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C-Sections By Choice

"This time is going to be different," Jennifer Berman told herself when she found out she was pregnant for the second time.

Her first labor, three years earlier, had been long (18 hours) and frightening, because her baby's head and shoulders got stuck in the birth cana. Max—born at 9 pounds, 8 ounces—suffered no lasting harm, but the monitoring probes inserted during labor gave Berman an infection that took more than a week to clear up. She also suffered from months of incontinence.

"It was all way out of control," says Berman, a urologist at UCLA Medical Center.

So for her second baby, she decided to have a C-section. Isabelle arrived by appointment weighing 7 pounds, 8 ounces.

Almost one in three babies in the U.S. come into the world by C-section, an all-time high, and rates keep rising. Now a growing number of women, like Berman, are choosing the option even when it's not medically necessary.

Some doctors are in favor of giving women the choice, especially if they may be at particular risk of urinary or other complications.

"While vaginal birth is a natural event, in essence what you're doing is rolling a bowling ball through the vagina," says urogynecologist Peter Sand, M.D., of Northwestern University's Feinberg School of Medicine, in Chicago. Many obstetricians, however, are reluctant to substitute surgery for vaginal birth.

The choice is controversial and has sparked a public debate. Recently, the American College of Obstetrics and Gynecology officially told its members that it's ethical to perform an elective cesarean.

But other groups think it's a terrible idea. "Medically necessary cesareans are one thing, but to give blanket approval to elective cesareans, instead of working with a mother to have a vaginal birth, could be dangerous to the health of the mother and the baby," says Barbara Hotelling, a mom and a former president of Lamaze International.

Why would a woman choose a C-section? Fear of labor pain is one reason; another is concern over the tearing that can occur in vaginal delivery. Still another is fear of incontinence later on due to wear and tear on the pelvic muscles. Some women mistakenly believe that a C-section will better preserve their pre-baby figure (it's pregnancy, not giving birth, that'll stretch your waistline).

For other moms-to-be, it's all about the baby: Maybe they know someone who's lost a child, or had a child permanently injured, during a difficult vaginal birth.

Doctors remain deeply divided about how much choice to give women. "Most women who come in asking for a cesarean do so because they're petrified of childbirth," says ob-gyn Kimberly Gregory, M.D., of Cedars-Sinai Medical Center, in Los Angeles. "In the past, the attitude was that these patients needed better education or counseling, not cesareans. Perhaps we're getting away from that. But I'd still feel uncomfortable if I did a procedure that was not indicated medically."

One thing is clear: For such an emotional issue as how your next baby should arrive, you'll need to understand all the pros and cons, for the baby, and for you.

Risks for the baby

During the final weeks of her third trimester, Michelle Ferguson of Tampa got the news that she had a very big baby—close to, if not more than, 10 pounds. Such babies are at higher-than-normal risk of birth complications. When labor begins, the obstetrician stands ready to perform a C-section if it suddenly becomes necessary. "My doctor told me I could go ahead and attempt labor and see how it goes," says Ferguson, "but I decided I didn't want all the drama." She opted to schedule her cesarean for the next day.

Declan did indeed weigh more than 10 pounds, but he emerged blue, with breathing difficulties. Luckily, he was fine after a brief resuscitation. Such breathing problems are more common in babies born through C-sections, even if they're planned. The risk is highest if the procedure is performed before 39 weeks, such premature birth can happen if the due date has been misjudged. Overall, though, the risk of serious respiratory distress is low.

Some moms and experts worry that even a successful c-section may interfere with breastfeeding and bonding, since the mom and the baby may be separated during recovery. But new research has revealed that bonding is a long-term process, and the method of delivery doesn't seem to affect it.

Benefits for the baby

Vaginal birth is no picnic for a baby. The U.S. death rate for full-term babies is approximately 2 in 1,000. Most occur in otherwise normal babies, leading some experts to say that scheduling a cesarean during the week before a woman is due—the 39th week—would save lives.

