The Problem with Cesarean Sections

by Asheya on May 21, 2010


The advancement in medicine to the point where the cesarean section was developed is wonderful! Many moms have been saved, and many babies have been saved by this surgery. The problem with c-sections is not inherent in the surgery itself; it is in how we use it.
The problem with cesarean section birth is this: surgical birth is more risky than vaginal birth.

The risks associated with cesarean sections are low, as this surgery has been performed so many times as to allow physicians and surgeons to fine tune their surgical methods. However, the complication, death, and injury rates are HIGHER with surgical births than with vaginal births. Nature still knows best.

Complications of vaginal births exist. However, the risk of complications due to cesarean section surgery is higher. Statistics do not generally accurately reflect such complications as spinal anesthesia, breastfeeding problems as a direct result of anesthesia/mother-infant separation post op/fluid bolus in conjunction with spinal anesthesia/hemorrhage post op, psychological trauma, or anything which arises more than a few weeks after the surgery is performed. But statistics still show us that complication rates, maternal mortality and morbidity rates, and infant morbidity rates are higher with C-sections.

The most common complications arising from cesarean surgery are as follows.
Increased risks to women including:

  • death
  • hemorrhage
  • infection
  • hysterectomy
  • surgical mistakes [including injury of visceral organs by scalpel or other surgical instrument, most often to the intestines or bladder, and including retained surgical instruments or articles]
  • re-hospitalization
  • scar separation
  • placental problems
  • stillbirth in future pregnancies.

[ICAN media release July 2007]

Sometimes the infant is injured by the scalpel. Babies born by c-section also have higher risk of

  • prematurity
  • low birth weight
  • respiratory problems
  • cuts from surgery

[ICAN]

Risks for future pregnancies include:

  • higher incidence of ectopic pregnancies
  • increased risk of uterine rupture in future pregnancies
  • increased infertility rates
  • increased rates of placenta previa and placenta accretia
  • increased incidence of uterine rupture during labour and during the third trimester in subsequent pregnancies.

The Society of Obstetricians and Gynecologists of Canada endorses lowering the overall Canadian cesarean rate.  In 2006, Canada’s C-section rate was 26.3% [Society of Obstetricians and Gynecologists of Canada]. This means that over 1 in 4 babies in Canada were born by Cesarean Section. In 2007, The United States’ C-section rate was 31.1% [National Center for Health Statistics, CDC].

An article by the American Congress of Obstetricians and Gynecologists (ACOG) states:
“For a low-risk childbirth that is progressing normally, C-sections require substantially longer recovery times and present greater risks of complications such as infection, bleeding, scarring, chronic pelvic pain, and damage to the intestines or bladder. C-sections also increase the risks during subsequent pregnancies, making a repeat C-section more likely. In 2007, research by the Canadian Perinatal Surveillance System found that elective C-sections have higher risks of anesthetic complications, major infections, obstetrical wound, and cardiac arrest. The study also notes that women who had an elective C-section were more likely to require an immediate hysterectomy due to bleeding. ”

The problem is not with Cesarean Sections themselves. The problem is in our OVERUSE of surgery to birth our babies.

One way to reduce C-section rates, which few seem to be advocating, is a more positive attitude towards trial of labour for repeat cesareans. Vaginal Birth After Cesareans (VBACs) have a 60%-80% success rate. The success rate for women trying to give birth vaginally with NO history of previous surgery is 73.7% in Canada. If the VBAC rate is 60%%-80%, I would say any VBAC has just about the same chance of delivering vaginally as a woman who ISN’T a VBAC. So why don’t we try?

This question has a complex answer. Baisically, there are two reasons that are most often given for NOT encouraging VBACs. One, there is an increased incidence of uterine rupture at the scar. Two, a woman who had ‘failure to progress’ or ‘Cephalo-pelvic disproportion’ is cited as likely to have it again in future labours, so to save her the grief of trying and failing again, and to save the medical system from unscheduled surgery (which is more costly and inconvenient from a medical standpoint), a repeat cesarean is recommended and surgery is scheduled.

Well, first of all there is an increased incidence of VBAC uterine rupture in the third trimester.

So, if we are going to advise women not to have VBACs because of an increase in rupture rates [women who have not had uterine surgery have a rupture rate of 0.01%. Those who have had c-sections have a rupture rate of 0.4%, which is a significant increase!], we should also advise them not to have any more pregnancies.  This is not logical nor fair.

Second of all, the chance that a woman’s uterus will rupture is low.  It is higher with VBAC than with normal vaginal birth, but it is still considered a rare event, just as serious cesarean complication rates are rare.

The second reason cited for advising against VBACs is that failure to progress or CPD will repeat itself. This is unproven statistically. Regardless of the reason for the first cesarean, the VBAC success rate is still 60%-80%.

