Issues to consider

Elective Caesarean birth is a controversial topic. Those in favor of it say that a woman has a right to choose how she wants to deliver her child. Those against it say that the risks of Caesarean birth outweigh any potential benefits. A verdict based on medical evidence hasn't been reached because the procedure hasn't been studied enough.

Because the procedure is controversial, you might find that health care providers' opinions on this subject are quite varied. Some may be willing to consider it. Others may not, believing that an elective Caesarean birth may be harmful and therefore against their pledge to do no harm.

You may wish to talk to your health care provider about an elective Caesarean birth if you've had difficulty with labor and delivery in the past. Be sure to discuss all of the risks and benefits with your health care provider. He or she can assess your medical history, the state of your pregnancy and the most current medical information.

The best way to make a decision — especially on a controversial issue — is to be as informed as possible about both sides of the issue. Learn the advantages and disadvantages of elective Caesarean birth. If possible, talk to other women who have had Caesarean births. Find someone who has had an elective Caesarean birth because a woman's experience of an emergency

Caesarean birth may not be similar to that of a woman who has had an elective procedure. Also talk to women who have had vaginal births. Then work with your health care provider to make the best decision for you and your child.

Potential risks of elective Caesarean birth

Some say that with advances in surgical techniques, elective Caesarean births are virtually as safe as vaginal deliveries. Others argue that they still carry the risk of more complications than do vaginal births.

Some of the possible risks of elective Caesarean birth for you include:

• Maternal death. Death as a result of pregnancy or labor is rare, whether you have a vaginal or Caesarean birth. But Caesarean birth may carry more than twice the risk of vaginal birth, although the rate of Caesarean-related maternal death has been decreasing over the last decade. Some studies now call even this rate into question, suggesting that it may be equal to or lower than the risk associated with vaginal birth. In addition, a planned Caesarean birth has a lower death rate than an emergency Caesarean.

• Long-term risks. Women who have had a previous Caesarean birth are at an increased risk of placental problems in subsequent pregnancies. This may complicate later pregnancies. It may lead to removal of your uterus (hysterectomy) and even death. A previous Caesarean birth may also increase your risk of uterine rupture, especially if you decide to try a vaginal birth after Caesarean birth (VBAC). Multiple pregnancies tend to increase the risk of complications with each successive pregnancy. Multiple Caesarean births increase your risk even more.

• Operative risks. Because Caesarean birth is a major surgery, it carries higher risks of infection, blood loss and injury. Blood loss during a Caesarean birth can be twice that associated with a vaginal birth. About 3 percent of the time, the mother needs a blood transfusion after a Caesarean birth.

The medications used during surgery, including those used for anesthesia, can sometimes cause unexpected responses, such as breathing problems. Most planned Caesareans are done with spinal or epidural anesthesia, which numbs your body from the chest down. Another option is general anesthesia, which causes you to be unconscious. Use of general anesthesia can sometimes lead to pneumonia, and it poses a small risk of you vomiting and breathing the vomit into your lungs. However, general anesthesia is usually used only in emergency situations, when the baby needs to be delivered as quickly as possible.

After delivery, women who had a Caesarean birth are more likely to have an infection of the mucous membrane lining the uterus (endometritis) or a blood clot. Some studies suggest that women who undergo Caesarean birth may be more likely to end up back in the hospital after childbirth.

• Decreased ability to breast-feed after delivery. Within the first few hours after delivery, you may not be able to breast-feed or do much with your child. But this is temporary. You'll have plenty of time to feed and bond with your child when you've recovered.

In addition to the risks listed here, Caesarean birth has the added drawback of being generally more expensive than a vaginal delivery. You may wish to check with your insurance company to see if it covers elective Caesarean births.

Some of the possible risks of a Caesarean birth for your baby include:

• Premature birth. If the gestational age of your baby hasn't been estimated correctly, your baby may be delivered a week or two prematurely. This can lead to breathing difficulties, low birth weight and other problems.

