Pros and Cons of Cesarean on Demand Debated

Peggy Peck

May 02, 2003

May 1, 2003 (New Orleans) -- Perinatologists and urogynecologists disagree widely about the risks and benefits of cesarean section on demand, but all obstetricians should be prepared to "counsel increasing numbers of women who show up in our offices demanding cesarean delivery," said Edward R. Yeomans, MD, professor in the Department of Obstetrics and Gynecology at the University of Texas in Houston.

Dr. Yeomans moderated a debate on the issue here at the 51st annual meeting of the American College of Obstetricians and Gynecologists. This is the second year that ACOG has devoted a scientific session to the cesarean section on demand controversy.

Dr. Yeomans noted that the cesarean section rate in Chile is 40% and in Brazil it is 75%, "so there is little doubt that this approach is used fairly rampantly by our South American colleagues, but it is not clear if this is because of fear of sexual dysfunction or if it is driven by the physician. What is clear is that there is a burden on us to be even-handed in discussing facts with patients."

He noted, for example, that "there seems to be a good deal of talk about the risks of VBAC [vaginal birth after cesarean], but I don't hear much about the risks of repeat cesarean section."

Peter K. Sand, MD, professor of obstetrics and gynecology and director of the continence center, division of urogynecology and reconstructive pelvic surgery at Northwestern University Medical School in Chicago, Illinois, seconded Dr. Yeomans' advice. Although Dr. Sand spoke in favor of cesarean delivery on demand, he said, "No country could develop policy that would promote repeat cesarean delivery for women who have more than two children."

But while accepting that caution, Dr. Sand said that there is little doubt that vaginal delivery -- even a single vaginal delivery -- is associated with increased risk for both urinary and anal incontinence, as well as increased risk for pelvic prolapse.

Dr. Sand compared vaginal delivery to "rolling a bowling ball through the vagina" and he said several studies indicate that vaginal delivery can create permanent myofascial and muscle changes and well as neurological difficulties with the most common being damage to the pudendal never. Moreover, he said that while most damage is short term, a significant number of women -- perhaps as many as a third of women who deliver vaginally -- will have long-term pelvic floor damage.

Carl Weiner, MD, professor of obstetrics, gynecology and reproductive sciences at the University of Maryland in Baltimore, opposed the concept of on-demand cesarean section because, he said, the procedure increases morbidity and mortality for "both the mother and the fetus."

Cesarean section dramatically increases the risk of hemorrhage, Dr. Weiner said, "although the risk is greater in emergent cesarean sections rather than planned cesarean deliveries." But even in elective procedures he said the "anemia rate is emergency cesarean section the relative risk for mortality is 1.7, but look at the relative risk of mortality in elective cesarean sections, it is around 1.4, although the numbers continue to change and we've seen a range of 0.2 to 2.0, but cesarean sections are operative and operative is going to add risk."

Moreover, Dr. Weiner said that after cesarean delivery women have increased risk for ectopic pregnancy, hysterectomy, and future placental complications.

In addition, cesarean delivery is associated with increased risk for transitory tachypnea, "which increases the child's risk for subsequent admissions for respiratory problems," he said.

Dr. Weiner suggested that cesarean section demand is driven by fear of labor and that intensive counseling with pregnant women can allay many of these fears. But one study in which that strategy was employed required obstetricians to have four 45-minute counseling sessions with women who also had a 45 minute session with a nurse midwife. He admitted that "few busy obstetricians have this kind of time."

Nonetheless, assuring women of the universal availability of epidural anesthesia could significantly undermine fear as a driver of cesarean section demand, Dr. Weiner said.

While Drs. Weiner and Sand did not settle the on-going cesarean delivery debate, both agreed that more studies are needed.

ACOG 51st Annual Clinical Meeting: 6th Scientific Session, Obstetrical Controversies II, A Debate: Cesarean Section on Demand -- Can You Have It Your Way? Presented April 29, 2003.

Reviewed by Gary D. Vogin, MD



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