Pure Pedantry

There is a big controversy among doctors and patients as to the wisdom of C-section vs. vaginal delivery. It is a complex issue.

For the first birth, there is no evidence that I am aware of that C-section or vaginal delivery are superior to one another with respect to the child’s health. Still, this is a point that is endlessly disputed in malpractice proceedings against obstetricians. You can always argue that the failure to do a C-section resulted in this or that problem in the baby. (We’ll get back to that.)

From the mother’s point of view, C-section can have numerous and severe consequences for the mother — it is a surgical procedure after all — but so can vaginal delivery. Damage to the pelvic floor during vaginal delivery can cause problems with urinary retention and sexual side-effects that many women find unacceptable. This is not even mentioning the ass load of pain involved.

The number of C-sections has been increasing over the last several decades in part due to elective C-section at the first pregnancy and in part due to C-section following a previous C-section. The reason for the second group is because, depending on the type of incision used in the earlier C-section, there is a chance that the uterus will tear if the woman follows a C-section with vaginal delivery. Controversy exists as to the costs and benefits in this case.

I can’t really speak with authority either for or against the use of C-sections in any specific case, but this article caught my eye. The researchers performed MRIs on asymptomatic newborns after vaginal delivery. They found that there was a higher incidence of intracranial bleeding in the infants delivered vaginally:

The first researchers to use magnetic resonance imaging (MRI) to study the brains of a large group of babies soon after birth found a small amount of bleeding in and around the brains of one in four babies who were delivered vaginally. The study appears in the February issue of Radiology.

“Small bleeds in and around the brain are very common in infants who are born vaginally,” said John H. Gilmore, M.D., professor of psychiatry and Vice-Chair for Research and Scientific Affairs at the University of North Carolina School of Medicine in Chapel Hill. “It seems that a normal vaginal birth can cause these small bleeds.”

For the study, 88 asymptomatic infants, equally divided between male and female, underwent MRI between the ages of one and five weeks. Sixty-five had been delivered vaginally and 23 had been delivered by cesarean section. MR images showed that 17 (26 percent) of the babies who had been delivered vaginally had intracranial hemorrhages (ICH), or small bleeds in and around the brain. Seven infants had two or more types of ICH. Prior studies have shown a smaller incidence–approximately 10 percent–of intracranial hemorrhage associated with vaginal birth.

While ICH was significantly associated with vaginal birth, it was not dependent on prolonged duration of labor or on traumatic or assisted vaginal birth.

“In our study, neither the size of the baby or the baby’s head, the length of the labor, nor the use of vacuum or forceps to assist the delivery caused the bleeds,” Dr. Gilmore said. “The bleeds are probably caused by pressure on the skull during delivery.”

In a newborn, the bones of the skull have not fused together, so the bones of the skull can shift and frequently overlap each other during vaginal delivery, to allow the baby’s head to fit through the birth canal. This shifting can compress the brain or cause blood vessels to tear, which causes bleeding.

Most of the bleeds identified were very small subdural hematomas–bleeding between the brain and the thick membrane that covers the brain below the skull–and a majority of them were located in the lower, back part of the brain over the occipital lobe or the cerebellum, which is below the occipital lobe.

Typically, small bleeds resolve over time without causing problems, though larger ones may cause problems later in the child’s life, including seizures, subtle learning problems or problems with motor development.

“We just don’t know at this time what these bleeds may mean over the long term,” Dr. Gilmore said. (Emphasis mine.)

Here is a link to the article in Radiology.

This is the first study that I have read suggesting that C-section might have health benefits for the child, but I emphasize the last sentence because we really don’t know what the consequences of these bleeds may be for the child over the long-term.

However, the fact that we don’t know what the consequences is not likely to discourage malpractice attorneys from suing OBs based on studies like this. Unfortunately, I feel like any study related to problems in newly born infants will be inevitably misused.

The more important concern is to not let that fact discourage us. We need to see studies like this through to the end. We need to actually determine whether these bleeds are affecting the infants in a negative way. If they are, we need to do something about it. Just because science is going to be misused does not free us from the need to find answers not based on speculation.

