Cesarean; America's Favorite Surgery

C-Section Too Early Risks Baby's Health
Babies Born by Surgical Delivery Before 39 Weeks May Suffer Health Problems
By AUDREY GRAYSON
ABC News Medical Unit

Jan. 7, 2009—

When 37-year-old Alicia Cooney of Cleveland was pregnant with her first child in October 2007, her doctor expressed no concern about scheduling her Caesarian delivery, or C-section, just 38 weeks into the pregnancy.

But when Cooney became pregnant with her second child last April, her doctor was singing a different tune about when to schedule a C-section.

"I did notice a change within the hospital that they really wanted to make sure my C-section wasn't before 39 weeks," Cooney explained.

Cooney said that her doctor expressed concern about the increased risk of wet lung -- or an accumulation of fluid in the newborn's lungs -- in babies delivered by C-section before 39 weeks of gestation.

Cooney's doctor may not be alone in changing his practice in the face of these risks. On Wednesday, a new study published in the New England Journal of Medicine found that C-section delivery before 39 weeks of gestation is, indeed, linked to increased health problems for babies.

According to the National Institutes of Health, a pregnancy of normal gestation lasts about 40 weeks, with "normal" pregnancies ranging from 38 to 42 weeks.

A team of researchers lead by Dr. Alan Tita from the department of obstetrics and gynecology at the University of Alabama at Birmingham examined the results of 13,258 women who had a scheduled, repeat C-section that was planned for no other medical reason than the fact that the woman had previously had a C-section.

The researchers found that, compared to babies delivered by C-section at 39 weeks of gestation, those born at 37 or 38 weeks had a higher rate of breathing problems, blood sugar problems and serious infections. Moreover, those babies were more likely to be admitted to the neonatal intensive care unit.

"Early elected delivery is associated with adverse outcomes for the baby," Tita explained. "And the earlier you deliver, the higher it increases the risk."

These findings are in line with current recommendations by the American College of Obstetricians and Gynecologists (ACOG).

Yet despite the long list of potential complications associated with C-section delivery before 39 weeks, the study also found that a large number of the women studied -- 36 percent -- chose to schedule a C-section delivery before 39 weeks anyway.

"I have seen women induced or have a scheduled C-section because they have family scheduled to be in town, because they want the baby to be born on an anniversary or someone else's birthday, because they want the baby born prior to Jan. 1 for tax purposes, or because they are simply sick and tired of being pregnant," said Dr. Elaine St. John, associate professor of pediatrics in the Division of Neonatology at the University of Alabama at Birmingham.

Other experts say that the increase in C-sections before 39 weeks is due to a lack of understanding of the dangers associated with elective late pre-term birth.

"Most women think the risks to their babies are the same whether the babies are delivered four, three, two or one week before the baby is due," explained Dr. Sessions Cole, director of the Division of Newborn Medicine at the St. Louis Children's Hospital. "This study should help mothers understand that there are significant risks to their babies associated with elective late preterm birth."

Patient Pressure Figures Big

Approximately 30 percent of all babies born in the United States are delivered by C-section. A study published in April 2005 in the journal Obstetrics and Gynecology found that elective C-sections accounted for about 28 percent of all C-sections performed in the U.S. in 2001.

However, many experts report a growing trend toward encouraging women not to schedule an elective C-section before 39 weeks at hospitals all over the country.

"The recommendations for years have been to avoid elective delivery of any kind until after 39 weeks," said Dr. Lisa Jones, a gynecologist at the New Bedford Community Health Center in New Bedford, Mass. "So all this study really does is reinforce what we already knew."

Still, some experts say that the power of maternal insistence in scheduling an early C-section is enough to convince many doctors to go along with their patient's wishes.

"I think the practice of early [C-section delivery] will only end if hospitals ban the practice," Holzman said. "There is little reason for [obstetricians] to stop since they are often pressured by patients."

The study also outlines some of the risks women must consider when opting to deliver by C-section after 39 weeks.

According to Tita, one such risk is having an unexplained stillbirth while waiting for the 39-week-mark to deliver. This risk is very small, but Tita said that it is still best for women to follow ACOG recommendations by waiting the full 39 weeks before delivering by C-section.

Early Surgical Delivery Sometimes Appropriate

There are, however, certain instances in which an early delivery is appropriate.

"If there [are] firm medical indications of risk to the mother's or fetus's ... health [such as] worsening maternal high blood pressure [or] lack of fetal responsiveness ... then delivery is indicated," Cole explained. "However, the risks of these conditions should be weighed against the risks described by this study."

Moreover, Holzman said, "For most of these [conditions], the risks to the fetus in delaying [delivery] are well known and predictable."

Many experts ultimately hope that this study will prove to the public that the risks of early C-section delivery greatly outweigh the benefits in most cases.

"Hopefully articles like this will help educate the general public and fewer babies will be placed at risk in the future," said Dr. Patricia Chess, associate professor of pediatrics at the University of Rochester Medical Center.

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