Concentrate on per via naturales: spare cesarean section and save the abdomen

Obtaining entry to obstetric and gynecology related organs is inviting to the connoisseur as it has two portals of entry, one natural and the other created by surgical intervention. The vaginal route is a natural one that invites and launches conception and the consequent obstetric cycle; it is the vaginal route through which the fetus emerges, delivery per via naturales. Likewise, it is the vaginal route that gives entry or exit to the mouth and cavity of the uterus and provides a natural gynecological route. No general surgeon or non Ob. Gyn. doctor can ever have in-depth knowledge of the art and science of making optimum use of the vaginal route for conducting normal or complicated vaginal delivery. Thus, the vaginal route is the natural one for obstetricians and gynecologists. Only when that route cannot be considered should the obstetrician turn to an unnatural alternate door, that is, the abdominal route. The two most common operations – in obstetrics, cesarean section and, in gynecology, hysterectomy – are performed by opening the abdomen as an alternative, to take out the fetus and uterus, respectively. The abdominal route is used by all and sundry – general surgeons, oncologists, urologists, biliary and plastic surgeons. There is not the faintest doubt that the cesarean is of great value when things go awry. However, when performed for controversial or illogical reasons or too liberally, without using the primary or natural route when required, critical analysis is required.

The rate of cesarean section has risen from approximately 5% in developed countries in the early 1970s to more than 50% in many geographical regions in the last decade [1], even though delivery per via naturales is the medically preferred method. Preventing primigravida from the first cesarean is the key, since the obstetrician will be far more comfortable performing a repeat cesarean than a cesarean on a parous unscarred uterus.

Successful vaginal birth after cesarean (VBAC) can reduce the large number of cesareans and ease the future Ob. Gyn. path. Elective cesarean without VBAC trial needs strict introspection and a ‘surgical audit’, as a higher incidence of cesarean can indicate obstetric weakness.

cesarean section, once performed, has the in-built potential to result in opening of the abdomen through repeat cesarean(s), ventral scar hernia, flimsy to uncommonly dense adhesions between the lower abdominal wall with the uterus and bladder depicted by the cervico fundal sign [2] and excess increase in obstetric hysterectomy due to placenta accreta and allied problems [3]. Again, at a future date, when required, hysterectomy is often performed abdominally, without any contra-indication to better alternatives, simply because of ‘vesicophobia’ borne out of scarring from the cesarean in the past. In the developing world, with ill-nourished candidates who may have only a namesake anterior sheath, a subumbilical suprapubic incision undertaken without due consideration is often a precursor of ventral scar hernia. Thus, cesarean acts as a nidus for invitation to yet another opening of the abdomen. Has the obstetrician, while deciding on a cesarean for a borderline or unconvincing indication in a primigravida, or avoiding VBAC trial in a patient with cesarean in the past, considered that a cesarean has an in-built potential to invite subsequent risk?

For a woman who has had a cesarean in the past, mere mention of a chance of uterine rupture, although uncommon (0.4–0.6%) [4,5], is sufficient to frighten her and her family and to frighten the obstetrician at the thought of long-term consequences and possible litigation. This leads to avoidance of the VBAC trial. In many places, the woman is at the mercy of the doctor’s opinion, whose personality, tongue and respectable qualifications have captured her faith. Thus, a cesarean section in the past becomes a convenient indication for a repeat cesarean, which suits many who are in search of an indication to perform repeated cesarean sections. This includes young obstetricians, as well as busy senior obstetricians. Cesarean will relieve relatives, enrich the hospital and, not least, save a lot of time for the attending obstetrician. The patient saves nothing but her perineum–pelvic floor from invasion.

The primigravida who is spared from cesarean has a tested pelvis and is much less likely to require a cesarean in the future. However, when a woman who has had a cesarean in the past is not given an opportunity for VBAC trial, cesarean for a second time guarantees that all future deliveries will require opening of the abdomen. An effective emergency intervention, which cesarean section is supposed to be, can do more harm than good when applied to healthy women who undergo elective cesarean without being given trial of VBAC. A study in Latin America showed cesarean section has not necessarily improved perinatal outcome, contrary to data from developed countries [1].

Obstetrics is an art and a science. Unfortunately, the art is withering at a galloping pace. Opening the abdomen and performing a cesarean is easier and more convenient for a busy obstetrician than mastering the art of obstetrics. A little deviation from normalcy sees doubts creep in. Doubts, in the words of Shakespeare, are ‘Traitors and make us lose the good by fearing to attempt’. Deviation from normal, or an unnatural happening, puts an obstetrician to the test, whether it is in giving a trial of labor for a primigravida – dark and untried horse – or a trial for VBAC. It may not always be a trial of labor that includes fetus versus pelvis or VBAC trial that includes fetus versus uterine scar but it is a trial of the attending obstetrician versus the science of obstetrics. No wonder Ian Donald expressed obstetric problems as doubts, fears and perplexities [6]. This is most likely to affect the medical professional used to performing cesarean sections at the least indication and also younger medical professionals. They certainly mature with every failure.

