Why was this c-section necessary?

Question

In a recent delivery in my family, the lady has to undergo an operation. The doctor initially said that the birth will be through normal delivery, but at a very last stage she said:

We tried our best to avoid operation, but we are helpless as the baby's head size is much more than the passage for bringing him out. The baby's head is stuck in between the two bones, above the opening. The opening is wide enough now (approx 10 cm), which is wide enough to bring the baby's head out side, but the issue is before that opening the passage is very narrow as the two bones are very close and it is impossible to widen the gap between these two bones- shall we apply force there?. If we force the baby to come out through this passage, we fear that we might damage the baby's brain. also we cannot wait any more because the baby is now not in the fluid, we broke that while trying for normal delivery. so we are going for operation now.

The doctors also gave the lady some injections for giving her pains-induced delivery.
The lady said she felt immense pain because of this.

Also the lady had gone for ultrasound several times, and the doctor herself said everything was normal.

Questions:

1. Why are cases of normal delivery reducing day by day. Till about 10 to 15 yrs back we used to hardly hear about birth by operations. But now this is very common.

2. Is it true that the doctors might go for operation because it is easier for them (i.e for doctors), and they can make more money?

3. Up to what extent the doctors argument about the proportionally narrow passage can be true? Is there no way to bypass/avoid/widen this passage? Why such cases were not prevalent 10-15 years back?

4. The induced delivery pain is more than the normal pain?

5. Post birth the mother and the baby both are fine. But what are the risk involved post operation, and what best can be done to avoid such births in future (e.g some exercises?).

I can see something fishy in Doctors arguments (though, I am not a biology student).

Update One of the argument I am getting from the first 4 answers is: "now a days bigger babies are born as compared to earlier, while the women hips are not widening at that proportion" and thus c-section is the only way for delivery in most cases. Can someone please put some authentic references in support of this argument? In fact I have read the opposite that 100s of years back people used be taller as compared to now, and they lived longer.

Answer 1

First of all, congratulations to the mother! To answer your questions:

1. As birth operations go up the rate of babies and mothers dying in childbirth goes down. Also, the rate of infant brain damage and birth-related injuries goes down. Be glad of this, without the operation the chances are good the child would have died or had permanent brain damage
2. There have been some cases where doctors go for caesarians for those reasons, but those are usually elective, in other words, before labor starts. Generally when a c-section is done after hours of labor it is an absolute emergency.
3. It was prevalent, the techniques for dealing with it were much more primitive and less successful leading quite often to the death of the child and/or mother
4. Yes, the reason that inducement hurts more is that the drugs they use to induce labor bring it on all at once. In a normal labor the pain builds up and the woman's body has a chance to ramp up natural pain-reduction mechanisms, but with induced labors the pain all slams in at once.
5. That's two questions really. As for risks post c-section operation other than infection the main recovery issue is that during the operation the abdominal muscles are cut through and have to heal. For at least 3 weeks the woman is unable to lift or carry anything, including the baby. As for what can be done to avoid these types of births in the future, nothing.

Humans have evolved big brains, and big brains need big heads. Human heads have evolved larger at a faster rate than womens' hips, so human women have many problems getting their baby's heads out. While this led to more deaths in childbirth the increased intelligence of the surviving children meant many more of them survived to procreate, so evolution selected even bigger heads. Now our big brains have enabled complex technology and surgical techniques to save many of the children that would otherwise die, taking evolution out of the equation.

Answer 2

To answer your overall question, whether the cesarean was necessary, the answer is "maybe".

It sounds like there maybe have been fears of shoulder dystocia. Sometimes changing positions can help this problem, or something called the "Gaskin maneuver" The lithotomy position is the stereotypical birthing position in hospitals, but it is one of the worst ways to give birth because the mother is pushing a 6-10 pound baby against gravity and over her pelvic bones. Squatting can shorten the birth canal and also let gravity help pull the baby through.

Forceps and ventouse (vacuum) extraction can be risky, and since the amniotic sac was ruptured, the doctor chose to perform surgery. There are a lot of factors into why surgery was chosen, but since I don't have any specifics, I'd wager that since induction was mentioned, this mother was on pitocin and had an epidural, and therefore movement was restricted. She probably also had been in the hospital for several hours and not been allowed food or drink (maybe ice chips), and was exhausted. Changing positions or pushing can sound overwhelming in that case, and therefore surgery sounds like the best choice.

But in the event that the baby was too large for that particular mother to deliver, which is rare but does happen, then surgery could not have been prevented. Another possibly side effect to an induction would be that the hormone responsible for loosening up the pelvic ligaments that facilitate childbirth would not have been able to do its work, especially if the induction was prior for 40 weeks gestation.

