Performing C-sections on request

I always thought that the primum non nocere injunction to physicians came from the fertile minds of Galen or Hippocrates, but I discovered that the elegant English version, first, do no harm, is attributed to Dr Thomas Sydenham (1624–1689), author of Observationes Medicae, a textbook of bedside practice and observations. Published in 1676, this book was used for 200 years, reminding physicians that every medical decision carries the potential for harm. 

Primum non nocere came to mind as I read the following headline in the National Post: “Women given final choice of C-sections,” “Doctors must perform upon patient’s request.” According to the article, the Society of Obstetricians and Gynaecologists of Canada (SOGC) now holds the view that in instances when there is no specific medical reason for surgery, the choice over vaginal birth or cesarean section should be the woman’s.

Reading the article took me back to the late 1950s when I was a general practitioner on the North Shore and Lions Gate Hospital was just a dream. The chart review committee of the North Vancouver General Hospital would call you on the carpet to explain the clinical reasons for having over 2% or 3% of your maternity cases end in a cesarean section. And they were serious about it. Dial forward some 60 years. The 2015 Canadian Census reported that 35% of all births in British Columbia were managed by cesarean operation. In that year about 3% of all births were assisted by forceps application and another 5% involved application of the vacuum extraction method.

In the National Post article Dr Jon Barrett, chief of maternal-fetal medicine at Toronto’s Sunnybrook Health Sciences Centre and one of the authors of the SOGC’s recent opinion, explains that the option for a choice would be reserved for expectant mothers who may have phobic fears of vaginal delivery, for older first-time pregnant women who think that this might be the only pregnancy they ever have, and for those who firmly believe that the surgical option would offer the least risk to their newborn.  

I can certainly understand some of these issues and I sympathize with anxious prospective mothers who seem to trust the surgical method as the safest one to bring their newborn into this world. I also sympathize with the obstetricians being squeezed between their patients’ heartfelt requests for cesarean section and the time-honored principle of having a valid medical reason for this procedure.

My concern is that little attention is being paid to the needs of the third party in this decision-making process: those of the newborn. There are a number of benefits to vaginal birth for the infant, which should not be forgotten, including the lower risk of respiratory problems, facilitation of stimulation of the baby’s cardiovascular system, endowment with protective bacteria as the baby passes through the birth canal, and other less–well defined advantages to the immediate health of the newborn and possibly to the well-being of the individual as a grown up. 

Would someone, please, stand up for the newborn? The first thing is to do no harm.
—George Szasz, CM, MD

Suggested reading
Kirkey S. Women given final choice for C-Sections. An Edition of the National Post in the Vancouver Sun. 27 June 2018. Pages NP1 and NP5.

This posting has not been peer reviewed by the BCMJ Editorial Board.

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