Cesarean Sections
Welcome back everyone. It is Saturday. I am on duty this weekend. I am going through my messages to patients on the Secure Reach system. It is the middle of the night, so there is no way I am going to call anyone. But I can certainly leave messages. I am taking a break right now and writing up my next blog.
I thought I would write about C-Sections. They are becoming more and more common through the years. The reasons for the increased rate is in the demographic changes that are occurring in women.
No doctor that I know sets out to deliberately increase the C-Section rate. On the contrary, Obstetricians have been engaging in the analysis of the C-Section rate for many years. The bean counters who are in charge of paying for these C-Sections are also highly interested in the rates of C-Sections. The state health department and the newspaper publishers have published C-Section rates, with the implication that a higher rate is something to avoid. Even the Federal Government has published a national goal of lowering the C-Section rate. Evidently all of these public figures are assuming that a C-Section is a bad thing and must be avoided at all cost. And the implication seems to be that only a lousy doctor would do any C-Sections.
The problem with all of this logic is that each pregnant woman is unique. Every pregnant women is evaluated and treated in a manner that she and her fetus are the only thing that matters. Whether too many or too few C-Sections are done is irrelevant to the evaluation of this women, right now, her labor, and her child. I can tell you that when I am evaluating a laboring women for safety, I don't consider my C-Section rate in the equations. What does it matter to her if my last three cases were vaginal births, or C-Sections? It shouldn't matter one iota. What matters is this woman's safety. And her child's safety. So I do what is right based on this case in front of me. I will do what is right based on the Golden Rule, the therapeutic alliance, and evidence based scientific knowledge.
Every case is evaluated on it's own merits. If this women and/or her child needs a C-Section, then I am going to offer to do it. The CS rate simply doesn't matter at the level of the individual case.
What are the CS rates? In our hospital it is about 30-40 percent. Most of these are for obvious reasons, like it is a repeat CS, the baby is breech, or the baby is very big, or there are twins. It we exclude the obvious cases from the statistics, and only look at healthy low risk full term uncomplicated pregnancies, we are left with a CS rate that is much closer to the ideal of about 15 percent. 15 percent is what is quoted as the national goal.
But since our hospital is a referral hospital, with a busy IVF clinic, a fantastic NICU, and a older patient base, we have a lot more of the high risk cases, and less of the low risk full term uncomplicated pregnancies. So our CS rate is naturally higher.
By the way, our NICU is run by a fantastic neonatologist named Dr Frank Manginello. His book is available on Amazon at http://amzn.com/0471239968.
Frank is a great guy and I know him well.
Why do we do most C-Sections? The most common reason by far is that the baby doesn't fit through the pelvic canal. This is a decision that can be made before labor, at the start of labor, during labor, or at the end of a long and unsuccessful labor. What happens is that the women may be in a strong labor, but for some reason the cervix doesn't open, or gets stuck opening before it gets to full dilation. Or maybe the cervix gets to full dilation, but then the baby doesn't come down the vagina, even with strong pushing. Sometimes this obstructed labor happens because the baby is just too big. Sometimes the obstruction is that the pelvic canal is too small. On the other hand, it may suprise some of you to know that sometimes the baby just doesn't cooperate with the proper maneuvers to get through the pelvis. In other words, the baby is crooked, and attempts to present the side of the head instead of the top. This is called asynclitism and is not too uncommon. When we finally deliver the child we find that the cone head molding is off to one side. A childs head cannot come through like that. It just won't fit.
But since our hospital is a referral hospital, with a busy IVF clinic, a fantastic NICU, and a older patient base, we have a lot more of the high risk cases, and less of the low risk full term uncomplicated pregnancies. So our CS rate is naturally higher.
By the way, our NICU is run by a fantastic neonatologist named Dr Frank Manginello. His book is available on Amazon at http://amzn.com/0471239968.
Frank is a great guy and I know him well.
