Elective caesarean section
Elective caesarean section, also called a planned caesarean section, is an elective surgery, which simply means that it is scheduled in advance rather than performed because of an unscheduled emergency. It is a caesarean section (CS), which is the surgical childbirth of an infant through an incision in the belly of a pregnant woman. Elective caesarean sections may be performed on the basis of an obstetrical or medical indication, or also because of a non-indicated maternal request for the caesaean section. Elective caesarean sections may be medically indicated for a range of reasons, but when they are not indicated, various health authorities recommend that they not be performed for a range of reasons including preventing harm of unnecessary health care to both parent and child.
When it is clear during a pregnancy, but prior to labor, that there is a medical or obstetrical reason to choose delivery via caesarean section, physicians will commonly perform the operation at a scheduled time, rather than waiting for the onset of labor. Such planned caesarean sections are performed for many reasons, including history of previous caesarean section, placenta previa, abnormal presentations, multiple pregnancy, known obstructions of labor, medical conditions (such as heart disease). The advantages of performing the delivery at a scheduled time include use of daytime services when hospital resources are optimal, and the ability to plan and prepare for the event. The approach has risk in that the surgery may be scheduled too early resulting in premature or compromised delivery. Prenatal testing mitigates this risk.
Critics of elective caesarean section, maintain that decision metrics are ambiguous, and that trial of labor would often be successful without open abdominal surgery. The cost to the patient and the baby for unnecessary surgery may be substantial. Critics also argue that because physicians and institutions may benefit by reducing night time and weekend work, that an inappropriate incentive exists to suggest elective surgery.
The fear of litigation is cited to drive the elective caesarean section rate higher: While a repeat caesarean section can be avoided for many women who wish to labour after a caesarean, (a process called vaginal birth after caesarean section, or VBAC), some argue that this can lead to an increase likelihood of uterine rupture.
Increasingly, caesarean sections are performed in the absence of obstetrical or medical necessity at the patient's request, and the term Caesarean delivery on maternal request has been used. Another term that has been used is "planned elective cesarean section". As of 2006, there is no ICD code, thus the extent of the use of this indication is difficult to determine. The mother is the only party who may request such an intervention without indication.
There are number of steps that can be taken during abdominal or pelvic surgery to minimize postoperative complications, such as the formation of adhesions. Such techniques and principles may include:
- • Handling all tissue with absolute care
- • Using powder-free surgical gloves
- • Controlling bleeding
- • Choosing sutures and implants carefully
- • Keeping tissue moist
- • Preventing infection
However, despite these proactive measures, abdominal or pelvic surgery can result in trauma that can lead to adhesions. In order to prevent adhesions from forming following a pelvic (gynecologic) surgery, such as hysterectomy, myomectomy or caesarean section, adhesion barrier can be placed during surgery to minimize the risk of adhesions between the uterus and ovaries, the small bowel, and almost any tissue in the abdomen or pelvis.
Adhesions can cause complications, such as:
- • Infertility, which may result when adhesions twist the tissues of the ovaries and tubes, blocking the normal passage of the egg (ovum) from the ovary to the uterus. One in five infertility cases is estimated to be adhesion related (stoval)
- • Chronic pelvic pain, which may result when adhesions are present in the pelvis. Almost 50 percent of chronic pelvic pain cases are estimated to be adhesion related (stoval)
- • Small bowel obstruction – the disruption of normal bowel flow, which can result when adhesions twist or pull the small bowel. 75% of small bowel obstructions are directly related to adhesions. (Scovill)
All the above complications have been associated with adhesions in clinical studies. [Source needed]
Caesarean sections are in some cases performed for reasons other than medical necessity. These can vary, with a key distinction being between hospital- or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick Caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined.
Non-medically indicated scheduling of childbirth before 39 weeks gestation brings "significant risks for the baby with no known benefit to the mother." Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%. The researchers found many benefits but “no adverse effects” in the health of the mothers and babies at those hospitals.
In this context, it is worth remembering many studies have shown operations performed out-of-hours tend to have more complications (both surgical and anaesthetic). For this reason, if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery.
Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits. Italian gynaecologyst Enrico Zupi, whose clinic in Rome, Mater Dei, was under media attention for carrying a record of Caesarian sections (90% over total birth), explained: “We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to defensive medicine. We will keep acting this way as long as medical mistakes are not depenalized. We are not martyrs. So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section "
Studies of United States women have indicated married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women, although they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone. In contrast, a recent study in the British Medical Journal retrospectively analysed a large number of Caesarean sections in England and stratified them by social class. Their finding was Caesarean sections are not more likely in women of higher social class than in women in other classes. Some have suggested, due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, patients should be discouraged or forbidden from choosing it.
Some 42% of obstetricians believe the media and women are responsible for the rising Caesarean section rates. A study conducted in Sweden, however, concludes that relatively few women wish to be delivered by Caesarean section.
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