Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Wednesday, April 06, 2016

At The Time and Place of Her Choice

"You've either tried a long time to get pregnant, or you've had IVF and finally you get pregnant and you say, 'I can't take any chances, I'm going to have a caesarean section. It makes perfect sense -- you've tried so hard for so long and you've got the idea this is your last chance. It's not safer, but it's believed to be safer [theoretical scenario]." 
"You have to put something in the surgical indication box [provide a valid medical reason to enable an elective C-section]. You can't just say, 'she wants one'. So you have to put something like pathological fear of vaginal childbirth. A favourite is fibromas [fibroids]. Apparently, we're having an epidemic of fibromas [popularity among pregnant women for caesarian delivery]."
"But I think that, even without this special case, the older mother will be more likely to be counselled to have a caesarean or choose a caesarean."
"The new generation of [female obstetricians] are living it for themselves -- an increasing proportion are choosing never to have a vaginal childbirth, so you can imagine what they're telling their patients. They're afraid of pelvic floor dysfunction, urinary incontinence, sexual dysfunction."
"If you think childbirth is nothing more than an opportunity to pee in your pants, you'll counsel  your patients accordingly."
Dr. Michael Klein, professor emeritus, University of British Columbia
"If you think of the days before anesthesia, women were told 'in sorrow thou shalt bring forth children'. There was almost this religious idea that pain is part of your rite to passage to motherhood, and there is an element of that still remaining -- the idea that all women should give birth vaginally unless they medically absolutely cannot."
Pauline Hull, coauthor, Choosing Caesarean: A Natural Birth Plan

"Sometimes it's the fear of the unknown of a vaginal birth, or the fear of damage to the perineum, or the act that they're older and they're going to have only one child."
"Maybe as we get older, we just like things more scheduled and less uncertain."
"And if they want it, [caesarean option], in many cases, we'll go ahead and do it."
Dr. Jon Barrett, chief of maternal-fetal medicine, Sunnybrook Health Sciences Centre
There was a time that caesarean sections represented emergency delivery, when the normal delivery route was not possible, because of a breech position, or some other kind of threat during childbirth to mother and child. Normal delivery was natural, it was the way that women have always given birth, assisted or otherwise, throughout the ages. And the kind of intrusive surgery characterized by a caesarean section was considered abnormal, dangerous and needful only under certain circumstances.

All that changed about a decade ago when women were persuaded that caesareans were more convenient; they could select a suitable delivery date and there would be no suspense. There would also be no tears, no pain, they'd be under the sedation of a skilled anesthesiologist and their baby would be neatly plucked out of its sanctuary, no need to push and grunt and feel excruciating pain. Apart from real medical emergencies when the baby's presentation is not favourable or other reasons, delivery by caesarean has skyrocketed.

At first the joke going the rounds was that these usually older women who chose the surgical technique were simply 'too posh to push', and then concern was raised among the medical community why so many sections were taking place as a matter of choice, not necessity. Women now give birth to fewer babies in the developed world, and the age of expectant mothers has increased as well, a potent driver of caesarean sections. It is a more dangerous method for both mother and child, and expensive as well.

During 2014-15, 17 percent of women under age 35 delivered their first baby by C-section, while for first-time mothers over age 35 that figure was 23 percent, according to statistics from the Canadian Institute for Health Information. Another study out of Ontario found that for women over age 40, almost one in two (43 percent) chose C-section.

Older women in pregnancy are likelier to present with obesity, gestational diabetes or other conditions increasing the likelihood of a surgical birth, but those complications in themselves don't explain the disproportionately high rates of C-sections. Genuine concern over lasting damage to the pelvic floor muscles along with an irrational fear of vaginal delivery, and then another symbol of the present age: "precious baby" syndrome all were seen to add to the push for surgical intervention.

Canadian researchers concluded through a study of breech pregnancies that healthy women carrying a healthy fetus undergoing a planned C-section risked rare but more prevalent postpartum cardiac arrest, bacterial infections in their reproductive tract, along with blood clots and hysterectomy, than those in the planned vaginal delivery contingent. A study undertaken in 2006 of over six million births discovered neonatal mortality rates to be higher among infants delivered by caesarean (1.77 per 1,000 live births) than those vaginally delivered (0.62 per 1,000 births.

The World Health Organizations states that doctors should not undertake C-sections "purely to meet a given target or rate, but rather focus on the needs of patients". Newly published guidelines support a woman's right to a planned caesarean, in Britain. According to Dr. Klein, some doctors are "running scared" as a result of a higher risk of unexplained stillbirths in older women. "The baby just dies in utero and we don't know why", explained Dr. Klein.

And Dr. Klein spoke of doctors being aware of a fallout of too many C-sections where a rise in placenta accreta occurs The placenta attaches itself to an old C-section scar on the uterus. Those who support maternal choice caesareans argue that though the costs associated with the section procedure have skyrocketed, the cost involved in surgery to repair damaged pelvic floors more than balances out the equation.


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