Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?

Peter S. Bernstein, MD, MPH

Disclosures

September 16, 2002

Recently, a movement has begun to gather momentum that argues in favor of a pregnant woman's right to choose to deliver by cesarean instead of undergoing a trial of labor. Supporters of this position argue that the safety of modern cesarean delivery has reached a point such that it is time to reevaluate its merits compared with the risks of a trial of labor -- both for the mother and fetus. Proponents cite in particular a survey of female obstetricians in England in which a third reported that if they had an uncomplicated singleton pregnancy at term, given the choice, they would opt for a cesarean delivery.[1] This position may be gaining additional support among physicians for medico-legal reasons, as doctors are more frequently being sued for failure to perform a cesarean rather than for performing one.

One argument often cited in favor of elective cesarean delivery is prevention of pelvic floor damage, which can occur with vaginal delivery. Stress urinary incontinence, pelvic organ prolapse, and anal incontinence have been associated with vaginal delivery. But these adverse side effects may be more the result of how current obstetrics manages the second stage of labor. Use of episiotomy and forceps has been demonstrated to be associated with anal incontinence in numerous studies. Perhaps also vaginal delivery in the dorsal lithotomy position with encouragement from birth attendants to shorten the second stage with the Valsalva maneuver, as is commonly practiced in developed countries, contributes significantly to the problem.

Nonetheless, the prevention of pelvic floor injury by routine elective cesarean delivery is not an appropriate solution. Rather, more research into the management of the second stage of labor is clearly necessary. Moreover, cesarean delivery does not guarantee protection against pelvic floor dysfunction, given reports of similar rates of urinary incontinence in nulliparous women as in parous women.[2]

A potentially more persuasive argument in favor of elective cesarean delivery is based on the potential for fetal risks before and during vaginal delivery, including intrapartum death, intrapartum acquired hypoxic ischemic encephalopathy, and stillbirth at term before the onset of labor. What is not clear, however, is how many cesareans would have to be performed to avert these disastrous events and what the cost would be in terms of maternal morbidity and mortality in order to prevent a single untoward fetal outcome. To suggest that performing an elective cesarean delivery in a low-risk patient will avert intrapartum fetal injury is very misleading. These outcomes are rare, even in higher-risk women. Indeed, they are so rare in women without any identifiable risk factors that an absurd number of cesarean deliveries would need to be performed to avert even 1 of these poor outcomes. Thus, resorting to cesarean delivery would not be appropriate standard procedure. Instead, it is clear that the tools we have to identify which pregnancies are at risk need to be improved, as reviews of cases of women whose pregnancies ended with these complications often reveal that many had factors that put them at risk for these outcomes, such as medical diseases or fetal growth restriction.

Although cesarean delivery has clearly become safer over the past 50 years with advances in antibiotics, anesthesia, and thromboprophylaxis, it is still not without risks. Women undergoing cesarean delivery have greater blood loss and risk of damage to internal organs. The mortality risk of undergoing an elective cesarean delivery with no emergency present has recently been reported as almost 3 times the risk of a vaginal delivery.[3] In addition, risks to the fetus associated with cesarean delivery range from lacerations to respiratory distress syndrome and transient tachypnea of the newborn. Although these are typically manageable, their cost will be multiplied many times over if more elective cesareans are performed.

One of the most significant risks of cesarean delivery is the need for a subsequent cesarean delivery. We can safely assume that most women who would opt for an elective primary cesarean delivery would not choose to undergo a trial of labor in a subsequent pregnancy. A repeat cesarean delivery carries significantly more risk in terms of placenta previa, placenta accreta, uterine rupture, injury to internal organs during surgery, excessive blood loss, need for hysterectomy, and maternal death. These risks rise with each subsequent repeat cesarean delivery. Risk of accreta and previa increases with each subsequent cesarean delivery, reaching a risk of > 60% in women with 4 or more cesarean deliveries.[4] In addition, the incidence of emergency peripartum hysterectomy for abnormal placentation seems to be rising as a result of the increasing rates of cesarean delivery.[5]

A move toward routine elective cesarean delivery may also have significant costs in terms of lost opportunities for bonding between the mother and newborn. A woman who has had a cesarean delivery may be less able to care for her child and may have a more difficult time breastfeeding as a result of discomfort from her surgery. Although this impact may be small for the individual patient, again, its costs multiplied over a large population may be great, based on the accumulating evidence for the benefits of successful long-term breastfeeding.

Arguments made by proponents of elective cesarean delivery that it should only be provided to women who intend to have only 1 or 2 children fall flat, given that the rates of unintended pregnancy in the United States approach 50%. And what of the woman who changes her mind 10 years later and chooses to have another child after having had 2 prior cesareans? There may be no legal liability to the physician who performed the patient's first cesarean section when the patient winds up with a hysterectomy or worse, but that does not clear that physician of responsibility for performing a surgical procedure of unclear benefits upon a patient's request.

Some argue that, from an ethical point of view, allowing a patient to choose to deliver by cesarean is not substantially different from allowing her to choose to undergo cosmetic surgery. But cesarean delivery is very different. The benefits of elective cesarean delivery relative to vaginal delivery are not established, and the risks are substantial, especially given the potential for future repeat cesareans. Other elective surgeries are usually meant to be 1-time events.

That women are seeking elective cesarean deliveries is probably more significant in that it indicates failures of modern medicine and society at large in the sense that women may fear the experience of labor, and birth attendants may fear the legal risks of allowing appropriate women to have a trial of labor. Modern management of labor should be reassessed to address the concerns raised by proponents of elective cesarean delivery. If elective cesarean delivery becomes an acceptable alternative, we may never be able to undo the practice.

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