CESAREAN DELIVERY

CESAREAN  (C-section)  DELIVERY 

                             

It’s a tad odd that I (a non-gynaecologist) am at a gynaecologists’ academic meeting as a ‘GUEST  OF  HONOUR’  today (December 13, 2018 -- 'Perundurai Obstetricians & Gynaecologists Meet').   They must have thought about me, perhaps because I write and talk on subjects ranging from ‘Piano to Pornography’ as the saying goes !!!   Almost all the practitioners of ‘Obstetrics & Gynaecology (OG)’ in India are women,  and in this first meeting of the practitioners of OG  all the specialists are women.  Thanks to the dynamic OG & Infertility specialist, Dr. Geeth Raj. G and her enthusiastic OG specialist friends who took the initiative to group together and organize this first academic programme of the  “Perundurai OG Specialists.”  The OG specialist doctors, Dr. K. S. Rama Devi, Dr. veena, Dr. Indira and Dr. Ramya made academic contributions on ‘Severe PE’,  ‘Ovarian Tumours’,  ‘Scar endometriosis’,  etc., and Dr. Geeth Raj was the moderator.   I am not detailing about the academic aspects, as this communication is meant more for the lay public.  I said something like the following which may be of general interest. And I added a little comment and a few links for the not-very-busy-reader.

The  GOOD  OLD  DAYS

In those days (half-a-century ago when I started my career in Perundurai) of the “easy-paced-Malgudi-type” of the silent and serene Perundurai, there was one Dr. P. J. Chennakesavalu, MBBS, a very handsome male general practitioner (popular for obstetric care), who used to conduct deliveries here around, even doing the job at houses in villages with no electricity.  A kerosene lamp and a torch light helped him in the child births.  He used to characteristically narrate the happenings of those good old days nostalgically. We have moved a long way … antique kerosene lamps to sophisticated surgical lamps, sleepy village houses to busy speciality hospitals, easy-to-approach GPs to frenetic-paced OG specialists, ancient ‘yagnas’ to state of the art IVF, EEVA, NGS, IVG … yes, ‘putra kameshti yagna’ was performed by King Dasaratha whose three wives were infertile.  The ‘yagna’,  advised by the sage Vashist, made them pregnant and produced four children – Lord Rama, Lakshman, Bharath and Satrugna !  Scriptures say that.  http://drtramaprasad.blogspot.com/2017/04/test-tube-babies-and-termination-babies.html 

                                                                                                                                                                SURROGACY

                                     

Yes, we have moved from ‘Ramayana’ to ‘virtual world’ to surrogacy … a child was born on December  9, 2017,  four years after the child’s parents died in a car accident in China !  The grandparents fought a long legal battle to take the stored fertilised embryos of the dead parents to Laos (as surrogacy is illegal in China), arranged for a Laos woman to be pregnant with the preserved embryos and brought her back to China for delivery !  

Yes, we too have moved a long way forward to conduct a meeting of OG specialists of Perundurai.  And, see the metamorphosis in the ‘Perundurai Sanatorium & Medical College campus’ by clicking on the link below -- http://drtramaprasad.blogspot.com/2017/09/perundurai-medical-college-sanatorium.html 

 (In India, the Lok Sabha passed a Bill on December 19, 2018  banning commercial surrogacy, allowing only close Indian relatives to be surrogate mothers and purely for "altruistic" reasons.)

CAESAR  and  CESAREAN

Although Cesarean deliveries (Caesarean delivery /  C-section -- cutting open the abdomen to deliver baby) were performed in Roman times (on dead mothers as a mother should not be buried with a child inside), there is no record of a surviving mother.  As such, the speculation that the Roman dictator JULIUS  CAESAR was born by Cesarean surgery and that the name of this surgery is due to that is apparently false.  But it is widely believed it to be so.     Roman law under Caesar decreed that all women who were so fated by childbirth must be cut open; hence, cesarean. Other possible Latin origins include the verb "caedare," meaning to cut, and the term "caesones" that was applied to infants born by postmortem operations.

