Friday, April 11, 2008

A Risky Rise in C-Section
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Experts worry that the trend is bad for mom and baby
Deborah Kotz
Posted March 28, 2008

Once the delivery option of last resort, cesarean sections
are now all the rage: Nearly 1 in 3 pregnant women had a C-section in 2006, compared with about 1 in 5 a decade earlier. "It's not unthinkable that in our lifetime, the majority of pregnant women will be having C-sections," says Bruce Flamm, an obstetrician-gynecologist at Kaiser Permanente Medical Center in Riverside, Calif., and spokesperson for the American College of Obstetricians and Gynecologists. "Is that a good thing or a bad thing? I think you get strong arguments on either side." Supporters believe that surgery eliminates the rare but terrifying complications of vaginal delivery that result in birth injuries or even a baby's death. Those who favor cutting back on cutting decry the lengthy recuperation and the increased risks during subsequent pregnancies of uterine rupture and other problems.

One driving force behind the surge in surgeries has been the sharp reversal in the trend toward "vaginal births after cesareans" after a handful of studies found a VBAC raises the risk of uterine rupture. Yet now doctors may have gone too far in limiting the practice, says Gene Declercq, a professor of maternal and child health at the Boston University School of Public Health who has researched the use of C-sections. More recent research contradicts the worrisome VBAC findings; a study published in the February issue of the journal Obstetrics & Gynecology found that of more than 13,000 women who attempted a VBAC, nearly three quarters were able to avoid another C-section, and the risk of uterine rupture was less than 1 percent.

Obstetricians' rising malpractice insurance premiums may play a role, too. Individual doctors in many states now pay upwards of $100,000 a year for coverage, a figure that can spike if they're sued for something that goes wrong during labor, regardless of the legal outcome. "If there's no labor, there can be no lawsuit related to labor," says Flamm, who points out wryly that parents rarely sue over unnecessary C-sections. Breech babies are now nearly always delivered via C-section, and the surgery has become routine for twins and large babies. "What would have been a forceps delivery 20 years ago would now be a C-section," says Flamm.

Efficiency factor. And the trend toward favoring surgery could be feeding on itself. "Obstetricians aren't as good at managing vaginal births as they used to be," says Declercq. It's a lot easier for them to, say, take an 8-pound baby out through an incision than maneuver him or her through the pelvic opening. What's more, the efficiency factor is enticing. "It organizes their day infinitely better to do scheduled C-sections," Declercq says.

A growing number of women, too, prefer planned surgical deliveries. Fewer mothers-to-be have the time or willingness to attend natural-childbirth classes, and some request a C-section even without a medical reason; those women now account for an estimated 3 percent of births in the country. Certain celebrities have even reportedly scheduled cesareans three or four weeks before their due date, to minimize stretch marks
and saggy loose skin. Flamm says he has done several C-sections without any medical indications, usually for patients afraid of the pain of labor. "One woman told me she witnessed her sister's 'nightmare' birth," he recalls, "and didn't want to go through that herself."

So what's the harm? For one thing, experts say, C-sections mean a longer hospital stay and weeks of recuperation. In a survey of nearly 1,600 new mothers, Declercq and his colleagues found that more than three quarters of the ones who had had C-sections felt abdominal pain
over the next two months and about 1 in 5 was having discomfort after six months. More worrisome is the higher likelihood during future pregnancies of having placenta previa, in which the placenta blocks the cervix and detaches during labor (potentially cutting off the baby's oxygen supply), or a ruptured uterus, increasing the possibility of hyserectomy and fetal death in utero. The surgery also carries a slightly elevated risk of death for the mother because of complications from anesthesia, infections, and blood clots. And scar tissue that forms at the incision site can lead to bowel obstruction years or decades later.

Lung risks. Having a planned C-section two or three weeks before the due date is particularly risky, even though babies born at that point are considered to be full term. In December, researchers reported in the British Medical Journal that babies delivered by elective C-section three weeks before the due date, compared with same-age babies delivered vaginally or by emergency C-section, had four times the risk of breathing complications and five times the risk of serious lung problems because of immature lung development. The risks were lower but still elevated among those born two weeks early. Although doctors are supposed to wait until 39 weeks—a week before the due date—to perform a planned C-section, all too frequently they do the surgery earlier for convenience or because of an incorrect estimation of the due date.

Going through the process of labor, regardless of how a baby is delivered, may confer benefits as well, says study leader Anne Kirkeby Hansen, a research fellow at Aarhus University Hospital in Denmark. "Certain stress hormones are released right before and during labor that are very important for lung maturity."

There's no question that some women need C-sections, such as those with placenta previa. But the World Health Organization recommends a cap of 15 percent of deliveries—the U.S. rate in 1978—based on evidence showing that higher levels don't benefit either mother or baby. Though the drama-free planned C-section certainly has its appeal, Declercq stresses that women and doctors need to "stop seeing it as just another surgery."

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