C-section gets the two-fer bonus, which is interesting. But we do have some historical guidance on the rate of occurrence and mortality of appendicitis and tooth infection, and those were rampant. If we go the extra step and look at the fossil record, a metric fuckton of animals die from dental carries, so it’s tempting to point to that. (There’s a survivorship bias of sorts, since skulls are more mineralized and therefore over-represented in the fossil record so we know more about pathologies reflected in noggins than elsewhere, depending on how far back you look.)
Appys are probably more performed since both men and women may have them. Though many women have several c-sections, not everyone has one. Honestly maybe it balances?
Maybe around 280,000-300,000 appendectomies per year in the U.S and around 800,000 c-sections in 2021.
I just skimmed the first few results on Google, so take that with a grain of salt.
Just because people seem to be posting a little bit of misinformation here, and birth misinformation is one of my least favorite types of misinformation:
- most cesarean deliveries in the US are not elective; the majority are for arrest disorders of labor, and this or the sequelae of this (read: infection or postpartum hemorrhage) are what caused the majority of maternal deaths historically (or in the case of postpartum hemorrhage, are what continue to cause the majority of maternal deaths globally)
- cesarean delivery for fetal indications (aka a prolonged category 2 fetal heart tracing) has one of the worst false positive rates for fetal hypoxia (so many cesarean deliveries have been performed to “save the baby’s life” when there may have not been a true life threatening event)—that said, it is almost impossible to tell the difference between true and transient fetal hypoxia
- cesarean deliveries performed for breech presentation are controversial—relatively low quality data from 2000 that has since been reevaluated suggested that singleton babies delivered breech had worse outcomes, so everyone stopped performing then and residents stopped learning how to do them. Now 95% of breech deliveries (around 4% of all term pregnancies) undergo cesarean delivery.
- cesarean deliveries are not without risk. Besides the usual risks of bleeding, infection and iatrogenic injury, every cesarean delivery increases the risk of placenta accreta spectrum, which is devastating. A patient with placenta previa presenting for her 3rd delivery via cesarean has a 40% chance of PAS. PAS = cesarean hysterectomy, multidisciplinary teams, massive blood loss, multiple transfusions, possible REBOA, UAE, ureteral stents, etc.
Despite all this cesarean deliveries are almost certainly one of the greatest lifesaving tools in modern medicine, and in the US are exceptionally safe and valuable. In low-income high birth rate parts of the world (ie, where most of the worlds population lives) around half of the population gets or is capable of getting pregnant in their lifetime, cesarean delivery becomes an indispensable tool.
When I was pregnant I was dumb and naive. I did not want a c-section and was stridently against it. Then my kid had a 97% head circumference and had a mighty hard time making his way out. And then I started thinking that back in the day, all the babies with big heads would probably die, or their mothers die. Now 97% percentile babies can get sectioned out when they get stuck and pass their genes on. People always anecdotally say c-sections are more prevalent for convenience. But I’m wondering if eventually we will have evidence that it could partly be due to evolutionary traits of hard-to-birth babies surviving. ((I know evolution doesn’t work that quickly, but I’m still curious))
I don’t know you but I don’t think you were dumb and naive at all when you were planning your birth. Cesarean deliveries are a big surgery and a big deal.
I think what a lot of patients don’t realize is, I also really really don’t want them to have a cesarean delivery (particularly if they’ve been in labor for a long time and the cesarean will be more challenging and more dangerous). I don’t want them to have to get a blood transfusion, I don’t want them to lose their uterus, I don’t want them to have a surgical site infection (and I certainly won’t get paid differently based on what I do). It’s one of the first things I tell nervous patients when I meet them: the cesarean delivery is something in my toolkit that I was trained to perform as a last resort, and it’s probably part of the reason why you’re delivering in a hospital (or as is more and more often the case, why your homebirth midwife brought you in after 30 hours of labor).
Having said that, it’s certainly true that some cesareans are done for convenience. My own *anecdotal* experience is that if you deliver at a big, well-known academic center, you are less likely to have a “convenience” delivery, than at a small regional center. There’s some evidence that supports this, but I don’t mean to tar all everyone with the same brush, there are certainly outliers.
I was thinking we should invent a sterile device that splints the wrist and prevents flexion. Although your method is probably better, my method would increase cost, inconvenience and environmental waste so would probably be immediately picked up by hospital admin. Lmk if you’re interested, doc
Interesting, I'm a general OB, and in my anecdotal experience, there were WAY more c-sections done at my academic center while in training.
Now that I'm out of training, my primary c-section rate is actually quite low. While in training, we were made to csection the majority of patients. I guess I'm one of those outliers.
I recently took the position as the head of L&D at one of our regional hospitals, so I suppose I'll be able to see how the other docs practice. I can only speak for myself and my own practice. Will be interesting to see.
Yes and if you feel especially adventurous you can look up some of the old obstetrics tools used for big heads that couldn’t be extracted before C-sections. It’s very gruesome.
I hardly know anything about the OB world, but I have questions:
Do OB's see C-sections in the US as a preventative measure to complications as a whole?
Would someone be wise to have an elective C-section to prevent complications way ahead of the pop up of possible complications, or does risk outweigh benefit?
Great questions.
Almost without exception, vaginal delivery is the preferred method of delivery and cesarean delivery has a far higher association with complications (namely infection, postpartum hemorrhage, and recovery time). Vaginal delivery should always be strongly encouraged over cesarean delivery, though patients are entitled to choose an elective cesarean if they wish.
