Caesar's army

I was not surprised to read in the 29 August 2003 Vancouver Sun that the cesarean section rate in BC has risen to 27.9%. Increases in maternal age, fetal weight, and multiple pregnancy account for some part of the rise, but the major changes have been in the skill and attitude of obstetricians.

At a retirement dinner for a veteran case room nurse I sang a song (which parodied “Those Were the Days”) part of which went:

Today nobody learns and no one teaches
All the many skills we had to know
Occipus patiriors and breeches
Were actually delivered from below
Those were the days, etc.

In the late 1960s or early 1970s a new generation of obstetricians emerged who found it easier to condemn various obstetrical procedures (often based upon improperly derived statistics) than to master them. These obstetricians are now the teachers! In the 1980s and early 1990s a last chance presented. Younger obstetricians, when confronted with a difficult vaginal delivery, had the opportunity to ask their more experienced colleagues for assistance and instruction. Rather than face this ego-shattering experience they usually resorted to cesarean. Now the experienced obstetricians have pretty well disappeared from the scene. Caesar’s army has crossed the Rubicon.

Obstetricians are now much less willing to supervise prolonged labors. While the economics of time and money may be partly responsible for this, the usual reason seems to be that the obstetricians have insufficient confidence in their judgment and skill to see it through. In fairness the current medico-legal atmosphere has made it more difficult.

One skill that has been firmly honed is that of note writing. The story on the chart, accurate or not, will usually survive the scrutiny of any lawyer or panel of peers. The buttock must be protected!

I regard with even less respect the obstetrician who performs a cesarean for convenience or because the patient “refused to undergo labor.” In my later years of practice I was presented with a few such cases. I was able to convince all but one to abandon their plans. In the remaining case I politely withdrew my services. Curiosity compelled me to check the outcome of this case. She found someone…

I won’t bore you with an outline of the potential physical and emotional sequelae of unnecessary cesarean. Rather I shall end on a note of hope derived from my first exposure to an “official obstetrician” (Dr Jan Christlaw) who sees it like it is.

The dinosaur is in an ugly mood.

—A. Krisman, MD
Vancouver