Will I Have a C-Section?

What If I Have a C-Section?
by Rita Rubin

An award-winning health writer answers all the questions a pregnant mom may have about this increasingly performed procedure-now used in nearly one in every four births

Thirty years ago, 1 in 20 babies was born by a C-Section. Today that number has swelled to almost 1 in 4. Yet despite the steep rise in C-Sections, there are very few books available to help moms-to-be sort out their options, allay their fears, and navigate their way through this serious and emotionally complex procedure.

With this book, Rita Rubin, a USA Today medical reporter, tells women:

   • The main reason Cesareans are performed
   • Exactly what the procedure entails
   • How to communicate with their doctors to insure the birth experience they want
   • Strategies that will help them recover from the surgery quickly and relatively painlessly
   • How to decide whether to have an elective C-Section and how to cope should surgery be medically necessary
   • How to sort out the controversy about VBAC (Vaginal Birth After C-Section)

Whether the reader is considering choosing an elective C-Section, worrying about what she will face should she need one, or recovering in the days after her delivery, she'll find the facts in this unbiased, authoritative, reassuring guide-along with steps she can take to make the birth of her child the healthiest, most joyous occasion possible.

A look at some of the common
medical reasons for C-Sections

Annie, 35, took a Lamaze class to prepare for the birth of her first child, now 6 months old. She doesn't remember learning anything about C-sections, but maybe that's because she, like most pregnant women, never expected to have one. "I was so focused on the fact that I was going to have a natural childbirth and on strategies for dealing with that: breathing exercises, stretching."

But when she arrived at the hospital to be induced, her doctor discovered that her son wasn't head-down in her uterus—the optimal position for delivery. He was in the breech position, and these days, few doctors are willing to deliver a breech baby vaginally. "My doctor really danced around it for a minute," Annie recalls. "I think he was very afraid of my reaction."

Her doctor explained that it might be possible for him to turn the baby head-down for a vaginal delivery, but the thought made her squeamish—so she resigned herself to having a cesarean. "It was not a hard decision, but I was a little bit bummed at first. I looked at giving birth as sort of a challenge. When they told me it was going to be a C-section, they were kind of taking that away from me."

Annie quickly got used to the idea that she was not going to deliver vaginally. "I was very proud that I was relaxed about the entire thing. I figured people have had babies for years. All of my friends have had babies. It's going to be a life-altering experience. The worst thing I could do was to make myself a nervous wreck."

Annie is part of a growing trend in the United States, and chances are higher than ever that you will be, too. Cesarean delivery is the most common major surgical procedure among U.S. women of reproductive age. In fact, it's one of the most common major surgical procedures in the United States, period.

In 2002, 261 out of every 1,000 babies born in the United States were delivered by C-section — the highest rate ever, although not nearly as high as in Brazil and some other Latin American countries. If the trend continues, half of all U.S. babies could be delivered by cesarean by the time your grandchildren are born (if not sooner). Some observers think cesareans have already become too common — that perhaps as many as half of them are unnecessary. The World Health Organization, for example, says that no more than 150 out of every 1,000 babies should be delivered by C-section. Others think that trying to reduce the number of cesareans is unnecessary, if not foolhardy. "Setting a target rate is an authoritarian approach to health care delivery," Harvard OB/GYNs Fredric Frigoletto Zeus and Benjamin Sachs wrote in 1999 in The New England Journal of Medicine.

Looking Back ... Abdominal deliveries are mentioned in ancient Hindu, Egyptian, Greek, and Roman folklore and in the Talmud. In fact, Greek mythology provides several examples of gods from Zeus onward delivering babies through their mothers' bellies.

Although experts aren't sure what the optimal cesarean delivery rate is, they know it shouldn't be zero. Clearly, C-sections can preserve the health of mothers and babies and sometimes even save their lives. Doctors are virtually in agreement that certain situations require a cesarean delivery, although these cases represent only a small proportion of all C-sections. If you're diagnosed with any of the following, you can pretty much count on having a C-section:

• Breech presentation. A baby who, like Annie's son, isn't head-down in your pelvis

• Cephalopelvic disproportion. A baby whose head is deemed to big to fit through your pelvis

• Placenta previa. A baby whose exit through the birth canal is blocked by the placenta

But you'll be happy to know that these three conditions aren't very common. Only about three or four out of every 100 babies isn't head-down at the time of delivery. True cephalopelvic disproportion happens mainly in the rare woman who is not just petite, but has an abnormally small pelvis—perhaps because of an injury suffered in an automobile accident. And placenta previa occurs in only about one out of every 200 births.

