Is the “French” caesarean section really dangerous?

The tragic death of a baby during birth by a “French” caesarean section last month at the English Hospital in Nazareth, once again brought the controversial French method into discussion. Only about a year and a half ago, the Ministry of Health decided to ban the performance of caesarean sections using the French method, but due to public pressure and after a discussion that took place in the Committee for the Advancement of the Status of Women in the Knesset, the Ministry retracted and approved the performance of the operation, subject to the informed consent of the woman giving birth.Following the incident at the English Hospital, the Ministry of Health opened an investigation, and on behalf of the hospital it was stated that they participate in the great grief of the family and accompany it. A medical official from the hospital wanted to emphasize that this is an unusual case after about 2,000 successful surgeries of this type have been performed in Israel, about 1,500 of them at the English Hospital.Despite the approval given by the Ministry of Health for the surgery to be performed in hospitals, in practice it is currently only performed in two hospitals, the English Hospital in Nazareth privately, and the Shamir Medical Center (Assaf Harofeh) as part of a clinical study. Despite the positive data that has emerged so far from the operation at the two centers, the Ministry of Health does not really express enthusiasm. In response to our request, we claimed that the chances of the surgery being subsidized by the state are slim, and the hospitals are actually not interested in performing it, because the surgery is dangerous for the mother and the newborn. Despite our request, we were not given the data on which the office is based. Moreover, and in a puzzling way, when we asked the ministry about the ongoing research at the Shamir Medical Center that was done under the supervision of the Ministry of Health, they doubted whether such research had actually been conducted.

A senior member of the health system with whom we spoke claims that the reason why hospitals do not perform the surgery is because they are not interested in building a dedicated system and training surgeons who will specialize in the required surgical skill. In addition to this, according to him, the hospitals are not in favor of the approval given for surgery for fear of losing budgeting due to mothers who will flow to medical centers that will perform the surgery. In fact, says the same source, those with interests are pressuring the Ministry of Health to continue claiming that the procedure is dangerous, even without actual information on the subject and without monitoring the procedure over time. In other words, the reason that the ministry asked to tighten the informed consent form that mothers with this method are asked to sign, is completely political and economic and does not stem from medical reasons. According to him, these actions completely ignore the welfare of the mother. “French caesarean section is an operation that benefits women, so what do we do? It is reduced, belittled.”

“Those with vested interests are pressuring the Ministry of Health to continue to claim that the French caesarean section is dangerous. It is an operation that benefits women, so what do we do? They minimize it, belittle it”

Senior in the medical system

“Believing the baby’s names is not related to the method”

At the Shamir Medical Center, as mentioned several months ago, they began a clinical study, which received the approval of the Helsinki Committee (responsible for ensuring that medical experiments are carried out in an ethical manner in accordance with national and international law), this after about 300 successful caesarean sections had already been performed at the center using the French approach, before the service was stopped by the ministry Health about a year and a half ago. These days, and following the case that occurred at the English Hospital in Nazareth, the hospital decided to suspend the study until the results of the Ministry of Health’s investigation are published.

However, Dr. Miki Moskovitz, director of the emergency obstetrics unit and deputy director of labor and delivery rooms at Shamir Medical Center, who is leading the study, says in an interview with Mako Health that one should not jump to conclusions. “This method is in the eye of the storm, but I believe that the baby’s death is not related to the method itself. The ‘French’ caesarean section is a safe procedure when you know how to perform it properly, and Dr. Handler, who performed the operation at the English hospital, is a seasoned and experienced surgeon. We have to wait for the results of the Ministry of Health, after an orderly and proper investigation, and then decide what to do.”

According to him, after the event he spoke personally with Dr. Handler. “We are in daily contact, he is also the one who taught me the method. I’ve been an obstetrician for almost 20 years and things have happened to me too, it’s an event that you don’t recover from for months. It is very difficult. Dr. Handler is not a doctor that passes him by, he takes it to heart. I know that he and the entire hospital are in continuous contact with the family.”

