In the U.S. today, roughly a third of infants come into the world by way of a cesarean delivery. The American College of Obstetricians and Gynecologists estimates that a small number of these cesarean deliveries, around 2.5%, are performed without a medical reason, simply at the request of the mother who preferred not to have a vaginal delivery.
In an opinion published this month, the American College of Obstetricians and Gynecologists (ACOG) urges both expectant mothers and their obstetricians to use caution when considering a cesarean delivery that is not for medical reasons. You may have read this story as the news media reported it. One pregnancy blog headlined “Why scheduled C-sections may be a thing of the past.” The author misunderstands ACOG’s statement entirely. Many c-sections are “scheduled.” During a prenatal visit, the obstetrician may identify a condition that makes a vaginal delivery unsafe. Some examples include multiples (more than two), breech position of the infant (the infant’s head is not down), an infant whose estimated weight is greater than 10 lbs. or a placenta lying low in the uterus completely or partially blocking the birth canal (placenta previa). We plan a cesarean delivery for these mothers and schedule it near their due date.
Most “scheduled” cesarean deliveries involve mothers with a history of a prior cesarean in a previous pregnancy. A mother may choose to not undertake the small but measurable increase in risk of attempting a vaginal birth after a previous cesarean delivery (VBAC). VBAC deliveries are a discussion for another blog post.
These “scheduled” c-sections are definitely not “a thing of the past.” They are and will continue to be an important part of safe obstetric care. The ACOG opinion does not address these situations. It refers only to those cesarean deliveries that were requested by the mother without any medical indications.
More importantly, ACOG’s statement does not represent a change in how we counsel our patients. Rather, the opinion paper is an excellent summary of the available research and expert opinion on the question.
In my own practice, it is fairly uncommon for a woman expecting her first child to request a cesarean delivery instead of a vaginal birth. Nonetheless, if a woman understands the issues and chooses the risks of a cesarean delivery over the risks of a vaginal delivery, I would support her in her choice even though I would recommend the vaginal delivery path. It is my responsibility to ensure that she understands the risks and benefits of each path.
The key point of the ACOG Committee Opinion is this: while there is not a “no-risk path,” the risks of cesarean delivery to mother and baby are greater than the risks associated with a planned vaginal birth. I agree completely with this risk assessment. The most common risks for each route of delivery differ somewhat, and weighing these risks favors a planned vaginal birth.
While the great majority of expectant mothers choose the lower risk path hoping for an uncomplicated vaginal delivery, an occasional patient will prefer to accept the risks of a cesarean instead of the risks of a vaginal birth. Most deliveries in the U.S. by either route proceed to a good outcome for mother and baby. I have confidence that, with the appropriate information, my patients will make responsible and well-informed choices for their own health and that of their newborn.