Obstetricians in Dublin, Ireland, avoid opening of the abdomen by taking recourse to cesarean section sparingly and deliver the baby per via naturales in almost 90% of confinements [7]. This needs to be a goal. However, in many affluent, as well as many developing countries, a 30–50% incidence of cesarean is reported, just as in gynecology, more than 60% of women undergo opening of the abdomen for the most common gynecological operation of hysterectomy, despite better and less invasive alternatives. This is vastly different from the more than 50% cesarean section rate from the obstetric centers where the principle of ‘meaningful wait and watch’ is not heavily respected. In other words, in many parts of the world, 20–40% or more of patients can easily be saved from cesarean and its aftermath, provided the attending obstetrician is conscientious and scientifically dedicated. We need to undertake some very serious introspection, keeping in mind the words of William Mayo, approximately 100 years ago, ‘The interests of the patient are the only interests to be considered’ [8].

The developing world, with much less proclivity for litigation, should not be led by reports from the affluent world, which is charged with a litigational atmosphere, despite gratifying rates of successful VBAC of 50–80%+ according to various reports. Elimination of VBACs in childbirth centers in the USA, despite 87% success rates, because of an increase of one perinatal death per 1000 in women having VBACs after one cesarean section, is a difficult level of standardization for a large obstetric world that very much needs VBAC trials. All those with emergency cesarean service availability need to look strictly at 87% success rates of VBAC trials [9]vis à vis perinatal and maternal mortality rates, the litigational atmosphere and overall settings. We have a task. Let us gracefully take heed of ACOG’s recommendation: ‘Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor’ [10].

How often has an obstetrician in cases of previous cesarean, close to full term or in early labor, asked himself these two questions?

•	Would this woman have delivered normally, had she had no cesarean in the past? If the answer is ‘Yes’, go to the next question
•	Will her cesarean scar stand the test of labor?

Avoiding cesarean and sparing an abdominal opening should give greater pleasure and satisfaction to the obstetrician than performing cesarean section; comparable with pleasure of a vaginal delivery in a primigravida with breech presentation.

More often than not, a country’s maternal and perinatal mortality and economic status (per capita income and/or GNP per capita) are not accorded the requisite importance when looking for reasons to keep the abdomen intact and take the natural path. What is applicable to the USA with a GNP per capita above US$25,000 and the UK with a GNP per capita above US$18,000 is inapplicable to countries with a GNP per capita of US$1000–2000. In a developed country, for each 1% increase in cesarean deliveries, there is an increase in cost of approximately US$9.5 million [11]. Likelihood of litigation in affluent countries often dictates the management of cases and this may even be termed ‘unscientific’. Each geographical area needs to look carefully at the multifactorial situation and it is vital to design the best treatment under the circumstances, based on the merits and demerits of the area. Just as every case needs to be treated on its merits, I feel, in countries with poor settings – developing countries – every treatment needs to be tailored to the area’s socio-economic merits and demerits. The words of Benson Harer should guide many: ‘Those who care for patients must consider factors beyond the mechanics of delivering their babies’ [12].

Is it our lethargy or incapacity to learn or the inadequate example of our peers, or is it that performing a cesarean is in keeping with the busy obstetrician’s lifestyle, in addition to being a lucrative proposition? There is no doubt that normal delivery is more economical for a patient. If the fees for the obstetrician to deliver cases of previous cesarean per via naturales were doubled, what would be long-term outcome? Is it that cesarean brings style and modernity, elates the woman and provides material for gossip at the bridge table about the intact perineum? The obstetrician has a god-given vaginal route at his disposal that provides the opportunity to put his judgment, knowledge and expertise to the test and to succeed; the primigravida in need of trial labor and cases of previous cesarean needing VBAC trial are waiting in large numbers.

The mindset of the practising obstetrician and gynecologist is vital and pivotal. The obstetrician recommends cesarean section or elective repeat cesarean to keep the perineum, in particular, and pelvic floor, in general, ‘intact’. Interestingly, the same obstetrician who turns to gynecological practice continues to open the abdomen and perform hysterectomy for a multiparous normal-sized uterus and leaves behind a torn perineum and/or bulging lower third of the posterior vaginal wall due to rectocele and/or glaring cystocele unattended. Similarly, let us look at the gynecologist who performs laparoscopic-assisted vaginal hysterectomy at all costs for a normal-sized uterus in a multipara and boasts of achieving minimally invasive surgery, while, on the other hand, in his obstetric practice, gives no consideration to invasive techniques while performing cesarean section as against possible delivery per via naturales. In the days of minimally invasive surgery, an invasive technique, such as cesarean section, is incomparable with delivery per via naturales, if necessary assisted with a forcep or ventouse. These are some of the fascinating facets that can stump anyone.

A procedure that is ideal in one situation and suited to a particular obstetrician may not be the same to another in a similar or different situation. Strategies and methodologies applicable in developed countries may not be appropriate or ideal, and may even prove problematic, in developing countries. The needs of the people and the settings and the resources available must be considered foremost in planning medical treatment. To do so is not easy; however, professionals must respect this necessity and generate a chemistry that works, rather than continue with something that is an obstacle to good practice [13].

‘Be not the first by whom the new are tried, Nor yet the last to lay the old aside.’ Alexander Pope, An Essay on Criticism.