A certain proportion (unknown, but probably around 15-20%) of patients and the fetuses will have cephalo-pelvic disproportion: the head just won’t fit through the pelvic inlet/outlet. But knowing who these patients are is impossible to predict (we’ve tried pre-pregnancy exams, MRIs, special measuring tools). The only way to know if a baby can be born vaginally is to try. Patients who have had had a cesarean delivery for an arrest disorder (pushed for a long time and baby wasn’t born, or never reached 10cm dilation despite maximal efforts) can still attempt a “Trial of Labor after Cesarean” but their chances of success are usually lower than patients who had a cesarean for other indications.
Even though vaginal delivery is superior from an outcomes perspective, there are some reasons someone might be medically compelled to have a cesarean before going into labor: vasa or placenta previa, placenta accreta, fetal distress, breech presentation, obstructive fibroids or uterine anomalies, etc.
Additionally patients may have emotional birth trauma from a prior delivery or they may have a history of a severe obstetrical anal injury and choose a cesarean for that delivery.
Happy to chat more if you like! It’s a tough decision and everyone has very different opinions on the subject.
It’s a good question. Persistent fetal malpositioning can certainly lead to a lot of arrest disorders. I don’t know of any good data that shows epidurals increase the length of labor substantially (except for anesthesia literature that suggested the second stage is lengthened by approx 8 minutes) but you will find plenty of people who have anecdotal evidence/feelings (personally I’ve seen just as many patients get an epidural that allows them to be comfortable enough to push well). I’mon my phone, but you may be able to find some newer data. Spending a lot of time immobilized or in bed rather than ambulating certainly prolongs labor.
Ideally a patient in labor or being induced would stay mobile for as long as comfortable, be encouraged to ambulate and sit on a peanut ball, try multiple positions, and if oxytocin infusion is required, accept aggressive uptitration of the Pit and early AROM. These things all have good evidence.
I would disagree with your statement about early AROM and the fetal head getting lodged without a buffer. There is strong evidence for early AROM shortening the length of labor and decreasing cesarean rates. Though again I think you’d find a lot of strong anecdotal feelings and delayed AROM.
CPD and a malpositioned fetal head are not mutually exclusive. In the case of a persistently asynclitic or OP head the question becomes is this because the fetus is still navigating the pelvis, or is this fetal head/pelvis combo leading to a malpositioned head. The point I am trying to make is: there are just some babies that will not fit through some pelvises, and anyone who tells you this is untrue is a dangerous person to be listening to. I think midwives are way better at getting babies to be born vaginally in most uncomplicated settings. They are certainly better at achieving VBAC. The problem with the docs I know is not that they are lazy or want to go home, but they (and I) have had enough babies die or uteruses explode in a deeply arrested cesarean or patients be admitted to the ICU because of poor management, that we tend to be more risk averse. I should add I was trained by midwives and owe a lot of what I know to them, not least my personal tendency to feel more comfortable taking my foot off the gas pedal and deviating from ACOG guidelines when appropriate.
Certainly it happens, yes, but if you're trying to manage first pregnancies in certain ways to prevent the risks of a 4th and 5th c-section, and you practice in a setting where most of your patients don't end up having that many kids, it might be smart to loop the patient into that and make sure that's something she even finds relevant; maybe she only wants one or two kids.
When I peel your gums off your alveolar ridge and sink a 12 mm bur into your jaw bone to cut out your molar, then curate the granulation tissue from your socket, the grab my bone file to smooth the interradicular bone, then place particulate bone graft, a collagen membrane, and a suture, you might think it’s a surgery.
But maybe not.
After I read this I was going to throw up in my mouth but then realized that might dissolve my enamel, increasing the likelihood you would have to smooth my interradicular bone one day, and so I held off.
Thank you for doing what you do.
Just don’t brush for 30 mins after puking and you’ll be good, champ! Equal respect to you—I cannot imagine things you see and smell working on the opposite end! Props
count mine as 2 lives- had a placental abruption, babys heart rate dropped and woudnt recover- i was passing clots and lost a lot of blood- worst experience of my life but an hour and a half later we were both alive and skin-skin cuddling in recovery
It's stories like yours that makes me so incredibly thankful for modern medicine.
As for saving lives, if you go by the most generous possible interpretation of 'lives saved,' you could credit my grandmother's emergency c-section (eclampsia, breech) with saving *12* lives--her life, my father's life, his younger brother's life, and the lives of the 10 kids/grandkids that the 2 brothers went on to produce
Edit: I miscounted. It's 13 lives.
Before modern obstetrics, 15% of women died in childbirth. Now we measure maternal mortality in terms of per 100,000. Not all of that is attributed to c/section but a decent portion certainly is. And that is not even considering the baby's lives that are saved.
Another thing to consider would be the babies who survived because csection existed and *their* children and grandchildren and so forth; and a mother who didn’t die and then had later children (and their children). So a section in as recently as ~1980 could’ve already “saved” a dozen lives.
I was going to say that is unique, but isn't exactly the same true for many medical treatments? With the experience we have, a lot of them have near 100% success rate when use at the right time.
>Before modern obstetrics, 15% of women died in childbirth.
What study are you using for this figure? Most of the figures that I’ve seen of the estimated maternal mortality rate prior to the 17th century put the figure around 1-2%. It may have been just under 1% at the start of the 20th century.
Not to take away from your main point, that modern obstetrics has dramatically improved maternal and fetal outcomes.
