Childbirth is a natural process, but when things go wrong it can have terrible consequences for expectant moms and their children, even in this day and age! In olden days, maternal deaths were very common, and quite unremarkable. Women used to give birth to numerous children, though all of them did not survive due to birth complications. Therefore, losing say eight children out of 18 was considered quite all right. Midwives delivered babies and quite a few of them were not trained, which often resulted in dire consequences for mothers. Many of these deaths were intra uterine and were quite unavoidable because Caesarean operations were not an option at that time.

With the advancement in medical sciences, Caesarean operations, popularly called C sections, became instrumental in saving the lives of expectant mothers and their children. The idea of C sections probably originated from ancient Rome, where according to a law, mothers who died during childbirth with babies in their wombs were to be buried only after the baby had been extracted, to make it possible for the mother and child to be buried separately. To achieve this end, after the death of mother, her abdomen would be cut open to extract the child. If the child's life was saved that way well and good; otherwise, she/he would be buried in a separate grave, as demanded by their religion. 'Caesarean', is probably derived from the Latin word caedere, which means to cut, and hence the name. This law probably gave birth to the myth that the great Roman emperor, Julius Caesar, was born as a result of an operation performed on his mother, Aurelia Cotta, who was cut open to save the child from dying along with his mother. This premise is not correct since Aurelia Cotta served as an advisor to Julius Caesar in the initial years of reign and women did not survive C sections in those days. C section was not the safe procedure it has become nowadays, though there were incidences of operations performed on women when it seemed that normal birth would fail. Mothers, unfortunately, never survived such operations.

The first caesarean section of modern times is attributed to a Swiss, Jacob Nufer, who operated on his wife after she had been in labour for several days, in 1500 AD. The authenticity of this story is doubtful, because Mrs Nufer subsequently had five successful normal deliveries!

After Nufer, the first caesarean sections with survival of the mother were performed in Ireland by Mary Donally in 1738; in England by Dr James Barlow in 1793; and in America by Dr John Richmond in 1827.

The 'first' in the British Empire outside the British Isles was performed in South Africa before 1821 by James Miranda Barry (an Edinburgh graduate who masqueraded successfully as a man from 1809 until her death in 1865).

Antibiotics, anaesthetics and new surgical methods have made C sections almost foolproof, but women were not always so lucky. In the olden days, many women were subjected to C sections while still alive, without the benefit of anaesthetics because their powerful husbands wanted the heirs to be born alive. No wonder women in such cases always succumbed to death after their terrible ordeal. With time, new methods were devised to save the lives of women and their children and from 16th Century onwards, significant scientific advances resulted in making C sections relatively safer for both the mother and child.

Nowadays, Caesarean operations or C sections are the commonest operations that are performed on women. A Caesarean delivery is a procedure used to deliver a baby surgically. Like all other operations, C sections carry risks but save lives, too. The incidence of Caesarean deliveries is on the rise these days. More and more women across the world are opting for Caesarean deliveries, and in Pakistan the trend is catching on. You! got a chance to speak to Dr Samrina Hashmi, President Pakistan Medical Association, Sindh about the pros and cons of Caesarean operations...

Dr Samrina Hashmi is a consultant gynaecologist, who obtained her MBBS from DOW Medical College in 1985. In 1987, Dr Samrina did her MCPS from the College of Physicians and Surgeons, Karachi. She  passed MRCOG in 1995 from Royal College of Obstetricians and Gynaecologists, London after training in Ireland and UK. RCOG awarded her FRCOG in 2010. She specialises in infertility and high risk pregnancies.

According to Dr Samrina, the incidence of C sections has increased due to a number of reasons, one of which is that doctors practise in many places. "A clinic here, a clinic there, so obviously they want to finish their work before leaving a place! They have made themselves unnecessarily busy. Instead of doing multiple clinics, they should practise in one place."

However, not all can be blamed on the doctors. Dr Samrina also points out that moms-to-be are also responsible. "Laziness is a major factor. Our women have become aram pasand (comfort loving). They don't move a finger in their houses! They should do the house work themselves and get rid of maids. Instead of lying on bed the whole day, they should walk and exercise to make their bones strong. In olden times, women used to be hard working. However, lifestyles have changed and when money comes, luxuries follow, which has made women indolent."

