The Caesarian Path

The Caesarian section has a fascinating, if largely apocryphal history. In all likelihood it was probably a procedure of last resort to save the unborn child when its mother was already dead or near death. That the famous Julius Caesar –like Shakespeare’s MacDuff- was ‘from his mother’s womb untimely ripped’ seems unlikely, however appealing the etymology. In fact, the name may well derive from the Latin verb ‘caedere’ –to cut- and hence the cognomen (originally a nickname). Pliny the Elder, according to Wikipedia, ‘refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, “cut from the womb” giving this as an explanation for the cognomen “Caesar” which was then carried by his descendants.’

At any rate, before the days of appropriate antisepsis let alone adequate analgesia, the survival rate for both the mother and baby would have been dismally low. And despite isolated reports of its use throughout recorded history in such diverse countries as India, China, and even Babylon, it was always a procedure of desperation. A triumph, as Samuel Johnson once wrote in another context, ‘of hope over experience.’

Unfortunately it has now become merely a triumph of experience -a default position assumed at what seems to be the slightest provocation. The fact that it is an operation that can be booked in advance under some circumstances, and therefore superimpose a degree of predictability on the scaffolding of the anticipated chaos of labor, has been seen as desirable in some quarters. And in fairness, there are those for whom labor carries undue risks for either mother or baby and its avoidance would be prudent if not lifesaving. The issue, I think, is in the interpretation of risk.

The other, perhaps more problematic concern, is that of choice. At least in a system of limited resources, or one in which the public purse is providing medical coverage, one could ask whether an elective Caesarian section for no other compelling obstetrical reason than patient choice, is a sustainable option. Or even a desirable one.

So, what about in a user-pay system? Is it merely a matter of supply and demand: build more hospitals to accommodate the needs and whims of those who can afford them? Is that an efficient use of their resources? Is it even an ethically defensible position? The matter has finally prompted the Brazilian government to wade in, as an article in the July 7/15 BBC news reports:

Of course, there are many reasons for elective Caesarian sections –some of which are the result of previous and unsuccessful attempts at vaginal delivery that necessitated Caesarian deliveries at that time. The desire to avoid a similar and frustrating trial of vaginal delivery is certainly understandable –if not always necessary- under those circumstances. These are the so-called elective repeat Caesarians. Others, as I indicated, are obstetrically mandated because of developing or pre-existing risk factors –once again, hard to argue against. There is an interesting and informative article that attempts to put the Canadian experience (2007-2011) into perspective –a classification system (the Robson Classification System) that can be used to make international comparisons in Caesarian section rates:

But getting back to the situation in Brazil. As the BBC article suggests, ‘Eighty-five per cent of all births in Brazilian private hospitals are caesareans and in public hospitals the figure is 45%’. And the new government rules ‘…oblige doctors to inform women about the risks and ask them to sign a consent form before performing a caesarean. Doctors will also have to justify why a caesarean was necessary. They will have to fill in a complete record of how the labour and birth developed and explain their actions.’ That they may not have been doing this routinely before is troubling, to say the least.

Also, ‘Each pregnant woman will now be assigned medical notes which record the history of her pregnancy, which she can take with her if she changes doctors.’ I would have thought this practice would have been universal and intuitive -without the need for a government fiat.

But, as worrisome as all of this seems, there is another, perhaps more subtle pressure on the woman to opt for a Caesarian delivery in Brazil: ‘Women who want to give birth naturally in a private hospital have reported finding all the beds are reserved for scheduled deliveries. There have been numerous reports of women going into labour without a caesarean scheduled and being forced to travel from hospital to hospital in search of a bed.’ And as Pedro Octavio de Britto Pereira, an obstetrician and professor at the Federal University of Rio de Janeiro, said in an interview with BBC Brazil last year, “The best way to guarantee yourself a bed in a good hospital is to book a caesarean.”

