Medicine

Doctor’s choice, mother’s trauma

Linda McQuaig July 28 1980
Medicine

Doctor’s choice, mother’s trauma

Linda McQuaig July 28 1980

Doctor’s choice, mother’s trauma

Medicine

Linda McQuaig

The last thing Janet Campbell remembers was the mask coming down over her face. She had been

lying in the hospital delivery room for about two hours and her contractions were coming on stronger and more often—a sign that her labor was progressing well. Certainly no one had mentioned the word “cesarean.” But an anesthetist leaned forward and, explaining that he was going to help

Campbell breathe more easily, clamped a mask over her face. After that she has only vague recollections of being urged to sign a form as she was wheeled semiconscious into the operating room.

Campbell woke up after the delivery to discover that, besides the usual 15-cm abdominal scar, the operation had left her with a bowel obstruction which kept her hospitalized on intravenous for eight days and in bed for most of the next two months. “It was a very long time before I could accept that child,” she says. “I associated him with all that misery.” When Campbell, who lives with her husband and three children near Halifax, asked her doctor six weeks after the operation why he had done it, he told her he couldn’t remember. Confused, Campbell got another doctor to check her hospital records, but he found no indication of “fetal distress”—a common factor leading to cesareans. Actually, her doctor’s quickness to avoid a long, drawn-out vaginal

birth may have had more to do with the fact that her labor began on Saturday morning — three days before Christmas.

Like hundreds of thousands of young women in Canada and the United States this year, Campbell prepared for normal childbirth only to find herself unexpectedly on the receiving end of a surgeon’s knife. In the past 10 years, cesarean rates have risen dramatically with little assessment of the dangers and disadvantages for the mother. The in-

crease reflects a growing willingness on the part of doctors to .intervene in the childbirth process in the name of fetal welfare. But there is little evidence showing the benefits of the operation, and critics charge that cesareans are often performed more for doctors’ convenience than for medical necessity.

Once a relatively rare operation performed only in unusual circumstances, cesarean sections now amount to close to one-quarter of all deliveries in some Canadian hospitals. Cesareans are considered necessary if the life of the mother or fetus is at risk—if, for example, the birth canal is blocked by the placenta. But Dr. Tom Baskett, head of clinical obstetrics at Winnipeg’s Health Sciences Centre, became concerned recently when, promising anonymity, he surveyed 10 Canadian teaching hospitals—where the concentration of highrisk patients tends to increase rates— and found some cesarean rates as high as 23 per cent. Doreen Hamilton, former

maternal and child health consultant to the Toronto Board of Health, says an informal survey of Metro Toronto hospitals last year showed that cesarean rates had jumped from 10 per cent six years ago to 20 to 25 per cent.

The sharp increase has important implications for the estimated half-million North American women who will undergo the operation this year for, despite improvements in methods of cesarean delivery, the operation is still major surgery. A 1977 Rhode Island study found that a cesarean patient is 10 times more likely to die from childbirth than a mother who delivers vaginally. Baskett insists that, while the number of deaths in Canada is extremely low, it isn’t something that should be ignored. In addition, about one-quarter of all cesarean patients develop infections or other complications. And most doctors insist that, for the mother’s safety, any future children of cesarean patients be delivered by cesarean—although recent medical evidence disputes this. Baskett argues that a woman who has had a cesarean is at greater risk—and so is her fetus—in any subsequent delivery, no matter what method is used. Dr. Joseph Lukezich of Toronto also points out that women can develop bowel problems as many as 10 years after the operation. But perhaps the most powerful effect on the majority of women is the pain.

“Most women have no idea of the pain before it’s done,” says Laurie Brant of Burnaby, B.C., a counsellor with the Cesarean Birth Group.

Doctors who defend the high rate of cesareans often point out that fetal mortality has declined in recent years as cesarean rates have climbed. But Dr. Charles Mahan, an obstetrician at the University of Florida, argues that reduced rates may have more to do with better nutrition and prenatal care. “Nobody has proved cesareans are improving baby care,” he says.

Ironically, the tendency of hospital staff to intervene more aggressively in childbirth can lead indirectly to cesareans. Some doctors rely heavily on newly developed electronic fetal monitors, opting for surgery when the machine indicates fetal distress even though the machine’s signals can be confusing. And labor-inducing drugs can intensify natural contractions, reducing the supply of oxygen to the fetus and triggering a “fetal distress” signal

and a subsequent cesarean. Catherine Leslie, a 28-year-old mother in Surrey, B.C., also blames her cesarean on another hospital procedure. Leslie was given an enema to prepare her for delivery, despite her objections and despite the fact that her amniotic sac— which surrounds the fetus—had broken, leaving her highly vulnerable infection. She didn’t make it to the washroom and her bowels emptied themselves forcefully into a bedpan, splattering excrement around her vagina. As a result, she developed an infection which she passed on to her fetus.

Just how many cesareans are per-

formed for convenience remains a disturbing question. Toronto obstetrician Dr. Alvin Pettle estimates that about half of induced labors—often with subsequent cesareans—are done because it’s convenient. Dr. Jean Marmoreo, also of Toronto, agrees that this is a problem: “There’s a lot of unnecessary induction because the weekend is coming or the doctor is going on holiday.” In fact, a survey of five New York hospitals in 1978 found that 62 per cent of first-time cesareans—supposedly emergency operations—took place during working hours.

Women who have had cesareans often complain that they were pressured into the operation at a time when they were least able to resist and least able to question the doctor. “They basically put it to you: ‘If you want a healthy baby, this is the only way,’ ” says Brant of the Cesarean Birth Group. With cesarean rates continuing to rise, more and more women are coming out of hospital— with permanent scars across their abdomens—to face weeks of painful recuperation. Says Toronto nurse Sandra Upton: “It can be kind of depressing working in maternity these days.” ;£>