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Baby by appointment
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Though delivery by Caesarean section makes it safer and easier, it is still fraught with risks. It should not be performed for the surgeon's convenience or compensation or the patient's fancy or superstitions, says Dr. R. VEDAVALLI.
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CAESARIAN births have been a part of human culture since ancient times, and numerous references appear in ancient Hindu, Egyptian, Grecian and Roman mythologies. It is believed to be derived from the surgical birth of Julius Caesar. Roman law under Caesar decreed that "all women who are dying due to child-birth must be cut open" — hence the term "Caesarian".
The number of babies being born by caesarian section has increased at such an accelerated pace in the past 20 years all over the world that this is what has inspired the author to write about its rationale.
By definition it means the delivery of a child through the abdomen, through an incision, on an intact uterus. The skin incision is below the umbilicus and can be vertical or horizontal along the pelvic brim. The vertical incision has the advantage of easy accessibility to the uterus, as it can be exposed within a matter of one to two minutes. But it has the disadvantage of post operative pain, especially while feeding the baby and the incidence of incisional hernia is more. Cosmetically, it leaves an ugly scar especially in women who have a tendency for keloid formation.
The transverse incision on the skin is along the pelvic brim. It takes a longer time to expose the uterus since the rectus muscle has to be separated from its sheath both above and below, for better exposure and space. This delay plays an important role especially when we have to perform a caesarian section for foetal distress. But in experienced hands, this should not be a problem. At the most it may take three minutes. Here the healing is better. Incisional hernia is almost negligible. Cosmetically it is invisible.
The incision on the uterus is always on the lower part. It is a curvilinear incision made on that part of the uterus which is underneath the bladder (after pushing the bladder down) taking care not to extend up to the uterine artery which runs along the lateral aspect. The bag of membranes is ruptured and the baby is delivered either by the head or by the leg depending on the situation. The delivery of the baby should be achieved within five to seven minutes of starting the anaesthesia.
But why should any woman undergo this ordeal? Traditionally, c.section is performed in situations where vaginal delivery has been considered dangerous either to the mother or to the baby. This leads us to the various indications for c.section as follows:
1. Cephalopelvic disproportion — i.e. the foetal head will not go through the maternal pelvis.
2. Abnormally situated placenta — placenta praevia, where the placenta covers the cervical os (i.e. mouth of the uterus) and causes torrential bleeding during labour.
3. Prematurely separated placenta — (i.e. the placenta gets separated before birth). Sometimes a caesarian was done to deliver even a dead foetus to save the mother from the poisonous effect of a prematurely separated placenta.
4. Umbilical cord prolapse (cord slipping out before the baby is born) and the baby is still alive.
5. Abnormal position of the baby. Baby lies transversely (instead of vertically).
6. Various medical diseases like hypertension, diabetes complicating pregnancy.
7. Advanced age (of the mother) after a long period of infertility.
8. Bad obstetric history — where the earlier babies have died either before labour or during labour.
9. Foetal distress — life of the baby is in danger in first stage of labour (before full dilation of cervix).
Some patients decide the future of the baby and request doctors to perform the caesarian at a particular "auspicious" time. Is this ethical? It can be done in cases posted for elective c.section (like when the mother has lost her previous babies due to birth trauma or severe hypertension).
This is done before labour pain starts, at a stipulated time when the doctor, anaesthetist and the patient are well prepared. Astrological considerations should not be the criterion.
Private nursing homes have been accused of using the c.section to make money. A normal delivery will cost a mother Rs. 4,000 to Rs. 5,000 while a c.section will cost her Rs. 15,000 to Rs. 20,000. Only the doctors concerned can answer this. If an obstetrician says that the baby developed distress during labour, who can question her? And which mother or her relatives would like to dispute that?
For all you know the doctor may be correct (we can prove the foetal distress by examining the ph of baby's scalp blood — but this is a technical, and expensive procedure). However, indications for elective sections can be scrutinised and regulated.
Once a caesarian section does not always mean a c.section again. It depends on the previous indication for c.section. However one should have a well-equipped hospital and dedicated personnel to monitor the mother and the baby.
How many c.sections is another question. Indian women can have three or four operations. In my experience, I have seen women in Central Asia having had 14 children with the uterus in good shape.
In India, a third or fourth pregnancy almost has the uterus tearing like a blotting paper (while operating). There must be something in our food habits, and constitution which alters the ground substance binding the uterine musculature.
The neonatal death rate has dropped. While analysing 31,905 deliveries in a tertiary referral hospital it was found that the neonatal death rate (after c.section) is 2.1 per cent when compared to 2.8 per cent after vaginal delivery.
While there are benefits, added surgical risks in a c.section do not always outweigh the benefits of surgery.
This is why now the International Caesarian Awareness Network (ICAN) and the World Health Organisation (WHO) want the c.section rate to be brought down to 10 per cent to 15 per cent.
What can happen
It is surprising to know how many mothers demand c.section. As a doctor, I have had to enlighten them about the risks:
For the mother:
1. Blood loss is twice as much as vaginal delivery
2. The risk of infection is high
3. There are anaesthetic complications like pneumonia, fall of blood pressure, aspiration
4. Pain factor: a) gas pain b) incision pain
5. Disturbed bowel function, acute discomfort
6. Psychological disturbance: a) sense of failure b) increased postpartum blues due to dependency c) delayed bonding with the child
7. Monetary aspect due to surgical intervention and longer stay in the hospital
8. Incisional hernia
9. Post-operative adhesions<18>
For the baby:
1. Prematurity — especially in elective c.sections
2. Respiratory distress syndrome
3. Effect of anaesthesia
4. Surgeon's nick with the knife
5. Delayed bonding with the mother
Conclusion
C.section is like a double edged sword — it makes delivery safer and easier but is still more hazardous than vaginal delivery. It should not be performed for the surgeon's convenience or compensation or a patient's fancy or superstitions.
R.V.
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