Cesarean section rates in the region of 30% are becoming the norm - is this appropriate?

Cesarean Section Rate - Summary

Cesarean section rates are rising and account for more than 30% of childbirths in the USA.

This rise can be attributed to:

• Relative safety of surgery with improvement in anesthesia, availability of blood transfusion and antibiotics.
• Greater emphasis on quality of offspring rather than quantity.
• Patient preference based on claimed benefits of planned caesarean section including greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience.

The potential disadvantages, include increased risk of major morbidity or mortality for the mother, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity.

The decision on optimum mode of delivery is the most commonly encountered question in clinical practice across all medical disciplines.

The number of factors to be taken into account is greater than in any other clinical situation across all medical disciplines.

There is undoubtedly a risk of litigation issue colouring obstetric decision making. An obstetrician is more likely to be subjected to litigation because a cesarean section was not performed or was perceived to have been performed too late than for complications of surgery. In the current climate, it is likely that cesarean sections are likely to continue rising.

Cesarean Section Rates are on the increase but many believe this trend should be reversed. what is the answer?

In the UK. between 2002-03 and 2003-04, the caesarean rate increased slightly from 22.0% to 22.7% - Government Statistical Service for the Department of Health A further 12% of deliveries are by forceps or ventouse and these figures are replicated across the "developed world".

At first sight it would seem remarkable that we should in effect be saying that "nature", which has kept the human race going for thousands of years, is so inept that surgical intervention is required for a third of confinements. Not surprisingly, many are questioning the validity of these interventions.

An article in the Daily Mail (November 2008) highlights the problem:

Samantha Shepherd had been in labour for three days when she was told by a doctor that her baby's life would be in danger if she didn't have a Caesarean section.

But the discussion was suddenly interrupted by the assistant anaesthetist, Nigel Baglin, who banged the door with his trolley and shouted: ' hell, why can't women in this hospital give birth naturally?'

Dr. Baglin defended his comments at a hearing, saying he'd simply been 'aghast' at the number of Caesareans being carried out at Newham University Hospital, East London.

Hospitals are 'fed up with too posh to push brigade' - but the wrong women may end up being targeted

Baglin was cleared of misconduct and his comments reflect a wider concern about Caesarean rates, with the Government and midwives determined to reduce numbers.

Why are we increasingly resorting to Cesarean Section?

Figure 1. The cesarean section rate in the UK has climbed above 20% in the UK and continues to rise by about 0.7% each year.

Figure 2. Source: U.S. National Center for Health Statistics

In December 2007, the National Center for Health Statistics released the preliminary U.S. national cesarean rate for 2006: 31.1%.

Cesarean section has become relatively safe over the last half century because of:-

• safer anaesthesia including regional blocks including epidurals and spinal blocks which can avoid general anaesthetic.
• availability of blood transfusion.
• antibiotics.

The two most common indications for cesarean section are

• delay in labour
• fetal distress

Delay in Labour

During normal vaginal delivery, the baby is expelled through the mother's pelvis. Human supremacy involves a compromise between the physical adaptations for bipedalism (walking on two legs) and encephalization (our brains are relatively large).⁰⁸⁰¹ The head is the largest part of a baby. As the human head is relatively large and women's pelvises are relatively small compared to all other species we commonly encounter "cephalo-pelvic disproportion" and this manifests itself by delay in labour.

Partograms allow provide a means to document progress in labour including the opening of the cervix (neck of the womb) and the descent of the baby into the maternal pelvis. When there is evidence that progess is slow then an oxytocin drip, which encourages the uterus to contract more and breaking the waters may be employed to expedite delivery. If progress remains slow then operative delivery will be indicated.

Fetal Distress

Until only the last two or three generations, couples had bigger families. This was influenced by primitive contraception and the survival rates of offspring was poor. In developed countries, we now have excellent contraception and the majority of babies will survive. Quality of offspring has become the prerequisite. As cesarean section has become safe, mothers are more than happy to be delivered operatively to reduce the chance of their baby being damaged.

Before the 1960's the condition of the baby during labour was assessed by checking the baby's heart rate intermittently with a fetal stethoscope - auscultation. Then technical advances led to our ability to monitor the fetal heart rate continuously - cardiotocography (CTG). Patterns of CTG abnormality became associated with possible fetal compromise and unless delivery is imminent, cesarean section is indicated. To reduce the number of cesarean sections, many obstetricians perform fetal blood sampling and if there is no evidence of increased acidity, then operative delivery might be avoidable. CTGs have undoubtedly contributed to a rise in cesarean section rates.⁰⁸⁰¹

The major concern with fetal distress is that it may lead to fetal demise or damage the baby and in particular the brain leading to cerebral palsy or reduced cerebral ability. There is extensive evidence that the majority of children born with these conditions do not develop them during labour. Correlations between degrees of  fetal distress or duration of fetal distress leading to morbidity are lacking. The author believes that It is possible that monitoring the fetal brain itself might shed light on this area but accurate technology has proven elusive to find.⁷⁹⁰²

Currently, we have no choice but to expedite delivery when there is reason to be believe that delay could cause problems.

