[Of course, the c-section rate does NOT need to be that high in women of size, but because of current practice patterns, it is skyrocketing. For more on this topic, read this.]
This is a travesty because surgery is riskier on larger people; more problems with anesthesia, more risk of infection, hemorrhage, blood clots, and wound complications. And cesareans have long-term health implications for women of all sizes, both for future pregnancies and the woman's own health.
But let's leave that for another rant and talk instead about the timing of planned cesareans, and why this is such an important issue, particularly for women of size.
Timing Is Everything
A woman's "due date" is about 40 weeks, and a "full-term" pregnancy is anywhere from 37 to 42 weeks. If, for whatever reason, an "elective" cesarean is planned, what is the most favorable time for scheduling that surgery?
Many doctors in recent years have been scheduling cesareans early. A repeat c-section at 38 weeks is routine in many communities, and 37 is not unheard of. Sometimes, women themselves advocate for a little early because they are uncomfortable and "tired of being pregnant."
Doctors, too, often want to "just get things over with" and get that patient off their books. Scheduling a c-section at 38 weeks means two less appointments cluttering up their busy schedules. They also have talked themselves into believing that scheduling a little early might prevent a few unexpected stillbirths at term (even though that risk is extremely low and outweighed by the risks of being born early).
So, over time, doctors decided that "term is term" and a few more days doesn't make an appreciable difference in the baby's condition.
However, new research shows that planned cesareans should not be performed prior to 39 weeks at the earliest.
The Benefits of Waiting
Before 39 weeks, the risk of breathing difficulties in the baby is quite a bit higher. The older the baby is, the more ready they are to breathe on their own.
In addition, younger babies have more difficulties regulating their blood sugar, have more jaundice, and have more difficulties learning to breastfeed. But it's the breathing difficulties that puts the babies most at risk.
In particular, cesareans without labor put babies at much higher risk for breathing difficulties. Babies born by cesareans after labor has begun have less trouble breathing, and vaginally-born babies have the least difficulty breathing of all. The baby that has the most difficulty breathing on its own is the baby born by planned cesarean before 39 weeks.
Why is this? Labor contractions help squeeze the baby's chest and expel the fluid there. Hormones that are produced during labor help the baby's body be ready to breathe independently. In addition, the umbilical cord gets cut very quickly at a cesarean, cutting off a significant portion of the placental blood meant to perfuse the baby's lungs and help them get ready to start working.
Gestational age also influences a baby's readiness to breathe independently. Preemies have a much harder time initiating breathing and maintaining it without apnea or oxygen saturation issues. Until recently, gestational age was not thought to be that important once babies reached "term" (at least 37 weeks), but now we know differently.
For some time now, research has shown that babies born before 39 weeks have higher rates of Transient Tachypnea of the Newborn (TTN), Respiratory Distress Syndrome (RDS), and Persistent Pulmonary Hypertension (PPH). These babies then need to go to neonatal intensive care (NICU), experience many interventive procedures, and accrue significant costs. Some experience long-term effects.
Because of this, many hospitals have begun strongly encouraging doctors to schedule cesareans no earlier than 39 weeks, and ACOG (American College of Obstetricians and Gynecologists) has recommended that planned cesareans be delayed until at least 39 weeks. Unfortunately, not all doctors follow this recommendation, and many many cesareans are still being done at 38 weeks.
New Evidence for Waiting
A new study, recently published in the New England Journal of Medicine, once again highlights the importance of delaying planned cesareans until at least 39 weeks. Here are some excerpts from the press release:
NEW YORK – Babies do better after a scheduled Caesarean section if they're born no sooner than seven days before their due date, a new large study of U.S. births shows. Those delivered earlier had more complications, including breathing problems, even though they were full term, the researchers reported in [the] New England Journal of Medicine. Even just a few days made a difference, they said....The study supports recommendations that elective C-sections be scheduled after 39 weeks unless tests show the infant's lungs are fully mature....
In the new study, the researchers, led by Dr. Alan Tita of the University of Alabama at Birmingham, examined a C-section registry from 19 academic medical centers to see how many of the surgeries were being done before the recommended 39 weeks and if the timing made a difference in the risk of complications.
They focused on 13,258 women who had a single child at a planned Caesarean and who had previously given birth the same way. Excluded were cases where medical issues warranted an early or immediate delivery. The infants were followed until they left the hospital or for four months.
More than a third of the C-sections were performed before 39 weeks, the researchers found. Those delivered at 37 weeks were twice as likely to have health problems, including breathing troubles, infections, low blood sugar or the need for intensive care. Fifteen percent of those born at 37 weeks and 11 percent born at 38 weeks had complications, compared to 8 percent of the babies delivered at 39 weeks.
If a woman's cycle is 35 days, that means her "due date" by Last Menstrual Period (LMP) will be too early by a week. This is a critical point, especially when discussing planned cesareans.
Even if doctors follow the latest recommendations and schedule an "obese" woman's elective cesarean at 39 weeks, in reality this may well mean the baby is only 38 weeks, and subject to the higher risk of breathing issues noted above.
If the cesarean is scheduled at 38 weeks instead (as 1/3 of cesareans were in the report above), her baby will actually be born at 37 weeks, raising the risk for problems even more.
Of the women of size I know who have had elective cesareans, many of them had them at 38 weeks. This is putting these babies at risk unnecessarily; putting off the surgery just a little more really improves outcomes and helps babies in so many ways.
But even better in most cases would be to give those babies and mothers the benefits of labor.