Caesarean section [BOUDHE OPERATION] refers to the delivery of a baby through an abdominal followed by uterine incision. Over the past thirty years, there has been an increasing shift in the rate of caesarean sections [CS] in the valley. Amidst a lot of benefits that CS provides, when CS is done without any medical or obstetric indication, the risk-benefit ratio tilts, thus putting the mother at high risk of morbidity and mortality. Well, human interventions can never challenge the natural ones. CS is the invention of just a century, and to put it in a more practical sense, the free use of CS is a story of just five or six decades.
Whilst vaginal delivery [lakutt operation] is the natural process of delivering the baby through the birth canal, the initiation of the process is itself the proof of many dilemmas as in the fetal maturity and the maternal birth canal adequacy. The CS due to its short duration puts a high strain on the adaptation of fetus from in utero to exutero life. The normal vaginal delivery [NVD] takes time, so that transition to the external world is slow and hence chances of any distress or maladaptation is most of the times ruled out. Most of the times CS is done prematurely so that iatrogenic [intervention-induced] fetal distress becomes the problem, well CS has got its benefits. You can’t wait for full-fledged labour to progress for 24-48 hours if any maternal or fetal problem doesn’t give you enough time to save both mother and baby. In these circumstances, CS is the life-saving procedure for the helpless duo.
The rising trend
Well, the rising trend of CS is attributed to many factors, of which the most important I find is the increasing age of marriage among girls in our part of the world. The ideal age of conception is 25 to 30 years, whereby the chances of fertility [ability to bear children] are optimal. As the concept of career-building among girls has evolved, there has been a delay in marriage, with average being 30 years, though we find women bearing first child even above 35 years. With delayed marriages, the chances of conception [pregnancy] decrease. Women are subjected to a lot of social and peer pressures. The use of interventions, both medical and surgical for inducing the fertility is increased, and consequently, even first pregnancy becomes precious. The whole family, including the couple, become anxious with respect to pregnancy and gets it terminated at the earnest by the shortest possible route, the CS, without having the patience of bearing the long duration labors. Also, even those women who want to get trials for NVD, find it difficult to bear the labor pains. Further, when age at first pregnancy increases beyond 30 years, what we call as an elderly primigravida, the chances of getting hypertension, diabetes, hypothyroidism and other medical complications increase, what we commonly refer as high-risk pregnancies, and opting for vaginal delivery in such cases puts mother and baby at equal risk, and hence the CS becomes the ultimate option. Another factor that is attributing to the rising CS trend is the very idea of the small family norm. Women are already determined to keep two or three children, and that gives them license to opt for CS, limiting the options of having children to just three.
The worst scenario seen is when a woman who has previously delivered children vaginally [natural birth] opts for CS owing to the benefit of getting tubes ligated [the process of female sterilisation] and it becomes very hard to make them understand the risks of CS compared to simple tubal ligation that could be done in future. The advancements in the field of anesthesia, pain relief and good technical know-how have made CS very trendy. It is but natural for an anxious pregnant lady to go for CS against the very lengthy laborious process of normal birth. There is also the trend of bed rest rampant among our people. Bed rest is the solution to no problem except in cases of placenta previa or cerclage operations [whereby the rest to uterus is must]. Most often the bed rest through nine months increases maternal weight and the fetal weight, which decreases the chances of big baby passing through mothers birth canal. Also, the bed rest makes pelvic floor muscles [birth canal muscles] very taut and resistant to the natural process of delivery.
Another factor, the important factor, prevalent among people is that they attribute any neonatal mishap [fetal or newborn death, distress or disease] to the very natural process of vaginal birth. Though from a lot of clinical studies, it has been proved that neonatal outcome is more or less independent of the mode of delivery. Though, in some serious situations, that put maternal and fetal health at stake, the urgent CS is justified. Also, it has been seen that most of the times, the neonatal mishap has to do more with antepartum factors [prior to labour], rather than intrapartum factors [during labour], which contribute to less than 10 percent of neonatal mishaps.
Where lays the solution?
The problem needs to be addressed at the grassroots level. It involves the collaboration of health care professionals, the family and of course the couple. Encouraging the early marriage of girls, counseling couples regarding the benefits of vaginal birth. Encourage the mothers towards bearing the labour pains. Let doctors, nurses and other labour staff including coucher develop a kind and sympathetic attitude towards agonizing labouring mothers. Let there be proper coordination between health care personnel and the family members. Let Government strengthen policies regarding boosting maternity health units. Let the doctor-patient ratio increase. Let newer and safer pain-relief alternatives be accessible to the labouring mothers. Let facilities for monitoring mother and fetal conditions be improved. Let people generate strong faith in the health care professionals towards supporting them for natural births. Let’s make the public aware that ‘once a CS is almost always a CS’.
The primigravidas [the women with first pregnancy] should be properly counseled and encouraged towards natural vaginal birth, because this may ease their chances of vaginal births in future pregnancies. If the mother opts for CS in the very first pregnancy, the chances of risky CS in future pregnancies are almost increased tenfold to a hundredfold, with additional risks of caesarean hysterectomy [removal of uterus at the time of CS] increasing.
The usual norm of inducing labour by medical or surgical methods at 40 weeks should be delayed for uncomplicated pregnancies, as the success of vaginal births increases with spontaneously induced labours. Let’s remove the fear of pregnancy from pregnant ladies. Pregnancy is a physiological state. It is not a disease per se. You need to work and need not to affect your routine. Bed rest is not going to help except in some conditions as already mentioned. Remaining active in pregnancy helps keep baby size average and makes pelvic floor muscles very flexible for successful vaginal delivery. Let’s fight it out jointly. Let’s join hands to address the cause. CS has already taken a toll on a large scale. The government policies are equally important as is the role of maternal health care personnel in delivering the fruitful services to pregnant women. At the same time, the cooperation and coordination from the family members are not to be ignored.
Dr Ruksana Farooq is Obstetrician and Gynecologist, SKIMS, Srinagar.