LETTER TO THE EDITOR

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

Giampiero Capobianco • Stefano Angioni •

Margherita Dessole • Pier Luigi Cherchi

Received: 20 October 2012 / Accepted: 21 January 2013 / Published online: 5 February 2013

� Springer-Verlag Berlin Heidelberg 2013

Dear Editor,

In the third millennium, there is a new ‘‘trend’’ of delivery:

cesarean section (CS).

Why the increasing rate? First of all, the delayed

childbearing, the second, safer anesthesia, and third, the

medical litigation.

The women, today, choose to get pregnant at an older

age 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 abortion

or 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 a

small percentage of cases, in spite of scrupulous manage-

ment of pregnancy and labor.

In Italy, about 38 % of women deliver by CS with

highest 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 in

the third millennium.

Recently, a Swedish study [1] demonstrated that two

decades after one birth, vaginal delivery was associated

with a 67 % increased risk of urinary incontinence (UI),

and UI [ 10 years increased by 275 % compared with

cesarean section. Nowadays, an increasing number of

women request CS for non-medical indications, and for

some this demand appears to be motivated by a desire to

prevent pelvic floor damage, including UI.

A CS: is it always safe? Complications that are related

to CS are increased risk of infections, transfusion, and

prolonged hospitalization. CS gets maternal and fetal

risks. Maternal risk may be dangerous such as pulmonary

emboly. The fetal risks regard the procedure itself such as

3.12 % accidental fetal lacerations per CS [2]. Recently,

Arikan et al. [3] compared maternal and perinatal mor-

tality and short-term outcomes of maternal and perinatal

health between a CS group with relative indications and a

vaginal 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 perinatal

morbidity were not significantly different between the two

groups. Newborns with the first minute Apgar score

below 7 were higher in the CS group (p \ 0.05). The fifth

minute Apgar scores and umbilical cord pH values were

similar. The authors concluded that short-term maternal

complications were more frequently seen in cesarean

deliveries with relative indications than spontaneous

vaginal deliveries. Furthermore, a recent cochrane data-

base systematic review [4] assessed the effects of a policy

of planned immediate cesarean delivery versus planned

vaginal birth for women in preterm labour and concluded

that there is not enough evidence to evaluate the use of a

policy of planned immediate cesarean delivery for pre-

term babies.

The last but not the least: medical litigation is increasing

in all the world. In some countries, no medical doctor want

to be obstetrician for the fear of medical litigation and

because the medical insurance do not cover the obstetri-

cian, especially if the obstetrician had a previous compli-

cation during delivery and relative compliant.

G. Capobianco (&) � P. L. Cherchi

Gynecologic and Obstetric Clinic, Sassari University,

Viale San Pietro 12, 07100 Sassari, Italy

e-mail: capobsass@tiscali.it

S. Angioni � M. Dessole

Gynecologic and Obstetric Clinic, University of Cagliari,

Cagliari, Italy

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Arch Gynecol Obstet (2013) 288:461–462

DOI 10.1007/s00404-013-2736-9

Thus, how can we reduce the high rate of cesarean

section in developed countries?

In our humble opinion, perhaps we will observe a

decrease in the high rate of CS if, and when the Judge will

not sentence, the obstetrician who faces a stillbirth while

using the forceps and/or vacuum, during delivery, and not

thinking it is useful to proceed directly to a CS. Unfortu-

nately, today, the medico-legal aspect preponderantly

influences medical practice and the decisions of the

obstetrician.

In the past, the woman had not many choices, if not

those proposed by the obstetrician and the ‘‘medicine

prescribed by the physician’’ was that which the patient

received. Whereas today, with informed consent and

greater participation of the woman, the ‘‘medicine of the

patient’’ is becoming more and more widespread in medi-

cal practice.

We claim that the obstetrician must be independent and

must have the power to decide. The obstetrician must not

be made a ‘‘victim’’ of choices made by the patients,

which may well be misguided if not completely wrong.

Thus, the obstetrician should serenely show patient what

his or her own experience, supported by medical literature

and medical guidelines, considers the best and safest thing

to do.

Conflict of interest We (authors) declare that we have no conflict

of interest.

References

1. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (2012) The

prevalence of urinary incontinence 20 years after childbirth:

a national cohort study in singleton primiparae after vaginal or

cesarean section delivery. BJOG Mar 14. doi:10.1111/j.

1471-0528.2012.03301.x

2. Dessole S, Cosmi E, Balata A, Uras L, Caserta D, Capobianco G,

Ambrosini G (2004) Accidental fetal lacerations during cesarena

delivery: experience in an Italian level III university hospital. Am J

Obstet Gynecol 191(5):1673–1677

3. Arikan I, Barut A, Harma M, Harma IM, Gezer S, Ulubasoglu H

(2012) Cesarean section with relative indications versus sponta-

neous vaginal delivery: short-term outcomes of maternofetal

health. Clin Exp Obstet Gynecol 39(3):288–292

4. Alfirevic Z, Milan SJ, Livio S (2012) Cesarean section versus

vaginal delivery for preterm birth in singletons. Cochrane Data-

base Syst Rev 6:CD000078. doi:10.1002/14651858.CD0000

78.pub2

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