Child delivery: Undertake C-section as last resort

Thursday January 18 2018

Operating.  Doctors carry out surgery on a

Operating. Doctors carry out surgery on a patient recently. Hospitals have registered an increasing number of mothers seeking to under-go caesarean sections rather than normal delivery. Photo BY RACHEL MABALA  


All 14 regional referral hospitals and the big four private hospitals have registered high numbers of mothers seeking caesarean section as their preferred mode of child delivery.
Caesarean section, also known as C-section or caesarean delivery, is the use of surgery to deliver babies. It is often applied when it is deemed a vaginal delivery would put the baby’s or mother’s life at risk.

A recently released annual health sector performance report indicates that 28,845 mothers delivered by caesarian section out of the 103,131 child deliveries registered at the 18 hospitals. This means the C-section accounted for 28 per cent of all the deliveries the said referral hospitals during the last Financial Year 2016/17.

Soroti and Nsambya hospitals had the highest C-section rates at 48 per cent followed by Lubaga (38 per cent) and Mengo (37 per cent). The lowest C-section rate was registered in Masaka Hospital at about 7 per cent.

Dr Othiniel Musana, an obstetrician and gyaenacologist at Nsambya Hospital explained that the C-section cases are high due to the big number of mothers who report with delicate conditions.
However, he says that due to life style changes and trends, some expectant mothers now demand to deliver through C-section surgery an option that relieve them of labour pains experienced during a normal delivery.

He said C-sections are common among elite women than rural women.
He says four in 10 mothers who deliver at Nsambya have high blood pressure whereas three in ten have diabetes.
“Institutions have different C-sections. For example Nsambya’s rate stands at above 40 per cent and mainly because of the nature of the investment,” Dr Musana explained.

He said, for instance, Nsambya has put in place facilities and experts to handle expectant mothers who present with diabetes or hypertension.
“Risky pregnancy women are normally sent to Nsambya. Secondly, due to lifestyle changes, women tend to have bigger babies,” he adds.

Risk measures
Dr Musana said the hospital cannot put an expectant mother on C-section on the basis that she has requested for it if she has no observed risk of complication during her antenatal visits.
However, he says some for-profit private hospitals offer C-sections upon request by mothers.
“Private-for-profit health facilities perform C-sections even when they are not necessary but sometimes expectant mothers put doctors on pressure to have the procedure as an option for delivery,” he says.

Daily Monitor talked to Ms Patricia Akello, a mother of two who said she has had a normal and a C-section delivery.
“I had my first child through a normal delivery but the second one, I was too weak to push and the gynecologist recommended a C-section,” Ms Akello says.
“It was after a working day in the evening. I started getting contractions in a taxi while on my way home.

When I arrived at the hospital, my baby had gotten stuck in one side of the womb. I wanted to deliver my baby normally but it would not be possible,” she adds.
Dr Musana says the status of the abdominal wall determines the number of babies a woman can deliver by C-section procedure. He says the cost is higher than that of normal delivery.

He says at Nsambya’s general ward, C-section costs about Shs1.1m compared to its private wing where the cost is much higher.
At Mulago National Referral Hospital, a C-section costs Shs2.5m when a mother delivers from the private wing. The hospital’s general wing offers the procedure free of charge.
Available literature traces the history of Caesarean sections in Uganda back to 1853.

A Briton Mr Robert Felkin, in his correspondence to Professor Peter Dunn of the Department of Child Health at Bristol University Southmead Hospital in England, indicated that he had personally observed one operation in Uganda in which both the mother and the child survived.
Despite the lifesaving aspect of the C-section, the Association of Gynecologists in Uganda recently expressed concern on the increasing rate of the procedure.

Prof Dan Kaye, the association’s chief executive officer, says mothers continue to request for C-sections, which should be discouraged.
“A caesarean should be an opportunity that should save life of a baby and that of the mother, it should not be done unnecessarily,” Prof Kaye charged.
He says some mothers walk to doctors and tell them a specific date they want to deliver and say they don’t want to go through labour pains.

He warns that C-section has its own risks such as rapturing the uterus or damaging other internal body organs such as the urinary bladder or kidneys.
“It should only be done on medical reasons and by qualified professionals because each C-section has a risk on the internal organs,” Prof Kaye cautions.
The association wants the vice checked.
However, he admits colleagues in the medical profession accept to offer surgery to mothers on request despite the act being unethical.

C-Sections By Choice
“This time is going to be different,” Jennifer Berman told herself when she found out she was pregnant for the second time.
Her first labour, three years earlier, had been long (18 hours) and frightening, because her baby’s head and shoulders got stuck in the birth cana. Max—born at 9 pounds, 8 ounces—suffered no lasting harm, but the monitoring probes inserted during labour gave Berman an infection that took more than a week to clear up. She also suffered from months of incontinence.

