Cesarean delivery on
maternal request
INTRODUCTION — Cesarean
delivery on maternal request refers to a primary cesarean delivery performed
because the mother requests this method of delivery in the absence of standard
medical or obstetrical indications for avoiding vaginal birth. The right of
patients to be actively involved in treatment decisions, including method of
delivery, is now widely accepted by physicians and patients
In a well-informed patient, performing a cesarean delivery on maternal
request is considered medically and ethically acceptable; in-depth reviews of
the ethical issues are available elsewhere.
However, obstetricians are not obliged ethically or professionally to
perform these procedures; early referral to another health care practitioner is
appropriate in such cases .
PLANNED CESAREAN
VERSUS PLANNED VAGINAL DELIVERY
No randomized trials on cesarean delivery for
nonmedical reasons have been performed [18]. Thus, it is
important to appreciate that conclusions about the risks and benefits of
cesarean delivery on maternal request are not based upon high quality evidence
and that the available data have serious methodological issues or provide
indirect evidence from studies on cesareans performed for breech presentation.
The risks and benefits of cesarean delivery on maternal request need to
be weighed against the potential outcomes from a planned vaginal delivery:
uncomplicated spontaneous vaginal birth, operative vaginal delivery (vacuum or
forceps), or cesarean delivery during labor because of problems such as
abnormal progress of labor or nonreassuring fetal heart rate pattern.
The patient and provider also
need to take into account patient-specific issues when estimating the risks and
benefits of planned cesarean delivery.
Comorbid medical conditions, body
mass index (BMI), future reproductive plans, prior childbirth experiences,
outcome of previous surgical procedures, and the patient's personal philosophy
about childbirth must be considered when choosing the method of delivery.
It is also important to inquire about the motivation for the request.
Are there family pressures that should be discussed? Concerns about pain may be
addressed by providing detailed information about obstetrical analgesia and
anesthesia, as well as consultation with an anesthesiologist.
Fear and anxiety stemming from previous childbirth, personal trauma, or
the experiences of friends and family should also be addressed. Providing these
women with the best available information about pertinent childbirth issues and
appropriate support may alleviate some of their concerns about attempted
vaginal birth.
The decision as to whether or not to proceed with cesarean delivery
should not be based on financial considerations.
REASONS WOMEN OPT FOR
CESAREAN DELIVERY ON REQUEST — Reasons for choosing cesarean on
request include:
- Convenience of scheduled delivery
- Fear of the pain, process, and complications
of labor
- Prior poor labor experiences
- Concerns about fetal harm from labor and
vaginal birth
- Concerns about developing anal and/or urinary incontinence from
labor and vaginal birth
- Worries about the need for and risks of
emergent cesarean or operative vaginal delivery
A patient’s statement during a case conference published in a journal
summarizes the opinion of some women: “I feel like there's a lot more that can
go wrong in a natural birth for the baby than can go wrong in the C-section for
the mom, and I feel like I’m more willing to take something happening to me
than something happening to my baby” [21].
POTENTIAL BENEFITS OF
PLANNED CESAREAN — Although no randomized trials have been completed, planned
cesarean delivery may have several potential benefits over planned vaginal
birth.
Known endpoint — A
planned cesarean delivery is usually scheduled. A known endpoint to the
pregnancy facilitates issues related to work, child care, and help at home for
the mother and her partner. It also provides an opportunity to schedule surgery
with a particular provider.
On the other hand, if a known endpoint is the goal, induction of labor
is a reasonable alternative, although induction may fail and lead to
unscheduled cesarean delivery.
Avoidance of postterm
pregnancy — Planned cesarean deliveries are typically scheduled between
39 and 40 weeks of gestation. Thus, postterm pregnancy, which is associated
with higher rates of perinatal morbidity and mortality than pregnancies
delivering at term, can be avoided.
On the other hand, if avoidance of postterm pregnancy is the goal, then
induction of labor is a reasonable alternative, although induction may fail and
lead to unscheduled cesarean delivery.
