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We have a complaint: Too many women in India are having cesarean sections to deliver babies. At least that’s the conclusion that some obstetricians are coming to when they look at the rising number of cesarean, or surgical births. Who is responsible for this situation? Doctors, patients and policymakers are all accountable for a steep increase in unnecessary, costly and risky procedures.

The recommended level of Cesarean birth in any population is 10-15%, according to a World Health Organization (WHO) report . But in the last decade or so, the numbers have escalated in many parts of the country—reaching as high as 41% of deliveries in Kerala, and 58% in Tamil Nadu, says a report by the ICMR School of Public Health. And it’s happening across both urban and rural areas: Mumbai saw an exponential growth in C-sections in both private and public hospitals, while one study (Jan 2007 to Dec 2012) demonstrated a spike from 31% to 51% over just six years in rural Haryana. During a study in undivided Andhra Pradesh, household surveys revealed that up to 80% of the women in some districts had undergone a C-section (this is not officially confirmed though).

The reasons for this increase are many: Private medical institutions have the potential to rake in money for a patient’s longer stay and medical attention. But the decision is not just in the hands of a physician.

Some women fear the labour pains and want to have an 'easy way out'. Late pregnancies, life style diseases are the causes given by some. There is also a spike in the number of patients who are obese, and those who develop gestational diabetes—two factors that can complicate pregnancy. A combination of dietary and metabolic changes, coupled with less physical activity, have led to skyrocketing rates of diabetes and obesity in recent years. Indians are highly vulnerable to Type 2 diabetes.

And as the number of children the couples are going for is reduced, they don't want to take 'any sort of risks' with regard to their offsprings even if the dangers are small.

Some excuses are bizarre! Some patients come with their own set of beliefs and biases. They want to deliver on auspicious dates and times. Some want their babies to come into this world on fancy dates like 1.1.11! Some trust the street corner pundits than the doctors and want to deliver only on the dates set by the former! Because these muhurts can yield good horoscopes for their children!

Some women fear that vaginal deliveries loosen their vaginas as they get stretched during the baby's travel through it. This makes, according to them, sex difficult and unpleasant.  Yes, vaginas get stretched - this is caused by relaxation of the pelvic floor musculature. These muscles will lose their tone with each successive birth, although pelvic floor exercises known as Kegels can help you tighten them up - but  they come back to normal size again after some time in young women. So there is nothing to worry. But whether or not your vagina returns to its original size depends on a number of factors: genetics, the size of your baby, the number of children you've had, your age and whether you do Kegel exercises regularly.

You can keep your vaginas in the right form by following these exercises... 

Since this includes the muscle that you use to stop and start the flow of urine, you can check if you've identified the right muscle by testing your Kegel technique while urinating: If you can stop the flow of urine when tightening, then you know that you're contracting the correct muscle (don't do your exercises while urinating — it can actually weaken the muscles and lead to urinary problems). Do them after completely emptying your bladder. You can start by tightening the muscle like while you try to stop the urine from coming out. Count ten and then relax it. Then start again.

As with any exercise, start doing Kegels a few at a time, a number of times each day. As your muscles start to feel stronger, gradually increase both the number of Kegels you do each day and the length of time you hold each contraction. Do the Kegels in sets of ten and try to work up to three or four sets about three times a day. Besides improving vaginal tone, pelvic floor exercises also help prevent urinary incontinence later in life.

Many studies show that vaginal delivery tends to produce better health outcomes for both baby and mother when it is an option. And another popular belief, that a woman can’t follow one C-section birth with a vaginal birth for her next pregnancy, is also largely unfounded.

Counselling and education go a long way to combat these myths, misconceptions, biases and beliefs. So let us see now why caesarean delivery is needed according to medical science.

Reasons for needing a planned caesarean...

*You've already had a caesarean section, and there were complications during the procedure. If there were no complications, a vaginal birth after a caesarean (VBAC) may be possible, and is successful in 70 per cent of cases.

