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| Sunday, 6 October 2002 |
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Compiled by carol aloysius Caesarean births: how safe are they? by Dr J Ashmore F Attapattu (Consultant Obstetrician & Gynaecologist) During the past 20 years there has been a dramatic increase world wide in caesarean sections from less than 5% of all deliveries in 1965 to more than 15% in 1978. The incidence varies from country to country influenced by several factors. In the premier Womens Hospital in Sri Lanka-Castle Street Hospital for Women (Teaching) Colombo there were 4285 (27.1%) caesarean sections in the year 2000, while in the year 2001 there were 4760 (28.1%) such operations. The total deliveries for the two years were 15788 and 16912 respectively. (Medical Records, CSHW).
The author recorded an incidence of 4.5 to 5% in the Base Hospital, Gampaha in 1974. There are many reasons attributable for this alarming increase in Caesarean deliveries. In general Teaching Hospitals and Private Institutions throughout the world record the highest rates. Common indications Failure of labour to progress is by far the commonest indication. Judgement and experience on the part of the attending obstetrician plays a major role in timing the termination of the natural process of labour. Sophistication in monitoring techniques and faulty interpretation also could contribute to this trend. Another common indication is a pervious caesarean section. Certainly if the indication for the previous section is absolute, caesarean section for the next pregnancy is justifiable. With relative indications, which are often non-repetitive in future pregnancies, performing a repeat section becomes controversial depending on the circumstances that prevailed at the previous operation. Craigin in 1916 went to the extent of postulating the dictum Once a Caesarean Always a Caesarean. This is totally not acceptable in the present day context. Today most obstetricians would give a trial of scar (which simply means an attempt at vaginal delivery when the mother goes into labour) taking into consideration the circumstances that prevailed at the previous operation, having ensured that there are adequate and reliable facilities. Unfortunately many private institutions are not geared for such a procedure. The labour monitoring nursing staff may not be adequately trained and the attending obstetrician would think twice to hand over responsibility to such staff, therefore resulting in an increased caesarean section rate. Breech presentation (when the babies buttocks and not the head presents in the lower part of the uterus) is another major indication for caesarean section. Most obstetricians prefer to deliver all frank breech presentations in women having their first baby by elective caesarean section. The incidence of caesarean section is also increased in all breech presentations due to the increased morbidity and mortality of the fetus associated with such presentations in contrast to a vaginal delivery with the head presenting. Another common indication is Fetal Distress. This simply means the baby in the uterus is experiencing some difficulty in oxygenation. This is reflected initially by an increased heart beat followed by a decrease and irregularities; the latter being more serious. With modern techniques of fetal monitoring the process of labour could be judged by the use of cardiotocography, which monitors the fetal heart by a wave pattern traced on a strip of paper. The procedure is performed by placing a diaphragm over the mothers abdomen connected to a machine which records the alterations of the heart beat of the baby on a strip of paper. Certain alterations of the wave pattern occurs when the fetus is in jeopardy. Interpretation of these patterns require experience and proper judgement. A wrong interpretation may result in an unnecessary caesarean section. In most western countries like the UK and USA rising malpractice costs and the very real emotional torment the obstetrician faces in being sued prompts him to perform a caesarean section rather than allow a vaginal delivery in the interests of the baby even though this may not have been warranted. Therefore defensive medicine will continue to contribute to the rising caesarean birth rate in these countries and probably so in Sri Lanka as well in the near future. There are other indications for caesarean section, such as pregnancy induced hypertension, certain diseases complicating pregnancy, prematurity, some cases of antepartum haemorrhage and many more. The introduction of epidural anaesthesia for vaginal deliveries, where the mother delivers her baby without much pain and discomfort is attracting more and more mothers to opt for vaginal deliveries. However there remains the other group of mothers who prefer a caesarean section to avoid the natural process of labour. There are still others who prefer to deliver their babies the normal way without any pain killing drugs and interference. Procedure Pre-operative preparation: For a planned caesarean section a minimum period of 6 to 8 hours fasting is advised. Most anaesthetists give some form of antacid such as sodium citrate. Others give framitidine a drug that stops the secretion of acid to increase the gastric motility some give metochlopropamide (Maxalon). These precautions are taken to avoid any acid secretions