Is patient-choice primary cesarean rational?
If—and only if—the patient brings up the subject, says NIH, go ahead and counsel her on risks and benefits
IN THIS ARTICLE
BREAKING NEWS
| ADVERSE OUTCOMES | |
|---|---|
| PLANNED VAGINAL DELIVERY | ELECTIVE CESAREAN |
| FETAL OUTCOMES | |
| Mortality 1:3,400. All low-risk attempted vaginal deliveries, including those resulting in intrapartum cesarean delivery | Mortality None (n=1,048 low-risk parturients)‡ |
| Morbidity | Morbidity |
| Shoulder dystocia | Transient mild respiratory acidosis |
| Intrauterine hypoxia* | Laceration |
| Fracture of clavicle, humerus, or skull | Fracture of clavicle, humerus, or skull32 |
| Intracranial hemorrhage 1:1,900 | Intracranial hemorrhage 1:2,050 |
| Facial nerve injury 1:3,030 | Facial nerve injury 1:2,040† |
| Brachial plexus injury 1:1,300† | Brachial plexus injury 1:2,400 |
| Convulsions 1:1,560 | Convulsions 1:1,160† |
| CNS depression 1:3,230 | CNS depression 1:1,500† |
| Feeding difficulty 1:150 | Feeding difficulty 1:90† |
| Mechanical ventilation 1:390 | Mechanical ventilation 1:140† |
| Persistent pulmonary hypertension 1:1,240 | Persistent pulmonary hypertension 1:270† |
| Transient tachypnea of newborn 1:90 | Transient tachypnea of newborn 1:30† |
| Respiratory distress syndrome 1:640 | Respiratory distress syndrome 1:470† |
| MATERNAL OUTCOMES | |
| Mortality 1:8,570 | Mortality 1:2,131‡ |
| Morbidity | Morbidity |
| Urinary incontinence | Endometritis |
| Fecal/flatulence (rectal) incontinence | Wound infection |
| Hemorrhage | Hemorrhage |
| Deep venous thrombosis | Pelvic infection |
| Subjectively decreased vaginal tone | Deep venous thrombosis |
| Dyspareunia | Delayed breastfeeding/holding neonate |
| Latex allergy | |
| Endometriosis | |
| Adenomyosis | |
| Gallbladder disease | |
| Appendicitis | |
| lleus | |
| Operative complications (ureteral, GI injury) | |
| Scar tissue formation | |
| Controversial | |
| After 3 elective cesarean deliveries, minimal to no protection from urinary incontinence | |
| After menopause and visceroptosis from advancing age, many elderly, regardless of parity or mode of delivery, will have some incontinence25 | |
| * Increased cesarean delivery rate has not decreased incidence of cerebral palsy.33 | |
| † Statistical significance. | |
| ‡ Neonatal and infant mortality in Brazil has decreased with increasing frequency of elective cesarean delivery.34 | |
| SOURCE: Mortality data rounded and adapted from Richardson BS, et al,35 Levine EM, et al,36 or Lilford RJ, et al.37 Morbidity data rounded and adapted from Towner D, et al,38 or Lilford RJ, et al.37 | |
Will poorer women have equal access?
Women in lower socioeconomic groups should not receive substandard care; however, the inverse care “law” describes a disturbing reality: The availability of good medical care is inversely related to the need of the population served.17,18 Thus, the concept of justice, or taking into consideration the greater good for society, is relevant to the elective cesarean debate.
