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Clinical Reviews


Is patient-choice primary cesarean rational?

If—and only if—the patient brings up the subject, says NIH, go ahead and counsel her on risks and benefits

May 2006 · Vol. 18, No. 5

IN THIS ARTICLE

BREAKING NEWS

CASE Is her request reasonable?

A 40-year-old primigravid woman presents for her first prenatal visit and asks for cesarean delivery. She explains that she has “waited all her life” for this baby and does not want to risk any harm to the infant during childbirth. She also admits that she is uncomfortable with the unpredictability of childbirth.

CASE Don’t try to dissuade her

The best way to handle this 40-year-old woman’s concerns is to avoid trying to change her mind. Instead, try to understand her view, which no doubt influences her experience of pregnancy, and do your best to remain unbiased as you gather information about her beliefs and constructs. Don’t fall into the trap of merely dispensing facts without her input, or the discussion will be unproductive.

When she reveals that other women have told her about their experiences with long labors and emergency cesarean delivery, you have an opening for discussion. Return to her concerns periodically during the course of antenatal care, telling her what to expect during pregnancy and delivery, and lay out the pros and cons of cesarean vs vaginal delivery. Other helpful resources are a second opinion, birthing classes, and prenatal yoga and expectant mothers’ groups. The next choice is up to you. Once she understands the fetal and maternal risks of cesarean delivery and still prefers an elective cesarean, the next choice is up to you. If you are morally opposed to the idea, refer the patient to another physician who would be willing to perform the cesarean delivery.

The patient should also consider how she will want to proceed if she presents in active labor before her scheduled cesarean section.

The request may be reasonable, but it is impossible to know without an extended discussion and an individualized decision.1-11

Requests for cesarean delivery are becoming more common as the cesarean delivery rate hits all-time highs and the media focuses greater attention on the risks inherent in labor and vaginal delivery. One indicator of the increasing incidence of maternal requests for elective cesarean is the recent State of the Science Conference on the subject, convened by the National Institutes of Health, March 27–29, 2006. (See for more on this conference.)

This article describes what considerations should go into the discussion of cesarean delivery on maternal request, including ways of predicting whether vaginal delivery will be successful, the importance of knowing the number of children desired, the need to observe key ethical principles, and the balancing act necessary between physician and patient autonomy.

Gauging the likelihood of safe vaginal delivery

Cesarean on demand, without a clinical indication, may be reasonable in some circumstances, although we lack data to prove that cesarean delivery is globally superior to vaginal delivery in terms of maternal and fetal morbidity and mortality.

Scoring systems may help. For example, maternal obesity is a leading risk factor for cesarean delivery, as are short height, advanced maternal age, large pregnancy weight gain, large birth weight, and increasing gestational age.12

Using scoring systems that assign values to these risk factors, one can reasonably predict a patient’s likelihood of undergoing cesarean delivery after attempted vaginal delivery.13,14

Fetal distress remains wild card

Unfortunately, these scoring tools cannot account for the unpredictability of “fetal distress,” which remains, along with shoulder dystocia, one of the main reasons for performing cesarean delivery in labor.15,16

Ethical concerns

The principles that guide medical decision-making and counseling are:

  • Respect for autonomy. The patient has a right to refuse or choose recommended treatments.
  • Beneficence. The physician is obligated to promote maternal and fetal well-being, and the patient is obligated to promote the well-being of her fetus.
  • Nonmaleficence centers on the goal of avoiding harm and complements the principle of beneficence.
  • Justice refers to fairness to the individual and physician and the impact on society.4-7

Consider both short- and long-term consequences

Epidemiologically, physicians bear responsibility for the short- and long-term impacts of their actions. For example, injudicious prescribing of antibiotics has led to drug resistance, and many patients now believe they have the right to request antibiotics for likely viral illness. In obstetrics, the lack of emphasis or counseling on breastfeeding created a cascade effect, which started with affluent women who rejected breastfeeding and eventually reached all socioeconomic groups.

TABLE

Maternal and fetal morbidity and mortality rates for planned vaginal and elective cesarean deliveries

ADVERSE OUTCOMES

PLANNED VAGINAL DELIVERY

ELECTIVE CESAREAN

FETAL OUTCOMES

Mortality 1:3,400. All low-risk attempted vaginal deliveries, including those resulting in intrapartum cesarean delivery

Mortality None (n=1,048 low-risk parturients)

Morbidity

Morbidity

Shoulder dystocia

Transient mild respiratory acidosis

Intrauterine hypoxia*

Laceration

Fracture of clavicle, humerus, or skull

Fracture of clavicle, humerus, or skull32

Intracranial hemorrhage 1:1,900

Intracranial hemorrhage 1:2,050

Facial nerve injury 1:3,030

Facial nerve injury 1:2,040

Brachial plexus injury 1:1,300

Brachial plexus injury 1:2,400

Convulsions 1:1,560

Convulsions 1:1,160

CNS depression 1:3,230

CNS depression 1:1,500

Feeding difficulty 1:150

Feeding difficulty 1:90

Mechanical ventilation 1:390

Mechanical ventilation 1:140

Persistent pulmonary hypertension 1:1,240

Persistent pulmonary hypertension 1:270

Transient tachypnea of newborn 1:90

Transient tachypnea of newborn 1:30

Respiratory distress syndrome 1:640

Respiratory distress syndrome 1:470

MATERNAL OUTCOMES

Mortality 1:8,570

Mortality 1:2,131

Morbidity

Morbidity

Urinary incontinence

Endometritis

Fecal/flatulence (rectal) incontinence

Wound infection

Hemorrhage

Hemorrhage

Deep venous thrombosis

Pelvic infection

Subjectively decreased vaginal tone

Deep venous thrombosis

Dyspareunia

Delayed breastfeeding/holding neonate

Latex allergy

Endometriosis

Adenomyosis

Gallbladder disease

Appendicitis

lleus

Operative complications (ureteral, GI injury)