Comments

  1. #1 quitter
    January 31, 2007

    Interestingly, in the last year I saw in article, I think in NEJM, studying women who had delivered only by C-section vs women who had vaginal deliveries. In terms of problems with urinary incontinence, pregnancy itself seemed the be the variable, with women who had C-sections having the same rate of urinary incontinence in later life compared to those who had a similar number of vaginal deliveries.

    I thought the main arguments for it was is safer, but that the recovery from the surgery was much longer and more painful than recovery from vaginal delivery.

  2. #2 RPM
    January 31, 2007

    I’ve heard that vaginal delivery introduces microbial parasites to the newborn infant, thereby strengthening the immune system. Any truth to that?

  3. #3 Jake Young
    January 31, 2007

    RPM,

    So it is true that vaginal delivery introduces pathogens into the infant. I am not certain whether there is an immune system component, but what they do is become the local colonists of the gut — preventing other more serious infections from taking hold.

    However, this can be a double edged sword. Sometimes women have vaginosis — a change in the character of the bacteria that normally infect the vagina. Vaginosis and other infections of the vagina have been associated with higher mortality in infants.

    Also, there is an added complexity of breast feeding. Whether you breast feed an infant affects what kind of gut flora they get.

    Because it is such a complex issue with good arguments either way, I don’t think that gut flora will factor in largely into the decision about whether to have vaginal delivery.

  4. #4 Jeanne
    February 1, 2007

    The component that is rarely mentioned when comparing vaginal delivery to c-section delivery is the recovery. While there certainly are women who heal quickly and are back to themselves in just a few weeks – many women are stunned by the pain and long recovery time. In the US, where many women get only 6 to 12 weeks of time at home before returning to work, the recovery from major abdominal surgery can color much of that precious time with their baby.

    Jeanne (creator of C-Section Recovery.com)

  5. #5 Colin K N A U F
    February 1, 2007

    The study on inter-cranial hemorrhage is an interesting bit of science. At first reading it looks to be very self serving. Many studies foisted upon us by the merchants of fear try to convince us that our industrial model of birth is best, then in vain try to support it with studies such as this.
    First off…it would be unlikely that any of these babies with ICH were born at home. If they had they would never have been in the study. If these births were obfuscated by the effects of induction, the births would be most likely be more traumatic.
    With the endocrine system at odds with the muscle contractions created by pitocin etc. the birth in all likelihood would be more difficult. Ligatures, cervix etc would not be bathed in the natural birthing cocktail to stretch/ripen in order to ease the delivery. The prolonged delivery would likely introduce the ICH and a lot of other complications, I would think.

    To have any validity the study would have to include vaginal births from outside of the medical model of hospital birth.
    As far as long term effects. We already have those studies: we have birthed naturally for over 120,000 years, surely that is long enough to know the long term outcomes!
    The longer term outcome is larger foreheads than Neanderthals.
    The real question:….. is that brilliance and larger brains or pooled blood from ICH?

    We also know the long term damage and outcomes from industrial birthing and c-section.
    The toll taken upon our health and well-being is inestimable. The profits to the pharmaceutical industry likewise are inestimable. (number two profit centre globally…only next to war armaments: in first place!)

    I would love to see a study on the rate of c-section and the rate of nuclear proliferation.

    The US has a c-section rate of 30% and Nuclear War Heads (listen to that phrase a minute: “war heads”!)
    90% of moms and babies meet each other for their first time and most significant meeting DRUGGED.
    We have 60% divorce rate….

    Korea has a c-section rate of 40% and now has Nuclear War Heads. The new threat to global peace and health.
    The new American Wanna-bees!
    They have more cars now too….but no place to drive them.
    Electric corkscrews won’t be far behind.

    Lets do more studies and put the truth forward.
    Our culture of profane profit dominating prudence and people has to stop.

    Lets present a culture to the world worth emulating.
    Not one that spends 100 million dollars an hour on the war effort.

    Natural birth is a HALLMARK OF PEACEFUL NATIONS!

    Lets start raising our children naturally,
    as intended, before we raze the planet.

    Pure Pedantry: Comment on Is C-section safer than vaginal delivery?