Why C Section

"C sections are performed when there are complications related to 'passage and passenger'. Passage problem means that the pelvis is smaller than it should be as compared to the size of the baby. This causes distress to the baby while giving birth. An android (narrow) pelvis can cause damage to the shape of the head of the baby. The passenger problems relate to the size of the baby and some other complications." shares Dr Samrina.

"Then there are several other factors pertaining to maternal health. If the mother is a gestational diabetic, there is risk of death for the baby. Blood pressure and high cholesterol also make C section obligatory. Then there are the dietary habits of the patient. You see, the fast food culture has created a lot of problems. I say, stop eating biryanis and junk food: it only leads to obesity and hypertension."

Many people think that C sections are risky for expectant mothers, but Dr Samrina denies this. "C section is almost entirely foolproof. There is hardly any difference between the lower segment C section and a normal delivery. Even the recovery period is almost the same. Women need stitches in normal deliveries, too, and these stitches are so painful that they are unable to sit up. However, in lower segment incision, patients go home the second day."

"If the labour is prolonged, C section should be done. There is no point in bearing all that pain and what women must keep in mind is that it is bad for the baby, too. Every time they push, the head hits the pelvis, and if it goes on for a longer period of time, it may have adverse impact on the baby. Then, if the baby is precious, which means that it has been conceived after a long period, it is not sensible to take risk. Such moms should go for elective C section," explains Dr Samrina.

Does this mean that C section is so desirable and risk free that women should not go for normal delivery? "Of course not! What I mean is that women should build their strength by eating proper and doing exercises. Their bones, muscles and ligaments should be strong enough to give birth, but if there is a problem there is no point in trying for a normal delivery. In rural areas, C sections are very rare because women work hard. Here, in cities, women go for elective C sections just to escape labour pain, which is not right unless the labour is prolonged," clarifies Dr Samrina.

One thing that Dr Samrina points out is indeed dismal. "In our rural areas, the healthcare units are not properly run. Mothers die due to complications as the option of C section is not available in most places. Children die in the womb and such intra uterine deaths are injurious to mothers' health as well. Sometimes they develop gangrene in the uterus and sometime the uterus bursts. A lot of work needs to be done in rural areas to prevent such happenings."

C sections are expensive, yet many women opt for them. Doctors also prefer to do Caesareans because they earn a lot more as compared to a normal delivery. Dr Samrina thinks it is a wrong practice for doctors to charge exorbitant sums for doing C sections. "It is made costly by doctors when it shouldn't be. As for myself and many of my friends, we charge more for normal deliveries and less for C sections, because C section only takes about 20 minutes. One-third of the surgeon's fees go to the anaesthetist. The rest of the expense i.e., the cost of sutures, antibiotics etc is the same. Normal birth, on the other hand, requires more time and effort from the doctors. In fact, doctors are supposed to be called only when complications set in. The delivery should be done by midwives, but trained midwifery units are unfortunately scarce."

So what are the risks to the mothers who undergo C sections? "None! Except for excessive bleeding. If the C section is elective and planned beforehand, every thing is monitored, date and time is set and a good, clean incision prevents any risk. Previously, longitudinal incisions used to create issues. Incisional hernias were very common. Women could not have more than three babies. Scar had to be watched during surgery, which was another reason why doctors did not go for normal birth in case the first birth had required C section, but the lower segment incision has revolutionised C sections. I recently delivered the eighth child of a mother who had all her children with caesarean operations," says Dr Samrina.

The recovery period for women who undergo C section and normal birth is not different. "I was on job 29 days after I had my C section. All this talk about bed rest is just nonsense. It is just the laziness that compels women to rest for 40 days or six months in case of C sections," she shares.

"Expectant moms should stay healthy, take lots of milk and more importantly should not gain more than 10 kg during pregnancy. A baby weighing eight pounds or more is difficult to give birth to. The average weight of babies in India and Pakistan is 2.6 kilograms. So don't gain too much weight. Don't go for prolonged labour. An old saying is that a woman should not see two suns, once she is in labour," advises Dr. Samrina.

Normal birth is preferable, because it is a natural process, but when there are complications, perhaps women should decide to go for elective C sections. Not only would it save them from prolonged labour, it would also enable the baby to be born without distress.