Dr. Olawunmi Adaramoye is a medical doctor with Lagos University Teaching Hospital, LUTH, Idiaraba. She is a Senior Registrar in the Department of Obstetrics and Gynecology better known as O&G.
In this interview with Wilson Adekumola, she gives an insight into child birth through surgery. Excerpts:
What has been your experience in the delivery process of women?
Many pregnant women don’t like to go through surgery for the delivery of their babies. However, some women cannot but go through it. This could be because of their previous pregnancies. If for instance, they have had surgeries before it is not advisable for such women to have a vaginal birth.
There are women who are just averse to surgery. They think it is not a good thing, some even think it is a curse to go through CS. But we try to educate them and let them know that either by caesarean birth or vagina birth what is important is the safety of both mother and child.
What is the percentage of women who come for delivery that has to go through Caesarean Section (CS)?
Ideally, the percentage should be about 15% or less. The figures are higher here, I am not too sure of the figure. But we hope it could be lower. We might even plan vagina birth for some women and something goes wrong and then we have to intervene and she has a caesarean birth.
Is there any reason to be afraid of CS and what is the success rate?
Well, caesarean section is quite safe now. But there are so many factors that determine its outcome. The woman’s medical background plays a critical role in the safety of the surgery. The administration of anaesthesia on the woman; that is the process that helps to reduce pain when the procedure is going on is a key factor. The antibiotics used to prevent infection, and then the availability of blood for transfusion when required in case of much blood loss, all are critical factors in CS.
The availability of blood is very important. This applies more to women who have had previous surgeries. The more a woman goes through surgery the riskier it becomes. That is why women are given proper counsel before the process begins. They are asked to sign before the surgery is carried out, which is a show of their knowledge and their approval to have the surgery.
That is before the surgery. The process will be adequately explained to her, to put her mind at rest. We also discuss care after the surgery with her. With the care of the nurse, the skill of the doctor and other variables the surgery will be safe. You cannot say a woman has a safe delivery until all these processes are complete. Even for vagina birth, we will still go through these before we can look back and say it was a safe delivery.
Why do some die in the process?
Usually, there is no reason to lose any patient during surgery if all the variables are in order. But then there could be an adverse outcome which could be maternal or fetal death. This could be due to some primary risk condition or the present state of the woman. Some come too late to the hospital and it may be too late to help them. There are some who die barely hours or minutes before getting to where proper care could be taken. Some have been to the wrong place before getting to a standard hospital. We have had cases of people who go to traditional homes before coming to seek help at tertiary care centres or general hospitals. Some would go back home after counselling saying they would rather take the risk and undergo vagina birth. But then end up complicating the whole process or even dying.
In all, the success of surgery or vaginal birth depends on the presence of skilled medical personnel attending the delivery. Those attending to the pregnant woman should be able to identify complications and refer them appropriately or intervene as early as possible. This is very important.
The number of women who undergo CS has been on the increase lately, what are the factors that cause the increase?
Factors that act together for a woman to have a vaginal delivery are how adequate her birth canal is, the baby’s size and how it is lying and when labour starts the ability of the womb to contract and the baby gets delivered. When a woman has had surgery before is a factor that increases her chance of having another surgery. If the baby is excessively big or not well-positioned such a woman might have to go through surgery. Sometimes it could be that something is obscuring the birth canal. The placenta might be at the lower part and may obscure where the baby will pass through and when we notice this we will tell the woman your placenta is blocking the way; there is no way the baby can pass through the placenta without her bleeding and could lead to death.
There are times the baby does not accept the stress of labour well or maybe she is not progressing as expected, for whatever reason. Things might go wrong for some other reasons that will necessitate a caesarean section. The goal should always be the safety of the mother and baby.
Is there any precaution a woman can take to avert CS?
Close monitoring of a woman when pregnant and in labour will be helpful, however, children born by CS or vaginal birth are normal.
From your experience are there cases where surgery is slated but had to be suspended because the woman delivered by herself, what could be responsible for this?
There are cases like that. Sometimes the woman might have been in labour and for the baby’s sake or she is not progressing well in labour, she is then planned for emergency surgery. So, for those women, she can be checked again before the surgery commences. However, the whole essence of taking all these precautions is to ensure the safety of the baby and the mother. The caesarean section now is safe. There is no reason for the woman to be afraid if there are skilled personnel and other conditions required are met one can go ahead with the CS.