Most women these days have 2 babies. This means that 13.15% of cesarean sections performed in Canada are repeat, elective sections (conjecture on my part). If we allowed all of those 13.15% of women to trial labour instead of scheduling their repeat sections, we could automatically reduce that number by 60% to 80%. I pulled out my calculator:
If 60% of women were successful at VBAC, our section rate would drop to 18.41%
If 80% of women were successful at VBAC, our section rate would drop to 15.78%

Other things we can do to reduce c-section rates? Normalize midwifery (my midwife’s c-section rate in 2008 was a mere 3%…though high risk deliveries are referred OUT of midwifery care and thus affect the intervention rates, low risk deliveries by general practitioner physicians are still in the 25% to 30% range, pointing towards midwives as the better way to go if the goal is a reduction in surgical rates). Discourage routine continuous external fetal monitoring for low risk deliveries.  Encourage the usage of doulas (intervention rates are automatically reduced when a doula is present). Encourage upright, mobile labour, upright delivery positions, and water births. Never leave a woman in labour and her husband or partner alone unless the woman is confident and requests privacy. Never invade the privacy of a woman in labour without her express consent, since birth is a parasympathetic nervous system function which functions best with as relaxed and calm a state as possible. Any fight or flight fear response will suppress this natural parasympathetic process. I think being left alone in early labour creates more fear than any other routine procedure in birthing. Fear taps into the fight or flight, sympathetic nervous system response, which automatically slows or stalls the rest/regeneration/reproduction, parasympathetic nervous system response. Failure to progress can result. Inability to push out a baby can result. Piddly labour can result.

Privacy, yes. Isolation, no.

But I think fundamentally at fault is our cultural belief that birth is dangerous, and that womens’ bodies are unable to give birth. Somehow, birth seems impossible. Many women believe their bodies are broken, or weak, or too small, or incapable…these fears are normal when we are pregnant, but they are untrue. Unfounded. If we believed in women’s ability to give birth, and if we believed that birth was difficult but beautiful and valuable in and of itself much like other feats of physical strength and endurance, perhaps we would be able to lower those rates of surgical birth.
Not perhaps.
Certainly.

World Health Organization Maternal Health
International Cesarean Awareness Network, Canada and U.S.
BC College of Midwives
Society of Obstetricians and Gynecologists of Canada
Dr. Sears Pregnancy and Childbirth
Dr. Rixa Freeze Pregnancy and Birth Blog
Birth and Feminism by The Feminist Breeder

{ 5 comments… read them below or add one }

Anonymous February 27, 2012 at 12:27 pm

I appreciate your intent behind this article- to educate and inform women.
But it is dangerous to explain one side of the story and completely ignore the other side.
If your aim is to ensure that women make informed decisions, don't you think you need to provide them with full information first?

You are not wrong in asserting that c sections are risky. But you are misleading the reader by your subtle assumption that a vaginal birth is risk free merely by virtue of being natural.

Here are the risks associated with vaginal birth for the baby-
1. Brachial plexus nerve palsy
2. Cerebral palsy
3. Brain heamorrheage
4. Spinal cord injuries
5. Intracranial heamorrheage
6. Shoulder dystocia which can cause the shoulder blades to fracture
7. Asphyxia and hypoxia which may cause brain damage and strokes

Here are the risks to mothers with a vaginal birth-
1. Severe perineal tearing, which requires a long recovery period
2. Incontinence (anal and urinary)
3. Uterine prolapse
4. Rectocele and cystocele
5. Recto-vaginal or colorectal fistulas
6. Pelvic floor dysfunction
7. In extremely rare cases, the need for a temporary or permanent colostomy
8. Vaginal laxity
9. Sexual dysfunction
10. Infection at the site of the episiotomy or perineal tear.
11. PPH is just as likely

A lot of the above conditions can deeply impact a woman's career, marriage, health and self confidence. They may also require major surgery to correct.

Women may have been giving birth without c sections for millennia, but not without complications and a fair share of morbidity and mortality. Despite your assertions to the contrary, birth is a risky process. It has the potential to cause both injury and death- that does translate to risky I'm afraid even if it shatters your illusions. In the 1700s the maternal mortality rate was almost 35%.

I am in no way implying that all women must have c sections. I am merely pointing out that the expectant mother alone has the right to decide how she wants to give birth- be it a home birth, a water birth, a hospital birth, a medicated birth or an elective c section.
Your suggestion that a trail of labour should become compulsory for women with previous c sections is patronising and paternalistic. Some women may not want to take the risk of uterine rupture and prefer the risks associated with a c section. You have no right to make that decision for anyone.

I'll also have you know that the WHO recently admitted that the 15% recommended c section rate is NOT based on exhaustive research. They have advised every hospital to form it's own targets based on individual demographics and requirements.