  6. #6 Sowmya
    February 1, 2007

    There was a recent study by Marian Macdorman et al which said “Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62).”
    and the reasons

    “One cause which researchers have cited is that vaginal labor and delivery releases a hormone which promotes greater and healthier lung functioning. C-sections on the other hand do not release this hormone. Researchers also stress that the force on the infant during vaginal birth pushes fluid from the lungs and prepares the young child to breathe on their own, another thing c-sections are unable to accomplish. Other causes are associated with possible cuts to the infant during the c-section procedure and delayed time before breast feeding can occur.”

    I think human beings are very well equipped to deliver vaginally, we have done it for longer than c-section procedures have existed. If you look at the neonatal moratlity rates with c-section and vaginal delivery, one can see which is more to the baby’s advantage, when there are no other medical complications involved

  7. #7 Sean
    February 6, 2007

    Jake and RPM,

    There are some significant and potentially dangerous errors and omissions in your above discussion about vaginal pathogens and newborns.

    First, newborns essentially have no immune system until about 6 weeks of age. They get maternal antibodies from blood and breast milk. These antibodies provide some protection against infection, but nonetheless, newborns are at a real risk of serious bacterial infection. This is why when a baby under 4 weeks has a fever, he/she gets a full septic workup (blood and urine cultures and LP) and empiric broad-spectrum antibiotics. Also, most vaccines are given after 2 months of age for the very reason that there is not much of an immune response before then. Thus, there is no rationale for strengthening a newborn’s immune system by exposing it to vaginal flora.

    Second, vaginal flora do not become gut flora. Just as in adults, the two populations are generally distinct. This is why colonization of the vagina with gut flora (as in little girls who unwittingly wipe back to front) can cause vaginitis. C-section babies develop gut flora normally without any exposure to vaginal flora.

    Third, vaginal flora are not harmless to newborns, whether the mother has vaginosis or not. There are real and well-known risks to newborns from normal flora and from pathogens. It is standard care to treat newborns’ eyes with topical erythromycin or a similar antibiotic to prevent bacterial infection. Additionally, Group B streptococcus, part of the normal vaginal flora in about 25% of women, is a leading cause of neonatal sepsis. Pregnant women should routinely receive vaginal swabs to culture for GBS at 35-37 weeks of gestation. If they are GBS-positive, they should be treated with antibiotics prior to delivery.

    For scheduled C-sections in GBS-positive women, there is no significant risk of neonatal GBS infection and no need for antibiotics. For C-sections that occur after labor starts or membranes rupture (ie water breaks), there is still a significant GBS risk. Also, maternal HIV infection and active maternal genital herpes infection are indications for C-section as well. Because newborns are essentially immunocompromised, herpes infection can rapidly spread and lead to meningitis. Thus, the benefits of C-section over vaginal delivery to reduce the risk of neonatal infection in certain cases is well established.

  8. #8 Janine
    February 25, 2007

    As a former manager within a major hospital Network in Mellbourne, I remain staggered by the amount of money that is spent on researching science and the kind of research that is conducted.

    I agree with Colin that it is very self serving in many cases being the life blood of some universities and private organisations and the source of income of seriously well educated and well connected individuals. C-section definately has its place and saves very many lives when used appropriately. But I can’t help but think that research to justify it in anything other than emergency cases is just to serve the medical community so they can schedule themselves better (they are often poor time managers) and a growing number of women who seem to have children completely disconnected from the idea of it changing their lives or the idea of being a parent and think they want to schedule when they can bring this baby into the world and go back to work and “get on with their lives again”. Not to be skeptical but what kind of world?? Why have a babe at all?

    Just once I would like to see this kind of research conducted by a woman who had had a baby, or many babies and hey ho, what about one who has had a vaginal delivery as well as a c-section. Yes it is possible.

    I can’t get over the number of women who are of a decent size who are told they won’t be able to birth their child naturally and frightenend into having c-sections. As a mum who birthed one child in hospital and one at home (both vaginally) I would like to see some more fundamental research on homebirths versus hospital birthsand the differences in birth outcomes of babes. Especially since the medical system is struggling to support itself both funding wise (that is in terms of people actually attending hospitals not the research component) and in terms of availability of hospital beds!! Why do research the results of which may due to fear propose higher c-section deliveries on a system already bursting at the seams? Especially research which seems fundamentally biased and doesn’t talk in detail about the effects or otherwise of the “brain bleeds”.

