Low-risk pregnancies and early elective C-section delivery
Do parents know what to expect?
When it comes to early elective C-sections, there are many potential harmful effects which parents may not be aware of, says retired neonatologist Professor Suzanne Delport.
Newborns are increasingly being delivered by elective C-section (i.e. planned surgery, often without a medical reason), before their expected date of delivery. This scenario is particularly common in the South African private sector with around 80% and more of newborns being delivered in this way. It is concerning that these infants have not been exposed to labour, as this puts them in a vulnerable position for complications.
The transition from fetus to baby remains the most profound physiological feat in human life and should be approached with the respect that it deserves.
Even though a newborn infant delivered via elective caesarean may display an adequate birth weight, there is still an element of prematurity because there was no exposure to labour. This is in stark contrast to a normal vaginal delivery where the mother and newborn infant are healthy and can fend for themselves immediately after the birthing process. Attachment and suckling occur effortlessly in most instances and the mother and infant are healthy.
An early elective caesarean delivery, on the other hand, which bypasses the physiological preparation that occurs just before birth, as well as the natural birth process itself, places both the mother and baby at increased risk of complications.
Both are prone to a prolonged recovery: the mother from major surgery and the infant from ‘iatrogenic prematurity’ (i.e. prematurity caused by a medical procedure) because of an early elective delivery by caesarean section.
Denying normal physiology
In a normal pregnancy, the unborn baby triggers labour followed by a surge of hormones. These hormones are not only associated with labour, but are also essential for the fetus, in the final preparation of its organs and enzymes for the outside world.
An elective C-section denies the fetus (unborn baby) the final cortisol and catecholamine surges associated with labour. Without these hormones, oxygenation, temperature regulation, glucose production, suckling and attachment do not fall into place at the very moment of birth, with potential life-threatening consequences.
Causing oxygenation issues
An unborn baby does not need his lungs in the uterus. Rather, blood is oxygenated in the placenta before being sent to the fetal vital organs. Before and during labour, cortisol and catecholamines play a vital role in preparing the lungs for breathing and reducing the amount of fluid in the lungs. This process is completed during labour and allows the baby to breathe air immediately after birth.
In the absence of labour, the lungs of a newborn infant after delivery are filled with fluid, which puts him/her at risk of respiratory problems. A normal fetus becomes an ill newborn because of a medically unnecessary procedure (i.e. early elective C-section), and admission to a specialised neonatal unit for respiratory support becomes mandatory.
Influencing temperature regulation
Hypothermia (when the body loses heat faster than it can produce heat) can be a potentially life-threatening complication, which should be prevented at all costs.
Infants born by a pre-labour elective C-section are prone to hypothermia for the following reasons:
- The ambient temperature of an operating theatre is often <26⁰C and therefore colder than a delivery room. The mother commonly experiences hypothermia before delivery occurs, which has a cooling effect on the fetus (unborn baby).
- The newborn is then exposed to the low ambient temperature of the operating theatre after birth.
- Skin-to-skin contact immediately after birth may lead to further heat loss due to conduction, should the mother be hypothermic.
- Brown adipose tissue, which facilitates heat production, is decreased in infants delivered before the expected date of delivery.
Affecting attachment and breastfeeding
After a vaginal delivery, the newborn is alert because of the surge of hormones during labour. This allows for a strong sucking reflex and effective suckling immediately after birth, which are essential for the initiation of successful short- and long-term breastfeeding, as well as attachment. The mother’s oxytocin secretion, which began during labour, is continued during suckling to facilitate the let-down reflex and the contraction of the uterus.
Hormonal effects are absent in a pre-labour elective C-section. The unborn baby is ‘taken by surprise’ because labour did not ‘alert’ the fetus. If the delivery is scheduled before full term (39–40 weeks), immaturity may complicate adaptation, disempowering the newborn from suckling effectively because of an immature sucking reflex. The mother – on the other hand – is recovering from major surgery and is not roomed in with her baby immediately after birth. Valuable time for attachment and breastfeeding is lost during this sensitive period because of separation.
Making the transition to motherhood trying
Oxytocin, often called the ‘love hormone’, rises dramatically during and after a normal birth and helps women in the transition to motherhood. It reduces stress, supports a positive mood, and promotes bonding and breastfeeding.
While not all C-section moms experience depression or a prolonged low mood, they have been denied the natural release of oxytocin that would occur with a natural birth, putting them at risk and tending to make the transition to motherhood more difficult.
Before opting for this procedure, parents should be aware that their newborn infant may need admission to a neonatal intensive care unit and that the mother may experience a number of unanticipated complications.
The negative effects of a pre-labour early elective C-section include serious complications such as respiratory distress, hypothermia, hypoglycaemia and feeding difficulties – conditions which rarely occur in vaginally-delivered infants. Continual support should be rendered to the mother since difficulties with transition to motherhood may have a negative impact on attachment and lactation, and ultimately on the neurodevelopmental outcome of the newborn.
Professor Suzanne Delport is a retired neonatologist with a particular interest in the wellbeing of the mother-infant dyad during the perinatal period.
This article was adapted from an article for midwives, originally published in Sensitive Midwifery Magazine in October 2016.