• Transient tachypnea. One of the more common risks to a baby after a Caesarean birth is a mild respiratory difficulty called transient tachypnea. This condition occurs when the baby's lungs are too wet. While your baby is in the uterus, his or her lungs are normally filled with fluid. During a vaginal birth, movement through the birth canal naturally squeezes the baby's chest and pushes the fluid out of the lungs. During a Caesarean birth, the squeezing effect isn't present, so your baby's lungs may still contain fluid after birth. This results in rapid breathing and usually requires additional oxygen delivered under pressure to get the fluid out. The condition usually goes away within a few hours or days.

• Effects of anesthesia. Occasionally, anesthesia-induced low blood pressure (hypotension) in the mother may cause decreased oxygen delivery to the baby, resulting in increased acidity in the baby's blood. This condition is usually temporary. With general anesthesia, some of the medication reaches the baby, which can result in depression in the baby's breathing. If necessary, the baby can be given medications to counteract the effects of the anesthesia.

• Cuts. Rarely, a baby may be cut during a Caesarean birth.

• Future risk of stillbirth.

Potential benefits of elective Caesarean birth

Some of the possible benefits for you that may come with an elective Caesarean birth include:

• Potential protection of your pelvic muscles. During a vaginal birth, the effort of pushing your baby out may weaken or damage pelvic muscles or cause injury to pelvic nerves. The resulting damage can lead to urinary or fecal incontinence. Less commonly, it may lead to pelvic organ prolapse, a condition where organs such as your bladder protrude into the vaginal canal.

Usually, urinary incontinence caused by pregnancy and labor goes away within three months. But some women have permanent damage.

At times, signs and symptoms of weakened pelvic muscles may not show up until years after childbirth. Factors that may increase your risk of pelvic muscle injury include a surgical incision to widen the vaginal opening for birth (episiotomy), large tears during labor and a forceps or vacuum-assisted delivery.

Having a Caesarean birth doesn't guarantee that you won't have incontinence problems. The weight of the baby during pregnancy also may weaken your pelvic muscles. Even women who have never had babies sometimes develop incontinence problems.

A 2003 study of more than 15,000 women found that 10 percent of women who had never had children reported signs and symptoms of incontinence during their lives. This rate increased to 16 percent of women who had all Caesarean deliveries and 21 percent of women who had all vaginal deliveries. Results for women with elective and nonelective Caesarean births were similar. When looking at women age 50 to 64, there was no difference in the rate of incontinence between women who had vaginal deliveries and those women who had Caesarean deliveries.

Women may use Kegel exercises during and after pregnancy to try to strengthen their pelvic muscles and prevent incontinence problems.

• Avoidance of emergency Caesarean birth. An emergency Caesarean birth, which is often conducted after a difficult labor that hasn't progressed, has higher risks than both an elective Caesarean and a vaginal birth.

• Avoidance of difficult labor. A difficult labor may lead to forceps or vacuum-assisted delivery. These methods usually don't pose a problem. But instrument-assisted deliveries that fail are associated with a higher risk of infant injuries.

• Greater ease in scheduling. Scheduling a Caesarean birth may allow you to be better prepared for childbirth. Scheduling may also ease demands on your medical caregiving team, helping to prevent fatigue and inadequate staff levels.

Some of the reduced risks to your baby may include:

• Fewer childbirth problems. A planned Caesarean birth may reduce certain rare childbirth problems. It may reduce labor-related infant death, shoulder dystocia, birth injury, which is a particular concern for high-risk women who have large babies, and breathing in of meconium, which occurs when a baby inhales fecal waste during childbirth. The events of labor also carry a very small risk of cerebral palsy.

• Reduced risk of infectious disease transmission. With elective Caesarean birth, there may be a reduction in mother-to-child transmission of infectious diseases such as the AIDS virus, hepatitis B, hepatitis C, herpes and human papillomavirus.

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