Cesarean sections, once performed to save the life of mother or baby, are now offered as an elective procedure. Women choose elective cesarean sections in the belief that the surgery is safe and vaginal birth poses risk of harm to themselves or their child. A look at studies and literature shows that these unwanted consequences of vaginal delivery result from the aggressive management of labor by obstetricians. Rather than resorting to major surgery, a return to the midwifery model of care will benefit mother and babies in low-risk pregnancies.
Elective Cesarean Section
Once reserved as a procedure of last resort to save the life of mother or baby, cesarean section (CS) surgery is now offered as an elective procedure to mothers who wish to avoid the experience of labor and delivery. The American College of Obstetricians and Gynecologists (ACOG) published a committee opinion in November 2003 supporting “the permissibility of elective cesarean delivery in a normal pregnancy, after adequate informed consent”(American College of Obstetricians and Gynecologists [ACOG], p. 1101). Women may choose this option in the belief that circumventing vaginal delivery preserves the integrity of their pelvic floor, or provides better outcomes for their children. Although some believe birth by elective cesarean section (ECS) is preferable to vaginal birth, it can be shown that in low-risk pregnancies, vaginal birth is safer for both mother and baby.
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Supporters of ECS believe vaginal delivery results in damage to the pelvic floor, which may lead to urinary incontinence (UI), anal incontinence, sexual dysfunction, or pelvic organ prolapsed (Nygaard & Cruikshank, 2003). There are studies that support this belief. In one “study of primiparous women twenty-six percent had incontinence at six months postpartum, the rate being lowest with elective cesarean (five percent), higher with cesarean during labour (twelve percent), higher still following a spontaneous vaginal birth (twenty-two percent) and highest following a vaginal forceps delivery (thirty-three percent)” (Hannah, 2004, p. 813). The physicians that champion the cause of ECS and the women who buy into their sales pitch for ECS believe they are preventing this damage.
However, an ECS may not guarantee prevention of pelvic floor damage, and its benefits are at best short-term. Some women who undergo ECS suffer from incontinence, suggesting pregnancy itself, along with hereditary indications, are risk factors (Leeman, 2005; Nygaard & Cruikshank, 2003). Other studies indicate there are no significant differences between the vaginal birth and CS groups at two years’ postpartum (Goer, 2001). Buschsbaum, Chin, Glantz, and Guzick (2002) found no significant differences exist in the prevalence of UI between nulliparous and parous women after menopause. Before we point the finger at the natural process of vaginal delivery as the cause of this pelvic floor damage, we should look at the interventions that may cause these problems.
Goer (2001) suggests obstetric interventions of second stage labor, not vaginal birth, causes damage to the pelvic floor. Obstetric management such as episiotomies, forceps and vacuum extractions, dorsal lithotomy position, and the Valsalva maneuver may be the cause of the pelvic floor compromise the ECS supporters are concerned about. Goer suggests using upright positions for pushing, following the patient’s natural urges to push, and elimination of routine episiotomies to decrease the damage to the pelvic floor. If she is correct, and alterations in routine obstetric care remove the concern of pelvic floor damage, then the safety of the baby becomes the cry of ECS supporters.
The ECS supporters argue the safety issue with multiple claims for the protective value of skipping labor and vaginal delivery. They claim we can preemptively protect the fetus by CS prior to the onset of labor. This protection can include: the reduction of stillbirth related to post-maturity, damage from oxygen deprivation secondary to cord compression during labor and delivery, and birth trauma related to use of forceps or vacuum extraction (Armson, 2007). For mothers with medical conditions or the compromised fetus, a scheduled CS is a valid option. However, labor and vaginal delivery is a natural, generally safe, process, not something from which the low-risk fetus needs protection.
Those opposed to ECS believe risks to the infant from vaginal birth are minimal and adverse fetal outcomes rare, however, we may be increasing risks due to unnecessary obstetrical interventions during labor and birth. For the low-risk patient, the increase in maternal morbidity and mortality (Armson, 2007) resulting from major surgery does not justify the possibility of preventing the rare adverse fetal outcome. Better screening of those patients at risk will properly identify those patients who would legitimately benefit from surgery. Similar to the suggestion that obstetric management causes damage to the mother’s pelvic floor, Goer (2001) argues that obstetric interventions also put the baby at risk. In first stage labor these interventions include pitocin augmentation and artificial rupture of membranes. In second stage labor, the same interventions that injure the mother, such as forceps, vacuum extraction, and sustained Valsalva maneuver, cause trauma for the infant. She suggests patience, gentle management of labor and delivery, and respect for mother’s natural pushing ability to reduce injury to the infant. Vaginal delivery with minimal interventions does not need to be feared.
