Tuesday, September 4, 2007

Giving birth has never been easy. Long hours of labor. Irresistible urges to push. Unexpected complications. Pain. All in the hope of bringing a beautiful baby boy or girl into the world.

Many women are opting to have scheduled Caesarean sections, bypassing traditional labor, says Dr. David Downing, associate chairman in the department of obstetrics and gynecology at Washington Hospital Center in Northwest.

“It’s not necessarily easier,” Dr. Downing says. “The benefits are definitely control. Sometimes, there is less potential trauma to the newborn.”

In 2004, the maternal mortality rate in the United States increased to 13 deaths per 100,000 live births, according to figures from the National Center for Health Statistics in Hyattsville. In 2003, the rate was 12 per 100,000 live births. Medical experts disagree on whether obesity and C-section births have contributed to the rise in this statistic.

Caesarean births account for approximately one in three births in the United States, according to the American Pregnancy Association in Irving, Texas. While some of the surgeries are done in emergency situations, more and more women are scheduling them ahead of time.

“It was one in four just as recent as last year,” says Brad Imler, president of the association. “The elective Caesarean plays a part in this.”

While many women opt for scheduled Caesarean births, Mr. Imler says he is still in favor of vaginal births. C-sections have a risk of infection, hemorrhaging, potential injury to other organs, adhesions and scar tissue.

“The body usually does a pretty good job taking care of things itself,” Mr. Imler says. “We certainly believe in interventions when necessity dictates that, but we don’t like moving into interventions when they’re not necessary.”

Once a woman has a Caesarean birth, she may not be able to have a vaginal birth in subsequent pregnancies, Mr. Imler says. Although it is possible, there is more risk involved. Mr. Imler has a doctorate in psychology and counseling.

“Our recommendation is to get educated on all the different options and look at your birthing choices,” Mr. Imler says. “Some people are completely fine with not having a vaginal birth. They want them all as C-sections.”

There is more public awareness about C-sections than there was a few years ago, Dr. Downing says.

“Women’s magazines have presented it as an option,” Dr. Downing says. “Some women fear, ‘I won’t be able to tolerate a vaginal birth.’ ”

One reason patients give for wanting a C-section is they know someone who has had pelvic floor problems after a vaginal birth, Dr. Downing says. Urinary incontinence, stool incontinence and a drop in bladder position are other possible complications.

Sometimes patients hear of a bad delivery experience. When they compare it to delivery at a specific time on a day of their choice, they opt for the C-section, he says.

In a more extreme example, a patient told Dr. Downing she wanted a C-section because she didn’t want to endure a vaginal examination, he says.

Despite the benefit of control with Caesarean births, recovery is usually quicker after a vaginal birth than a C-section, which can take two to four weeks of recuperation, he says. Also, C-sections are two to three times more expensive in overall costs than vaginal births because of operating room costs and longer hospital stays for patients.

The scar tissue from a Caesarean can cause blockage in the intestines and fallopian tubes, Dr. Downing says. The surgery also can cause blood clots in the legs.

Induced labor is more common than C-sections, Dr. Downing says. Some patients may have a business trip or family obligation and would like to have labor induced. At least 40 percent of women use medication, such as Pitocin, during labor to make the contractions stronger, he says.

“If the cervix is ripe, it’s not a problem,” Dr. Downing says. “If the cervix is not ripe, induction of labor can be difficult and increase the chances of the mom needing a C-section.”

By the end of a pregnancy, some women are uncomfortable and just want to deliver the baby, so they request induction, says Dr. Jude Crino, director of perinatal ultrasound in Johns Hopkins Hospital’s department of gynecology and obstetrics in the division of maternal-fetal medicine.

“They say, ‘I want to have a normal delivery, and I just want to have it now,’ ” Dr. Crino says. “You can start your induction today, but you may still deliver tomorrow.”

Inducing labor or performing a C-section for nonmedical reasons should not be done before 39 weeks, which is a week before the due date, he says. Before that, the baby’s lungs may be underdeveloped.

When a mother asks for a C-section for a nonmedical reason after 39 weeks, practitioners must decide whether it’s a good idea, Dr. Crino says. The medical community is debating that question.

“I personally do not do C-sections on maternal request,” Dr. Crino says. “During a C-section, there is definitely more risk to the mother and more short-term respiratory risk to the baby without any clearly proven benefits to the mother or the baby.”

With older mothers and other high-risk pregnancies, some women request a C-section because they consider it a safer mode of delivery, says Dr. Mark B. Reiter, chairman of the department of obstetrics and gynecology at Sibley Memorial Hospital in Northwest.

“Women who have spent time in their profession usually enter pregnancy later,” Dr. Reiter says. “They may have had difficulty conceiving and used reproductive endocrinology. They may be looking at their one and only pregnancy, and they are trying to eliminate the risks of labor and delivery.”

In today’s litigious society, if anything happened to the mother and baby, the patient may blame the doctor for not trying to perform a C-section sooner, Dr. Reiter says.

“Some of that pressure starts pushing people to do C-sections, rather than sticking with labor and delivery,” Dr. Reiter says. “You can look at it as a battlefield. There will be some degree of trauma. You can’t have a vaginal birth without some trauma. You can’t have a C-section without some trauma.”

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