The Problem with C-sections

I'm not an obstetrician and the decision-making around calling a C-section is complex, but as an anesthesiologist watching from the sidelines, I've developed a lot of notions and opinions. Since the modern C-section was first performed in the 1880s, it has quickly become one of the most common surgeries in the United States with an incidence around 1/3 of all pregnancies. This statistic just amazes me; how can it be that birth happened for centuries and centuries (albeit with a higher maternal and infant mortality rate) without problem but now, a third of all pregnancies end in surgery?

One problem is that surgery begets surgery. Once a woman has a C-section, she's much more likely to have subsequent sections; trial of labor after Cesarian continues to be uncommon. Fetal monitoring has lead to increased rates of C-section, though fetal monitoring has never been scrutinized through well-conducted prospective randomized controlled studies. And in the back of medical economist heads, the question of medical malpractice lingers. A woman who has surgery but a healthy baby is unlikely to sue for unnecessary surgery whereas a woman who did not receive surgery but has infant morbidity or mortality is much more litigious. It's safer for obstetricians to err on the side of going to surgery.

Ideally, we would have informed, in-depth discussions with our patients about the rationale for a C-section, the risks, the benefits, and the alternatives. But with a laboring woman in pain, a fetal strip showing late decelerations, and the commotion of labor and delivery, I've rarely seen the balanced conversation. However, it's important to remember that surgeries and C-sections should not be taken lightly. Though our anesthetic and surgical techniques make it generally safe, complications happen and they can be catastrophic if they do.

Image shown under Free Art License, from Wikipedia.