Wednesday, February 25, 2009

The problem with cesarean sections

The advancement in medicine to the point where the cesarean section was developed is wonderful! Many moms have been saved (especially moms who develop eclampsia; still the biggest maternal killer in obstetrics), and many more babies have been saved by this surgery. The problem with c-sections is not inherent in the surgery itself; it is in how we use it.
The problem with cesarean section birth is this: surgical birth is more dangerous than vaginal birth.
The risks associated with cesarean sections are low, as this surgery has been performed so many times as to allow physicians and surgeons to fine tune their surgical methods. However, the complication, death, and injury rates are HIGHER with surgical births than with vaginal births. Nature still knows best.
[when, oh, when will we trust this?]
Complications of vaginal births exist. However, the risk of complications due to cesarean section surgery is higher. Statistics do not generally accurately reflect such complications as spinal anasthesia, breastfeeding problems as a direct result of anasthesia/mother-infant separation post op/fluid bolus in conjunction with spinal anasthesia/hemorrhage post op, psychological trauma, or anything which arises more than a few weeks after the surgery is performed. But statistics still show us that complication rates, maternal mortality and morbidity rates, and infant morbidity rates are higher with C-sections.
The most common complications arising from cesarean surgery are, in order of frequency:

Future incidence of placenta previa
Fever (indicates infection)
Wound infection
Opening of uterine scar
Injury of visceral organs, most often to the intestines or bladder, usually made by the scalpel

Sometimes the infant itself is injured by the scalpel.

Risks for future include a higher incidence of ectopic pregnancies, increased risk of uterine rupture in future pregnancies, increased infertility rates, and etc. The incidence of uterine rupture is increased, statistically, during labour and during the third trimester in subsequent pregnancies.

The World Health Organization has analyzed data from studies around the world to determine what would be a balanced cesarean section rate that reflected a balance between helping/intervening when necessary, and avoiding unnecessary exposure to the risks involved in surgical birth. The WHO conclusion is that a safe cesarean section rate should be no higher than 10 to 15%. Otherwise, moms and babies are being harmed because of surgical birth. In 2006, Canada's C-section rate was 26.3% [citation]. This means that over 1 in 4 babies in Canada were born by Cesarean Section. In 2007, The United States' C-section rate was 31.1% [Wikipedia].

This article by ACOG states:
"For a low-risk childbirth that is progressing normally, C-sections require substantially longer recovery times and present greater risks of complications such as infection, bleeding, scarring, chronic pelvic pain, and damage to the intestines or bladder. C-sections also increase the risks during subsequent pregnancies, making a repeat C-section more likely. In 2007, research by the Canadian Perinatal Surveillance System found that elective C-sections have higher risks of anesthetic complications, major infections, obstetrical wound, and cardiac arrest. The study also notes that women who had an elective C-section were more likely to require an immediate hysterectomy due to bleeding.2 "

Babies born by c-section have higher rates of prematurity, respiratory distress, and other problems associated with surgical birth.

The problem is not with Cesarean Sections themselves. The problem is in our OVERUSE of surgery to birth our babies.
One way to reduce C-section rates, which few seem to be advocating, is the ROUTINE trial of labour for repeat cesareans. Vaginal Birth After Cesareans (VBACs) have a 60-80% success rate. The success rate for women trying to give birth vaginally with NO history of previous surgery is 73.7% in Canada. If the VBAC rate is 60-80%, I would say any VBAC has just about the same chance of delivering vaginally as a woman who ISN'T a VBAC. So why don't we try?
This question has a complex answer. Baisically, there are two reasons that are most often given for NOT trialing labour in VBACs. One, there is an increased incidence of uterine rupture at the scar. Two, a woman who had 'failure to progress' or 'Cephalo-pelvic disproportion' is cited as likely to have it again in future labours, so to save her the grief of trying and failing again, and to save the medical system from unscheduled surgery (which is more costly and inconvenient from a medical standpoint), a repeat cesarean is recommended and surgery is scheduled.
Well, first of all there is an increased incidence of VBAC uterine rupture in the third trimester. This third trimester rupture rate is generally conceded to be 0.4%. The incidence of uterine rupture in VBAC labour? 0.4%.
So, if we are going to advise women not to have VBACs because of an increase in rupture rates [women who have not had uterine surgery have a rupture rate of 0.01%. Those who have had c-sections have a rupture rate of 0.4%, which is a significant increase!], we should also advise them not to have any more pregnancies.
Most women who are electing to have repeat sections do not know that their rate of rupture does not increase in labour as compared to the third trimester. Nor do they know that vaginal birth is still safer than surgical birth for other complications.
The second reason cited for advising against VBACs is that failure to progress or CPD will repeat itself. This is unproven statistically. Regardless of the reason for the first cesarean, the VBAC success rate is still 60-80%.

