17 July 2017

Rwanda: C-Section - What You Should Know About This Birth Option

Every expectant woman always looks forward to delivering a healthy baby. But no matter the circumstances, medics say one cannot rule out the possibility of cesarean section, which they advise should be only recommended by a gynecologist.

When and why C-section

According to Rachna Pande, an internal medicine specialist, Caesarean section or C-section is normally done in cases of prolonged labour or in cases where there is a perceived risk to the baby or mother.

She notes that these include a short pelvis, uncontrolled hypertension in a mother, foetal distress, and twin pregnancy, among others.

For it to be done, Emmanuel Ssemwanga, a gynecologist/obstetrician at La Croix Du Sud Hospital in Kigali, says there must be a clear indication explaining how and why it should be carried out.

He points out that one of the indications for a C-section is when the baby is malpositioned.

Ssemwanga notes that the baby's head is supposed to be facing down towards the pelvis, but when it's transverse (lying sideways across the tummy) or is seated in the womb, or in a position to the extent that it's disproportional to the maternal pelvis, C -section is the only option in order to save the lives of the mother and baby.

He, however, says even in cases where C-section has been done, a mother can be allowed to try normal birth.

"You might find that a woman has had a C-section more than once, and if the previous indication was not that the baby was transverse or was in danger, she can go for normal delivery as it's advisable," he says.

Ssemwanga says in cases where a mother has two or more scars, they must go through C-section again.

He explains that this is because when surgery is done, the gynecologist normally applies the surgical blade on the uterus, and once they come again for another delievery, they go through the same scar.

Ssemwanga adds that this reduces the thickness of the uterine muscles making it thin and fragile. He says if a woman who has these scars is allowed to deliver normally, the contractions can make the site (scar) rupture and can cause the baby to go to the abdomen which can result in its death.

He says it also poses a risk to the mother as well, as it might lead to over bleeding which could lead to death.

"Due to the likely complications, especially uterus rapture, this is why C-section is recommended for women who went through surgery for the first delivery or those having more than one scar," says Ssemwanga.

After C-section, it is always advisable to rest for more than six months to allow the wound to heal well.

"One should avoid getting pregnant for at least six to twelve months after a C-section. A subsequent delivery can be normal or another C-section may be needed, depending on the underlying indication," says Pande.

Although each c-section enhances the post operative and risks and late sequel, it can be done more than two times depending on the advice from the physician. After a c-section, women are advised to adopt some contraception and avoid pregnancy.

According to Ssemwanga, it all depends on the assessment of the patient.

"The toleration can go up to four times, but bilateral obligation must be done. It will again depend on the circumstances. For instance, if one has four scars and from those scars, she lost all or two kids, then we normally consider giving her another chance to try," he says.

To some extent, Ssemwanga also notes that if the mother still wants to get a fifth pregnancy due the loss of other babies, counselling is required before another chance can be given.

However, he says when this has to happen, close monitoring is required starting from antenatal care to the time of delivery, adding that delivery can now be done at thirty four weeks to avoid any complications that might occur.

Further, Ssemwanga adds that because of massive adhesions (pains while walking, bending or doing other activities), someone who has gone through the surgery during delivery tends to experience such pains.

Why normal delivery is better

Iba Mayale, a gynecologist at Doctors Plaza Clinic in Kimironko, Kigali, says every surgery is risky, and the reason there must be a clear indication for one to be done.

"This is because sometimes anything can happen accidentally. And most of the times, due to complications that might occur unknowingly, that's why there must be indication as to why surgery has been opted for," he says, emphasising that all other options must be considered first before surgery.

Joseph Muganda, a Kigali-based gynecologist, says the reason some women opt for C-section is because they think it has no disadvantages as one doesn't have to go through labour pains.

He notes that what they need to know is that if a woman delivers normally through the birth canal, it carries more advantages to both the baby and the mother, compared to C-section.

"C-section is comfortable in a way as the woman does not suffer labour pains. But it does not provide antibodies acquired by the baby born through the vagina. With a C-section, a woman is exposed to all risks of surgery like post C-section bleeding, infection, pain and many others," he says.

Muganda adds that adhesions and hernia can occur at the operation site later as a sequel to c-section, while, on the other hand, with a vaginal delivery recovery is faster.

Pande also points out that as the baby passes out from the birth canal, extra fluid is squeezed out from his lungs, thus preventing risk of aspiration and respiratory distress for the baby.

She notes that natural delivery is always better than C-section as it is the natural method of giving birth and the body is well equipped for it.

For C-section, she says women should only go for it if they are advised by their obstetricians due to some clear indications.

Mayale notes that even though checkups are done during the whole period of pregnancy, there are always cases where C-section has to be done.

"Some complications can be worked on during pregnancy, but where nothing can be done, close monitoring is important because it ensures safe delivery," he adds.

In case of maternal request

Caesarean delivery on maternal request is birth requested by the pregnant woman without any medical reason.

For those women who choose to have a C-section even if they have no medical need, Semwanga says as an obstetrician, first they need to be counseled and advised about the implications.

"After a session of counseling, if a woman still wants to go for it, the doctors are allowed to do so as it's a patient's request. But for any surgery, there must be a clear indication; if not, it's not ideal to go for it."

EXPERTS SHARE TIPS

Joseph Mucumbisti, pediatrician and president of Rwanda Heart Foundation

After delivery through C-setion, it's important to check if the baby has no breathing problems. On the other hand, the mother needs enough rest and they should avoid strenuous exercises. However, walking is important as the movement speeds up the process of healing.

Daniel Gahungu, general practitioner

After C-section, giving the mother painkillers such as paracetamol and diclofenac is important in relieving the pain. Depending on the surgical procedure, the surgeon can suggest feeding the patient with soft meals and drinks after six hours.

Claudine Uwajeneza, final year medical student at University of Rwanda

After a surgical procedure one is supposed to avoid lifting heavy weights, and excessive bending downwards for at least three months. This is to avoid urinary problems that might occur. It also allows faster healing.

Raymond Awazi, pediatrician

Sometimes babies born through caesarean tend to have breathing problems. To prevent this developing into a bigger problem or complication, one of the best ways to treat this is to prevent dehydration, which can be done by breast feeding the baby exclusively.

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