Sunday, May 15, 2011


It's hard to start a discussion about VBAC (vaginal birth after cesarean) until we've established what a cesarean section is and what it's for. So this post will be about c-sections specifically, and the next post will be about VBAC. This is a series of posts that are more "clinical" in nature than personal, but it's all from my own perspective, having been through both scenarios.

I'm not here to tell you that you shouldn't have a cesarean section, or that if you had one by choice, you did something wrong, or that if you had one that wasn't by choice, that you were in some way wronged. I'm not here to tell you that there is never a need for a c-section, or that all c-sections are bad, or that I wish c-sections never had to happen.

Indeed, thank G-d we have the medical knowledge to perform a c-section when necessary, because a necessary c-section is a routine, reasonably safe alternative to vaginal birth that can save the lives of both mother and child.

I do, however, believe that c-section is an overused procedure. A c-section is a sometimes-necessary abdominal surgery which requires the doctor to cut through layers of skin, fat, and muscle, rearrange internal organs, cut through the huge muscle that is the uterus, pull the baby out, and then close it all back up. It isn't a simple procedure like the removal of an ingrown toenail or unwanted mole. Major abdominal surgery carries risks to both mother and baby. The most common risk to the mother is post-surgical infection. Other risks for the mother include severe blood loss, reaction to anesthesia, and blood clots. Risks to the baby include lung or breathing problems and birth injury (such as being cut by the scalpel). Risks to the baby of a planned (scheduled) cesarean, as opposed to one that occurs during labor, also include premature delivery, which can carry many complications of its own. It should be noted that a planned cesarean does appear carry fewer risks to the mother than an emergency c-section.

There are also long-term risks of c-section, or multiple c-sections. These include increased risk of future placenta previa (where the placenta is blocking the cervix), future placenta accreta (where the placenta is too deeply attached in the uterine wall), uterine rupture, and risk of future emergency hysterectomy during birth. These risks increase exponentially with each additional c-section.

What Is A Cesarean Section?

A cesarean section is a surgery used to deliver a baby. Rather than a typical birth, during which the baby is pushed through the cervix and vaginal canal in order to leave the mother's body, in a cesarean section, a surgeon cuts through the mother's abdominal wall and into the uterus and removes the baby through this incision, then repairs the incision with sutures.

Here is an excellent photo essay with explanations showing a typical cesarean delivery. (Slightly graphic, although photos are small. If blood or depictions of surgeries disturb you, I don't recommend clicking.)

Basically, the surgeon cuts through the abdomen with a scalpel, makes an incision in the uterine wall, retracts (pulls back) the sides of the incision, suctions out the amniotic fluid, disengages the baby from the pelvis (if necessary), and delivers the baby head-first through the incision. When the head is out, the fluids are suctioned from the baby's mouth and nose to clear the lungs and airway, then the rest of the body is pulled free of the incision, the umbilical cord is cut, the baby is (usually) shown to the mother, then taken to the warmer to be cleaned and examined. The placenta is removed and examined to ensure it is intact. Then the uterus is sutured and the abdominal incision is closed up. The entire procedure typically takes about 45 to 60 minutes, with the first 5 to 10 minutes being delivery of the baby.

Depending on the practices of your particular doctor and hospital, it may be possible to hold your newborn on your chest during the second phase of the surgery, and even breastfeed him or her if desired. This would have to be discussed with the doctor prior to surgery.

When Is A C-Section Necessary?

**This is not a comprehensive list, just a sampling of instances when cesarean section is indicated.**

There are instances when a c-section is medically necessary. In such cases, it is determined that a vaginal delivery carries too much risk to mother and/or baby, and a c-section is a safer way to deliver the baby.

  • Placenta previa. This is when the placenta is blocking the cervix. Attempting to deliver vaginally under such a circumstance would cause severe maternal blood loss, often leading to maternal death.
  • Prolapsed cord. This is when the umbilical cord precedes the baby through the birth canal.
  • Fetal or maternal danger which requires immediate delivery of the baby when induction of labor fails or would be too dangerous. An example of this would be preeclampsia or eclampsia, which is a dangerous rise in maternal blood pressure that can cause seizures or stroke. Eclampsia is often fatal to the mother. If maternal blood pressure fails to come into a safe range within a reasonable amount of time, delivery of the baby immediately is indicated, as delivery of the baby is the only "cure" for preeclampsia/eclampsia. Medical induction may be attempted, but if it fails, cesarean delivery is necessary to protect both mother and baby.
  • True fetal distress during labor.
  • Abrupted placenta. This is when the placenta detatches from the uterine wall before delivery of the fetus.
Thus, there are times when a cesarean section is absolutely needed, clearly saves the life of mother and/or baby, and we can be grateful that such a relatively safe method of delivery exists when vaginal birth is not possible or indicated.

Why So Many C-Sections?

