Cesarean Section – CS – is not a Death Sentence

One of the challenges of medical profession is determining how, when, and the extent of adequate information to give to patients about their health to aid them make an informed decision. One time, it is a smooth ride and you are able to relay information to the patient and he/she makes the right decision. At other times, you find yourself going overboard, even persuading a patient to make the right decision.

In a system like ours where religion is the chief source of influence on patients especially pregnant women, it is always a difficult task to purge clients off their religious ideation.
Some of this religious beliefs has robbed women off their health which sometimes results in death of either the pregnant mother or child or even both. Sometimes, it may leave the mother or child in serious lifelong morbidity.

Few days ago at the facility where I work, I was meant to convince one of my patients’ consent to an “elective cesarean section” which she had already declined from the beginning of her pregnancy. Note that this woman already had three previous surgical deliveries. From the onset of her antenatal, I tried to explain to her the implication of the path she was planning to take. In her defense, she told me that her previous surgeries was done because she was outside Nigeria and away from her “Church General Overseer”. According to her, now that she is in Nigeria where the power is, I should sit and watch how God manifests. In her words, there are powerful testimonies from her Church even bigger than what she is about to do.

I referred her to a senior doctor colleague but all efforts proved abortive. She decided to go into labour to prove us wrong. Two days after labouring on her own, her husband persuaded her to consent to an emergency CS. Sadly, the baby was severely asphyxiated and eventually died. One of the implications of asphyxiation is that, even if the baby survives, the baby is likely going to be raised as an “abnormal” child with cerebral palsy. This is because lack of oxygen to the brain causes an irreversible damage to the immature brain of the child.

No doctor would want to undergo the stress of getting a patient under anesthesia for any type of surgery if it isn’t absolutely necessary and important. In cases of two previous successive cesarean section, the woman is medically advised to deliver via surgery, only to minimize the risk of uterine rupture that can lead to fetal death, severe bleeding or even the death of the mother.

Another experience of a colleague from another facility few months ago, also left the family in deep loss. The 34 year old primigravida with estimated gestational age (EGA) of 38weeks (and her 40 year old husband) came in after almost a day of contraction and drainage of liquor at home. After stabilizing her, she was dilating but contraction stopped and as the hours go by, the fetal heart rate (FHR) stated to drop significantly, signifying that the baby was in distress and needed to come out as soon as possible via the fastest route available to save its life.

However, on counselling the couple about the state of things and the possibility of an “emergency CS”, they refused vehemently. But they didn’t just decide to refuse, they refused because the husband said he had called “his Pastor who was also a doctor” and the pastor told them to wait for the expected delivery date (EDD) the obstetric ultrasound scan (USS) result gave them – which was in 5days time. 5 DAYS FROM ACTIVE DRAINING OF LIQUOR, CERVICAL DILATATION (up to 8cm) & DROPPING FHR! All efforts to speak with the wife and husband separately and together to see reasoning proved abortive, as she stood on what her pastor said, that she will trust God and wait till 29th before she consent to the CS.

EDD by USS is not the exact date of delivery but usually an “estimated” date within a range of + or – 2 weeks from the date given. This means delivery of a healthy baby can occur anytime between 2 weeks before or after the date reported by the ultrasound scan.

After exhausting all the options of counselling, documenting extensively on all risks associated (neonatal sepsis, chorioamnionitis, IUFD etc.), escalating to senior experts, speaking with the “pastor/doctor” on phone (who also insisted that it wasn’t yet the EDD as reported by the USS, hence no CS, but to keep waiting) and even referral to secondary/tertiary hospitals, these couple refused intervention by CS or even to leave the hospital and go elsewhere (on account of the hospital been affiliated with their Health maintenance organization (HMO) and they can’t go where they’ll have to pay out of their pocket for care), while FHR continued to drop dangerously.

Eventually, after several attempts at failed augmentation since patients refused to consent to CS, hours of loss time, the couple signed a discharge-against-medical-advice (DAMA) form and waited on their “pastor/doctor” to take them to his own facility, where she will deliver “normally” on her own by Gods grace – apparently, the pastor/doctor had a community facility. On a follow-up call to the couple the following day, the husband said they eventually had to do the CS early in the morning because his wife said “she wasn’t feeling anything anymore” and had stopped draining liquor, but they brought out an already dead baby. Only if they had listened and done the CS earlier, their baby would have been alive.

Prevention is better than cure. Cesarean section is not a death sentence. Cesarean section doesn’t cause obesity and big tummy. Planned cesarean section saves the mother and the child. For every one big testimony in Church trying to make mockery of medical practice, 10 unsaid ones didn’t end well. Be wise.

The role of religious and traditional leaders in medicine cannot be ignored. However, proper orientation and education on maternal and child healthcare issues and how their decisions or influence affect the outcomes would go a long way. Also, encouraging them to speak about and pray for wives/expectant mothers that either CS or Vaginal delivery will go well, while helping to raise the money for it among the congregation would also help ameliorate a lot of stigmatization and fears attached to CS as a normal means of child delivery. Finally, for physicians, continuous adequate communication to patients and extensive documentation can be life saving.

Editor’s note:

This article was contributed to by Dr. Ifunanya Igweze and Dr. D. O., both medical officers of facilities in Lagos state, Nigeria.