The first modern Cesarean by transverse incision was done by Ferdinand Adolf Kehrer in 1881.  In 2012, about 23 million Cesareans were done in the world.             

                                                                                                                                                                                    WHY  SO  MANY  SUDDENLY  ?

 There is a report in today’s newspaper (The Hindu, Dec 13, 2018) that   Cesarean deliveries formed  46% of the deliveries conducted at the GMK Medical College Hospital in Salem in November 2018.  I brought this news to the notice of the specialists in the meeting and asked them why the figure is so high.  Some explanations were put forth. 

TARGET of  1,000  DELIVERIES !

And, more odd than my presence among the OG specialists here today is the reported statement of the dean of the government medical college at Salem.  It reads as follows: “We had set a target of 1,000 deliveries in November, but exceeded the target and managed 1,028 deliveries.”  Do the doctors and hospitals set targets and vie with each other to maximise Cesareans,  to treat so many patients, to do so many heart surgeries, to see so many diabetic patients, to treat so many psychiatric patients, to keep so many ICU patients, to do so many CT scans,  to carry out so many endoscopies & echos, and to rake in so much of money ???  OK, that may be the 'normal' of the 'Kaliyuga',  but, why in a government-run medical college hospital also ?  Perhaps, the dean might have meant and said something else, and the press report may be one out of the context, as it happens sometimes.  Probably, he wanted  to convert the risky home deliveries into safer institutional deliveries.  Perhaps, it's my wishful thinking.

DEBATE  ON  UNDEBATABLE

The World Health Organization (WHO), set that the desirable figure for Cesareans should not be more than 15% some years ago  ... but later withdrew the figure and said that it may be done as and when medically indicated.   Globally, there has been an alarming increase in the Cesarean surgeries which may be associated with serious risks, generally unknown to the public.  Are many of these operations needless or are there justifiable reasons to do ?  This has been a matter of serious debate and concern in academic circles.  Even in the US, the figure went up to 32% (2017) because of -- 1. Fear of lawsuits against doctors, if some harm happens to the baby during normal delivery,  2. Increased indications for the surgery,  3. Patients’ preference,  4. Associated lifestyle diseases (cardiovascular diseases, diabetes, obesity, etc. due to bad foods, lack of exercise, electronic screens, smoking, pollution, etc.),  5. Late marriages & more pregnancies around the age of 30,  6.  Lack of prenatal training and preparation for normal delivery, etc.  Many of these are common to other countries also.

CESAREAN  SURGE

 More than 45 countries globally have Cesarean rates less than 7.5%.  The Cesarean rates in public sector differ from those in private sector.  Brazil has one of the highest Cesarean rates in the world, with rates in the public sector of 35 - 45%,  and 80 - 90 in the private sector.  China is said to be having a figure of 50% of Cesareans out of the total number of deliveries.  In India, the figure was around 8.5% until 2010 (WHO).  It has gone up to 41% in Kerala and 58% in Tamil Nadu (ICMR School of Public Health Report) and up to 80% in some districts of Andhra Pradesh.  This skyrocketing has puzzled many healthcare analysts. People pressurise doctors for Cesarean for varied reasons – auspicious time for child birth, astrological imperatives, personal convenience, fear of labour pain, etc., without realising the immediate and long term risks (uterine rupture & abnormalities in the placenta in subsequent pregnancies).  More than half of the child births in private sector occur through the Cesarean route.  And, doctors have to ruminate on this ominous trend and do some introspection and soul-searching.                                                    

GOOD  or  BAD 

                                               

                                                               

All the same,  it is a fact that cesarean deliveries saved lives of millions of mothers and infants, and prevented life-long disabilities in children caused by unduly prolonged distress during natural delivery.   Some surgeons say that the sincere desire to minimise the risk to mother and child might have increased the number of cesareans.   At least one surgeon told me that cesarean must be preferred to normal delivery, to the extent possible, for the benefit of the mother and child,  and that 90% of the deliveries she conducts are C-sections.   Another seemed to be happy with finishing one cesarean in half-an-hour and moving on to the next instead of 'wasting' hours and hours on one normal delivery.  In other words, cesareans should be the norm !  The editorial pasted below says 'Normal deliveries should be the norm' !  In the midst of the "Corona Pandemic" the  editorial in The Times Of India of August 3, 2020, titled "Caesarean Pandemic", observed that 'C-sections save lives when there is a medical crisis but endanger health when they are elective'.

