A Caesarean section, also known as C-section or Caesar, is a surgical procedure in which incisions are made through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk, although in recent times it has been also performed upon request for childbirths that could otherwise have been natural.
The World Health Organization (WHO) recommends that the rate of Caesarean sections should not exceed 15% in any country. In 2006, the last year with available data, the rate of U.S. births by C-section was 31.1%, the highest it has ever been.
The caesarean section rate in South Africa’s private hospitals has reached a staggering 70%. Depending on the hospital and doctors practicing there, this can be as high as 85% if not more.
It gives one food for thought ……
Indications for Caesarean Section
Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. Not all of the listed conditions represent a mandatory indication, and in many cases the obstetrician must use discretion to decide whether a caesarean is necessary.
- Failure to progress during labour (Failure to progress needs to be investigated first)
- Foetal distress
- Cord prolapse
- Uterine rupture
- Placental problems (placenta praevia, placental abruption or placenta accreta)
- Abnormal presentation of baby (breech or transverse positions)
- Failed induction of labour – ussually seen when mother is induced to early in pregancy and the uterus is not ready for birth
- Failed instrumental delivery (by forceps or ventouse. Sometimes a ‘trial of forceps/ventouse’ is tried out – This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a caesarean section.)
- Abnormal shape of the pelvis, this is very rare
Other complications of preganancy, pre-existing conditions and concomitant disease such as:
- Multiple births if lie of babies are not conducive for natural birth
- HIV infection of the mother (not indicated in all cases)
- previous Caesarean section (though this is controversial – See VBAC article)
- Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In most situations women can birth under these circumstances naturally. However, obstetricians are not always trained in proper procedures and are uncomfortable attending these births])
- Improper Use of Technology (Electric Foetal Monitoring)
Research into reasons for emergency cesareans found that 66% occur between the day shift hours of 8 am and 3 pm, and the least between 5 pm and 6 am leading the authors to conclude that physician convenience is a leading cause of “emergency cesareans.” (Goldstick O, Weissman A, Drugan A.The circadian rhythm of “urgent” operative deliveries.Isr Med Assoc J. 2003 Aug;5(8):564-6.)
Dr S. Bewley has written extensively about the issues surrounding these procedures, which are often given the misnomer: ‘cesarean by choice’.(Bewley S, Cockburn J. The unfacts of ‘request’ caesarean section. BJOG. 2002 Jun;109(6):597-605.) A cesarean is a life threatening medical procedure that is obviously ultimately decided upon by a doctor or several doctors.
Analyzing the rise in caesarean section rates, the US National Institutes of Health says that rises in rates of caesarean sections are not, in isolation, a cause for concern, but may reflect changing reproductive patterns:
Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. There is no consistency in this ideal rate, and artiﬁcial declarations of an ideal rate should be discouraged. Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances.
Nonetheless, some commentators are concerned by the rise and have tried to generate theories to explain it. Louise Silverton, deputy general-secretary of the Royal College of Midwives, says that not only has society’s tolerance for pain and illness been “significantly reduced”, but also that women are scared of pain and think that if they have a caesarean there will be less, if any, pain. It is the opinion of Silverton and the Royal College of Midwives that “women have lost their confidence in their ability to give birth.”
Silverton’s analysis is controversial. Dr Maggie Blott, a consultant obstetrician at University College Hospital, London and a Royal College of Obstetricians and Gynaecologists spokeswoman on caesareans, responds: ‘There isn’t any evidence to support Louise Silverton’s view that increasingly pain-averse women are pushing up the caesarean rate. There’s an undercurrent that caesarean sections are a bad thing, but they can be life-saving.’
Elective caesarean sections
Caesarean sections are in some cases performed for reasons other than medical necessity. Reasons for elective caesareans vary, with a key distinction being between hospital or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature’s schedule and deliver a baby at an hour that is not predetermined. Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits.
Studies of United States women have indicated that married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women even though they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated that their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone.
In contrast to this, a recent study in the British Medical Journal retrospectively analysed a large number of caesarean sections in England and stratified them by social class. Their finding was that Caesarean sections are not more likely in women of higher social class than in women in other classes. While such mother-elected Caesareans do occur, the prevalence of them does not appear to be statistically significant, while a much larger number of women wanting to have a vaginal birth find that the lack of support and medico-legal restrictions led to their Caesarean.
Some 42% of obstetricians blame expectant mothers (among other sources) for the rising caesarean section rates. Studies from Sweden also confirm this.