Reduction of risks
associated with unplanned surgery — An emergency cesarean
delivery is often a traumatic experience for women, and has been associated
with postnatal depression and posttraumatic stress. Emergency surgery is also
associated with slightly higher maternal and fetal risks than elective surgery.
These risks include, but are not limited to, infection, accidental injury to
abdominal organs, fetal laceration during hysterotomy, hemorrhage, and
anesthesia-related complications.
Prevention of late
stillbirth — Once the fetus is delivered, it is no longer at risk of
intrauterine fetal demise and other complications of pregnancy. The clinically
relevant question is: "How many fetuses reach maturity in-utero and are
then involved in a catastrophe leading to severe neurologic damage or perinatal
death?" [28]. The literature
suggests that 1 in 500 to 1 in 1750 fetuses reach maturity in-utero and are subsequently
involved in a catastrophe resulting in death or severe disability, the
frequency of intrapartum fetal death is even lower (estimated as 1 in 5000
births. The large range in frequency is not surprising since many elements of
the calculation cannot be defined with precision. It is clear that timely
prophylactic cesarean delivery at term would save some babies destined for
disaster; however, only one stillbirth would be prevented per approximately
1200 surgeries at 39 weeks of gestation.
Reduction in
nonrespiratory neonatal disorders — Cesarean delivery prior to
the onset of labor reduces or eliminates fetal morbidity and mortality related
to the process of labor and vaginal birth. Intrapartum complications that are
potentially reduced or avoided include brachial plexus injury related to
shoulder dystocia, bone trauma (fracture of clavicle, skull, humerus), and
asphyxia related in intrapartum events (eg, umbilical cord prolapse, abruptio
placentae, uterine rupture).
Reduction in risk of
pelvic floor injury — Fear of perineal injury and urinary and fecal incontinence
from labor and vaginal delivery is a common reason for maternal request
cesarean delivery; however, these concerns are not based on high quality
evidence.
Fewer women have urinary incontinence in the months after planned
cesarean delivery but, in the Term Breech Trial, urinary incontinence rates two
and five years after delivery were not significantly different between women who
planned cesarean delivery and those who planned vaginal births . In addition,
planned cesarean delivery did not appear to confer protection against fecal
incontinence compared to planned vaginal delivery. In contrast, another study
of women 5 to 10 years after delivery compared outcomes between those who had
had cesarean deliveries without labor (n = 200), those who had cesarean
deliveries in labor (n = 400), and the remainder who had a spontaneous or
operative vaginal delivery (n = 400). Compared to women with only cesarean
deliveries before labor, the risk of pelvic organ prolapse was increased in
women with a history of spontaneous vaginal birth or operative vaginal birth
(adjusted OR 5.64, 95% CI 2.16-14.70 and aOR 7.50, 95% CI 2.70-20.87,
respectively).
Thus, it appears cesarean delivery on maternal request may reduce the
long-term risk of pelvic organ prolapse. However, the relationships between
pelvic organprolapse/urinary incontinence/anal incontinence and pregnancy/labor/vaginal delivery/cesarean delivery are not yet
well defined.
POTENTIAL
DISADVANTAGES AND RISKS OF PLANNED CESAREAN — In addition to the concern
that planned cesarean delivery is “not natural,” objections to planned cesarean
include:
- Increased risk of anesthetic complications
- Longer recovery period (hospitalization and
post-hospitalization), which may interfere with mother-infant interactions
- Increased maternal morbidity related to
surgery (eg, organ injury, wound infection, thromboembolism,
intraabdominal adhesions)
- Increased risk of neonatal respiratory
problems
- Increased risk of abnormal placentation in
future pregnancies
- Increased risk of uterine rupture in future
pregnancies
- Cost
Anesthetic
complications — Given the need for surgical level anesthesia, planned
cesarean is associated with a higher rate of failed regional anesthesia and
conversion to general anesthesia than planned vaginal delivery.
