The following list of articles represents a portion of the literature that raises serious questions about any attempt to downplay the risks or overstate the benefits of cesarean section.
The big picture:
Why not recognize that there is inadequate evidence to either support or refute elective cesarean and begin appropriately designed studies? This seems like the appropriate time to avoid mistakes observed in the past with fetal monitoring, tocolysis, and new surgical techniques. Perhaps any trial of elective cesarean should be approved prospectively by a cesarean review panel set up in each hospital so the data can be collected and carefully evaluated long term.?
Scott, JR. Putting elective cesarean into perspective. Obstet Gynecol 2002;99;967-8.
Our findings suggest that either a trial of labor or elective repeat cesarean delivery may be a reasonable option for women with at least one previous cesarean delivery. A trial of labor may result in small increases in the uterine rupture rate and in fetal and neonatal mortality rates while maternal morbidity including febrile morbidity and the need for transfusion or hysterectomy may be reduced with a trial of labor.
Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labor: A meta-analysis of the literature from 1989 to 1999.
Infection/Negative Outcomes:
Cesarean deliveries are potentially morbid procedures with quoted overall infectious morbidity rates of up to 25%
Bashore RA, Phillips WH, Brankman CR III. A comparison of the morbidity of midforceps and cesarean delivery. Am J Obstet Gynecol 1990;162:1428-35
Van Ham reported a cesarean section postpartum hemorrhage rate of 7%, a hematoma formation rate of 3.5%, a urinary tract infection rate of 3%, and a combined postoperative morbidity rate of 35.7% in a high-risk population undergoing cesearean section.
VanHam MA, van Dongen PW, Mulder J. Maternal consequences of cesarean section. A retrospective study of intraoperative and postoperative maternal complications of cesarean section during a 10-year period. Eur J Obstet Reprod Biol 1997;74:1-6.
?These data indicate differential morbidity associated with method of delivery serious enough to warrant rehospitalization following childbirth. They underscore the need to avoid unnecessary cesarean section.?
Research Letter from Webb DA, Robbins JM. JAMA 2003; 289.
Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA 2000;283:2411-6.
Lydon- Rochelle M, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatic and Perinatal Epid 2001;15:232-240
The Cochrane Collaborative concluded that the reduction of postoperative endomyometriosis (infection of the uterus) by up to 75% justified a policy of routine administration of prophylactic antibiotics to women undergoing both elective and nonelective cesarean deliveries. However, uncertainties persist regarding the selection of the antibiotic agent, the dosing regime, and the route of administration.
Harrigill KM, Miller HS, Haynes DE. The effect of intraabdominal irrigation at cesarean delivery on maternal morbitidy: A randomized trial. Obstet Gynecol 2003;101:80-5.
Pencillin is currently the drug of choice for group B streptoccocus but penicillin resistant group B strep may emerge. Many group B strep strains are resistant to erythromycin and clindamycin and resistances appears to be increasing nationwide.
Manning SD, Foxman B, Pierson CL, et. al. Correlates of antibiotic resistant Group B streptococcus insolated in pregnant women. Obstet Gynecol 2003;101:74-9.
Risks of repeated cesarean sections:
Placenta accreta, increta and precreta reflect different degrees of an abnormal attachment of the placenta to the uterus. In most cases of such abnormal attachments women will hemorrhage and a hysterectomy is required to save the life of the mother. There is a marked increase in the incidence of placenta accreta in women with a previous cesarean delivery.
Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean delivery and higher parity. Obstet Gynecol 2002;99:976-80.
Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First birth cesarean and placental abruption or previa at second birth. Obstet Gynecol 2001;97(5):765-76
Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: A review. Obstet Gynecol Surv 1998;53:509-17.
Brien JM, Barton JR, Donaldson ES. Obstetrics: The management of placenta precreta: Conservative and operative strategies. Am J Obstet Gynecol 1006;175:1632-8.
Risks to the newborn:
The risk of persistent pulmonary hypertension in the elective, no-labor newborn is 3/1,000, almost five fold higher than those delivered vaginally.
Levine, EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases of newborns. Obstet Gynecol 2001;97(3):439-42.
Pelvic Pain:
Researchers from Brazil have found that chronic pelvic pain is directly linked with cesarean section which raises serious public health consequences in Brazil, where increasing numbers of women are having cesarean sections.
Almeida ECS et al. Cesarean section as a cause of chronic pelvic pain. Inter J of Gynecol Obstet 2002;79:2:101-104.
Incontinence:
Despite a prevalence rate that is estimated to be 35-40% in elderly women, little is known about the etiology of urinary incontinence. The prevalence of incontinence in nulliparous, predominantly postmenopausal nuns is similar to rates reported in parous, post menopausal women
Buchsbaum GM, Chinn M, Glantz C, Guzick D. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol 2002;100:226-9.
This study ?would call to question the belief that anal incontinence is caused solely by the effect of labor on the pelvic floor and can always be avoided by the performance of a cesarean section before labor.?
Lal M, Mann CH, Callender R, Radley S. Does cesarean delivery prevent anal incontinence. Obstet Gynecol 2003;101:305-12.
Other:
Although episiotomy use has decreased over time, the most recent rate of 39 per 100 vaginal deliveries remains higher than evidence-based recommendations for optimal patient care.
Weber AM and Meyn L. Epiosiotomy use in the United States, 1979-1997. Obstet Gynecol 2002;100:1177-82.
