The Demedicalization of the Caesarian Section.

First off, I am not in favour of natural childbirth.  I am interested in history so when I visit places that have a history, I occasionally visit graveyards.  I am always struck by the number of young women buried next to a newborn baby, because the mother and baby died in childbirth.  In Cuba when this happens, the baby is buried with the mother between her legs.  This is natural childbirth and if we want to accept mothers and babies dying as a natural occurrence, we should embrace this. 

Having said all this in my lifetime the Caesarian Section rate has gone from 20% to 30% with very little decrease in maternal or foetal morbidity or mortality.  It is at the same time well documented that materanal morbidity is increased with caesarian section versus vaginal delivery.

I was on call recently and did quite a few sections which gave me some time to reflect on this.

We do almost all our sections under regional nowadays.  This is a major change from when I was a resident where the majority of Caesarian Sections were done under general.  We would always see the patient the night before and try to convince them to have their section under epidural which was how we did them then.  Now patients are told by OB they are having their section under spinal and it is very rare to have a patient demand a general (some "experts" in OB anaesthesia think we now do too few GAs).  Sections under general anaesthetic were always a major stressor at least as a resident and even as a junior staff.  The patient would be awake in the room, the OR team scrubbed and the belly prepped and draped.  You would pre-oxygenate the patient and the nurse would apply cricoid pressure after which you would inject a pre-set dose of pentothal followed quickly by succinylcholine.  You would then attempt to intubate the patient, this was made difficult by the fact that you had to work with the drapes and one hospital where I trained made things especially difficult by insisting on using the ether screen.   ("Fortunately ", we didn't have a pulse oximeter for most of my residency; it was probably when we and the OB saw how low the sats went that regional began to be pushed more aggressively.)  The pregnant airway is as we are all told more difficult and I shudder to think of giving GAs to the BMI 60 patients we routinely see now for sections.  The fact that a significant number of these GAs were in the middle of the night or you had had to drop everything and rush up to do it added to the stress.

As I mentioned sections are now done exclusively under regional and it must be at least two years since I did a GA section.  After we put in the spinal or top-up the epidural, the patient is draped, the block tested and then the father is invited to come and sit at the head of the bed.  This is not always the husband/father, it could be the mother, a sister or a friend.  I remember on occasion having two people in the room but I suspect infection control has blocked that. Under regional, the sections are little more relaxed as there is not the race to prevent baby from getting some of mom's general anaesthetic drugs and in 5-10 minutes we have a baby.

This is when what I call the "love-in" starts.  Everybody's IQ drops about 20 points, everybody coos how beautiful the baby is, the father is invited over to the bassinet to cut the cord, photos are taken etc.  Our hospital now does skin to skin.  Such a beautiful and special moment.  Except.....

The mother still has a large abdominal incision and a big hole in her pregnant highly vascular uterus.  There is still the matter of getting the placenta out which may or may not be easy.  And there are little issues like amniotic fluid emboli and pre-eclampsia.  Further the OB is probably going to exteriorize the uterus which means that means that your patient is going to get nauseous and if the block is the least bit patchy, uncomfortable.  She may also get hypotensive from the spinal and from the blood loss.  In other words, your patient is not out of the woods and may need your attention still.

This happened to a colleague of my a few years ago.  I don't remember exactly what happened but he felt he needed some help with the patient and so asked for assistance from one of the nurses.  The love in was still in process and the nurses ignored him accidentally or intentionally.  This lead to him raising his voice (his version) or yelling (their version) and he got written up and had his wrists slapped.  I wasn't there and only heard his version so I can't really comment.

This is a difficult issue to discuss because a Caesarian Section is life saving for the mother or the baby in some circumstances.  Just how often is the question.  Certainly not 30% of the time.  A lot of women really wanted have the perfect labour and delivery and push out their baby and when in their best interests we have to section them, they may feel that they have failed and we don't want to reinforce this.  At the same time we read about the "too posh to push" mothers who chose to have a section rather than even attempting vaginal delivery.  There are probably variants of this and I imagine discussions going on in the OB office where the prospective mother states her concern about the difficult labour of her sister, friend or mother and states that if things look like they are headed that way, she wants a section.  I am not sure whether these discussions happen, I strongly suspect that they do and a significant number of "failure to progress" or "non-reassuring tracing"  sections are as a result of these discussions.

The demedicalization of the Caesarian section, benefits mostly the OB who no longer feels guilty (assuming they are capable of that) when she does a questionable section, because she wants to get back to her office, go for dinner, not have to hand off the patient etc, doesn't have to worry about depriving the mother of a wonderful birthing experience because after all a section is a birthing experience with mom awake and the father or whoever invited to participate.  

My argument is that by making the Caesarian Section less medical, more routine and more pleasant we are making it too easy and maybe we need to find some type of balance.  Not holding my breath on that.