Dr Sherene Kalloo
MBBS, DGO, DM, FACOG, MDW
Specialist Obstetrician & Gynaecologist
April is c-section awareness month. A cesarean delivery or c-section is the delivery of a baby through surgical incisions made in the abdomen and uterus. We as obstetricians must recognise that our patients are human too and will have fears and we must understand and encounter this by educating all involved parties on what are the indications for c-sections–elective vs emergency–and reassure our patients that vaginal delivery is always a first choice unless otherwise indicated.
Also, a c-section is not as bad as it sounds as modern techniques, especially anaesthetic options, have allowed moms to be involved in the delivery process with fewer risks. Remember, ultimately, the most important factor is the delivery of a healthy baby and a healthy mom. There’s no need to fear a c-section. You need to be able to trust your obstetrician and have open discussions on what’s best and safest for both baby and mom.
Caesareans or vaginal births: should mothers or medics have the final say?
With easy access to the Internet, many couples are more knowledgeable and make decisions based on the information available. It is up to the doctors to discuss properly with patients the indications for c-sections to determine the safest outcome for both mom and baby. Some moms now request an elective c-section–MRC or maternal request caesarean–for various reasons. Whether it’s the fear of labour or the desire to not traumatise the pelvic floor by pushing out a baby for fear of “stretching the vagina,” the request of a patient must be respected and the patient must be made aware of the risks and benefits of both vaginal and c-section deliveries. The ultimate decision is based on discussions between doctors and patients and finding the safest, most comfortable outcome.
The increase in c-sections worldwide has been causing alarm for the World Health Organization (WHO). What are your views on what’s happening in T&T? Are we seeing more babies in T&T being born by c-section? Are the figures alarming?
It’s a known fact that globally there has been an increase in c-section rates for various reasons. Some say that the increased rate of c-sections was being fuelled by the rise in maternal obesity, obstetricians’ fear of being hit with a lawsuit if something goes wrong during labour, prolonged labour or failure to progress, and a small number of women asking to have the procedure.
In T&T in the 1990s c-section rates were quoted as under 20 per cent, in the public sector we have also noted an increase of up to 33 per cent in 2019, but there’s interestingly a noted decline down to 28 per cent as recorded for 2022.
Are we seeing more elective caesareans or emergency caesareans?
I’m seeing more emergency c-sections than electives in my practice. I’m also faced with patients requesting elective c-sections–whether it’s to plan a date or fear of delivery, but once discussed, I have been successfully able to convince patients to do epidural vaginal deliveries with good outcomes. So good communication between caregiver and patient is important.
While massive global inequalities in safety and access persist, caesareans are considered major but safe surgery in high-income countries. What’s your view?
Over the years and with advancements in experience and technology, c-sections are indeed a major surgery but definitely considered safe. We in T&T are also more advanced as our maternal outcomes over the years with the reduction in morbidity and mortality show this.
It’s a controversial topic. The WHO says that c-sections are associated with risks for both mother and baby, which is why it campaigns to reduce unnecessary c-sections and considers them a last resort, only to be done when medically necessary...How do you respond to this?
The risks associated with c-sections are well documented, a surgical procedure will always have risks with anaesthesia and the surgical procedure itself. I agree that surgery should always be a last resort and only be done if necessary. In fact, that’s what I practice, so with all patients, once there’s no contraindication to a vaginal delivery we aim for that, and only if a caesarean becomes necessary eg, fetal distress or failure to progress or preeclampsia, etc, to save the life of a baby and/or a mom, then it’s performed with the consent of the patient.
What are the risks and benefits of c-sections?
The risks of c-sections would be from both the surgical and anaesthetic perspectives. Risks to moms although rare include surgical injury to the bladder or bowel, blood loss, infection, reactions to anaesthesia whether it’s spinal or general, increased risk of blood clots (DVT, pulmonary embolism), increased risk in future pregnancies eg uterine rupture or placenta praevia.
Risks to the baby, again rare, include surgical nicks to baby skin and breathing issues. Benefits have been documented and include a lower risk of urinary incontinence and sexual dysfunction, lower risk of oxygen deprivation to baby, lower risk of trauma to baby, and, of course, it’s safer and faster if medical conditions to mom and baby pose an imminent danger.
