The right to choose a C-section
May 17, 2004

Should pregnant women have the right to demand a cesarean section even if there's no bonafide reason for the operation? Or be allowed to have the C-section on a lucky day?

Today more women are asking for this right. But is this request utter madness?

Years ago it would have been sheer folly to perform a C-section unless there was a serious emergency. Women would have died from either uncontrollable bleeding or infection.

Now it's a different story with improved surgical techniques and antibiotics.

The International Federation of Gynecology and Obstetrics claims that since there's no evidence that a patient-chosen cesarean has any benefits, it's not ethically justified.

The World Health Organization also adds that a cesarean section rate above 15% is questionable.

This figure automatically condemns both Brazil where the rate is 32% and Hong Kong's rate of 27%. And in some private Brazilian clinics, the rate is 75%!

Natural birth organizations such as Lemaze International label the proponents of cesarean-on-demand as orchestrating a campaign of misinformation.

So what is the risk of a C-section?

Dr. Mary Hannah of the University of Toronto reports that of 100,000 women having an elective cesarean, 5.9 will die compared to 2.1 women who have a normal vaginal delivery.

Babies delivered by cesarean require more oxygen therapy at birth. There's also increased risk of bleeding in subsequent pregnancies. In addition, wounds can become infected and there's an increased risk of a blood clot forming in the legs.

NOT WITHOUT MERITS

On the other hand, a patient- chosen C-section is not without merits.

A huge benefit is future freedom from urinary incontinence often associated with coughing or sneezing. Or, as sometimes happens, a loss of urine without stress. In one study, 26% of women suffered this annoyance six months after a normal delivery.

And if you're one of the 4% who have fecal incontinence, that's another matter.

Patients who have these complications often require surgery later in life when they're usually less healthy. And if you are looking at 100,000 of these operations, some women are going to die.

A planned C-section also decreases the risk to the baby. There's less likelihood of stillbirth, fetal heart abnormalities and prolapse of the cord cutting off oxygen supply to the baby.

So who is right?

One needs the wisdom of Solomon to answer this question. Certainly no surgeon is going to amputate an arm simply at the request of a patient. But a "patient-choice cesarean" is not a black and white issue. I believe this request is reasonable in 2004.

My crystal ball says that there will be more patient-choice cesareans in the future. And like any procedure, it's vital that the risks and benefits be fully explained to those who request it. Moreover, if a decision is made for an elective cesarean and a complication occurs, patients should not run to a lawyer. Most complications are acts of God.

A PERFECT CHILD

Today, too many couples expect a perfect child when we know that about 4% of babies are born with an abnormality.

Some readers may wonder, "What would I do if I were pregnant?" The risk statistics I've used are so similar that they would not be a part of my decision.

You must also realize I'm a trifle biased due to personal experience.

I've spent many hours in surgery trying to relieve women of urinary and fecal incontinence due to natural childbirth. I knew that some of the operations would fail. I also know that patients with incontinence are much more aware of this distress than the surgeon who performs the operation.

In all probability, I'd request a patient-choice cesarean and accept the consequences.

LUCKY DAY

But there's one thing I'd never do. In Bangkok, Thailand, some women are asking for a C-section on a lucky day, such as the birthdays of their revered king and queen, or on Valentine's Day.

And in China, women, for the same reason, are requesting birth at the Chinese New Year.

That's a dangerous game to play. The lucky day could be the wrong day as far as the fetus is concerned.