Reply

melissa v. March 15, 2012 at 11:18 pm

Thank you for taking the time to comment. This post was originally written in 2008, before the World Health Organization rescinded the recommendation that cesarean rates be below 10%, and republished here in 2010, before the change was widespread knowledge.
If you read our website as a whole, you may find a more balanced representation of our view on risk and birth than you find in this article, although I would like to refer you to this quote: "The risks associated with cesarean sections are low, as this surgery has been performed so many times as to allow physicians and surgeons to fine tune their surgical methods" this is from the above article and clearly states that cesarean section is safe.
We support women's right to informed choice. Often women are not supported in choosing VBAC and indeed are in some regions banned from doing so altogether. If this post seems to lean very far in the direction of supporting VBAC and vaginal birth, this is likely because it pushes back against the medical norm which is biased in favour of ERCS.
If you read the post again, you will see that in reference to VBAC rates, we encourage "Routine trial of labour," NOT as you stated "Compulsory trial of labour." Women should not be compelled to do anything, and suggesting that this is our position indicates your lack of familiarity with our organization's values, mission, and activities. The routine recommendation of VBAC by care providers would indeed reduce the cesarean section rate, but does not suggest women be encouraged to VBAC when clearly contraindicated. One of these contraindications is in fact when women refuse VBAC and choose ERCS. These contraindications can be found on the SOGC website, here http://www.sogc.org/guidelines/public/155E-CPG-February2005.pdf
Also, your assertion that in the above post we show a "subtle assumption that a vaginal birth is risk free merely by virtue of being natural" is incorrect. As clearly stated in the above article:
"Complications of vaginal births exist." These complications are not the topic of this particular post, and are acknowledged elsewhere on this site.

I challenge your assertion that birth in the 1700s had a maternal mortality rate of 35%. All over the world? In every country? Across all socio-economic classes? In every birth place? (You also don't reference this statement). Birth related mortality rates vary wildly around the world and between classes. The maternal mortality rate in Darfur, for example (as stated by the WHO) is 1 in 7. In Canada, the maternal mortality rate is 12 per 100,000 births. Do you think that access to cesarean section is the only factor influencing the distance between those two statistics? Are not poverty, nutritional status, access to water, the presence of trained birth attendants, and the status of women in a society also of consideration?

If something has the potential to cause both injury and death is it automatically risky? If so, then having a bath is risky. Sitting on your lawn is risky. Being alive is risky. Relative risk is important to consider when discussing inherent risk in birth, and a look at statistical data shows that relative to vaginal birth, cesarean birth holds more risk. Slightly higher, and rare risk. But more.

Where an individual's threshold of 'safe' lies is variable, and it seems that yours puts birth in the category of 'risky,' while ours puts birth in the category of 'safe.' Regardless, the statistics say that the vaginal birth complications you list are rare, and the cesarean complications we list are slightly less rare. We believe that scaring women into believing birth to be riskier than it is interferes in the natural process of labour, disempowers women, and leads to iatrogenic dystocia, distress, and interventions. Increasing women's confidence and access to a variety of choices with regards to birth counterbalances this.

Thank you again for your comment.

Reply

Anonymous March 20, 2012 at 9:54 am

Yes, you stated that a vaginal birth is risky. But did you take the trouble to actually list those risks like I did? For that matter did you mention the risks associated with a VBAC?
How exactly are women supposed to make an informed decision when you only list one side of the risks? You talk about VBAC, but not once do you even mention how catastrophic a uterine rupture during labour can be.
Obviously you are not suggesting that women attempt a VBAC when contraindicated. However, to suggest that a trial of labour become 'routine', to me seems to imply that you don't think women should get to choose a repeat cesarean if they prefer the risks associated with it as compared to those of a VBAC. Did it occur to you that some women may not want a VBAC and may prefer the option of a CS?
For the record, I fully support a woman's right to choose VBAC, as long as it's an informed decision and as long as women also have the right to choose repeat CS. Neither option should be denied or forced.

As per your request, this is where I got my statistics from-
http://en.wikipedia.org/wiki/Maternal_death

I never stated that the maternal mortality rate is currently 35-40%. However, the above link clearly states that in the 1700s and 1800s, in certain institutions across the world the maternal mortality rate climbed to 40%.

Contrary to your assumption, not all the risks of a VB are rare. Different studies will show different numbers, but birth injuries to mum and baby during a vaginal birth are not uncommon and neither are post partum complications.

You cannot deny that childbirth has the potential to cause injury, complications and in rare cases death. To some people that translates to 'risky', to you it may not. It doesn't make either one of us wrong does it?

Some women (like you) view childbirth as inherently safe, while others (like me) view it as inherently risky. There is place for both of us in world! It isn't fair to campaign against anyone else's valid choices, while fighting passionately for your own. That amounts to hypocrisy.

