Caesarean Section: En Vogue?

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Caesarean section (CS) rate is going up, most women are delivering by CS, these comments are frequently heard nowadays, but who is really to blame? is it the obstetrician or the patient? Is CS the easier route for delivery? Should we obstetricians be promoting vaginal delivery or should we be pushing more women towards CS?


There has been a noticeable and significant increase in the CS rate all over the world and in Egypt in particular. It can be considered the new trend of this era. Some women feel it is a more dignified way of delivering a baby, others believe it is a more sophisticated route of delivery as they are “too posh to push”. The media in general is very hard on obstetricians, there is always bad propaganda about doctors not willing to allow vaginal delivery as they are more time consuming and less rewarding financially. On the other hand a lot of women are requesting CS as they are afraid of the pains of normal delivery or as they are worried that something may go wrong with the baby during a lengthy labour. They feel that delivering the baby through a cut in the tummy would definitely carry less risk to their precious one. Many women have a strong belief that they have a special neck of womb that won’t stretch and allow vaginal delivery.


The Myths:


There are many myths surrounding the last few weeks of pregnancy. Some believe that exceeding or even reaching the due date is an indication for CS. Others believe that a cord around the neck is another indication. Other myths we hear about are like “My water broke and I am not in labour, then I should have CS”. Unfortunately some obstetricians believe that a high head or a large baby is an indication for CS. We hear very strange reasons for CS stated by the women as regards previous delivery; “Baby was drowning in the water around it” as if the baby has not been in that same water for the past 9 months!


Some earlier reports have shown that vaginal delivery can affect your sex life; it can increase the risk of prolapse “dropping of vagina or womb” and may cause as well urinary incontinence “leakage of urine”. It causes painful intercourse due to the scar of the vaginal cut (episiotomy) or due to the occurrence of vaginal tears. It is known as well that the risk to the baby is higher during vaginal birth as compared to CS.


CS around the world:


Should we then as obstetricians push more women to have CS due to the above reasons or should we put more effort towards attempting vaginal delivery? It is a very difficult question to answer. What about the rest of the world, what is the practice elsewhere? In the United Kingdom most women if not all deliver in the national health hospitals, they feel they receive a high standard of care and thus no need for delivering privately. One should remember that it is a completely different culture, as pregnant women are willing to have their antenatal care mostly under the care of the midwives; they are willing as well to be delivered by midwives not doctors. However they are aware that if things deviate from normal the midwife will call a doctor immediately. British women feel that having a natural vaginal delivery without any pain relief is a great achievement; some women who end up having CS feel they are complete failures! The midwives who deliver the babies are based in the same unit they don’t have private practices and thus they don’t have to rush deliveries and run around from one unit to the other delivering babies. No wonder why the CS rate is very low ranging between 16 and 21% in most hospitals in the United Kingdom. The wide practice of safe instrumental delivery like ventouse or forceps to help deliver the baby is an important factor as well for reducing CS rate.


What about in other countries like Brazil where there is a high percentage of private practices; some earlier reports showed the CS rate to be above 70%, which may be the case in  Egypt. However, it is difficult to tell since there are no accurate reports especially in the private sector.


So as a woman wanting a vaginal delivery the best place to deliver is in a country like the UK. We cannot provide similar care to pregnant women in Egypt as that of the UK without a complete change of culture and believes. We have to get rid of many myths and start applying what is called evidence based medicine. So do women in Egypt really want that?  Do they want to give up the luxury of choosing their obstetrician, choosing the hospital to deliver in and sometimes even choosing the date to have their baby? Are women willing to be delivered by a doctor they have never seen before or most probably by a midwife?


Despite the above argument most obstetricians are very keen on vaginal deliveries; they feel a sense of achievement which is worth more than money. Women need to help their doctors; they need to be open minded, accept evidence rather than myths and trust their obstetricians.


Caesarian Section Vs Vaginal Delivery:


Vaginal delivery is the better route, it is definitely better for the mother, recovery is faster, the incidence of a leg clot is significantly lower, and there are no scars inside the tummy that can cause some problems in the future. A lot of women suffer from chronic pelvic pains due to the presence of adhesions (scars sticking internal organs together); these scars are mostly following surgery like CS. These scars can cause as well pain during intercourse, painful periods, and pain on passing urine or opening their bowels. These scars need to be removed through key hole surgery, which means subjecting women to more surgery. Women who had CS are more prone to complications if they undergo any future surgery for example hysterectomy, again due to the presence of adhesions. Thus women who had one CS should be encouraged to deliver vaginally the following pregnancy. One CS is not an indication for another CS unless in the rare event of contracted pelvis, but otherwise every effort should be spent to allow them to have a vaginal delivery.


There are certainly indications for CS for example the presence of a  low lying placenta, breech presentation where the baby is presenting by the buttocks or legs, the presence of a swelling below baby’s head that would stop delivery, having had  two or more CS and fetal distress where the baby is unhappy and needs immediate delivery. 


It is the job of the obstetrician to explain facts clearly to the couple, provide evidence and help reassure the parents as regards the mode of delivery. It is ultimately the choice of the parents especially the woman to decide the best for her baby and herself based on the knowledge provided by her caring doctor.

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