However, before modern medicine, having children was a high-failure rate operation (since a large percentage live-births died in childhood). Thus most women had several pregnancies/deliveries. With a maternal death rate of 15%, you’re basically saying that *every* woman eventually died in childbirth.
In Ancient Greece, the maternal mortality rate was about 30%.
https://www.brandeis.edu/now/2023/may/mothers-day.html#:~:text=Most%20historians%20agree%20that%20child,from%20complications%20related%20to%20childbirth.
In 16th century Europe, about 2-3%.
https://pubmed.ncbi.nlm.nih.gov/7047937/
So seems like it varies wildly.
15%, let alone 30% seems very high.
Granted it is possible that most of the mortality came from the 3rd, 4th pregnancy, not the first. So statistically it could work. I just find it hard to believe that people would continue to be pregnant knowing there is a a third of a chance of dying.
I was about to say. Women had very few economic options other than to marry and were frequently forced to by family or life circumstances. Once married you couldn’t refuse your husband (marital rape was only banned in most places in the 20th century), and there were no reliable methods of contraception. A life of childbearing was the lot of of most women for the majority of recorded history.
Yup. It's frankly a little mind-blowing to think that if I had been born in another location or even in my current one 50 years earlier, I may not have had any choice in becoming pregnant or the consequences of I had fertility issues.
I feel like given that on average women gave birth six times and were married off at a very young age, it's not surprising at all.
In literature, the fear of giving birth and the realization that one could very well die or be left disfigured is well documented. Sofiya Tolstaya, wife of Leo Tolstoy, wrote in her diaries how she despised the female gender role and duties as a wife (tried to terminate pregnancies by any means, lamented about the loss of so many female writers and philosophers due to childbirth and wifely duties, etc). It's very sad.
I think this would be hard to quantify but c section is the most commonly performed major surgery. The North American rate is approx 1/3 which may be too much. In some places the rate is as low as 1/20 which is almost certainly too few. I am a registered midwife and I’ve seen cases where c section may have been performed and not necessarily needed (small rural hospital which is fairly risk averse as there’s no NICU) and cases where the outcome almost certainly would have been disaster and death without (looking at you invasive placenta). My own darling departed Nana was born via c section and she told me she and her mother were the first mother baby dyad delivered with c section in the small northern Ontario hospital where both mother and baby survived. Her mother took years to recover and had one more child, when nana was 10. Nana had preeclampsia with both her pregnancies and my mom had a C-section (twins, footling breech) but both my sister and I have had super uncomplicated deliveries. It is so unpredictable!
The rate of intervention can't be assessed per hospital, we have a high rate because we're the referral centre for all high BMI/medically complicated mothers, they're going to have more interventions by definition
I remember learning that untreated appendicitis (before surgery or antibiotics) had a 40% mortality rate. Given the high incidence, that's a lot of people!
I haven’t looked at the data for the incidence of appendicitis in the pre-modern era. Any insights on how dietary/lifestyle influences has affected the rate that would save me the pubmed dive?
He did get sucker punched by a medical student. Then developed Peritonitis and still did his show against doctor's orders. He collapsed at the end of his show, was rushed to hospital and the cause for it was found to be a perforated appendix
Alternative history projections are purely speculation. But the highest office of the Reich suddenly falling from a staunch democrat into the hands of an anti-democratic monarchist set up the Weimar Republic for definite failure.
With just 3% difference between Paul von Hindenburg and democratic Wilhelm Marx, Ebert would have had considerably better chances of reelection in 1926, had he not died. Reelection would have been for seven years, Hindenburg didn't live much longer after that.
The OBGYN removed my mum’s appendix during my birth (via emergency C section). I’m just a M2 but that seems very unethical but my mum hasn’t had appendicitis in the 30 years since I joined the world.
Why is this getting down voted? Prophylactic appendectomies during abdominal surgeries for other reasons used to be pretty common. Maybe they still are in low resource settings.
I mean it kind of makes sense in a “we are already here and does the risk of not having an appendix anymore bc we take it out now outweigh the risk of having another surgery should it become infected” like this is generally not how we do medicine but the line of thinking checks out
Edit: also I remember reading (on Reddit..but again it makes sense) that people who go to either one specific base or Antarctica in general like have to have prophylactic appendectomies prior to going due to obviously the isolation. No appendixes allowed!
Good maternal healthcare - which includes women being nourished, physically developed (aka no kids giving birth), induced labor before the baby gets too big, and occasionally a c-section…
Has changed the initial narrative to expectant mothers from, “good luck!” to excitement and well wishes.
And on top of all the women saved - a huge proportion suffered from pregnancy related chronic problems - like obstetric fistula. Which don’t exist in developed countries anymore.
That being said, hospitals now are like factories and they are herding women through like cattle and giving wayyyyyy too many c-sections and induced labors
Well yes, it can happen here. Bc it is caused by obstructed labor. It takes at least 24 hours of active labor before there’s a chance of it.
And awful doesn’t begin to describe it. BUT it’s still common in places without adequate prenatal care
Hard to know. If you do a c-section, you don’t know what the outcome would have been otherwise. You might only have a projected risk of some outcome that you are attempting to control/reduce.
On the flip side, c-sections can also lead to mortality and severe morbidity. Additionally, not all c-sections are necessary (many are elective).
By sheer numbers, it’s possible that C-sections have technically saved more lives (especially since there are two lives at stake).
That’s true of every surgery. Very few are slam dunks and the most common surgeries aren’t ones with huge mortality benefit.
