Although one doesn’t expect hear the phrases “C-section” and baseball season “opening day” in the same breath, that’s what happened last week when sportscaster Boomer Esiason criticized New York Mets second baseman Daniel Murphy on Esiason’s morning radio show for Murphy’s decision to miss the first 2 games of the regular season to be with his wife and newborn son. And when Esiason suggested that the couple should have opted for “elective” cesarean delivery of their son before the season started, it triggered an avalanche of criticism for his remark and sparked discussions about paternity leave and the potential risks of elective cesarean delivery.
According to the Centers for Disease Control and Prevention, 1 of 3 births in the United States is a cesarean delivery. However, elective cesarean delivery, which is performed before the onset of natural labor based on the mother’s request, is a small fraction of overall births. Because there are no medical reasons for performing this surgery, there also are no clear-cut health benefits for either mother or newborn.
In contrast, medically indicated cesarean deliveries are performed to benefit the health of the mother or baby, primarily because of placental abnormalities (such as placenta previa, in which the placenta covers all or part of the opening of the cervix) or the position of the fetus (such as a breech presentation, in which the infant’s feet or buttocks enter the birth canal first rather than the head). Pregnant women with genital herpes simplex infection who have active lesions or women with HIV infection who have high levels of the virus in their bodies also are advised to undergo the procedure to prevent transmitting the infection to the infant during childbirth. In addition, women who have had a previous cesarean delivery are often advised to undergo the procedure with subsequent births.
“We do [cesarean delivery] all the time for breech babies,” explains Caren Stalburg, MD, clinical assistant professor of obstetrics and gynecology at the University of Michigan. But obstetricians also see patients who feel they have compelling reasons for requesting the procedure on an elective basis. Stalburg says that when a woman requests a cesarean delivery, she begins a discussion early and tries to understand the patient’s reasons, such as worries about tears in the perineum, the area between the vagina and anus. “I explore the topic and massage all of the reasons. Is she afraid of the birth process? Is she worried about her perineum?”
Stalburg has coined what she calls the “6 Cs” of elective cesarean delivery: clarification of request, comorbidities (other health conditions) in the mother, number of children planned, consent, correct gestational age, and confirmation of insurance coverage. These 6 Cs provide a useful framework for decision making about elective cesarean sections. “The discussion is very different in a 21-year-old having her first child vs a 40-year-old having her only child,” explains Stalburg, who notes that the risk of surgical complications and subsequent placental abnormalities increase with each additional cesarean delivery.
As with any medical procedure, the risks and benefits of planned cesarean delivery should be considered. In addition to convenience, a concern about pelvic floor dysfunction (which occurs when the muscles in the pelvic area are weakened or injured, resulting in problems such as urinary incontinence) is frequently cited as a reason for opting for the procedure on an elective basis. But “risk of pelvic floor dysfunction shouldn’t be the only reason to have an elective section,” says Stalburg, who notes that although the incidence is lower with cesarean delivery, some risk remains. On the risk side of the equation, the procedure involves an increased likelihood of breastfeeding difficulties, postoperative pain, longer recovery time, and wound infection.
Risks of elective cesarean delivery also extend to the newborn. For example, uncertainty surrounding gestational age can result in prematurely delivering an infant thought to be full term. Stalburg explains that infants have an increased risk of respiratory difficulties if they are delivered before 39 weeks of gestation, so it’s important to confirm gestational age.
Regarding insurance coverage, some carriers may not provide full coverage for elective cesarean delivery. Stalburg advises all of her patients to discuss potential restrictions with their insurance company.
Finally, social issues frequently play a role in the birth process. For example, Stalburg has cared for patients whose husbands were going to be deployed on a particular date. “Although elective C-section is an option, scheduled induction of birth may be another option,” says Stalburg, who adds that a woman’s recovery after an uncomplicated vaginal birth is generally faster than after cesarean delivery.
Stalburg says it is essential that women who feel they have compelling reasons for requesting an elective cesarean delivery understand the ramifications.
“If she has made an informed choice and has a good understanding of the risks and benefits, and if after multiple discussions and visits, she decides this is the best option for her and her baby, I feel ethically comfortable with the option,” says Stalburg.
For additional information:
Ecker, J. Elective cesarean delivery on maternal request. JAMA. 2013:309:1930-1936.