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.