And look at the Maternal Mortality Rate (MMR).   It is steeply decreasing in India --  130 per one lakh live births in 2015,   122 in 2016  and  113 in 2018.  And Infant Mortality Rate (IMR) has come down to 30 per 1,000 live births of children under one year of age.  Part of this decline may be due to increased C-sections.

In Japan, the IMR is very low (4 per 1,000) because of "Boshi Kenko Techo  (Maternal and Child health Handbook)" and the excellent universal access to good antenatal and obstetric care.  And there most births occur to women aged 25 to 29.  Unexpectedly,  the IMR is higher in the US (6 per 1,000).

But, Dr. George A. Macones, the chairman of Obstetrics & Gynaecology at Washington University and a spokesperson of the American College of O&G expressed:  “ … Many of the Caesareans are not going to be good for anybody … what we are worried about is that the Cesarean section frequency is going up without being proportionally beneficial to the babies or moms …”  

What  do  WHO  and  NSO  say ?

The WHO states that cesarean intervention is very life-saving when it is restricted to the real need of about 10% of the births, and that above the 10% (which are done for non-essential needs) would only add to the hazards for both mothers and children -- depression and serious difficulties with subsequent pregnancies for mothers, and for children, due to subtle alteration in neonatal physiology, higher incidence of obesity, asthma, juvenile arthritis, etc.  The latest (July 2020) NSO survey report found that the share of women delivering through C-section had crossed the unacceptable level of 28%, in India.  And another glaring fact is that C-sections are 17% in government hospitals and 55% in private hospitals.  C-sections save lives in emergencies, but impact the health of mothers and their children when they are done by choice.

REDUCE  THE  NEED

The need for the surgery may be reduced by living a life of good lifestyle and by getting trained mentally and physically during the pregnancy period for normal delivery… in some places there are good training centres run by qualified persons. 

EVOLUTIONARY  NEED

Interesting connections are made linking CHARLES  DARWIN's theory of evolution and the increasing numbers of Cesarean section.  Cesareans may play a part in natural selection, particularly in mothers' pelvic size and babies' birthweight.  It may be a part of the evolution that maternal pelvis may get smaller and foetal head size larger over a period of time,  leading to more Cesareans and more children of bigger brain size and higher 'Intelligence Quotient' due to higher survival rates in cases of cephalo-pelvic disproportion, thanks to the Cesarean intervention -- https://www.courant.com/health/hc-xpm-2011-02-11-hc-weir-darwin-c-section-0212-20110211-story.html

                                                                                                                                           A  MATTER  OF  SERIOUS  CONCERN

About two years later, today (July 31, 2020), I have seen a more unpalatable and disturbing news about Cesarean surgeries (C-sections) in The Times Of India and other news media.   Reports released in July 2020 by  'National Statistical Office (NSO) and others reveal that 'too many C-sections are being done in India which cost Rs.5,000 crore per year'.  Read the photocopy of the news attached below. Should we think that the medical indications for C-section are increasing day by day for valid scientific reasons ?  Has the concern for the safety of mother and child has increased resulting in more number of C-sections ?  Or is it due to the increase in the vulnerability to venality ?  Yes, like the 'Schrodinger's cat', it may be both !   If the 'excess' is done out of ulterior motive, it is just a superficial manifestation of a deeper and wider malaise.  If interested to know about the ramifications, go to:  http://drtramaprasad.blogspot.com/2017/04/modern-medicine-good-bad-and-ugly_30.html

February 3, 2021

    Various surveys - NFHS-3, NFHS-4, NFHS-5 - have shown that the percentage of births by 'Cesarean Section' (C-section) in India varied widely from State to State and also between public sector and private sector (see the newspaper clipping below) -- Public Sector:  Bihar 3.9%,  Telangana 44.5%;  Private Sector:     Nagaland 23%,  Tripura 90%.  The 'alarming' rise in C-sections in private hospitals in many States made the Union Ministry of Health and Family Welfare tell the Parliament on February 2, 2021 that an expert committee was constituted in December 2020 to examine the state-wise findings related to C-sections.  Why is there so much variation ?  Same country, same doctors !  