*A current problem that has led to difficult labour and cesarean before, such as a narrow pelvis and a large foetus (cephalopelvic disproportion).
*Factors that increase the risk of uterine rupture during labour, such as having a vertical scar, triplets or more, or a very large foetus.
*Your baby is in a bottom-down (breech) position, and external cephalic version (ECV) { if your baby remains in the breech position by late pregnancy, your doctor can try to turn her by hand. This procedure is called external cephalic version (ECV). During ECV your obstetrician places firm but gentle pressure on your tummy to encourage your baby to turn a somersault in your womb (uterus). Your baby will then be head-down. ECV works for roughly half of the women who have it. If you have no pregnancy complications and are having just one baby, you should be offered ECV. You can have ECV from 36 weeks of pregnancy up to when your labour is beginning. The procedure will be carried out in hospital, where there is equipment to monitor your baby's heartbeat and ultrasound to check your baby's position } isn't recommended, or hasn't been successful.
*You are expecting twins or more (multiple pregnancy), and the first baby isn't in a head-down position. The direction and size of the incision depends on the position of the foetuses. In particular, cesarean delivery may be needed for multiple births involving - twins that share one amniotic sac (monoamniotic twins), because of the risk that the cords will get tangled, three foetuses or more, twins that are joined by any part of the body (conjoined), an overstretched uterus that cannot contract adequately during labour (uterine inertia), making labour prolonged and difficult, poorly positioned or large foetuses.
*Your baby is in a sideways (transverse) position, or keeps changing his position (unstable lie).
*You have severe pre-eclampsia or eclampsia (in case the placenta isn't working properly. It can make you and your baby quite ill if you don't receive the treatment you need. Pre-eclampsia causes the flow of blood through the placenta to be reduced. This means that your baby won't get enough oxygen and nutrients, which may restrict his growth. Pre-eclampsia usually happens in the second half of pregnancy, or shortly after the birth. You're most likely to develop it after 27 weeks of pregnancy), and having your baby by vagina will take too long to be safe.
*Estimated foetal size of over 9 lb (4.1 kg) to 10 lb (4.5 kg) or more.
*You have a low-lying placenta [placenta praevia - the placenta develops wherever the egg embeds in the womb (uterus). Placenta praevia happens when it develops low down in the womb and stays low-lying beyond mid-pregnancy. If your placenta is near your cervix when you’re ready to give birth, it may block your baby’s exit route through your vagina. Placenta praevia can also cause bleeding in mid-pregnancy to late-pregnancy. The placenta may be partly covering your cervix (minor placenta praevia) or completely covering it (major placenta praevia). In both cases your baby will need to be born by caesarean section. By the end of pregnancy, about one in 300 women has some degree of placenta praevia. Most of these are minor placenta praevia].
*You have a medical condition, such as a certain type of heart disease.
*You had a previous traumatic vaginal birth.
*You caught genital herpes for the first time in your third trimester. Open sores from active genital herpes near the due date, which can be passed to the foetus during vaginal delivery.
*You have HIV and are either not receiving retroviral therapy, have a high viral load, or also have hepatitis C. A vaginal birth is an option if your HIV is under control.
*A known health problem with the baby, such as spina bifida (a birth defect in which the bones of the spine (vertebrae) don't form properly around the spinal cord. If it's severe, part of the spinal cord or spinal nerves may be exposed. This can cause nerve damage and lead to serious problems, so surgery may be needed soon after birth. But in most cases, the defect is mild and hidden, and it doesn't cause problems. Spina bifida develops early in pregnancy, often before a woman knows she is pregnant. A woman can reduce her chance of having a baby with spina bifida by eating a healthy diet and taking folic acid supplements before and during pregnancy).

Sometimes, certain conditions go together, giving more than one reason to have a planned caesarean. For example, you may have a low-lying placenta that has contributed to your baby settling into a breech or transverse position.

Reasons for needing an emergency or unplanned caesarean...

*Your baby becomes distressed - identified by a very rapid or very slow heart rate - during labour. Distress is a sign that a baby is unwell, or isn't coping well with the demands of labour. Your baby may become distressed if: She is smaller than average. This usually happens when the placenta is not working well, and the oxygen supply via the umbilical cord is reduced. She has an infection. She is post-term, which means that you are more than 42 weeks pregnant. If your pregnancy has not been straightforward, this may affect your baby's birth. Your baby is more likely to become distressed if - you have pre-eclampsia that affects how your placenta functions, have too much amniotic fluid, or too little amniotic fluid, have a chronic condition, such as diabetes or high blood pressure, you are pregnant with twins or more, you are age 35 or over.

*Your labour is long and slow (dystocia- failure to progress) as your cervix isn't opening enough to allow your baby to move down the birth canal.
*Labour that has stopped completely (failure to progress)
*There has been an unsuccessful attempt using instruments such as forceps or ventouse.
*The placenta has come adrift in late pregnancy or during labour (placental abruption), which puts you and your baby in danger. Placenta abruptio, can cause excessive bleeding (hemorrhage) and decreased oxygen supply to the foetus.
*A scar from a previous caesarean tears (uterine rupture). This happens to one in 200 women, so isn't common.
*The umbilical cord slips through your cervix ahead of your baby (prolapse of the cord). This uncommon complication means that there's a danger that the cord will be squashed as your baby descends, cutting off your baby's oxygen supply.

