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 £30 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.

!APat Thomas

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).