So what is a “French” caesarean section?

The French method was developed more than 20 years ago, by Dr. Denis Fauque, a French surgeon and gynecologist who combined techniques from other fields of medicine. “Over the years, Dr. Fauque operated with colleagues, surgeons from different fields, and acquired ideas and knowledge from them in anatomical areas And in tissues that gynecologists are less knowledgeable about,” says Dr. Moskovitz, “they directed him and that’s how he built a different, friendlier surgical procedure.”

Dr. Moskovitz explains that in contrast to the usual and well-known caesarean section, in the French caesarean section the connective tissues that surround the rectus abdominis muscle are cut longitudinally, with the anatomical direction of the nerve endings, and not perpendicular to them, as is done in a normal cesarean section, and in this way less nerve endings are damaged He also notes that “with the French method, one does not enter the abdominal cavity, but reaches the uterus from the side, a very old approach from the middle of the last century, which aims to avoid exposure of the abdominal organs to the contents of the uterus, which is sometimes contaminated during childbirth.”

“There is no difference in the possible risks between a caesarean section using the usual method and between a ‘French’ caesarean section, and this is also what is known in the world. What gets complicated here gets complicated here, and this is very unusual, these are rare things”

Dr. Miki Moskowitz, Shamir Medical Center

In response to the opponents’ claims, the doctor points out that there is no difference in the possible risks between a cesarean using the usual method and a “French” cesarean. “We know this since the first round of surgeries we performed at the Shamir Medical Center, even before we started the clinical research, and this is also what the world knows. What gets complicated here gets complicated here, which is very unusual, these are very rare things.” He further adds that in some of the surgeries he performed, the mother’s condition was better in several aspects, whether in terms of a smaller amount of blood loss, or in the hemoglobin values ​​recorded after the birth.

Dr. Moskovitz also refers to the claims that have been made regarding the use of special spoons to extract the baby. “Since the incision is smaller, and the field is narrower, extracting the baby’s head is a little more complex, and to do this we create a path for the baby to come out using special ‘spoons’. A lot of people call it tongs, but it’s really not tongs. The pawls do not lock like tongs, so if too much force is applied in the pull, they will break off. On the other hand, with forceps, the handles are actually locked and the force applied by the obstetrician is applied directly to the fetus’s head.”

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“Two significant incidents of harm came to the office”

And yet, when we talk to the Ministry of Health, we get a different picture, of a very dangerous operation. In a debate held about a year and a half ago in the Knesset, Dr. Hagar Mizrahi, head of the medical division at the Ministry of Health, claimed that the ministry came across two significant incidents in which children were harmed, and that the rate of complications in this surgery is high. There are incidents of injury to the face, and some doctors claim that it can damage the skin and create nerve damage with lasting damage. In women, there is a risk of injury to the bladder and there is a fear of injury and a wider scar of the uterine wall, which may cause lasting damage in the years to come,” she said at the hearing.

Dr. Moskovitz explains that the Ministry of Health issued an updated signature form also for women who want to undergo a “French” caesarean section, in which he added sections regarding possible damage to the bladder and the extraction of the fetus. “In my opinion, this is unnecessary, but this is what the Ministry of Health decided, and we respect it and sign the women for it. For some reason, the Ministry of Health sees the complications in a slightly different way.”

According to him, the ministry’s position is based on a study that was done several years ago at the Bnei Zion Medical Center, which was well planned and by serious doctors, the first surgery performed as part of it was also the first surgery ever performed at the medical center. “I started researching the ‘French’ caesarean section after having performed more than 300 surgeries myself, it’s heaven and earth. Just learning to perform the surgery without entering the peritoneal cavity takes time and experience, there must be a learning curve for a surgical process, you can’t start from scratch, and you can’t Basing the Ministry of Health’s position on this research.” However, he points out that this is the information available today, and this is also one of the reasons why the Shamir Medical Center lifted the glove to conduct another and comprehensive study. The doctor points out that in the current study, after having already proven the safety of the procedure, they are focusing on the main question – does the surgery using the French method significantly affect the course and duration of the mother’s recovery.

