Clinical Review

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

OBG Manag. 2008 May;20(5):58-68

References

1. Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice cesarean: an evidence-based review. Obstet Gynecol Surv. 2004;59:601-616.

2. Hopkins K. Are Brazilian women really choosing to deliver by cesarean? Soc Sci Med. 2000;51:725-740.

3. FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health. Ethical Issues in Obstetrics and Gynecology. November 2006. Available at www.figo.org/docs/Ethics%20Guidelines%20-%20English%20version%202006%20-2009.pdf. Accessed April 3, 2008.

4. ACOG Committee Opinion No 386: Cesarean delivery on maternal request. November 2007. Available at www.acog.org/publications/committee_opinions/co386.cfm. Accessed April 3, 2008.

5. National Institutes of Health state-of-the-science conference statement. Cesarean delivery on maternal request March 27-29, 2006. Obstet Gynecol. 2006;107:1386-1397.

6. Allen VM, O’Connell CM, Farrell SA, Baskett TF. Economic implications of method of delivery. Am J Obstet Gynecol. 2005;193:192-197.

7. McCourt C, Weaver J, Statham H, Beake S, Gamble J, Creedy DK. Elective cesarean section and decision making: a critical review of the literature. Birth. 2007;34:65-79.

8. Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth. 2007;34:316-322.

9. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. National Institute of Child Health and Human Development Maternal-Fetal Medicine Unit Network. Obstet Gynecol. 2006;107:1226-1232.

10. Chervenak FA, McCullough LB. An ethically justified algorithm for offering, recommending, and performing cesarean delivery and its application in managed care practice. Obstet Gynecol. 1996;87:302-305.

11. Newborns’ and Mothers’ Health Protection Act of 1996, 29 U S.C.S. §1185.

12. Laugesen MJ, Paul RR, Luft HS, Aubry W, Ganiats TG. A comparative analysis of mandated benefit laws, 1949-2002. Health Serv Res. 2006;41(3 pt 2):1081-1103.

13. National Center for Health Statistics Technical Appendix. Vital statistics of the United States, 2004. Vol. I: Natality. US Department of Heath and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Hyattsville, Md. Available at www.cdc.gov/nchs/nvss.htm. Accessed April 3, 2008.

14. National Vital Statistics Reports. Vol. 55, No. 12, April 19, 2007. Available at www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_12.pdf. Accessed April 3, 2008.

This raises the question: Is a scheduled C-section in the absence of obstetric indications dangerous? Harmful? Imprudent? The medical community has accepted these inherent tensions in the field of aesthetic plastic surgery, but societies in obstetrics and gynecology continue to struggle with the ethical principles involved in maternal-choice cesarean.

FIGO: C-section for nonmedical reasons is not justified

The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women’s Health bases its guidelines on the use of cesarean delivery for nonmedical reasons on the principles of beneficence and social justice. It concludes: “Cesarean section is a surgical intervention with potential hazards for both mother and child. It also uses more health-care resources than normal vaginal delivery…performing cesarean section for nonmedical reasons is ethically not justified.”³

ACOG: Individualize the decision consistent with ethical principles

The American College of Obstetricians and Gynecologists (ACOG), in a recent Committee Opinion, acknowledged the paucity of research data directly comparing cesarean delivery on maternal request with planned vaginal delivery. The document reviews the National Institutes of Health (NIH) State-of-the-Science Conference on Cesarean Delivery on Maternal Request (see below), which was convened in 2006, and notes the panel’s conclusion that the available body of evidence does not allow for a conclusive recommendation of one mode of delivery over another.⁴ The ACOG Committee Opinion states: “Any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.”⁵

Different world views likely account for different conclusions

The difference in the FIGO and ACOG positions may arise from differences in cultural contexts between a general world health view and a highly patient-centered Western perspective. The former view bases the decision on universal good and the utilization of scarce health-care resources; the latter view recognizes the individual within an ethical context.

Both views acknowledge the limited data available to inform the decision. So what do the data say, and how can we help our patients understand it?

NIH State-of-the-Science Conference

In March of 2006, an independent panel of experts from a range of medical fields reviewed the scientific literature regarding cesarean delivery on maternal request at the NIH in Bethesda, Maryland. Although the panel found no Level I, or strong, evidence within the literature, it was able to characterize the risks and benefits of maternal-request C-section based on Level II (moderate), Level III (weak), and Level IV (absent) evidence.

Moderate evidence was scarce

From a maternal perspective, the panel found that “the frequency of postpartum hemorrhage associated with planned cesarean delivery is lower than that reported with the combination of planned vaginal delivery and unplanned cesarean delivery,”⁵ although hospital stay is longer than with vaginal delivery.

From a neonatal perspective, moderate evidence favors vaginal delivery because of a decreased incidence of respiratory morbidity, such as transient tachypnea of the newborn and respiratory distress syndrome. Respiratory morbidity is directly related to gestational age, and there is a risk of iatrogenic prematurity with scheduled C-section. The possibility of incorrect obstetric dating would seem to favor awaiting the spontaneous onset of labor at term and an attempt at vaginal delivery to reduce the risk of respiratory complications due to iatrogenic prematurity.

Weak evidence goes both ways

Weakly supported evidence favored both cesarean section and vaginal delivery for either the mother or fetus. Weak evidence favoring vaginal delivery for maternal interests included:

decreased maternal infectious morbidity and anesthetic complications, compared with C-section
greater ease establishing breastfeeding, due to logistical challenges surrounding mother–infant bonding after C-section
greater freedom in planning family size because increasing numbers of repeat C-sections with subsequent pregnancies increase risk of uterine rupture, cesarean hysterectomy, and abnormal placentation.

Weak evidence supporting elective cesarean for maternal interests included:

lower rate of postpartum stress urinary incontinence, compared with women undergoing vaginal delivery, in the short term
lower risk of surgical morbidity and traumatic obstetric lacerations with elective C-section, compared with the injuries that can occur at the time of unscheduled C-section or vaginal delivery.

However, the committee was unable to document definitive evidence that favored one mode of delivery over the other in regard to long-term outcomes such as subsequent anorectal function, postpartum pain, postpartum depression, sexual function, pelvic pain, fistula formation, or venous thromboembolic disorder (TABLE).

Weak evidence of neonatal benefit

From the neonatal perspective, the NIH Consensus Committee found weak evidence favoring C-section. A scheduled C-section protects the neonate from stillbirth arising from postdates intrauterine fetal demise, because, with elective cesarean, a pregnancy is not usually allowed to continue post-term.