Other reasons for planned cesareans include severe high blood pressure, herpes, and multiple babies; but research suggests that most women with these conditions deliver vaginally. Now you're beginning to enter the wide gray zone of C-section land. They don't call medicine an art for nothing. In the majority of cases, you could present two doctors with the same pregnant woman, and one might recommend a cesarean while the other holds out for a vaginal delivery. And a third doctor might have a tough time deciding who's right.

Sometimes, medical judgment isn't the only factor at play here. Some doctors (as well as many of their patients) perceive cesareans to be less risky than vaginal deliveries for babies and mothers. They believe that if you have a C-section, you'll be less likely to sue them for malpractice. OB/GYNs are among the specialists most likely to get sued, according to malpractice insurance industry data, so you can't blame them for practicing defensive medicine.

It's those gray-area cases that account for the most dramatic variations in C-section rates among doctors and hospitals. You can see these variations even among doctors practicing at the same hospital, as well as at different hospitals in the same city. For example, in Pennsylvania hospitals, the 1999 rates for women considered at low risk for a C-section—basically, first-time moms whose babies were full-term and head-down—ranged from about 8/2 percent to 28 percent. In other words, if you'd delivered in 1999 at the Pennsylvania hospital with the highest cesarean rate rather than the lowest (and there's no reason to think the situation was any different in other states), you would have more than tripled your chance of having a C-section. If you don't have an obvious reason for a planned cesarean, such as a baby who's lying sideways, is there any way to predict you're going to end up with one anyway? Unfortunately, no, although researchers are hunting for clues. Most C-sections are still performed after hours of labor. But researchers at the University of Colorado Health Sciences Center recently uncovered five possible signs of a likely C-section that your doctor can assess within the first couple of hours after you're admitted to the hospital in labor:

   • Preeclampsia (also called toxemia)
   • How much your cervix dilates in those first 2 hours
   • Your weight
   • How far along you are in your pregnancy
   • How far down your baby is in your pelvis

If you and another woman were nearly the same as far as the other four factors, but you had preeclampsia and she didn't, you'd be nearly six times more likely than she would to have a C-section. If you and this hypothetical other woman were the same except that she didn't dilate as much as you did during those first 2 hours in the hospital, she'd be four times more likely to have a cesarean. And if you were the same except for the fact that you weigh ed 25 pounds more than she did, you'd be 172 times more likely to wind up in the O.R.

Now, this was only one study—and a retrospective one at that (in other words, it looked at women who had already deliver ed) . The challenge will be to see if the five clues really can predict the chance of a C-section in laboring women. If so, doctors someday might be able to use them to help patients decide whether they should continue aiming for a vaginal delivery.

MIDLIFE MOTHERHOOD:
WHAT'S AGE GOT TO DO WITH IT?

If you're trying to figure out your chances of having a C-section, look in your wallet. If you have a health insurance card, research shows that you're more likely to deliver by cesarean than a woman who's uninsured or covered by Medicaid, the state/federal program for low-income Americans. And your driver's license yields more information than all those diplomas hanging in your obstetrician's office—that is, if you were honest about your age and weight when you applied for your license!

If you were over your ideal weight before you conceived, or you gained more than 40 pounds while pregnant, you're more likely to deliver by cesarean. Those extra pounds raise your risk of developing diabetes or high blood pressure, which in turn increases your chance of having a C-section. Even if you avoid those complications, it's important to remember that the more weight you gain, the bigger your baby might be — and bigger babies tend to be harder to push out. Studies by researchers at the National Institutes of Health and elsewhere also suggest that the heavier you are, the longer your labor might be.

And even if you're a rail, simply being closer to your 40th than your 30th birthday raises your chance of delivering by cesarean, especially if it's your first baby. If you're one of those so-called "mature" pregnant women (don't you love those terms?) preparing to deliver your first baby, you're in good company. Growing numbers of women who delayed childbearing because of graduate school, career advancement, infertility, or late and second marriages are now tossing hair dye along with diapers into their shopping carts. Just look at these numbers from the National Center for Health Statistics, part of the federal Centers for Disease Control and Prevention:

• In 2002, birth rates for women age 35 to 39 and age 40 to 44 were the highest in more than 30 years—41 births per 1,000 women and 8 per 1,000 women, respectively.

• From 1990 to 2002, the number of babies born to women age 40 to 44 nearly doubled—from 48,607 to 95,788.

• The birth rate for women age 45 to 49 has been stable since 2000, but the actual number of births to women in this age group more than quadrupled between 1984 and 2002. That's because there are more of these women — thanks to the baby boomer bulge — and they're more likely to give birth, partly because of infertility treatments.

