Clinical Review

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

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

Caren M. Stalburg, MD, MA

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

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IN THIS ARTICLE

What the NIH Conference concluded
Risks and benefits of planned C-section
An algorithm for decision making

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.

Fast Track

In the United States in 2004, 18% of births, or nearly 750,000, involved primary C-section

NIH panel: With planned C-section, the frequency of postpartum hemorrhage is lower than with combined planned vaginal delivery and unplanned C-section

There is a risk of iatrogenic prematurity with scheduled C-section

C-section protected against intracranial hemorrhage, neonatal asphyxia, encephalopathy, birth injury, and neonatal infection

Women who opt for elective cesarean for their first delivery may be committing themselves to C-section with subsequent deliveries

In some states, a patient who elects a scheduled C-section at term without obstetric indications may be required to pay for her obstetric care

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