean. Don’t be afraid to let your family know how much you need their unconditional emotional support.

 

Attend VBAC support meetings and join national organizations. Through meetings and newsletters, you will hear from others who have been there, sharing their VBAC experiences. Read "The VBAC Experience" by Lynn Baptisti Richards, a collection of VBAC stories.

 

Having a VBAC is worth it! You can do it. Not everything is within our control — however, it is within all of us to prepare ourselves as best we can to maximize the chance of VBAC.

 

This may be copied and distributed with retained copyright.
© International Cesarean Awareness Network, Inc. All Rights Reserved.