Centuries under the knife: Weighing the risks, benefits of a Cesarean birth

It once was believed that Julius Caesar's was the first cesarean birth, though this was later disproved - his mother survived the labor and, at the time, cesarean births were performed exclusively to save the baby's life when the mother was dying or already dead.

Cesareans continued to be performed throughout the ages into modern times. In 1970, the cesarean rate held at 5 percent of births. By 1991 the rate was 23.5 percent, and globally the United States rated third most prolific in cesarean deliveries, behind Brazil and Puerto Rico.

In spite of the cesarean's rise in frequency, many individuals still feel that childbirth is best left to the forces of nature. Jennifer Block, the author of "Pushed, The Painful Truth about Childbirth and Modern Maternity Care," explains that "(c)hildbirth ... is chaos that the body can resolve itself. If everything goes normally, order will come - a baby will be born, creation will trump destruction."

Physiologic, or natural, births are fewer and further between these days. As Block states, what is "normal is being redefined: from vaginal birth to surgical birth; from "My water broke," to "Let's break your water"; from "It's time," to "It's time for induction."

The national goal of the Healthy People 2010 project was to reduce the cesarean rate to 15 percent per annum. There has been, however, a 46 percent increase in cesareans since 1996, resting at 30 percent in 2005 - a national high. In King County the rate is 30 percent.

In addition to urgent, medically indicated cesareans, the process can also stem from a number of symptoms termed non-urgent, including the mother's previously having had a cesarean sections, the "failure to progress," or a baby in breech position. And, finally, there are those surgeries coined elective cesareans.

The decision to have either an induction or a cesareans birth is highly personal, though the final choice of procedure often involves more than just the mother's personal wishes.

Brigitte, an expecting mother, was given the drug pitocin after her labor "stalled" at four hours. The medical team recommended a spinal, against her protests. Dealing with an on-call doctor in lieu of her regular OB/GYN, Brigitte gave in but quickly asked to be removed from the spinal hook-up because she couldn't feel herself push.

Within the hour of being off the pitocin and spinal, she gave birth to a healthy baby boy. In retrospect she said she felt pressured or "pushed" by the doctor, and was made to believe that "there simply wasn't enough time, and a c-section was looming."

On other occasions a cesarean is critical for the health and well-being of both the mother and the infant.

Jennifer, who was 34 when she became pregnant with her second son, had effaced (the membrane had thinned) on the upper side of the uterus. In addition, her son was in distress - there was meconium in the amniotic fluid and, despite her position, the baby's heart rate was decelerating on every contraction.

Due to similar complications, Jennifer had undergone a c-section with her first son, though she intended to have a vaginal birth after cesarean (VBAC) with her second. In light of her compromised uterus and the baby's distress, however, it was decided that a cesarean was the only way to birth her son and to save her life, since her uterus was in danger of rupturing.

There are several mitigating factors that figure into the rapid rise of cesarean sections, including:

Doctors' fear of lawsuits, or "defensive" cesareans;

Forced cesareans - (mothers being advised to have second and third-time cesareans, as well as undergoing cesareans for "failure to progress") when not otherwise medically indicated;

• A growing belief that c-sections are "safe";

• An increasing failure to support normal physiologic labor.

Throughout Block's book, doctors acknowledge that there exist pressure to perform c-sections to avoid malpractice suits, even when the procedure is not medically indicated. As one physician states: "You see the ultrasound and think maybe it's [the baby] too big, maybe we'll have shoulder dystocia, better do a cesarean. A lot of that is driven by fear of liability."

Over the last 10 years, the VBAC rate has fallen 67 percent, and studies indicate a 90 percent repeat cesarean rate in the United States. Women are having difficulty finding doctors who are willing to perform VBAC, even when it is medically indicated that a vaginal birth might be favorable.

It should be noted that a cesarean is considered major surgery, carrying substantial risk. Some of the most common concerns include maternal mortality (one in 2,500, as opposed to one in 10,000 for vaginal births), infection, the risk of blood clots and stroke.

As the situation becomes more complex, communication between women and their doctors must remain open. Experts suggest that expecting mothers write and assert a birthing plan. Two resources for this are can be found on-line at www.babyzone.com and http://childbirth.org.

The resources Childbirth Connection and Childbirth Solutions suggest that the mother, or the mother's partner, should not hesitate to ask doctors the following questions:

• "I don't understand what you're saying, please explain this to me."

• "What could happen to me or my baby if I do that? Or if I don't?"

• "What are my other options?"

• "What will happen if I choose to do nothing?"

The reasons for cesarean rates climbing can be attributed to a number of possible factors that may be legally centered, convenience-based and/or indicated by a lack of interest in the lengthy nature of physiological birth. More than ever, this crisis demonstrates a need for women and their partners to come to the fore and assert their rights, so they make sure they receive the birth they intended.

As history shows, there will always be cesarean sections performed out of necessity; the procedure has proven to be a remarkable tool for saving the lives of both mother and infant. The goal, after all, is to ensure that either procedure is driven by medical necessity and not by convenience or systemic fear.

achel Bravmann is a freelance writer living in Seattle. She can be reached c/o rtjameson@nwlink.com.

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