However, the rate of cesarean section in the United States now exceeds 30% of all births. It's hard to fathom that almost one-third of all pregnancies and births result in a life-or-death situation such as one listed above. If that were the case, we would be seeing mothers and babies in mortal danger during childbirth far more often than we do. Indeed, the maternal and neonatal mortality rates in this country are reasonably low. What are some reasons for cesarean section that may not be medically necessary? (In some of the following examples, the end result of c-section may actually have been necessary. However, they are not emergency situations, and usually there are or would have been ways to avoid c-section in these cases.)
  • Maternal preference. Some women just don't want to go through labor, so they request to schedule a c-section. This enables them (and their doctors) to know exactly when and how the baby will be born.
  • Previous c-section. Many doctors and hospitals do not allow VBAC, so a woman giving birth through a particular care provider may not be offered the option of VBAC. In such a case, she will be advised to schedule a c-section. Alternatively, a woman may feel that the risks of VBAC are not ones she is willing to face and so elects a c-section. Or, perhaps the difficult or traumatic labor which resulted in the previous c-section makes her unwilling to attempt labor again, and planned c-section seems to be a more palatable option for her. Finally, depending on the reason for her previous c-section, she and her doctor may feel that any future labor would also result in c-section, so rather than take the risk of needing an emergency c-section, or of going through labor only to result in a second c-section anyway, she elects a planned c-section. In addition, if a woman has had three or more previous cesarean births, VBAC is considered too risky. Also, VBAC is not considered safe if the previous c-section incision is not the "low transverse" or "bikini" incision.
  • Breech presentation. Breech presentation is when the baby is not head down at the end of the pregnancy or when the mother goes into labor. The preferred way to deliver a baby vaginally is head-first. Some babies do not turn around near the end of the pregnancy and present feet-first or buttocks-first at or near the onset of labor. Most OB/GYNs in the United States prefer not to attempt a vaginal delivery of a breech baby, and so they will recommend a scheduled c-section in order to ensure safe delivery of the baby. There are variations of breech presentation that would make vaginal delivery impossible or very dangerous to mother and/or baby, in which case, of course, a c-section is indicated.
  • Prolonged labor. Some women may labor for many hours or days. Sometimes this is because labor is not progressing as it should, the cervix is not dilating properly, or despite hours of pushing, the baby does not come down into and through the cervix even after full dilation. These cases are usually labeled "failure to progress," and the doctor or midwife may suggest a c-section to deliver the baby and relieve the mother. It is difficult to know from case-to-case whether a c-section was necessary, because it depends on the reason that labor is not progressing. However, often the mother, doctor, midwife, or other birth attendant can make changes that may help move labor along. I won't get into a long list here, but "failure to progress" is a vague term, and in order to determine whether c-section was medically necessary, one needs to know the reason for the stalled or prolonged labor.
  • Twins. It is possible to deliver twins vaginally, although most OB/GYNs and hospitals prefer to deliver twins via c-section. There are additional risks during vaginal delivery of twins that simply do not exist in the delivery of a single baby, so these risks need to be discussed with your doctor.
  • Large baby. Sometimes it is estimated that a baby is simply very large and the mother will have a very difficult time delivering him or her vaginally. This is not to say that a vaginal birth is definitely impossible with a large baby (plenty of women have delivered 10+-pound babies vaginally). However, if it looks like your baby is headed into the 10-pound or more range, your doctor may bring up the possibility or probability of scheduling a c-section.

I really want to stress that neither the first list, of universally indicated reasons for c-section, or the second list, c-sections that may not have been necessary, is comprehensive. Depending on your situation, you should discuss with your doctor or midwife your birth preferences and particular conditions before determining whether you should have a c-section. Obviously, during labor, especially during an emergency in labor, there isn't time for much discussion, so it is important to be fully informed of the risks and benefits of c-section in various cases before delivering your baby or going into labor.

Non-Medical Risks Of C-Section

C-section, especially unplanned or unwanted c-section, can result in feelings of failure on the part of the mother, i.e., Why couldn't I deliver naturally? Why did my body fail me? Why couldn't I make a perfect pregnancy? This can lead to postpartum depression and delayed bonding with the baby. C-section, depending on the environment or circumstances in which it was performed, can also delay initiation of breast-feeding, which carries its own set of risks for mother and baby.

In this blog, I am more concerned with the non-medical risks of c-section, although I do think it's important to know that, even though c-section is a routine medical procedure that is relatively safe, it is still major surgery that carries risks to both mother and baby that do not exist (or exist at a much lower rate) during a traditional vaginal birth.

Elective C-Section 

I want to expand on elective c-sections for a moment before signing off for tonight. Many women choose to schedule a c-section near their due dates despite having no medical reason to consider c-section. Perhaps they simply do not want to experience labor, or they want control over when their baby will be born. For many women who choose this route, they are very satisfied with the outcome, do not harbor negative feelings toward their chosen method of birth, and both mother and baby recover well and quickly.

My only concern in such cases is that c-section is, as described above, major abdominal surgery that does carry risk. If we look at c-section as elective surgery, we can discuss it in similar terms to something like gastric bypass. In most cases, or nearly all cases, gastric bypass is a "last resort" attempt to control obesity and its associated health problems. Typically, a person is not a candidate for gastric bypass unless all other weight control options have been eliminated and the person's health is in danger from obesity-related complications such as hypertension, diabetes, arthritis, etc. Gastric bypass carries risks that need to be weighed against the benefits of performing the surgery, and against the risks of not performing the surgery. Certainly, gastric bypass has helped many individuals lose weight and improve their quality of life and is a viable option when risks and benefits have been appropriately discussed.

I feel that c-section should be considered in the same way. It is a life-saving surgery that has helped many women and babies survive relatively unscathed a birth scenario that without c-section may have ended in tragedy. However, like any other surgery, c-section involves risks that must be weighed against (a) the benefits of having a c-section, and (b) the risks of attempting a vaginal birth. If both mother and doctor approach the topic of c-section in this way, a more productive discussion of birth options will result.

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