Longer recovery
period — The postpartum recovery period is longer after cesarean
delivery than after vaginal delivery, and the duration of hospitalization after
delivery may be longer after cesarean, as well. By three months postpartum,
however, pain scores after planned cesarean and planned vaginal delivery are
similar.
Increased maternal
morbidity — Maternal morbidity appears to be higher with planned
cesarean delivery than with planned vaginal delivery. In one of the largest
series, composite severe morbidity after planned cesarean and planned vaginal
delivery was 27.3 and 9.0 per 1000 deliveries, respectively (OR 3.1, 95% CI
3.0-3.3).
Compared to the planned vaginal delivery group, the
planned cesarean group had a significantly higher postpartum risk of cardiac
arrest (OR 5.1), wound hematoma (OR 5.1), hysterectomy (OR 3.2), major puerperal
infection (OR 3.0), anesthetic complications (OR 2.3), venous thromboembolism
(OR 2.2) and hemorrhage requiring hysterectomy (OR 2.1).
Increased risk of
respiratory problems in offspring — Neonatal respiratory
problems (eg, respiratory distress syndrome, transient tachypnea of the
newborn) are more common after elective cesarean than after vaginal delivery,
and may lengthen the neonate's hospital stay .
This was illustrated in a study that found the
incidence of respiratory problems for neonates delivered by cesarean before the
onset of labor was 35.5/1000, which was
significantly higher than that for neonates who underwent cesarean during labor (12.2/1000) or vaginal delivery (5.3/1000) . An association
between elective cesarean delivery and asthma and bronchiolitis has also been
reported.
Respiratory problems are more frequent after cesarean delivery without
labor because mechanisms to reabsorb lung fluid are not fully activated and,
sometimes, as a result of iatrogenic prematurity. However, respiratory distress
related to prematurity is virtually eliminated if delivery occurs after 39.0
weeks of gestation. The American College of Obstetricians and Gynecologists
(ACOG) recommends that cesarean delivery on maternal request be performed at
≥39 weeks of gestation.
Increased neonatal
mortality — A population-based study used birth certificate data and an
intention-to-treat methodology to examine the risk of neonatal mortality for
low-risk births by method of delivery. All United States live births and infant
deaths from 1999 to 2002 (8,026,415 births and 17,412 infant deaths) were
examined. Low-risk births were defined as singleton, term, vertex births with
no medical risk factors, placenta previa, or prior cesarean delivery noted on
the birth certificate. The "planned vaginal delivery" group consisted
of vaginal births and those cesareans performed in the setting of labor
complications or procedures (n = 7,755,236), while the "planned cesarean
delivery" group comprised women who underwent cesareans with no documented
labor complications or procedures (n = 271,179). After adjustment for maternal
age, race/ethnicity, education, parity,
smoking, infant birthweight, gestational age, and exclusion of infants with
congenital anomalies, the odds of neonatal death with "planned cesarean
delivery" were significantly higher than with "planned vaginal
delivery" (OR 1.93, 95% CI 1.67-2.24). The accuracy of these findings is
limited by (1) reliance on birth certificate data, which can be inaccurate and
incomplete, (2) the absence of data on the indication for cesarean, and (3) the
absence of information on the causes of neonatal death.
A subsequent retrospective cohort study of 56,549 late-preterm and term
deliveries from Geneva, Switzerland also reported an increase in neonatal
mortality and clinically relevant morbidities (neonatal intensive care unit
[NICU] admission, respiratory problems) in term births by elective cesarean
delivery compared with planned vaginal delivery. The authors speculated that a
policy of restricted indications for elective cesarean delivery possibly
selected pregnancies with higher neonatal risk and thus may have led to an
overestimation of unfavorable outcomes.
Risks in future
pregnancies — Women considering planned cesarean delivery should consider
the consequences of this decision on future pregnancies. The relative risks and
benefits change as the number of cesarean deliveries increases.
