When Is a C-Section the Best Delivery Option?

From the WebMD Archives

Oct. 19, 2000 -- Though many experts say the U.S. rate of cesarean deliveries, or C-sections, is too high, a growing number of women are actually choosing to have their babies this way, either because they fear the pain and possible complications of a vaginal delivery or because they want to be able to choose their delivery date.

Now there's a new twist to the vaginal-vs.-C-section debate. A recently published study shows that cesarean deliveries are far safer for babies who are in the breech position (positioned in the birth canal with the feet or rear end pointing down).

Approximately 22% of all U.S. births are by cesarean delivery, but government experts say that figure should be closer to 15%. C-sections are typically meant to be used only in cases of complications that threaten the life of the mother or the baby.

Although many women are now opting for C-sections even when there's no medical reason, some experts argue that elective C-sections are too costly, and that women who get them have more complications -- including life-threatening ones -- and are more likely to be rehospitalized after giving birth. Studies suggest that women lose about twice as much blood during a C-section as with a vaginal delivery, and some women have reactions to the anesthesia or develop infections.

Still, some doctors think it's time to give women a choice.

"It's a matter of what women want," says Mary Wilson, MD, a New York obstetrician who says she often sees women who have relatives or friends who have had difficult vaginal deliveries and, as a result, have a prolapsed -- or sagging -- uterus or permanent rectal injury. More C-sections also are being done these days for large babies. Still another group of women who may prefer C-sections are those who have had a previous cesarean. The current medical thinking is that such women should try to deliver vaginally, but not all of them want to because of a slightly higher risk of uterine rupture.

"If she is afraid of that, if she doesn't want to take any risks whatsoever, I will go with a second C-section. But most women go with a [vaginal delivery]," Wilson says.

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According to Wilson, a marked change is under way in medical attitudes toward cesareans. As evidence, she points to comments made by W. Benson Harer Jr., MD, president of the American College of Obstetrics and Gynecology, that the final decision on a C-section should be left to the woman. Wilson says doctors have a responsibility to make sure women have all the facts and says she will counsel a woman against a C-section if she feels it is unnecessary or not a good choice. But, she says, if women have a good reason for wanting a cesarean, doctors should not be so quick to overrule their decision.

More evidence that women are choosing cesareans comes from a London study showing that one-third of female obstetricians would choose a C-section for themselves, even if there was no medical indication for one. In Brazil, the C-section rate is estimated to be as high as 60% in the general population and 90% among the most affluent women.

Breech birth is one medical indication for C-section, but not everyone agrees that it is the best way to proceed. Some obstetricians may try to turn a breech baby from the outside in a technique known as ECV, then have the woman deliver the baby vaginally. This, however, does not work in all cases.

Tom Howard, MD, a practicing specialist in complicated pregnancies in Fort Worth, Texas, says ECV has "gone in and out of fashion," over the last 15 years or so but remains a popular choice with some doctors and patients.

But a study just published in the journal The Lancet may change the minds of some doctors who still perform vaginal deliveries for full-term breech babies, study author Mary Hannah, MD, tells WebMD.

In the study of more than 2,000 women with babies in the breech position, who were randomly assigned to a planned delivery either vaginally or by C-section, the stillbirth and newborn death rate for C-section babies was three times lower. The C-section babies also had fewer serious illnesses as newborns. The results were so much better with cesarean sections, in fact, that the study was stopped early.

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"The finding of much better outcomes in the planned cesarean group ... would suggest that even with experienced people [performing vaginal deliveries], planned cesarean is still better," says Hannah, of Sunnybrook and Women's College Health Sciences Center at the University of Toronto.

She says that, ultimately, the decision regarding C-sections for breech birth will be up to the mother and her obstetrician. But based on the new study, she says, doctors now have clear evidence to turn to when helping women make the decision.

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