entering the lungs during the process of intubation. The dreaded condition called "Mendelsons Syndrome" may result if such measures are not taken. A stat dose of a broad spectrum antibiotic is also given by some before surgery is commenced. A rectal suppository of glycerine or dulcolux also helps in emptying the rectum. Blood should always be available. In emergency situations the scenario changes dramatically. Mothers who are severely dehydrated and electrolyte depleted should always be rehydrated and the electrolyte imbalance corrected before surgery is commenced. Sometimes a gastric tube may be necessary to empty the stomach. At surgery most obstetricians use a low transverse incision (Pffanenstiel). The operation itself entails a transverse incision on the lower segment of the uterus. Once the baby, placenta and cord are delivered the uterus is repaired in layers. Proper apposition of muscle layers is mandatory; special attention being paid to the corners. Today synthetic material such as Vicryl is used instead of catgut. After the uterus is repaired having ensured haemostasis the abdominal wall is repaired. The post-operative period is managed like any other major surgical operation. Ambulation is mandatory from the first day itself. Most mothers are discharged on the 3rd day if there are no complications. Advice regarding contraception is given. She is seen again in six weeks to ensure that both mother and baby are normal. Complications Complications resulting from caesarean section should be rare today. This has been achieved by modern anaesthesia, proper surgical techniques, blood availability and antibiotics. Risk of death should be of the order of one per 2000 procedures. Caesarean section is a surgical procedure. It would therefore entail all complications of any other major surgical operation such as paralytic ileus (non active small gut), haemorrhage, infection, deep vein thrombosis and chest complications. Peculiar to caesarean section there are other complications. Haemorrhage could result from a non-contracting lax uterus due to atony or adherent placental tissue, a coagulopathy (deficiency of certain clotting factors). Early intervention with oxytocics (drugs which contract the uterus), adequate blood transfusion, replacement of coagulation factors, bilateral ligation of the internal iliac arteries or a hysterectomy could save many a mother under these circumstances. Wound infection could be evident on inspection. A collection of pus requires drainage and appropriate antibiotics. Endometritis results from infection inside the uterus. An offensive discharge, fever and tenderness will be observed. Culture of the pus and antibiotic sensitivity has to be done and the appropriate antibiotics should be given in high doses. Evacuation of the uterus may be required if products are retained inside. Retention of urine is possible if no indwelling catheter has been used. Simple catheterization and advise to empty the bladder on her own is often what is needed. Urinary Infection could result with repeated catheterization. Culture of the urine with antibiotic sensitivity and appropriate antibiotic therapy is required. Deep vein thrombosis and Pulmonary Embolism are serious complications but are rare in Sri Lanka. Appropriate anticoagulation therapy should be instituted without delay. Disseminated Intravascular Coagulation is another dreaded complication. This occurs as a result of consumption of coagulation factors in conditions such as accidental haemorrhage and pregnancy induced hypertension. When mothers present with these conditions and caesarean section is contemplated it is essential that a blood coagulation profile is performed before any surgery is contemplated. The deficiencies should be corrected as fast as possible. Many a maternal death could thus be prevented. Uterine laceration is possible at the delivery of the head. The tears may extend and involve large vessels resulting in massive haemorrhage. The tear should be identified and sutured ensuring haemostasis. Care should be taken not to injure the utterers during this procedure. Failure at suturing could result in a hysterectomy. Injury to the ureters are possible with tears that have extended laterally to involve the broad ligaments. Bowel injuries are rare. It is sometimes possible to injure bowel especially with previous caesarean sections. It's best that the repair be handled by a general surgeon if the obstetrician is not experienced in bowel surgery. Late complications Repeat caesarean section, placenta paraevia (placenta in the lower segment of the uterus), placenta accreta (adherence of the placenta to the muscle wall of the uterus), uterine rupture in a subsequent pregnancy, dysfunctional bleeding, and infertility due to infection are some of the late sequelae of caesarean section. ****************** Why do people wheeze? Wheezing is a whistling or sighing sound resulting from narrowing of the lumen of respiratory passageway. It may be a feature of asthma, bronchitis, obstructive airway disease, in one type of Heart Failure and rarely in tumours, foreign obstruction and allergy. What really happens in wheezing condition is, that tiny tubes leading to the lungs become narrowed due to spasm of the muscles of the bronchioles, swelling of the inner lining and excessive secretions of mucus plugging those tubes. Hence, there is difficulty in breathing during an attack. Wheezing problems are prevalent in the majority of our population. Most of the sufferers had their first attack in childhood. Many young children are prone to wheezing in the early years, but outgrow this as they mature. The commonest wheezing problem today is wheezing bronchitis. It can be caused by three factors. Just one of these factors may be involved or perhaps all three factors. 