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.

The Committee also documented protection from intracranial hemorrhage, neonatal asphyxia, encephalopathy, birth injury, and neonatal infection with C-section, compared with vaginal delivery.⁵

The socioeconomic picture matters

From a socioeconomic standpoint, women who request C-section may have financial concerns such as the amount of time off from work that may be necessary for both themselves and their partners. The availability of family support may be relevant and improved if a specific time frame for delivery is anticipated.

In many cultures, “lucky days” exist, and women may have preferences or aspirations for their child to be born on one of them.

Last, although it may be more cost-effective for a patient to undergo vaginal delivery, we, as health-care providers, cannot predict who will be successful in that regard. A complicated labor that necessitates unscheduled, urgent, or emergent C-section costs more in health-care dollars than does a C-section without labor.

Canadian researchers in 2005 examined the hospital care costs over 18 years in 27,614 pregnancies associated with varying types of delivery and found that the cost of delivery was highest for a C-section performed after the onset of labor ($2,137). The lowest cost was for spontaneous vaginal delivery ($1,340), followed by C-section without labor ($1,532).⁶ Therefore, some could argue that the overall cost to the patient and system is lower with a scheduled cesarean delivery because it avoids the other possible comorbidities and utilization of resources.

TABLE

Risks and benefits of planned cesarean delivery

BENEFIT	RISK	UNCLEAR EFFECTS
The mother
Protection against urinary incontinence Decreased surgical complications Decreased risk of postpartum hemorrhage Cultural factors Availability of social support Economic advantage	Increased length of stay Infection Anesthetic risk Subsequent placentation Difficulty breastfeeding Complication from future cesarean section Comorbidities related to obesity	Anorectal function Sexual function Pelvic organ prolapse Maternal mortality Postpartum pain Postpartum depression Thromboembolism
The child
Reduced mortality Decreased risk of intracranial hemorrhage Decreased risk of neonatal asphyxia Decreased risk of neonatal encephalopathy Decreased risk of brachial plexus injury	Iatrogenic prematurity Increased hospitalization Increased risk of respiratory complication	Breastfeeding Fetal laceration

When a patient raises the subject

Your first responsibility is to clarify her request. Key to this discussion is the patient’s reason for requesting a scheduled C-section. Many women—especially primiparous women—have a fear of labor itself, not to mention concerns about their safety and the safety of their baby.⁷ Another major concern to many women is the risk of injury to their perineum and pelvic floor.¹ These fears and concerns may motivate their request.

Educating patients about labor and discussing options for pain relief during labor can help soothe the patients’ fears. Clarifying long-term risks and benefits in regard to pelvic floor dysfunction also is important. Patients may have an unrealistic understanding of C-section and its potential complications. Often, education about the birth process and mode of delivery can alleviate a patient’s fears and change her hopes for delivery.

Explore any comorbidities

Because C-section is a major abdominal surgical procedure, maternal factors such as weight, age, surgical history, and medical comorbidities are relevant considerations when discussing the risks and benefits of cesarean in the absence of obstetric indications. Even in the absence of such comorbidities, certain risks of surgery should be clarified, including the risk of hemorrhage, infection, wound complication, thromboembolism, need for future surgery, and postoperative recovery.

The risks and benefits of vaginal delivery also should be discussed, including the factors that may lead up to an un-scheduled cesarean delivery despite the desire for a vaginal delivery.

How many children are planned?

Given the reluctance of health-care providers to manage attempted vaginal birth after C-section, women who opt for elective C-section for their first delivery may be committing themselves to C-section with subsequent pregnancies, too.⁸ Data suggest that an increasing number of C-sections place women at increasing risk of placenta accreta or previa, hysterectomy, blood transfusion, cystotomy, endometritis, prolonged operative time, and longer hospital stays. That said, overall maternal mortality from C-section remains low.⁹

Therefore, if a patient plans to have more than one or two children, she needs to understand the ramifications of repeat C-section at the time of her next delivery as well as in any additional pregnancies. Although a successful vaginal delivery cannot be guaranteed for any parturient, an attempt at vaginal delivery might be preferable for a woman hoping for a larger family.

Ensure clear consent

Chervenak and McCullough have provided an algorithm for offering C-section that balances the ethical concepts of autonomy and beneficence; that model is described above.¹⁰