We learnt that preeclampsia (a condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and proteinuria.) is one of the complications of pregnancy. What is the cause and how can we prevent this?
We don’t really know why it happens. Studies are still going on to try to find the root cause but we just have theories for now. We know it is something that has to do with the placenta. Some say it is the abnormal implantation of the placenta when it is being formed. That is the closest possible explanation.
How do you avoid it? A woman ideally should have antenatal care. Antenatal is care given to a woman who is pregnant, with the aim to monitor her, try to identify any complications and things that could go wrong, timely intervene and ensure she has safe delivery and she is fine.
It is important for pregnant women to register early for antenatal care. There are interventions that should be given for pregnant women at risk of preeclampsia. We give some medication such as Aspirin which has been proven to be helpful in reducing the risk of preeclampsia in most women. Unfortunately, many women don’t register on time.
For those who require close monitoring, they will be told at their first visit. But when they come in too late; by the time the placenta has been implanted, we will not be able to institute necessary intervention. Some even come when they have preeclampsia already. In such a case, it may be too late to do anything to prevent it.
Hypertensive disorder of which preeclampsia is one, is a cause of maternal mortality that is, could lead to maternal death and we don’t want that. We advise that women should register early as soon as they notice they are pregnant (that is in their first trimester which is about 8 weeks) for women that have identifiable risk factors we could institute things that would assist them or could reduce these risks in them.
Cervical incompetence is a challenge to pregnancy. What is the cause and can a woman who undergoes cerclage (Cervical cerclage refers to a variety of procedures that use sutures or synthetic tape to reinforce the cervix during pregnancy in women with a history of a short cervix? The cervix is the lower part of the uterus that opens to the vagina) to correct such have vagina birth?
Yes, some will be allowed to have a vaginal birth. The cerclage will be removed at term for such women and allowed to fall into labour and deliver. But for women who have had surgery before, we may not remove it until after she has her surgery because the risk of going through labour or in some there might be the risk of rupture of her womb and we don’t want that happening.
We must realize that every woman will not have the same treatment. But when they see a specialist and are counselled the risk of losing the pregnancy or having still birth will be reduced. But when they don’t come early for antenatal, there is little that can be done to help. Cervical incompetence is more like a weakness of cervix. For some, it is because of previous interventions they have had. Some women even without anything the neck of the womb will just open and the baby will come out.
How many CS can a woman undergo in a lifetime?
I don’t think it is a good idea to put out a number, I won’t do that. The whole of medicine is more of individualized care. A woman should see a specialist for counselling. Generally, women should start seeing the doctor before pregnancy so they can be counselled appropriately and prepared for pregnancy well ahead of time.
There is something called pre-conceptional care that is, a care that is given to a woman of reproductive age. This is the care she has before pregnancy. During such care, the doctor looks into problem a woman could have or what could go wrong before pregnancy and tackle it by giving intervention to help her get pregnant and when she gets pregnant those things will not affect the pregnancy.
What is the God factor in the theatre of operation; are there any significant developments you can share?
Well, as for me, before I perform surgery after counselling a woman I will still ask her to pray. That goes a long way because everyone believes in God so God factor is primary. Basically, we cannot rule that out. All of us have our beliefs I don’t think it is right to downplay that. God factor is the key in the care of everyone or every woman. Your belief is important. We encourage praying and that has given them a strong support also. Anytime they ask me what should they do I tell them to pray that the surgery goes well. Good enough, it has helped them psychologically also. Some of them pray or sing even while the surgery is going on, God factor is very important.
What practical guide would you give pregnant women?
I will advise them to register early but preferably be seen before they get pregnant. A woman that is about getting married should start folic acid. Folic acid should be taken three months before she gets pregnant. They should eat right, that is important. Eating right means eating balanced diet. Those that have other medical condition should tell their doctor before they get pregnant so that care will be adequate and if she needs different specialist care it will be ensured. Women should start antenatal care immediately they missed their period for the second time. What they don’t understand they should ask their doctor they should not embark on self-medication.
What do you think of private hospitals that are ill-equipped that also carry out surgery?
The woman has the choice to make. I will advise that a woman should register in a standard hospital. Some private hospitals are also good and optimal.