1. Allergy: In children this is a prime cause. How one can exactly finds out this cause, is by carefully describing to your doctor the circumstances under which the child's attack of wheezing occur. For instance, they may occur when visiting a neighbour with a cat or dog, or may be, the child is particularly prone to an attack in certain climatic conditions, when the air is heavy with dusts or pollen from trees and flowers. Or perhaps he is worse in the rainy season, when much time is spent indoors - suggesting a possible allergic reaction to the common 'House Dust mite.' These mites live on the dead skin cells which all of us are shedding all the time, as our outer layer of the skin is being renewed itself. 2. Emotional factors can also play a large part in the onset of a wheezing attack. The emotion need not necessarily be our unpleasant one. A child may succumb to an attack of wheezing when excited over a holiday, birthday party or a special treat. This excitement process may not be seen or felt physically (or bodily) by the parents - as it occurs in the unconscious part of the mind. When the emotional factors act in conjunction with the other potential factors, the likelihood of wheezing attack is greater. The current medical and traditional treatment of wheezing is mainly pointed towards the physical aspect only. As such the emotional factors as the root cause has been completely neglected; or not considered at all. 3. Infection of the respiratory tract: is another factor which leads to wheezing - specially viral infections. Regardless of the cause the end result is contraction of the smaller tubes in the lungs, swelling of inner-lining of the same, and over production of mucus within the tubes. Thus, starved of a proper oxygen supply, the sufferer forces air into his lungs, but because of their blocked up state has difficulty in exhaling. Attacks may be brief or last several hours. Some relief may be obtained by sitting the patient up and loosening his clothing and by use of various drugs and inhalers etc. Treatment: Long term treatment includes breathing exercises: Isolation from any allergies (allergy producing agent) by, for example, a change of the environment, occupation etc. Specially in case of children, teaching of good breathing habits i.e. fully expanding their lungs with each breath, swimming is also a beneficial exercise because breath control is important in this activity. Prevention: This must be directed by the factors relevant to the onset of an attack. If allergy is the major factor - as far as possible, avoid contact with the substances that bring on an attack - dog or cat fur, feathers, soft toys and carpets in which the house dust mite lives. Cleaning of mattresses, beds and upholstered chairs, regularly. Damp dusting of furniture also help, as does frequent change of bed-linen pillows etc. If emotion is the trigger, play down the excitement or worry before various out of the way events. You can help your child to do this by your own calm reactions to unusual events. If infection, plays a frequent part in attacks, avoid crowded places as much as possible, go for a walk in the fresh air every day and treat any respiratory infections promptly. Wheezing is an unpleasant condition. But by no means every "wheeze" in childhood is "asthma," for every child who has asthma there are nine others who "wheeze" at some time during their childhood, but who do not have asthma. by Dr. Sampath R. Nanayakkara, Family Physician. ****************** Maternal morbidity and mortality after caesarean section An appalling maternal mortality rate of 75% after caesarean section was the order of the day up to the late 1800s. A dramatic reduction of mortality was observed by the end of the 19th century. This was the result of asepsis, improved techniques of anaesthesia, antibiotics, blood transfusion and improvement in surgical techniques. Today the maternal mortality attributable to caesarean section in some settings is nil and certainly should be less than 1%. At Castle Street Hospital for Women (Teaching) Colombo the total maternal deaths from all causes including caesarean section for the year 2000 was 1.1% and in 2001 0.9%. Those purely attributable to caesarean section was not available (medical Recordes, CSHW). It is alarming to note that of 19 deaths from February to June 2002 due to negligence reported in the Sunday Observer of september 16. from a few hospitals in Sri Lanka there were 13 maternal deaths of which 8 were attributable to caesarean section. Caesarean Section is a major operation and should not be taken lightly. It is safe in the correct hands. From the few incidents published in the tabloids it is evident that varying degrees of inexcusable negligence is steadily creeping in making the operation a dangerous one in the wrong hands. It is the duty of the Ministry of Health to take the necessary remedial action to rectify and deficiencies. ****************** medical update : Muscle dysmorphia syndrome identified