Sunday, January 11, 2009

Cesarean Births: Too Early?

A USA Today article, "Elective C-sections performed too early 36% of the time", reporting on a recent study published in the New England Journal of Medicine, begins with this startling information:
"More than a third of elective C-sections are performed too early, increasing newborns' risk of respiratory distress and other problems, researchers report today."
Full-term is now defined as 37-41 weeks (used to be full-term was considered 38-42 weeks), and although the American College of Obstetricians and Gynecologists (ACOG) recommend that elective cesareans are performed no earlier than 39 weeks gestation, the study results found that 36% of the time, ceseareans are performed before 39 weeks.

Highlights from the article include this statement about the difference between baby-initiated labor and induced labor/cesarean birth:
"At 37 weeks, babies are considered fullterm, but there's a difference between those delivered vaginally and by elective C-section, says coauthor John Thorp, professor of obstetrics and gynecology at the University of North Carolina, Chapel Hill. "We would not worry about a 37 1/2-week baby born vaginally with the onset of labor," Thorp says. In that case, 'there is some signal from a baby to his mother that says, "I'm ready …"'".
People mature - physically and emotionally - at very different rates. Think of the range for puberty... some girls start menstruating at age nine, and others at fourteen. Both situations are within the normal range, and indicate that particular body's readiness for puberty. I was one of the fourteen year olds; my body was no where near puberty or womanhood at age nine. Of course, we can't induce menstruation on young girls - who would want to?

But ask a woman when she's nine months pregnant if, uninformed of any risks, she might want to birth her baby a few weeks early. She just might be inclined to jump at the chance to meet her baby and end the last, frequently uncomfortable, stage of pregnancy.

What are the risks? Well, the USA Today article explains that
"Overall, about 10% of the babies at birth had at least one of these problems: respiratory distress, low blood sugar, infection or need for a respirator or intensive care. Those born at 37 weeks were twice as likely and those born at 38 weeks 50% more likely to have a problem than those at 39."
Are most women informed about these risks when their cesarean birth is scheduled? I doubt it.

Also, note that this article discusses "elective" cesarean births. Just to clarify, so this post does not add to the myth that many women are choosing elective cesarean births, the vast, vast majority of "elective" cesarean births are not a mother's first choice. In the Listening to Mothers II study, only one mother in 1500 indicated that a cesarean was her personal birth choice while many others (25%) indicated that they felt pressure from their care providers to "choose" a cesarean. Read Childbirth Connections interesting article, "Why the National U.S. C-Section Rate is Rising" for more information.

What's the best way to minimize the risk of performing a cesarean birth too early? If possible, don't schedule it! Wait until labor begins, and then go to the hospital for the cesarean birth. In many "elective" cesarean births, this method should be without additional risks: for a twin birth, or a breech birth, or birth after a previous cesarean (though for all of these situations, a trained care provider can frequently have just as safe or safer outcomes with a vaginal birth). There are, of course, other situations when this "contractions before cesarean" method would not be safe, for example, if the placenta covers part or all of the cervix (placenta previa).

Does waiting until labor sound inconveniant? There could certainly be inconveniances with this strategy, of waiting for labor to begin and then going in for surgery: the inconveniance of waiting; the inconveniance of not knowing when labor will start; the possible discomfort/inconveniance of going into labor; inconveniance for the doctor's schedule. But balance those inconveniances with the increased risk of a NICU stay... short- or long-term medical problems... the emotional roller coaster... the larger possibility of immediate and prolonged separation.

Add future safety to the list too: ICAN reports that women who went into labor on their own before a Cesarean birth were less likely have a uterine rupture during a subsequent VBAC. The study, published in Obstetrics and Gynecology found that
"Women with a history of either spontaneous labor or vaginal birth had one rupture for every 460 deliveries, compared with one rupture in 95 among women without this history who also required induction for their trial of labor."
For more information about the risks of Cesarean births versus the risks of vaginal births, as well as several links on this topic, visit one of my earlier posts: "In the News: Where is Birth Going & Who is Taking it There?" Additional, very complete and scholarly information is available on ICAN's webpage "Fighting the VBAC-Lash: Critiquing Current Research".

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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