What are the current controversies surrounding cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Further investigation continues to evaluate which patients should undergo a trial of labor after having a cesarean delivery. Many variables play a role in this discussion and have not been clarified. The NIH held a consensus conference in March 2010 to further discuss the trend in rates of vaginal birth after cesarean delivery (VBAC; see the image below). [121]  

Go to Vaginal Birth After Cesarean Delivery for complete information on this topic.

Vaginal birth after cesarean delivery rates. Vaginal birth after cesarean delivery rates.

Increased implementation of VBAC is part of a larger movement towards decreasing the cesarean delivery rate in the United States. Recently ACOG, and SMFM issued joint guidelines providing a framework for individual organizations and key players at the state and federal level to work with local hospitals to set the agenda to decrease the rate of primary cesarean deliveries. Decreasing the rate of primary cesarean deliveries will result in a decreased number of repeat cesarean deliveries.

A large prospective randomized study is needed to look at single-layer versus double-layer closure and risk of future uterine rupture when a trial of labor is attempted after previous low-transverse cesarean section.

The recommendation that all breech presentations should be delivered by a cesarean delivery is currently a subject of active debate. Additional information is required to address this issue in the setting of appropriately trained physicians and under well-established guidelines.

Urogynecologists suggest that all women should consider outright cesarean delivery to prevent pelvic floor dysfunction. This is an extremely controversial area that continues to receive attention, particularly in that short-term outcomes do not appear to relate to long-term outcomes. [122] Genetic factors appear to play an important role in long-term outcomes, which overshadows the effects that laboring and delivery itself have on short-term outcomes.

Cesarean delivery on maternal request (CDMR) also continues to be an area of debate. A survey of participants in the 2006 state-of-the-science conference revealed that most obstetrician/gynecologists believe that a woman has the right to CDMR, but fewer agree to perform the procedure than they did in 2006. In general, obstetricians/gynecologists associate more risks with cesarean delivery and attribute fewer benefits to it. [123]

Finally, more research evaluating the link between cesarean birth and obesity (in those born by cesarean section) will be needed. A recent article, (Yuan, Gaskins, Blaine et al, 2016) associated cesarean birth with increased risk of obesity later in life. The authors successfully addressed some of the shortcomings of previous studies that analyzed the issue, especially the effects of pre-pregnancy BMI. However, they also acknowledge that more research is needed to strengthen this relationship as well as to evaluate its generalizability to minorities and the strength of the relationship between cesarean birth, obesity and increased risk of advanced cardiometabolic outcomes in these individuals. [124, 125]  Another study by Cai et al that included data from 727 infants reported that elective cesarean delivery was associated with high body mass index–for–age z score at 12 months. [126]

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