The Delivery Debate

DEBORAH PIKE OLSEN THOUGHT A C-SECTION WAS A SCARY WAY TO HAVE A BABY. AFTER WHAT SHE'S BEEN THROUGH, SHE'S CHANGED HER MIND.

When i was pregnant with my first child three years ago, I desperately wanted to give birth vaginally. Everything about cesarean sections—the major surgery, the long recovery, even the scar—terrified me. Labor aside, vaginal birth just seemed easier, more natural, more how it was supposed to be. So when my healthy, 7-pound daughter arrived that way, I couldn't have been happier.

Then the painkillers wore off. I had rectal swelling so bad, I felt like I was carrying a bowling ball in my behind. That pain, which was from a torn anal muscle, lasted for three months. Sex was unthinkable for six. In all, it took a good year for me to feel normal again. I'd never heard of anyone suffering as much as I did in the aftermath of giving birth. Could I have been an exception to the rule about recovery being quicker from vaginal births?

Like any good reporter, I started to dig, and what I discovered astounded me: My experience was not unique. While not many women have injuries as severe as mine, hundreds of thousands have debilitating short- and long-term complications after a vaginal birth, yet doctors rarely discuss the potential risks with moms-to-be. "The question I often hear from patients is, 'Why didn't someone tell me that this could happen?'" says John DeLancey, M.D., director of the Pelvic Floor Research Group at the University of Michigan Medical School in Ann Arbor.

Why, indeed? For one, most doctors practicing now were taught that vaginal births were safer for moms than invasive surgery, and many still cling to that idea, says Benjamin Sachs, M.D., professor and chairman of obstetrics and gynecology at Beth Israel Deaconess Medical Center at Harvard Medical School in Boston. But research is starting to show that a planned C-section is probably no more risky to mothers than a vaginal birth, Dr. Sachs says. While traditional delivery has its pluses (often less medication, a shorter hospital stay and usually a quicker recovery), a cesarean also has some long-term benefits. Because the baby comes straight out of the belly, there's little damage to the mother's pelvic floor, the muscles that support the bladder, uterus, vagina and rectum. That detour drastically lowers a woman's chance of suffering incontinence. And unlike many women who give birth vaginally, those who do it surgically don't usually experience pain during sex later, Dr. Sachs says.

But because the research comparing the risks for vaginal and planned surgical births is still ongoing, some physicians aren't convinced that women should be allowed to choose between the two, says Bruce Flamm, M.D., research chairman at Kaiser Permanente Medical Center in Riverside, California. Besides, until very recently, women had no say as to how their babies would be delivered: Insurance companies often pushed for vaginal births because hospital stays are shorter and the fees lower. So because traditional delivery was likely to be a woman's only option, listing all the possible complications seemed needlessly scary. But over time, factors such as these built vaginal birth's reputation as the best way to have a baby.

The problem is that not every woman can or should have a vaginal birth, says Linda Brubaker, M.D., professor and director of female pelvic medicine and reconstructive surgery at the Loyola University School of Medicine in Chicago. And yet women often feel guilty or as if they've failed if they have a C-section. "Many people feel that there's an unspoken womanliness associated with vaginal delivery," Dr. Brubaker says. Though it's absurd to consider women who have cesareans less motherly or female than others—only a woman can deliver by any method—the idea has such a strong hold that Dr. Brubaker was picketed by nurse-midwives a few years ago while giving a talk about the pelvic effects of childbirth. "People are afraid that the science will show vaginal birth can be risky for some women," she says. "But a woman is charged with taking care of herself as well as her baby, and she should have the birth that's best for her."

Of course I would have had a C-section if that was safest for my daughter, but at the time I was glad I didn't have to—that is, until the excruciating pain set in. That's when a nurse told me I'd suffered a laceration of the anus, a third-degree tear. If that sounds bad in medicalese, it's worse in English: My anal sphincter (the muscle that controls bowel movements) was torn. I had no idea that was even a possibility and feared I wouldn't be able to walk, run or ride a bike again without pain.

