- The Washington Times - Tuesday, July 9, 2002

Twenty years ago, an obstetrician wouldn't allow a pregnant patient to schedule a Caesarean delivery. Doctors only resorted to the surgical procedure in the case of a complicated birth.

Today, with advances in anaesthesia, antibiotics and surgical techniques, some mothers are opting for Caesarean births without even trying to give birth in the traditional manner.

That change in thinking is one reason Caesarean, or "C-section" deliveries are now performed in the United States in nearly one out of every four births.

Dr. Bruce Flamm, an obstetrician at Kaiser Permanente Medical Centers in Riverside, Calif., says "Caesareans on demand" bespeak a seismic shift in both medical advances and the public's perception of a surgery that meant a death sentence for turn-of-the-20th-century moms.

The numbers bear him out.

According to a Feb. 12 report by the Centers for Disease Control and Prevention's National Center for Health Statistics, Caesarean birth rates increased for the fourth year in a row in 2000 to nearly 23 percent of all births, the highest percentage since 1989.

The increase represented a 4 percent jump in the rate of primary Caesarean deliveries and a 12 percent drop in the number of vaginal births after previous Caesareans, known as VBACs. Recently, doctors have reported complications with VBAC deliveries, which has fueled their decrease.

In a Caesarean delivery, a horizontal incision known as a transverse cut is made in the area below the navel, typically following where the top of a standard bikini bottom would begin, says Dr. John Larsen, professor and chairman of George Washington University Hospital's department of obstetrics and gynecology.

The incision length varies, depending on the size of the woman and the baby, though a 20-centimeter cut is common.

The doctor cuts through the skin and the fatty layer underneath, then the abdominal muscles are separated, not cut, to reach the uterus.

Then, the baby and the placenta are taken out and the mother is sewn back up.

Caesarean births are most often performed when the labor is unusually long, if the baby is too large or if it is emerging either feet or buttocks first. The procedure also comes into play if the baby shows signs of distress, such as a low heart rate.

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While today's Caesarean birth is far safer than those of yore, the procedure isn't without health risks. The Centers for Disease Control and Prevention report says Caesarean births represented 81 percent of cases of placenta previa, in which the implantation of the placenta at least partially covers the cervix. The condition is spurred, in part, by previous surgery on the uterus.

The procedure also carries the potential complications concurrent with any surgery difficulties with anaesthesia and infection and mothers are left sore for weeks, if not months, following the procedure.

Dr. Larsen says the Caesarean rates at George Washington University Hospital have hovered around 17 percent for the last few years.

What has increased, though, is the number of repeat Caesarean sections as more mothers shy away from vaginal births following Caesareans.

Some patients are concerned about VBACs, he says.

Studies have suggested giving birth vaginally after a Caesarean delivery puts the mother at risk of a ruptured uterus. A 1996 edition of the New England Journal of Medicine reported that the rates of uterine rupture, as well as hysterectomy and injury during surgery increase for women who give birth vaginally following a caesarean birth.

Dr. Fredric Frigoletto, chief of obstetrics at Massachusetts General Hospital and professor of obstetrics and gynecology at Harvard Medical School, adds that evidence emerged in the late 1990s that VBACs included risk of infant death, blood loss and permanent damage to the fetus.

The media carried word of these developments, which helped fuel the rise in repeated Caesarean section deliveries, Dr. Frigoletto says.

A statement by the American College of Obstetricians and Gynecologists also played a role in the upswing in Caesarean births.

The group issued guidelines in July 1999 which said if a mother wanted to have a VBAC, she had to be somewhere with facilities "immediately" available for an emergency Caesarean. That meant the mother-to-be no longer could give birth at home.


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While doctors generally agree on the need for Caesarean sections, given certain conditions such as a breech birth, Dr. Larsen says planned Caesarean sections are another matter.

"Some say it's too new it's a concept that hasn't really been tested. But it's right on the edge," Dr. Larsen says. "It's just a matter of explaining the pluses and minuses and people making an informed choice."

Caesarean births have been performed for decades, but as recently as 1970 the Caesarean rate stood at under 5 percent, Dr. Flamm says.

Some mothers aren't pleased with the increase.

Anita Woods, vice president of the International Caesarean Awareness Network, bristles at the notion that some women and their doctors are greenlighting planned Caesarean sections.

"There's an emotional element in recovery [from Caesarean child birth]," says Ms. Woods, whose Redondo Beach, Calif., group helps women either recovering from or seeking to prevent Caesarean births. Even a planned Caesarean can be traumatic, she argues. "To have that child surgically yanked from you can be devastating."

Theresa Fry, a 24-year-old first time mother from Reston delivered her first son, David, via Caesarean section delivery three months ago.

Mrs. Fry says she is just beginning to bounce back from the surgery.

"I had great difficulty moving or picking anything up, including my baby, for a few weeks," says Mrs. Fry, who still feels some soreness from the operation.

Before her delivery, her doctors discovered she had a small leak of amniotic fluid. The doctors tried to induce her labor naturally to avoid a possible infection. That, plus the position of the baby, convinced her doctors to opt for a Caesarean delivery, she says.

If possible, she says, her second child will be born via a vaginal birth.

Tammi McKinley, a mother of two from Arlington, had her first child by Caesarean delivery and her second at home by the traditional method.

"One of the worst parts [of the Caesarean birth] is that you don't get your baby right away," she says. "She didn't come to me until she was three or fours hours old," she says. "That was very, very distressing."

She understood the risk of potential uterine rupture that faces women choosing vaginal births after a Caesarean birth.

"It's less than 1 percent," she says. "It wasn't a big concern. Lots of times, it happens before you go into labor. I was willing to take that risk."

Dr. Flamm says Caesarean rates cross socio-economic groups. Women older than 35 encounter more difficulties during childbirth that require Caesarean procedures. Plus, older mothers more frequently are undergoing infertility treatments than younger women, which increases the chances of needing a Caesarean section birth.

The procedure has become more palatable to the patient in recent years. A mother can opt for an epidural, a local anaesthetic that eases the pain of labor. Or she can be hooked up to a device that allows her to control a limited amount of painkillers to assuage any discomfort following the birth.

Dr. Flamm says another factor bumping up Caesarean figures is a guerrilla campaign, fueled partly through the Internet, in which vaginal births are blamed for damaging the bladder or rectum, leading to incontinence.

"There's precious little data to support that," he says. "Most women 65 years old have had a vaginal birth. That's not cause and effect. It's a vast jump to a conclusion."

Word of mouth may be playing a serious role in the increase in Caesarean births, he suggests.

"{A mother-to-be's] friend may say, 'I had a vaginal birth years ago and it was tough then I had a c-section and they put a narcotic in my IV I never had any pain,'" Dr. Flamm says.

"A lot women don't want to go through labor," he says. "I can't say I blame them."


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