Out of almost 4 million births in the USA, approximately 30% of them occur by cesarean section. The majority of mothers and doctors prefer natural birth over the operative one. However, nowadays, we do encounter a group of women requesting a C-section as their preferred mode of delivering the child.
ACOG estimated that between 1% and 3% of cesarean sections are done per mother’s request (ACOG source).
Can You request a C-section?
The short answer is Yes. However, if you do, your situation may get a little complicated. Some obstetricians will be willing to do it, but not all of them. Also, your health insurance company may dispute charges for a surgical procedure such as C-section if it is not “medically indicated.”
American College of Physicians and Obstetricians opined that: “In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended,” and further concluded: “cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks; and, given the high repeat cesarean delivery rate, patients should be informed that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery.” (ACOG source)
If you want a simple version, it means that they encourage obstetricians to recommend natural birth in the absence of medical indications for cesarean section. However, they do not ban them from performing the C-section on maternal request if the mother is well informed and aware of data on risks and benefits.
Additionally, ACOG emphasized in their report that a lot of data on outcomes after c-sections vs. natural delivery are of poor quality, therefore relying on them to make decisions may be difficult.
What reasons do women give when requesting to have a C-section instead of a natural delivery?
Scientific source article here.
Fear of pain and complications of natural labor.
Fear of pain and complications associated with natural labor can be mitigated by a discussion with your obstetrician. Also, if needed, consultation with anesthesia services could be arranged to talk about different options available to you to decrease pain during labor. You have to remember that C-section requires anesthesia too.
Concern for baby getting injured during labor and natural birth.
Mothers worry that some babies can suffer from injuries during natural delivery. The most frequently cited ones are brachial plexus injury, hematomas, bruises, and broken bones.
Concerns about trauma to their pelvic organs.
Some women suffer from urine and stool incontinence or have sexual dysfunctions. Some reports are saying that C-section may be beneficial for women if they want to avoid those problems; however, data is not of good quality.
Concerns about the need for emergency C-section, forceps or vacuum-assisted delivery.
Many planned natural deliveries end up as forceps, vacuum-assisted deliveries, or urgent C-sections. Certain mothers would want to avoid exposing their babies to those urgent interventional unscheduled procedures fearing that they may be associated with a higher risk of complications for the mother and the baby.
Prior bad experience with natural labor.
If a mother had prior bad experiences such as the death of the baby, severe injury to the baby, or very prolonged, painful, difficult labor, obviously she would want to increase chances that this time outcome will be very different.
The need to be in control and to have scheduled delivery.
Some women want to be in control. They want to be able to predict when and for how long they will have to be away from home and work. They may need to hire additional people or ask family members for help to take care of children and different affairs.
It seems that having an exact date for the birth of the baby would make the planning much more manageable.
What are the potential benefits of C-section on request?
Decreased risk of post-term delivery and stillbirth.
Babies who are born post-term tend to have more medical problems after birth. Waiting for a labor beyond due dates is associated with a small risk of having a stillbirth (stillbirth is defined as a baby dying in utero before birth).
Available literature suggests that probably 1 out of 500 to 1 out of 1750 babies who reached maturity but were not born yet, may die in utero, or have a severe disability that could have been potentially avoided by earlier delivery, such as at 39 weeks by cesarean section on request. Statisticians estimate that we would have to perform about 1200 cesarean deliveries to prevent one stillbirth baby. (Source article)
Known date of delivery (being in control).
Knowing the exact date of the operative delivery allows you to schedule it with the chosen doctor and ensure that the hospital has all the needed resources (anesthesiologist, nurses, etc.). You can also arrange for child care and plan for your absence at work if it applies to you.
Reductions in risks associated with operative natural delivery or emergency C-section.
Babies who are born by scheduled or “requested” C-section before the onset of labor have a lower incidence of some non-respiratory conditions:
- brachial plexus palsy (nerve damage in shoulder area affecting movements of your arms and hands)
- clavicular fracture
- skull fracture
- humerus fracture
- brain damage due to low oxygen levels during complicated natural labor
- HIV or Herpes acquired from the mother
Many of those conditions are associated with exposure to pressure in the birth canal during vaginal delivery. Others are related to sudden complications of natural labor such as shoulder dystocia (shoulder dystocia=inability to deliver rest of the body after baby’s head came out from birth canal), prolapsed cord, or rupture of the uterus.
Decreased risks of pelvic floor injury.
Pelvic floor disorders affect women’s quality of life, and up to 20% of them need surgery for it during their life. Pelvic floor diseases include pelvic organ prolapse, urinary incontinence, and fecal incontinence. It is well established that having a child contributes to and increases the risks of having these problems.
The rate of urinary incontinence for a woman with no children is 6.5% if she had one child – 9.7%, with two children – 16.3% and with three children is 23%.
Several studies report on the rates of pelvic floor injuries among women who had children by vaginal delivery and those who had a C-section. Sometimes results are contradictory.
The “Term Breech Trial” reported on rates of urinary incontinence. The study found that women who delivered by C-section had lower rates of urinary incontinence in the months following the delivery. However, the incidence of urinary incontinence was the same among those two groups of women five years later.
A different study that followed women for 5-10 years after delivery found a significantly higher risk. The risk of urinary stress incontinence was at least 2.9 times higher, and pelvic organ prolapse 5.6 times higher for the women who had a vaginal birth when compared to the women who had a C-section without labor (Source article).
I think the jury on this topic is still out. Still, the available data and physiologic mechanisms of those problems suggest that the c-section may be beneficial if you want to avoid pelvic floor disorders.
Reductions in early post-partum bleedings and other maternal conditions.