The majority of pregnant women over 35, or even over 40, de liver healthy babies. But there's no getting around the fact that the older you are, the more likely you are to deliver your baby by C-section. For example, Harvard researchers found that 43 percent of first-time mothers age 40 and older who delivered at Boston's Brigham and Women's Hospital in 1998 had cesareans, compared to only 12 percent of those under 35. One reason for that disparity is pretty simple: The older you get, the more likely you are to experience pregnancy complications that predispose you to a cesarean. They include:

   • Multiples (often a result of infertility treatments)
   • Breech babies
   • Illnesses such as diabetes and high blood pressure

But even if you don't have any of the above risk factors, you should be aware that simply being a first-time mother who's at least 35 years old increases your chance of having a C-section. Part of that may be physiological; part of it may be cultural. A San Francisco study of 8,500 first-time moms who delivered full-term, head-down babies found that the older they were, the longer they labored. Their cervixes dilated more slowly, and it took longer for them to push their babies out. Not surprisingly, then, the older they were, the more likely they were to receive oxytoc in (frequently referred to by one of its brand names, Pitocin) to ramp up their labor. But it's not like your uterus suddenly heads south when you hit 35. Here's a cheery thought: The study found that the chance that your uterus has lost its oomph actually begins to increase when you're in your early 20s — long before you begin to entertain thoughts of Botox or bifocals.

Even if you're as healthy as a horse and your uterus is chugging along just fine, your age might st ill mean the difference between a C-section and a vaginal delivery. Perhaps you've spent many years and many thousands of dollars in your quest for motherhood. It's understandable that you — and your doctor — might be a little more anxious about your baby's safety than if you were 10 or 15 years younger. This condition has been dubbed "precious baby" or "premium baby" syndrome, and it can lead to a lower threshold for performing C-sections. In other words, if there's even the slightest suggestion that your baby is in trouble during labor, your doctor would resort to a cesarean faster than with a younger patient who could easily get pregnant again. You might find this line of thinking perfectly logical, or you might not. But however you feel about it, you should discuss your feelings with your doctor well in advance of your due date. No matter what your age, remember that you're not destined to have your labors tall or your doctor choose a C-section without your knowledge or consent.

Talking Point

If you're expecting your first child at age 35 or older, ask your doctor whether he might be quicker to perform a C-section on you than on a younger patient, all other factors being equal.

FEET (OR BOTTOM) FIRST:
WHEN BABY IS BREECH

Babies in the womb have better moves than any contortionist you'd see at the circus. In their first 36 weeks, they take advantage of their relatively roomy quarters and change position frequently. Three or four weeks before they're due to exit, though, they usually settle into a head-down position. By that time, space is getting pretty tight, so they're unlikely to change position.

But about three or four babies out of every 100 prefer not to be upside down, making a vaginal delivery tricky, although not necessarily impossible. Most doctors have become leery of delivering breech babies vaginally, due to liability concerns, so vaginal delivery of these babies is rapidly becoming a lost art. In 2001, 86 percent of their moms gave birth via C -section.

Sometimes babies' buttocks are the lowest part of their body, with their legs extended straight up in front of them (talk about contortionists!). This is called a frank breech presentation, and it's the main position (other than head-down) that some doctors are willing to deliver vaginally. Sometimes babies are sitting cross-legged, although their buttocks are still the lowest part of their body. This is called a complete breech, and vaginal delivery is still possible. Sometimes babies' knees or feet are closest to the birth canal, a position called footling breech, which virtually always requires delivery by C-section. And sometimes babies are side ways, the transverselie position, which requires a cesarean.

There's a reason babies are normally born head-first. Think about it: The head is by far the biggest part of baby's body. It stretches mom's cervix, allowing the rest of his body to slide through fairly easily. If his feet or rear end come out first, it gets more difficult to guide the baby's head out. In addition, there's a higher risk of the umbilical cord slipping through the cervix and into the birth canal before the baby exits—a serious condition called a prolapsed cord. This can stop the flow of blood through the cord. Several factors further increase the risk of complications in breech babies delivered vaginally.

© 2004 by Rita Rubin. All rights reserved. No Part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any other information storage and retrieval system, without the written permission of the publisher.

About the Author

Rita Rubin is a prize-winning health journalist and the woman's health reporter at USA Today. Formerly a medical reporter for U.S. News & World Report, Rubin has written for Health, Ladies' Home Journal, The Journal of General Internal Medicine, and Reader's Digest, among many other medical and lay publications.