Have you heard? The c-section rate in the United States is at an all time high. One in three babies is brought into the world by surgery.
Do you care? Maybe not. Maybe not until you, your partner, your mom, your friend or your sister is told that her baby is too big for vaginal birth and is wheeled off to the operation room for a major abdominal surgery that she doesn’t need.
The World Health Organization recommends no higher than a 10-15% for all nations, which is based on its 2007 study in which higher rates of morbidity were found in countries with rates below 10% and higher than 15%. This ideal rate is sometimes dismissed as arbitrary at best, yet even if the “ideal rate” were 20%, it would still amount to approximately 509,420 unnecessary surgical deliveries in the United States.
The Cesarean section is an essential, life-saving surgery for both mother and child when performed with medical indication. However, too many women and their partners are unnecessarily coerced into the surgery by doctors under the argument that it’s what’s best for their baby or babies and for their body.
Doctors have been pressured to lower their rates for decades and yet the rate climbs. The onus of lowering this rate does not rest solely on the shoulders of the medical community.
The current cultural trend in the United States is for women to check themselves into hospitals in labor with the mentality that they are going to receive a series of safe technologically and scientifically based management services from doctors, midwives and nurses which will result in the following:
*Information about their body’s and their baby’s progress during labor
*Delivery of a perfect baby
If the consumer is not happy with the end result of the services that they feel the hospital was responsible for providing them, they might demand reparations as consumers do when they are not content with a product or a service.
Hospitals now create a paper trail and preemptively counter the unrealistic expectation that their medical training and expensive technology will guarantee a safe birth experience for mother and baby by over-managing pregnancy and labor—unnecessary tests and drugs, induction drugs of questionable safety and, frequently, the cesarean section.
Many would find it inconceivable that their doctor would perform risky, unnecessary procedures that do not lower morbidity or improve outcomes. The American College of Obstetrics and Gynecologists (ACOG) issued very specific guidelines on fetal macrosomia in 2001. The article includes the following:
The diagnosis of fetal macrosomia is imprecise . For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold’s maneuvers).
… [R]andomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown.
Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered.
In cases of term patients with suspected fetal macrosomia, current evidence does not support early induction of labor. Results from recent reports indicate that induction of labor at least doubles the risk of cesarean delivery without reducing the risk of shoulder dystocia or newborn morbidity.
Women who are pressured by their doctors or hospital midwives to schedule a primary c-section or submit to an early induction based on the estimated size of their baby can feel comfortable asking their care provider for the evidence behind their recommendation before they get a second opinion on whether major abdominal surgery is necessary.
But surely doctors who unnecessarily perform surgery on a patient in defiance of the guidelines issued by ACOG would be condemned for their actions, right?
ACOG more recently issued a statement that doctors are ethically justified in performing an elective c-section if they believe that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth. Doctors that habitually fail to heed ACOG’s guidelines yet believe that they are operating ethically and in the best interest of their patients need to disclose their biases to their patients. The portrait of the dollar-hungry, over-scheduled obstetrician who wants to control the unpredictable process of birth to avoid being awakened in the middle of the night to attend a woman in labor is oft painted. Any profession can be tainted by those who do not choose to conduct themselves ethically. However, when doctors truly do not believe that a woman can vaginally deliver a large baby and that a prophylactic c-section promotes her and the baby’s overall health and welfare, then they have been given a pass by ACOG to do so based on their belief.
Perhaps these beliefs are rooted in lack of experience or in having experienced a tragic birth with irreversible injury or death to mother or child. If a surgeon holds onto the belief that his or her scalpel can prevent mother, baby, family, nurses and HIMSELF or HERSELF from experiencing the pain of a birth that doesn’t go well, then is he or she not ethically justified in sparing women from the risks of childbirth?
Unfortunately, c-sections are risky business. Childbirth Connection, a national not-for-profit organization founded in 1918, identified 33 evidence-based areas where cesarean section was found to involve more risk than vaginal birth , and a mere four areas where vaginal birth was found to involve more risk than cesarean section. The United States is experiencing the highest maternal mortality rates it has seen in decades , which many attribute to the dramatic increase in the number of c-sections performed.
Prevention of shoulder dystocia is often cited as the justification for inducing or operating on the mother of a suspected large baby. ACOG ascertains that shoulder dystocia occurs unpredictably in infants of normal size as well as their macrosomic counterparts. In January 15, 2001, American Family Physician, a semi-monthly, peer reviewed journal published an article entitled Management of Suspected Fetal Macrosomia, which stated the following:
Unfortunately, case series indicate that one half of all cases of shoulder dystocia occur at birth weights of less than the most commonly used cut-off—4,000 g. Furthermore, almost one half of all cases of permanent brachial plexus injuries occur in infants weighing less than 4,500 g.
If half of all cases of shoulder dystocia occur in babies weighing less than 8 lbs., 13 oz. and half of all permanent cases of BPI occur in those babies weighing less than 9 lbs., 15 oz., then could doctors not justify a 100% c-section rate to prevent shoulder dystocia?
As absurd as a 100% surgical delivery rate sounds, any woman who enters a hospital as a consumer with the mindset that a medical doctor and the most advanced technology will guarantee her a perfect, healthy baby without any pain or undignified squatting is setting herself up to have her baby surgically removed. Confronted with this kind of pressure from patients, fearful of skyrocketing malpractice insurance rates and loss of professional and personal assets if found responsible for injury or death, unsure of whether or not a woman’s body really can birth a large baby and inexperienced in how (normal) birth unfolds without medical intervention, a surgeon will do everything he or she can to keep the family happy and bring a child into the world using his or her skill set.
To perform an unnecesarean on a few to save one is not only unethical but costly and illogical. Nearly 3,700 Cesarean sections would need to be performed on suspected macrosomic (4500 g) to prevent ONE permanent case of brachial-plexus injury . In today’s current medical climate, the majority of women are not permitted to vaginally birth their babies in hospitals after having had a previous c-section, which means that the reproductive lives of women who wish to give birth in institutions is forever impacted by a doctor’s decision to operate.
The bottom line is that birth is unpredictable, in spite of the machines to which a woman is hooked or the number of years of medical school attended by her doctor or the skilled, knowing hands of her midwife that palpates her belly every week. Zamorski and Biggs’ article describes the desire to predict the unpredictable and control the uncontrollable. [Emphasis mine]
What clinicians really want to predict is not macrosomia, per se, but the serious complications that physicians mistakenly associate as occurring only with macrosomia, such as brachial plexus injury or shoulder dystocia. Such complications, however, are not determined by birth weight alone, but by a complex and poorly understood relationship between fetal and maternal anatomy and other factors.
Moreover, the vast majority of macrosomic infants who are delivered vaginally do very well, even if they experience shoulder dystocia. The weight estimate of the suspected macrosomic fetus should be recognized as uncertain.
[The content of this page was written and published in August 2008.]