Caesarean Operations – The Cutting Edge?
Question: When is an operation not an operation? Answer: When it’s a section.
It’s only recently that caesarean operations (known inexplicably as “sections”) have become commonplace. Earlier this century, caesareans were used as a last ditch attempt to save the baby usually after the mother had died. Fifty years ago mothers were likely to die from the operation due to infection, thrombosis and anemia. Today, improved surgical techniques and anesthesia, the availability of antibiotics and blood transfusions means they are less risky than they used to be. As a result they are also more common.
In 1970 the caesarean rate was 5.5 per cent in the US and 4.3 per cent in the UK. In 1975, it was observed that “. . . during the next 40 years the allowing of a vaginal delivery or attempted vaginal delivery may need to be justified in each particular instance. Perhaps it is not altogether too provocative to suggest that vaginal delivery may yet become the exception rather than the rule” (Clin Ob Gyn, 1975; 2: 241-61). In 1986, not long after another article appeared proposing that all births should be caesarean (New Eng J Med, 1985; 312: 1264-7), the rate had soared to 22 per cent and 11 per cent, respectively. Today best estimates are 24 per cent in the US (where it is the most commonly performed surgery) and 15 per cent in the UK.
Analysis of available data reveals that there is no correlation between the fall in deaths of babies at birth and the rise in caesarean rates (Ob Gyn, 1983; 61: 1-5).
There is now general agreement that a rate between 6-8 per cent is both realistic and achievable (being the aggregate figure of all absolute indications for caesarean) and that any rate above that ceases to improve or make any difference in the overall outcome for mothers or babies (Effective Care in Pregnancy and Childbirth, Iain Chalmers, et al, eds, Oxford University Press, 1995). This means that one half to three quarters of all caesarean operations are unnecessary. The cost of this can be measured both in terms of emotional and physical damage and in dollars and pounds. In the UK around lb30 million a year is spent on unnecessary caesareans (Financial Times September 17, 1993), in the US it is a staggering $1.5 billion (MMWR, 1993; 42: 285-9).
While most caesareans are “sold” to mothers as life saving options, the majority will have had unnecessary surgery. The most common reasons for performing a caesarean are “failure to progress” (dystocia) and “fetal distress”. But these are more likely to be subjective opinions than medical diagnoses, and often they can be based on personal prejudices and the enforcement of active management protocols. Some such protocols state, among other things, that a woman in active labour should achieve 1 cm dilation per hour and only be allowed a maximum of two hours to push the baby out. Any labour not meeting this standard is said to be “failing to progress”.
In spite of the lack of evidence pointing to the benefits of active management (BMJ, 1994; 309: 366-9; Am J Ob Gyn, 1987; 157: 174-7) and the low caesarean rates in those clinics where doctors practice “expectant watchfulness”(Lancet, 1990; 335: 977-98), nearly 55 per cent of the hospitals in one comprehensive survey of all the consultant maternity units in England said that, once labouring women had achieved full dilation, the doctors applied an upper limit of one hour for the second stage of labour for first time mothers and a half hour for women having their second or subsequent child. After this time some action would be taken to deliver the baby either instrumentally or surgically (Midwifery, 1989; 5: 155-62).
Other non medical indications for caesarean section also prevail. Fear of litigation is a powerful determinant on both sides of the Atlantic (JAMA, 1993; 269: 366-73, but there are other less obvious influences. In one Chicago hospital more caesareans were performed for non acute conditions, such as dystocia, between the hours of midnight and 8 am (J Repr Med, 1984; 29: 670-6). On weekends and public holidays the rate is also higher (BMJ, 1978; 2: 1670-3). The mother’s age and parity can also play a role. Women over 35 having their first baby are twice as likely to end up with a caesarean as comparable younger women and 50 per cent more likely than those of the same age having a second or subsequent child (Eur J Ob Gyn, 1995; 62: 203-7). Rates can also vary wildly between doctors in the same hospital. In one US hospital with a caesarean rate of 26.9, individual rates ranged between 19.1 per cent and 42.3 per cent (New Eng J Med, 1989; 320: 706-9). British research has shown similar variations (J Bio Science, 1980; 12: 353-62).
These factors and others have led one study to propose that caesarean rates may ultimately depend on how carefully a physician’s actions are monitored and what he feels he can get away with. The authors conclude that reducing caesarean rates may have more to do with “the management of physicians than the management of labour.”