In 2010, Geller published data gathered from over 26000 deliveries between 1995 and 2005. He compared results between two groups: planned vaginal delivery and planned C-section based on the intent to deliver one way or the other and not on the final mode of delivery.
The group with planned cesarean delivery had lower rates of chorioamnionitis (maternal infection) at 2.2% versus 17.2% and post-partum bleeding at 1.1% versus 6%.
Unsurprisingly, the group with planned C-section delivery had more extended hospital stays at 3.2 days versus 2.6 days for the group with intended vaginal delivery.
In addition, researchers found that if the cesarean section was performed on women who already entered labor, it was associated with increased risks compared with both vaginal delivery and planned cesarean section without labor (Source article).
What are the potential adverse outcomes of C-section on request?
Increased risks of placental abnormalities in future pregnancies.
Each surgical procedure carries some risks for the woman’s future health and future pregnancies. It is well established now that having one cesarean section or more increases woman’s risk of having abnormal placenta attachment during future pregnancies (placenta previa or placenta accreta). Both types of placentas may be associated with massive bleeding, severe complications, and the need for removal of the uterus during the subsequent vaginal delivery or cesarean section.
Although the risks mentioned above are not that high in absolute numbers, it is indisputable that they exist. The risk of placenta accreta with the second C-section is 0.3%, with the third C-section 0.6%, and with the 4th C-section is 2.1% (Source article)
Increased risks of uterine rupture with future pregnancies during natural labor.
Having a cesarean section in the past puts you at an increased risk for the rupture of the uterus if you choose to try vaginal labor during future pregnancies. The scar that formed from the healed incision of the uterus made to remove the baby makes uterus weakened and increases the chances of uterine rupture during labor.
Complications of anesthesia.
Like with any surgery requiring anesthesia, there is a possibility of developing side effects from the anesthesia. People may have an allergy to a medication, get an inappropriate dose of drugs given by mistake, or react with a sudden drop of blood pressure. Of course, most of these reactions are treatable but still sometimes dangerous.
The longer recovery period after C-section.
Recovery from the delivery and needed hospitalization are unsurprisingly longer for the women who underwent a cesarean section. After surgery, women need a more extended hospital stay to achieve appropriate pain control and be watched for complications of operation such as bleeding or wound infections. The good news is that three months after the surgery level of pain in a group of women with natural birth and group with a C-section delivery are the same.
Complications related to adhesions post-surgery.
Each abdominal surgery, including C-section, is associated with adhesions, making it more difficult for a surgeon to do a future operation in the same area. A large number of adhesions can increase the risk of bladder or bowel injury during future surgeries.
There are reports that up to 24% of women have adhesions during the 2nd C-section and up to 42% of women during their 3rd C-section. Each subsequent surgery in the presence of adhesions will take much more time to perform due to those difficulties (Source article).
Complications related to the incision area.
Any incision on your abdomen may be the location of the future abdominal hernia. In addition to that, a scar and damage to the nerves caused by the incision may lead to numbness in the surrounding area of your skin.
Increased risk of respiratory problems in a child.
Babies who are born by scheduled or requested C-sections without labor have a higher incidence of respiratory problems right after birth. During labor, mother and baby secrete various hormones that influence the production and absorption of fluid in the baby’s lungs.
An increased amount of lung fluid contributes to the baby’s respiratory problems. The incidence of respiratory problems in babies increases with the decreasing gestational age at the time of birth. Thus, scheduled c-sections before 39 weeks of gestational age are strongly discouraged unless there is a good medical indication to deliver baby earlier than that.
Also, there are reports that children who were born by cesarean section tend to have a higher incidence of asthma before 12 years of age. The exact mechanism of that is unknown.
Baby is not exposed to maternal microbial flora.
Some mothers who wanted vaginal delivery and ended up having C-section are very concerned about their babies not being exposed to their genital microflora. As we are getting more knowledge on the importance of our microbiome or bacteria that colonize our bodies, that concern may garner more attention in the future.
In my opinion, we do not know enough about this subject yet, to say how concerned we should be. There may be a solution to this concern as well. People find artificial ways of colonizing the baby with the mother’s microflora. Unfortunately, the safety and efficacy of those techniques have not been studied well.
Is maternal mortality rate affected by C-sections on request?
The available evidence indicates that there is no significant difference between the mortality of mothers delivering baby vaginally and mothers having a scheduled C-sections.
It seems that modern anesthesia techniques and available post-surgery monitoring affected the safety of scheduled C-sections positively. One needs to remember, though, that the risk of death for women during or after the c-section, and during natural labor still is real.
When should C-section on request be scheduled?
If there are no medical indications to deliver baby before the due date, scheduled or “requested” C-section should never be performed before completed 39 weeks of gestational age. A baby who is born before 39 weeks has a much higher chance of developing respiratory problems after birth. Some of these breathing problems will require treatment with oxygen, ventilator, IV fluids, antibiotics, and will result in prolonged hospitalization.
Can obstetrician deny your request to have a C-section without clear medical indications?
At this time, it is acceptable for an obstetrician to refuse to do a C-section on request since it is a surgical procedure not medically indicated. However, if requested, your obstetrician should be able to refer you to a provider who would perform the C-section provided you are fully aware of all the risks.
Summary:
Can You have a C-section on request? Yes, you can. Once you prove that you are aware of the risks associated with it, you should be able to find an obstetrician who will do it for you. In the era when doctors try to be more mindful of choices made by their patients, most likely, you will be able to find an obstetrician who will respect your choice.
You should also know that studies cited to describe potential benefits and risks associated with the C section on request are sometimes of questionable quality.
If you would like to know what are all medical indications to have a C-section, read my article on this topic here.
Disclaimer:
This article is only for general information purposes. It should not be viewed as any kind of medical advice. There is a chance that information here may be inaccurate. You should always discuss all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.