Comment

Labouring towards consensus

The elective c-section debate rages on, with the 'too posh to push' pitted against pro-choice. One ob/gyn joins the fray

By Dr Richard Gruneir

Dr Mary Hannah seems to have set off a firestorm with her comments in the Canadian Medical Association Journal in March, that c-sections on demand should be made available. Some called the idea immoral (including one provincial health minister), while others hailed her suggestion. Even the Globe and Mail had an editorial on the subject.

This is no easy issue. Women's groups have argued both that c-sections on demand are empowering to women and that they victimize women by turning them into vain baby machines. Obstetricians argue that surgery is safe and dangerous at the same time. There is good evidence that the perineum and anal verge is protected against urinary and fecal incontinence by c-section. But there's also evidence that the problems occur regardless of the type of delivery. No matter what their agenda, most people feel that vaginal birth is the way nature intended babies to be born � but there are exceptions to every rule.

We as obstetricians have always had a duty to provide the safest possible care for both of our patients; the pregnant woman and her unborn child. We have laboured (with them) to make the transition from an intra-uterine to an extra-uterine environment with low perinatal mortality and morbidity, as well as low maternal complications. Pregnancy and birth have always been potentially dangerous. We've done a great job in the past 50 years to dramatically reduce those risks from what they were. Research continues on many fronts to reduce the impact of diabetes, hypertension and prematurity. Operative vaginal births are less likely to occur, but the fact that mid cavity forceps use is dangerous is always borne in mind. Breech singletons are no longer delivered vaginally, again because the alternative approach is safer.

LABOUR THE CAUSE
Yet, c-sections without what we consider labour identified indications, seem to have caused a great reaction. We know the risks of surgery and we know the risks of vaginal birth. Statistically we know that they are about the same. Yet somehow letting the woman decide when and if the surgery should be performed has met with a fair bit of resistance, as if we are losing our ability to manage things � even though we've already encouraged women to plan how they labour, who'll help, and what medications they'll use.

I don't know why there is resistance.

As gynecologists we already perform surgery on patients if they want it done. We perform tubal ligations electively, therapeutic abortions electively, egg harvesting and everything else associated with the assisted reproductive techniques, at the patient's request. This doesn't even include cosmetics or other specialties.

Vaginal birth after a previous c-section (VBAC) is slowly losing popularity in Canada. It is almost completely out of favour in the US as the national obstetrical association advises against it, calling the uterine rupture a 'litigin,' producing an assured loss within the assured lawsuit. Although the rupture risk isn't high, it is high enough to scare a lot of doctors into recommending a repeat c-section. More importantly, the risk of rupture has made more and more women request that the surgery be performed to reduce their � and their baby's � risk. But it could also be argued that this c-section doesn't have strong indications.

During the pregnancy, the patient decides which optional tests she wants performed, such as maternal serum screening for Down's, neural tube defects, as well as HIV. So where is the problem in letting her decide howshe wants to deliver? With ultrasound, term is term. Most women already get an anesthetic during labour, so having one for a c-section doesn't really change this side of the equation. There's no practical limit to the number of c-sections that can be performed when most families are having only 2 or 3 children.

The only argument not refutable is that the cost is higher because length of stay is longer. So if elective c-section is not to be, the government will have to step in and make the decision. And in my opinion, no government is going to step in where there are women's health care choice issues in this day and age.

Richard Gruneir, MD, FRCSC, is an Ob/Gyn in Leamington, ON