Caesarean operations are considered a matter of routine for many doctors, but not so for mothers. A caesarean is major abdominal surgery, leaving women with an increased number of emotional and physical consequences to deal with, including more backache, constipation, depression, tiredness, insomnia, hemorrhoids and flatulence than other mothers (Birth, 1992; 19: 190-4).
Mothers who have “emergency” caesareans experience the most emotional and physical damage. Often they have to cope with their own feelings of frustration, confusion and sense of failure, in addition to feeling physically unwell for considerably longer after birth (Birth, 1992; 19: 190-4). They may have negative feelings about their babies (J Clin Med, 1992; 1: 33-7) and have trouble establishing breastfeeding.
There may be wound infection and damage to internal organs, resulting in adhesions and fistulas which can compromise health and subsequent pregnancies (Clin Ob Gyn, 1985; 28: 763-8, Ob Gyn, 1987; 69: 696-700). According to the National Institutes of Health in America (NIH, 1981, Publication 82-2067) the overall complication rate for caesareans is 5-10 times higher than that of vaginal birth.
Caesarean mothers are also 5.1 times more likely to die from infection, hemorrhage, embolism and anesthetic complications than others 31 per 100,000 as opposed to 6 per 100,000
(Br J Ob Gyn, 1990; 97: 883-92). One American study has put the figure higher at 60 per 100,000 (Am J Ob Gyn, 1981; 139: 681-685). These figures may seem small until we note that the death rate for women aged 15-34 from automobile accidents is 20 per 100,000 (Cl Ob Gyn, 1985; 28: 763-9). For the baby there is a risk of prematurity (Am J Ob Gyn, 1969; 105: 579-88) and the chance of being cut, sometimes quite deeply, by the surgeon’s knife.
Unnecessary caesareans also have implications for future pregnancies and births. A very large study in Aberdeen of 22,948 women found that women who have caesareans are 23 per cent less likely to go on to have another baby than those who do not (Br J Ob Gyn, 1989; 96: 1297-1303). It remains unclear whether this is because of the secondary infertility (Fertil Steril, 1985; 43: 520-8) which can be caused by a caesarean or whether fear of another caesarean prevailed.
There also appears to be a rising rate of placenta praevia in mothers who have had a previous caesarean (J Ob Gyn, 1994; 14: 14-6). This is often accompanied by a more disturbing condition, placenta acreta, where the placenta implants itself so deeply into the scar tissue of the uterus that delivery of the organ can lead to uncontrollable haemorrhage (Eur J Ob Gyn, 1993; 52: 151-6). The likelihood of this condition increases with the number of previous operations and if the mother does not die, often the only “cure” is hysterectomy.
Women who have had previous elective caesareans or those performed before they have reached 4 cm dilation are more likely to suffer slow or halted labours the next time around, increasing the possibility of repeat surgery (Ob Gyn, 1990; 75: 45-7). In addition, an elective caesarean performed well before term is likely to cut into the thicker upper segment of the uterine muscle instead of the thinner connective tissue near the cervix. Since the upper part of the uterus is the most active in labour, this may slightly increase the risk of uterine rupture should the mother wish to have a vaginal birth the next time round.
There is also the uncertainty of the type of previous uterine incision. Low transverse scars have the lowest rupture rates, and while all of today’s caesareans are described as “lower segment”, women have no guarantee that the surgeon has actually followed any strict protocol. Time pressure, lack of skill, tiredness and sometimes carelessness mean that the incision can be anywhere on the uterus and of any shape, even the inverted
T-shape, known to be more prone to rupture (Daily Telegraph, December 6, 1993). Even so, it must be stressed that the incidence of scar rupture is minute. (See box, p 3).
Few practitioners are able to stop, or acknowledge their role in, this epidemic. Evidence and education, it appears, make no difference to clinical practice. In one study in Denver, Colorado, educational presentations were made to doctors and nurses on many aspects of obstetric care, including the management of previous caesarean sections, fetal distress and dystocia in the hopes of reducing the number of caesareans in the city. That year the rate rose from 17.3 to 19.5 per cent! (Ob Gyn, 1990; 75: 133-6)
What, then, will make a difference? Ironically the very system which made the most significant contribution to high caesarean rates may ultimately aid its decline.
Blue Cross and Blue Shield in New Jersey is now paying physicians the same for a vaginal birth as for a caesarean (Med Health, 1995; 49: 3). In addition physicians receive a $100 bonus for vaginal births after a previous caesarean. Other healthcare plans now have a similar payment scheme though it is too early to tell what the impact will be. In the end, the most effective action to reduce caesarean rates may simply be the stubborn refusal, by healthy women, of “fetal extraction” as a substitute for birth.
