When I started my training as obstetrician Caesarean section deliveries were done much less frequently than today. There were various reasons for this including…
- Caesarean sections were considered more dangerous for the mother than vaginal deliveries and so vaginal deliveries were preferred.
- In the past obstetricians were better trained, more skilled and experienced at doing more complicated vaginal deliveries and procedures than today.
- There were many more difficult operative vaginal deliveries than today.
- Breech presenting babies were routinely delivered vaginally.
- Twins were routine delivered vaginally.
- Most women who had had a Caesarean section previously had a successful ‘trial of scar’ labour (VBAC attempt).
- There were various manoeuvres that are not done today to facilitate the likelihood of a vaginal delivery.
- There were often ‘trials of labour’ if there was concern about the baby being too big for the birth canal, rather than opting for an elective Caesarean section.
- There were ‘trials of forceps’ where there was lack of progress in second stage labour and concern about the possibility and safety of a forceps operative vaginal delivery.
- There were no ‘Caesarean section by choice’ deliveries.
Caesarean section deliveries were usually done under general anaesthetics. Regional blocks were usually not suitable. Epidurals often did not as effective an anaesthetic, probably because of the more limited range of anaesthetic drugs. The spinal block needles we have today had not been invented. The spinal anaesthetic needles in the past were larger and so there was greater risk of a dural tap headache.
The incidence on Caesarean section deliveries has been gradually increasing for multiple reasons including…
- Caesarean sections are now safer that in the past.
- It is now safer for a mother and her unborn baby to have a Caesarean section delivery than a more difficult operative vaginal delivery.
- Many younger obstetricians have not had the clinical training and to not have the clinical skills to do the vaginal procedures that were popular done in the past. Their recommendation of a Caesarean section sometimes can reflect their lack of confidence in doing the potentially more challenging vaginal procedures.
- Patient expectations have changed. Patients now want more say in their management and have a greater expectation that all will go well with their pregnancy and childbirth. In the past pregnant women were more accepting of the possibility and occurrence of an adverse outcome.
- Increased medical litigation. In the past medical litigation was very uncommon. When I graduated my medical indemnity insurance premium was less than $1,000 per year. It is now over $100,000 per year. Medical indemnity premiums would be far more than this had there not been changes introduced by the Howard Federal Government (see ‘Pregnancy care management fee‘ article). We live in a far more litigious society than in the past. There is now a considerable likelihood that a patient will want to blame the doctor if something goes wrong, even when the adverse outcome had nothing to do with the doctor’s management. Consequently, doctors practice a more ‘defensive’ medicine. A Caesarean section has a more predictably good outcome for mother and baby than a more challenging operative vaginal delivery. With this likelihood and with mothers expecting to know risks (in contrast to in the past) and wanting to minimise risks, the Caesarean section rate increased.
- The outworking of this expectation of a good outcome is the higher incidence of Caesarean sections today for breech presenting babies, twins, history of previous Caesarean section and if it is likely to be a more difficult vaginal delivery.
- In the past there was not the option ‘Caesarean section by choice’. A ‘Caesarean section by choice’ is a consequence of a Caesarean section being much safer than in the past and now pregnant women having much more opportunity, at least in the private sector, to choose the type of delivery that they prefer.
With consideration of all these factors it is not surprising there has been an increase in the incidence of Caesarean sections today, compared to in the past. As well, there is a reduction in the incidence of operative vaginal procedures.
There has been ‘push back’ about the increased Caesarean section trend from the NSW Department of Health with its ‘Towards normal birth’ policy, from some midwives and from some women in the community. Consequences of this ‘push back’ are some pregnant women are being coerced into having vaginal deliveries, even though they would prefer Caesarean section deliveries. As well, there is an increased likelihood, and case reports, of adverse outcomes for mothers and babies because of the increased incidence of operative vaginal deliveries. This will be more likely when they are done by doctors who do not have the appropriate level of clinical skills.
A trend I have noticed over more recent years is not to close all the layers that were incised with entry with a Caesarean section operation. Senior registrars have confirmed to me this is what is now being taught in some teaching hospitals. When I was a trainee obstetrician I was taught to close all layers carefully. I have always had done this. While not closing all layers is quicker for the doctor operating, it is not necessarily in the patient’s best interests. There is increased risk of poor healing with adverse consequences. A patient who had this problem was discussed in a previous article titled ‘Another reason why not to go public for pregnancy care’.
My technique for doing a Caesarean section has not to ant significant extent changed over the years. This is because the human anatomy has not changed, and I had excellent training to become an obstetrician. My technique has stood me well. Instruments used in the operation also have not changed. There has been a change in patient drapes. We now use disposable rather than material drapes that were to be cleaned, sterilised and reused. Suture materials for closure of the various layers have also changed. We now use better synthetic suture material that breaks down, for all layers including skin. I suspect this has helped facilitate quicker better healing. We also use an excellent clear dressing for covering the wound that has only been available for the past few years.
To complement the husband’s/partner’s greater involvement in the childbirth experience over recent years there has been the introduction of ‘baby-friendly’, also called ‘family-friendly’, Caesarean sections in some hospitals, including both the hospitals where I confine patients. That means a patient’s husband/partner and her baby stay with her in the operating theatre and in the recovery ward. In recovery ward mum is encouraged to breastfeed her new baby. Photos of the birth of the baby and of the parents with their new baby in the operating theatre are encouraged.
