To cut, or not to cut?

IT has been theorised that the Greek dictator Julius Caesar may have been delivered via Caesarean section (C-section) in 100 BC, thus giving rise to the name of the most popular surgery performed globally. However, one of the first documented Caesarean sections in history was to Bindusura, an emperor of India in 320 BC, whose mother accidentally consumed poison and died during delivery. At that point, the Queen’s advisor made up his mind that the baby should survive, and delivered the baby through the Queen’s abdomen.

Before modern medicine, C-sections were always done when labour was prolonged or obstructed after many hours or even days, and invariably resulted in the death of the mother because of excessive bleeding. With modern advances in drugs and improved surgical techniques, many C-sections are performed daily with minimal complications. In the United States alone, up to 1.4 million babies per year (30 per cent of births) are delivered via C-section and women are usually home by the end of the second day after surgery, alive and well!

In the 1980s, the World Health Organization recommended that countries should aim to have a C-section rate of no greater than 10 to 15 per cent as there is no evidence that health care quality improves when the rate is greater than 15 per cent (and thus may result in an extra burden being placed on the country’s economy). In the US presently, this rate is 32 per cent and up to 38 per cent in some parts of Europe.

Where does Jamaica fall in this grand scheme? Not too far behind. In 2011, I found that the rate at the University Hospital of the West Indies, Mona, was 34 per cent, again proving how common this surgery is.

What is a Caesarean section ?

Babies can be delivered vaginally or abdominally. A C-section involves a skin incision on the mother’s abdomen, then entering through the various levels of the abdomen including the abdominal muscle. Once the uterus is reached, an incision is made on the uterus and the baby is delivered, followed by the placenta. The inside of the uterus is cleaned and the incision on the uterus is closed, followed by the layers which were entered and then finally, the skin. The surgery is usually done under spinal anaesthesia (anaesthesia inserted into their nerves around the spinal cord) resulting in the mother being awake during the surgery and also being pain free. In uncomplicated cases, the surgery typically lasts 30 to 45 minutes.

Why Caesarean section?

Historically, it is well known that the best and safest route of delivery is vaginally. However, when a vaginal delivery poses a risk to the mother or the baby, a C-section should be performed to decrease this risk. C-sections are conducted for medical, personal and social reasons. C-sections can be classified as either being elective or emergency. An elective C-section is a planned surgery and is usually done due to medical reasons. It is usually conducted at 39 weeks of gestation. An emergency C-section occurs when complications of pregnancy onset suddenly during or before labour, and involves the rapid delivery of the baby abominally in order to save the mother’s or baby’s life, or even both.

Indications for elective C-section include:

— Previous c-section (most common)

— Previous uterine surgery (myomectomy)

— Abnormal presentation such as breech

— Large baby ( more than four kilograms)

— Twins or multiple pregnancies

— Maternal short stature resulting in a small pelvis (cephalopelvic disproportion)

— Abnormal foetus

— HIV infection (to decrease the transfer of the virus to the baby)

— Genital infections such as herpes and vaginal warts

— Abnormal uterus

— Low placenta (placenta previa)

Many women are requesting C-sections from their private obstetricians with indications ranging from fear of pushing and damaging the vagina and pelvic floor — too stush to push — to planning a particular birthday for the unborn child. Though very attractive to many women, this practice, however, is questionable in a country like Jamaica which has a health sector that is already under tremendous financial constraints.

Some emergency C-section indications include:

— High blood pressure (preclampsia)

— Failed induction of labour

— Cord prolapse

— Uterine rupture

— Prolonged/obstructed labour

— Foetal heart abnormalities

— Placental abnormalities (abruption – premature separation of placenta)

— Post mortal (to save baby when mother has died).

Complications

In spite of this surgery being so common, there are associated complications with C-sections. Immediate complications include damaging other structures in the abdomen such as the bowel and the bladder; bleeding and the risk of blood transfusion; and potential risk of hysterectomy (removal of the uterus if bleeding does not subside). Later complications include the risk of post spinal headache; wound infection; and the development of blood clots in the legs and lungs. In future pregnancies, the placenta can become adherent to the uterine wall (placenta accreta). In addition, C-sections are associated with the formation of scar tissue (adhesions) within the abdomen, and hernia formation. These adhesions can potentially make future surgeries much more difficult.

Can I deliver vaginally even though I had a C-section in the past ?

The simple answer is yes. The greatest concern when a mother is in labour with a previous C-section is that of uterine rupture (the uterus opening at the previous scar) resulting in the potential death of the mother and baby. The perfect candidate is a woman who is well motivated, has had at most two normal C-sections, a normal size baby who is head first, no placental abnormalities, and last pregnancy was at least 18 months prior. These women should be monitored continuously throughout labour and if any sign of distress an emergency C-section should be conducted.

Caesar was a wise dictator. Wisdom is key in choosing the right route of delivery. Your obstetrician has had a lot of experience and wants the best outcome for you and your baby, whatever the route may be, so take heed!

Dr Daryl Daley is a consultant OBGYN at Gynae Associates, 23 Tangerine Place, Kingston 10, and Shops 46-50, Portmore Town Centre, St Catherine. Telephone him at 929-5038/9 and 939-2859 or e-mail drdaryldaley@gmail.com.