I sincerely doubt that most doctors would perform surgery to get more money. Maybe there are a few, but I would imagine that would be an exception. I've heard anecdotes about ob/gyns who have a ridiculously high cesarean rate, so that is the best place to start when choosing a doctor. But it is a good way for the doctor to avoid malpractice lawsuits. If a doctor performs a cesarean, then they will be able to demonstrate that they did everything possible to save the baby and mother.

I also wanted to mention some risks of cesareans that have not yet been mentioned. For future pregnancies, it can cause complications with where the placenta attaches in the uterus (placenta accreta and placenta previa). The risks increase with every additional cesarean. Doctors in the US are reluctant to attend VBACs (vaginal birth after cesarean) because malpractice insurers do not wish to cover them. Here's an article on additional risks. Hemorrhaging and other complications are also more common in repeat cesareans.

Kegels will not help prevent cesareans. They may help prevent uterine prolapse, but that typically affects women who have given birth vaginally. However, they can help strengthen the pelvic muscles and get rid of that horrible "sneeze pee" that new moms sometimes get.

Some further reading:

• Pushed: The Painful Truth About Childbirth and Modern Maternity Care / Jennifer Block
• Ina May's Guide to Childbirth / Ina May Gaskin
• Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First / Marsden Wagner

Answer 3

While I did not plan for or want a cesarian section, my child was born via one.

1.Why are cases of normal delivery reducing day by day. Till about 10 to 15 yrs back we used to hardly hear about birth by operations. But now this is very common.

You can find a lot of answers to this question depending on who you ask. The natural childbirth community may variously tell you that it is fear of lawsuits, laziness on the part of the doctors, problems caused by earlier interventions (inductions via pitocin, epidurals, etc.), or an improper idea on the part of the medical community as to how birth should progress. I'm no expert in this area, but I'd add one more possibility that I definitely saw in my own case - doctors want mothers and babies to live. Are emergency c-sections always necessary when they are performed? I'd guess not. Are they better than the worst-case alternative? Yes.

2.Is it true that the doctors might go for operation because it is easier for them (i.e for doctors), and they can make more money?

Skeptics would say yes. In the days of largely group care by OBs who get to go home at the end of their shift regardless I'm not sure the easier argument holds, but one labor and delivery nurse I know definitely dealt with cases in the 1980s where a doctor would declare failure to progress (which is different than what happened to your relative) so that a c-section could be performed and the doctor could go home. If one wants to avoid a doctor who might tend towards doing a c-section simply ask during early pregnancy what the doctor's c-section rate is and pick the doctor with the lowest rate. Also make sure you pick a doctor you trust. Then you won't be wondering if your doctor did a c-section just to make an extra $2000 off of your insurance.

1. Up to what extent the doctors argument about the proportionally narrow passage can be true? Is there no way to bypass/avoid/widen this passage? Why such cases were not prevalent 10-15 years back?

There are several exercises used within the natural childbirth community both before and during delivery to help properly position the baby. Lamaze classes teach such activities. For anyone interested in a normal delivery I would definitely recommend looking into them. However the modern medical community does seem to be moving more and more towards some of these positioning techniques (for example having women in a different position other than flat on their backs during the pushing phase) and c-sections are still sometimes necessary. Even in the natural childbirth community there will always be c-sections. There have actually been c-sections since at least the time of ancient Rome.

4.The induced delivery pain is more than the normal pain?

Absolutely yes. Induced contractions (at least those induced by pitocin) are stronger than those the body would naturally produce on its own. It is fairly rare that a woman will be induced and not have some form of medicinal pain management to help her deal with the pain, although it happens.

5.Post birth the mother and the baby both are fine. But what are the risk involved post operation, and what best can be done to avoid such births in future (e.g some exercises?).

Post-operation there are some risks for both mother and baby. A c-section baby usually has more fluid in the lungs because they do not have the compression of contractions to help remove it. Regular suctioning with a bulb aspirator takes care of this. The mother must make sure to take it very easy and follow doctor's orders, which usually include limiting items lifted and limiting use of stairs. A c-section is major abdominal surgery and should not be taken lightly. However as long as a woman is in relatively good shape before the c-section and the doctor performing the operation was skilled the recovery can be fairly smooth. There is a very small higher risk of uterine rupture with future deliveries and if I remember right some types of induction are contra-indicated by a prior c-section.

As for avoiding c-sections due to a narrow birth canal/improper positioning, I highly recommend looking into Lamaze. Where possible also avoid induction and epidurals, which have a proven higher rate of emergency c-sections. Also some doctors have a time frame which they require between a prior c-section and future conception before they will allow an attempt at a subsequent normal delivery.

Answer 4

There's a LOT of questions there. I'm going to handle the most important one first..

5) Post birth the mother and the baby both are fine. But what are the risk involved post operation, and what best can be done to avoid such births in future (e.g some exercises?).

