Roger Harms, M.D., Mayo Clinic specialist in obstetrics-gynecology

In Brazil right now, if you're among the upper socioeconomic status, it's generally felt that you would not stoop to having a vaginal delivery. That you will have a Caesarean delivery for all your children has become sort of a status symbol. In the United States there is very little motivation among the status symbol side. But there has been concern by women about the future risk of uterine prolapse and urinary incontinence, which for years we docs have recognized as associated with vaginal delivery. It's not exclusively associated with vaginal delivery, but it is a symptom that women would like to avoid. So, for a variety of reasons a small cohort of women that seem to be growing substantially every year are requesting a Caesarean delivery as their birth plan. They don't want to try anything else except an elective Caesarean delivery.

In the first delivery, the difference in risk to mom's life between a C-section and a vaginal delivery is extremely small. It's still higher for a C-section but is extremely small. So on the face of it, it's the choice the patient should weigh and consider. Where problems accrue is in the subsequent pregnancies and … the more Caesarean deliveries you have, the more risky that surgery becomes. So an extremely well informed patient who understands the risks and benefits, who is planning a very small family perhaps a singleton (one child), I guess I would not say that I would never do an elective Caesarean delivery for that kind of patient. But I don't think that it's the right thing for a very large portion of the population. What I always like to tell my students in residence is that our species got this far very nicely without us physicians intervening, and obstetrics is a normal phenomenon. Turning every delivery into a Caesarean section is the greatest abrogation of our respect for nature that I can imagine. Nature has done a very nice job in bringing our species this far, and intervening that profoundly, I think that will probably cause troubles. What will those troubles be? Uterine ruptures prior to labor, which do happen. Abnormal placental implantation with placenta previa and abnormal adherence to the placenta is something we're already seeing as the result of multiple Caesarean sections being done.

Editor's note: Placenta previa, which arises when the placenta implants so low as to cover the baby's exit, is often a reason for Caesarean delivery. And abnormal adherence is a significant risk for bleeding in pregnancy and after delivery.

So those complications, which are very profound and life-threatening to both mother and baby, will accrue if we keep putting scars in uteri. So, my advice for patients is to take such a course with a great deal of caution and to not be swept up by the enthusiasm that we're currently seeing for its adoption.

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