There are few reasons for a C-section that everyone can agree on–a prolapsed cord and placenta previa are among them. Most of the other reasons are subject to disagreement. Some doctors will require their patients to have C-sections if they think the baby is too big, or the mother’s pelvis is too small, or the father is big while the mother is little, or….or….or…..
When looking at reports of the C-section rate increasing, and looking at various studies on C-sections and their effects on mothers and babies, one thing is crystal clear–there needs to be standardization on how C-sections are coded. The problem with a lot of studies that look at C-sections is that sometimes the negative effect a baby has might be the result of a difficult labor (often induced; or perhaps the epidural sent the baby into fetal distress). So, when a C-section is done and the baby has breathing problems, or has a low Apgar score, it might be debatable whether the effect is due to the C-section or if it’s due to something else. So, most studies that look at this question will compare vaginal birth to planned, scheduled, or elective C-sections. (You can check out Jennifer Block’s “Pushed” blog and the International Cesarean Awareness Network links over on the right for a lot more information on this topic.)
Recently, a woman told me that her doctor had refused to allow her to have a vaginal birth with her second child because she had a C-section with her first. She argued and begged and pleaded, but he would not change his mind. After the operation, she discovered that he had coded her second C-section as “maternal request.” Needless to say, she was furious. She was not given an option, but the way her surgery was coded, it looked as if she had wanted it to be that way. So when I hear about the statistics of “maternal request” Cesareans increasing, it makes me wonder how many of these major abdominal surgeries are actually truly elective.
My sister-in-law planned a home birth and ended up with a C-section. She had a long and difficult labor, plus a few hours of pushing, and was just absolutely exhausted. Although the baby was tolerating labor fine, she was just done. Was this C-section “elective” or “medically indicated”? It seems to me that there is a gray area. She had not intended to have a C-section, so you can’t really say it was elective; but her baby was fine, so it wasn’t really “medically indicated.” I don’t know how this C-section was coded in her hospital record for statistical purposes, so I couldn’t say what the doctor thought of it.
There is also the questions of “emergency” C-sections. One of the many studies I’ve looked at recently noted a wide margin of “decision to incision” time in unplanned C-sections. While most hospitals strive for a 30-minute maximum, this study showed that there was no increase in fetal deaths when it went up to 90 minutes. (They divided the emergency C-sections into two groups–the first was surgery begun prior to 30 minutes after the decision, and the second was from 30-90 minutes.) However it was obvious from looking at the data (and the authors noted this as well), that the “true” emergencies (such as absent fetal heartbeat or known prolapsed cord, or sudden vaginal bleeding) were more likely to be in the first group, while the (I guess you would have to say) less emergent emergencies were in the second group. So, it seemed to me that doctors were hesitant to let the woman continue to labor, and just monitor the baby more closely when the fetal monitor zigged when it should have zagged, but they weren’t rushing down the hall yelling “Code blue,” either.
So there seems to be a gray area here, that I wish were better defined. Most unplanned C-sections are not true emergencies–either the mom just gets tired of laboring, or she takes longer than normal to push, or the fetal heartrate starts dropping a little too much (which indicates a possible problem, but is not a “code blue emergency”), or the induction fails, or the mom doesn’t dilate as fast as the doctors would like. I think it would probably clear up a lot of problems that currently exist–at least in my mind, and probably most of the public’s mind too–in figuring out why nearly one out of every three babies is born through a cut in his mother’s abdomen. You see, only when we understand what the problem is, can we figure out how to fix it. If it were clearly indicated why so many C-sections were performed–different codes for “too posh to push,” true fetal distress (and any known or suspected reasons for this), suspected fetal distress, cord prolapse, mom too tired, etc.–then we could get a better picture of what causes this, and what perhaps may be done about it.