Women Talk: Cesarean sections: Not just a whim

My pregnant patients often ask me, “Doctor, will I deliver normally?” I usually answer in the affirmative, because the probability of a successful normal spontaneous delivery is high among pregnant patients. And yet, a minority of them will end up with a cesarean section or CS.
 

Is there a foolproof way to predict who among these women will be able to deliver normally, and who will not? Sadly, most of the time there is none.

 

When labor starts, women go into a trial of labor while being closely monitored in the Labor Room. It is only during these times, when the doctor continues to assess the effect of labor on the opening of the cervix and whether the head of the baby comes down, that a normal delivery can more or less be predicted.

 

The baby’s position

 

Obstetrical indications for a cesarean section are many, and the most common is failure to progress in labor. This means that the woman is already at the labor room for some time, but after a long watchful waiting, the cervix does not open, or, the baby’s head does not descend, even with good uterine contractions. 

 

The usual reason for this is that the pelvic passageways are too narrow for the baby to pass through. Another reason is the position of the baby’s head, which normally should be flexed, so that it becomes more compact. Sometimes the baby’s head becomes extended, or it presents in an asymmetrical manner, both of which increase the diameter that passes through the pelvis. Basically then, it is an accommodation of the baby’s head through the maternal bony pelvis. 

 

Another obstetric indication is when the baby presents with something other than the head. If it presents as a breech (that is, the buttocks come first), a cesarean section is indicated, especially if it is the first baby. This is because the pelvis of the mother is still “untried” —that is, we do not know how adequate the passageways are.

 

Moreover, cord prolapse (the umbilical cord falls down and comes out before the baby) or failure to deliver the after-coming head (the baby’s body is already out, but the head fails to be delivered) may occur. Unlike in head presentation where the skull occupies the whole pelvis, in breech presentations there are spaces where the cord can insinuate itself and fall through. Cord prolapse is an emergency, and a CS is done immediately. 

 

Some older and more experienced obstetricians though, with much technical dexterity, deliver breeches vaginally. However, when the term infant presents with the shoulder (transverse presentation), or with one or both feet (footling breech), a CS should be done.

 

During labor too, the baby’s heartbeat is monitored through a stethoscope, or a fetal monitor. Many times these may show that the baby is having difficulty (“fetal distress”) and an emergency cesarean section is done to save the baby’s life.

 

The mother’s condition

 

On some occasions, the reason for a CS is the abnormal implantation of the placenta. Normally, the placenta -- which contains large blood vessels -- is implanted high in the uterus. Sometimes though, it is found low and even encroaches on the cervix, a condition called placenta previa. When the placenta totally covers the cervix, massive bleeding will occur before the baby can come out normally. In these cases, an elective CS is usually scheduled when the baby is at least 38 weeks. Unfortunately some placenta previa bleed before the baby is mature; when this happens, there is no other choice but to do an emergency CS and hope that the baby survives.

 

In some instances too, there is premature separation of the placenta (abruptio placenta), which is another emergency situation. Many times this occurs when the mother is hypertensive, and with the separation, the baby’s life is in grave danger.

 

Also, when the mother’s blood pressure is very high and eclampsia (convulsions because of high BP) is imminent, CS is the best option.

Sometimes, a large myoma mechanically obstructing the descent of the baby’s head is an indication for an abdominal delivery.

 

Elective CS 

 

Some obstetricians opt for a cesarean section on women who have heart disease, because they feel that the stress of labor is too much for their patients. However, some point out that the stress of the surgery is also detrimental to the patient’s heart. It is best to speak with your obstetrician, especially when there is a need for an elective CS.

 

Many times too, obstetricians choose to do CS when there is genital herpes in the mother to prevent infection of the baby as it passes through the passageways. 

 

Some would choose the surgery on patients with a high viral load of HIV to lessen vertical transmission to the baby, but this is still controversial. 

 

Vaginal Birth After a Cesarean (VBAC)
 

Many doctors allow patients to deliver vaginally after a CS, when the indication for the first CS is no longer present (e.g. placenta previa before). Many patients deliver successfully in this way.
 

Rupture of the scarred uterus of course, is a main worry, so VBAC patients are chosen carefully, monitored very closely during labor, and the Operating Room is always ready for any emergency CS when the need arises. 

Moreover, there are strict Clinical Practice Guidelines for VBAC that we usually follow.

Pros and cons

In spite of the current misconception that a CS can be decided on a whim, the decision to do a cesarean section is based on strong obstetrical and medical indications.
 

On one hand, during these modern times, a CS is a relatively safe procedure, especially with regional anesthesia (spinal or epidural). The mother is awake, and can hold and cuddle her baby immediately after it is born.  

On the other hand, a CS is still a major surgical procedure, with its concomitant complications: wound infection and bleeding, with  longer hospital stays, and longer recovery time compared to a vaginal delivery.

Some patients feel like a “failure” when they could not deliver normally, and I often advise them there is no room for this sentiment, especially when the indications are clear-cut. — YA, GMA News

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Dr. Alice M. Sun-Cua is an author and practicing obstetrician-gynecologist at the San Juan de Dios Hospital in Pasay City.