Clinical Review

Is patient-choice primary cesarean rational?

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If—and only if—the patient brings up the subject, says NIH, go ahead and counsel her on risks and benefits


 

References

CASE Is her request reasonable?

A 40-year-old primigravid woman presents for her first prenatal visit and asks for cesarean delivery. She explains that she has “waited all her life” for this baby and does not want to risk any harm to the infant during childbirth. She also admits that she is uncomfortable with the unpredictability of childbirth.

CASE Don’t try to dissuade her

The best way to handle this 40-year-old woman’s concerns is to avoid trying to change her mind. Instead, try to understand her view, which no doubt influences her experience of pregnancy, and do your best to remain unbiased as you gather information about her beliefs and constructs. Don’t fall into the trap of merely dispensing facts without her input, or the discussion will be unproductive.

When she reveals that other women have told her about their experiences with long labors and emergency cesarean delivery, you have an opening for discussion. Return to her concerns periodically during the course of antenatal care, telling her what to expect during pregnancy and delivery, and lay out the pros and cons of cesarean vs vaginal delivery. Other helpful resources are a second opinion, birthing classes, and prenatal yoga and expectant mothers’ groups. The next choice is up to you. Once she understands the fetal and maternal risks of cesarean delivery and still prefers an elective cesarean, the next choice is up to you. If you are morally opposed to the idea, refer the patient to another physician who would be willing to perform the cesarean delivery.

The patient should also consider how she will want to proceed if she presents in active labor before her scheduled cesarean section.

The request may be reasonable, but it is impossible to know without an extended discussion and an individualized decision.1-11

Requests for cesarean delivery are becoming more common as the cesarean delivery rate hits all-time highs and the media focuses greater attention on the risks inherent in labor and vaginal delivery. One indicator of the increasing incidence of maternal requests for elective cesarean is the recent State of the Science Conference on the subject, convened by the National Institutes of Health, March 27–29, 2006. (See for more on this conference.)

This article describes what considerations should go into the discussion of cesarean delivery on maternal request, including ways of predicting whether vaginal delivery will be successful, the importance of knowing the number of children desired, the need to observe key ethical principles, and the balancing act necessary between physician and patient autonomy.

Gauging the likelihood of safe vaginal delivery

Cesarean on demand, without a clinical indication, may be reasonable in some circumstances, although we lack data to prove that cesarean delivery is globally superior to vaginal delivery in terms of maternal and fetal morbidity and mortality.

Scoring systems may help. For example, maternal obesity is a leading risk factor for cesarean delivery, as are short height, advanced maternal age, large pregnancy weight gain, large birth weight, and increasing gestational age.12

Using scoring systems that assign values to these risk factors, one can reasonably predict a patient’s likelihood of undergoing cesarean delivery after attempted vaginal delivery.13,14

Fetal distress remains wild card

Unfortunately, these scoring tools cannot account for the unpredictability of “fetal distress,” which remains, along with shoulder dystocia, one of the main reasons for performing cesarean delivery in labor.15,16

Ethical concerns

The principles that guide medical decision-making and counseling are:

  • Respect for autonomy. The patient has a right to refuse or choose recommended treatments.
  • Beneficence. The physician is obligated to promote maternal and fetal well-being, and the patient is obligated to promote the well-being of her fetus.
  • Nonmaleficence centers on the goal of avoiding harm and complements the principle of beneficence.
  • Justice refers to fairness to the individual and physician and the impact on society.4-7

Consider both short- and long-term consequences

Epidemiologically, physicians bear responsibility for the short- and long-term impacts of their actions. For example, injudicious prescribing of antibiotics has led to drug resistance, and many patients now believe they have the right to request antibiotics for likely viral illness. In obstetrics, the lack of emphasis or counseling on breastfeeding created a cascade effect, which started with affluent women who rejected breastfeeding and eventually reached all socioeconomic groups.

TABLE

Maternal and fetal morbidity and mortality rates for planned vaginal and elective cesarean deliveries

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