High C's

High C’s

by Robin Tricoles

The C-section rate has spiked. An Emory neonatologist ponders why.

Word has it that Julius Caesar was delivered by C-section; hence, the name of the procedure. But some say this can’t be so because Caesar’s mother, Aurelia, lived to see her son become a military leader and politician. Back then, Caesarian sections, or C-sections, were performed to save the baby only when the mother was dead or dying.

But if in fact Caesar had been delivered via C-section, he and his mother would have missed out on a profound and important event—labor. Labor triggers a chemical and hormonal cascade that can mean the difference between a healthy baby and a sickly one.

While researchers and physicians are learning more and more about the benefits of labor and full-term pregnancies, C-sections at the same time are on the rise.

“In the 1970s, the C-section rate in the United States was only 5%, and now it’s 31%,” says Emory neonatologist Lucky Jain. The rise has been so steep over such a short time that researchers are just now beginning to get a glimpse of the long-term effects of bypassing vaginal delivery and labor. What they are finding is that skipping labor can have undesirable consequences, says Jain.

It’s important that mothers and their obstetricians carefully weigh the benefits of a vaginal delivery versus a C-section. A C-section may be indicated if a baby is in a breech position, if the mother’s hips are narrow and the baby is large, or if the mother has a high risk of complications with vaginal delivery.

But there is a clear increase in the number of C-sections performed even in low-risk situations. Why? The reasons are numerous.

Rising interest rates

Today, physicians monitor mothers and their babies more closely than ever, leading to the detection of more subtle abnormalities and follow-up testing. Far too often, these tests elicit false positive results, which may influence doctors to intervene with a C-section, says Jain.

Women also are starting families later in life. When it comes to vaginal delivery, older mothers are considered to have a higher risk for complications than their younger counterparts. For example, a woman over 40 is twice as likely to have a C-section than a woman younger than 30, according to Jain. And once a woman has had a C-section, her next deliveries will likely be Caesarian too. “Vaginal birth after a Caesarian has gone down because there’s a rare occurrence of uterine rupture,” Jain says. “That is, the scar from the previous delivery can rupture. Although rare, a rupture can be catastrophic, risking both mother and baby.”

Artificial reproductive technology has led to more twin and triplet pregnancies, which have a much higher rate than single pregnancies of C-section and early delivery.

Likewise, the rise of maternal obesity and maternal diabetes is driving up the number of C-sections because of the increased risks during labor and delivery. 

Finally, whether to have a C-section or not also can come down to the mother’s preference—depending on her lifestyle, energy level, and fitness. Some women choose C-sections because they believe the procedure may reduce the chance of future urinary incontinence or sexual dysfunction.

Money and legal considerations also come into play. The current medical payment system encourages C-sections because they are a quick, controlled method of delivery. “The obstetrician can do a C-section under very controlled circumstances in less than half an hour, while vaginal delivery can consume much more of the obstetrician’s time,” says Jain.

C-sections also decrease the likelihood of medical malpractice lawsuits. Obstetricians as a group are especially vulnerable to legal action. If a baby has health problems after a delivery, the obstetrician is often held responsible, but if the mother asks or consents to a C-section, the physician’s level of responsibility shifts. But so does the genuine due date.

Douglas Eaton

Emory pediatrician Lucky Jain: "From a pediatrician’s standpoint, the most important thing for parents to remember is that one out of 10 Caesarian babies get admitted to the ICU."

On-time delivery?

Determining gestational age is difficult, and estimates of due dates are accurate within only a week or two of the genuine date. A C-section may lop off as much as two weeks of fetal development, which can lead to short- and long-term adverse effects, especially in the lungs and maybe the brain.

“For thousands of years, Mother Nature’s clock has been the best predictor of full-term gestation,” says Jain. “Anytime we bypass that, we can end up having babies delivered a week or two early.”

That’s important because in the last five or six weeks of gestation, the lungs become ready to breathe. “I liken it to a plane preparing for a safe landing,” says Jain. “The ‘landing gear’ includes a sufficient maturity of the lungs to be able to transition to air breathing and to rapidly clear lung fluid as well as taking over the many functions that the mother’s body had regulated for the baby.”

While the lungs are full of fluid at birth, full-term babies can clear it rapidly while early-term babies often cannot. “Labor and delivery are part of a transient burst of activity of chemicals and hormones that prepares the baby for newborn transition,” says Jain.

One of those chemical cascades involves the hormone oxytocin. Released by the mother, oxytocin helps regulate cervical dilation and uterine contractions during labor. The hormone also paves the way for breastfeeding and pair bonding. For this reason, mothers who have had a C-section may have difficulty in initiating breastfeeding.

And it’s not just the mother who releases hormones. The fetus does too. Just around the time of spontaneous labor or slightly before, the fetus releases corticosteroids, a class of steroids crucial to fetal development—especially the lungs. In fact, the fetus continues to release corticosteroids throughout labor and even into early birth.

“From a pediatrician’s standpoint, the most important thing for parents to remember is that one out of 10 Caesarian babies get admitted to the ICU,” says Jain. “Most of them come into the ICU with an inability to transition to air breathing. They often start breathing fast because the lung fluid has not been cleared.”

Additionally, catecholomines, the fight-or-flight hormones, rise to astronomical levels during labor, says Jain. Like corticosteroids, they too play an essential role in maturation of the fetus.

Researchers are just now beginning to look at the long-term consequences of elective C-sections. There is growing evidence that asthma, celiac disease, and neurologic difficulties may be linked to foregoing labor and vaginal delivery. That’s why, says Jain, parents must clearly understand and carefully consider the risks and benefits of a C-section before making a decision to choose one. Because the decision of whether to have a vaginal birth or C-section depends on so many variables, he believes the doctor is the best judge. -EH

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