|
Let's face it-someone is trying to get away
with something. To simply suggest that we should routinely
"offer" elective cesarean delivery, at term, to
all pregnant women (1) something is not based on any sound
scientific evidence that would support its benefits. This
ultimate intervention (cesarean section), which is relatively
dangerous and potentially life-threatening (compared with
vaginal delivery), interferes with a normal physiologic process
(labor) that we have no right to circumvent without evidence
of compelling benefit. The compelling benefits simply are
not present in most pregnancies. Indeed, vaginal delivery-probably
benefits fetuses, at least in terms of removal of lung water
and decreasing transient tachypnea of the newborn (2), and
subdural or cerebral hemorrhage is less in spontaneous vaginal
delivery than elective cesarean delivery before labor (3).
Why are we treating pregnancy as a disease?
"Offering" cesarean delivery or consenting to perform
it electively at term is irresponsible, dangerous, and ultimately
unfair to many women. The lack of fairness centers about informed
consent. Like it or not in medical care a great deal of perceived
power and influence is present, and the advice of physicians
is seriously heeded by many under our care. Are we truly able
to relate all of the surgical risks of cesarean delivery versus
a vaginal delivery to the majority of patients? I would suggest
that only a small number truly understand the relative risks.
The less informed woman is merely agreeing to our recommendation
without true knowledge of the consequences. This is inherently
unfair and a blatant misuse of power.
Fortunately, a sensible and knowledgeable
woman will see through this guise and reject the offering.
Insufficient scientific evidence is available to support routine
elective cesarean delivery, and she will seek the normal physiologic
process (labor) to protect . herself. Less educated, more
fearful, or less aware women will comply, however, consenting
to scheduled cesarean delivery rather than Proceeding to labor,
and herein lies the societal unfairness of this wayward recommendation.
Physicians have a duty to "First, do no harm."
In their article Gamble and Creedy have
analyzed the literature that deals with the issue of "women's
request for a cesarean section" (4). This careful analysis
of the literature alerts caregivers to what they instinctively
already know: far fewer women truly request cesarean birth
than has been intimated in several literature reports. Practitioners
must raise their suspicions of the motives of the researchers
and those who are asking the questions. Remember the physics
principle -the presence of the observer affects the outcome
of the experiment.
This only makes sense to practitioners who
strive to provide good quality health care to women. At least
in the upper midwest United States, a request to forego labor
(before the start of labor at least) and proceed to cesarean
delivery is very rare indeed. We have, however, all heard
the requests (and resisted them to various degrees) as labor
has proceeded.
The slow evolution of the labor nursing
staff in an obstetric unit that adopts a practice with a high
percentage of labor epidurals has been observed. Eventually,
the labor nurses are less able to handle any patient in pain.
It often becomes the nurse who calls for the labor epidural
first, before the woman has requested it. Epidural analgesia
has been "sold" to childbearing women and applied
in very high numbers without a truly informed discussion of
its risks, including a higher rate of cesarean delivery for
dystocia.
This sad scenario may well occur with elective
cesareans; practitioners will eventually be unable to handle
any degree of labor, or worse, a vaginal delivery. What is
a vaginal examination or a presenting part? What is this pulsating
mass in the vagina? Cord? Face? Breech?
What would the motivations be for caregivers
to recommend elective cesarean delivery before labor? What
would their life be like? It would not be all bad. We would
all get more sleep! We could lay off all the labor nurses
and fire all the midwives. We could stop using so much penicillin
for vaginal B streptococcus colonization. We would have probably
fewer cystoceles and rectoceles in older women. Maybe we could
charge more money for fewer hours of work and sweat and waiting.
We would not need obstetricians; we could simply use all general
surgeons for these operations!
However, we would have more dead mothers.
One more is too many. We would also treat far more cases of
endometritis, wound infections, and deep venous thromboses.
Women would die from pulmonary emboli and hemorrhage (accreta)
(5). These are problems we could not avoid.
Simply put, it is not worth it. Who is trying
to get away with something and for what reason? Stay the course
of the normal physiologic process. Use cesarean delivery for
truly indicated obstetric conditions and no more. It is medically
inappropriate, unfair, and unethical to offer anything less.
References
I. Harer WB. Patient choice cesarean. ACOG
Clin Rev 2000. 5(2):I, 13-16.
2. DeMott RK, Sandrnire HF. The Green Bay
Cesarean Section Study 1. The physician factor as a determinant
of cesarean birth rates. Am J Obstet Gynecol 1990; 162:15
93-1602.
3. Towner D, Castro MA, Eby-WiMns BS, Gilbert
". Effect of mode of delivery in nulliparous women on
neonatal intracranial injury. N Engl J Med 1999;341:1709-1714.
4. Gamble JA, Creedy DK. Women's request
for cesarean section: A critique of the literature. Birth
2000;27(4):256-263.
5. American College of Obstetricians and
Gynecologists. Evaluation of Cesarean Delivery. Washington,
DC: Author, 2000; 5.
Robert DeMott is an obstetrician/gynecologist
in private practice in Green Bay, Wisconsin. He is author
of the Green Bay Cesarean Study, and his partners assist in
delivery of approximately 600 babies annually with a total
cesarean delivery rate of 8 percent.
Address correspondence to Robert K. DeMott,
MD, Ob/Gyn Associates of Green Bay 704 South Webster Ave.,
Green Bay, WI 54301.
10 2000 Blackwell Science, Inc.
back
to Professional Forum |