Reply

melissa v. April 14, 2012 at 11:45 am

The point of this article was to propose a part of the solution to rising cesarean rates. A rarely acknowledged factor in cesarean rates is the elective repeat cesareans that women are by and large encouraged by their care providers to have.
If the point of this article was to fully inform women regarding VBAC, we would have failed. But in fact we were exploring the option that if it were standard to encourage VBACs rather than discourage them, rates of successful VBAC would increase and rates of maternal mortality and morbidity would decrease. Rates of mortality for infants is the same, but morbidity is slightly higher with cesarean birth (cochrane review, SOGC) and includes respiratory distress and decreased immune system functioning. Also decreased breastfeeding rates which affects health outcomes for babies and for women.

Also, citing Wikipedia is not generally accepted in academic circles. Wikipedia is a good source for images, definitions, and general information, but not academic citation. There are several problems with the assertion that maternal mortality rates were in the 35 to 40% range in the 1700s. Primary amongst these are the dearth of surviving records. Secondary would be that medicine in the 1700s was not institutionalized or standardized and care practices and outcomes therefore varied widely. Birth was not generally considered a medical event in the 1700s and was almost entirely attended by midwives at home. Many midwives, though skilled, were illiterate and as a result did not keep records. One such record exists that I am aware of, and that is Martha Ballard's midwifery records. She was a midwife in the 1700s in the U.S. She attended nearly 2000 births and had a 1% maternal mortality rate. A pulished copy of her records is avaliable on Amazon http://www.amazon.ca/Midwifes-Tale-Martha-Ballard-1785-1812/dp/0679733760/ref=sr_1_1?ie=UTF8&qid=1334426527&sr=8-1 and makes fascinating reading.

Apart from that, some records survived from 'lying in' hospitals in the U.S. These facilities were designed to service the poor and destitute, often had multiple parturient women per bed, and served a population that was fraught with poverty, poor nutrition, and frequently prostitution which resulted in overall poor maternal health. Bacteria and viruses had not yet been discovered and handwashing by physicians was negligent, which spread puepurial fever like wildfire in these lying in facilities. These facilities often had maternal mortality rates of 40% or higher. But they were not representative of overall rates amongst the general population. This information is available in the NY library which has a section on medical history from that area, and in journalist Tina Cassidy's book "Birth: The Surprising History of How We Are Born."

Reply

melissa v. April 14, 2012 at 11:46 am

As for your assertion that our statement that the risks of vaginal birth are rare is an assumption, I can only point you to scientific practice regarding statistical analysis. Data is collected and rates are determined and placed in a "per thousand" category. Per thousand rates for vaginal AND cesarean complications are both considered scientifically 'rare' in Canada by definition.
For example, prolapsed cord events happen at a rate of 6 per 1000 births. This is an obstetrical emergency requiring an immediate cesarean, because the neonatal mortality rate with vaginal birth and prolapsed cord is 17%.
Similarly, uterine rupture rates for one prior cesarean with transverse cut are 4 in 1000. 0.5 per 1000 will be catastrophic uterine rupture.
6 and 4 and 0.5 per 1000 are scientifically categorized as 'rare.' Risks of vaginal birth ARE rare. And with an evidence based approach to maternity care and a midwifery model of care, vaginal birth injuries can be even rarer in Canada than they currently are, since birth injuries are commonly preventable.

It is not hypocritical to write an article that endorses increased support for VBAC amongst medical personnel, and especially by primary care physicians to their clients who are pregnant after a prior cesarean. These are the frontline suppliers of birth information to Canadian women, and they lean heavily in favour of elective repeat cesareans, even going so far as to refuse to care for a woman who desires a VBAC in some cases. This is unethical and unsound. And THIS was the focus of our article.

Once again, if you read other articles on our site regarding cesarean birth and VBAC, you will see a more thorough look at safety. In particular this article http://www.mothersofchange.com/2010/10/having-safe-vbac-vaginal-birth-after.html looks at ways to increase your safety with VBAC, which inherently acknowledges risk therein.

It is not hypocritical to advocate for increased VBAC rates in Canada, no matter how much you may disagree. Scientific data shows that VBAC has good success rates (66 to 98%, with an average rate of approximately 75%, varying according to care provider and reason for the initial cesarean). It also shows that birth injury rates are slightly higher with cesareans and that the maternal mortality rate is five times higher with elective repeat cesarean than with VBAC.

Mothers of Change consider both options to be safe, based on scientific data available through the Cochrane Review and the World Health Organization, but that women should be encouraged to VBAC more often. There is a vast difference between encouragement and compulsion, which I addressed in my previous reply to your previous comment.

You may not agree with us, but we firmly advocate higher VBAC rates in this country because we believe that this would improve maternal health overall, and neonatal outcomes overall. We also advocate for empowering women to make their own health choices, which is evident in every article we post.

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