Cesarean delivery reduces some risks, raises others

As health care practitioners, ob.gyns. must continually evaluate potential consequences of a management strategy to our patients’ health and well-being. This is especially true when determining the best method of delivery – vaginal or cesarean section – because our approach can affect not only the mother but also the baby.

It is well known that vaginal deliveries can be associated with long-term complications for women, including pelvic floor disorders (that is, prolapse), pelvic injury, and incontinence. For women who have undergone a cesarean section, the uterine scars caused by the surgery can lead to increased risk for placenta previa or, more seriously, placenta accreta, as well as possible miscarriage or stillbirth.

If a cesarean section is indicated cause of fetal size, such as large for gestational age or macrosomia, greater risks exist for the child developing overweight or obesity, or metabolic syndrome and possibly diabetes, later in life. In addition, whereas babies delivered vaginally have fluid expelled from their lungs during the birthing process, babies delivered by cesarean section do not. This can predispose the child to develop respiratory conditions.

Because the best possible care must also be informed care, every ob.gyn. should conduct periodic reviews of the scientific literature. Research continually advances our knowledge and our practice. For example, the recent work on the use of statins to prevent preeclampsia is an area of intense interest. Although we’ve known about hypertensive disorders of pregnancy for many years, management and prevention strategies are adequate at best. This new and exciting line of research has the potential to solve a conundrum we’ve grappled with for centuries.

The study by Keag et al. analyzes the findings from observational studies on the risks and benefits of cesarean versus vaginal delivery, within certain limitations. The study authors found that cesarean deliveries are associated with lower risk of urinary incontinence and pelvic prolapse, but higher risk of placenta previa, miscarriage, and stillbirth. Additionally, the authors reported that babies delivered by cesarean section had a higher risk of developing asthma and obesity.

Although the results of the study are not surprising, the findings reinforce the idea that ob.gyns must make decisions on a case-by-case basis and on obstetrical indications. We cannot use a set of possible complications as a reason to choose one delivery route over another. Every patient is unique. Every circumstance is unique. Every delivery requires us to make an informed decision to achieve the best possible outcome. Otherwise, we run the great risk of doing a disservice to our patients and their families.

E. Albert Reece, MD , PhD, MBA, specializes in maternal-fetal medicine and is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He has no relevant financial disclosures.