These days, many doctors are wont to deliver women through caesarean section (CS). But the World Health Organisation (WHO) is urging doctors not to breach ethics in the use of CS, writes OYEYEMI GBENGA-MUSTAPHA.
Some women give birth with ease; some do not. To help such women out, doctors ask then to go for Caesarean Section (CS). So, when is cs necessary? It is when there is a medical reason for it, says the World Health Organisation (WHO) where normal delivery is possible, doctors should shun cs, WHO adds, noting that many go for CS without any medical reason, thereby putting mothers and their babies at risk.
According to WHO, CS is a common surgery whose rate is on the rise, particularly in high and middle-income countries.
CS becomes necessary when vaginal delivery poses a risk to the mother or baby – for example due to prolonged labour, foetal distress – or because the baby is presenting in an abnormal position.
“However, caesarean sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications,” it stated.
The WHO Statement on Caesarean Section Rates is based on two studies carried out by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme for Research, Development and Research Training in Human Reproduction. This programme is the main instrument within the United Nations system for research in human reproduction, working within the Department of Reproductive Health and Research of the World Health Organisation.
Ideal rate for CS
The global health watch dog said since 1985, the international healthcare community has considered the “ideal rate” for caesarean sections to be between 10 percent and 15 percent. New studies reveal that when caesarean section rates rise towards 10 percent across a population, the number of maternal and newborn deaths decreases. But when the rate goes above 10 percent, there is no evidence that mortality rates improve.
“These conclusions highlight the value of caesarean section in saving the lives of mothers and newborns,” said Director of WHO’s Department of Reproductive Health and Research, Dr Marleen Temmerman. “They also illustrate how important it is to ensure a caesarean section is provided to the women in need – and to not just focus on achieving any specific rate,” she said.
She added: “Across a population, the effects of caesarean section rates on maternal and newborn outcomes, such as stillbirths or morbidities – birth asphyxia – are still unknown. More research on the impact of caesarean section on women’s psychological and social well-being are still needed. Due to their increased costs, high rates of unnecessary caesarean sections can pull resources away from other services in overloaded and weak health systems.”
International use of Robson
classification
The organisation said the lack of a standardised internationally-accepted classification system to monitor and compare caesarean section rates in a consistent and action-oriented manner is one of the factors that have hindered a better understanding of this trend, hence WHO is proposing the adoption of the Robson classification as an internationally applicable caesarean section classification system.
The Robson system classifies all women admitted for delivery into one of 10 groups based on characteristics that are easily identifiable, such as number of previous pregnancies, whether the baby comes head first, gestational age, previous uterine scars, number of babies and how labour started. Using this system would facilitate comparison and analysis of caesarean rates within and between different facilities and across countries and regions.
“Information gathered in a standardised, uniform and reproducible way is critical for health care facilities as they seek to optimise the use of caesarean section and assess and improve the quality of care,” explained Temmerman. “We urge the healthcare community and decision-makers to reflect on these conclusions and put them into practice at the earliest opportunity,” she added.
A member of Society of Gynaecology and Obstetrics of Nigeria (SOGON), Dr Adebayo Bamisebi, explained why more women are undergoing CS. He said: “There is a better understanding of the relevance of CS to safe delivery nowadays. Before now there is a morbid fear on what CS entails and does not. But with better enlightenment, more professionalism and equipment to work with, professionals launch into CS to save mother and child. The fear is based on the notion that anything that pertains to operation in this part of the world is fearful because we don’t trust our medical experts, with a mindset that anything can happen.”
Bamisebi continued: “There are many reasons a health care provider may feel that an expectant woman will need to have a CS delivery. Some caesareans occur in critical situations, some are used to prevent critical situations and some are elective.
“Some reasons for the increased use of caesarean childbirth include the use of heart rate monitors to evaluate the fetal heart rate pattern; baby positioned in a manner other than head first; woman’s preference for repeat caesarean sections; labour does not progress to delivery; mother has an active genital herpes infection (the baby needs to avoid potential exposure through the birth canal); mother has HIV infection; presence of obstructions such as benign or malignant tumors in the lower reproductive tract or pelvic anatomical abnormalities; malpractice concerns, i.e, birth in a private, for-profit hospital; woman’s higher level of education and social status and increased maternal age, as more women are having babies later in life.”
He said: “Also, the most frequent reasons for performing a caesarean delivery are repeat cesarean delivery: There are two types of uterine incisions – a low transverse incision and a vertical uterine incision. The direction of the incision on the skin (up and down or side to side) does not necessarily match the direction of the incision made in the uterus.”
He said the medical reasons for CS are: “Previous cesarean deliveries as women with a prior history of more than one low transverse cesarean section are at slightly increased risk for uterine rupture. This risk increases significantly when the woman has had three caesarean deliveries. If an abdominal delivery is planned and a trial of labor is not an option, the best time for delivery is determined when the lungs of the fetus are mature.
“Lack of labour progression: If the woman is having adequate contractions but no change in the cervix (opening to the uterus) beyond three centimeters dilation or the woman is unable to deliver the fetus despite complete dilation of the cervix and “adequate” pushing for (generally for two to three hours or more), cesarean delivery may be performed.
“Abnormal position of the foetus: In a normal delivery, the baby presents head first. This is the way it happens in most births. The smallest diameter of the human skull is presented to the pelvis in the most advantageous way. This increases the success of a vaginal delivery. There are various other presentations of the fetus, which make vaginal delivery difficult, including the commonly known breech position (when the baby’s buttocks are in the lower portion of the uterus). Certain forms of breech delivery have a very low increased risk to the fetus. Breech deliveries may cause more complications, including death and neurologic disability. Careful counseling, analysis of the exact type of breech position, an estimate of the baby’s weight, and other information are required before making any decision about an attempted vaginal delivery or delivery by cesarean section.”
Bamisebi added: “The fetal status, although an attractive and much-used tool, the fetal heart rate monitor has not improved birth outcomes as once expected. Some believe the lack of improved outcomes is because many current practicing doctors are poorly trained in interpreting the subtleties of fetal heart rate patterns. Since the use of continuous fetal heart rate monitoring in labour was begun, however, birth experts say death of a fetus during labour is much rarer than in the past.
“Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency caesarean section. When performed within 10 minutes of the onset of cardiac arrest, the procedure may save the newborn and improve the resuscitation rate for the mother. This procedure is performed only in the direst of circumstances. Likewise, elective sterilisation, but desire for elective sterilisation is not an indication for caesarean delivery. Sterilisation after a vaginal delivery can be performed via a tiny three-cm incision along the lower edge of the umbilicus or as a delayed procedure six weeks after delivery with laparoscopic surgery or vaginal surgery.”
