Infectious Disease

Specialists focus on the advantages and dangers of a caesarean part

January 05, 2021

5 min read

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Disclosure:
Neale does not report any relevant financial information. Miller reports that he has received funding from the DHB Foundation. In the study you will find all relevant financial information from all other authors.

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In the US, almost a third of deliveries in 2018 – 31.9% – were made by caesarean section, according to the CDC.

Several studies have been published that suggest that children born via a caesarean section are at increased risk of developing certain conditions.

Even so, the American College of Obstetrics and Gynecology (ACOG) estimates that 2.5% of all births in the United States are elective caesarean deliveries performed at the mother’s request. In its clinical guide, updated in 2019, ACOG recommended that a maternal-requested caesarean delivery should not be performed before the 39th week of pregnancy. Due to the high rate of repeated Caesarean sections, doctors should discuss increased risks with each subsequent Caesarean section.

In 2015, the WHO recommended that caesarean sections only be performed if medically necessary, due to the possible short- and long-term health risks for mothers and children.

Healio Primary Care spoke to experts to learn more about the effects of caesarean section on mothers and children, and what doctors should say to patients requesting a caesarean section when it is not medically indicated.

Medical indications for caesarean section

Donna Maria Neale, MD, The Assistant Professor of Obstetrics and Gynecology and Maternal Fetal Medicine at the Johns Hopkins School of Medicine told Healio Primary Care that caesarean sections are sometimes required to “keep the mother and child safe.” The most common reason, she said, is when a woman is in active work and her cervix stops expanding.

“These would likely be women who, before we had a caesarean delivery technique, would not survive the labor process, because if their cervix did not fully expand to allow the baby to deliver, infection and / or bleeding would result occur. This leads to the death of the fetus and / or the mother, ”said Neale.

She added that if the fetus is not coping well with labor, the delivery may need to be speeded up by caesarean section, especially if the mother is “distant from childbirth, that is, not giving birth quickly”.

Some fetal presentations also indicate when a caesarean delivery is required. For example, if the baby is in a horizontal position, that is, if it is lying across the uterus, the cervix can never expand so far that a safe vaginal birth is possible. Additionally, in some occlusion presentation cases, a caesarean section is required, Neale explained.

Maternal conditions that dictate the need for a caesarean delivery include certain cardiac or neurological conditions that could be aggravated by pressing during delivery. Or, explained Neale, if there is an abnormal implantation of the placenta such as placenta previa or placenta accrete, then a caesarean section is indicated.

Women who have previously had uterine surgery with cuts in the body of the uterus also need a cesarean section. For example, Neale said that if a woman “had a myomectomy before pregnancy and the myomectomy was such that the uterine cavity was entered, she must have a cesarean section. Similarly, women who have had a previous classic caesarean section or utero-fetal surgery will need a caesarean section for delivery. “

She added that certain fetal abnormalities, particularly those affecting the central nervous system or the anterior abdominal wall, would require a cesarean section.

Childhood Risks of a Caesarean Section

Previous studies have linked cesarean delivery to adverse events in children, including an increased risk of developing allergies, obesity after 12 months, respiratory infections, and asthma.

Recently, a study published in Science Translational Medicine found that the association between caesarean sections and an increased risk of asthma in childhood may be caused by differences in a child’s gut microbiome, since the birth canal microbiome is not exposed during vaginal delivery.

Caesarean sections are also linked to an increased risk of transient tachypnea in the newborn, Neale said. That risk, she said, is that these infants won’t “skip over their breathing status because crossing the birth canal squeezes the normal fluid in the airway and cesarean delivery doesn’t give you that squeeze. “

Another study published in PLOS Medicine found that children born via a caesarean section were at higher risk of infection-related hospitalization than children born vaginally.

Photo by Jessica Miller

Jessica Miller

“Our study was an observational study suggesting some possible mechanisms, particularly the microbiome in early life, that could be targets for future interventions to optimize the microbiome and immune function of newborns.” Jessica Miller, MPH, PhD, A postdoctoral fellow at Murdoch Children’s Research Institute at Royal Children’s Hospital in Parkville, Australia told Healio Primary Care.

The study, which included data from Denmark, Scotland, England and Australia, included single births from 1996 to 2015. Of the 7,174,787 births examined, 23% were cesarean sections; 43% of these caesarean deliveries were electives.

The researchers found that in children born vaginally, in children born by caesarean section, the risk of at least one infection-related hospitalization (HR = 1.10, 95% CI, 1.09–1.12) im 5 years old was 10% higher. The risk was higher for both elective (HR = 1.13; 95% CI, 1.12–1.13) and emergency (HR = 1.09; 95% CI 1.06–1.12) cesarean sections than during vaginal delivery.

“The absolute risks for children born through a caesarean section are small,” Miller added. “Children born by caesarean section should not be treated differently. All parents should be aware of the danger signs of more severe infection in their children, and children should be vaccinated fully and on time. ”

Maternal Risks, Concerns

Neale said caesarean sections benefit women and children when medically necessary. “But for a healthy woman with a normally grown fetus that is structurally normal, I don’t know that there are any advantages to elective caesarean delivery.”

She added that there has been an increasing trend in recent years among women requesting a caesarean section and that doctors needed to remind them of the risks of those deliveries.

“Although caesarean sections are common and well done, there is always a risk of surgery in the US, so if you don’t have to have surgery, you don’t want to take those risks,” Neale said.

These risks include infection, injury to other organs, and bleeding. Bleeding is a leading cause of maternal mortality in the United States and the leading cause of maternal mortality worldwide.

Studies have also shown that women are prescribed opioids after having a caesarean section. Although attempts have been made to reduce their exposure, efforts are still needed to reduce persistent opioid use in these women.

“As a provider, we always want to use a shared decision-making model in our patient care,” said Neale. “We want to hear the patient. We want to hear your reasons for elective surgery. Our responsibility to our patients is to make sure they understand the risks, benefits, and alternative options in order to make informed decisions. “

In her experience, Neale said that the desire for an elective cesarean section often stems from a woman’s fear of pain during childbirth and delivery.

“This is where educating the patient about the tools we have in our toolbox to help women achieve safe, (relatively) painless vaginal births can go a long way,” she added.

Another reason some women request an elective cesarean section is because they are survivors of sexual assault and abuse and fear that the labor process could trigger memories and physical manifestations of their trauma, according to Neale. That’s why when a patient asks about an elective caesarean section, she said, “It’s not a dogmatic no.”

“While not recommended, I think it allows a conversation between the patient and the provider to see where that desire is coming from,” she said. “Our primary goal as obstetricians is to keep the mother and fetus healthy during pregnancy and delivery. Additionally, it is our responsibility as a healthcare provider to ensure that our patient understands the risks and benefits of the procedure and can make informed decisions with the most accurate and up-to-date information. “

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