Cesarean Section, an Imminent Fate?

Cesarean section, also known as “abdominal delivery” as compared to the more natural “vaginal delivery”, is the procedure through which the baby is delivered from his/her mother’s belly via an abdominal incision. Cesarean section is considered to be a surgical procedure requiring regional or general anesthesia, with many pros and cons. Some people (including physicians) tend to advocate for cesarean sections while others support the more natural vaginal route of delivery. The purpose of today’s article is to explore the benefits and drawbacks of the cesarean section, and to go through its most common indications.

The first reported cesarean section was performed in Switzerland in 1500 after a woman remained in labor for days! Both the baby and the mother survived the operation. Since then, cesarean sections have become increasingly common in both developed and developing countries. Some countries report a very high cesarean section rate reaching up to 50-60% of their deliveries (such as Egypt and Brazil) while other countries have a very low cesarean section rate in the range of 15% (such as the Nordic countries). What’s the reason behind this huge discrepancy among countries? And what is considered to be an acceptable cesarean section rate?

Well, before answering these questions, let us explore the reasons behind cesarean section. Some C-sections are actually medically indicated. But a big number seems to be unwarranted and unjustifiable.

Here are the most common obstetric/medical indications for cesarean sections

Failed Labor

Labor is the process of uterine contractions and changes in your cervix (the structure between your uterus and vagina) enabling the proper vaginal expulsion of a healthy baby. Sometimes this labor fails because of inadequate contractions, big baby or small pelvis. So, some women, despite being given enough time with adequate uterine contractions, still fail to deliver normally and end up with a cesarean section. These women can fail during the early or late stages of labor. Of course, women who previously had a successful vaginal delivery tend to have a lower labor failure rate in subsequent pregnancies, yet this rate is never 0% no matter how many deliveries the woman had before.
The problem is that we as physicians cannot predict with a 100% certainty whether a woman can have a successful labor process or not, hence the only determining factor is labor itself.

Fetal Intolerance to Labor

During labor, women are hooked continuously or intermittently to fetal heart rate monitors (external monitors placed on the mother’s belly to display the contractions as well as the fetal heart rate). One of the most common indications for cesarean section is fetal intolerance to labor or what we call "fetal distress". Some babies, for one reason or another cannot seem to endure the labor process and that’s when a cesarean section becomes medically warranted and useful. Yet, you should know that the fetal heart rate is expected to change along the course of your labor, and sometimes the baby is able to pick up and you can still proceed with a normal vaginal delivery despite occasional fetal irritations, but the decision for cesarean section depends on the general well-being of the baby. So, no need for you to obsess about the fetal heart rate as it should be monitored by specialists (nurses and doctors)!

Fetal Presentation

The fetal position is very important during labor as nowadays we only proceed with normal vaginal deliveries for cephalic babies (when the head is oriented downwards). In the past even breech babies (feet down) used to be delivered vaginally, yet studies have shown that cesarean sections for breech presenting babies are safer for the baby than vaginal breech deliveries. Thus, all breech babies nowadays are scheduled for a cesarean section. Also, another fetal presentation known as transverse baby (when the baby is lying in a horizontal fashion in your belly) is an indication for cesarean section as normal vaginal delivery is risky and almost impossible. Therefore, your baby’s position plays a very important role in determining the adequate mode of delivery.

Fetal Weight

As I have previously mentioned, sometimes big babies tend to negatively influence the labor process, so can we prevent this by scheduling all mothers with big babies for cesarean section? Well yes, to a certain extent. The limit of fetal weight for a cesarean section in a healthy mother is 5 kg. but if you have gestational diabetes (insulin resistance specific to pregnancies), then an upper fetal weight limit of 4.5kg becomes an indication for cesarean section. So, yes a big baby can be a direct indication for cesarean section, however you should bear in mind that most “big” babies causing labor failure are below these 5kg and 4.5kg cutoffs.

Gestational Age (How many weeks are you into your pregnancy?) 

Extreme fetal prematurity is sometimes considered an indication for cesarean section. For example babies are more likely to be born by cesarean section at 7 months compared to 9 months of gestation. This is secondary to 2 main factors; firstly at 7 months your body is not ready yet for a vaginal delivery and thus the latter is more likely to fail, and secondly the more premature the baby is, the less reserve he\she has and thus the more likely for him/her to be in distress in the setting of labor leading to a higher cesarean section rate. 