As for performing the surgery in the public hospitals, Dr. Moskowitz explains that even in France, where the surgery is more popular and common, it is not intended for public hospitals and is performed privately only. It’s just part of an overall approach that sees the birth process in a different and different way. “It’s a whole concept of how the entire birth process should look, how a woman should behave, how to let her continue to feel like a woman even after the operation and not like one who has been operated on. Their attitude is amazing in this respect, and in my vision I would like women to come and enjoy this possibility at my hospital as well.”

According to him, in a few years, and especially after the publication of the research results in the coming months, the surgery will become more popular and common in Israel. “Although the hospitals are not jumping on it for the time being, but in my opinion the reason for this is not just politics, these are people who understand the issue. Until now there was not enough organized information. We have shown that from a safety point of view there is no difference or difference in risk from a regular caesarean section, and this is also how the operation is treated in the hospitals The others, but from here until they come to study it, or send people who will be trained for it, it’s already their consideration, how much effort and resources they want to invest in it. I don’t want to think that there are other considerations here, I want to believe that they are simply afraid of a new procedure about which there is not enough information , and we try to contribute to that.”

“The surgery is part of an overall approach that sees the birth process in a different and different way. It is a complete concept of what the entire birth process should look like, how a woman should behave, how to let her continue to feel like a woman even after the surgery and not like one who has been operated on”

Dr. Mickey Moskowitz

Prof. Eliezer Shalu, chairman of the National Council for Women’s Medicine, former director of the women’s and obstetrics department at the Emek Hospital and dean of the Faculty of Medicine at the Technion, also refers to the controversial method and tells Mako Health that “the council thought that the issue required an examination, and commented on possible problems with the approach the French, however, babies die even after normal caesarean sections, so I don’t want to discuss or refer to the specific case that happened in the English hospital. It is possible that there was another problem related to the baby and not to the way of delivery.” According to him, in general, it is necessary for women to know the possible problems and risks, and for there to be an orderly and clear procedure. “There is no surgery that does not have both advantages and disadvantages. It is known that the way to remove the newborn in the French approach is slower and more complicated to a certain extent, it is also a matter of different skills than the usual caesarean section. On the other hand, surgery has its advantages, and the mother in the end has to decide if she prefers to take the risk.”

Along with those who support the procedure, there are also doctors whose position is the same as the position of the Ministry of Health and who strongly oppose the French caesarean section. Prof. Tal Biron-Shantal, an expert in gynecology and high-risk pregnancy, says that “caesarean section is not accepted in Israel and in the world and for good reason. In caesarean section, the extraction of the newborn is more difficult and more problematic and therefore puts the baby at risk. In most cases forceps are used to remove it because the space created to remove the baby is smaller and tighter. The method has not been proven to improve the women’s recovery. Not only does it have no advantages, it also poses a risk to newborns. This is the reason why the managers of the women’s departments in Israel rejected the method after examining it and carefully going over the literature, it is not performed in the world except in one or two centers and is not recommended by any professional organization in the world. In Israel it is performed by only one doctor, at the English Hospital in Nazareth and only privately. It’s not accidental.’

The response of the Ministry of Health:

The Ministry of Health cares for the health of patients and newborns and respects the free choice of every woman. Any other claim is fundamentally unfounded. The Ministry of Health approved the operation after the completion of the work of a professional committee that examined all the considerations and data, and included hospital managers, directors of maternity and newborn departments, chairmen of the relevant professional unions, and more. One of the considerations for approving the operation was, among other things, maintaining the women’s autonomy, on the condition that the woman giving birth be informed of the risks associated with this specific operation, which are additional to a caesarean section.

The decision on the indications for surgery, contraindications and the manner of performing medical operations, including surgical methods, is the responsibility and discretion of the managers of the hospitals and departments, based on the professional literature and position papers of the professional bodies. It will be clarified that births, including cesarean sections, are financed by the National Insurance and are not part of the health basket.