As I prepared to deliver a baby, the patient's husband asked me, “You're going to do a C-section, aren't you?”

“No, I'm not,” I answered.

“Shit!” he exclaimed. “I want you to do a C-section.”

“ER doctors don't do C-sections unless it is a real emergency, and the baby is coming out just fine.”

“Do it anyway!” he commanded.

“Why do you want her to have a C-section?” I inquired.

“Because I don't want her to get loose down there. Some of my buddies said it just ain't the same when that happens. We talked it over with the obstetrician, and he agreed to do the C-section.”

“Well, he's not here right now, and it is too late for a C-section, anyway. Sorry, I need to run.”

After the delivery, one of the student nurses who overheard this conversation asked me for my opinion on the merits of C-sections as opposed to vaginal deliveries. Since the ER was slow at that time, we sat down to chat for a few minutes.

“I did not have time to get in a protracted discussion with that man, but I am an advocate of C-sections.”

“Why is that?” she asked.

“When children are delivered vaginally, certain problems may develop which compromise the child's supply of oxygen. In some cases, this deficit may be enough to cause recognizable brain injury. Those cases are not very common, but they certainly aren't anything to gloss over, either. What is far more common is an occult decrement of the child's intelligence.”

“What do you mean by that?”

“Let's say that a child was destined to have an IQ of 130—a borderline genius, by definition. Let's also say that this child's brain was deprived of enough oxygen during childbirth so that some brain injury occurred. Perhaps not enough to warrant a diagnosis of cerebral palsy or mental retardation, but enough to lower his IQ to 100, which is average. No one is going to sit around crying about how this kid has average intelligence because it is so difficult to retrospectively appreciate the tragedy that occurred.”

“So are kids born by C-section smarter on average?”

“Not necessarily. Since many C-sections are not performed until some problem has developed, a simple statistical analysis of the intelligence of children born by C-section versus vaginal delivery does not serve to adequately illuminate the cerebral risk of vaginal birth.”

“Are there other reasons to favor C-section?”

“Yes. C-sections can be performed almost painlessly, but vaginal childbirth can be excruciating. There is a longer healing time after having a C-section, but if I were a woman, I would prefer that to the acute pain of delivering vaginally. Also, pelvic stretching induced by vaginal birth can precipitate stress incontinence. In fact, this causes some women to empty their bladder whenever they have an orgasm.”

“Not very dainty, I'd say. But what about the vaginal stretching the husband was referring to?”

“Unless the baby is very small, such as from a premature birth, the vagina will be permanently changed. This affects different women to different degrees, but an average woman who delivered vaginally will have a noticeable change. That's probably more of a problem for the man than the woman, but it can reduce the pleasure of intercourse for both partners.”

“Why haven't I heard men complaining about that before?”

“That's not an easy thing for a man to say. We talk about it amongst ourselves, but men have a very difficult time broaching the subject of vaginal tightness with women. By the time the average man realizes this, it is too late anyway. So he either keeps his mouth shut, or divorces his wife and chases younger women.”

“That really happens?”

“Of course it does, and I know men who have dumped their partners for that reason. They would never admit it to the women, though. They just run away. Most men are not very good at communication.”

“So when I graduate should I counsel pregnant women to consider having a C-section for the reasons you discussed?”

“You can try, but you're probably wasting your breath. Some women are constitutionally unable to give up their fixation on vaginal childbirth. In most women, it is so ingrained it seems to be genetic. If you have any luck, let me know. I am just trying to help women so in the future they're not bitterly dwelling on why they were divorced. The women I know who were divorced by their husbands are very traumatized. There are obviously many other reasons why people get divorced, but this is one. Since it is preventable, why ignore it?”

“Why is there a move away from doing C-sections?”

“To save money. Your HMO or insurance company doesn't care if your child is less intelligent, or if you have stress incontinence, or if your husband is boinking a woman half your age. They don't care about anything except making more money. Twenty years ago, people were taken in by the promise of HMOs and other managed care organizations (MCOs) to save money. For a while, it appeared as if they might be able to deliver on their promise because healthcare costs were temporarily restrained, but now they're spiraling upward again. Those conniving SOBs that run HMOs and MCOs just used the illusion of cost containment to get their foot in the door and become firmly entrenched. The difference is that now a lot of money is going into their pockets, instead of toward your care. They return the favor by making you wade through interminable layers of red tape. I've had patients call me practically crying because they were at wits' end after fighting for a year or so to have an ER bill paid. If I couldn't make the bureaucrats understand, I'd just cancel the bill from my company so the patient could get that nightmare behind them. I also know that some physicians spend a few days per week just dealing with bureaucrats at HMOs and MCOs. It seems to me that the doctor's time would be better spent with his patients. But do the HMOs and MCOs care about all the strife they're causing? Heck no. They're just leeches who are tickled to have a new home.”

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