NEED  TO  BUILD  TRUST

As judgements and ambitions vary from surgeon to surgeon, official regulations have a limited role.  It's the conscience,  knowledge and experience  of the surgeon that matters.  Conscience is more important as it is an essential ingredient in the making of a good human being.  People are becoming more conscious of the conscience.  That's the reason for the increasing demand for regulation in medical service.  It is neither possible nor desirable to regulate emergency surgeries by any authority,  as in such emergencies, the surgeon's word is the god's word.  There wouldn't be a choice to go around for a second opinion at that critical moment.  And the surgeons may differ.  The surgeons need to build trust.  Then there won't be a need for regulation.

CORONA  IMPACT

And finally, about the CORONA impact.  The media reports say that during the first half of 2020,  the deliveries had gone up in government hospitals,  perhaps, owing to the reluctance of the private sector for various reasons.  Data are not available yet of the cesareans done in the public sector during the 'corona period'.

PREGNANCY  and  CORONA



            As on July 16, 2020,  in Tamil Nadu,  1,606 pregnant women tested 'positive' for coronavirus.  At theInstitute of Obstetrics and Gynaecology(IOG) and Hospital for Women and Children, Egmore, Chennai,  39 newborns tested 'positive', accounting for nearly about 12%.  National Health Mission has issued 'Special Protocol' for the care of antenatal women to the Comprehensive Emergency Obstetric and Newborn Care (CEmONC) centres and private obstetricians.

        A four-day-old baby girl tested positive died of Meconium Aspiration Syndrome at Government Rajaji Hospital on August 2, 2020.  Her mother also tested positive.  Another nine new borns were treated  at the same hospital.  All this may just be the tip of the iceberg.

        As of 12th August, 2020,  100 Covid positive women gave birth to their babies at MGMGH, Trichy --  22 of them were normal deliveries, while 78 were of C-sections.  Two of these babies tested positive.  It was reported that more cases are being attended to at government hospitals as private hospitals are turning away patients fearing the virus infection.

            VERTICAL  TRANS-PLACENTAL transmission.  At least six published studies suggest this route of transmission.  A publication in Nature Communications (Daniele De Luca of Paris Saclay University, France, July 2020) has confirmatory evidence that the virus can infect a foetus through mother's blood via placenta.  Amniotic fluid positive.  Placental tissue positive.  Congenital SARS-CoV-2 infection. Cerebral vasculitis - white matter injury -  The newborn had neurological manifestations.  

https://www.nature.com/articles/s41467-020-17436-6

 

Sasson Hospital in Pune, India and some hospitals in the US and France also reported similar cases of vertical transmission.  Vertical transmission is well-documented in HIV and ZIKA virus infections.

 

https://www.whattoexpect.com/news/pregnancy/coronavirus-during-pregnancy/

    A survey done abroad revealed that many couples now are either deciding to have pregnancy some time later or never to have children, due to the consequences of the pandemic.

https://www.nytimes.com/2010/03/24/health/24birth.html

https://qz.com/india/326402/cesarean-births-in-india-are-skyrocketing-and-there-is-reason-to-be-very-worried/

http://drtramaprasad.blogspot.com/2017/04/modern-medicine-good-bad-and-ugly_30.html

Dr. T. Rama Prasad, Website: www.rama-scibbles.com & Twitter: @DrRamaprasadt & Facebook: T Rama Prasad, 'PAY WHAT YOU CAN’ Clinic, Perundurai, Erode Dt., TN, India., Former Medical Superintendent (Special), RTS & IRT Perundurai Medical College and Research Centre, Perundurai.