An anal tear is only one of several devastating injuries a woman can suffer during a vaginal delivery. A recent study in Obstetrics & Gynecology found that one in five laboring women tear their pelvic-floor muscles. A weak pelvic floor can lead to incontinence or prolapse, in which the organs descend and bulge out through the vaginal opening. Urine leakage is the most common symptom of pelvic-floor damage: About one in three women experience it in the first six months after childbirth, and some even experience anal leakage in the first few months postpartum. Having a C-section doesn't fully protect against such problems—sometimes the weight of the pregnancy itself can weaken pelvic muscles—but in general, the procedure cuts the risk for urinary incontinence in half, according to a recent study in The New England Journal of Medicine. Fortunately, most women do recover within a year, but symptoms can worsen after subsequent deliveries, says Joseph Schaffer, M.D., director of urogynecology and reconstructive pelvic surgery at the University of Texas Southwestern Medical Center at Dallas. I was lucky. I had one bout of urine leakage during a coughing fit when my daughter was a year old. I was spared the other kind.

Experts have only recently begun to study how and why pelvic-floor damage occurs. They know there's more risk when a woman's birth canal is small and her baby is large. Those moms have to push with more force, which puts more stress on the muscles that support the bladder, uterus and rectum. Plus, there's a greater chance the doctor may need to use forceps or a vacuum extractor to get the baby out. Those instruments are used in 10 to 15 percent of all deliveries (and often only when the fetus is in distress), and they have been shown to contribute to severe tearing. In a study of more than 50,000 births in Miami, nearly one in five women whose doctor used forceps suffered an anal sphincter laceration, and about one in 10 who had a vacuum-assisted delivery had anal or rectal damage. The high rates are partly because many doctors also performed an episiotomy, an incision of the perineum (the area between the vagina and anus) to widen the birth canal. Although the procedure was once routine—doctors thought it would prevent serious tearing—research has proven the opposite. You may think that a little cut down there couldn't compare to the deep incision a C-section requires, but making even a small incision can weaken the vaginal wall, causing it to split open more easily, Dr. Schaffer says. The current view: Unless your baby is in danger and needs to be delivered quickly, you don't need an episiotomy. Be sure to ask your OB about her use of the procedure well before you're due.

While you're at it, you can also ask about her approach to pushing. Some research has suggested that bearing down too hard at the wrong time could also be a threat to the pelvic floor. "The standard practice is the directed approach to pushing, in which the doctor says, 'Push as hard as you can for 10 seconds,'" says Carolyn Sampselle, Ph.D., the Carolyne K. Davis collegiate professor of nursing at the University of Michigan. But that prolonged, intense pressure can cause abrupt stretching and tearing, she says. "A woman may be less likely to be injured if she acts on her own urge to push." When a woman bears down only when she feels the need, the birth is a slower process: The head comes out a little, then goes back a bit, then comes out a little more, gradually stretching the tissues.

What's perhaps the biggest selling point of vaginal births is the generally speedy recovery. Most women with a short labor and no episiotomy heal within a week to 10 days (it could be longer if the delivery was complicated or prolonged) compared with the six to eight weeks doctors typically allow for cesareans, Dr. Sachs says. But many of Dr. Sachs's own C-section patients recover in a few weeks, too. "Some doctors say, 'You can't drive for six weeks, and don't climb the stairs after a C-section,'" Dr. Sachs notes. But he says that as soon as women are off their pain medication and feeling comfortable, they can do both.

All this cesarean news sounded so appealing that when I became pregnant again a year later, I considered going straight for a C-section. But because I had recovered and my doctors said the risk for such a severe injury recurring was fairly low, I decided to give birth vaginally again. I tore almost as badly as before.

I was furious. How could such bad luck have struck twice? It could have been worse, though. This time, I was back on my feet in a flash and had only six weeks of major pain instead of six months. Looking back, it's easy to say I should have gone for a C-section, but I didn't want to risk a longer-than-necessary recovery and overall, I'm happy I got to decide how my baby would be born—all women should make an informed decision. But if I ever have a third baby, I'm pretty sure I'll opt for the operating room.

If I ever have a third baby, I'll opt for the operating room.