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Dr. Jones: Okay, today is a quiz. True or false, question one, is a cesarean the safest way to deliver a baby? Question two, are there too many cesareans being done in the US?
Well, the answer to the first is true and false, about the safety of cesarean. But the answer to the second, are there too many cesarean deliveries done in the US, is very probably true. How many births in the US are done by cesarean? What was it in years past and why has it changed and what are the risks? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care. How should your baby come out? And this is The Scope.
So, how many cesareans should be done for the safety of the baby and the mom? The United Nations world health report in 2010 suggested that a cesarean rate of about 15% should be about right. And Scandinavian countries with the best maternal and child mortality rates in the world–Iceland, Sweden, Norway–get it right at about 15-17%. The United Kingdom comes in at 22%, Canada at 28%, and the US comes in at 33%.
The UN calculates a cost of about $687 billion. Let me say that again, $687 billion extra dollars in US health care for what might be extra cesarean deliveries over 15%. In 1965, the C-section rate was about 4.5%, 17% in 1985, and now we’re at 33%. Our maternal and baby health hasn’t increased significantly since 1980 and the C-section rate has.
First of all, Utah is doing great. We have the third lowest rate of cesarean births in the United States at 23.1%. Good for us and our doctors and our mothers. Alaska has the lowest at 22.6%, closely followed by New Mexico at 22.8%. Kentucky comes in at the highest at 39.7%. Brazil comes in at 46% with 82% of women who live in Rio de Janeiro with health insurance being delivered by cesarean. What’s up with that?
So, should we worry? Is cesarean safer? Certainly for some women and babies it is, and that’s where the 15% comes from. Babies coming out sideways, babies that are too big, babies in fetal distress, moms who are very sick and need to get delivered right away. Okay, that’s where the 15% are. But all things considered, a vaginal delivery is safer for the mom and not riskier for the baby. In fact, scheduled repeat cesarean sections may be done too early and the babies aren’t ready yet. So, what are the risks of cesarean? Well, for the moms, slightly higher risk of hemorrhage and infection and severe illness and death. For the baby, it’s the risk of being born too soon. And there’s an increased risk of problems with the placenta in pregnancy after the one with the cesarean.
So, one-third of cesareans are done for what doctors have called labor arrest, meaning the mom isn’t making progress quickly enough. So, the question is, fast enough for whom? The doctor? The mom? This is where we could make some changes. ACOG, the American College of OBGYN, recommends that the first part of labor, when the cervix is starting to open, should be extended to 6 centimeters. This is the time when normally labor takes a while, and we should just wait and let it happen if the mom and baby are okay.
Secondly, the pushing stage can go on longer. It used to be said that if a woman hadn’t pushed her baby out in two hours, then you should consider a cesarean. This was never really true and if mom and baby are okay, this stage can do on for three hours or longer. Then, women with an epidural are going to take longer and moms and doctors should be patient. Lastly, but very importantly, induction of labor, labor that’s started by the doctor, shouldn’t happen except for good medical reasons. Labors that are induced take longer. Moms and doctors should be patient.
No mom wants to be pregnant one minute longer than necessary, but unless there are good medical reasons, moms and their doctors should wait until the body and the baby think it’s time. A natural labor may go better. So, we should save cesarean operations for women and babies who really need it. Moms and doctors need to be patient. A scar on the uterus isn’t the best thing for the next baby coming. This is Dr. Kirtly Jones and thank you for joining us on The Scope.
Published: Apr 4, 2014. By University of Utah Health Care
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