Cesarean section: to be or not to be, is this the question?

Abstract

Dear Editor,In the third millennium, there is a new ‘‘trend’’ of delivery:cesarean section (CS).Why the increasing rate? First of all, the delayedchildbearing, the second, safer anesthesia, and third, themedical litigation.The women, today, choose to get pregnant at an olderage in comparison to the XX century. What women want?Obviously, the women want one healthy newborn; thus,they do not accept to have a malformed fetus, an abortionor a complication through the vaginal delivery. However,medicine and obstetrics, in particular, are not exact sci-ences; in fact, complications (which may even be lethal)for the fetus and pregnant woman may occur, even in asmall percentage of cases, in spite of scrupulous manage-ment of pregnancy and labor.In Italy, about 38 % of women deliver by CS withhighest rate in the south of Italy (about 60 % in Campania).WHO in 1980 stated that 10 % of CS was the gold stan-dard, but now this rate is too low and is not achievable inthe third millennium.Recently, a Swedish study [1] demonstrated that twodecades after one birth, vaginal delivery was associatedwith a 67 % increased risk of urinary incontinence (UI),and UI[10 years increased by 275 % compared withcesarean section. Nowadays, an increasing number ofwomen request CS for non-medical indications, and forsome this demand appears to be motivated by a desire toprevent pelvic floor damage, including UI.A CS: is it always safe? Complications that are relatedto CS are increased risk of infections, transfusion, andprolonged hospitalization. CS gets maternal and fetalrisks. Maternal risk may be dangerous such as pulmonaryemboly. The fetal risks regard the procedure itself such as3.12 % accidental fetal lacerations per CS [2]. Recently,Arikan et al. [3] compared maternal and perinatal mor-tality and short-term outcomes of maternal and perinatalhealth between a CS group with relative indications and avaginal delivery group. Maternal morbidity was signifi-cantly lower in the vaginal birth group than the CS group(7 vs 30, p\0.05). Perinatal mortality and perinatalmorbidity were not significantly different between the twogroups. Newborns with the first minute Apgar scorebelow 7 were higher in the CS group (p\0.05). The fifthminute Apgar scores and umbilical cord pH values weresimilar. The authors concluded that short-term maternalcomplications were more frequently seen in cesareandeliveries with relative indications than spontaneousvaginal deliveries. Furthermore, a recent cochrane data-base systematic review [4] assessed the effects of a policyof planned immediate cesarean delivery versus plannedvaginal birth for women in preterm labour and concludedthat there is not enough evidence to evaluate the use of apolicy of planned immediate cesarean delivery for pre-term babies.The last but not the least: medical litigation is increasingin all the world. In some countries, no medical doctor wantto be obstetrician for the fear of medical litigation andbecause the medical insurance do not cover the obstetri-cian, especially if the obstetrician had a previous compli-cation during delivery and relative compliant.