Sidebar: When a caesarean is necessary
- Placenta praevia (low lying placenta)True cephalopelvic disproportion (when the baby’s head is too large to get through)
- A baby in a transverse lie (though some doctors now advocate turning the baby in labour to avoid surgery)
- Fulminating pre eclampsia
- Cord prolapse
- Certain other medical conditions which affect a mother’s health may also indicate surgery. These include:
- Severe heart disease
- Kidney disease
- HIV (although under certain circumstances HIV infection may not pass to the baby).
Caesareans are unlikely to be necessary for:
- Failure to Progress *
- Fetal Distress *
- Breech Presentation
- Twins
- Scarred Uterus
* providing, of course, no interventions have been used.Surgery is necessary for:
Sidebar: VBAC success
Scar rupture is the most frequently cited and feared reason for repeat surgery, but the incidence of rupture is minute (Am J Ob Gyn, 1989, 160: 569-73).
Some scars do rupture, but without any symptoms such as bleeding or pain. These are minor ruptures which cause no problems to mother or baby and heal by themselves.
The rate of scar rupture for women undergoing a trial of labour with single, normal babies is measured in fractions of a percent 0.09 to 0.22 per cent for women with a lower segment “bikini line” cut. It is estimated that the risk of a woman requiring a caesarean for true emergency conditions such as placenta praevia, cord prolapse or fetal distress is 2.7 per cent – nearly 30 times greater than the risk of uterine rupture (Effective Care in Pregnancy and Childbirth, 1995, Oxford University Press).
A substantial review of medical literature on vaginal birth after caesarean (VBAC) from 1950 to 1980 found that out of 5,325 recorded VBACs there was not a single maternal death related to uterine rupture (Ob Gyn, 1982; 59: 135). This concurs with other findings.
There is almost no physiological reason to refuse VBAC. Research puts the success rate as high as 90 per cent, depending on the reasons for the previous caesarean (Am Fam Physician, 1988; 37: 167-77; Ob Gyn, 1990; 76 (5 pt 1):750-4). Women most likely to achieve VBACs are those who had surgery for a breech baby (85 per cent). Those who had the operation because of “failure to progress”, “fetal distress”, fetopelvic disproportion or more than one previous caesarean have achieved a VBAC in 50-75 per cent of cases (Clin Ob Gyn, 1992; 35: 445-56).
Sidebar: Emergency or elective
It’s one of the peculiar twists of medical language that any unplanned caesarean is referred to as an “emergency”, even though the decision to operate is quite often not taken under emergency conditions. Nobody can predict when a caesarean may be necessary. The only proving ground is a period of labour. Should labour genuinely not be progressing, should the mother become tired or unwilling to go on, there is usually plenty of time to site an epidural, let the mother rest and then operate.
Elective caesareans when the baby is delivered surgically on an elected date before the mother goes into spontaneous labour are rarely necessary or desirable except in circumstances where the mother’s or baby’s health may be severely compromised by labour. An elective repeat caesarean carries a greater risk of serious complications in the next labour (Am J Ob Gyn, 1990; 163: 738-42) and six times greater risk of death than a vaginal birth (Pursing the Birth Machine, Ace Graphics, 1995).
In spite of this, a substantial number of caesareans are elective and for non medical reasons (Lancet, 1993; 341: 246; Birth, 1992; 19: 21-2). Some doctors even claim that this is justified because it is in response to women’s wishes. What may prompt a significant proportion of healthy women to ask for or accept unnecessary surgery may be linked to a very deep fear of the process of birth in women and their practitioners. As one American obstetrician noted, “When someone is scared it is not an indication for surgery. It is an indication for education.” (OBG Mgt, March 1991).
Even if a caesarean is unavoidable, there is considerable evidence to show that a baby can benefit from a period of spontaneous labour (Sci Arena, April 1986; 92-102, Ob Gyn, 1985; 65: 818-24). Stress hormones, known as catecholamines, released during labour, trigger the baby’s lungs to begin drying out in readiness for life in an airy environment. These hormones also stimulate the liver, kidneys and digestive system to begin to function independently. Elective caesarean deprives the baby of this important preparation for life.
