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Patient Choice Cesarean Section (PCCS):
Look Before You Leap

woman jumping off cliff The March 2, 2009 article in Time Magazine on VBAC’s and the January 2009 New England Journal of Medicine (NEJM) study on elective cesarean delivery give you much to consider as you evaluate your options for delivery.

What is patient choice cesarean section (PCCS)?

PCCS, also termed “cesarean delivery on maternal request” (CDMR) is “defined as a primary cesarean delivery at maternal request in the absence of any medical or obstetrical indication”. (ACOG–American College of Obstetrician and Gynecologists, Committee Opinion, Number 394, December 2007)

PCCS a movement that originated in the 1990s in South America in which women opt to have a cesarean section without labor, rather than go through labor.

Why do women choose PCCS?

“Avoiding vaginal birth prevents trauma to the vagina and perineum”  –Myth or Fact?

Cesarean section prior to onset of labor reduces stretching of the vagina, and a few studies have shown it decreases the incidence of incontinence in the first year after birth. Studies comparing rates of incontinence in women who’ve had cesareans without labor vs. women who’ve delivered vaginally show a five to ten percent reduction of urinary incontinence in women who delivered by cesarean without labor.

However, other studies on the pelvic muscles and nerves have shown that twenty-five percent of the weakening of the pelvic floor muscles occurs during pregnancy before labor. The weight of the pregnancy stretches and strains the nerves that innervate the pelvic muscles. So just carrying a pregnancy to term affects pelvic floor muscles and nerves.

Maternal Risks of C-Section vs. Risks of Incontinence

A study reported in the February 2009 issue of Obstetrics and Gynecology evaluated 32,276,863 deliveries between 1998 and 2005. The study notes that the cesarean delivery rate increased from 21% in 1998 to 31% in 2005. Attending this increase in the cesarean delivery rate was an increase in the following severe (some potentially fatal) complications of delivery:

  • Kidney Failure–20% increase
  • Respiratory Distress Syndrome–20% increase
  • Shock–20% increase
  • Pulmonary Embolism (clot in the lungs)–52% increase
  • Blood Transfusion–92% increase

History of cesarean delivery increases a woman’s risk in future pregnancies of abnormal implantation of the placenta including: placenta previa, placenta accreta, and vasa previa. These placental abnormalities increase the risks of all the scary things above.

Timing of Elective Cesarean Delivery at Term Greatly Impacts Newborn Healthbaby_techno

The study on timing of elective cesarean delivery and impact on newborn health published January 2009 in the NEJM revealed an increase in all of the following adverse outcomes for newborns delivered prior to 39 weeks gestation (35.8% of cesareans in that study  of 24,077 births) up to 150 to 400 percent, depending on gestational age and outcome:

  • Adverse respiratory outcomes
  • Mechanical ventilation
  • Newborn sepsis (infection)
  • Low blood sugar in newborn
  • Admission to the Neonatal ICU
  • Hospitalization for 5 days or more

So, while cesarean before labor may reduce the risk of urinary and fecal incontinence, is it worth the increased risks to both mom and babe?

Incontinence can be prevented by pelvic floor muscle training (PFMT-Kegel exercises) and it can be treated with these and other conservative measures–more on this next week.

What has your experience been with:

  • vaginal birth
  • cesarean birth
  • repeat cesarean birth
  • incontinence of gas, urine, and stool after birth?

Want more info on pregnancy, birth, and post-partum? check out DIY Baby: Your Essential Pregnancy Handbook

P.S. If anyone bothered to check out the article in Time, they incorrectly reported my location as “Colorado Springs” rather than “Glenwood Springs”. Hey, it’s Time Magazine, I’m not complaining.

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{ 2 comments… add one }

  • Heather Hawkins April 11, 2009, 12:25 pm

    HI! Just wanted to let you know, I had my first baby via Emergency C-section, after which I started having SLIGHT urine incontincence. I went on to have my second baby via VBAC (Vaginal Birth After Cesarean), and have seen no change for the worse with the incontinence (if anything, it is better now!). Now, I am pregnant with my 3rd, and have partial placenta previa, and my placenta is mostly placed over my scar, increasing my risk for placenta accreta (which usually will end in a hysterectomy)…both of which are a result of the risks I unwillingly took on with my initial C-section. It really stinks, and I think women should be MUCH more aware of how likely they are to have major risks to their baby, their self, and future pregnancies, when they have C-sections.

    • Shelley Binkley April 17, 2009, 9:29 am

      Hi Heather,
      If you are under 26 weeks your placenta may still “move” up the uterus, away from your scar. I sincerely hope this happens for you.
      Placenta accreta has been described in recent ob literature as “an epidemic”. Most of the data on the incidence of accreta and percreta are from before 2000 so there’s not a lot of good data on the incidence of this problem in 2009. However, it is becoming more of a concern as VBAC has fallen by the wayside and elective primary cesarean section is on the rise. I agree with your opinion women should be much more aware of the risks of various delivery options. The fact is 85% of women having their first birth can have normal uncomplicated deliveries. I think both physician and patient anxiety about birth, malpractice, etc. has pushed the primary c-section rate to over 30% in some geographic areas. Prior to the wide acceptance of cesarean section, the c-section rate was 6% (e.g. pre-1970). There’s been much discussion over what an “acceptable c-section rate” is but it’s probably in the vicinity of 10% plus or minus 5%.
      I’m sorry to hear about your placenta previa. I hope you have an uncomplicated birth, be it by c-section or VBAC. Blessings for you and your baby.
      Shelley

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