Kegel exercises are the officially approved solution. As you might imagine, this is just strengthening the muscles through which the baby passes. But that's for the future. Right now, the risks are basically the same as after any operation (e.g. infection, rupturing, bleeding) and after your first childbirth (exhaustion, complete upending of entire life, post-natal depression/psychosis, soreness, concerns that you're "doing it wrong").

For the operation-based issues, make sure you get checked regularly and monitor stuff like temperatures and infections in the mother. For the childbirth stuff, see other existing questions

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1) Why are cases of normal delivery reducing day by day. Till about 10 to 15 yrs back we used to hardly hear about birth by operations. But now this is very common.

You hear more about this now because Western media's started talking about birth in a more realistic manner. It used to be that, in order to provoke drama, women in film would give birth almost anywhere apart from a hospital. In order to avoid squeamishness, births would involve significantly less blood, mucus and poop than the reality. So the only place you'd see a caesarean is on shows like ER, which again, ramped up the drama making it seem like a special event, rather than a routine procedure.

Also, the reason you're hearing about it more now is because you've moved from "single person" to "expectant couple", and so more stuff about birth is discussed anyway.

If you look at the charts, while it's gone up a bit recently, it's been pretty static for the last 40 years. The big jump was when caesareans became seen as less of a "last-resort" around the 70's, following on from years of improving surgical treatment.

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2) Is it true that the doctors might go for operation because it is easier for them (i.e for doctors), and they can make more money?

This question neatly combines being too cynical and not cynical enough. You're cynical enough to suspect a doctor doing a potentially dangerous operation (and all operations carry risk) purely for financial gain. I seriously doubt this.

Frankly, if you want to go cynical, in terms of cost-benefit analysis, the "easier" route is to allow your wife to give birth naturally, as the doctor can't be blamed for that. And as natural birth takes ages, with significantly less work on the doctor's part (most of the time they're not even in the room), they'd probably make more money per amount of work that way. But this really isn't how doctors work.

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3) Up to what extent the doctors argument about the proportionally narrow passage can be true? Is there no way to bypass/avoid/widen this passage? Why such cases were not prevalent 10-15 years back?

Yes, this is true. Humans have abnormally large brains, which implies abnormally large heads. An 10 pound baby going through a 5-foot woman is obviously a potential risk. And while they could theoretically apply something to relax the muscles of the woman, that would dramatically reduce the chances of a successful labour, which depends on those muscles contracting and relaxing.

As stated above, this happened all the time 10 years ago. Either the woman got medical treatment, or she suffered massively, potentially being near-crippled for a certain amount of time, or at least one somebody died. While an understanding of clean environments was the biggest leap in protecting against the worst of this stuff, and the culture of natural vs. medical shifts back and forth, once something's going wrong, it's going wrong.

Generally speaking, people simply didn't talk much about this 10 years ago, and they talk more about it now. Certainly they unburden themselves way more to first-time expectant parents.

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4) The induced delivery pain is more than the normal pain?

On behalf of my wife, who was induced, YOU'D BETTER BELIEVE IT. It's more intense, because they've directly applied a chemical that is normally regulated by the woman's body. Induction is normally a choice made when there are potential risks, and waiting on the natural course is more likely to lead to a stillbirth than the alternative. It's all about gauging the probabilities, and doctors do this by looking at the results when it's gone wrong.

Answer 5

I can understand your worry about this situation, but from what I read in your question, the doctors really did the right thing. Let me try to address your specific questions, but please note that I am just another father and not a doctor so this is not expert advice:

1. Children have been gaining birth weight and size for several decades. The simple reason is our improved welfare as a society: better nourishment, better health, bigger children. We also grow taller as adults and live longer as a result.
2. I highly doubt that doctors would prefer an operation. Every surgery and every anesthetization includes a list of risks to the patient. In the case of a c-section, the risk is double. The well-being of the patient always has priority. (I guess every business has its bad exceptions but that is a very small part.)
3. The pelvis has an opening for the child to pass through. There is no way to bypass this without a c-section. During normal birth, this opening becomes softer and wider but even so, it still has its limits. See my point #1; childrens' birth size are increasing but not the size of the mother - at least not at the same rate.
4. I cannot answer this because I don't have enough information to understand your question.
5. Post-op risks are very similar to that of any other stomach surgery - mostly infections, and the risk of tearing open the stitches due to wrong movements or lifting too much weight. Don't lift anything heavy, and be very careful how to handle the body - just the motion of getting out of bed needs to be with care. Keep in mind that the stomach muscles are not in their right place yet; they moved apart, to the sides of the body, to allow the big belly to protrude. They need some time (weeks) to move back to their normal "six-pack" position - failure to care for this might prevent them from moving back fully, permanently leaving the mother with very poor strength.
   There are pre-natal exercises that can help, but they address the tissues and muscles, not the bones. If the skeletal birth canal is too narrow then future births will have to be c-sections too.