This is a guest article by Silvio Aladjem MD. – Simon Barrett

In the last blog, I discussed the continuous controversy about the high rate of cesarean section.

As you may remember, there is no such a thing as an absolute number of cesarean sections that is “ideal” or “desirable”. My position is that there are two modes of delivery: “vaginal” and “cesarean section”. When needed, cesarean sections should be performed without hesitation, and, when not, they shouldn’t. Or should they?

In the last few years, there has been a movement towards preforming a cesarean section upon the request of the patient, without any medical indication. There are a number of articles and opinions on the subject, for or against. Those that are against, support their views because a cesarean section is a serious operation with potentially serious complications. Those that oppose this concept, support their views by reminding us that vaginal deliveries are not benign either and have their own immediate and long term potential complications.

As straightforward as this may sound, it really is not.

Vaginal delivery is how “nature” so arranged for us to be born. Over the centuries, women gave birth to their children vaginally. There was no other way. If labor progressed well, the birth of a child was a happy event. But this was not always the case. Infections, arrested labors because of a baby being to large or the pelvis being too small, malposition of the baby in utero and a number of other potential complications did occur, and still do. This was why the forceps was invented: to pull the baby out of the uterus in such circumstances. The result was usually a damaged or dead baby and a sick mother, because of infection or other problems associated with forceps delivery followed, in far too many cases, by her death. Of course, that type of vaginal delivery is now history. Like everything else, nothing is perfect. Complications can still occur. That is when emergency cesarean sections are performed.

Cesarean sections, were, historically, procedures of last resort, and were always considered a major and threatening operation. The reason why such procedures were feared was because of postoperative complications and sometime death of the mother. I am talking of, somewhere in the middle twenties or before. Surgery, like everything else, is a reflection of the times. Without antibiotics or blood available, with primitive anesthesia (i.e. ether or chloroform), it is surprising that anyone survived. In the 21st century, this is not what surgery, or cesarean sections, are all about. Surgical techniques have made enormous advances, so did anesthesia, blood banks, infection control and postoperative intensive care. That made all surgeries, not only cesarean sections, safe with a minimal risk. Like everything else, nothing is perfect. Complications can still occur. That is when the full power of modern medicine helps us.

Surgeries upon patient’s demand are performed every day. Plastic surgery, and Bariatric surgery, are two common examples. A nose job, a face lift, a breast enlargement or reduction, are not medical indications, but are performed on demand. In bariatric surgery, unless the patient is morbidly obese (400 lbs. or more), it is really surgery “on demand”. They are all very serious surgeries with potential serious complications. Why not, then, cesarean sections? What is the difference between a woman that desires a face lift operation and a pregnant woman that wants to deliver by cesarean section? Both are surgeries that have potential serious complications, in spite of their notable proven surgical safety. We accept plastic surgery on demand, but not cesarean sections.

In today’s world, patients make decisions all the time, based on the information that their physicians give them. Patients accept risks, compare alternatives and make their own decisions. Physicians respect those decisions.

At this point, I must clarify that until very recently I was in the group of physicians who would have been hard pressed to perform a cesarean section without a medical indication.

I was once told that politicians change their positions because it may be convenient; we, physicians, change our ideas because our learning never stops. Yes, I have now changed my mind. The time has come for us to support women making an informed decision regarding how they want to be delivered. They have their choice for a vaginal delivery experience or a birth by cesarean section, without medical indications. It should be a decision between the pregnant woman and her physician, after a thorough evaluation of the patient’s intrinsic risks based on her medical history or circumstances, and not based on our own bias on the subject.

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Suggested reading: “Choosing Cesarean: A Natural Birth” by Magnus Murphy MD and Pauline McDonagh Hull (Prometheus Books, 2012).

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SILVIO ALADJE MD, an obstetrician/gynecologist and Maternal Fetal Medicine (high risk obstetrics) specialist, is Professor Emeritus in obstetrics and gynecology at Michigan State University, College of Human Medicine, in Lansing, MI. He is the author of “10,000 babies: my life in the delivery room” now available on Amazon, Barnes and Noble and other book stores. Dr. Aladjem published extensively in Scientific Medical Journals and wrote several textbooks in the specialty. He can be reached through his website, www.drsilvio.com

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