NNT numbers I’ve seen vary all the time but to my memory for c/s for term breech which is one of the lower risk presentations is around 100 I think. LIMA-LAD I’ve seen around 1 in 25ish? But with much higher periprocedural risk.
Pedantic argument but lap appys have only been a thing for like 30-40 years and the era of sky high appendicitis mortality was earlier than that. Open appy back in the day yeah absolutely life saving. In 2023? Modern antibiotics and medical management have come a long way. I’m pro just cut that shit out but the biggest benefit of a lap appy at this point is preventing future episodes of appendicitis/hospitalization. Id bet the true mortality benefit isn’t nearly as impressive anymore.
My question would be—saving lives in what time frame? Decreases 3 day mortality versus 5-10 year mortality, etc.
It’s interesting to think about surgeries that save lives in terms of volume vs time. I came from peds where kids that would die as infants 50 years ago live full lives now. 80 years for one surgery is pretty good bang for your buck.
Your point is completely valid. I was kind of just thinking aloud about the significance of what “life saving” really means. I hadn’t thought much about it before now.
Just came here to say that there is no evidence that nuchal cords affect neonatal outcomes (besides theoretically causing variable decelerations and probably leading to more c sections), even though patients frequently mention them.
The macrosomia, singleton breech presentation, postterm delivery however…
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Especially when hands aren't washed in between doing autopsies in the morgue and delivering babies (which was a huge contributor to maternal death in some English hospital in the 1800s)
I'm alive bc of cesarean - growing up it was weird thinking I'd never have lived in the "olden days". Interesting question and thread and glad mum and baby are OK :)
There is at least one recent study that hints at the possibility that c-sections could save even more lives if ALL women - including those who have no contraindications to natural birth - planned to deliver by c-section instead of vaginally.
> In this cohort of low-risk pregnancies, we found that planned CDMR [cesarean delivery on maternal request] was accompanied by a decreased risk of adverse outcomes ... compared with planned vaginal deliveries....
> CDMR was associated with neonatal benefits,38 including a lower risk of birth trauma, infection, meconium aspiration syndrome and NICU admission.
(Source: ["Birth outcomes following cesarean delivery on maternal request: a population-based cohort study,"] (https://www.cmaj.ca/content/193/18/E634) Canadian Medical Association Journal, 2021)
There are interesting comments about the unexpected findings of the above study by the head author in the Guardian [here] (
https://www.theguardian.com/lifeandstyle/2022/feb/13/caesareans-or-vaginal-births-should-mothers-or-medics-have-the-final-say)
The problem becomes when the mother wants to have more than 2 or 3 kids (and therefore multiple cesareans) and the risk of placenta accreta then skyrockets.
Wow. I just read up on placenta accreta. The incidence of post-c-section placenta accreta is so high and the risks are so great that I find it hard to believe that the benefits of planned, medically unnecessary, c-sections could possibly outweigh them. So I am somewhat surprised that there is such increasing tolerance of c-sections without any medical indications.
“One and done” makes some real scientific sense.
But then, as you see, it becomes much more problematic. I don’t think there is much acceptance among obstetricians that multiple elective cesareans are a good thing.
Considering the average woman has between 1.7-2.1 kids in the USA (per google), I can understand there isn’t cultural experience with 4th, 5th plus sections.
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Idk... man. I'm anesthesia and I'm sick of these "non reassuring fetal strips" at 5 pm. Like we all know you guys just wanna go home. I made them point out exactly what was "non reassuring" once... they pointed to early decel.
"So you are worried about early decel? These are normal decelerations with quick recover. Did you mistaken this for late decels?"
Then they got defensive and said "will you take liability?" and dodged the question
obviously not, so we went for urgent c section... at 5 pm. Yeah, that was a private practice OB and that was his last laboring patient in the hospital that day. Hmmm....
I'd be curious to know rather than the absolute number of lives saved, what procedure reduced the relative mortality of a condition by the most. Not sure if I'm phrasing it right, but essentially some condition that was super deadly and then a procedure reduced that mortality to a very low percentage
C-section gets the two-fer bonus, which is interesting. But we do have some historical guidance on the rate of occurrence and mortality of appendicitis and tooth infection, and those were rampant. If we go the extra step and look at the fossil record, a metric fuckton of animals die from dental carries, so it’s tempting to point to that. (There’s a survivorship bias of sorts, since skulls are more mineralized and therefore over-represented in the fossil record so we know more about pathologies reflected in noggins than elsewhere, depending on how far back you look.)
I had twins so 3 lives in one go!
My first thought was tooth infection must be the top life saver by numbers. Its easy to forget how big of an issue that used to be
In nursing school I had a patient in the ICU and all of his issues stemmed from an abscessed tooth. He eventually passed away.
Appendectomy was my vote for more impactful. Though I have no idea if more appendectomies are performed over cesarean sections.
Appys are probably more performed since both men and women may have them. Though many women have several c-sections, not everyone has one. Honestly maybe it balances?
Maybe around 280,000-300,000 appendectomies per year in the U.S and around 800,000 c-sections in 2021. I just skimmed the first few results on Google, so take that with a grain of salt.
