An informed patient should be granted “cesarean on demand”



Every time I read an article written by an “expert” regarding cesarean section on demand, I roll my eyes. Dr. Stalburg regurgitates the tiresome ethics jargon, statistics, and recommendations from our infallible professional organizations. This is a classic illustration of the “town versus gown” phenomenon, in which academic physicians and community physicians most definitely do not see eye to eye. In this age of patient empowerment, does anyone really believe that an informed patient cannot determine the way her baby is delivered? To argue otherwise is old-fashioned paternalism.

My patients are bright and informed. I discuss with them the risks and benefits of cesarean section versus vaginal delivery, as I do with any treatment. A straightforward vaginal delivery is enjoyable, but a difficult one can be horrible. No matter how many studies are performed, it will forever be impossible to accurately predict which “low risk” patients will develop complications such as shoulder dystocia, pelvic floor damage, severe lacerations, dyspareunia, and so on. That is simply the nature of obstetrics.

One more point: If a patient is denied a C-section and a complication ensues….Well, I guess I don’t have to spell out the consequences.

Andrew Broselow, MD
Lubbock, Tex

Dr. Stalburg responds:

A reflexive response to a patient’s request serves no one

It seems that Dr. Broselow did not recognize the aim of my article, and I am grateful for the opportunity to clarify it for all who may have interpreted it as biased toward one viewpoint or another.

I completely agree that our patients are intelligent and well informed; hence, their presentation to our offices with an initial request for cesarean section. Our challenge, given the unpredictable nature of obstetrics specifically and the future in general, is to provide the best care possible within a patient-centered context. Understanding the request for cesarean section and factoring in future considerations such as family size, confounding medical issues, insurance coverage, and timing of the requested C-section, all fall under our aegis as the patient’s expertly informed partner in care. To ignore, deny, or discount those mitigating factors out of fear of litigation or because of one’s altered vision meets no one’s interest.

The intent of the article was to provide a well-rounded presentation of the multitude of issues involved when considering an elective primary cesarean section—a presentation based on available evidence and designed to help each provider partner with his or her patient to determine the best plan of care. One gown-size does not fit all, and rather than reflexively granting or rejecting a patient’s request, I would hope that we would engage in a deliberate discussion to provide a focused view of the issues for the patient and ourselves.

NOTE: At a plenary session at the recent ACOG annual meeting, there was agreement that a standardized informed consent form for elective cesarean delivery would be useful, and one is currently in development at the College (personal communication MDP).

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