The gray zone
Few question the value of C-sections—in certain instances. “When there are serious medical reasons or the life of the mother or baby is at risk, no one disputes that surgery is appropriate,” says MCA executive director Maureen Corry, M.P.H. Situations that nearly guarantee a C-section include a baby in the breech position (not head-down); a baby whose head is too large to fit through the birth canal; and placenta previa, a condition in which the placenta blocks the baby’s exit.
A small but rising number of women are having the surgery for no apparent medical reason, however. A British Medical Journal review of data from 1991 to 2001 showed a 67 percent increase in C-sections among American women with no reported medical risk. First-time mothers over age 34 were most likely to have such “elective” C-sections, though vaginal-delivery risks are no greater for a healthy 40-year-old than for a 20-year-old, Minkoff says. VBAC candidates with risk factors for uterine rupture, a potentially serious complication, are advised to schedule a C-section. (In a recent New England Journal of Medicine study of nearly 18,000 women who had VBACs, .7 percent, or 124 women, experienced a uterine rupture.) But sometimes, even women likely to have a successful VBAC, such as those with only one previous Cesarean and what’s called a low-transverse incision, are denied the chance. More than 300 hospitals nationwide have banned VBACs, according to a recent poll by the International Cesarean Awareness Network, a Redondo Beach, Calif.-based nonprofit group. That’s why groups like MCA say it’s important for first-time mothers to know all the facts when it comes to C-sections: A woman’s chances of trying for a vaginal birth the second time around are dwindling.
The controversy isn’t limited to VBACs. “The interpretation of fetal heart rate tracings and the diagnosis of failure to progress represent the most gray areas,” Lockwood says. In these cases, as well as situations such as twins or a woman with a health condition like high blood pressure, one physician or midwife may recommend surgery where another may not. Fear of malpractice suits plays a role, he adds: Opting for surgery almost always equates to less risk of being sued.
The decision is one that physicians and patients should make together—a fact easily forgotten when you’ve been laboring for what seems an eternity. When Carolyn Walkin, 36, of Brooklyn, N.Y., had a C-section after 26 hours of labor due to “failure to progress,” for example, she felt shut out of the decision-making process, partially due to exhaustion. Says Walkin, “I should have asked about alternatives.”