The rates of cesarean deliveries continue to increase, and among these rising numbers are those performed by maternal request without medical necessity. The issue was addressed at the recent National Institutes of Health State-of-the-Science Conference in Bethesda, Maryland.
"The medical, social, and economic consequences of this trend need to be evaluated carefully," says Lucky Jain, MD, a professor of pediatrics and the executive vice chairman for the department of pediatrics, Emory University School of Medicine. "There is a great amount of information available to mothers over the Web, and some of it relates to long-term urogenital complications of vaginal deliveries. Armed with this information, mothers often seek their physicians' opinion about Cesarean delivery.
"Many believe that physicians are all too eager to offer cesarean sections without informing mothers of all the pros and cons," Dr. Jain adds. "And so goes the debate."
Dr. Jain's presentation at the conference addressed respiratory morbidity in term- and near-term infants delivered by elective cesarean section (ECS) not preceded by labor. According to Dr. Jain's article, ECS infants are more likely to be admitted to intensive care units, primarily because of delayed respiratory transition. Evidence has also shown that physiologic events in the last few days of pregnancy, coupled with spontaneous labor, brings about hormonal changes in the fetus and the mother that plays a critical role in fetal maturation and its preparation for delivery and neonatal transition.
He writes: "When infants are delivered by elective cesarean section before the onset of spontaneous labor, the fetus is deprived of these hormonal changes, making the neonatal transition more difficult."
Newborns delivered before the onset of spontaneous labor often experience respiratory distress such as transient tachypnea and pulmonary hypertension, the presentation mentioned. Consequently, the infants also have higher rates of admissions to neonatal intensive care units, mechanical ventilation, and death. Most of the neonates who experience respiratory distress can recover without long term consequences; however, a significant number progress to severe respiratory failure.
In spite of these issues, infants delivered by ECS are less likely to sustain brain damage and trauma related to prolonged labor and difficult vaginal birth. This coupled with elimination of the rigors of labor makes Cesarean an attractive alternative to many mothers. Potential advantages to maternal urogenital anatomy are often offset though by the potential complications that are more often associated with multiple Cesarean births.
"There is an urgent need for therapeutic strategies that can facilitate normal neonatal transition when elective delivery without labor is anticipated. Moreover, future research can help gather the evidence needed for making appropriate decisions," Dr. Jain says. "Beneficial studies could include one comparing planned elective cesarean sections versus attempted vaginal deliveries, or a study evaluating the effect of antenatal steroids on neonatal outcome after elective cesarean."
Dr. Jain is a neonatologist with special interest in respiratory disorders of the newborn. His research has focused on elucidating the physiology of lung sodium and fluid transport, and on strategies to prevent lung edema formation.