Additional factors increasing cesarean rates.

• Too Posh To Push (see below)
• Previous cesarean section. In the USA it would seem that vaginal births after previous cesarean has fallen to almost nil although in the UK we try for vaginal delivery whenever possible. In every country, a previous cesarean increases the chance of a subsequent cesarean.
• Breech presentation. Cesarean section is safer than delivery.⁰⁰⁰¹
• Many premature births are more safely conducted by cesarean section.
• Women are delaying their families and older women are more prone to obstetric complications and more likely to require cesarean delivery^{9101, 9601}

Data from Canada in the Health Policy Research Bulletin (following graphs) demonstrates the complex dynamics behind recent fertility trends, including transformations in family structure.

There has been a reduction in number of children from 7 in 1871 to 1.5

Figure 3.

Women are delaying commencing their families. In one generation the peak age for first child has moved from 22 years to 28 (1976-1996).

Figure 4.

The peak age for starting a family in women with university education is 35 compared to 31 in those who have not attended university.

Figure 5.

Older mothers are more prone to pregnancy complications including high blood pressure and gestational diabetes.

These may contribute to cesarean rates rising.

Figure 6.

Fertility is reduced and miscarriage rates increase with age.

As women leave their childbearing to later than previous generations, they are more likely to encounter fertility difficulties and increased risk of miscarriage. Pregnancies in women who have had such difficulties are considered to be particularly precious and consequently the threshold for operative delivery is lowered.

Figure 7.

"Too Posh To Push"

Perhaps the most contentious indication for cesarean section is maternal request without obstetric indication.

The claimed benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience.

The potential disadvantages, include increased risk of major morbidity or mortality for the mother, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity.

Requests for elective caesarean section in an uncomplicated pregnancy are not uncommon. Performing a caesarean section when it is not clinically indicated has traditionally been considered inappropriate, but views have changed. Public opinion is increasingly veering towards women having a right to choose.⁰⁸⁰²

There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term.⁰⁶⁰²

What are the Risks of Cesarean section?

Every operation is associated with an element of risk.

Mortality is higher with cesarean section than vaginal delivery (relative risk 3.7). There are, however, confounding factors. Cesarean section, however, is more commonly performed when there are high risk factors such as severe hypertension or placenta praevia which may predispose to mortality.

Figure 8. Maternal Mortality in the UK 2000 - 2002 -  Department of Health Data.

Morbidity is also higher with cesarean section. Rehospitalizations in the first 30 days after giving birth is more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000).⁰⁷⁰² The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000).

The average initial hospital cost of a planned primary cesarean of US dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days).⁰⁷⁰²

There is 1% of a scar dehiscence (the scar gives way) in a subsequent pregnancy and a history of cesarean delivery increases the chance of cesarean section being required next time.

The baby is more likely to have breathing difficulties if delivered by cesarean section.

Informed Choice

It is essential that mothers should make an informed choice. In the UK, The National Institute for Health and Clinical Excellence (NICE)²⁰⁰⁴ recommends that the benefits and risks of cesarean compared with vaginal birth should be discussed. "Maternal request is not on its own an indication for CS and specific reaons for the request should be explored, discussed and recorded." 

The Royal College of Midwives is campaigning for normal births as well, under the banner: "Intervention and caesarean shouldn't be the first choice - they should be the last."^RCM

But choosing a Caesarean is not just a lifestyle issue, research suggests. C- sections are the preferred way of giving birth for many female doctors, possibly because they are aware of the risks of childbirth.

Scottish female obstetricians, when asked for their personal choice regarding delivery and showed that only 15.5% would choose elective caesarean section compared with 31% and 21% in two surveys of London female obstetricians.⁰²⁰¹

One argument offered as a reason for elective cesarean section is the protection of the pelvic floor. There is no doubt that vaginal delivery is a major factor in the later development of urinary stress incontinence. While a significant number of women's health care professionals are prepared to offer cesarean delivery to nulliparous women, informed choice seems to motivate the offer rather than a conviction that cesarean delivery will protect the pelvic floor.⁰⁵⁰¹

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