Cesarean section is the name of the abdominal operation used to deliver a baby. The most recent birth statistics from the Centers for Disease Control and Prevention (CDC) reveal that 24.4% of the 4 million births in the United States in 2001 were by cesarean section, meaning that 1 million cesarean sections were performed in 2001, making it the most commonly performed surgical procedure in the United States. This is also the highest national rate since 1989. The rate was 22.9% in 2000.
It is widely believed that the term cesarean refers to the birth of Julius Caesar, presumably by a surgical method. Historical documentation is rather sketchy about this subject, but there is evidence that Caesar’s mother lived to hear of her son’s invasion of England. This causes some question as to Caesar’s birthing method because cesarean type births at that time were done only in an attempt to save the baby when the mother was dead or nearly so.
One of the most common indications, or reasons, for having a cesarean section is a history of a previous cesarean section. This is referred to as a “repeat cesarean.” In 2001, 7.5% of all births were by repeat cesarean. This leaves 16.9% as the rate of primary, or first-time, cesarean sections. The most common reason for a primary cesarean is failure to progress in labor. Causes of failure to progress include the arrest of dilation of the cervix, arrest of descent of the head, or cephalopelvic disproportion (baby’s head is too large to fit through the birth canal).
Other indications for cesarean section include breech presentation, twins (or higher order multiples such as triplets), fetal distress (the proper medical term is “fetal intolerance of labor” or “non-reassuring fetal status”), placenta previa (placenta blocking the birth canal), abnormal vaginal bleeding (possibly due to placental abruption which is when the placenta begins to detach from the uterine wall before the baby is born), and active herpes or HIV infection.
Delivery by cesarean section is felt to be more risky for a woman’s health than vaginal delivery and usually the recovery time is longer. Risks include postoperative infection (such as uterine infection or wound infection), hemorrhage, and associated blood transfusion, injury to other organs such as the bladder or bowel, and possible injury to the baby such as a cut during delivery. Additionally, having a first cesarean may increase the risk that subsequent deliveries will also be by cesarean. Cesarean section is also more costly than vaginal delivery.
Some patients may be candidates for a vaginal birth after cesarean (VBAC). The success rate for attempted VBAC is about 75%. Furthermore, subsequent deliveries are also likely to be vaginal. However, subsequent trial of labor in the presence of a prior cesarean scar increases the risk for a tear in the uterine scar, referred to as a uterine rupture. The risk of uterine rupture is about 5 per 1,000 for spontaneous labor, but increases if labor is induced or augmented with oxytocin (a medication commonly used to make contractions more effective). A uterine rupture can lead to fetal oxygen deprivation or death, and possibly a maternal hysterectomy if the damaged uterus cannot be repaired.
Some ways to avoid a cesarean section include the turning of a breech baby to head down by a practitioner skilled in this procedure (called an external cephalic version). Limiting one’s pregnancy weight gain to the normal range may help keep the baby’s weight lower and possibly prevent a cesarean for failure to progress, although there are little data to support this statement.
Is the rate of cesarean too high?
Many authorities feel that the birth of one in four babies in this country by cesarean is too high. There are national efforts to try to lower the rate. One target that has been published is a cesarean rate of 15%. In general, there has a been a drop in the rates of VBAC over the last several years.
One reason cited for the sharp drop in the rate of VBAC may be due to a growing fear of the potential risk of uterine rupture, which though rare can occur suddenly without warning and be potentially catastrophic. This carries an increased risk of liability and may be a deterrent to some practitioners counseling patients to try VBAC.
Additionally, there is growing evidence that vaginal delivery may have long-term risks that can be minimized by cesarean delivery. For example, urinary incontinence, pelvic relaxation, and pelvic prolapse are conditions seen later in life that may require surgery or other treatments, and these conditions occur far more often in women who have delivered babies vaginally than by cesarean section. Some doctors feel that a woman should be able to request a cesarean delivery.
There is no consensus as to the maximum number of cesarean sections that a woman can safely undergo. Reports in the literature have been conflicting with the highest number reported as being 13.
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