This piece is a work of fiction inspired by non-fiction research.
A 27-year-old woman walks into the door of my practice. She is completely healthy but wants her first baby to be delivered by a C-section. I have never encountered this situation before and many questions start running through my head: Why doesn’t she want a vaginal birth? How informed is she about primary elective C-sections? Is she making the right decision for her and her baby? The patient interrupts my train of thought by repeating her question: “I would like a C-section, can you perform one on me?” Curiosity takes over, and I ask her: “Why do you want a C-section?” She states that she doesn’t want to deal with and is afraid of the horrendous pain of vaginal delivery. Without considering any evidence, my initial thought is to agree because I would be adhering to the patient’s preferences. However, before I utter a word, I remember that I am taking care of two patients, not just one. I have to consider the effects that this operation would have on the baby, so I say to the 27-year-old: “I’ll need some time to do more research to better inform you about the decision you are making.” The patient agrees to come back the next day so that I have time to find expert opinions and evidence on this topic.
I call Dr. Jean Clerk, a colleague of mine, to provide me with her evidence-based opinions on primary elective C-sections. She tells me that moms who choose to have a C-section are more than twice as likely to have complications in surgery than those who have vaginal births or unplanned C-sections. Feeling distraught and perplexed, I drop my coffee mug on the floor and watched it shatter like detritus. It has become so commonplace to have surgeries for everything nowadays that I did not even consider that the surgery itself may have adverse effects on a healthy patient. In fact, part of the reason why C-sections have been increasing over the past 30 years is because surgeries have become commonplace.
Dr. Clerk further emphasizes that newborns are twice as likely to die in the first month if they are delivered by surgery over vaginal birth. In terms of the complications for the newborn, there aren’t many long-lasting ones. The main short-term complication that arises is Transient Tachypnea of the newborn, which makes sense because in a cesarean, there is no vaginal pressure to squeeze out the fluid in the baby’s lungs.
Based on the detriments Dr. Clerk tells me about the procedure, the complications to the baby are not that serious or life-threatening. However, because of the potentially devastating effects on the mom due to complications in surgery, I thought it might be best if I referred this 27-year-old to another OB/Gyn with more experience in this area. However, before I refer this patient to my colleague, I want to see whether or not there are any benefits of conducting a primary elective cesarean section, so I What’sApp Dr. Jenny Jenkins, who I met two years ago during my residency. At that time, she introduced me to a doctor who performs at least two primary elective cesareans every day.
Dr. Jenny tells me that a benefit of opting for a cesarean is that it decreases the likelihood of developing urinary incontinence. This, of course, is a serious issue but is present in many older woman, not just people who undergo vaginal deliveries, so I say to Dr. Jenkins, “This isn’t a life-threatening issue. Are there any other benefits of conducting a C-section?” She then adds that cesareans reduce the likelihood of haemorrhoids, which also aren’t dangerous and I ask, “Is there anything else I should consider?” And then Dr. Jenkins assumes that I, like many others, am contributing to the rise in cesarean deliveries: “It would save you so much time! You should take the patient!” With that statement, I realize that Dr. Jenkins is trying really hard to find benefits of the operation that are not really there.
The last step I need to take before my patient’s appointment tomorrow is to consult the committee on obstetric practice. Their evidence is in line with my sources, so I am convinced that this committee would lead me in the right direction. Since my patient is a healthy woman and the only reason she is electing to get a cesarean is because she does not want to go through the pain of vaginal birth, the committee recommends that I tell my patient to have a vaginal birth. At first, I am enthralled to hear that the committee agrees that the risks outweigh any benefits of elective cesareans. Then I remember that my patient was very adamant about pursuing an elective cesarean.
During our appointment the next day, I inform the patient about all the risks associated with her decision and that a vaginal birth would be much safer for her. As I expected, she does not waver; she wants a C-section. At this point, I rely on the practicalist approach article I read in medical school. I had done everything that I could as a physician to explain the benefits, detriments, and alternatives to this patient. I had not only taken medical utility into account by weighing the risk/benefit ratio of this operation for the mom and baby, but I had also considered this patient’s autonomy when making this decision. She may have not told me all the reasons why she does not want a vaginal birth, and I wouldn’t assume anything. Since she was still opposed to a vaginal birth after consultation, there is not much else I could do to sway her opinion.
My duty as a physician is to do no harm. If I agree to conduct a cesarean on her, there is a higher likelihood that it will result in harm than if I were to do a vaginal delivery. However, if I refer her to other physicians with a lot of experience in this area, they may ignore the risks because they have already completed so many deliveries in this manner.
Ultimately, my goal is to give my patients the care that is best for them. My coffee mugs can break but I will never let that happen to my patients. If this means that I have to send this patient to a psychiatrist so that she can discuss through her fear of having a vaginal birth or the lack of control she may feel, then I will do it, but I will not perform a primary elective cesarean section on her.