Scar tissue formation

Controversial

After 3 elective cesarean deliveries, minimal to no protection from urinary incontinence

After menopause and visceroptosis from advancing age, many elderly, regardless of parity or mode of delivery, will have some incontinence25

* Increased cesarean delivery rate has not decreased incidence of cerebral palsy.33

† Statistical significance.

‡ Neonatal and infant mortality in Brazil has decreased with increasing frequency of elective cesarean delivery.34

SOURCE: Mortality data rounded and adapted from Richardson BS, et al,35 Levine EM, et al,36 or Lilford RJ, et al.37 Morbidity data rounded and adapted from Towner D, et al,38 or Lilford RJ, et al.37

Will poorer women have equal access?

Women in lower socioeconomic groups should not receive substandard care; however, the inverse care “law” describes a disturbing reality: The availability of good medical care is inversely related to the need of the population served.17,18 Thus, the concept of justice, or taking into consideration the greater good for society, is relevant to the elective cesarean debate.

Costs and complications

Cost analysis has shown that expenditures are minimally increased by elective cesarean delivery at 39 weeks’ gestation, which also involves more efficient and predictable use of staffing resources.19

Parallel placenta accreta rate

The risk of morbidity and mortality associated with pregnancies exceeding 39 weeks’ gestation may be reduced.1 However, the 10-fold increase in placenta accreta over the past 50 years parallels the rise in cesarean deliveries.20

Fundamentals of patient counseling

Lay out benefits and risks

A detailed comparison of the relative benefits and risks of cesarean delivery (elective, intrapartum, and emergent) versus vaginal delivery (spontaneous, operative, and failed operative) is warranted, along with exploration of the patient’s fears and pressures.1-10,16

Unfortunately, trials comparing all these modes of delivery and all possible adverse outcomes are lacking. (A brief summary of adverse fetal and maternal outcomes is given in TABLE.) Operative vaginal delivery and intrapartum cesarean delivery generally do increase the risk of injury to maternal pelvic structures, as well as the risk of shoulder dystocia and fetal intracranial hemorrhage.

It is important to remain as unbiased as possible when counseling a patient, and to try to balance the conflict between your own autonomy and hers. Acting as a fiduciary for the patient should not involve suppressing your own sound medical judgment. Nor does it remove the patient’s responsibility to remain involved in her care.1-8

Although the patient’s right to refuse treatment is usually considered absolute, she can be prevented from demanding intervention when such intervention is not medically supported.2,4-6,21

Don’t forget future risks

Patients desiring elective cesarean delivery should be apprised of the complications that can arise in subsequent pregnancies.

Some women choose elective cesarean delivery to avoid the hazards of a trial of labor, but may not realize additional hazards, such as placenta accreta, can arise in pregnancies after a cesarean.

Although most women choosing to have only 2 children may experience no complications from elective primary and elective repeat cesarean delivery, some run the risk of placenta previa and possible accreta during the second gestation. These women may experience severe bleeding and require preterm repeat cesarean delivery with hysterectomy. Thus, it is vital to take the patient’s reproductive goals into consideration.

Fear of urinary and rectal incontinence is another reason women often give for desiring cesarean rather than vaginal delivery. However, Rortveit and colleagues22 demonstrated that incontinence affects most elderly women regardless of parity. In addition, it is possible that pregnancy itself contributes to pelvic organ prolapse.10,23,24

Be open to a second opinion

After counseling the patient about risks and benefits of elective cesarean delivery, raise the issue of a second opinion, and offer the appropriate referrals if one is desired.4-8,25

NIH asks Is patient-choice primary cesarean rational?
ObGyns and patients answer emphatically

BREAKING NEWS

OBG Management Senior, Editor Janelle Yates covered the NIH, Conference March 27–29, 2006 in Bethesda, MD., The panel’s draft statement is available online at consensus.nih.gov The final statement is expected this month.

Passions ran high at the NIH State of the Science Conference on Cesarean Delivery on Maternal Request, last month. On one side were the 17 panel members and Chair Mary E. D’Alton, MD, of Columbia University, who were charged with reviewing the data and responding to questions and comments from audience members—many of whom adamantly opposed patient-choice cesarean.

On the other side were audience members themselves: a mix of physicians, researchers, nurses, nurse-midwives, and the media.

At issue was whether patient choice even exists in obstetrics or is merely a byproduct of physicians’ unwitting influence over their patients.

“My doctor said it, so I did it”

Susan Dentzer, health correspondent for The NewsHour with Jim Lehrer, posed the question: “When is a request not really a request but a kind of going along with the moment, often with the provider’s strong preference, and electing the best of the options as they are presented to you at a particular point in time?”

Dentzer, a veteran of elective cesarean, had been invited to speak on the patient’s perspective. She later quipped: “Here’s my complicated decision-making process: My doctor said it, so I did it.”

One ObGyn’s perspective

Continued...
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