Planning Ahead: Preplanned Versus Unplanned C-Sections By Rita Rubin   An excerpt from What If I Have a C-Section?: How to Prepare - How to Decide - How to Recover Quickly

You might be thinking of going ahead and scheduling a cesarean because you figure it's got to be safer than undergoing one at the last minute after hours of labor. That sounds logical, but few studies distinguish between the two. As a result, what appear to be complications of cesareans may actually be related to protracted labor or the factors leading to it. Such complications might have been prevented if the C-section had been planned instead of an emergency. "We've saved their lives by doing a C-section," Walters says. "When they have a complication, we blame the C-section."

One advantage of planning your C-section is that it's likely to take place during bankers' hours. When you deliver vaginally, especially if your labor isn't induced, you don't have much say about when your baby is born. Some older studies, done in the 1970s, suggested that the timing of a delivery could affect its outcome. Babies born during the daytime and on weekdays, when doctors, nurses, and other hospital staff tend to be more rested and numerous, were found to have lower death rates than babies born at night or on weekends. More recent research findings about the time of day or day of the week have been inconsistent, though. In a study of nearly 700,000 births, published in 2003, scientists from Stockholm's Karolinska Institute found that babies born at night had a higher risk of dying shortly after birth than babies born during the day. (Remember, though, few babies died overall, so the difference in the actual number of deaths between the two groups was quite small.) However, another huge study -- this one of more than 1.6 million live births in California -- found no evidence that the quality of care before, during, or after delivery was compromised on weekends.

For the most part, preplanned C-sections appear to be safer and, not surprisingly, more acceptable to moms than unplanned emergency C-sections. Recent research by obstetricians at the University of Vienna in Austria suggests that as far as psychological factors, pain levels, and birth experience, there's no comparison between the two types of C-sections. Using questionnaires and psychological tests, the researchers evaluated 1,050 pregnant women 2 weeks before their due date and 3 days and again at 4 months after delivery. A total of 147 women delivered by planned cesarean -- 3 for medical reasons and 44 at the patients' request. Another 93 women had unplanned C-sections. The women who had elective cesareans reported having the best birth experience, while the 41 who had vaginal deliveries with vacuum extraction reported having the worst. The researchers concluded that elective C-sections were safe and "psychologically well-tolerated," and that the results were similar to uncomplicated vaginal deliveries.

In a recent study of more than 18,000 pregnancies, Nova Scotia researchers found that if you deliver by a planned C-section, you tend to fare better overall than if you deliver by emergency C-section or vaginally with the help of forceps or vacuum extraction. The scientists identified only one minor drawback to preplanned cesareans: Afterward, you're twice as likely to run a fever of more than 100.4 degrees than if you had labored before delivering. Still, your actual risk of an elevated temperature is pretty low. Fewer than 1 percent of all women in the study developed a fever.

This is reassuring: A University of Washington study suggests that planned C-sections are just as safe as vaginal deliveries, at least as far as your risk of dying afterward, which is extremely low to begin wi th.Only11 out of the 265,471 women in this study died of pregnancy-related causes within 6 months of giving birth. After accounting for advanced maternal age and severe preeclampsia, there was no difference in pregnancy-related death rates between the C-section group and the vaginal delivery group. The researchers concluded that it wasn't C-sections that raised the risk of dying, but the medical conditions that necessitated them.

In a separate report, though, the researchers did find one disadvantage to having a cesarean: If you deliver by that route, you may be nearly twice as likely to require re-hospitalization within the next 2 months as women who deliver vaginally without the help of forceps or vacuum extraction. Once again, the overall risk appears to be exceedingly low. Just over 1 percent of the more than 250,000 women in the study had to go back into the hospital within 2 months of delivering their babies. Common reasons for re-hospitalization were uterine infections, wound complications, and blood clots.

Chances are excellent that you won't need to be re-hospitalized after having a C-section, but you probably won't return to your normal activities as quickly as you would after a vaginal delivery. The University of Washington researchers found that about two-thirds of first-time moms who had a spontaneous -- no forceps or vacuum extraction -- vaginal delivery said they could perform vigorous activities such as running, lifting heavy objects, and participating in strenuous sports by 7 weeks after giving birth. Just under half of the women who delivered by C-section felt the same way. Interestingly, normal household tasks seemed to be more of a challenge than pumping iron or sweating it out on the track or tennis court: Only half of the women who had unassisted vaginal deliveries and a third of those who had C-sections said they could do routine chores around the house without difficulty. Hmmm. Either this finding illustrates the psychological component of recovery, or the women's homes must have really been a mess.

After the cesarean delivery of her first daughter, now age 3, 26-year-old Jaime says, "I was in so much pain, I couldn't do anything when I went home. I could hardly lift my daughter." Jaime's C-section came after 3 days of labor, which may have slowed her recovery. Clair, on the other hand, was an exception to those University of Washington research findings. For her, ecstasy over finally becoming a mother worked better than any painkiller ever could after her elective C-section. "I knew it would be harder for me to recover, but I bounced back pretty quickly," she says. "I was literally fine 3 to 4 weeks afterward. I felt great."

Some doctors are concerned that higher numbers of patient-choice cesareans could reveal long-term problems with the procedure that haven't yet surfaced. A small Brazilian study might provide an inkling of what's to come in the United States. Brazil's C-section delivery rate is the highest in the world, and the majority are scheduled without a pressing medical reason. Among women in the higher socioeconomic groups, at least, C-sections greatly outnumber vaginal deliveries. You might relate to at least some of the reasons for C-sections' popularity in Brazil, although you might not call them unjustified, as a Sao Paulo OB/GYN did in a letter a few years ago to BMJ, a British medical journal.

"Some unjustified fears cause this situation, including the fear of fetal distress during labor, the notion that labor lasting more than 6 hours is unbearable for the mother, the fear that a vaginal delivery will ruin the woman's sex life, and the idea that a cesarean section is better and more 'modern,' since it is the preferred form of delivery for rich women in our country. The patients also want to plan the day of the birth, choosing a relative's birthday or avoiding a holiday, for instance."

Colleagues of the letter-writer at the University of Sao Paulo blame the over-use of cesareans to a rise in cases of chronic pelvic pain seen at their hospital. They reached that conclusion after comparing 116 patients who underwent a laparoscopy for the diagnosis of chronic pelvic pain with 83 patients who didn't have pain, but who underwent a laparoscopy to have their tubes tied. Two-thirds of the women with chronic pelvic pain had had a C-section, compared to a little more than a third of the women without pain. "I am convinced that cesarean section can be a cause of chronic pelvic pain," says co-author Antonio Alberto Nogueira, M.D. At his hospital, Nogueira says, he's seen an increase in patients with chronic pelvic pain who've had two or more C-sections. You might think this would never happen to you if you had a C-section, and you probably would be right. But it might be one more thing to consider when weighing the pros and cons of requesting a C-section.

Reprinted from: What If I Have a C-Section?: How to Prepare, How to Decide, How to Recover Quickly by Rita Rubin © 2004 by Rita Rubin. (September 2004; $12.95US/$18.95CAN; 1-57954-907-1) Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735 or visit their website at www.rodalestore.com.

Author
Rita Rubin is a prizewinning health journalist at USA Today. Formerly a medical reporter for U.S. News & World Report, Rubin has written for Health, Ladies Home Journal, Reader's Digest, and The Journal of General Internal Medicine, among many other medical and lay publications. She lives in Bethesda, Maryland, with her husband and two daughters.

For more information, please visit www.writtenvoices.com.

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