Should primary elective cesarean section be performed on demand in the absence of medical indications?

OB/GYN News, Oct 15, 1999

Should primary elective cesarean section be performed on demand in the absence of medical indications?

YES Allowing a woman who has no medical indications for cesarean section to choose between primary elective C-section and a trial of labor is the only option that makes sense ethically because we don't have compelling scientific evidence that vaginal birth is better.

Assumptions that vaginal delivery is safer are based on the fact that in looking at the risks associated with C-section, the consequences of emergency C-section are invariably lumped in with cesareans in general. But there's a world of difference between the risks of primary elective cesarean section and a trial of labor followed by an emergency C-section.

Certainly, from the infant's standpoint, a primary elective cesarean that requires a 5-minute delivery period in a controlled environment is almost always safer than attempted vaginal delivery because of the avoidance of brain injury.

From the mother's standpoint, there's no doubt that primary elective C-section involves a longer recovery period and more severe short-term consequences.

But to many women, short-term morbidity may be far preferred to the longer-term morbidity associated with vaginal birth. Injuries to the pelvic floor and genital tract can cause uterine prolapse as well as stress urinary incontinence and fecal incontinence, both of which are massive problems in the aging population that are largely underreported.

It's estimated that half of all women with vaginal deliveries have some degree of stress incontinence and 10% have urinary incontinence that's severe enough to dramatically curtail their activities.

We know that the bigger the baby or the more babies a woman delivers, the greater the likelihood of stress incontinence. So this problem is a predictable long-term consequence of vaginal birth that could be avoided by liberalizing the use of elective C-section.

People rarely talk about the fact that women who give birth vaginally often experience a decline in sexual functioning from a loss of muscle tone and sensitivity to sexual contact. Injuries to the genital tract during vaginal birth can also result in dyspareunia. If there is something that can be done to avoid this morbidity, we should discuss it.

Doctors tend to exaggerate the advantages of vaginal delivery and the disadvantages of C-section. They do so even in situations in which it's clear from the outset that a woman has a 50% chance of undergoing a long, arduous trial of labor only to require a cesarean at the end of it.

In such cases, wouldn't it be more ethical to discuss the alternatives and let her decide?

Dr. David Campbell Walters practices in Mt. Vernon, Ill., and is author of "just Take It Out!: The Ethics and Economics of Cesarean Section and Hysterectomy"

NO Why should we offer a choice when one option is dearly more dangerous?

Although it's true that maternal morbidity and mortality associated with cesarean section have improved in the past 50 years ago, there's no doubt that it's still not as safe as vaginal birth and it never will be.

An estimated 11 women die for every 100,000 vaginal births. Twenty-six women die for every 100,000 scheduled and emergent C-sections combined. But the truth is, there are relatively few truly emergent C-sections. So cesarean sections are at least twice as dangerous. They also increase the risk of endometriosis and infertility.

Nor is cesarean section necessarily a panacea for preserving sexual function. Plenty of studies indicate that C-sections can lead to painful intercourse.

While perianal trauma and prolapse can be avoided with cesareans, the tradeoff is long-term morbidity with intraabdominal adhesions, which can complicate future surgeries.

C-sections are not necessarily safer for the baby either. In the 1970s the cesarean-section rate was 5%. Today, it's four times higher and the rates of perinatal morbidity and mortality are virtually unchanged.

During a trial of labor there is also a critical lung maturation and drying process that occurs. In the absence of this process, four or five times as many infants have transient tachypnea with C-section delivery not preceded by a trial of labor.

It's virtually impossible to predict which mothers may undergo a trial of labor only to require a C-section hours later. Studies show that infants over 10 pounds have a 75% chance of being delivered vaginally But I'm certainly not a good enough obstetrician to predict which mothers are in that slim quarter and should forego a trial of labor and go straight to the operating room.

Labor is the only true test of whether a baby will descend and deliver, and no one can predict that accurately

One exception is women with type 1 diabetes who are carrying a baby over 10 pounds: Their chance of dystocia and brachial plexus injury is high enough to warrant a C-section without a trial of labor. The other exception is women with a history of shoulder dystocia.

I also have serious ethical concerns about the motivations of people who would provide C-sections on demand. It's obviously a lot more convenient for the doctor to schedule a cesarean than to sit with a woman and help her through a labor at 3 a.m.