Elective Cesarean Section

I am a urologist–not a gynecologist–and by no means an expert on pregnancy, labor, and delivery. However, I am fellowship trained and board certified in female urology and provide care for women with bothersome pelvic issues resulting directly from birth trauma. Although the process of vaginal childbirth will not inevitably change one’s vaginal and pelvic anatomy and function, it does so commonly enough. Undesirable consequences of obstetric “trauma” include urinary incontinence, pelvic organ prolapse, and vaginal laxity. Today’s entry discusses a means of avoiding obstetric trauma and its consequences and reviews the advantages and disadvantages of cesarean versus vaginal delivery. My intent is not to provide medical advice regarding C-section versus vaginal delivery, only to delineate the pros and cons of each. As much as elective C-section spares one from birth trauma and adverse pelvic consequences, it is a much more involved procedure than vaginal delivery and many women have no ill consequences after vaginal delivery.

Cesarean Section (C-section) is a delivery via an incision in the mother’s lower abdomen. Cesarean delivery is often performed when vaginal delivery would possibly put the baby or mother at risk, although there are many other reasons for choosing this form of delivery.

“Labor” is called so for a genuine reason! The hours one spends pushing and straining are often unkind to pelvic anatomy and function. Vaginal delivery is the ultimate pelvic and vaginal traumatic event. The soft tissues of the pelvis get crushed in the “vise” between the baby’s bony skull and mother’s bony pelvis and are simply no match for the inflexibility of these bones. The vagina, pelvic floor muscles and connective tissues are frequently stretched, if not torn, from their attachments to the pubic bone and pelvic sidewalls, and the nerves to the pelvic floor are often affected as well.

Elective C-section avoids labor and vaginal delivery and affords protection from obstetric trauma. However, prolonged labor culminating in emergency C-section is equally as potentially damaging to pelvic anatomy and function as is vaginal delivery.

The consequences of vaginal delivery or emergency C-section include stress urinary incontinence (leakage with sneezing, coughing and exertion), pelvic organ prolapse (descent of one or more of the pelvic organs–bladder, uterus, rectum–into the vaginal cavity and sometimes projecting beyond the vaginal lips), and a loose and gaping vagina. Anatomical changes may adversely affect sexual activity, making sexual intercourse less satisfying for affected women and their partners. It may lead to difficulty achieving climax, difficulty retaining tampons, difficulty retaining the penis with vaginal intercourse, vaginal filling with water while bathing, and vaginal flatulence (passage of air).

All of the aforementioned potential consequences may be avoided with elective C-sections. The World Health Organization considers the ideal C-section rate (to reduce infant and mortality rates) to be 10-15% of all births. In the USA, almost one-third of births are via C-section and in certain countries, the rate is substantially higher. Latin American and Caribbean regions have the highest C-section rates in the world. In the Dominican Republic the rate is about 60% and in wealthy areas of Brazil the rate is near 90%. Elective C-sections are a status symbol among Brazil’s elite and affluent. Interestingly, many female physicians and other health care personnel choose elective C-section over vaginal delivery.

Vaginal Delivery: Advantages

“Natural” form of delivery

Intimate, unique and special experience shared between mother and child

Earlier contact of newborn with mother

No extra scarring, aside from possible episiotomy

Shorter hospital stay and recovery

Avoids risks of surgery

Vaginal pressure on the newborn’s chest squeezes fluid out of the baby’s lungs to help initiate breathing

Vaginal Delivery: Disadvantages

Long, physically demanding process

Labor is labor

Baby’s head often beaten up from delivery through birth canal

Possible injury to baby

Need for episiotomy

Stretching and tearing damage to vaginal and pelvic anatomy possibly resulting in incontinence, prolapse, altered sexual function

Elective C-section: Advantages

Avoids labor and unpredictability of natural childbirth

Conveniently pick date and time of delivery and have your own obstetrician take care of the delivery, not the doctor in the group who happens to be on call

Avoid vaginal and pelvic trauma, keeping anatomy and function intact

Can be lifesaving in event of maternal or fetal distress

Baby’s head less beaten up than with vaginal delivery

Elective C-section: Disadvantages

“Unnatural”

Surgical and anesthesia risks: blood loss, infection, bladder or bowel injury, etc.

Extra scar, prolonged recovery time, and longer hospital stay

Mother misses the birth experience (In the words of Leslie Jamison: the critique of the C-section is that it is: “Birth without labor, pain, or sacrifice, avoiding the heroic effort of pushing a baby through the birth canal.”)

Vaginal delivery in a subsequent pregnancy (VBAC– vaginal birth after C-section) is not always possible and a failed trial of labor after cesarean has more potential complications, including the rare incidence of rupture of the uterus

Risks of multiple C-sections include surgical adhesions, increased bleeding and placental issues including placenta accreta (placenta grows too deeply into uterine wall and following birth part or all remains intact causing serious bleeding), placenta previa (placenta lies low in uterus and covers the opening in the cervix) and placental abruption (separation of placental from uterine wall before birth)

Bottom Line: When it comes to elective C-section versus vaginal delivery, there are pluses and minuses, advantages and disadvantages, and benefits and risks that need to be weighed carefully in order to arrive at an informed choice that should be a shared decision made after collaboration with your obstetrician. As a urologist, I can state emphatically that it is extremely rare for women who have had elective C-sections to have the adverse pelvic consequences that are not uncommonly seen with women who have had multiple vaginal deliveries.