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No Clear Advice on Elective C-Sections

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WASHINGTON (AP) _ Women who want several children should avoid the new trend of purely elective Caesarean sections _ planned surgical births when there's no clear medical need _ government advisers said Wednesday.

But for mothers-to-be who plan only one or two children, there's too little research to say definitively whether it's a good or bad idea.

So concluded scientists assembled by the National Institutes of Health who spent three days hearing an impassioned debate on the apparent rise in elective C-sections _ only to conclude there are few easy answers.

``We don't believe it should be discouraged or encouraged,'' said Dr. Mary D'Alton, obstetrics chief at Columbia University Medical Center, who chaired the panel.

Instead, there are important pros and cons to different methods of childbirth, and women and their doctors must have ongoing, honest discussions to tailor the choice, the panel said.

``There's not one right answer for everyone,'' said panelist Barbara Hughes, a nurse-midwife at the University of Colorado Health Sciences Center.

Caesarean rates have reached an all-time high, 29 percent of U.S. births _ a 40 percent increase since 1996, and a rise that shows no sign of tapering off.

No one knows exactly how many of those C-sections are purely elective, although some studies suggest there may be 80,000 or so a year. Convenience, the need to schedule care for other children, distance from a hospital, or fear of something going wrong during labor are all reasons doctors hear.

Amid the uncertainty, the NIH convened specialists to determine just how much is known about the risks and benefits of a pre-planned Caesarean in a woman who medically doesn't need one, and how to ensure that women get those facts.

Make no mistake: A C-section can be life- or health-saving for many mothers and babies. Fetal distress, twins or more, or diseases that make labor risky for the mother are important reasons to have one.

But a Caesarean is major abdominal surgery that poses some rare but serious, occasionally life-threatening, side effects, such as hemorrhage, infection and blood clots. Perhaps of bigger concern as the Caesarean rate rises, each C-section a woman has increases the risk of complications in future pregnancies.

The panel's chief recommendations:

_That risk to future pregnancies means that women planning more than one or two children should not have a purely elective Caesarean. Topping the concern is that a prior Caesarean significantly increases the risk of a life-threatening placenta problem in a later pregnancy.

_Newborns are more likely to have respiratory problems if they're born by Caesarean, regardless of the reason for the surgery. So doctors should perform elective C-sections only if they're sure the woman has reached at least 39 weeks of gestation, when fetal lungs are fully mature.

Full-term pregnancies are typically defined as lasting 40 weeks from the start of the last menstrual period, but gestational age can be difficult to measure correctly. The March of Dimes last week reported that most births now take place at 39 weeks, a change the nonprofit group attributed in part to pre-planned C-sections, which it fears also may drive inadvertent delivery of slightly premature babies.

_Doctors should never bring up the option of a purely elective C-section. But if a mother-to-be requests one, the health provider should determine her reason for the request and help weigh the risks and benefits.

_If the woman's reason is a fear of pain during labor and delivery, doctors should help her choose from among the multiple safe options to avoid that; pain-numbing epidurals are the most effective. Caesarean recovery can be painful, too.

``No woman who wants pain relief should be made to suffer the pain of childbirth today,'' stressed Dr. David Birnbach, an anesthesiologist at the University of Miami.

The panel called for more research comparing how mothers and babies fare when similarly healthy women either pre-plan a Caesarean or a vaginal birth, including strategies that influence a successful vaginal birth. It urged the government to open a consumer-friendly Web site that would help women weigh scientific evidence in choosing.

Caesarean critics questioned what was a purely elective Caesarean, telling the panel that many women feel pushed into a surgical birth by doctors who don't like middle-of-the-night deliveries.

``When a woman cannot trust her provider, it's time for her to get another provider,'' responded Dr. Vern Katz, perinatal chief at Sacred Heart Medical Center in Eugene, Ore.

It is hard to define a purely elective Caesarean, D'Alton said. Obese women, for instance, are more prone to complications that may make them C-section candidates even though obesity itself isn't a clear medical need.
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