C Section By Choice

Why would a woman choose a c-section over a vaginal delivery?

The idea gained notoriety several years ago from stories in the British tabloids about celebrities who were "too posh to push" and chose to have their babies by c-section. A series of stories followed in the U.S. press, suggesting that more and more first-time moms were choosing cesareans for no clear medical reason. 

Why would a woman choose major surgery over vaginal childbirth? Some women felt that scheduling their delivery was more convenient than waiting for labor and childbirth, allowing them to more easily arrange for work leave and extra help at home. Others believed that a c-section would help them avoid the pain or certain complications -- such as tearing, incontinence, orsexual dysfunction -- that they associated with a vaginal delivery.

In terms of complications, what little evidence there is doesn't show that a so-called "maternal request" c-section is the safer way to go for a first delivery. And there's good evidence that if you end up having more than one or two children, it's much more risky. Read on to see what we know about the risks and benefits of maternal-request c-sections, and what the experts think about them. 

Is a planned cesarean really more "convenient" than a vaginal birth?

Scheduling a c-section may give some women a feeling of control over what's an inherently unpredictable experience. After all, if you knew the date your baby would be born you could plan more easily for family help, work leave, etc. Wouldn't it be better to relax and enjoy your last few weeks instead of waiting anxiously for your contractions to kick in at any moment?

But just because you've scheduled a c-section, that doesn't mean your baby will wait until that date to be born. Since you can't schedule the surgery earlier than 39 weeks, you'll still need to remain flexible in your plans in case you go into labor before then.

Plus, once you're in the hospital, the obstetrician and anesthesiologist take over and you become a surgical patient. It's true that planning for a vaginal delivery doesn't mean you'll end up with one. But if you do deliver vaginally, you can have much more control over what happens during the birth process and some women find that very empowering.

After a c-section, you're facing the difficulty of recovering from major surgery. You're in the hospital for longer (an average of 4 days instead of 2), you can't lift anything for two weeks, and the pain from your incision can make it uncomfortable to breastfeed. Finally, studies show that you have a significantly higher risk of needing to go back into the hospital with complications after a c-section. That's not very convenient.

What if I'm scared of the pain of labor and childbirth?

It may seem like the guarantee of anesthesia that accompanies major surgery would be a better bet than the uncertainty of pain control during labor and delivery. What if the epidural doesn't work well or if you don't get a chance to have one at all?

Almost every pregnant woman has heard some horror story about labor pain. If this is a concern for you, discuss it with your practitioner so that she can review your pain control options with you and make sure your delivery team knows that you want pain medication as early as possible.

Also, it's a good idea to talk to women who have had a c-section. They may not have felt much pain during the surgery, but chances are they had a longer, tougher recovery than most women with vaginal deliveries.

What if I'm terrified of tearing?

Many women who give birth vaginally do have some degree of tearing in the vagina or the perineum — the area between the vagina and the anus. But the vast majority of them are either superficial tears that cause little discomfort or lacerations that may require stitches but usually heal well within a few days.

A small number of women who deliver vaginally (about 4 percent) end up with a more serious tear that may cause pain or discomfort for several months and can lead to problems with anal incontinence later. You can reduce your chances of being in this group by choosing a caregiver who rarely cuts episiotomies or uses forceps, both of which greatly increase your risk of a serious tear.

How many women are requesting these c-sections?

No one really knows. It's true that more women are having c-sections than ever before. In 2011, about 33 percent of births in the United States were cesarean deliveries, up from about 20 percent in 1996. But it's hard to say how many of these c-sections were actually requested by women. 

Several studies have tried to estimate how many c-sections are done at the mother’s request, but it's been hard to get good data. Most of these studies were based on birth certificates or hospital billing records, which don’t necessarily show whether there was a medical reason for surgery. And they definitely don't show whether the woman asked for the procedure.

When the National Institutes of Health (NIH) held a State-of-the-Science conference in March 2006 to discuss maternal request c-sections, the expert panel acknowledged that there were no solid estimates of how common the procedure is. But there was a general feeling among the participants that these cesareans were on the rise.

That same year, researchers sent out a questionnaire about maternal request c-sections and 701 ob-gyns responded. According to the report published in Obstetrics & Gynecology in January 2007, 58 percent said that more women had been asking about cesarean deliveries over the previous year. And about half the doctors acknowledged having performed at least one c-section on maternal request.

Another group of researchers surveyed women directly. In October 2006, Childbirth Connection released the results of the first national study asking women about this issue: Of the 1,314 participants who might have requested a c-section for no medical reason in 2005, only one woman -- 0.08 percent -- said she did. (Two women said they had cesareans for no medical reason because their healthcare provider suggested it.)

What are the risks and benefits of a maternal request c-section?

If you're expecting your first baby and considering a c-section for no medical reason, you may want to consider what studies show about the risks and benefits of the surgery compared to a planned vaginal delivery. (Keep in mind that some women who plan to deliver vaginally end up with a c-section or an assisted vaginal delivery.)