Of course the blame does not wholly fall on the medical profession there –nor even, perhaps, on their preferred management strategies in pregnancy. ‘Researchers say many women also see caesareans as more civilized and modern, and natural birth as primitive, ugly and inconvenient. In Brazil’s body-conscious culture, where there is little information given about childbirth, there is also huge concern that natural birth can make women sexually unattractive.’

It is always dangerous to judge another country and another culture by our own standards. Our own sensibilities. And yet the risks are transnational and universal. They do not disappear simply because of a differing national mythos. Surgery is surgery; complications are inevitable co-travellers with it in spite of all precautions, and good intentions -the hidden, unwanted occupants of every operating theatre. And while we may never be able to stem the tide of primary elective Caesarians –even education on the subject has challenges overcoming fear or fashion- we may be able to convince women that their choice does not come without baggage. Unintended risks. To journey through a new geography, it helps to have thought about it first; planned the route to avoid unnecessary problems; consulted a knowledgeable guide –someone who will travel along with you. And remember what Seneca wrote: ‘Be wary of the man who urges an action in which he himself incurs no risk’.


The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination:  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’

The surgical option

I’m not opposed to the surgical option, it’s just that there are many roads to Rome, and sometimes an indirect route is more satisfying. Don’t misunderstand; I’m an Ob/Gyn surgeon. It’s what I do, but not to the exclusion of everything else. There are times when surgery is necessary, life-saving, difficult to avoid. There are few ethical or acceptable options available in the case of a ruptured tubal pregnancy, for example. The patient presents in the emergency department bleeding internally, often in shock, sometimes requiring an immediate blood transfusion. Things do not go favourably for her if there is any delay in stopping the bleeding -operating, in other words.

On the other hand, fibroids -benign uterine muscle growths- present a different spectrum of choices. In the past -admittedly with fewer therapeutic tools at their disposal- surgery was the favored option if they were at all symptomatic. Medications meant to slow their growth or decrease vaginal bleeding, were fraught with side effects and seldom satisfactorily resolved the problem. Pain, anemia, or increasing symptoms from the ever-expanding tumours were often the only alternatives to surgery. And because there was a long-honoured tradition of removal, surgery was expected, maybe even desired. If all the female members of your family had hysterectomies, you might be inclined to view yours as inevitable, even if undesirable.

But there is a profound difference between life-saving surgery, and elective surgery. In the latter, options become important. The ability, and knowledge to be able to choose solutions, to see if they will work or even lessen the burden of the condition is an important step in problem solving. Moving from a simple attempt at life style or diet modification for, say, painful periods, to medications of increasing sophistication -and cost- to a hormone-containing intrauterine device, to laparoscopic investigation of the pain in the operating theatre might be a sensible route to follow. Or at least to know about.

For fibroids causing heavy menstrual bleeding -they don’t all do this, by the way- the use of antiprostaglandin medications (ibuprofen being the most widely known of these) to attempt to decrease the bleeding, maybe followed , if necessary, by the progesterone-containing intrauterine device if appropriate, and then if that fails, blocking off the blood supply to the artery that is responsible for providing nutrients to the growing fibroid (embolization)- all of these could be considered before resorting surgery.

Clearly there are features of each problem that might suggest other creative adaptations, although my point is not that they should be chosen, but rather acknowledged. We all have a right to determine our own unique paths through the thorns of life, and we should be given enough background and knowledge to allow us to make informed choices -choices whose logic and consequences we can understand. In  non-life threatening situations we may make a choice we regret, but if there are a series of progressively more serious options, we would probably be more accepting of their side-effects than if we had been forced into the treatment before we were ready.

Yes, I am a surgeon, and if surgery were the correct choice all along, then you will work your way along the path and eventually realize that for yourself. And come to accept it. It’s not my place to force you there. I am neither your father nor your boss. I do not possess absolute knowledge of the inevitable consequences of your actions. I see myself as merely a guide through a dark and often confusing forest, pointing out each fork in the road and offering suggestions that years of experience have taught me about the smoother trail.

It is, I hope, what doctors do.