Should women have the right to choose a Caesarean section? Is the answer: a) yes, but only if they’re pregnant; b) yes, but only if there’s a clear medical indication; or c) no, unless they’re doctors, doctors’ wives or celebrities wishing to preserve their pelvic floor?
It’s a debate that’s been doing the rounds in many kitchens since the National Institute for Clinical Excellence decided that normal delivery should be promoted unless there is an established clinical need to reach for the scalpel.
NICE bases its guidelines on the best evidence, but front-line experience tends to trump controlled trials every time. Doctors only ever get called to deliveries that go wrong, and we’ve seen enough painful and disastrous vaginal deliveries where the pelvic floor has been ripped to shreds to decide we – or our partners – would rather not have that. Hence the popularity of elective Caesareans among doctors, even when they advocate the alternative for their patients.
It’s not just the precipitate arrival of an 11-pounder with shoulders like Hattie Jacques’ that puts us off. We can all remember trying to repair the damage afterwards. For some obscure reason, really bad tears were not given to experienced midwives with a good knowledge of anatomy and even better needlework skills. No, anything more than a minor laceration was handed over to the most junior SHO.
Dr Ten-thumbs, who was brought up on the philosophy "Have a go first, before you ask for help," then gathered all the catgut he could find and tried not to stitch the inside of the vagina to the outside of the anus. That anyone can manage intercourse after a novice episiotomy repair is a miracle.
Contrast that with the elective Caesarean under spinal block I witnessed the other day. I was filming a documentary about the history of anaesthetics, and how we’ve gone from theatrical amputations on screaming patients, to knocking everyone out by taking them as close to death as possible and, finally, to keeping them awake and completely pain-free.
The birth was as moving as any I’ve witnessed, and much less emotionally traumatic. Nobody argues that Caesareans don’t work – you’ve got to be pretty bad if you don’t manage to get the baby out – so why shouldn’t women have the right to choose one?
One argument against is that women who choose Caesareans do not have a balanced view of the risks and benefits; they don’t appreciate the dangers of anaesthesia, operative mishap, DVT, pulmonary embolism and the length of recovery. But whose fault is that?
As doctors we pay lip-service to informed choice when usually it just means time-pressured persuasion of patients to go along with what we think is best. Healthcare professionals can be bad at offering patients unbiased choices, so it was comforting to hear that some obstetricians and midwives are using evidence-based decision aids that allow women time to choose. Even better, after weighing up the evidence most decide to try a normal delivery.
But I think the few who still want a Caesarean should be allowed one ... if the NHS can afford it. And there’s the rub. The NHS could save between £9 million and £15 million if it drastically reduced the number of elective sections. But how does this fit in with the new mantra of patient choice, where patients are seen as experts in their own needs and preferences?
Choice will always be limited, and for the choice agenda to work the Government needs to be very explicit about which choices are in and which are out because of cost or effectiveness (or both). Finally, all the choices left have to be based on quality.
Women should never have to put up with clumsy, inexperienced juniors going anywhere near their babies or their pelvic floors.