    What is the effect of doing an MRI on a newborn for example? We are talking nuclear medicine on a precious little fragile babe when we are constantly told to have as few x/rays and the like tests as a robust adult as possible.

    I have also heard stories from women who have had c-sections who tell that they could feel all the jerking around inside their bodies and were watching the clock wondering what was going “wrong” when the c-section which was supposed to take 10 minutes was taking 45 minutes and no one bothered to think to talk to her about it during the surgery. Having seen a c-section delivery, I can see why many women stay sore for so long. To be honest, I have never seen such rough handling of a living human body, it is like unzipping a school bag, rummaging around inside for the book at the bottom and fishing it out before rezipping the bag up. The one I witnessed in a major metropolitan hospital with a specialty in womens health was to be honest frightening in terms of the level of apparent disrespect for the woman having the c-section.

    I also cannot help but wonder what might be the effect of the unfamiliar environment, level of pain management (to deaden the pain of childbirth for the mother eg peth, epidural etc) and the stress and fear created by many in the medical model on these intracranial bleeds. Is it caused by vaginal delivery really or all the alterations, modifications etc of the vaginal delivery and stress associated with the entirely unnatural environment of the medical model. A model predominated (without prejudice) by men who frankly are not good at dealing with others distress or pain and often I can’t help thinking that the pain management is more for the comfort of those present than the women giving birth.

    To what extent might brain bleeds be due to the inability of many women to fully participate in the birth due to the pain management they have received than the vaginal delivery in it’s “pure” form? What other factors/variables that have modified vaginal births might be contributing to the supposed higher incidence of brain bleeds of vaginal births. Also, what other factors such as smoking, drinking, poor nutrition and obesity during pregnancy might also contribute to these complications other than the “vagina” itself!! Also, in comparing the two, what are the detrimental effects of c-section delivery over vaginal delivery on the infant and mother.

    I seriously worry about fear mongering research that can be readily accessed by women trying to make complex decisions about birth that is so specific that it paints a biased picture about the risks of vaginal delivery compared to c-section delivery without qualifying itself in any way or at least pointing to other research which allows for more even consideration of these complex issues.

    Finally, I fear that in our hustle and bustle world where corporate rules and motherhood is just something we are supposed to fit in, expecting mothers are not supported during their pregnancy to make the most of the experience and prepare adequately for the birth, but instead continue on full speed through their jobs as if nothing is different and expect life to continue as it had in the past once the babe is born.

  9. #9 Organic Chemistry Help
    April 12, 2007

    One of the things the article does not address (I guess one could write an entire dissertation on the subject) is the effect of the anathetic on the baby for the first three days…I believe studies have shown that b/c the liver is so new that it does not handle the painkiller very well and this can have long term effects on the child’s ability to process toxins….i think.

  10. #10 ElaineS
    December 18, 2007

    Don’t forget when comparing the aftermath of vaginal to c-section deliveries to take into account how many of the c-section deliveries were ALREADY problematic & or emergencies. We can’t assume these c-section numbers were all planned healthy pregnancies. Diabetes, pre-eclampsia, and many more issues may have come into the picture unfortunately for the poor mother & baby. But this will of course affect the recovery time, emotional recovery, mortality & after birth statistics, etc.

  11. #11 Sanaz
    April 21, 2008

    Does anyone know much about the effect of c-sections on subsequent pregnancies? Im aware of the placental problems but are there any other complications?

  12. #12 Mary C
    July 2, 2011

    One school of thought is that it is unsafe for a women to attempt a vaginal delivery after a c section. I am sute there are reasons for this but a friend of mine had twins via c section, then another baby by c section. Hovever with her next baby she managed a sucessful normal delivery with no complications.

  13. #13 Alicia
    November 4, 2011

    I have had an emergency c-section around a year
    Ago & I am currently pregnant again (7mnth), my
    Cerserian caused my bladder to become stuck to my scar tissue,
    I have been told that I can have a normal birth,but when I ask my midwife
    /doctor which delivery is most safer for me and the baby they don’t give me
    Straight answers,so I was wondering if you know
    Which is the safest one ??

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