Here is a morality tale for our times. The National Institute of Clinical Excellence has asked doctors to reduce the number of elective Caesareans that they perform, as much as anything on grounds of cost. Another facet seems to have been overlooked. Even elective, non- emergency Caesareans can have serious complications.
My wife and I recently had our fourth child by Caesarean. The first three sections had been a breeze; beautiful healthy babies delivered on time, mum only a few days in hospital. There was no question of attempting a "natural" delivery this time; the scar would probably not have been strong enough, and a ruptured uterus is an obstetric disaster.
The sympathetic consultant who delivered our first two explained that we could, safely, have a maximum of four. We sailed blithely into this fourth pregnancy until our 20-week scan. This was when the first cloud appeared.
The placenta was attached too low, a condition called placenta praevia. It appeared to be the most severe form where the exit to the uterus was completely obstructed. Normal delivery, which was out of the question anyway, would undoubtedly have killed both mother and baby.
The consultant obstetrician visibly blanched when we attended his hectic ante-natal clinic a few weeks later, clutching our ultrasound report. He was concerned that we had even more dangerous complications, either placenta accreta or placenta percreta. These mean that the placenta has invaded the scar from the previous Caesarean sections or, even worse, poked out of it.
Placenta burrows into normal tissue as invasively as many cancers; this could have spelled real trouble, with catastrophic bleeding. We were lucky; just run-of-the-mill Grade 4 praevia for us. Such complications may, according to some experts, be more common in women who have had previous sections.
Fast-forward to the delivery. We knew by now that it might not be straightforward. We signed consent to an emergency hysterectomy in case of uncontrollable bleeding. At first, all seemed well. The placenta came away easily and we were wheeled out of theatre, happily clutching our new baby.
Almost immediately things became worse. I was left with the baby while mum was rushed back to theatre to control the bleeding. A couple of hours later she was back, to my great relief. We were over the worst, weren't we?
My mother-in-law - also a doctor - dropped in during the evening and commented on my wife's ashen pallor. Shortly afterwards she developed shoulder pain - a classic sign of free blood irritating the diaphragm - and her pulse rose and blood pressure dropped. This time things were beginning to get really serious. She had lost so much blood by now that she was missing all the factors needed to make it clot. This in turn causes more bleeding, until...
Now, late at night, she was wheeled back to theatre. An off-duty specialist willingly came in to help the team. With skilful, gentle surgery and replacement of all the lost blood products, the bleeding was stabilised.
The next moment was the worst for me; seeing someone you love distorted by the paraphernalia of tubes and wires in intensive care is not an experience I want to repeat. As predicted, though, on the next day she was allowed back on to the ordinary ward and was home within a week.
Why had we chosen Caesareans in the first place? We are both doctors. We had witnessed normal parturition as medical students during our midwifery training. The problem with being a doctor is that you see so much illness; our views of childbirth were highly coloured by some of the complicated deliveries that we had witnessed. We knew that uncomplicated, planned Caesarean section is one of the safest means of having a baby - for the baby, at any rate. Both of us had spent many hours holding retractors and admiring consultant surgeons' golf anecdotes as medical students. The functional sterility of the operating theatre held no terrors for us. We weighed up the figures and made a choice, ignoring the sanctimony of some of the midwives we encountered. Besides, what is "natural" in the modern world? As doctors, we spend most of our time preventing nature from taking a malignant course.
Were these complications directly a consequence of the previous Caesareans? It is perfectly possible to have any of them without having had surgery on the uterus. Text books offer differing views. Some state categorically that these are recognised complications of previous surgery. The eminent consultant who guided us through these stormy times is convinced that he will encounter them increasingly often.
I do not want to frighten anyone, especially if they are thinking of choosing the elective Caesarean option. They are indubitably safe. Even in the darkest, moments, I knew objectively that we would be all right. But uninformed choice is not real choice. Spontaneous, "normal" uncomplicated vaginal delivery is probably safer.
Most people will probably not have four children, by this method or any other, and we probably pushed our luck. When I look at our lovely, thriving new daughter, though, then I know it was worth it. And thank God for the NHS.Reuse content