The Myth of the Unnecessary Cesarean
nec·es·sar·y: being essential, indispensable, or requisite
One thing I have learned by being active in the obstetrics and birthing blogosphere is that there are a whole lot of people out there that think that most cesarean deliveries are unnecessary. While most of them will admit that some cesareans are medically required, its pretty rare that the ones that have had a cesarean looks at their cesarean that way.
A popular term bandied about is “Unnecesarean”, a catchy little phrase that implies the underlying belief that most cesareans are unnecessary. Frequently, commenters state that they had a cesarean that they didn’t want, and that at some point later in their life someone let them in on the secret that their cesarean wasn’t really necessary, and this is completely accepted as fact. In some cases, people believe that they were robbed of the vaginal birth they were destined to have, or even that they were somehow raped by the their physician.
Frankly, I am tired of it.
Anyone that has followed my writing knows that I am not a big fan of cesareans, and believe that a fair number of the cesareans we do might be avoided. I have discussed the relationship between sensitivity and specificity for identifying abnormal labor and heart rate tracings, and how where we put our thresholds will effect how many cesareans we do. I have discussed how the Friedman curve is too strict, and that to hold women to this curve is to place the label of abnormal on a huge number of women who area laboring normally, potentially leading to avoidable cesareans. I have even talked about how VBAC access needs to improve, and that we should be encouraging more women to attempt VBAC.
That all being said, I have never seen an unnecessary cesarean delivery(*). In fact, no one has.
What some members of the blogosphere likes to call “unnecessary” cesareans are misnamed. They are misnamed because the word necessary implies something that cannot be applied to this situation. As was noted in the introduction, necessary means something that is essential, indispensable, or requisite. Specifically to cesarean, necessary would imply that the procedure is required in order to have a favorable outcome for the fetus or mother. The problem with the term is that we don’t know what would have happened if we hadn’t done the cesarean, and as such we have no idea if the cesarean was necessary. If fact, the true necessity of any cesarean can never be determined, as we will never know what the outcome of the alternative decision would have been. As such, it is completely unjustified to label any particular cesarean unnecessary, and with apology to Jill, the term “Unnecesarean” isn’t fair.
So assuming that there are some cesareans going on that might have been avoided, how should we talk about them? How about using the correct terminology: indicated vs unindicated. When something is indicated, it means that given the current state of practice and knowledge, the proposed procedure should be done. Unindicated means that it shouldn’t be done. Unlike “necessary”, these terms can be used prospectively. They do not claim that the choice they lead to is absolutely the correct choice – they only mean that with the best information we have at the time, it is the most appropriate course of action.
So here are indications for cesarean:
- nonreasurring fetal heart rate tracing remote from delivery. In most cases, this means a NICHD Category III tracing that cannot be resolved through medical treatment or expedious vaginal delivery.
- An elective repeat cesarean in a woman who after appropriate counseling chooses one.
- Arrest of dilatation
- Arrest of descent
- Previous uterine surgery with high risk of uterine rupture
- Maternal pelvic reconstructive surgery with a desire to preserve the repair
- Malpresentation of a singleton pregnancy
- Malpresentation of a subsequent baby in a multiple pregnancy, when breech delivery of the second twin is not feasible.
- Maternal request
Are these indications absolute? Of course not. They just mean that when these indications are present, we think that a cesarean in in the best interest of mother and/or baby. Does that mean that to not do the cesarean would absolutely injure either party? No. It just means that the risk/benefit of pursuing vaginal delivery is no longer in favor of it, to the best of our knowledge.
So lets not call cesareans unnecessary. Lets just say that maybe a particular cesarean was not indicated. We can all have a great intellectual discussion about what it means to truly have an arrest of dilatation, or whether or not a breech singleton can be safely delivered vaginally. We can argue about that risk/benefit analysis, and even retrospectively argue that the risk/benefit of a particular situation was prospectively misinterpreted. We should pursue these arguments, because dialogue helps us to develop our knowledge. But arguing that a cesarean was unnecessary because one believes that they were going to go on to have a healthy vaginal delivery without it is fallacious. It implies something that just isn’t true, and is ultimately unfair to all parties involved.
* At least not by my definition of the word unnecessary. As the commenters have pointed out, it depends on how you use the word (added 7/28/10)