Costs and complications
Cost analysis has shown that expenditures are minimally increased by elective cesarean delivery at 39 weeks’ gestation, which also involves more efficient and predictable use of staffing resources.19
Parallel placenta accreta rate
The risk of morbidity and mortality associated with pregnancies exceeding 39 weeks’ gestation may be reduced.1 However, the 10-fold increase in placenta accreta over the past 50 years parallels the rise in cesarean deliveries.20
Fundamentals of patient counseling
Lay out benefits and risks
A detailed comparison of the relative benefits and risks of cesarean delivery (elective, intrapartum, and emergent) versus vaginal delivery (spontaneous, operative, and failed operative) is warranted, along with exploration of the patient’s fears and pressures.1-10,16
Unfortunately, trials comparing all these modes of delivery and all possible adverse outcomes are lacking. (A brief summary of adverse fetal and maternal outcomes is given in TABLE.) Operative vaginal delivery and intrapartum cesarean delivery generally do increase the risk of injury to maternal pelvic structures, as well as the risk of shoulder dystocia and fetal intracranial hemorrhage.
It is important to remain as unbiased as possible when counseling a patient, and to try to balance the conflict between your own autonomy and hers. Acting as a fiduciary for the patient should not involve suppressing your own sound medical judgment. Nor does it remove the patient’s responsibility to remain involved in her care.1-8
Although the patient’s right to refuse treatment is usually considered absolute, she can be prevented from demanding intervention when such intervention is not medically supported.2,4-6,21
Don’t forget future risks
Patients desiring elective cesarean delivery should be apprised of the complications that can arise in subsequent pregnancies.
Some women choose elective cesarean delivery to avoid the hazards of a trial of labor, but may not realize additional hazards, such as placenta accreta, can arise in pregnancies after a cesarean.
Although most women choosing to have only 2 children may experience no complications from elective primary and elective repeat cesarean delivery, some run the risk of placenta previa and possible accreta during the second gestation. These women may experience severe bleeding and require preterm repeat cesarean delivery with hysterectomy. Thus, it is vital to take the patient’s reproductive goals into consideration.
Fear of urinary and rectal incontinence is another reason women often give for desiring cesarean rather than vaginal delivery. However, Rortveit and colleagues22 demonstrated that incontinence affects most elderly women regardless of parity. In addition, it is possible that pregnancy itself contributes to pelvic organ prolapse.10,23,24
Be open to a second opinion
After counseling the patient about risks and benefits of elective cesarean delivery, raise the issue of a second opinion, and offer the appropriate referrals if one is desired.4-8,25
ObGyns and patients answer emphatically
BREAKING NEWS
OBG Management Senior, Editor Janelle Yates covered the NIH, Conference March 27–29, 2006 in Bethesda, MD., The panel’s draft statement is available online at https://consensus.nih.gov The final statement is expected this month.
Passions ran high at the NIH State of the Science Conference on Cesarean Delivery on Maternal Request, last month. On one side were the 17 panel members and Chair Mary E. D’Alton, MD, of Columbia University, who were charged with reviewing the data and responding to questions and comments from audience members—many of whom adamantly opposed patient-choice cesarean.
On the other side were audience members themselves: a mix of physicians, researchers, nurses, nurse-midwives, and the media.
At issue was whether patient choice even exists in obstetrics or is merely a byproduct of physicians’ unwitting influence over their patients.
“My doctor said it, so I did it”
Susan Dentzer, health correspondent for The NewsHour with Jim Lehrer, posed the question: “When is a request not really a request but a kind of going along with the moment, often with the provider’s strong preference, and electing the best of the options as they are presented to you at a particular point in time?”
Dentzer, a veteran of elective cesarean, had been invited to speak on the patient’s perspective. She later quipped: “Here’s my complicated decision-making process: My doctor said it, so I did it.”
One ObGyn’s perspective
Millie Sullivan Nelson, head of Obstetrics and Gynecology at the Christie Clinic in Champaign, Illinois, offered the general obstetrician’s point of view, zeroing in on the high-tech way of giving birth in the 21st century. Over the past 15 years, there has been “a subtle infusion of technology into obstetrics, the goal being to improve the quality of birth outcomes,” she said. “Today’s women may have up to 16 different tubes, drugs, or attachments during their labor process. No wonder some women choose cesarean delivery.”