Sidebar: Avoiding an in necessary Caesarean
Caesareans and all their potential side effects can be avoided. However, since all the evidence points to the relative lack of effectiveness of practitioners in reducing the number of surgical deliveries, mothers may have to be extra vigilant. Here are the steps which can help:
Avoid Active Management
When active management is applied in labour, caesarean may be genuinely necessary to rescue women and their babies from the side effects of unnecessary interventions such as induction, electronic fetal monitoring (EFM) and pain relieving drugs. Syntocinon, when used on women with scarred uteri, has been shown to increase the caesarean rate for failure to progress (J Ob Gyn, 1994; 14: 420-2). When used in conjunction with an epidural it increases the likelihood of rupture, leading to a repeat caesarean (BMJ, 1987; 294: 1645-6). In an unscarred uterus, induction can lead to hyperstimulation, producing erratic and eventually ineffective contractions and depriving the baby of oxygen for longer periods of time.
Not surprisingly, induction is associated with higher caesarean rates for fetal distress and increased incidents of dystocia (Ob Gyn, 1992; 80: 111-6).
Induction can lead to further interventions, most commonly EFM. Continuous monitoring has been shown to have no effect on perinatal outcomes (Lancet, 1987; 2: 1375-7), and in a random sample of British obstetricians (Caesarean Birth in Britain, Middlesex University Press, 1995) 19 per cent said they would perform a caesarean “because of fetal monitoring”, confirming data from other reports that EFM leads to increased caesarean rates (New Eng J Med, Mar 1, 1990).
Epidural anesthesia is known to slow the first and second stages of labour (Lancet, 1989; 69: 1250-2) and make limp and ineffective the pelvic muscles necessary to rotate the baby into optimum position for birth. Epidurals have been associated with an up to 10 times greater risk of caesarean than other form of pain relief (Am J Ob Gyn, 1993; 169: 851-8).
Stay Upright and Mobile
Walking has no known side effects and is as effective as syntocinon for augmenting labour (Am J Ob Gyn, 1981; 139: 669-72). Women who walk, stand or sit upright during labour have shorter labours, use less pain relief and less augmentation than those who are supine and immobile (Effective Care In Pregnancy and Childbirth, Oxford University Press).
Choose Midwifery Care
Studies show that midwifery care equals low caesarean rates. One survey of 84 free standing birth centres, staffed by midwives, in the US reported a overall caesarean rate of 4.4 per cent (New Eng J Med, 1989; 321: 1804-11). Equally, the presence of a doula (or trained birth companion) has been shown to cut the average length of labour by half from 19.3 to 8.8 hours (New Eng J Med, 1980; 303: 597-600). Factors influencing low caesarean rates among midwives may include greater continuity of care. The more confident and familiar a woman is with her practitioner, the greater confidence she will have in herself.
Be Patient
Some labours, especially first labours, simply are long. Women with a previous caesarean, especially one performed before 4 cm dilation may have long labours comparable to those of women having their first baby (Ob Gyn, 1990; 75: 45-7).
Consider a Home Birth
This may be the surest way of achieving all the prerequisites listed above. For healthy women and their babies, home birth may well be the safest option (J Nurse Midwifery, 1991; 34: 95-103; BMJ, 1991; 303: 1517-9; J Rep Med, 1977; 19: 281-290).
Sidebar: WDDTY verdict
There can be no doubt that far too many caesareans are being performed all over the world without any real benefit to either mothers or babies. Even if a surgical delivery is unavoidable there is evidence to show that both mother and baby benefit from a period of spontaneous labour.
There are many areas of concern regarding the rising caesarean rates, particularly the growing number of non medical reasons for performing this form of major abdominal surgery. Chief among these is doctors’ fear of litigation, should they not intervene soon enough in a difficult labour (though considering the number and severity of side effects of caesarean delivery, it is only a matter of time before a case is brought against a doctor for intervening when it was unnecessary). Physician’s impatience and convenience also play a disproportionate part.
Where caesarean is necessary, it can sometimes be because of interventions earlier in labour. For instance, artificial rupture of the membranes to induce or augment labour can lead to cord prolapse, where the umbilicus comes out before the baby does and is crushed by the baby descending into the birth canal. This in turn can cause brain damage and death unless a caesarean is performed quickly (usually under a general anaesthetic, which carries its own specific risks). Reducing the caesarean rate is likely to be the result of multi dimensional pressure brought to bear on our practitioners.
Some of the information in this article has been adapted from the newly published book Every Woman’s BirthRights by Pat Thomas (Thorsons, £7.99).
- This article first appeared in the August 1996 (Volume 7 Number 5) edition of What Doctors Don’t Tell You.
