Like most expectant mothers, Stephanie Crowe of Monroe, New York, never imagined that she would end up having a cesarean section. But, after 16 hours of labor and numerous medical interventions, she hadn't dilated enough to deliver her baby. While the baby wasn't in danger at that point, Stephanie's doctor suggested a cesarean because he felt her labor was not going to progress the way it should.
Serena Gordon

A cesarean section is the surgical delivery of a baby, and it's something you may not give much thought to unless you find yourself in labor and having problems. Childbirth classes sometimes discuss cesareans, but few give much detail on the procedure. Yet, it's something we all should prepare for because expectant mothers today face a nearly one in four chance of delivering by cesarean.

What to expect if you have a c-section
If you need a cesarean, usually you will be given an epidural. In some cases, spinal blocks are given; in an emergency, a general anesthetic often is used, according to Dr. Bloom. With an epidural or a spinal block, you are awake for the procedure.

You'll then be prepped for surgery. Your abdomen will be washed and shaved if necessary, and sterile drapes will be placed below your neck. Your arms will probably be strapped down. The surgeon will then make an incision low on your abdomen, at the bikini line. Once the surgical team opens your uterus, they will break your water (if it hasn't already broken) and deliver the baby through the uterine incision. Just as in a vaginal birth, the umbilical cord is clamped and cut.

Next, the placenta is delivered, and the layers of incisions are sewn shut. The whole procedure usually takes between 45 and 90 minutes, says Bloom. Women who have had a cesarean usually stay in the hospital for four to five days, and the recovery time at home is longer than for a vaginal birth.

The cesarean rate for the year 2000 was 22.9 percent, according to a recent report from the U.S. Centers for Disease Control and Prevention (CDC). This represents the fourth consecutive annual increase and the highest rate recorded since 1989. Previously, the cesarean rate had been dropping every year, from a high of 24.7 percent in 1988 down to 20.7 percent by 1996.

What accounts for the current rise? According to the CDC report, advanced maternal age may play a role. Also, according to a study published in the June 2001 issue of Obstetrics and Gynecology, another factor is often at work too: induction. The incidence of cesarean delivery is significantly greater among women whose labor is induced (19 percent versus 14 percent in women with spontaneous labor, a 40 percent difference). However, despite the fact that most obstetricians, gynecologists and midwives agree that vaginal birth after cesarean (VBAC) usually is preferred over a repeat cesarean, fewer patients are attempting it -- and this may be one of the biggest factors in the cesarean rate increase.

Fewer VBACs
Dr. Steven Bloom, assistant professor of obstetrics and gynecology at the University of Texas Southwestern in Dallas, agrees. "The striking decline in VBAC is probably the most significant factor that explains why the overall cesarean rate continues to increase."

Bloom says the VBAC rate is down because of concern over possible complications. A recent New England Journal of Medicine study concluded that the risk of uterine rupture, though rare, is higher in women attempting VBAC, particularly those whose labor is induced. Because of this risk, Bloom says, obstetricians are trying to figure out just who is an appropriate candidate for VBAC. The result is that fewer women are being given that option because of the potential risk.

Anita Woods, president-elect of the International Cesarean Awareness Network (ICAN), says a lot of the decline in VBAC is because of a change in obstetrical policy. She says that the American College of Obstetricians and Gynecologists (ACOG) used to say physicians should be "readily" available during a VBAC attempt. Now, those guidelines say a physician needs to be "immediately" available. That change, Woods says, has forced some hospitals to stop offering VBAC because they can't afford to have an obstetrician on call all the time.

Unacceptable norm
Whatever the reasons for the increase, most experts agree the rate is still too high and needs to come down. "While every decision to have a cesarean or not has to be evaluated on its own individual merit, I do think the overall cesarean rate is higher than it should be," says Barbara Hughes, a certified nurse-midwife from Aurora, Colorado, and spokesperson for the American College of Nurse-Midwives.

The cesarean rate for healthy women pregnant with a single child should be about 15 percent, according to the U.S. government's Healthy People 2010 report. That goal is certainly attainable. Many nurse-midwifery practices already have rates far below the target goal. "Our rate is 13 percent," says Hughes, "which, for a nurse-midwifery practice, is even on the high side."

Just 30 years ago -- in 1970 -- just 5.5 percent of expectant mothers delivered by cesarean. Not until 1980 did the rate jump past 15 percent, according to CDC data.

The use of continuous fetal monitoring during labor likely accounts for a large part of the rise, but fear of litigation is another reason the rates rose so dramatically in the 1980s, explains Woods. "Doctors say, 'The only cesarean you get sued for is the one you didn't do.'" Woods also believes that cesarean delivery has become much more accepted by society over the past 30 years and says some women even mistakenly believe that cesareans are as safe as vaginal birth.

The power of support and information
Surgery might be required for a number of reasons. A breech position -- meaning the baby is positioned either feet or buttocks firstī‚ž is a very common one. Others include fetal distress, failure of labor to progress, preeclampsia and multiple births.

While many of the reasons for needing a cesarean are out of your control, some aren't. First, make sure you attend all your prenatal checkups, eat right, take prenatal vitamins and follow your healthcare provider's instructions, suggests Bloom. "Everything that we do to better the health of the mother and the fetus probably helps reduce the risk of needing a section."

Woods says women should consider having a nurse-midwife or a general practitioner deliver their babies, because their patients have lower rates of cesarean births. She says the presence of a doula (birthing assistant) significantly lowers the rate, too.

Learning everything you can about cesarean ahead of time is important, stresses Hughes, so if you run into trouble while in labor, you can make an informed decision. Also, during your prenatal visits, ask your practitioner what her cesarean rates are. If they're high, ask why. For example, some obstetricians handle a lot of high risk pregnancies and will probably have a justifiably higher than average number of cesarean births. Ask your doctor what he is doing to reduce the incidence of first-time cesareans in his practice, especially among those patients who are low risk. If you're not comfortable with the answers you get, consider switching practitioners, recommends Hughes.

She says if you're suddenly faced with the possibility of a cesarean during labor, ask your doctor or midwife to explain the reasons and your options. If it's an emergency and your health or the baby's health is immediately at risk, you'll just have to trust your doctor's judgment at that point, says Hughes. But, if it's not an emergency, ask what would happen if labor continued? Are there any other interventions you could try, such as moving around in bed or getting up and walking? She says having someone there to help you make these decisions -- a spouse, doula, friend or family member -- is helpful, too, because women in labor are so vulnerable.

Some women are disappointed after having a cesarean birth and feel as if they've failed because they didn't give birth vaginally, adds Hughes. For these women, she explains, "A cesarean birth is still the birth of your baby. Although the mode of birth is different?it's still a wonderful and miraculous event."

That's exactly how Lydia Michaels*, a mom of three from Wilmington, Ohio, feels about the birth of her first child by cesarean six years ago. "For years, I was disappointed that I had to have a cesarean. I felt like my body had failed me, and it took me awhile to work through that issue. Eventually, I did make peace with my body and the birth. Now I can rejoice in each of my birth experiences -- even the unexpected cesarean -- and how they all contributed to making me the person I am today."


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