One thing is clear: Each c-section you have increases your risk for some serious complications in future pregnancies. That's why most experts recommend trying for a vaginal delivery if you plan to have several children.

One complication, placenta previa (a placenta that's close to or covering the cervix), can cause bleeding during pregnancy, which may require you to deliver prematurely. Another is placenta acreta, in which the placenta doesn't separate properly at delivery. Both of these increase the risk of hemorrhage and emergency hysterectomy during delivery.

Even if you're sure you don't want more than one or two children, consider this: Studies show that many women are wrong about what their final family size will be when they're making delivery decisions about their first child. Either they change their mind or they end up with an unplanned pregnancy.

A 2008 study in Obstetrics & Gynecology found that almost 40 percent of surveyed women planning no more than two children ended up with more, primarily due to unplanned pregnancies. Twenty percent of these women ended up having four or more children.

But let's assume that you'll only have this one child and maybe one other. What do we know about the risks and benefits for women choosing a cesarean delivery by maternal request versus those planning a vaginal delivery?

Unfortunately, we don't know very much because very few studies have directly compared these two situations. Most of the data used to discuss maternal request c-sections is derived from studies designed for other purposes. When the 2006 NIH panel reviewed these studies, they warned that many of their conclusions "must be interpreted cautiously."

For most outcomes -- such as the risk of urinary and anal incontinence, and sexual dysfunction -- the panel found that the evidence either didn't support or only weakly supported one delivery method over the other. In fact, the panel found moderate-quality evidence to support one delivery route over the other for only three variables:

• Hemorrhage: There's some evidence that you're less likely to hemorrhage if you plan a c-section than if you plan a vaginal birth. (Remember that some women who plan to have a vaginal birth end up with an unplanned c-section, which tends to be associated with more blood loss than a planned c-section.)
  
  On the other hand, when it comes to the risk of hemorrhage leading to hysterectomy, what little evidence there is shows no difference between first-time moms planning a c-section versus those planning a vaginal delivery. And as mentioned earlier, there is good evidence that having multiple c-sections increases your risk of life-threatening hemorrhage and hysterectomy.
• Length of hospital stay after delivery: Women who deliver vaginally go home sooner after birth than women who have a c-section, regardless of whether it's a planned c-section or one following labor. What's more, according to a 2007 study, women who planned a c-section were more than twice as likely to be readmitted to the hospital during the postpartum period as women who planned a vaginal delivery.
• Breathing problems: Babies born by planned c-section are more likely to end up in the neo-natal intensive care unit (NICU) with breathing problems than are babies who are born vaginally. It's not clear exactly how labor and vaginal birth may help a newborn's lungs adapt to life outside the womb, but they do.
  
  Babies delivered by c-section before 39 weeks are particularly prone to this problem. They're also more likely to have problems adapting in other ways, too, such as low blood sugar and body temperature. For these reasons, experts agree that no c-sections should be scheduled before 39 weeks unless there is a medical reason to deliver earlier.

What do the experts say about maternal request c-sections?

Healthcare providers disagree about whether it's appropriate to operate on a woman who wants a c-section when there's no clear medical reason to do so.

The debate spilled into the public eye in 2003 when the American College of Obstetricians and Gynecologists (ACOG) issued a statement addressing cesareans by maternal request. In a bow to "patient autonomy" ACOG took the position that doctors may ethically perform a c-section that's medically unnecessary as long as they think it's "in the best interest of the patient."

That position, which ACOG has since updated somewhat, sparked heated opposition from a number of professional organizations. For example, the International Federation of Obstetrics and Gynaecology guidelines state that because there's no hard evidence of benefit to the patient, performing a c-section for non-medical reasons is ethically not justified.

Also disagreeing with ACOG are the American College of Nurse-Midwives, Lamaze International, and the International Cesarean Network. These groups argue that birth is a natural physiological process that should be allowed to unfold naturally unless there's a medical reason for intervention.

And in 2008, the Society of Obstetricians and Gynaecologists of Canada, the Canadian Association of Midwives, and several other Canadian healthcare provider organizations issued a joint policy statement in which they said unequivocally: "A Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby."

Basically, these groups believe that you should have solid evidence that the benefits outweigh the risks before intervening in the birth process, much less replacing it with major surgery.

Some critics have even suggested that some obstetricians may be thinking of themselves first when they agree to their patients' requests for a c-section (or don't try very hard to talk them out of it). After all, doctors can schedule the surgery at their convenience, avoid the risk of being sued for a labor that didn't go well, or even get paid more for it by insurers than they would for a vaginal delivery.

In the 2006 survey of 701 ob-gyns, 55 percent said a woman should have the right to request a c-section. But the study authors noted that "their discomfort with the procedure was evident." As one respondent stated, "I think the media's portrayal of Hollywood personalities having planned cesarean births has made it a glamorous option...much to the detriment of our patients."