“Doctor, I want a C-section.” How should you respond?
Is she motivated by a fear of childbirth or a true wish for C-section? Here’s how to identify candidates.
IN THIS ARTICLE
If the patient requests C-section, but the clinician is uncomfortable performing one under the circumstances, referral is reasonable.
A patient’s thoughtful request can be considered out of respect for autonomy and supported by thorough counseling.
The decision to perform cesarean delivery is one of the most common clinical ethical challenges in obstetric practice today—“a challenge that will only increase with the growing influence of managed care,” observe Frank A. Chervenak, MD, and Laurence B. McCullough, PhD, who have written widely about ethical challenges in obstetrics and gynecology.10
In 1996, they proposed a model to help guide practitioners through the decision-making process of choosing cesarean delivery. According to that model, C-section is justified in four situations:
- when C-section is the only reasonable option based on clinical judgment, such as in a patient with a previous classical uterine incision. In this case, the clinician does not offer vaginal delivery but recommends only C-section based on beneficence
- when either C-section or vaginal delivery may be appropriate. This scenario warrants a clear discussion with the patient about the risks, benefits, and inherent controversy between delivery modes when all choices are equal in one’s best clinical judgment. An example might be the vertex/breech presentation of twins
- when vaginal delivery is preferable but C-section would also be indicated, such as in attempted vaginal birth after C-section
- when cesarean delivery is not generally supported over vaginal delivery, but the patient requests C-section and that request is based solely on autonomous principles. This is the case of cesarean delivery by maternal request, which necessitates clear counseling and education of the patient. Fear of pain is not a justifiable reason for cesarean delivery, because we can offer options for adequate pain management in labor.
Ensuring a correct gestational age
Once the decision to proceed with scheduled C-section is made, accurate determination of gestational age is crucial to avoid iatrogenic prematurity.
ACOG Educational Bulletin No. 230 (November 1996) lists a number of criteria by which to infer gestational age and, therefore, fetal lung maturity. The criteria include:
- documented fetal heart tone for 30 weeks by Doppler ultrasound
- 36 weeks having passed since reliable documentation of a positive urine or serum human chorionic gonadotropin pregnancy test
- crown–rump measurement by ultrasonography (US) at 6 to 11 weeks of gestation that supports the current gestational age of 39 weeks or more
- US measurement at 12 to 20 weeks’ gestation that supports the clinically determined estimated gestational age above 39 weeks.
Insurance concerns are vital to the decision
The Newborns’ and Mothers’ Health Protection Act (NMHPA) was passed in 1996. The law delineates a minimum requirement of coverage by insurers for hospital stays of 48 hours after vaginal delivery or 96 hours after C-section, thereby preventing health insurance plans from restricting hospital stays after delivery.11 The law was passed as a response to political concerns about “drive-thru deliveries.”
The NMHPA also allows for provider discretion regarding the length of stay required after childbirth, meaning that, if an attending-level provider deems discharge feasible in less than 48 or 96 hours, the insurer is not mandated to continue coverage beyond discharge.
The law, however, does not mandate coverage by health insurance plans for prenatal care, delivery, and postpartum care. Confounding the actions of health insurance companies are state laws governing the care of newborns and mothers, as these laws superceded the NMHPA. So, although most states have mandated benefit laws regarding a variety of services, as of 2002, only 18 states had laws mandating specific maternity services.12 Some states specifically mention elective C-sections as nonmandated services, meaning that a patient who elects a scheduled C-section at term without obstetric indications may be required to pay for her obstetric care.