Why do we do most C-Sections? The most common reason by far is that the baby doesn't fit through the pelvic canal. This is a decision that can be made before labor, at the start of labor, during labor, or at the end of a long and unsuccessful labor. What happens is that the women may be in a strong labor, but for some reason the cervix doesn't open, or gets stuck opening before it gets to full dilation. Or maybe the cervix gets to full dilation, but then the baby doesn't come down the vagina, even with strong pushing. Sometimes this obstructed labor happens because the baby is just too big. Sometimes the obstruction is that the pelvic canal is too small. On the other hand, it may suprise some of you to know that sometimes the baby just doesn't cooperate with the proper maneuvers to get through the pelvis. In other words, the baby is crooked, and attempts to present the side of the head instead of the top. This is called asynclitism and is not too uncommon. When we finally deliver the child we find that the cone head molding is off to one side. A childs head cannot come through like that. It just won't fit.
A less common reason to do the CS is that the fetal heart rate becomes suspicous, or what is called non-reasuring. If we suspect that the baby may be losing oxygen, then there is no choice but to deliver the baby. This happens routinely, but it is not as common as an obstructed labor. About one in a thousand babies will be born with Cerebral Palsy. In the past, the Obstetrician would be blamed for ignoring signs of fetal stress. The scientific analysis of this subject shows that about 90 percent of CP has nothing to do with events in labor. The Ob sometimes gets blamed anyway. Enterprising lawyers make billions of dollars on these claims. And these claims put Ob's out of business. Even when the claim is unjust, the lawyers can still make a lot of money. This is how John Edwards, the politician who was almost elected as VP of our country, made his giant amount of money that financed his political career. He sued Obstetricians for CP claims and won. His official position is that Ob's don't do enough CS. According to him, we all need to be doing much more of them.
The problem with his logic is that despite doing many more CS over the years, increasing the rate from 5 to 40 percent, the incidence of cerebral palsy has not dropped even a small amount. The theory that CP is caused by difficult labors doesn't hold water. CP is caused by unmanagable catastrophe, in utero injury, such as undiagnosable in utero viral encephalitis, undiagnosable in utero partial umbilical cord obstructions (as complete obstructions would be lethal), and maldeveloped fetal brains. Some legal judgements against Obstetricians are a giant miscarriage of justice.
But there are cases where CS is required. Placental Abruption is one of them. If the placenta disconnects from the mother, there is a short window of time to get the baby born before the baby suffocates. If the patient is in the labor suite when it happens, we can save the baby if we hurry. I have done it many times. But if the women is not at the hospital, then there will likely be a bad outcome.
There are many other reasons to do a CS. Breech, for instance. Or, for maternal request. Many years ago, an OB was forbidden to honor a women's request for an elective CS. That prohibition has since been rescinded. We are now allowed to honor a maternal request. We must get a proper informed consent. The women must understand the risks and the benefits, then we can do it. It is becoming more popular. The most commen reason for maternal request is that women want to protect their vaginas from stretching and long term damage. As you all know by now, that fear is real. In fact, in some hospitals in the world, the CS rate is approaching 90 percent.
If I women is facing a needed CS, how should she feel? It is something awful, to be feared, is it scary, should she be in tears?
I would submit to you for consideration that it is none of the above. A CS can be a great relief. It most certainly can be an enjoyable experience. It can be fun. It can be calm. We can play music, tell stories, and chit chat. There is usually no pain at all while we are doing it. Most women can and should watch the baby come out. We have mirrors set up just so the women can watch. If she is watching, I like to explain how it is going and how we are doing. Some of you may have seen me on the TV show called "The Baby Story" on The Learning Channel. I have done this many times.
And, I can tell you for sure that even an 8 cm "bikini cut" just above the pubic bone, that doesn't even cut any muscles, can get the baby out with less pain and trauma than a traumatic vaginal birth that has 8 cm tears into the bladder and the rectum.
So a CS should not be thought of as an awful thing, that wrecks your life. It should be thought of as a reasonable option. It is not a failure at all. It is simply a different way of doing something. And in many cases it does a lot of good. Thinking of it as a failure is unnecessary, and it frequently leads to inconsolable tears and depression. It is better to think of it as a successful way to avoid danger.
And it is always safer for the baby.
