Caesarean Sections- Is Decision to Incision Time Too Long or Too Risky?
It has been 15 long hours of labouring; first, the doctor examined her and artificially ruptured her membranes; then there was the nurse at her side, infusing a powerful drug needed to coax along her contractions; an epidural to lessen the pain; monitors, and finally the doctor coming into offer a choice between forceps and a caesarean section because the baby’s heart rate was falling.
Gone was the happy and exhilarating expectation of delivering and holding a new life in her arms. In its place, a desire for a positive end to the agony and uncertainty, and the absolute fear for her child and herself.
A labouring mother may face a life-or-death or life-and-limb decision at a time when she is exhausted, anxious and in significant pain. Yet, everyday in hospitals across Ontario and Canada, women face such a choice and very little time to consider the options.
For several years, when a decision is made to undertake an unplanned caesarean section, the rule hospitals and doctors follow is 30 minutes from that decision to the first surgical incision (decision to incision time). That meant that a woman would have to be prepared for major abdominal surgery, moved to an OR, with a team in place including an anaesthetist, surgical nurses, and a pediatrician, pediatric nurse and respiratory therapist to receive and revive the baby if needed.
A recent review of medical literature and standards in the US and UK suggest that in some circumstances, the 30-minute rule may be too long, and in others too short. (Bank et al, 2022 in press AJOG.org) What appears to be clear is that in cases where the fetus is suffering from bradycardia due to irreversible causes ( such as placental abruption, uterine rupture, preeclampsia, cord prolapse, and failed forceps or vacuum delivery), an important marker of newborn health, pH, fell each minute of delay. If the cord is fully blocked, meaning no oxygen is being delivered to the fetus, then logically, speedy delivery is required. The point is that the fetus has to have oxygen, and deprivation of oxygen is not good.
On the other hand, an emergency caesarean as compared to a scheduled section is associated with higher rates of complications for the mother, like infections and wound separation. Surgery always comes with the potential for complications.
Where the delivery takes place can make a difference to the outcome. In a major teaching hospital, access to ORs for sections within 20-30 minutes is very doable. However, smaller hospitals may have to call in a team, an anaesthetist and have limited operating room availability. Labouring at home may mean a trip in an ambulance added to the timeline.
There are recognized risk factors in a pregnancy that suggest a planned section, or a trial of labour with a conversion to an urgent but not “crash” caesarean, should be discussed with the expectant mother. If labour stalls, the baby is in a poor position for delivery, hypertension, infection, placenta previa, previous section, preterm labour, may point to a section being done before matters become urgent. Even before going to hospital, assessment of risks associated with conditions such as prior section, diabetes, disproportion of the fetal head and maternal opening (a large baby), obesity or being underweight, twins plus, amniotic fluid abnormalities, mother’s health conditions and STDs, should be addressed as relevant with the health professional.
A study published in the Canadian Medial Association Journal from May 03,2021 (193:E633-44 Guo et al), found that over a 6-year period, the number of women requesting a planned section in Ontario was relatively stable, around 0.4%. The characteristics of those seeking a section for non-medical reasons included “late maternal age, higher education, conception via in vitro fertilization, anxiety, nulliparity, being White, delivery at a hospital providing higher levels of maternal care and obstetrician-based antenatal care. Women who planned CDMR( c-delivery, maternal request) had a lower risk of adverse outcomes than women who planned vaginal delivery...”
In 2019, the American College of Obstetricians and Gynecologists gave this advice to their members:
When a woman desires a caesarean delivery on a maternal request, her healthcare provider should consider her specific risk factors, such as age, body mass index, the accuracy of estimated gestation age, reproductive plans, personal values, and cultural context. In the absence of maternal or fetal indications for caesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended. After exploring the reasons behind the patient's request and discussing the risks and benefits, if a patient decides to pursue caesarean delivery on maternal request, the following is recommended: in the absence of other indications for early delivery, caesarean delivery on maternal requests should not be performed before the gestational age of 39 weeks; and, given the high repeat caesarean delivery rate, patients should be informed that the risks of placenta previa, placenta accreta spectrum and gravid hysterectomy increase with each subsequent caesarean delivery.
No one wants to face a “crash” or emergency C-section. Everyone- mother, partner, family and health professionals - wants the birth experience to be a joyful and calm experience, with few surprises. Everyone wants a healthy baby and a healthy mother, ready to take on the world. Women should have frank conversations with their obstetrician, midwife or nurse practitioner to ensure that the conversations had, and choices made, are done in time to avoid a forced, emergency c-section.
If you have experienced a negative outcome, through trauma to your baby, HIE, brain injury, dystocia, or infection, contact us.