In many cases, a caesarean happens for clear health reasons, and is the safest option for mother and baby when handled by well trained doctors and when a pregnant woman cannot have normal vaginal delivery. Sometimes, though, the decision to operate is based on information that is open to interpretation, or reflects the skill or experience of your obstetrician. This means that decisions can vary from hospital to hospital and doctor to doctor.

Talk to your doctor to find out more about it before taking any decision. Always ask for a second opinion if you are unsure if the decision is right for you.

Remember it's a major surgery, and major surgery has some risks. Let us see what they are now...

Cesarean section is considered relatively safe. But it does pose a higher risk of some complications than does a vaginal delivery. If you have a cesarean section, expect a longer recovery time than you would have after a vaginal delivery.

After cesarean section, the most common complications for the mother are: infection, heavy blood loss, a blood clot in the legs or lungs, nausea, vomiting, and severe headache after the delivery (related to anesthesia and the abdominal procedure), bowel problems - such as constipation or when the intestines stop moving waste material normally (ileus), injury to another organ (such as the bladder which can occur during surgery), maternal death - although very rare - about 2 in 100,000 cesareans result in maternal death, restricted movements and work for at least six weeks and may take more time too if the woman is not very healthy, incision care.

Cesarean risks for the infant include: injury during the delivery, need for special care in the neonatal intensive care unit, immature lungs and breathing problems, if the due date has been miscalculated or the infant is delivered before 39 weeks of gestation.

While most women recover from both cesarean and vaginal births without complications, it takes more time and special care to heal from cesarean section, which is a major surgery. Women who have a cesarean section without complications spend about 3-10 days in the hospital, compared with about 2 days for women who deliver vaginally. Full recovery after a cesarean delivery takes 4 to 6 weeks. Full recovery after a vaginal delivery takes about 1 to 2 weeks.


Long-term risks of cesarean section...

Women who have a uterine cesarean scar have slightly higher long-term risks. These risks, which increase with each additional cesarean delivery, include: breaking open of the incision scar during a later pregnancy or labour (uterine rupture), placenta previa, the growth of the placenta low in the uterus, blocking the cervix, placenta accreta, placenta increta, placenta percreta (least to most severe). These problems occur when the placenta grows deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, and sometimes may require a hysterectomy.

So why should a woman be subjected to more risks based on myths and false beliefs? Or for someone else's monetary benefits? Except for the reasons mentioned above, there is absolutely no need for a woman to go for a C-section delivery. 

So the verdict is very clear: It is better to go for normal vaginal delivery whenever possible and plan for it with the help of your doctor from the day you take a decision to have children.

And it effects evolution too...

Effects of c- section births on evolution

Caesarean section (or C-section) deliveries can save lives when babies are too large to be born naturally - or if there are other health complications - but they also appear to be affecting how humans are evolving, scientists report.

In the past, larger babies and mothers with narrow pelvis sizes might both have died in labour.  Thanks to C-sections, that's now a lot less likely, but it also means that those 'at risk' genes from mothers with narrow pelvises are being carried into future generations.

Cases where a baby can't fit through the birth canal have increased from 30 in 1,000 births in the 1960s to 36 in 1,000 today because of this C-section effect, according to estimates from researchers at the University of Vienna in Austria.  That's a significant shift in just half a century.

"Without modern medical intervention, such problems often were lethal and this is, from an evolutionary perspective, selection.

The team used a mathematical model based on obstructed child birth data to reach their estimates.

More detailed studies would be required to actually confirm the link between C-sections and evolution, as all we have now is a hypothesis based on the birth data. But Mitteroecker and his colleagues say it's important to consider the effect the rise in these procedures is having.

There are already a few conflicting evolutionary forces at work here, scientists think, in what's known as the obstetrical dilemma.

The 'dilemma' is that the larger a baby is when it's born, the more likely its chances of survival. At the same time, women have evolved with smaller pelvic sizes to aid upright walking and to limit the chances of premature births.

Both evolutionary pressures are working to try and keep babies healthy... but they're also working against each other.

"One side of this selective force - namely the trend towards smaller babies - has vanished due to caesarean sections.

This evolutionary trend will continue but perhaps only slightly and slowly.

Cliff-edge model of obstetric selection in humans

http://www.pnas.org/content/early/2016/11/29/1612410113

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