Dr. Nelson offered a straightforward and engaging recitation of her family history to illustrate the dramatic changes in the typical childbirth experience over the past century. She noted that her maternal grandmother, born in 1895, suffered from rickets, yet beat the odds by giving birth to 4 children—all via cesarean section with vertical incisions. Dr. Nelson’s mother, born in 1926, had 12 children by spontaneous vaginal delivery—5 of them breech presentations. All 12 deliveries took place in “an era of minimal intervention,” she observed.
Dr. Nelson herself had 4 vaginal deliveries. “All of my deliveries were induced to facilitate my personal professional life and that of my obstetrician, who was my partner,” she said. In contrast to her mother and grandmother, who labored and delivered in 2 different rooms, Dr. Nelson had continuous fetal monitoring, her family at her bedside, and delivery in the same room where her labors took place. All 4 deliveries were videotaped.
Too posh to push?
“Now what about today’s woman?” Dr. Nelson asked, choosing pop idol Britney Spears as an example. When Spears chose primary cesarean as her preferred method of delivery, the tabloids accused her of being “too posh to push.”
Despite the furor in some quarters, Dr. Nelson believes times have changed. “My personal opinion is that there has been a gradual acceptance of cesarean section as an option for women, both on the part of the patient and the physician.”
Insurers still behind the curve
Another force shaping the debate is the insurance industry, Dr. Nelson noted. “In my community, precertification of all electively scheduled cesarean sections is required.” When a patient recently asked for cesarean delivery—she was 4 foot 11 and estimated fetal weight was 4,000 g—the insurer refused. The outcome: The woman had “first-stage arrest of labor and descent and ultimately went to cesarean section after 18 hours of labor.”
Litigation for unnecessary cesarean?
Dr. Nelson brought up one of the most influential factors in the cesarean-on-demand debate—the threat of lawsuits: “To my knowledge, there is no history of litigation for unnecessary cesarean section,” she said. “My patient is a consumer of services; I am the supplier of that service. It is a win-lose situation. She expects no pain and suffering and an outcome with zero tolerance for error. She demands 6-sigma quality—and when things go wrong she holds me responsible.”
Attention creates demand
Some attendees were frustrated by the increasing focus on cesarean delivery in general, claiming it raises the profile of cesarean section even further. Better to turn attention to ways of improving vaginal delivery, said Wendy Ponte of Mothering magazine. “When does the NIH plan to hold a similar state-of-the-science conference on optimal vaginal birth practices?”
THE PANEL’S FINDINGS
- Not enough data. There is insufficient evidence “to fully evaluate the benefits and risks of cesarean delivery by maternal request as compared to planned vaginal delivery,” said Dr. D’Alton. Therefore, “any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.”
- Not for women wanting large families. “Given that the risks of placenta previa and accreta rise with each cesarean delivery,” said Dr. D’Alton, “cesarean delivery by maternal request is not recommended for women desiring several children.”
- Not before 39 weeks. The increased incidence of respiratory morbidity in term and near-term infants delivered via C-section, “has been well documented in the literature and accounts for a significant number of admissions to intensive care units worldwide,” according to presenter Lucky Jain, MD, MBA, from the Emory University Department of Pediatrics. The panel’s conclusion: “Cesarean delivery by maternal request should not be performed prior to 39 weeks or without verification of lung maturity because of the significant danger of neonatal respiratory complications.”
- Pain of childbirth should not be an issue. Women should be offered adequate analgesia during vaginal delivery so that avoidance of pain is not a reason for requesting cesarean delivery.
- Let the patient raise the subject. The patient should be the one to raise the issue of cesarean delivery by maternal request. “We do not believe it should be brought up by the provider to the patient,” said Dr. D’Alton, adding that, when the patient raises the subject, “a discussion should take place.”
- Forget the notion of a target rate. As panel member Michael Brunskill Bracken, PhD, MPH, of Yale University, explained: “The position that the panel has taken is that rather than create an artificial number, we should concentrate on having modes of delivery that are optimal for the mother and child. And if we can achieve that, then the total C-section rate will be whatever it is, but it will reflect optimal C-sections within a particular population.”
