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Elective Cesarean Sections: Choosing Not to Labor
If you could choose to have a cesarean section without even trying to labor, would you?

While many pregnant mums investigate ways to have the most “natural” childbirth experience they can, there is a growing contingent that would opt for an elective cesarean section if given the chance. Some women fear the pain and uncertainty of labor and childbirth and would rather skip the process entirely. Some believe that cesarean sections will be the safest option for their babies. Others worry about potential long-term consequences of a vaginal birth such as painful or unsatisfactory sexual relations, difficulties with urination or defecation, or prolapse (displacement) of pelvic tissues.

Years ago, it would have been difficult to convince most doctors to perform a cesarean delivery without a compelling medical reason. Cesarean sections are surgeries, and like all surgeries, have their risks. In some countries, however, elective cesareans are fairly common. In Brazil, for example, the cesarean section rate is over 50%, with some private hospitals performing cesarean sections on over 80% of first-time mothers. Recently, The American College of Obstetrics and Gynecology issued a statement concluding that doctors should have the ethical right to offer a cesarean section as an alternative to a vaginal delivery. Furthermore, a study from the United Kingdom revealed that one third of women physicians would choose to have their own babies by cesarean section.

While avoiding a vaginal delivery may be an attractive option to some, it is worth reviewing some of the factors that should be considered in making this decision.

Cesarean births are associated with higher rates of hemorrhage, urinary tract injury and infection than vaginal deliveries. Women who have had cesarean sections have risks of complications in subsequent pregnancies including higher rates of unexplained stillbirth, placenta previa (placenta positioned over the cervix), and uterine rupture. There may be increased rates of ectopic pregnancies and spontaneous miscarriage following a cesarean, as well.

Recovery from a cesarean section can involve a longer hospital stay, and will usually require a longer recuperation. As with vaginal deliveries, some women have difficulties with urinating and with bowel function. The cesarean scar can be painful or irritating for weeks or even months, interfering with breastfeeding and caring for a newborn infant.

While cesarean sections are thought to be safe for babies, there are some risks associated with these deliveries, too. Babies born by cesarean sections have a higher risk of short-term respiratory problems; newborn lungs may benefit from the process of being squeezed through the birth canal. There is also a small risk of laceration from the surgery itself, and of prematurity, when cesareans are inadvertently performed before 37 weeks of gestation.

One of the most compelling arguments in favor of a cesarean delivery is to prevent damage to the pelvic tissues. Difficult vaginal births may result in injury to the vagina and surrounding structures, resulting in long-term difficulties with urination and/or rectal function. These problems may be more common with use of forceps or vacuum assistance, or with forced, early pushing in the second stage of labor.

To date, we have no studies comparing the long-term effects of women having elective cesarean births with women having uncomplicated, spontaneous vaginal deliveries. And, while the data suggests having a cesarean section may protect women from bladder and bowel incontinence later in life, we don’t know this for sure.

While the medical arguments in favor or against elective cesarean birth can be debated, qualitative issues remain for us to consider on a more personal level. Birth is a profound, natural process that is deeply rooted in our biology and psychology. In the last century, women have made efforts to reclaim and embrace this human experience, fighting for greater autonomy in the delivery room, the involvement of friends and family in the birthing process and the reduction of unnecessary medical interventions. I have seen women profoundly connect to their bodies and their families through labor and birth. Childbirth can have powerful psychological and spiritual effects, and allows women to recognize their innate strengths and extraordinary biologic capacity to create life. I worry about the psychological impact on mothers and on our society when we routinely view birth as a surgical procedure rather than a profound life experience.

I would argue that rather than urging cesarean sections to become a routine choice, we should continue to study ways to enable vaginal births to be as healthy, comfortable and safe as possible. Cesarean sections do have an important role to play in modern obstetrics; however, I believe they should be performed selectively in response to medical indications.

Laura E. Stachel M.D. Obstetrician & Gynecologist