Many women these days are requesting delivery by cesarean section and sometimes the decision might have no medical rationale behind it. The reasons could be many like excessive fear of childbirth, fear of being in pain for too long or a general notion that invasive methods of delivery are safer for both mother and child.
For some, the healthcare provider might prompt them to choose a c-section in case of an anticipated complicated pregnancy. Other times, the ball will remain in the mother’s court to decide how she wishes to deliver the baby. While many women will want to follow the natural course of childbirth, some might voluntarily choose to come under the blade. Getting a request for an elective cesarean cut has been a topical concern among medical practitioners and has left many of them uncertain of how to respond to it. As per experts, c-sections can have a long-lasting impact on a woman’s health and can have unpredictable emergencies associated with them that could surpass the risks associated with vaginal delivery.
Caught between the devil and the deep blue sea
Many healthcare providers find themselves caught up in a difficult choice of whether to uphold patient autonomy or to help them take a medically sound decision that might benefit them in the long run. Also, with greater awareness of the impact of psychological distress on labour, the perspective on women voluntarily choosing c-sections has softened over time. An international media outlet reported a story of a mother of two children born by elective cesarean. The story brought out the guilt and prejudice suffered by the mother who was a part of society that called her too privileged to push. The woman suffered from tokophobia, the extreme fear of labour which might in some cases make women averse to pregnancy.
Dr Chennuru Nishitha, a Telangana-based gynaecologist believes that the patient’s request for an elective cesarean and the doctor’s decision to go with it have many layers to them. The uncertainty of how the psychological factors might roll out during the delivery, the strong demand to uphold the patient’s autonomy and unforeseen complications that might arise during childbirth can sometimes put the healthcare provider in a weak position to convincingly make women believe that a natural birth might work out well for them when there are no obvious red flags to be seen at the moment.
Psychological factors do play a role
Dr Nishitha while talking to healthsite.com informed that psychological distress whether anxiety, depression or other mental conditions can have a monumental effect on labour and might hinder the process to the extent that might prompt the doctors to provide invasive intervention or surgery.
Labour happens in three stages, during the first stage your cervix dilates or stretches in preparation for childbirth. Following this comes the active phase where the mother has to push the baby downward and the last stage begins with the birth of the baby. Among the three phases, the second phase involves active participation by the mother who has to make the effort. Sometimes due to psychological distress, high pain sensitivity and tiredness, the mother might stop pushing the baby downward. Sometimes the uterus might fail to contract sufficiently. Experts call this condition uterine inertia.
Dr Nishitha said: “Pregnancy is not always a predictable process. It is different for different women. As medical professionals, we can’t foresee everything in the beginning. It is not practically possible. The decisions we take are very much based on our experiences of how the patient is responding at various stages of pregnancy, both physically and mentally. Natural delivery has far many benefits over surgery but we can’t convince our patients of it unless we are sure in ourselves that it is going to be a smooth ride ahead. Psychological distress can make our patients land in situations like uterine inertia. These factors can’t be completely ruled out. However, we always try if the baby can be delivered normally. Ideally, it is a clinically sound choice.”
We can’t assert but we can always counsel
Dr Nishitha informed that upholding the patient’s autonomy while they make decisions around treatment is very important. She said: “We can’t assert or impose a decision on them but we can help them take a decision that would benefit them in long run. As a doctor, our power lies in the counsel. When pregnant women meet us in OPD, we do give them prenatal advice. We critically assess their situation by doing an exhaustive examination of the pelvis, placental position and other factors favourable for a natural birth and then plan our counsel accordingly. If a woman can deliver naturally through the vaginal passage, then we might focus more on the benefits associated with natural delivery. Contrary to this, if we can foresee some complications, we might counsel them on how a c-section can ensure safe delivery. There might be a complication that might affect one in 500 but we have to make them clear that we cannot promise them that they won’t be the rare one.”
Natural scars are easy to heal, surgery can be a life-long pain
The gynaecologist explained in great detail how a normal vaginal delivery ensures fast recovery and how it can be beneficial to not just the mother but the baby as well. She explained that while assessing the method of delivery to opt, factors like the mother’s age, socioeconomic background, and physical and psychological health are considered.
“As a doctor, we always try to deliver the baby normally unless there be any complication or request for surgery. This method ensures fast recovery, no surgery-related morbidity, less scars, and lesser post-delivery pain and there is also a lower risk of developing anaesthesia-related complications. From a child’s health point of view, a natural birth might ensure immediate skin-to-skin contact between the baby and mother and an early start of breastfeeding. Since the child has been in the amniotic fluid for so long, natural childbirth ensures fast squeezing out of the fluid from its lungs and a lower risk of the baby developing respiratory issues.”
Dr Nishitha said that there is a probability that the mother might experience severe pain and discomfort and sometimes there could be an increased risk of tissue wear and tear, weakening of pelvic muscles, and bladder problems such as urine incontinence. However, the health expert said that these could be easily healed over a period of time and are unlike those scars and complications that could arise from a c-section.
Some don’t have a choice
While talking about patient autonomy and choice, Dr Nishitha said that women coming from a higher socio-economic background might be more confident about their choices because they might have more control over their lives and better resources to afford surgical intervention. However, women coming from lower socioeconomic backgrounds might struggle to have a voice.
“We see cases where the woman inside the labour room is pleading to be operated on and the family waiting outside insisting on a natural delivery.”
Dr Nishitha also shared an anecdote where a family’s strong religious beliefs pressurized the doctors to force the mother to keep trying to push for more than 36 hours. The family had denied any surgical intervention as they were guided by the religious head to do so.
Too privileged to push?
As per reports, women who voluntarily choose c-section over normal delivery often become a target in society which might see them as too feeble. As per reports, some people might consider these women as too pain sensitive or too privileged to push the baby downwards. Dr Nishitha shared her opinion on the social situation.
She said: “Only a woman can understand in true sense what labour can feel like. A woman has to suffer pain either way if she is going for natural delivery or surgery. However, it must be her choice to make what she can take and what she cannot. Some women might also see it in this way if her mother didn’t go through the pain, then why should she? In my opinion, a woman’s decision to go for a natural delivery or not has nothing to do with her strength. The process can be painful for either choice they make and some women might choose one over the other.”