Clinical Review

“Doctor, I want a C-section.” How should you respond?

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Is she motivated by a fear of childbirth or a true wish for C-section? Here’s how to identify candidates.



The author reports no financial relationships relevant to this article.

In general, when a patient inquires about elective primary C-section, it is best to consider the “6 C’s of elective cesarean” in a careful discussion with her. That approach entails consideration of the following:

  • Clarification of her request
  • Comorbidities in maternal health or surgical history
  • number of Children planned overall
  • clear Consent for the procedure
  • Correct determination of gestational age at the time of planned delivery
  • Confirmation of coverage by her insurance carrier.
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One trend is clear: Maternal requests for primary cesarean delivery are on the rise in the United States, although we lack precise data on exactly how fast the rate is rising. Many experts estimate it to be 4% to 18%.1 In Brazil, the rate of elective C-section for women in private hospitals is thought to be as high as 80% to 90%.2

As more celebrities and other prominent figures undergo elective C-section, more American women are beginning to ask for the same “privilege.” In this article, I lay out an evidence-based and ethically sensitive approach to counseling patients who request C-section on an elective basis.

How fast is maternal-request cesarean increasing?

In 2004, the United States saw 4.1 million births, 18% of which—or nearly 750,000—involved primary C-section.13 However, it is difficult to discern how many of these primary C-sections were performed for nonobstetric, or elective, indications, because such data are not routinely collected.

Birth certificates are changing

Efforts to improve birth certificate data have begun. In 2003, the revised US Standard Certificate of Live Birth was adopted by seven states, allowing for a more detailed description of births. The new certificate provides for more robust information in several areas, including

  • risk factors in the index pregnancy
  • obstetric procedures performed
  • characteristics of labor and delivery
  • method of delivery
  • normal conditions of the newborn
  • congenital anomalies in the newborn.

It also specifies whether or not a trial of labor was attempted before cesarean delivery, but it is limited by the inclusion of breech presentation in the statistics.14

Data collection remains an inexact science

Even with the new birth certificate data, it remains difficult to accurately quantify the number of nonobstetrically indicated primary C-sections, although many experts have estimated the rate at 4% to 28%.1

The points raised in the list that begins this article are all discussed here.

The difficulty of calculating the rate of primary C-section

We are limited by terminology and data-collection practices, as well as a multitude of confounding obstetric factors. Practicing providers recognize the inherent difference between a planned C-section at term without the onset of labor and an unplanned C-section at term after the onset of labor—as well as every scenario in between.

Unplanned C-section can be performed to address fetal compromise or an unsuccessful attempt at vaginal delivery—each scenario replete with its own risks and potential complications. The urgency of C-section also confounds subsequent maternal and fetal complications. Underlying maternal factors such as obesity and medical and surgical history further complicate the scenario.

For these reasons, the discussion of elective C-section is best managed by limiting the parameters considered to the requested, scheduled, elective C-section at term without maternal or fetal indications. Most patients have this paradigm in mind when they make their request, even though physicians and midwives understand that this is the ideal and not generally the reality.

Medicolegal and ethical considerations

The ethical principles surrounding cesarean delivery upon maternal request balance on the tension between beneficence and patient autonomy. The former requires the promotion of the patient’s overall health and well-being, along with attention to the closely related dictum, primum non nocere, or “first do no harm.”

Patient autonomy requires respectful consideration of the patient and her world view when making a medical decision. The ethical principle of patient autonomy is usually understood as a right to decline medical intervention—not necessarily to demand dangerous or unproven intervention.1


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