Do c-sections cause psychological harm?
Psychological harm from anything can be reduced by ensuring all parties involved are well informed during the antenatal period of all risks involved. Also, by reassuring your patient that c-sections are only done when absolutely necessary. Some patients blame themselves for being inadequate in some way, that something is wrong with them, that their partners will look at them differently, that they may never lose the belly fat, that they are less of a woman if they did not deliver vaginally, that they would never feel what true motherhood is if they had a c-section. There are many misconceptions and we as caregivers have to constantly take the time to find out the problem and reassure our patients.
Women are self-conscious about caesarean scars, how do you address their concerns?
A surgical scar, whether it’s a c-section or otherwise, as women we would definitely be self-conscious for cosmetic reasons and also the fact that we know it would restrict our independence. However, with a c-section, once a woman is aware that it can save her baby’s life, it becomes more accepting because her child is now the most important factor and nothing else matters at that time. Education and explanation of benefits and knowing a c-section is a last resort helps to make the acceptance more desirable. I try to do my c-section cuts as small as possible for cosmetic reasons. I guess being a woman who has been through both normal and c-section deliveries allows me to be more patient and understanding, so I do what I would like for myself, and for my patients as well. Makes the whole process easier. Some heal better than others so follow-up is important for both the physical and psychological aspects.
A 2015 UK Supreme Court case described how a mother with an unusually large baby was purposefully not told about the risks of her delivering vaginally to avoid her requesting a c-section. During the birth, her baby was deprived of oxygen and later developed cerebral palsy. The court ruled that she should have been made aware of the risk and the alternative of a c-section, to give informed consent. What are your views?
I’m in full agreement with the court. How can one not be told of the risks of delivering a large baby vaginally? It’s an obstetrician’s nightmare to have a head delivered and then shoulders stuck (shoulder dystocia). Once a baby is assumed and estimated to be large over 4.5kg then all risks must be told to a patient and an elective c-section should be offered.
But concerns are sometimes disregarded and a doctor’s suggestions challenged. What are your views?
I’ve always maintained that the patient is always right and we must, as caregivers, respect the wishes of our patients but ensure we still educate all risks involved and together find the best outcome. For eg, a heart condition affecting a relative would have traumatised anyone to think the same can happen to them but joint management with a cardiologist can reassure the patient that their situation may be different and not genetic. If a patient still has overwhelming psychological distress and prefers a c-section, then it should be a consideration and offered as an option.
What is the cost of a c-section in T&T?
The cost of a c-section in the private sector varies depending on the hospital and the surgeon. The total cost can range from $35,000 to about $45,000.
Insurance companies do cover depending on your premium and coverage. I’ve noticed an emergency c-section getting better coverage than an elective booked c-section. The insurance companies say pregnancy is not a sickness so unfortunately the coverage is not much.
Indications for a c-section
*Labour isn’t progressing normally. Failure to progress. Labour that isn’t progressing (labour dystocia) is one of the most common reasons for a c-section. Issues with labour progression include a prolonged first stage (prolonged dilation or opening of the cervix) or a prolonged second stage (prolonged time of pushing after complete cervical dilation).
*The baby is in distress. Concern about changes in a baby’s heartbeat might make a c-section the safest option. Less than 120 beats per minute or more than 160.
*The baby or babies are in an unusual position. A c-section is the safest way to deliver babies whose feet or buttocks enter the birth canal first (breech) or babies whose sides or shoulders come first (transverse).
*You’re carrying more than one baby. A c-section might be needed for women carrying twins, triplets, or more. This is especially true if the first baby is not in a head-down position.
*There’s a problem with the placenta. If the placenta covers the opening of the cervix (placenta previa), a c-section is recommended for delivery.
*Cord prolapse. A c-section might be recommended if a loop of umbilical cord slips through the cervix in front of the baby.
*There’s a health concern. A c-section might be recommended for women with certain health issues, such as a heart or brain condition.
*There’s a blockage. A large fibroid blocking the birth canal, a pelvic fracture or a baby who has a condition that can cause the head to be unusually large (severe hydrocephalus) might be reasons for a c-section.
*You’ve had a previous c-section or other surgery on the uterus. Although it’s often possible to have a vaginal birth after a c-section, a healthcare provider might recommend a repeat c-section.