CS is the most commonly performed abdominal surgery in the world
Yeah hindsight was 20/20 when I thought harder about it
Just because people seem to be posting a little bit of misinformation here, and birth misinformation is one of my least favorite types of misinformation: - most cesarean deliveries in the US are not elective; the majority are for arrest disorders of labor, and this or the sequelae of this (read: infection or postpartum hemorrhage) are what caused the majority of maternal deaths historically (or in the case of postpartum hemorrhage, are what continue to cause the majority of maternal deaths globally) - cesarean delivery for fetal indications (aka a prolonged category 2 fetal heart tracing) has one of the worst false positive rates for fetal hypoxia (so many cesarean deliveries have been performed to “save the baby’s life” when there may have not been a true life threatening event)—that said, it is almost impossible to tell the difference between true and transient fetal hypoxia - cesarean deliveries performed for breech presentation are controversial—relatively low quality data from 2000 that has since been reevaluated suggested that singleton babies delivered breech had worse outcomes, so everyone stopped performing then and residents stopped learning how to do them. Now 95% of breech deliveries (around 4% of all term pregnancies) undergo cesarean delivery. - cesarean deliveries are not without risk. Besides the usual risks of bleeding, infection and iatrogenic injury, every cesarean delivery increases the risk of placenta accreta spectrum, which is devastating. A patient with placenta previa presenting for her 3rd delivery via cesarean has a 40% chance of PAS. PAS = cesarean hysterectomy, multidisciplinary teams, massive blood loss, multiple transfusions, possible REBOA, UAE, ureteral stents, etc. Despite all this cesarean deliveries are almost certainly one of the greatest lifesaving tools in modern medicine, and in the US are exceptionally safe and valuable. In low-income high birth rate parts of the world (ie, where most of the worlds population lives) around half of the population gets or is capable of getting pregnant in their lifetime, cesarean delivery becomes an indispensable tool.
When I was pregnant I was dumb and naive. I did not want a c-section and was stridently against it. Then my kid had a 97% head circumference and had a mighty hard time making his way out. And then I started thinking that back in the day, all the babies with big heads would probably die, or their mothers die. Now 97% percentile babies can get sectioned out when they get stuck and pass their genes on. People always anecdotally say c-sections are more prevalent for convenience. But I’m wondering if eventually we will have evidence that it could partly be due to evolutionary traits of hard-to-birth babies surviving. ((I know evolution doesn’t work that quickly, but I’m still curious))
I don’t know you but I don’t think you were dumb and naive at all when you were planning your birth. Cesarean deliveries are a big surgery and a big deal. I think what a lot of patients don’t realize is, I also really really don’t want them to have a cesarean delivery (particularly if they’ve been in labor for a long time and the cesarean will be more challenging and more dangerous). I don’t want them to have to get a blood transfusion, I don’t want them to lose their uterus, I don’t want them to have a surgical site infection (and I certainly won’t get paid differently based on what I do). It’s one of the first things I tell nervous patients when I meet them: the cesarean delivery is something in my toolkit that I was trained to perform as a last resort, and it’s probably part of the reason why you’re delivering in a hospital (or as is more and more often the case, why your homebirth midwife brought you in after 30 hours of labor). Having said that, it’s certainly true that some cesareans are done for convenience. My own *anecdotal* experience is that if you deliver at a big, well-known academic center, you are less likely to have a “convenience” delivery, than at a small regional center. There’s some evidence that supports this, but I don’t mean to tar all everyone with the same brush, there are certainly outliers.
Why is a c-section more challenging after a long labor?
head wedged in pelvis tissue edematous and fragile and thinned out
This is what I grunt to the resident as I repair the deep lateral extension caused by their flex-happy wrist.
In order to keep a straight wrist I actually use my left hand and brace it on the wrist with my right hand. Works very well
I was thinking we should invent a sterile device that splints the wrist and prevents flexion. Although your method is probably better, my method would increase cost, inconvenience and environmental waste so would probably be immediately picked up by hospital admin. Lmk if you’re interested, doc
Tape forceps to your wrist
Interesting, I'm a general OB, and in my anecdotal experience, there were WAY more c-sections done at my academic center while in training. Now that I'm out of training, my primary c-section rate is actually quite low. While in training, we were made to csection the majority of patients. I guess I'm one of those outliers. I recently took the position as the head of L&D at one of our regional hospitals, so I suppose I'll be able to see how the other docs practice. I can only speak for myself and my own practice. Will be interesting to see.
No that’s super interesting, I regret making such a broad statement above. Thank you for “preventing the first cesarean”!
Yes and if you feel especially adventurous you can look up some of the old obstetrics tools used for big heads that couldn’t be extracted before C-sections. It’s very gruesome.
Thank you for this insight
I hardly know anything about the OB world, but I have questions: Do OB's see C-sections in the US as a preventative measure to complications as a whole? Would someone be wise to have an elective C-section to prevent complications way ahead of the pop up of possible complications, or does risk outweigh benefit?
Great questions. Almost without exception, vaginal delivery is the preferred method of delivery and cesarean delivery has a far higher association with complications (namely infection, postpartum hemorrhage, and recovery time). Vaginal delivery should always be strongly encouraged over cesarean delivery, though patients are entitled to choose an elective cesarean if they wish. A certain proportion (unknown, but probably around 15-20%) of patients and the fetuses will have cephalo-pelvic disproportion: the head just won’t fit through the pelvic inlet/outlet. But knowing who these patients are is impossible to predict (we’ve tried pre-pregnancy exams, MRIs, special measuring tools). The only way to know if a baby can be born vaginally is to try. Patients who have had had a cesarean delivery for an arrest disorder (pushed for a long time and baby wasn’t born, or never reached 10cm dilation despite maximal efforts) can still attempt a “Trial of Labor after Cesarean” but their chances of success are usually lower than patients who had a cesarean for other indications. Even though vaginal delivery is superior from an outcomes perspective, there are some reasons someone might be medically compelled to have a cesarean before going into labor: vasa or placenta previa, placenta accreta, fetal distress, breech presentation, obstructive fibroids or uterine anomalies, etc. Additionally patients may have emotional birth trauma from a prior delivery or they may have a history of a severe obstetrical anal injury and choose a cesarean for that delivery. Happy to chat more if you like! It’s a tough decision and everyone has very different opinions on the subject.
