Dr. Neel Shah, Obstetrician & Professor at Harvard did a live Facebook video session on the Birth India page. The focus of the talk was on C-Sections, which is what Birth India has been highlighting this month – since April was C-section awareness month. Dr.Shah spoke on many aspects of caesarean sections, which are major abdominal surgeries, in response to the questions that participants raised.
He pointed out that “Every person deserves to be able to start or grow their family with dignity – with access to childbirth services that are safe, supportive and empowering. Birth and death are life’s only two certainties, and people will procreate whether they have a dignified way to do it or not. That means that whatever the status quo is becomes the normal.”Pointing out the terrible state that the current status quo is in Dr. Shah reminded that in the US 1 in 3 women have major abdominal surgery to have their babies and 1 in 10 have their babies sent to the neonatal ICU.
Globally 1 in 4 babies born as C-section and in India there are hospitals in the private sector where Caesarean rates are 100% during the day; and 0% at night – not a naturally occurring phenomenon. The reason for a concern about this, he pointed out was that C-Section rates and birth didn’t use to be this way. This is a change that has happened in the last generation, which definitely comes with a big share of consequences.
He elaborated some of the consequences of major abdominal surgery for birth – which include- higher odds of hemorrhage, significant infection, chances of organ injury being 3 times higher. In addition to this, the mother is overwhelmed by going home and taking care of an infant with an incision across her abdomen.
He pointed out that often doctors are trained to focus on the immediate case, and forget that the current pregnancy has significant consequences on future pregnancies, and most women have more than one child. Dr. Shah opined that ‘Caesareans could be the most common and consequential surgical errors’ since the decisions to do a C are often inaccurate.
Weighing in on the long term impact – without invalidating anyone’s experience – he remarked that OBs are the only surgeons who are trained to cut on the same scar repeatedly, no other docs would be comfortable doing that. Scar tissue complicates a surgery every successive time.
One of the real dangers in a second or successive C-Section is that the placenta sometimes ends up getting caught up in the scar tissue of the earlier C, which could cause massive bleeding. He shared that in the US, they have been seeing higher and higher rates of deaths due to this.
Another long term impact of uterine scarring he said, was that women who have uterine scarring are 50% more likely to get a hysterectomy, and in that situation, or other abdominal surgery they are likely to have more complication because of the previous scar tissue.
Regarding VBAC, Dr. Shah said, “Vbac is always a better and safe choice for a woman – anything to avoid have a repeated surgery at the same place is always good.”
He pointed out that lack of evidence in childbirth is an issue all over the world. But at the same time, he reminded that there are a lot of things we should be doing for a woman in labour that are not about empirical evidence, but are more about values and being kind to people. You do not need randomized control trials to show that women need to be treated with dignity and respect as part of their care.
The overuse of C section is a failure and can usually be traced back to two reasons – 1. Ignorance – not knowing the answer, 2. Ineptitude – know your answer but failing to do it.
When well informed, well intended people are messing up, it means that you need a different solution – need to fix the system itself, he said. This is especially necessary when we consider that there has been no update in the way we manage labour in a century. Approaching childbirth in the same way as you fix diseases – leads to OBs taking over childbirth from midwives. In many ways we are massively overdoing and causing a lot of harm as a result.
Dr. Shah remarked that having the primary goals of ensuring that mother and baby are safe is insufficient. We need to track 3 or 4 goals that are real – in order to improve the existing system.
Maternity care providers are very good at responding to obvious emergencies – we are not good at preventing emergencies before they happen, he said. Also, he reminded the group that we have to create permission for women to express what they uniquely know – and make those opportunities happen. Knowledge is power and having advocates with you when you are birthing is a good way to ensuring your wishes are respected.
When it comes to fixing the system, he pointed out that “Right now what we lack is a process where everybody involving is sharing the same information with the same mental model of what to do with it” – which is a system that he is trying to develop as part of his ongoing work. The focus should be on having midwives and doctors – both working together as an integrated team. Also, the existing training curriculum would need to go through a change to get the system back on track as a partnership.
Summing up, he said “The key to improving normal birth rates around the world is PATIENCE”.
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Posted by Birth India on Wednesday, 25 April 2018