What I mean is, the fetal mortality rate from a planned vaginal birth is about 1 in a thousand births. The fetal mortality rate from a planned CS is about 1 in 10,000. They are both safe with those large numbers, but the CS is 10 time safer for the baby. Of course the surgery is less safe for the mom. A women who has a CS is therefore trading some of her safety for her babies safety. Many women will gladly make that trade off in a heart beat. And then with the vaginal protection, some women will actually opt for an elective CS.
If a woman understands the risks and the benefits either way, I will honor their request for a CS.
So, why is the CS rate dramatically increasing?
First of all, babies are bigger than they have ever been. Big babies don't easily fit through the limited space of the pelvic canal. This is reason number one.
Second, women are having babies much older than in the old days. No matter which way you want to look at the data, a 40 year old woman's skin and tissues are not as soft and stretchy as a 20 year woman's. And older women naturally have bigger babies. That is a double strike against older women's labors.
Third, the John Edward lawyers of the world are breathing down the necks of Obstetricians, and telling women that if there is CP (cerebral palsy), it is the doctors fault. And one in thousand babies will have CP, even if we did a CS on all of them. So, in general, obstetricians are intolerant of borderline cases of fetal heart rate changes. Rather than trusting their judgement that the baby is OK, the Ob orders a CS, for a diagnosis of "non reassuring fetal heart tracing". In almost all of those cases, the baby will be delivered vigorous and completely nonstressed. But, in some rare cases this CS will, in fact, deliver a baby that shows signs of stress. So, whether there are too many CS done for "nonreassuring tracing" depends more on your point of view than on any scientific analysis. Many, many women, and many midwives, have the point of view that they would rather not do a CS unless the evidence of fetal stress was unequivoval. Most Obs would not take it that far. If the Ob does take it that far, and there is CP, then there may be a legal case. I am oversimplifying a bit because there are some objective factors that the OB can use besides the tracing itself, but this is the underlying meaning.
Fourth, of course there are the elective CS done for maternal request. This is why some hospitals have a 90 percent CS rate. It is certainly not that high where I work.
So, why is the CS rate dramatically increasing?
First of all, babies are bigger than they have ever been. Big babies don't easily fit through the limited space of the pelvic canal. This is reason number one.
Second, women are having babies much older than in the old days. No matter which way you want to look at the data, a 40 year old woman's skin and tissues are not as soft and stretchy as a 20 year woman's. And older women naturally have bigger babies. That is a double strike against older women's labors.
Third, the John Edward lawyers of the world are breathing down the necks of Obstetricians, and telling women that if there is CP (cerebral palsy), it is the doctors fault. And one in thousand babies will have CP, even if we did a CS on all of them. So, in general, obstetricians are intolerant of borderline cases of fetal heart rate changes. Rather than trusting their judgement that the baby is OK, the Ob orders a CS, for a diagnosis of "non reassuring fetal heart tracing". In almost all of those cases, the baby will be delivered vigorous and completely nonstressed. But, in some rare cases this CS will, in fact, deliver a baby that shows signs of stress. So, whether there are too many CS done for "nonreassuring tracing" depends more on your point of view than on any scientific analysis. Many, many women, and many midwives, have the point of view that they would rather not do a CS unless the evidence of fetal stress was unequivoval. Most Obs would not take it that far. If the Ob does take it that far, and there is CP, then there may be a legal case. I am oversimplifying a bit because there are some objective factors that the OB can use besides the tracing itself, but this is the underlying meaning.
Fourth, of course there are the elective CS done for maternal request. This is why some hospitals have a 90 percent CS rate. It is certainly not that high where I work.
Thank you for reading my blog. I hope it has been informative.
One of our labor room nurses has asked me to write about Endometriosis. It causes a lot of pain, misery, infertility, and disability. It is hard to diagnose, and on average requires women to get multiple second opinions, and average 7 visits to the doctor to get a proper consideration of endo. I will write about endo next.
One of our labor room nurses has asked me to write about Endometriosis. It causes a lot of pain, misery, infertility, and disability. It is hard to diagnose, and on average requires women to get multiple second opinions, and average 7 visits to the doctor to get a proper consideration of endo. I will write about endo next.
Please post links and share it around. And comments below are appreciated. Thank you very much.
Sincerely,
John Marcus MD FACOG
89 North Maple Ave
Ridgewood NJ 07450
201-447-0077
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