Despite improvements in the safety of CS over the years, vaginal birth remains safer than a CS for both mother and baby in low-risk pregnancies. In contrast to ACOG’s committee opinion, The American College of Nurse-Midwives “Identifies vaginal birth as the optimal mode of birth for women and their babies” and “this practice [cesarean section] is not supported by scientific evidence” (American College of Nurse-Midwives, 2005). Cesarean sections carry significant risks to mother, baby, and interfere with the mother-baby dyad.
Short term, vaginal birth is the safest choice for low-risk women, eliminating many of the complications inherent to a CS as listed by Armson (2007):
The overall risk of severe maternal morbidity was 3.1 times that in the planned vaginal delivery group, including increased risks of postpartum cardiac arrest, wound hematoma, hysterectomy, major puerperal infection, anesthetic complications, venous thromboembolism and hemorrhage requiring hysterectomy . . . hemorrhage requiring transfusion, hysterectomy and uterine rupture; intensive care admission; and postpartum readmission to hospital (p. 475).
Women who birth vaginally face fewer complications, leave the hospital quicker, and have a shorter recovery time (Hannah, 2004). The benefits of vaginal birth are not limited to the immediate period of birth and postpartum.
The choice between vaginal and CS impact the entire range of a woman’s childbearing years. Future labors tend to be shorter for women who birth vaginally. Their deliveries are quicker, and they are less likely to need a CS in the future. In comparison, internal scar tissue and adhesions following a CS increases risk factors for future pregnancies, independent of the future method of delivery (Leeman, 2006). These risks include: “infertility; ectopic pregnancy; miscarriage; placenta abnormalities such as placenta previa or placenta acretia; [and] complications of repeat cesarean birth” (Armson, 2007, p. 475). Women with placental abnormities face higher maternal mortality and morbidity rates (Lyerly & Schwartz, 2004), as well as an increased need for hysterectomies (Armson, 2007). Primary cesarean birth is also “associated with increased risks in subsequent pregnancies of preterm delivery, low birth weight, stillbirth and neonatal death” (Armson, 2007, p. 476). The mother’s choices regarding mode of delivery have long reaching effects for herself, as well as the child that she carries.
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Vaginal birth is also the safest choice for babies, as they avoid many of the neonatal complications which follow pre-labor CS. These risks include: “respiratory problems, persistent pulmonary hypertension, asphyxia, delayed neurologic adaptation and neonatal intensive care admission” (Armson, 2007, p. 476). Many et al. (2006) suggest that the mechanism of labor benefits the baby’s respiratory system. Other complications CS babies face are iatrogenic prematurity (Lyerly & Schwartz, 2004), and lacerations or other neonatal trauma during surgery (Armson, 2007). Babies born by CS also face long term health risks; they are more likely to develop asthma, diabetes, food allergies and obesity than vaginally born children (Steer, 2009). The benefits to the mother and the baby as individuals also benefit the mother-baby unit.
Finally, mother-baby couplets benefit from a vaginal birth in multiple ways. The natural hormonal rush which occurs in labor prepares a woman for breastfeeding and facilitates bonding. Women who birth vaginally have less discomfort and shorter recovery times following birth and are thus better able to care for, and bond with, their babies. This enhances mother-baby interaction and supports baby’s emotional development. Breastfeeding rates are higher and depression rates are lower following vaginal birth (International Cesarean Awareness Network, 2008). These benefits extend long term; they establish the foundation of the lifetime mother-child relationship.
The decision to give birth by CS greatly affects mother, baby, and future pregnancies and should not be offered electively as if it were a minor cosmetic surgery. The benefits of ECS compared to vaginal birth have not been proven, and the risks are substantial – to not just one, but two (or more) patients. Women may fear labor. Birth attendants may fear legal risks from adverse fetal outcomes. These fears do not indicate that women’s bodies are incapable of birthing; rather, they indicate the failure of obstetric management of labor. We should not base our decisions on fear or faulty research.
We should address the concerns of ECS proponents raise. We need to conduct more research into prevention of pelvic floor damage. The American College of Nurse-Midwives (2005) offers the follow guidelines:
Supports women’s right to accurate, balanced and complete information regarding the risks and benefits of both vaginal birth and cesarean section.
Promotes decision-making about mode of delivery that is evidence based and not unduly influenced by factors such as liability, convenience or economics.
Supports further research to evaluate the short and long-term medical, psychosocial, economic and cultural sequelae for mothers, babies, including future pregnancies associated with elective primary cesarean section.
As birth attendants follow these guidelines, women will be empowered to make informed decisions about their care. These decisions affect the physical and emotional health of these women and their children for a lifetime. We have an obligation to manage birth in a manner that causes the least harm to mother while providing the best outcome for babies.
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