Placental and Umbilical Cord Locations

The placenta is the organ that gives all the nutrients and oxygen to your baby, and takes away his/her waste products. Sometimes the location of the placenta stands in the way of a normal vaginal delivery, this condition is called “Placenta Previa” and that’s when the placenta implants too low and thus blocks the cervix (which is the first passage way the baby should make before reaching the vagina). In such instances, it is not possible to proceed with a normal vaginal delivery without jeopardizing both the mother and baby and consequently a cesarean section becomes recommended.  Here again, the exact location of the placenta should be known prenatally by ultrasound, because sometimes the placenta is low but not low enough to risk the delivery process and you can still proceed with a normal vaginal delivery.
In some other instances also, the umbilical cord (the cord linking the baby to the placenta) seems to cover the cervix and thus you cannot deliver normally as any cervical changes (dilation or thinning in your cervix) can risk rupturing these vessels and exsanguinating the baby, thus a cesarean section becomes a must for fetal benefit. This condition is known as “Vasa Previa” and can be diagnosed prenatally by ultrasound as well.

Twins and Triplets

Other common indications for cesarean section are twin pregnancies. The guidelines actually allow you to have a vaginal delivery for twin pregnancies if; your twins have two separate sacs (different amniotic sacs for each baby) and the presenting baby (baby A) is cephalic (head first). But this is easy said than done, because the obstetrician should be well training in twins’ normal vaginal delivery, because the delivery of the second baby is always trickier and thus riskier than the first, accordingly some might elect for a scheduled cesarean section for twin pregnancies regardless of their presentations.
In the setting of an even higher order pregnancy (triplets and beyond) then cesarean section is the only choice for delivery, especially that these deliveries occur at much earlier gestational ages than twin pregnancies.

History of Cesarean Section

Also, another known indication for cesarean section is a history of previous cesarean section. “Once a cesarean, always a cesarean”, this can hold true especially if the reason for your first cesarean section was a failure in your labor progress, because such condition is more likely to recur in subsequent pregnancies. But keep in mind that if you had 1 previous cesarean section for a non-recurring factor (such as, fetal distress in your previous pregnancy, or breech baby..) then you may proceed with a normal vaginal delivery (called TOLAC: trial of labor after cesarean section) so make sure to ask your physician about this option (a full article will be tackling this entity in the future)

Infections

Other less commonly encountered reasons for cesarean section include HIV infection, especially if you are not on therapy and/or if the viral load is unknown or higher than 1000, then a cesarean section is much safer for the baby compared to normal vaginal delivery. But many HIV positive women on treatment and negative viral loads can still proceed with a normal vaginal delivery!

Other infections preventing a vaginal birth include active genital herpes. If you have active genital herpes or symptoms of herpes (even in the absence of visible lesions) at the time of labor, it is contraindicated to proceed with a vaginal delivery because of the high risk for transmission to the baby and accordingly a cesarean section becomes warranted. If you have a history of genital herpes but at the time of labor you have no active lesions and no symptoms whatsoever, then you can still proceed with a normal vaginal delivery.

What about genital warts?
Having genital warts is NOT an indication for cesarean section. The only reason for a cesarean section in the setting of genital warts (HPV related warts) is when the warts are too big and obstructing the vaginal tract, or if they are sizeable and located in areas expected to bleed and threaten the mother’s health, then an elective cesarean section would be advocated. But you should know that few warts in the genital area should not preclude you from having a normal vaginal delivery.

Maternal Medical Condition

Some maternal medical conditions (severe lungs and heart problems) hinder women from having a normal vaginal delivery because of the women’s inability to push and spend hours in active labor. In such instances an elective cesarean section can be lifesaving to the mother.

So, as you can see, there are multiple medical indications for cesarean section, and thus countries with no resources to perform these indicated cesarean sections (such as some African Countries) will have higher maternal and fetal complications during vaginal delivery. However, when we perform cesarean sections unindicated, we remove the pros from the equation and we are left with only the cons. 

So what about these disadvantages? 

Cesarean delivery is a surgery, and thus it is associated with a much higher chance of organ damages (bladder, bowels and major vessels), infection, bleeding and blood transfusion when compared to normal vaginal delivery. Also, it is associated with a higher incidence of blood vessels clotting (both during and after the delivery). In addition, higher post-delivery pain and need for stronger pain killers are witnessed in women delivering by cesarean section compared to those delivering vaginally.
Moreover, the recovery period takes longer in these women compared to women delivering normally.
These are few of the short-term complications of cesarean section that all patients should be informed about. But other major long-term complications should also be put on the table. As cesarean section is associated with a higher chance of abnormal placental implantation into the wound in subsequent pregnancies, which puts women at danger for, severe bleeding, early delivery, hysterectomy (surgical removal of the uterus) and death! Also, with every cesarean section we perform, we further weaken the uterus putting it at a higher risk for tearing and rupturing in subsequent pregnancies.
Henceforth, cesarean sections are not a game, and one should avoid performing them unless obstetrically and medically indicated!

