A 2-month-old female came to clinic for her well-child care. She had been born to a G2P2 female by cesarean section for maternal diabetes type 2, fetal macrosomia, fetal intolerance to labor and previous cesarean section. She had problems with hypoglycemia after birth but otherwise was well and had regained her birth weight by 8 days of life using formula. The mother had no concerns.
The pertinent physical exam showed a well-appearing female with all growth parameters around the 90%. Her examination was normal.
The diagnosis of a healthy 2 month old was made. During the patient presentation the intern noted that the mother had had several risk factors for a repeated cesarean section. “I know the baby and mother are at risk for problems around birth because of the cesarean section, but do they also have problems later?” she asked. “I remember reading about increased risk of obesity and I think asthma. I really only see it in research studies, so there probably are other long-term problems I’m not aware of,” he answered.
Discussion
The goal of maternal care for successful pregnancy and delivery is a healthy mother and a healthy baby. Most babies are delivered by spontaneous vaginal birth, but other methods to support and assist mothers are available. Birth methods include:
- Vaginal birth – spontaneous, induced, VBAC (vaginal birth after cesarean section)
- Assisted birth – forceps, vacuum
- Cesarean section (CS) – planned, unplanned
- Possible common reasons for CS:
- Planned
- Breech or other abnormal position
- Fetal macrosomia
- Maternal conditions: hypertension, HIV, active herpes simplex
- Multiple infants
- Placental previa
- Uterine obstruction
- Previous CS
- Unplanned
- Cord prolapse
- Fetal distress
- Labor not progressing
- Maternal hemorrhage
- Placental abruption
- Planned
CS is the surgical delivery of a fetus. It can be a life-saving procedure when complications occur. While there are immediate, short- and long-term potential problems with CS, it generally is a safe procedure. (For more information about potential maternal health problems see To Learn More below). Across the world, the number of CS deliveries is increasing. The optimal threshold or percentage is very difficult to determine. 10-15% of deliveries is considered generally normative with less than 10% possibly indicating “…inadequate access to medically indicated CS,” and > 15% possibly indicating over-use for a myriad of reasons.
A 2018 study of the global epidemiology of CS which included of 98.4% of the world’s 2015 births, estimated 29.7 million CS (21.2%) which was increased from 16 million (12.1%) in 2000. Country rates varied from 0.6% to 58.1%. Rates “… were driven both by an increasing proportion of births occurring in health facilities (accounting for 66.5% of the global increase) and increases in CS use within health facilities (33.5%)….”
Learning Point
There are numerous studies evaluating potential problems associated with CS for infants and children. Each has its own specific methods which can lead to different findings.
A 2020 systemic review and metanalysis found that CS was an increased risk factor in offspring for respiratory tract infections, asthma and obesity. This study did not find an increased risk for diabetes mellitus type 1 and metabolic disorders.
A 2018 review from The Lancet of short- and long-term effects of CS reported a summary listing of potential problems with an increased risk including:
- Short-term (birth – 3 years)
- Respiratory diseases
- Behavioral outcomes (stress-related)
- Altered gut microbiome
- Allergies (mixed results)
- Altered immune function
- Cardiovascular function (mixed results)
- Long term > 3 years
- Overweight and obesity (mixed results)
- Asthma and allergies (mixed results)
- Behavioral outcomes including Autism, ADHD (mixed results)
- Gastrointestinal problems – inflammatory bowel disease (mixed results)
- Diabetes, Type 1 (mixed results)
- Autoimmune diseases – juvenile arthritis
Questions for Further Discussion
1. What are some risks of a teenage pregnancy? A review can be found here
2. What are potential risks for a baby born with macrosomia or large-for-gestational-age? A review can be found here
3. What is the rate of CS in your local area or country?
Related Cases
- Disease: Cesarean Section
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Age: Infant
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Cesarean Delivery and Childbirth.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. The Lancet. 2018;392(10155):1341-1348. doi:10.1016/S0140-6736(18)31928-7
Sandall J, Tribe RM, Avery L, et al. Short-term and long-term effects of caesarean section on the health of women and children. The Lancet. 2018;392(10155):1349-1357. doi:10.1016/S0140-6736(18)31930-5
Betran AP, Temmerman M, Kingdon C, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. The Lancet. 2018;392(10155):1358-1368. doi:10.1016/S0140-6736(18)31927-5
Slabuszewska-Jozwiak A, Szymanski JK, Ciebiera M, Sarecka-Hujar B, Jakiel G. Pediatrics Consequences of Caesarean Section-A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2020;17(21):8031. doi:10.3390/ijerph17218031
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa