Cesareans: Are Cesareans Really a Safe Option?

Lately, prominent obstetricians, including Dr. Benson Harer, the president of the American College of Obstetricians and Gynecologists, have been waging a campaign intended to increase our already outrageous cesarean rate. They are trying to convince the public that cesarean section is so safe, and vaginal birth so injurious to mothers and babies, that women should not be deprived of cesareans on demand. An article in the December 4, 2000 Newsweek and Harer's appearance last summer on Good Morning America are cases in point. Without access to the obstetric research, their arguments for the benefits of c-sections seem reasonable. In my opinion, this is on a par with tobacco company spokespeople of yore claiming that cigarette smoking improved lung function.

Does Vaginal Birth Injure the Mother?
The belief that vaginal birth harms women has come largely from the observation that women tend to have weaker pelvic floors shortly after vaginal birth than women having planned cesareans. In addition, many older women experience uterine prolapse (the uterus sags into the vagina) or urinary or anal continence problems (incontinence of gas, urgency, or fecal incontinence) related to weakness or injury. This has led some obstetricians like Dr. Harer to leap to the conclusion that planned cesarean is protective.

To begin with, vaginal birth probably has some adverse effects, as does pregnancy, in that some women develop urinary incontinence during pregnancy. However, the main source of problems is obstetric management, principally the largely unnecessary, but still common, practice of episiotomy. None of the justifications for its routine or frequent use are supported by the medical research (9,12,14,37,42), and women with no episiotomy have the strongest pelvic floors after childbirth (23). This should not come as a surprise. Logic dictates that cutting muscles would weaken them. Moreover, episiotomies can extend, tearing into, or through, the anal sphincter. Anyone who has ever snipped a piece of cloth in order to tear off a length will readily understand why. Anal sphincter injury almost never occurs except as an episiotomy extension (22), and anal tears permanently weaken the sphincter. Even without extending, episiotomy can cause hidden injury to the anal sphincter (35). Forceps delivery can also do considerable genital damage and anal sphincter injury, as, to a lesser degree, can vacuum extraction (6,19-20,38,41).

That older women have problems due to weak pelvic floor muscles and injury is a moot point. They all had large episiotomies with each birth, and many had routine forceps deliveries as well. In addition, the command to begin prolonged straining at full dilation, in defiance of any natural urge, would seem to be a recipe for overstressing pelvic floor muscles and connective tissue. So would pushing while lying flat or nearly flat on one's back, which means pushing the baby uphill. As with episiotomy, no evidence supports either practice, yet they were universal until recently, and are still the norm in most hospitals today.

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