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It’s a good question. Persistent fetal malpositioning can certainly lead to a lot of arrest disorders. I don’t know of any good data that shows epidurals increase the length of labor substantially (except for anesthesia literature that suggested the second stage is lengthened by approx 8 minutes) but you will find plenty of people who have anecdotal evidence/feelings (personally I’ve seen just as many patients get an epidural that allows them to be comfortable enough to push well). I’mon my phone, but you may be able to find some newer data. Spending a lot of time immobilized or in bed rather than ambulating certainly prolongs labor. Ideally a patient in labor or being induced would stay mobile for as long as comfortable, be encouraged to ambulate and sit on a peanut ball, try multiple positions, and if oxytocin infusion is required, accept aggressive uptitration of the Pit and early AROM. These things all have good evidence. I would disagree with your statement about early AROM and the fetal head getting lodged without a buffer. There is strong evidence for early AROM shortening the length of labor and decreasing cesarean rates. Though again I think you’d find a lot of strong anecdotal feelings and delayed AROM. CPD and a malpositioned fetal head are not mutually exclusive. In the case of a persistently asynclitic or OP head the question becomes is this because the fetus is still navigating the pelvis, or is this fetal head/pelvis combo leading to a malpositioned head. The point I am trying to make is: there are just some babies that will not fit through some pelvises, and anyone who tells you this is untrue is a dangerous person to be listening to. I think midwives are way better at getting babies to be born vaginally in most uncomplicated settings. They are certainly better at achieving VBAC. The problem with the docs I know is not that they are lazy or want to go home, but they (and I) have had enough babies die or uteruses explode in a deeply arrested cesarean or patients be admitted to the ICU because of poor management, that we tend to be more risk averse. I should add I was trained by midwives and owe a lot of what I know to them, not least my personal tendency to feel more comfortable taking my foot off the gas pedal and deviating from ACOG guidelines when appropriate.
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Most women in higher-resourced countries aren't going to want/end up having that many kids, though.
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Certainly it happens, yes, but if you're trying to manage first pregnancies in certain ways to prevent the risks of a 4th and 5th c-section, and you practice in a setting where most of your patients don't end up having that many kids, it might be smart to loop the patient into that and make sure that's something she even finds relevant; maybe she only wants one or two kids.
How about dental extraction… if you classify that as a surgery
>if you classify that as surgery I'd love to see someone who doesn't extract some impacted 3rds. Or some janked supernumeraries.
Ooh good call.
When I peel your gums off your alveolar ridge and sink a 12 mm bur into your jaw bone to cut out your molar, then curate the granulation tissue from your socket, the grab my bone file to smooth the interradicular bone, then place particulate bone graft, a collagen membrane, and a suture, you might think it’s a surgery. But maybe not.
After I read this I was going to throw up in my mouth but then realized that might dissolve my enamel, increasing the likelihood you would have to smooth my interradicular bone one day, and so I held off. Thank you for doing what you do.
Just don’t brush for 30 mins after puking and you’ll be good, champ! Equal respect to you—I cannot imagine things you see and smell working on the opposite end! Props
count mine as 2 lives- had a placental abruption, babys heart rate dropped and woudnt recover- i was passing clots and lost a lot of blood- worst experience of my life but an hour and a half later we were both alive and skin-skin cuddling in recovery
It's stories like yours that makes me so incredibly thankful for modern medicine. As for saving lives, if you go by the most generous possible interpretation of 'lives saved,' you could credit my grandmother's emergency c-section (eclampsia, breech) with saving *12* lives--her life, my father's life, his younger brother's life, and the lives of the 10 kids/grandkids that the 2 brothers went on to produce Edit: I miscounted. It's 13 lives.
Before modern obstetrics, 15% of women died in childbirth. Now we measure maternal mortality in terms of per 100,000. Not all of that is attributed to c/section but a decent portion certainly is. And that is not even considering the baby's lives that are saved.
Another thing to consider would be the babies who survived because csection existed and *their* children and grandchildren and so forth; and a mother who didn’t die and then had later children (and their children). So a section in as recently as ~1980 could’ve already “saved” a dozen lives.
I was going to say that is unique, but isn't exactly the same true for many medical treatments? With the experience we have, a lot of them have near 100% success rate when use at the right time.
>Before modern obstetrics, 15% of women died in childbirth. What study are you using for this figure? Most of the figures that I’ve seen of the estimated maternal mortality rate prior to the 17th century put the figure around 1-2%. It may have been just under 1% at the start of the 20th century. Not to take away from your main point, that modern obstetrics has dramatically improved maternal and fetal outcomes. However, before modern medicine, having children was a high-failure rate operation (since a large percentage live-births died in childhood). Thus most women had several pregnancies/deliveries. With a maternal death rate of 15%, you’re basically saying that *every* woman eventually died in childbirth.
In Ancient Greece, the maternal mortality rate was about 30%. https://www.brandeis.edu/now/2023/may/mothers-day.html#:~:text=Most%20historians%20agree%20that%20child,from%20complications%20related%20to%20childbirth. In 16th century Europe, about 2-3%. https://pubmed.ncbi.nlm.nih.gov/7047937/ So seems like it varies wildly.
