By Dr. Rukmani Gopal
Childbirth also known as labour and delivery is the termination of pregnancy with the arrival of one or more babies. Full term pregnancy is 9+months or 38 to 40 weeks. Babies born before 36 weeks of pregnancy is preterm birth and depending on the country, the incidence varies from 12- Sometimes babies are born >40 weeks and referred to as post-term delivery and incidence is around 3-5%.
Increase in the incidence of C-section:
In the olden days, normal delivery was the norm, while in the present day, C-section has become as common as a normal delivery. C-section rate continues to rise throughout the developed world. WHO withdrew its previous recommendation of C/S rate 15% in June 2010 and they recommend that C-section should be done based on medical needs as caesarean delivery iis lifesavingfor the mother & baby. In 1996 C/S rate in US was 20% and in 2011 the incidence has jumped to 33%. China has the highest C/S rate in the world 46%; Italy in Europe is high at 40% but Nordic countries it is 14%. India seems to be on par with China. A recent article mentions that in the state of Telangana C-section incidence is 74% and Tamil Nadu & Karnataka are not lagging behind. Why and what is the reason for such an increased incidence of C-section is the topic of discussion. First let us understand the History of C-section.
The history behind C-section:
History of caesarean delivery dates back as far as 715 BC from Ancient Roman period . The procedure was used to save baby from the womb of the mother who is dying or died (posthumous birth) Roman Royal law required the child be removed from the womb of the dead mother and not buried with the baby inside her. Ceasar or Caedere in Latin means” to cut”. Legends say Julius Caesar was born by C-delivery but it is debatable since his mother Aurelia lived through the childbirth. Children delivered this way were referred as Caesons. Ancient Jewish religious text mentioned this procedure as Yotze &Iran’s religious book Shanameh mentions birth of Rostum their national hero delivered by C-delivery. Mauryan king Bindusara’s mother consumed poison and Queen’s womb was cut open immediately by Chanakya to save baby’s life.
As per Hindu mythology, Lord Hanuman was born through a similar procedure. The first record of both the mother and the baby surviving a Caesarean delivery comes from Switzerland in 1500, Jacob Winfer performed the operation on his wife as a last resort after 13 midwives tried and couldn’t help her deliver the baby. After the introduction of antiseptics and anaesthesia in 1800, survival of both mother & baby became a reality. Successful caesarean birth is happening in the last 150 years only and since then mothers with a small frame and small pelvis and mother’s carrying big baby were lucky to survive because of the caesarean delivery.
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Vaginal birth has been taking place for ages now. Young girls have been married off at an early age and have become mothers as early as 10 or 12 years. Normal ossifications of pelvic bones are completed by the age of 18years and in young girls before ossification is completed the pelvis opens up easily referred to as the give of the pelvis, it was a favourable factor for vaginal birth. Teenage pregnancy babies tend to be small and preterm births were common so the babies could easily come out. These are some reasons why delivering a baby was not an issue those days.Women delivered in the house (domiciliary delivery) attended by DHAI or birth attendant and the anxiety & fear associated with labour pains was effectively tackled by the elders at home by tender loving care.
People were mortally afraid of any surgery and in complicated cases with obstructed labour women died during childbirth mostly due to rupture uterus or uncontrolled bleeding. Blood transfusion ever since it was introduced has saved lives of many women. With the advent of antibiotics, simplified techniques in surgery and advanced anaesthetic procedures, fear of surgery is gone and nowadays women find it convenient to go for C-section without the hassles of normal delivery. In the present scenario if the labour is delayed for some reason both the doctor & the patient are distressed and opt for C-section. Caesarean Delivery on Maternal Request- modern indication for C/S but ethically not correct. Modern lifestyle is one of the reasons for increased C-section rate.
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Lifestyle implications
- Women are educated and ambitious about their career so they get married late after the30’s.Quality of egg production comes down drastically with age and Infertility problems becomes an issue
- Many women by the time they are in their 30’s either due to sedentary life or due to overeating become obese and diabetic, these women tend to have large sized babies.
- As age advances hypertension, diabetes and obesity have an adverse effect on their pregnancy with added risk of Down’s syndrome when a woman conceives after 35 years.
- High-risk pregnancies are best managed in tertiary hospitals and invariably end up as C-section.
- Women with Previous –section have only two options – VBAC (vaginal birth after caesarean) or elective C/S but VBAC has the inherent risk of scar rupture, so many prefer repeat C-section as a safe option.
- High tech diagnostic aids such as Doppler studies, USG and CTG are helpful in assessing fetal well-being hence fetal distress is diagnosed early but they have contributed to high rate of C-section.
- Previously assisted vaginal delivery using LMC forceps were extensively used but the risk of maternal injuries and fetal asphyxia with resultant cerebral palsy have made women go for safer options- either normal labor or C-section. Some centres still use outlet forceps and vacuum extraction for assisted vaginal delivery.
- USG has revolutionised modern Obstetrics – anomalous babies are diagnosed early in pregnancy and women opt for abortion. Destructive procedures like craniotomy, decapitation have become obsolete.
- ART &IVF procedures are mushrooming in India due to rise in the incidence of Infertility cases and when they conceive after ART and these procedures are expensive, it is always elective surgery.
- Legal suits on the doctors and consumer court penalty have made Doctors apprehensive and no risk attitude and defensive medical practice is the present day mindset of doctors
Caesarean section is performed as elective or planned surgery or as an emergency procedure when complications occur during labour.
(This concludes Part 1 of the 3-part series on childbirth and C-section by Dr. Rukmani Gopal)