in weight lifters Weightlifters may be at risk from a newly emerging distorted body image syndrome which could be a negative consequence of their training, scientists said on Tuesday. Although pumping iron has given them muscular and toned bodies, men suffering from muscular dysmorphia (MD) have a poor body image. They are convinced they look scrawny and are driven to work harder to enhance their physique. "Muscle dysmorphia is a new syndrome characterised by highly muscular individuals (usually men) having a pathological belief that they are of very small musculature," said Dr Precilla Choi, of Victoria University in Melbourne, Australia. In addition to thinking that their muscles are not big enough, men suffering from MD are also worried about gaining fat and are particularly concerned about the shape and look of their buttocks, hips, thighs and legs. MD is a unique form of body dysmorphic disorder (BDD), a condition in which people are abnormally preoccupied with a real or imagined defect of their physical appearance. Someone with BDD may think their nose is too long or their legs are too fat, which may lead to depression and anxiety. Instead of being unhappy with a particular body part, men suffering from MD are dissatisfied with their entire body. ****************** Noise pollution In an age when loud sounds constantly assail our ears few realise the dangers they can cause to one's health. Dr. D. P. Atukorale discusses the adverse effects of loud music, the harsh tooting of horns and constant banging of a door on your hearing and speech. Noise can cause masking of unwanted sounds, interference with speech and communication (as in wedding receptions with loud music held in five star hotels), pain and injury and temporary or permanent loss of hearing. With a few exceptions, loud noises are products of modern man and evolution has had insufficient time to develop adequate protection against extreme exposures. It is the permanent noise induced hearing loss (NIHL), noise induced deafness or accoustic trauma which mostly concern us. The intensity of sound is expressed in terms of the square of the sound pressure. The bel is a ratio and is equivalent to a 10-fold increase in sound intensity; a decibel (dB) is one tenth of a bel. Sound is made up of a number of frequencies ranging from 30 hertz (Hz) to 20 kHz with most being between 1 and 4 kHz. In practice a scale known as A-weighted sound in used. So sound levels are reported as dB (A). A hazardous sound source is defined as one with an overall sound pressure greater than 90 dB (A). Repeated prolonged exposure to loud noise, particularly in the frequency range of 2 - 6 k Hz causes first temporary, and later permanent hearing loss owing to the damage to the organ of Corti; with destruction of hair cells and eventually the auditory neurones. This is a common occupational problem not only in industry and in the armed forces but also in the home (e.g. from electric drills and sounders) in sport (in motor racing and in entertainment (pop stars, their audiences and disc jockeys). Serious noise hearing loss is almost wholly preventable by personal protection (ear muffs, ear plugs). Little treatment can be offered once deafness occurs. It has been suggested that excess noise affects the development and reading skills of children. It may also have an effect on psychiatric disorders. I am aware of some heart patients who get up early morning with angina due to use of loudspeakers in the early hours of the morning. I have been using sedatives and long acting antianginal drugs to prevent early morning insomnia and early morning angina. In the same way regular use of loud speakers cause severe noise pollution. Occupational noise pollution occurs predominantly on heavy industry, especially ship building and aerospace activities. Symptoms and signs There is a gradually increasing difficulty in hearing, usually in people of late, middle to elderly age leading in severe cases to considerable social handicap. In moderate cases there may be difficulty in speaking with groups of people whilst there is no problem in conversing with an individual at home. Words may be confused and wrong answers given to questions. Tinnitus (ringing or hissing sounds heard within the ear) may be the only symptom, the subject being unaware of any deafness. A disturbance in balance may also occur. Management of noise pollution There are a few more depressing or unrewarding conditions than those with permanent occupational hearing loss. Once the diagnosis of hearing loss is established, little can be done to alleviate matters. Withdrawal from further noise will preclude any worsening of the condition. Prevention Noise induced hearing loss is almost a wholly preventable disease and adequate preventive measures are available. Hearing conservation measures include identification of noise sources and control of exposure by protective devices. Although initial exposure to high noise levels may be unpleasant to the novice, people get used to the noise after a while. Disc Jockeys gradually turn up the volume to maintain a "good atmosphere". Soft synthetic rubber plugs can give up to 30 d B protection at higher frequencies while the ear muff can give up to 40 d protection over the critical 2-4 kHz frequency. Both devices must be closely fitted and worn consistently. |
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