Cesarean Awareness Month: April 2009

Once again, it's April, Cesarean Awareness Month 2009. Every year the CDC announces the latest statistics; every year for the past fifteen at least, the percentage of births via cesarean has gone up.

So, what's the big deal? What difference does it make which way a baby comes out, as long as it does? Vaginal birth, cesarean birth-- it's all the same, isn't it? After all, a healthy baby is all that matters...

More than thirty percent of pregnancies in the United States now end in surgical delivery. Estimates vary, but at least half of these operations-- probably many more than half, in truth-- are of questionable necessity, and a huge number of those are outright unnecessary. When truly indicated cesarean surgery can, of course, be a lifesaving procedure for mothers and infants; however, it is clear that the majority of cesareans today are performed for nonemergent reasons.

One simple fact that cannot be argued is this: a cesarean, no matter how we dress it up and make it palatable for general consumption, is major abdominal surgery, with all its attendant risks. A mother undergoing a cesarean is four times more likely to die as a woman who delivers vaginally. Morbidities are inarguably higher: risk of infection, significant blood loss (sometimes requiring transfusion, which introduces another level of risk in and of itself), damage to bladder and bowel, blood clots, adhesions. Post-op moms face longer recovery times, lingering pain, even long-term or permanent nerve damage. Anesthesia-- even that "harmless" epidural society embraces as the savior of laboring women-- adds another tier of risk, one that is rarely addressed by physicians.

Women are almost never informed about the risks to future pregnancies, but there are many, and they are not benign. Uterine rupture, used so often by physicians to frighten mothers into scheduling repeat sections, is a potential complication-- probably the best publicized, if not the most common. Abnormal placentation, secondary infertility, stillbirth-- all are sharply increased after surgical delivery.

Cesareans, despite what apologists would have us believe, are not without risk to babies, either. Mechanical injury-- scalpel wounds, nerve and soft tissue damage from less-than-gentle extractions-- are more common than one might think. Elective sections, touted as "mother's choice" and "humane" by proponents, are often scheduled for 37-38 weeks' gestation-- technically term, at least by the obstetrician's reckoning, but babies can't read calendars, and surgeons frequently fail to account for the diversity of women's menstrual cycles and ovulation times. The lungs are the last organs to mature; when an infant is forced from her cozy womb at 7:34 a.m. (first scheduled section of the day; after all, the OB wants to be done in the operating room by 11 so he can get back to the office for more lucrative appointments) on a Tuesday, she may simply not be physically ready to part from the umbilical cord and placenta and transition to air breather. Respiratory distress is common-- disturbingly so-- in cesarean-born babies; many suffer transient tachypnea of the newborn, often referred to as "wet lungs." For many babies this translates into several days of labored breathing that resolves with time and may eventually manifest later in life as asthma. For too many others, it means a stay in the neonatal intensive care unit with assisted ventilation, IV lines, antibiotics, ultrasounds and chest x-rays, brain scans, eye exams, and unexpected complications such as NEC (necrotizing enterocolitis)-- a disease that still claims the lives of too many babies every year. This is certainly not a situation most parents envision when consulting their schedules to choose their little ones' birthdays, but it's one that is played out all too often.

The emotional cost of cesareans cannot be underestimated either. Women in late pregnancy are primed by their hormones to react, on a subconscious, emotional, or "gut" level, a certain way to labor, birth, and the early postpartum experience. This is to insure that our primal mammalian selves will receive and nurture the newborn-- simple biology at work. Often, that chemical cascade is interrupted, throwing bonding off track and making it difficult for mothers to transition fully to their new role. Cesarean mothers may be at higher risk for postpartum depression and are less likely to breastfeed their newborns. There are many reasons for this: the post-op mom is tired, hurting, hampered by an abdominal incision. She can't get around easily-- forget jumping up at her baby's first cry. Even a tiny infant starts to weigh a ton when she's resting on a fresh surgical wound. Breastfeeding is awkward and hard to manage when mom can't change positions easily and without significant pain. Let's face it: surgery is a lousy way to begin motherhood!

If asked, the majority of mothers who choose cesarean deliveries will respond that they are most concerned with providing a safe birth for their children. They cannot be faulted for this conviction: the medical establishment and the media are responsible for convincing the public that c-sections are safe and even preferable to vaginal birth. The serious potential for permanent injury-- or even death-- during and after the surgery is rarely mentioned. The cesarean is presented as an easy, convenient, scientific, controlled alternative to the inherently messy, unpredictable way designed by nature.

Convenience is a huge driving factor in the rising cesarean rate. Obstetricians prefer cesareans for many reasons, not the least of which is their ability to exercise some control over nature by making birth conform to the physicians' schedules. It is not cost-effective to attend a woman in labor; birth happens at all times of the day and night, every day of the week, heedless of holidays, vacations, special occasions, even plain exhaustion. Cesareans, on the other hand, can be timed quite specifically without creating conflict for the OB: all he has to do us appear at the appointed hour, scrub in, and be presented with the neatly draped and sterilized belly of the pregnant mother. Forty-five minutes later, the surgeon strips off gown and gloves, pauses to dictate or jot a delivery summary in the patient's chart, and is back on his way to his office, where a waiting room full of paying customers sit patiently for their fifteen-minute time
slots for check-ups or consults.

Parents like the convenience as well. Scheduling surgery means that family can be on hand at the prescribed time, employers can be informed and leave arranged-- down to the minute!-- well in advance. Mothers need not worry about how much longer their pregnancies will last, instead focusing on the matter of preparing for their new arrivals. Dad can be certain his job will accomodate his time off; grandma can be right there to scoop up her precious new grandchild; care can be arranged for siblings without any middle-of-the-night drama or panicked phone calls. All that stress eliminated-- sounds ideal. Why not schedule a cesarean? It just makes sense.

Except...

Regardless of what ACOG, a trade union dedicated to furthering and protecting the interests of its members, and the popular media insist, cesarean surgery is simply not the optimal way for a baby to be born. Vaginal birth is infinitely more complex than purple-pushing an inert lump through one's "bottom" to produce a squalling newborn. It is a complicated, carefully calculated dance, choreographed down to one's very cells, perfected over millenia to provide human infants their very best start in life. No manmade intervention, no matter how well-intentioned (for the mother or the physician), can replicate the delicate and profound forces that combine to bring a child into the world. It is sheer arrogance for surgeons to assert that they can match, much less surpass, a process millions of years in the making.

Fortunately, there are those who recognize this folly, and are fighting to be heard above the rhetoric and misinformation. There is support for mothers trying to recover from cesareans, for mothers wanting to avoid them, for women planning a birth after a cesarean-- whether that's a vaginal birth or a more empowered surgical delivery. I want to add my voice to theirs, to speak my truth: Birth is Life, and we were designed to live it.