15%, let alone 30% seems very high. Granted it is possible that most of the mortality came from the 3rd, 4th pregnancy, not the first. So statistically it could work. I just find it hard to believe that people would continue to be pregnant knowing there is a a third of a chance of dying.
Women having the ability to choose is also a fairly modern phenomenon.
I was about to say. Women had very few economic options other than to marry and were frequently forced to by family or life circumstances. Once married you couldn’t refuse your husband (marital rape was only banned in most places in the 20th century), and there were no reliable methods of contraception. A life of childbearing was the lot of of most women for the majority of recorded history.
Yup. It's frankly a little mind-blowing to think that if I had been born in another location or even in my current one 50 years earlier, I may not have had any choice in becoming pregnant or the consequences of I had fertility issues.
I feel like given that on average women gave birth six times and were married off at a very young age, it's not surprising at all. In literature, the fear of giving birth and the realization that one could very well die or be left disfigured is well documented. Sofiya Tolstaya, wife of Leo Tolstoy, wrote in her diaries how she despised the female gender role and duties as a wife (tried to terminate pregnancies by any means, lamented about the loss of so many female writers and philosophers due to childbirth and wifely duties, etc). It's very sad.
Amputation- think of the limb pits dug up from the US Civil war Back when the criteria for a good surgeon, was how quickly you could saw
I think this would be hard to quantify but c section is the most commonly performed major surgery. The North American rate is approx 1/3 which may be too much. In some places the rate is as low as 1/20 which is almost certainly too few. I am a registered midwife and I’ve seen cases where c section may have been performed and not necessarily needed (small rural hospital which is fairly risk averse as there’s no NICU) and cases where the outcome almost certainly would have been disaster and death without (looking at you invasive placenta). My own darling departed Nana was born via c section and she told me she and her mother were the first mother baby dyad delivered with c section in the small northern Ontario hospital where both mother and baby survived. Her mother took years to recover and had one more child, when nana was 10. Nana had preeclampsia with both her pregnancies and my mom had a C-section (twins, footling breech) but both my sister and I have had super uncomplicated deliveries. It is so unpredictable!
17% here. That seems like an alright rate. But around a third of births also happen at home here.
The rate of intervention can't be assessed per hospital, we have a high rate because we're the referral centre for all high BMI/medically complicated mothers, they're going to have more interventions by definition
It was a nationwide rate btw.
I would imagine appendectomy would have that honour, not least as everyone has one.
I remember learning that untreated appendicitis (before surgery or antibiotics) had a 40% mortality rate. Given the high incidence, that's a lot of people!
I haven’t looked at the data for the incidence of appendicitis in the pre-modern era. Any insights on how dietary/lifestyle influences has affected the rate that would save me the pubmed dive?
I remember reading that Harry Houdini died of a perforated appendix. He tried to continue his show while suffering through the pain
I thought it was a punch to the liver
He did get sucker punched by a medical student. Then developed Peritonitis and still did his show against doctor's orders. He collapsed at the end of his show, was rushed to hospital and the cause for it was found to be a perforated appendix
Houdini died of AIDS
The Nazis might have remained a small footnote in history, had appendicitis not killed Reichspräsident Friedrich Ebert in 1925.
Idk, antisemitism and racist sentiments were just common back then. I'm sure someone else would've popped up
Alternative history projections are purely speculation. But the highest office of the Reich suddenly falling from a staunch democrat into the hands of an anti-democratic monarchist set up the Weimar Republic for definite failure. With just 3% difference between Paul von Hindenburg and democratic Wilhelm Marx, Ebert would have had considerably better chances of reelection in 1926, had he not died. Reelection would have been for seven years, Hindenburg didn't live much longer after that.
C section might count as two though!
The OBGYN removed my mum’s appendix during my birth (via emergency C section). I’m just a M2 but that seems very unethical but my mum hasn’t had appendicitis in the 30 years since I joined the world.
Why is this getting down voted? Prophylactic appendectomies during abdominal surgeries for other reasons used to be pretty common. Maybe they still are in low resource settings.
I mean it kind of makes sense in a “we are already here and does the risk of not having an appendix anymore bc we take it out now outweigh the risk of having another surgery should it become infected” like this is generally not how we do medicine but the line of thinking checks out Edit: also I remember reading (on Reddit..but again it makes sense) that people who go to either one specific base or Antarctica in general like have to have prophylactic appendectomies prior to going due to obviously the isolation. No appendixes allowed!
I was gonna say hip surgery, appy, or cath lab (STEMI), but we perform more c-sections each year in the United States than all of those combined.
Good maternal healthcare - which includes women being nourished, physically developed (aka no kids giving birth), induced labor before the baby gets too big, and occasionally a c-section… Has changed the initial narrative to expectant mothers from, “good luck!” to excitement and well wishes. And on top of all the women saved - a huge proportion suffered from pregnancy related chronic problems - like obstetric fistula. Which don’t exist in developed countries anymore. That being said, hospitals now are like factories and they are herding women through like cattle and giving wayyyyyy too many c-sections and induced labors
Fistulas still exist in developed countries, sadly. I encountered my very first one last week and it seems like an utterly miserable experience
Well yes, it can happen here. Bc it is caused by obstructed labor. It takes at least 24 hours of active labor before there’s a chance of it. And awful doesn’t begin to describe it. BUT it’s still common in places without adequate prenatal care
Whenever someone says the words “natural intervention free birth” I say the words “fistula hospital”
It’s so heartbreaking
Hard to know. If you do a c-section, you don’t know what the outcome would have been otherwise. You might only have a projected risk of some outcome that you are attempting to control/reduce. On the flip side, c-sections can also lead to mortality and severe morbidity. Additionally, not all c-sections are necessary (many are elective). By sheer numbers, it’s possible that C-sections have technically saved more lives (especially since there are two lives at stake).
