Thursday, April 18, 2013

The Easy Way Out?

The elective cesarean section.  At some point along the way, it occurs to a lot women that just having a c-section and getting it over with might be the best way to go.  No muss, no fuss.  You schedule things and just go to the hospital and get the baby out.  Perfect for the type-A personalities out there, right?  Wrong.

I'm here to say that there is NO EASY WAY  to have a baby.  I was reminded of this today while I was on call.  I spent the entire night pushing with a patient (for real, the entire night; EIGHT hours of pushing--a new record for me).  She, of course, questioned whether she should have just chosen a c-section from the start.  However, she ultimately delivered vaginally a vigorous baby girl.  The question becomes, is a vaginal delivery after a 38-hour induction and incredible physical, mental, and emotional fatigue the best way to accomplish things?  That, of course, completely depends on your perspective. 

An important disclaimer here is that I personally had an elective cesarean section, and I do elective c-sections when that's what my patients ultimately decide they prefer.  My point here is not to say it's the wrong thing to do, just that it is not an easier way to go.  When I discuss this issue with patients, I give them the pros and the cons and let them decide.  This is one place I know that personal experience has made me a better doctor.

A lot of people, especially those who have had uneventful vaginal deliveries in the past, wonder why any of us would have elective surgery.  The reasons vary: fear of trauma to the nether-regions, concern for fetal well-being, worry about pain, anxiety about the unknown, shame about pooping while pushing.  In my case, the reason was all of the above, but the over-riding fact was that I knew I would be overly anxious about labor.  I knew I would have to be induced because of some complications (at first, just a history of high blood pressure; later on, the list of issues grew), which I knew would be a long process, and I knew that I would be watching the fetal heart rate the entire time and would ask to go to the operating room with the first abnormality, no matter how mild.  Some of my colleagues just ask to put the heart rate monitor outside the room; that is not something I can conceive.  I guess I'm a bit of a control freak.  Anyway, it just made more sense for me to nip it in the bud and just go to the OR from the start.  But that decision was made, of course, with a very clear understanding of the down-sides of having a c-section.

 Although the data show that a planned cesarean section is probably not any more dangerous for mom and baby than a vaginal delivery, there are some real disadvantages.  The biggest ones are postoperative pain and physical limitations.  I always tell people that you get pain on one side or the other--either during the labor itself (few women get their epidurals so early in the process that it's not at all painful) or afterward.  Vaginal deliveries often result in a sore bottom for a few days, but it's nothing like the pain of an abdominal incision, which takes weeks to heal.  You don't realize how much you use your abs until you've had surgery.  Hard enough with just a newborn to deal with, but so much harder with the second (or third, fourth, etc.) baby, when you have older children to care for.  If you're not supposed to lift over 20 pounds, how are you going to manage your 2-year-old?  Then there's the additional day or two in the hospital.

Then there are longer-term effects: the once-a-c-section-always-a-c-section reality in many communities (including mine), the scar tissue caused by surgery that makes any abdominal surgery in the future more difficult, the lingering numbness and tenderness of the incision years later.  More serious issues include the higher risk of serious complications in subsequent pregnancies, particularly an increased risk uterine rupture (when the scar on the uterus tears open and can result in stillbirth if the baby isn't delivered immediately) and of placenta accreta (when the placenta grows into the uterine wall and usually results in an emergency hysterectomy at the time of delivery).  Not minor issues.

Time will tell how today's patient feels about her delivery in the long-run.  All things considered, I still feel that an elective cesarean was the right decision for me, and I'm still open about that fact when discussing with my patients.  But my circumstances were very different from most women's, and I definitely had deeper understanding of the risks when making that call.  From my perspective, I am also very glad that my patient this morning stuck with it and had a successful vaginal delivery.

And when baby Elizabeth is older, I'll be sure she knows how much thanks she owes her mom!


  1. I have enjoyed reading your blog posts, thank you! This one definitely hits home with me. I had a very difficult delivery with my first child (easy pregnancy) and I would have chosen a planned c-section after what I learned the first time. During the c-section with that first child I made sure my future children would be c-sections, I needed the reassurance right then. I appreciate your stance of letting your patients decide for themselves after presented with the pros and cons.

  2. I appreciate your comment. To be clear, I don't bring the option for a c/s up with patients myself, but if they bring it up to me, we have some long talks about it. Most will end up opting for a vaginal delivery, but if cesarean is their decision at the end of it all, that's what we do.