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Risks of caesereans
The risks of cesarean section may be divided into immediate or short-term risks, long-term risks or the risks of accumulating cesareans, and risks affecting future pregnancies and births.
Short-term risks can include:
· Pain, debility, and a longer recovery period: In one study, one-quarter of the women reported pain when interviewed two weeks after their cesareans and 15 percent still reported pain at eight weeks (33). More than 15 percent reported difficulties with normal activities such as getting out of bed, walking, bending, lifting and tending the baby at two weeks. One in ten still reported problems at eight weeks.
· Surgical complications: A ten-year review at one hospital reported a 4.5 percent incidence of major complications, that is, severe hemorrhage, need for repeat surgery (generally to investigate bleeding), pelvic infection, blood clots, pneumonia, blood poisoning (septicemia), or clotting dysfunction (a result of severe hemorrhage) (56). Nearly one-third of cesarean mothers experienced minor complications, including fever; hemorrhage; blood-filled swelling (hematoma); urinary tract, wound or uterine infection; blood clots in the legs (phlebitis); paralyzed bowel (ileus); or bladder paralysis. An analysis of women in Washington State, found that women having cesareans were nearly twice as likely to be readmitted to the hospital as women having normal vaginal births (30).
· Surgical injury to bowel, bladder, uterus, or uterine blood vessels: two percent.
· Hemorrhage: Between one and six percent of women needed a transfusion. Hemorrhage may sometimes require a hysterectomy.
· Infection: 8 to 27 percent. Antibiotic resistant infections are starting to be a problem as well (10).
· Paralyzed bowel: one percent.
· Blood clots: 6 to 18 women per 1,000 experienced leg-vein clots; 1 to 2 per 1,000 threw a clot into the lung (pulmonary embolism).
· Maternal death: An analysis in Great Britain revealed that women were 5.5 times more likely to die of an elective cesarean, than a vaginal birth (9 versus 2 per 100,000) (25). A Dutch study found that c-sections caused seven times more deaths than vaginal births (28 versus 4 per 100,000) (50). Obviously some factors that lead to c-section also threaten the mother?s life. However, the British study used elective cesarean to minimize that possibility and the Dutch study investigated the exact cause of death. The numbers in the British study may also be low. Data culled from vital statistics undercount cesarean death rates by 40 to 50 percent (43, 46).
· Cutting the baby: This complication occurred in a little over one percent of head down babies and six percent of breech babies in one hospital and in one percent of babies overall in another (54, 56).
· Baby born in poor condition: Several studies get at the effect of cesarean section on the baby by looking at outcomes when the cesarean was not done for the baby's sake. One study concluded that newborns with low Apgar scores (a measure of the baby?s condition at birth) after healthy pregnancies are nearly half again as likely to be delivered by elective cesareans as born vaginally (11). Another study compared babies born by cesarean for reasons unrelated to the baby?s condition with low-risk vaginal births (6). Babies born by cesarean were nearly five times as likely to be admitted to intermediate or intensive care and five times more likely to need assistance with breathing. A third study reported that persistent pulmonary hypertension, a life threatening respiratory complication, occurred 4.5 times more often in babies delivered by elective cesarean than in vaginally born babies (29).
· Psychological problems: Regardless of whether women feel satisfied with the decision to perform a cesarean, many women have negative feelings afterwards (34). Some of those feelings are the expected emotional aftermath of any major surgery (34). Others originate specifically in having a cesarean, including such issues as the loss of the expected birth experience or needing an operation to have a baby. Postpartum depression is more likely after a cesarean (8). A few women experience posttraumatic stress reactions such as nightmares, flashbacks, or an overwhelming fear of pregnancy (47). Psychological problems can also lead to marital stress or difficulties forming an attachment to the baby (34).
· Scar tissue adhesions: Adhesions can cause pelvic pain, bowel problems, and pain during sexual intercourse. They also make subsequent cesareans more technically difficult and injury to other organs more likely.
Complications that could affect future pregnancies and births can include:
· Infertility: According to one survey, women whose first birth was a cesarean were 13 percent less likely to have had a second child five years later than women whose first birth was vaginal (28). Women are also slightly but significantly more likely to miscarry (27).
· Ectopic pregnancy: A life-threatening condition in which the embryo implants outside of the uterus, usually in the Fallopian tube leading to the ovary. 25 percent more likely (27).
· Placental abruption: Placenta detaches before the birth. Two to four times the risk compared with an unscarred uterus depending on whether the woman?s first birth was a cesarean, or she has more than one prior birth and at least one cesarean (27).
· Placenta previa: Placenta overlays the cervix. 4.5 times the risk with one prior cesarean, 7 times the risk with 2 to 3 and 45 times the risk with 4 (5).
· Placenta accreta or percreta: Placenta grows into, or through, the muscular wall of the uterus. 11 times the risk with multiple prior cesareans compared with one prior cesarean -- nearly 1 per 100 versus 1 per 1,000 (7). This complication is particularly deadly. In a study of 109 cases of placenta percreta, 40 percent of women required transfusion of more than 10 units of blood, nearly all had hysterectomies, and 10 babies and 8 mothers died (36).
· Uterine rupture (symptomatic scar separation): Planned repeat cesarean does not eliminate this risk. One study of nearly 67,000 California women reported that the scar gave way in 3 per 1,000 women having elective repeat cesareans, not much less than the 5 per 1,000 rate with trial of labor (23). Similarly, in a study of 29,000 Swiss women with prior cesareans, the rate of symptomatic scar separation was 4 per 1,000 in VBAC labors, but it was still 2 per 1,000 in repeat cesareans (41). All of these cesarean-related problems are rare. Nonetheless, in a series of 711 women with one or more prior cesareans, 1 in 42 women had a catastrophic complication, defined as maternal or fetal death, severe hemorrhage, hysterectomy, the need to tie off a major artery, or a uterine rupture requiring emergency surgery or resulting in a baby born in poor condition (12).
Because of the pain and debility that accompany any major surgery, even a cesarean with no complications will almost certainly make the early days and weeks after your delivery more difficult compared with a vaginal birth. Developing a minor complication, such as a mild infection, will magnify your difficulties and prolong recovery; developing a major one will magnify them many-fold. Also, cesarean section can put you behind a psychological eight-ball, adding to lesser or greater degree to the stresses of adapting to motherhood.
What is a reasonable cesarean section rate?
For nearly two decades, the U.S. national cesarean rate has drifted between 20 and 25 percent. That means one of every four to five women, or 800,000 to one million women, have given birth by major abdominal surgery every year. A reasonable cesarean rate for the typical obstetrician would be half or less of that percentage -- certainly no more than 15 percent.
Several U.S. hospitals serving primarily high-risk, low-income women have been able to maintain cesarean rates in the 10 to 12 percent range without any detriment in newborn outcomes, and one has consistently kept its rates below ten percent (24, 35, 39, 44, 48). Moreover, the World Health Organization concluded that since countries with some of the lowest stillbirth and newborn death rates (perinatal mortality) in the world had cesarean rates of less than 10 percent, there was no justification for any region to have a cesarean rate more than 10 to 15 percent (58). As for midwives, in looking at six studies of hospital-based midwives, all but one study reported rates of 10 percent or less, while of 29 studies of midwives attending births outside of the hospital, none reported a cesarean rate over seven percent (20).