Experts discuss benefits, risks of cesarean section

In the United States, almost a third of deliveries in 2018 — 31.9% — were completed via cesarean section, according to the CDC.

Multiple studies have been published suggesting that children born via cesarean section are at an increased risk for developing certain conditions.

Despite this, the American College of Obstetrics and Gynecology (ACOG) estimates that 2.5% of all births in the U.S. are elective cesarean deliveries that are performed at the mother’s request. In its clinical guidance, which was updated in 2019, ACOG recommended that maternal-requested cesarean delivery should not be conducted before 39 weeks gestation, and because of the high rate of repeat cesarean section, physicians should discuss increased risks with each subsequent cesarean section.

In 2015, WHO recommended that cesarean sections only be performed when medically necessary due to the potential short- and long-term health risks to mothers and children.

Healio Primary Care spoke with experts to learn more about the effects of cesarean section on mothers and children and what physicians should say to patients who request a cesarean section when it is not medically indicated.

Medical indications for cesarean section

Donna Maria Neale, MD, assistant professor of gynecology and obstetrics and maternal fetal medicine at Johns Hopkins School of Medicine, told Healio Primary Care that cesarean sections are sometimes required “to keep mom and baby safe.” The most common reason, she said, is if a woman is in active labor and her cervix stops dilating.

“These would probably be women who before we had a technique of cesarean delivery, would not survive the childbirth process because if their cervix failed to fully dilate to allow for the delivery of the baby, then ultimately an infection and/or bleeding would ensue, leading to the demise of the fetus and/or the mother,” Neale said.

She added that if the fetus is not tolerating labor well, delivery may need to be expedited via cesarean delivery, particularly if the mother is “remote from delivery, i.e. not going to deliver quickly.”

Some fetal presentations also indicate when a cesarean delivery is needed. For instance, if the baby is in a transverse presentation — meaning it is lying crosswise in the uterus — the cervix could never dilate enough to allow for a safe vaginal birth. In addition, in some instances of breech presentation, cesarean delivery is necessary, Neale explained.

Maternal conditions that dictate the need for cesarean delivery include certain cardiac or neurological conditions that could be worsened by the process of pushing during delivery. Or, Neale explained, if there is abnormal implantation of the placenta such as placenta previa or placenta accrete, then cesarean section is indicated.

Women who have had prior uterine surgeries with incisions in the corpus of the uterus also require cesarean delivery. For example, Neale said that if a woman “had a myomectomy before pregnancy, and the myomectomy has been such where the uterine cavity has been entered, she then requires cesarean delivery. Similarly, women with history of prior classical cesarean section or in utero fetal surgery also require cesarean section for delivery.”

She added that a cesarean section would be needed in the presence of certain fetal anomalies, particularly those that affect the central nervous system or anterior abdominal wall.

Childhood risks of cesarean section

Previous studies have linked cesarean section to adverse events in children, including an increased risk for developing allergies, being overweight at 12 months, respiratory infections and asthma.

Recently, a study published in Science Translational Medicine found that the link between cesarean delivery and an elevated risk for asthma in childhood may be caused by differences in a child’s gut microbiome due to a lack of exposure to the microbiome of the birth canal during vaginal delivery.

Cesarean sections are also linked to an increased risk for transient tachypnea of the newborn, Neale said. This risk, she said, is because these infants do not “transition in terms of their respiratory status because with the traversing of the birth canal, there’s a squeeze of the normal fluid that’s in the airways, and with cesarean delivery, you don’t get this squeeze.”

Another study published in PLOS Medicine found that children born via cesarean section had a greater risk for infection-related hospitalization than children delivered vaginally.

Jessica Miller

“Our study was an observational study that points to some potential mechanisms, particularly the early life microbiome, that may be targets for future interventions to optimize the newborn microbiome and immune function,” Jessica Miller, MPH, PhD, a postdoctoral researcher at Murdoch Children’s Research Institute at the Royal Children’s Hospital, Parkville, Australia, told Healio Primary Care.

The study, which included data from Denmark, Scotland, England and Australia, included singleton births from 1996 through 2015. Of the 7,174,787 births assessed, 23% were cesarean deliveries; 43% of those cesarean deliveries were elective.

Researchers found that, compared with children born vaginally, those delivered via cesarean section had a 10% greater risk for at least one infection-related hospitalization (HR = 1.10, 95% CI, 1.09–1.12) by 5 years of age. The risk was higher with both elective (HR = 1.13; 95% CI, 1.12–1.13) and emergency (HR = 1.09; 95% CI 1.06–1.12) cesarean section compared with vaginal delivery.

“The absolute risks for children born by cesarean section are small,” Miller added. “Children born by cesarean section should not be treated differently. All parents should be aware of danger signs of more severe infection in their children and children should be immunized fully and on time.”

Maternal risks, concerns

Neale said that cesarean sections benefit women and children when it is medically necessary, “but for a healthy woman who has a normally grown fetus that is structurally normal, I don’t know that there are benefits for an elective cesarean delivery.”

She added that in recent years, there was an increasing trend of women who requested cesarean delivery, and physicians have needed to remind them of the risks of these deliveries.

“Although cesarean sections are done often and done well, in the U.S., there’s always risk of surgery, so if you don’t need to undergo surgery, you don’t want to incur those risks,” Neale said.

These risks, she said, include infection, injury to other organs and hemorrhage. Hemorrhage, she added, is one of the leading causes of maternal mortality in the U.S. and the leading cause of maternal mortality worldwide.

Additionally, studies have found that women are over-prescribed opioids after cesarean delivery. Although attempts have been made to lower their exposure, efforts are still needed to reduce persistent opioid use in these women.

“As providers, we always want to utilize a shared-decision model when providing health care to our patients” Neale said. “We want to hear the patient. We want to hear her rationale for wanting to have an elective surgery. Our responsibility to our patients is to make sure they understand risks, benefits and alternative options to be able to make informed decisions.”

In her experience, Neale said the desire for elective cesarean section often stems from a woman’s fear of pain during labor and delivery.

“That’s where educating the patient in terms of the tools we have in our toolbox to help women achieve a safe, (relatively) painless vaginal birth can go a long way,” she added.

But another reason some women request an elective cesarean section is because they are survivors of sexual assault and abuse, and they fear that the labor process may trigger memories and physical manifestations of their trauma, according to Neale. Therefore, she said if a patient is asking for an elective cesarean section, “it’s not a dogmatic no.”

“Although it’s not recommended, I think it allows for a conversation between the patient and the provider to figure out where this desire is coming from,” she said. “Our primary goal as an obstetrician is to keep both mother and fetus healthy during the pregnancy and delivery. Moreover, it is our responsibility as health care providers to make sure our patient understands the risks and benefits of the procedure and are able to make informed decisions with the most accurate and up-to-date information.”

References:

• ACOG. Cesarean Delivery on Maternal Request. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/01/cesarean-delivery-on-maternal-request. Accessed December 21, 2020.
• CDC. Births: Final Data for 2018. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdf. Accessed December 21, 2020.
• Miller J, et al. PLOS Med. 2020;doi: 10.1371/journal.pmed.1003429.
• WHO. Caesarean sections should only be performed when medically necessary. https://www.who.int/mediacentre/news/releases/2015/caesarean-sections/en/. Accessed December 18, 2020.