“It was all way out of control,” says Berman, a urologist at UCLA Medical Center.
For her second baby, she decided to have a C-section. Isabelle arrived by appointment weighing 7 pounds, 8 ounces.
Almost one in three babies in the U.S. come into the world by C-section, an all-time high, and rates keep rising. Now a growing number of women, like Berman, are choosing the option even when it’s not medically necessary.

Some doctors are in favor of giving women the choice, especially if they may be at particular risk of urinary or other complications.
“While vaginal birth is a natural event, in essence what you’re doing is rolling a bowling ball through the vagina,” says urogynecologist Peter Sand, M.D., of Northwestern University’s Feinberg School of Medicine, in Chicago. Many obstetricians, however, are reluctant to substitute surgery for vaginal birth.
The choice is controversial and has sparked a public debate. Recently, the American College of Obstetrics and Gynecology officially told its members that it’s ethical to perform an elective cesarean.

But other groups think it’s a terrible idea. “Medically necessary cesareans are one thing, but to give blanket approval to elective cesareans, instead of working with a mother to have a vaginal birth, could be dangerous to the health of the mother and the baby,” says Barbara Hotelling, a mom and a former president of Lamaze International.
Why would a woman choose a C-section? Fear of labour pain is one reason; another is concern over the tearing that can occur in vaginal delivery. Still another is fear of incontinence later on due to wear and tear on the pelvic muscles. Some women mistakenly believe that a C-section will better preserve their pre-baby figure (it’s pregnancy, not giving birth, that’ll stretch your waistline).

For other mothers-to-be, it’s all about the baby: Maybe they know someone who’s lost a child, or had a child permanently injured, during a difficult vaginal birth.
Doctors remain deeply divided about how much choice to give women. “Most women who come in asking for a cesarean do so because they’re petrified of childbirth,” says ob-gyn Kimberly Gregory, M.D., of Cedars-Sinai Medical Center, in Los Angeles. “In the past, the attitude was that these patients needed better education or counseling, not cesareans. Perhaps we’re getting away from that. But I’d still feel uncomfortable if I did a procedure that was not indicated medically.”
One thing is clear: For such an emotional issue as how your next baby should arrive, you’ll need to understand all the pros and cons, for the baby, and for you.

Risks for the baby
Big babies are at higher-than-normal risk of birth complications. When labor begins, the obstetrician stands ready to perform a C-section if it suddenly becomes necessary.
Some breathing problems are more common in babies born through C-sections, even if they’re planned. The risk is highest if the procedure is performed before 39 weeks, such premature birth can happen if the due date has been misjudged. Overall, though, the risk of serious respiratory distress is low.
Some mothers and experts worry that even a successful c-section may interfere with breastfeeding and bonding, since the mom and the baby may be separated during recovery. But new research has revealed that bonding is a long-term process, and the method of delivery doesn’t seem to affect it.

Risks for the mother
Unlike vaginal birth, a C-section is major surgery, and that means recovery and the risk of complications. Fortunately, the risk of losing the mother to surgical complications has declined dramatically over the past century. But excessive bleeding, infection, and injury to such abdominal organs as the uterus, intestines, and bladder can occur. Women who’ve had a c-section are slightly more likely than those who’ve given birth vaginally to need readmission to the hospital, most commonly for uterine infection or bleeding. Again, most complications occur in unplanned cesareans performed after a woman’s water breaks and labor begins.
Then there’s recovery, which can take weeks.

Benefits for the mother
For many women, the most important long-term benefit is the protection of the pelvic floor, the muscles that support the uterus, bladder, and other abdominal organs. When the baby’s head passes through the birth canal, it can damage the nerves and muscles there. The risk increases if the doctor has to use forceps.
This can lead to postpartum incontinence, uncontrollable urination that often occurs when you run, cough, or even laugh. Fortunately, it usually goes away in a few months.
For a minority of women, though, incontinence keeps returning. For more, vaginal delivery contributes to a gradual, age-related weakening of the pelvic floor, which increases the chances of incontinence in later life.
Women who have a C-section not only avoid postpartum incontinence but also have a lower risk of it when they’re older: Those who’ve delivered only by cesarean are less likely to suffer from moderate to severe incontinence as women who’ve given birth vaginally. Another medical advantage: If your cesarean is planned, you won’t need to have it in an emergency situation, which is far more likely to cause injury, or worse.

Making the choice
No two birthing experiences are alike. For every horror story about a vaginal or cesarean delivery, there are many more infused with joy and satisfaction.
Canadian researchers recently followed some 1,600 pregnant women, half of whom planned to deliver by cesarean and half vaginally after learning that their babies were in breech position. Three months after delivery, both groups said they were equally satisfied. More of those in the c-section group said that they liked that their childbirth experience hadn’t been very painful. More of those in the vaginal-delivery group reported that they were happy that their recovery hadn’t been difficult. And the two groups of women didn’t differ in how promptly they were able to return to an active, pain-free sex life.