The main reason is that the trip through the birth canal can cause head injuries. Those risks go up if a fetus weighs more than 10 pounds, is in breech position, or is one of multiples. In each case, it's more likely that forceps would be needed to bring the baby out, and this procedure can cause head damage in rare instances. So obstetricians routinely give women the option of having a cesarean delivery under those circumstances.

"From the beginning of my pregnancy, I really wanted a C-section," says Sue Zeilnhofer of Bayville, New Jersey. "I had heard all the horror stories about 24-hour labors and babies pulled out with forceps." Her fears worsened a week before her due date, when her doctor concluded from her final sonogram that her baby would weigh around 8 pounds, 11 ounces. "I thought, she's going to rip me apart," she recalls. The sonogram also revealed that her baby was in breech position, and her doctor told her he wanted to consult with a colleague about trying to turn the fetus. "But I said, 'No, really, I prefer a cesarean.'"

Zeilnhofer delivered Emma on a Wednesday and brought her home that Saturday, happy with her decision. "If I ever have another, I want it the same way," she says.


Risks for the mom

Unlike vaginal birth, a C-section is major surgery, and that means recovery and the risk of complications. Fortunately, the risk of losing the mother to surgical complications has declined dramatically over the past century. But excessive bleeding, infection, and injury to such abdominal organs as the uterus, intestines, and bladder can occur. Women who've had a c-section are slightly more likely than those who've given birth vaginally to need readmission to the hospital, most commonly for uterine infection or bleeding. Again, most complications occur in unplanned cesareans performed after a woman's water breaks and labor begins.

Then there's recovery, which can take weeks. "I couldn't get out of bed without hurting," says Ferguson. "So I let my husband do everything. I didn't even change my son's diaper for two weeks, not until my husband had to go back to work." After this experience, she wanted a vaginal birth with her second pregnancy. Because of the risks of "vaginal birth after cesarean," or VBAC, she couldn't find a hospital or birthing center willing to perform one. Eventually, she found a midwife to deliver her second child at home, an experience she describes as "awesome." After ten hours of active labor, Ferguson delivered 8-pound, 12-ounce Liam: "I was walking around the house the second day and nursing without problems."

Benefits for the mom

For many women, the most important long-term benefit is the protection of the pelvic floor, the muscles that support the uterus, bladder, and other abdominal organs. When the baby's head passes through the birth canal, it can damage the nerves and muscles there. The risk increases if the doctor has to use forceps.

This can lead to postpartum incontinence, uncontrollable urination that often occurs when you run, cough, or even laugh. Fortunately, it usually goes away in a few months.

For a minority of women, though, incontinence keeps returning. For more, vaginal delivery contributes to a gradual, age-related weakening of the pelvic floor, which increases the chances of incontinence in later life.

Women who have a C-section not only avoid postpartum incontinence but also have a lower risk of it when they're older: Those who've delivered only by cesarean are less likely to suffer from moderate to severe incontinence as women who've given birth vaginally. Another medical advantage: If your cesarean is planned, you won't need to have it in an emergency situation, which is far more likely to cause injury, or worse.

Making the choice

Because both vaginal and planned cesarean deliveries are highly safe, women's concerns over which to choose often center on the amount of pain and recovery involved with each. But no two birthing experiences are alike. For every horror story about a vaginal or cesarean delivery, there are many more infused with joy and satisfaction. Even women who have experienced both kinds of delivery frequently differ over which they'd prefer next time they have a child.

Canadian researchers recently followed some 1,600 pregnant women, half of whom planned to deliver by cesarean and half vaginally after learning that their babies were in breech position. Three months after delivery, both groups said they were equally satisfied. More of those in the c-section group said that they liked that their childbirth experience hadn't been very painful. More of those in the vaginal-delivery group reported that they were happy that their recovery hadn't been difficult. And the two groups of women didn't differ in how promptly they were able to return to an active, pain-free sex life.

"Overall, if I had to pick one, it would be hard," says Jennifer Berman of her two very different childbirth experiences. What really matters, she says, is not the final decision but that she—and other women—have the ability to choose. And most important of all is the baby you get to take home afterward.