Thursday, February 26, 2009

Questioning the elective c-section

I have a few concerns about what's presented as fact by a mother interviewed about her elective cesarean delivery. Chief among them is that she asserts that because her baby was breech she would have "ended up with an emergency C-section and that's the thing you want to avoid".

That's just not true. Leaving aside the option of vaginal breech birth (difficult to arrange in terms of finding a provider, but not some kind of anatomical impossibility and very common elsewhere in the world) a known breech is not going to end in an emergency c-section. One of two things will happen: 1) the mother has a scheduled c-section before going into labor or 2) the mother goes into labor before her scheduled surgery, goes to the hospital, and has a c-section. Neither of these scenarios involve an "emergency" c-section. (I was also puzzled by her reference to a doctor in an emergency c-section not always being able to do a low transverse ("bikini line") incision. Does anyone know about this? I've heard of doctors cutting a classical incision for other reasons, but not emergency-related.)

The reference to differentiating between risk in planned and emergency c-sections is also not really accurate. Even studies that control for whether or not the cesarean was indicated based on risk have found a difference between cesarean and vaginal births.

Finally, I was struck by comments like "You don't have these awful stitches 'down there'" (I guess "inside and outside your abdomen" is better?) as if women are guaranteed tearing and/or an episiotomy at a vaginal birth.

I'm happy that this woman had a positive outcome from her elective cesarean section, but that doesn't change that cesarean section is riskier than vaginal birth. At the end they ask if she would have another elective c-section for future children, and she says "Absolutely!" While you could argue that the absolute difference in risk between c-section and vaginal delivery at the first birth is small, it is undeniably true that the gap grows with every subsequent c-section. Women planning to have multiple children should in particular think hard about choosing a cesarean.


Jill said...

Besides the misinformation in there that you pointed out, what's with "I had to discuss it with him, and we found a medical reason"?

WE found a medical reason. That is so effing insulting to every woman that has ever fought to give birth normally in a hospital setting. So she and her doctor colluded to find a medical justification for it.

Other than that (and the fact that she's promoting c-sections as delightfully pain-free...come on now), who cares? I'd tell her, "Welcome to motherhood." Enjoy.

The trend of female OBs and male (or female) OBs goading their wives/partners/sisters, etc. into c-sections is nothing new. It's not a testimony to the safety and desirability of the surgery; rather, it's a commentary on the sad state of obstetrics that doctors can't fathom that vaginas, when left alone, do not get ripped to shreds. Here's a tip-- GET YOUR HANDS AND INSTRUMENTS OUT OF THERE.

By the way, the absence of data differentiating maternal req c-sections from emergency c-sections doesn't mean that there is evidence for performing them. It means that there is no evidence, but obstetrics is the Wild West of medicine. Practice first, then try to find justification or convince women that your clinical judgment is sound.

publichealthdoula said...

Oh yes, thanks for pointing that out!

I'm really waiting to find out how much longer it takes before we figure out all the risks of c-section we HAVEN'T noticed yet. It's that "practice first" thinking.