What about the baby? Well a cesarean section is considered safe for your baby, but sometimes babies born by cesarean section tend to have temporary respiratory problems because of a reduced fluid resorption from their lungs, compared to vaginally delivered babies.   

 

So, we have established by now that cesarean section is a commonly performed obstetric procedure (the most common procedure actually), and when it is indicated it is beneficial for both the baby and the mother. However, one should be vigilant on when and how to perform a cesarean section and not to perform it unindicated.
Women also have the duty to be educated and informed about their choices. All benefits and drawbacks of cesarean sections should be laid in front of patients so that they can have an informed decision before going under the knife.

 

Finally let us debunk few myths!

Myth 1: "I am 40 years old I cannot deliver vaginally"

Fact 1: It is true that with advancing maternal age, the success rate for a vaginal delivery decreases, yet cesarean sections should not be electively performed in all “old” mothers. Regardless of your age a trial of vaginal delivery should be offered.

Myth 2: "I am short and/or obese so I cannot deliver normally"

Fact 2: Again here, short and obese women are known to have a higher labor failure rates, but your height and weight are never the only predictive factors for your vaginal delivery success rate. So, you should be offered a trial of vaginal delivery regardless or your body habitus.

Myth 3: "I have a vaginal infection, I cannot delivery normally for the sake of the baby"

Fact 3: Not true. The only infections known to be direct indications for an elective cesarean section are HIV (with an elevated viral load above 1000) and active genital herpes. Bacterial vaginal infections and yeast infections should not preclude you from a trial of normal vaginal delivery.

Myth 4: "My pregnancy is a product of IVF (In Vitro Fertilization) so I should deliver by cesarean section".

Fact 4: All pregnancies, including those resulting from assisted reproduction can have a trial of vaginal delivery .

Myth 5: "My baby is precious, I cannot risk a trial of labor"

Fact 5: I find the concept of a “precious” baby futile, as all babies can be regarded as precious by their respective parents. In addition to the fact that vaginal delivery is not risky if followed by professionals in the field. You should know that whenever the baby shows any signs of distress and intolerance to labor, cesarean section can be performed in a timely fashion without jeopardizing the fetal well-being. But performing an elective cesarean section for the sole purpose of preventing any potential fetal distress is not wise.

Myth 6: "I delivered by cesarean section once, so I cannot deliver vaginally again"

Fact 6: This is not true, as nowadays women with a previous one cesarean section for a non-recurring indication, can still proceed with a trial of labor in their subsequent pregnancies (this discussion should be detailed with your physician)

Myth 7: "I am carrying twins so I cannot deliver vaginally"

Fact 7: As I have previously mentioned, twins can be delivered vaginally if satisfying some criteria.

Myth 8: "I cannot breastfeed after my cesarean section"

Fact 8: Breastfeeding can be done regardless of the mode of delivery

Myth 9: "I cannot have skin to skin during my cesarean section"

Fact 9: Nowadays cesarean section can be performed under regional anesthesia, and thus women can still have skin to skin performed during their cesarean sections.

Myth 10: "Cesarean section is a guarantee that I don’t suffer from postpartum depression"

Fact 10: Regardless of the mode of delivery, the risk for postpartum depression is the same as the hormonal changes are the same. Actually, one might say that a vaginal delivery can have a more positive impact on the baby-mother bond, reducing the risk of postpartum depression

 

In conclusion, the introduction of cesarean section was one of the most important landmarks in obstetrics. When medically indicated it has more benefits than drawbacks, but if unindicated, it can cause more harm than good. Going back to the introduction, some countries do have a very high cesarean section rate, and this is considered unacceptable because most of these cesarean sections are unjustifiable. On the other hand, poor underdeveloped countries with no resources have a very low cesarean section rate but a higher than normal fetal and maternal complications. According to the International Healthcare Community the ideal rate for cesarean sections is around 15%. This number does differ in the same country between hospitals and physicians, but I believe that it is the duty of patients (as well as physicians) to always advocate for a normal vaginal delivery. However, you should also be aware about certain conditions that cannot be managed in ways other than cesarean section.
Always seek knowledge in order to have an informed decision about your health.

 

Karam