What to Expect - Labor and Delivery
Most healthy pregnant women with no risk factors for problems during labor or delivery have their babies vaginally. However, the rate of babies born by cesarean section in the United States is on the rise. In 2004, 29.1 percent of babies were born by c-section in the U.S which is an increase of more than 40 percent since 1996. Many experts think that up to half of all c-sections are unnecessary. It is important for pregnant women to get the facts about c-sections before they deliver such as finding out what c-sections are, why they are performed, and the pros and cons of this surgery.
What is a Cesarean-Section?
During a c-section, the doctor makes a cut in the mother's abdomen and uterus and removes the baby surgicially. Most women get spinal or epidural anesthesia during a c-section which allows her to stay awake without feeling pain but in some cases general anesthesia is needed. With general anesthesia the woman is asleep during the entire procedure. A c-section can save the life of a baby or mothe by allowing the doctor to get the baby out very quickly. A cesarean section is major surgery and all surgeries have risks. This includes infection, dangerous bleeding, blood transfusions and blood clots. Women who have c-sections stay at the hospital for longer than women who have vaginal births and recovery time is longer and is often more painful than that after a vaginal birth. C-sections should only be done when the health or the mother of baby is in danger.
When is a Cesarean Section Recommended?
Doctors recommend c-sections when the health of the baby or mother is in danger. However, there are risks of delivering by c-setions. Limited studies show that the benefits of having a c-section may outweigh the risks when:
- the mother is carrying more than one baby (twins, triplets, etc.)
- the mother has health problems including HIV infection, herpes infection, and heart disease
- the mother has dangerously high blood pressure
- the mother has problems with the shape of her pelvis
- there are problems with the placenta.
- there are problems with the umbilical cord
- there are problems with the position of the baby (e.g. breech presentation)
- the baby shows signs of distress (e.g. slowed heart rate)
- the mother has had a previous c-section
Elective C-Sections: Can Women Choose?
A growing number of women are asking their doctors for c-sections when there is no medical reason. Some women want a c-section because they fear the pain of childbirth while some others like the convenience of being able to decide when and how to deliver their baby. Still others fear the risks of vaginal delivery including tearing and sexual problems. Is it safe and ethical for doctors to allow women to make medical decisions? The answer is unclear and further research on both types of deliveries will provide the answer. Many obstetricians feel it is their ethical obligation to talk women out of elective c-sections. Others believe that women should be able to choose a c-section if they understand the risks and benefits.
Experts who believe c-sections should only be performed for medical reasons point to the risks. C-sections can be dangerous for the mother and baby because it is major surgery which increases the risk of infection, bleeding and pain in the mother. C-sections also increase the risk of problems in future pregnancies and c-sections cause a higher risk of uterine rupture. If the uterus ruptures, the the baby's and mother's lives are in danger. Babies born by c-section have more breathing problems right after birth and are very rarely cut during the surgery.
Those who support elective cesarean sections say that this surgery may protect a woman's pelvic organs, reduces the risk of bowel and bladder problems, and is as safe for the baby as vaginal delivery.
Vaginal Birth after a Cesarean Section (VBAC)
Some women who have delivered previous babies by c-section would like to have their next baby vaginally. This is called vaginal delivery after c-section or VBAC. Women have various reasons for wanting a vaginal delivery after c-section. Some want to avoid the risks and long recovery of surgery while others want to experience a vaginal delivery.
Studies show that vaginal delivery after c-sections are more risky for the woman and baby than a repeat c-section. The most serious danger of vaginal delivery after c-sections is the chance that the c-section scar on the uterus will open up during labor and delivery, or uterine rupture. While very rare, uterine rupture is very dangerous for the mother and baby. Uterine rupture can lead to life-threatening bleeding for the mother and brain damage or even death for the baby.
The biggest and best study on vaginal delivery after c-section was published in the New England Journal of Medicine in 2004. The researchers studied more than 30,000 women who had had a c-section and were pregnant again. Some of these women chose to have a vaginal birth after c-section while others decided on a repeat c-section. The doctors compared the health of the women and babies after both types of delivery. Almost three-quarters (73%) of women had a successful vaginal delivery after c-section. The other 27% of women who tried to deliver vaginally ended up having another c-section. While rare, problems with the woman and baby were more common among vaginal delivery after c-sections compared with repeat c-sections. Only 0.8 % of women had a uterine rupture. Women who tried vaginal delivery after c-sections had more blood transfusions and a greater risk of endometriosis than those who had repeat c-sections. Babies born by vaginal delivery after c-section had a higher risk of brain damage than those born by repeat c-section.
The percentage of vaginal delivery after c-sections is dropping in the United States for many reasons. There are worries about the rare, yet possible problems of vaginal delivery after c-sections. A growing number of doctors and hospitals are not allowing vaginal delivery after c-sections because they are afraid of lawsuits that might follow vaginal delivery after c-sections that go wrong. In 2004 the American College of Obstetricians and Gynecologists recommended that hospitals have a surgical team standing by whenever a woman is having a vaginal delivery after c-section .
Doctors are also discouraging or flat out refusing to perform vaginal delivery after c-sections. Sometimes this is because their affiliated hospital does not allow them. In other cases, doctors can not get malpractice insurance to cover claims related to vaginal delivery after c-sections. And some doctors admit they are afraid of getting sued if a vaginal delivery after c-section goes wrong. Choosing to try a vaginal delivery after c-section is a difficult decision for many women. If you are interested in a vaginal birth after a c-section, talk to your doctor and read up on the subject. Only you and your doctor can decide what is best for you. Both vaginal birth after cesarean and planned c-sections both have their benefits and risks. Learn the pros and cons and be aware of possible problems before you make your decision.
The American College of Obstetricians and Gynecologists (ACOG) recommends that doctors consider vaginal delivery after c-section when:
- a woman has had 1 previous planned c-sections done with a low, horizontal cut or incision ("bikini" incision)
- a woman has no other uterine scars (aside from the prior c-section) or problems
- a woman has no known problems with her pelvis
- a doctor is present during all of labor and delivery and can perform an emergency c-section if needed
- an anesthesiologist and other members of a surgical team are standing by in case an emergency c-section is needed
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