Most women these days have 2 babies. This means that 13.15% of cesarean sections performed in Canada are repeat, elective sections (conjecture on my part). If we allowed all of those 13.15% of women to trial labour instead of scheduling their repeat sections, we could automatically reduce that number by 60 to 80%. I pulled out my calculator:
If 60% of women were successful at VBAC, our section rate would drop to 18.41%
If 80% of women were successful at VBAC, our section rate would drop to 15.78%
The WHO recommendation is that a region's C-section rate be 15% or lower. So, JUST BY THE ROUTINE APPLICATION OF VBACs, we could reduce Canada's c-section rate to within 3.41 to 0.78% of the WHO recommendation!!

Other things we can do to reduce c-section rates? Normalize midwifery (my midwife's c-section rate last year was a mere 3%...though high risk deliveries are referred OUT of midwifery care and thus affect the intervention rates, low risk deliveries by general practitioner physicians are still in the 25 to 30% range, pointing towards midwives as the better way to go if the goal is a reduction in surgical rates). Discourage routine continuous external fetal monitoring. Encourage the usage of doulas (and even have their services covered under health insurance--way cheaper than paying for a cesarean section! Intervention rates automatically go down when a doula is present). Encourage upright, mobile labour, upright delivery positions, and water births. Never leave a woman in labour and her husband or partner alone. I think it is being left alone that creates more fear than any other routine procedure in birthing. Fear taps into the fight or flight, sympathetic nervous system response, which automatically slows or stalls the rest/regeneration/reproduction, parasympathetic nervous system response. Failure to progress can result. Inability to push out a baby can result. Piddly labour can result.

But I think fundamentally at fault is our cultural belief that birth is dangerous, and that womens' bodies are unable to give birth. Somehow, birth seems impossible. Many women believe their bodies are broken, or weak, or too small, or incapable...these fears are normal and valid when we are pregnant, but they are untrue. Unfounded. If we believed in women's ability to give birth, and if we believed that birth was difficult but beautiful and valuable in and of itself [much like other feats of physical strength and endurance], perhaps we would be able to lower those rates of surgical birth.
Not perhaps.


Caryn and Dan said...

Wow, amazing post.

I agree with so much of what you said, and I can testify that overuse of the fetal heart monitor throughout labour can SLOOOOOW the whole process BIG TIME! It wasn't until I got that stupid thing off of me and was able to move around freely(this happened when the shift changed and I had a better nurse!) that my labour FINALLY progressed.

Sara said...

I had a midwife for both of my labors and after extreme preeclampsia with my first and 2 days of minimal effacement during active labor I had c-sections. Is it something I planned for? No. Was I worried? Yes. But what was most important for me was the arrival of a healthy baby and mother.

I think that you have painted a rather sad statement here, I am not for elective sections but sometimes that is the way the baby needs to come out. By putting fear into having sections will build a greater foundation for women to feel disappointed in themselves. Everyone on my delivery team was trying for a VBAC - I don't feel it was discouraged in the least.

No woman is less of a mother for having a section. Although your stats sway in your favor I have 2 beautiful & healthy sons. And if I had to do it again - I would in a heart beat.

As someone who is thinking of training to become a midwife you need to balance out your views. Stop spouting out facts and think with your mind and heart.

tamie said...

Mel, I really appreciated this post. You did a lot of research and obviously put a ton of thought into it. Even though I don't have children, and don't know if I will or want to have children, it is something I think about a lot. Oddly. And even something I have a lot of opinions on! I've known several people who have had VBACs and they were so thankful that they did. Here in Flagstaff it's a very political thing; actually, at our local hospital they won't let women have VBACs. If you want to have a VBAC, you have to go to Phoenix or Tucson. Crazy, eh? I just think it's totally ridiculous not to allow a woman to labor in the way she wishes.

Thanks for all the wonderfully helpful info. I appreciated your post.

Breanne said...

Hmm...not sure how I feel about this. I had a great midwife, I had a loving supportive partner and Sister with me the whole time so I was never left alone.

I had a normally progressing labor, but it was in fact my midwife who encouraged my section because every time she checked me there was a LOT of meconium and she was worried about aspiration.

In fact, so worried that I barely had a chance to absorb what was happening before I was whisked away.

If it hadn't been for the saving grace of a c-section, who knows what might have happened?

I do agree that the procedure seems to becoming quite the "norm" these days, but now looking at my beautiful, healthy, child I'm forever grateful for it!