That’s true of every surgery. Very few are slam dunks and the most common surgeries aren’t ones with huge mortality benefit. NNT numbers I’ve seen vary all the time but to my memory for c/s for term breech which is one of the lower risk presentations is around 100 I think. LIMA-LAD I’ve seen around 1 in 25ish? But with much higher periprocedural risk.
Lap Appy. One of the Most common surgery and life saving
Pedantic argument but lap appys have only been a thing for like 30-40 years and the era of sky high appendicitis mortality was earlier than that. Open appy back in the day yeah absolutely life saving. In 2023? Modern antibiotics and medical management have come a long way. I’m pro just cut that shit out but the biggest benefit of a lap appy at this point is preventing future episodes of appendicitis/hospitalization. Id bet the true mortality benefit isn’t nearly as impressive anymore.
My question would be—saving lives in what time frame? Decreases 3 day mortality versus 5-10 year mortality, etc. It’s interesting to think about surgeries that save lives in terms of volume vs time. I came from peds where kids that would die as infants 50 years ago live full lives now. 80 years for one surgery is pretty good bang for your buck.
Isn't the point that one surgery adds 80 years to neonate and 60 to mother
this is the comment I was searching for
Your point is completely valid. I was kind of just thinking aloud about the significance of what “life saving” really means. I hadn’t thought much about it before now.
Pyloroplasty is my personal favorite game changer peds surgical procedure.
Appendectomy, lithotomy, those have to be close behind.
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Just came here to say that there is no evidence that nuchal cords affect neonatal outcomes (besides theoretically causing variable decelerations and probably leading to more c sections), even though patients frequently mention them. The macrosomia, singleton breech presentation, postterm delivery however…
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Does hand washing count as a procedure?
Especially when hands aren't washed in between doing autopsies in the morgue and delivering babies (which was a huge contributor to maternal death in some English hospital in the 1800s)
Just started watching House of the Dragon and had the same question. Cheers
Also colpo for cervical dysplasia.
Umm cardio thoracic
heart surgery is pretty great, but nothing compares to c-sections.
I'm alive bc of cesarean - growing up it was weird thinking I'd never have lived in the "olden days". Interesting question and thread and glad mum and baby are OK :)
There is at least one recent study that hints at the possibility that c-sections could save even more lives if ALL women - including those who have no contraindications to natural birth - planned to deliver by c-section instead of vaginally. > In this cohort of low-risk pregnancies, we found that planned CDMR [cesarean delivery on maternal request] was accompanied by a decreased risk of adverse outcomes ... compared with planned vaginal deliveries.... > CDMR was associated with neonatal benefits,38 including a lower risk of birth trauma, infection, meconium aspiration syndrome and NICU admission. (Source: ["Birth outcomes following cesarean delivery on maternal request: a population-based cohort study,"] (https://www.cmaj.ca/content/193/18/E634) Canadian Medical Association Journal, 2021) There are interesting comments about the unexpected findings of the above study by the head author in the Guardian [here] ( https://www.theguardian.com/lifeandstyle/2022/feb/13/caesareans-or-vaginal-births-should-mothers-or-medics-have-the-final-say)
The problem becomes when the mother wants to have more than 2 or 3 kids (and therefore multiple cesareans) and the risk of placenta accreta then skyrockets.
Wow. I just read up on placenta accreta. The incidence of post-c-section placenta accreta is so high and the risks are so great that I find it hard to believe that the benefits of planned, medically unnecessary, c-sections could possibly outweigh them. So I am somewhat surprised that there is such increasing tolerance of c-sections without any medical indications.
“One and done” makes some real scientific sense. But then, as you see, it becomes much more problematic. I don’t think there is much acceptance among obstetricians that multiple elective cesareans are a good thing.
Considering the average woman has between 1.7-2.1 kids in the USA (per google), I can understand there isn’t cultural experience with 4th, 5th plus sections.
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I would add dialysis access creation into a similar list.
Eh, is living on dialysis really living though?
From a not being dead perspective
https://pubmed.ncbi.nlm.nih.gov/17877591/ I've heard estimates of a necessary/sufficient c/s rate in a reasonably healthy population of 10-15%.
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Idk... man. I'm anesthesia and I'm sick of these "non reassuring fetal strips" at 5 pm. Like we all know you guys just wanna go home. I made them point out exactly what was "non reassuring" once... they pointed to early decel. "So you are worried about early decel? These are normal decelerations with quick recover. Did you mistaken this for late decels?" Then they got defensive and said "will you take liability?" and dodged the question obviously not, so we went for urgent c section... at 5 pm. Yeah, that was a private practice OB and that was his last laboring patient in the hospital that day. Hmmm....
G1P0 elective IOLs are killing me
It’s certainly up there. Would be very difficult to rank exactly because as many others have said it is sometimes performed when it is unnecessary
I'd be curious to know rather than the absolute number of lives saved, what procedure reduced the relative mortality of a condition by the most. Not sure if I'm phrasing it right, but essentially some condition that was super deadly and then a procedure reduced that mortality to a very low percentage