One in three Singapore women deliver their babies by Caesarean section. Are doctors or parents just too “scissor-happy”?
Whether it’s a fear of labour pains, a wish to time Baby’s arrival to fit work schedules or to match an auspicious date, it appears more mums-to-be here and around the world are opting for an elective or “patient-choice” Caesarean. “The caesarean section is the most commonly performed surgical intervention in the developed world, and increasingly in developing nations,” says associate professor Tan Lay Kok, senior consultant with the department of obstetrics and gynaecology at Singapore General Hospital (SGH).In SGH, C-sections account for 35 per cent of deliveries, while for private hospitals, the percentage is far higher, he shares in the January/February 2016 issue of Singapore Health.
It’s about 38 per cent in South Korea, 30 per cent in the US and Australia, and 26 per cent in China – figures that the World Health Organization (WHO) says are much too high. WHO estimates that, medically, C-section rates should make up no more than 10 to 15 per cent of all births, which means the remaining 15 to 20 per cent are likely avoidable.The International Cesarean Awareness Network agrees. Stating its position on patient-choice caesareans, ICAN says on its website (www.ican-online.org) that research shows no benefits to infant health or mortality once a country’s caesarean rate climbs above 10 per cent.It goes on to criticise obstetricians who perform “unnecessary surgery on healthy women with normal pregnancies” as “unethical” and going against their code to not bring harm to their patients.
The non-profit organisation aims to reduce unnecessary caesareans through education, provide support for caesarean recovery, and promote vaginal birth after caesarean (VBAC).However, Dr Tony Tan, consultant obstetrician and gynaecologist at Raffles Hospital, attributes the rise in C-section rates partly to improvements in the safety record of caesareans over the years. He also disputes the notion that the procedure is being taken too lightly by patients and their doctors. “The majority of women prefer normal vaginal delivery and the majority of obstetricians do not recommend this procedure too easily.”
Dr Tan adds that patients, too, are well aware of the risks as most obstetricians counsel their patients thoroughly, briefing them on the immediate risks of such a major surgical procedure, including bleeding, infection, deep vein thrombosis, injury to bowel, bladder and foetus, and the higher maternity mortality rate than with natural births.
Too posh to push?
A procedure that once was used in an emergency or for medical reasons such as cervical cancer in the mother, a C-section has become more and more of a lifestyle choice. It is scheduled to ensure the time of birth is “favourable”, if the woman is afraid of developing incontinence and pelvic organ prolapse as a result of vaginal delivery, or is simply too fearful of painful contractions – dubbed by some media as being “too posh to push”, Prof Tan of SGH says. Most caesareans, according to doctors, do have an underlying medical cause. Dr Tony Tan of Raffles Hospital says these include factors such as:
• placenta previa (where the placenta is partly or completely blocking the cervix)
• malpresentations (for example, a breech baby)
• cephalopelvic disproportion (Baby’s head is too big to ease out of the birth canal)
• a previous caesarean where the patient has decided against trying for a natural birth
• multiple pregnancies where the mumto- be is pregnant with two or more babies
Meanwhile, emergency caesareans may be performed after the onset of labour, usually when the progress of labour is too slow, or if the foetus shows signs of stress or distress during labour. Dr Ann Tan, a consultant obstetrician and gynaecologist, agrees that the number of women requesting a C-section is still very small and “the majority of them are those who are older and have had assisted reproduction done”.
As a specialist in infertility treatments and high-risk pregnancies who runs the Women and Fetal Centre at Mount Elizabeth Hospital, she sees more complicated cases, which may require C-sections. She says: “I recommend a C-section when there is a danger to the foetus in attempting a vaginal birth, such as when the foetus is too big or has very little water to cushion him in labour, and induction is not an option.”
’’A procedure that once was used in an emergency or for medical reasons... has become more and more of a lifestyle choice.’’”
Avoiding the cut
So what can you do to minimise the chances of ending up on the operating table? Other than ensuring a healthy pregnancy by eating right, exercising and avoiding toxins like alcohol and cigarettes, “the most important factor is to avoid a first delivery by C-section”, Dr Tony Tan says. “Occasionally, some women may have pre-existing medical conditions such as hypertension, diabetes mellitus or thyroid disorders, or develop complications during pregnancy, which may threaten the well-being of mother and/or foetus,” he adds.
“Having good control over these conditions may reduce the chances of having a potentially compromised foetus and subsequently reduce the chances of a C-section during labour.” The good news, however – for those who have already gone under the knife – is that the old adage “once a caesarean, always a caesarean” is no longer a given. VBACs, once shunned for fear of uterine ruptures at the scar site, are increasingly recognised as the safer option to a repeat caesarean.
“If the first C-section was for a non-recurrent cause, the woman can attempt to have a VBAC,” says Dr Ann Tan. “If she is successful, then she can continue to try and have a VBAC for the third baby.” Raffles Hospital’s Dr Tony Tan, however, says he would advise surgery for a woman who has had at least two C-sections.
This lowers the risk of uterine rupture, a rare but life-threatening tear in the wall of the uterus, most often at the site of the scar of the previous caesarean. Meanwhile, naturalbirth advocates point to increasing research and statistics of successful vaginal births for breech babies, large babies and even women who have had more than one previous caesarean. They say the success of natural birth is largely dependent on finding a supportive obstetrician and other caregivers. Ultimately, it boils down to patient choice.
Dr Ann Tan says: “As doctors, we go through the possible risks and benefits of a caesarean versus a vaginal delivery and if patients understand it fully, we will proceed with the mode of delivery they wish to have.” “There are few absolutes in medicine,” says Dr Tony Tan. “After being informed of the options, the patient has a choice — and she can choose another doctor if the one she’s with isn’t supportive of her birth choice.”
Be prepared
If you need to have a C-section, here’s what to expect and how you can prep for the surgery.
Discuss the procedure with your doctor Find out as much as possible about the medication and anaesthesia that will be used, as well as all possible side affects to you and the baby.
Read about the C-section and talk to friends and relatives who have gone through it. There are even preparation courses by midwives and doulas.
Have an epidural lower section C-section, if you can, says Dr Ann Tan. “Get to experience the wonder of hearing and seeing your baby at the time of delivery and even take photos with your spouse in the operating theatre with the baby. And you can breastfeed soon after you come out of the theatre, too.”
Practise the deep breathing and relaxation methods you learnt in childbirth class. Use these to help calm you before the surgery begins.
Inform your midwife or doctor if Hubby is keen to cut the cord. Ask for the baby to be put on your chest so you can have skin-to-skin contact, as well as breastfeed after the surgery.
Be prepared for pain at the incision site after the operation and pain from the uterine contractions, especially during breastfeeding. This may largely be controlled by medication given during the regional anaesthesia and after the operation.
There may occasionally be vomiting or severe itch after the operation, but you can get medication to reduce these effects.
Compared with mums who’ve had vaginal births, your hospital stay will usually last a day longer, shares Dr Goh Shen Li, a consultant obstetrician and gynaecologist in S L Goh Women’s Clinic.
While you lie in bed recovering, try to exercise your lower legs to reduce the risk of blood clots developing in your legs.
If your gynae prescribes painkillers to help, you’ll probably be able to get out of bed and move around within a day or two after giving birth.
Take it easy and avoid strenuous activities, Dr Goh reminds; the pain will subside after about two weeks.