Increased risk of
placental disorders — Placenta previa and accreta are significantly more common
in pregnancies following one or more cesarean deliveries, and increase with the
number of prior cesarean deliveries. Moreover, these complications may
necessitate cesarean hysterectomy. For this reason, cesarean delivery on
maternal request is not recommended for women desiring several children, given
that the risks of placenta previa, placenta accreta, and gravid hysterectomy
increase with each cesarean delivery.
First delivery by cesarean also may be associated with a higher risk of
abruptio placentae in future pregnancies.
Increased risk of
uterine rupture — Most uterine ruptures are related to a trial of labor after
a previous cesarean delivery. Uterine rupture may require hysterectomy and is
associated with an increased risk of fetal and maternal morbidity and
mortality.
Complications from
multiple abdominal surgeries — Adhesions increase the difficulty of
future intraabdominal surgical procedures, and may increase the risk of bladder
or bowel injury. There does not appear to be a causal relationship between
cesarean delivery and subfertility.
Stillbirth — The
effect of cesarean delivery on future stillbirth is controversial. A 2013
systematic review and meta-analysis reported a significant positive association
between cesarean delivery and stillbirth anytime in a subsequent gestation; the
significant association was present for both explained stillbirth (OR 2.1) and
unexplained stillbirth (OR 1.47) (but not unspecified stillbirth)
OUTCOMES THAT ARE
SIMILAR FOR BOTH PLANNED VAGINAL AND PLANNED CESAREAN BIRTH
Maternal mortality — Although
not of high quality, the available evidence suggests there is no significant
difference in maternal mortality for planned cesarean versus planned vaginal
delivery . There are no data specifically addressing the maternal death rate
for patient choice cesarean delivery. The lack of data is due, in large part,
to the absence of well-designed clinical trials, failure to analyze existing
data by intent (eg, classifying women in the vaginal delivery group if they
undergo emergency cesarean in the course of planned vaginal delivery), and the
rarity of maternal death in developed countries.
It is likely that the risk of maternal death from maternal request
cesarean delivery is similar to that with scheduled repeat cesarean delivery
prior to the onset of labor. This risk ranges from 1 in 5000 cesarean
deliveries to less than 1 in 70,000 cesarean deliveries.
If cesarean is more dangerous than vaginal delivery, then one would
expect a higher maternal mortality rate among populations with a high cesarean
delivery rate, but this association has not been demonstrated. In fact, using
national estimates of cesarean delivery rates after 1990 in 19 Latin American
countries, one study demonstrated that the highest maternal mortality was found
in populations in which the cesarean delivery rate was lowest. Although this
does not prove cause and effect, it does cast doubt on the assumption that
cesarean is more dangerous than vaginal delivery.
Postpartum sexual
function — Postpartum sexual function does not appear to be related to
method of delivery.
PHYSICIAN
RESPONSIBILITIES — Because data are limited and recommendations are uncertain,
the option of cesarean delivery on maternal request does not need not be
discussed with every patient. When asked about cesarean delivery on maternal
request, the clinician should find out the reasons for the patient’s request,
address her concerns and any misinformation leading to those concerns (eg,
unavailability of effective pain management), and provide a balanced discussion
over a series of visits about the risks and benefits (relative and absolute) of
the procedure with her, and possibly her support persons . Obstetricians are not obliged
ethically or professionally to perform cesarean delivery on maternal request;
early referral to another health care practitioner is appropriate in such cases.
INFORMATION FOR
PATIENTS — UpToDate offers two types of patient education materials,
“The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical
jargon.
SUMMARY AND
RECOMMENDATIONS
- Cesarean delivery on maternal request refers
to a primary cesarean delivery performed because the mother requests this
method of delivery in the absence of conventional medical or obstetrical
indications for avoiding vaginal birth.
- For patients considering a planned cesarean
delivery in the absence of standard indications for abdominal delivery, we
have a thorough discussion of potential benefits and risks. The best
available evidence suggests that planned cesarean delivery is associated
with a lower risk of fetal injury than planned vaginal delivery, but
longer hospital stay/recovery, an increased risk of
neonatal respiratory problems, a greater risk of abnormal placentation in
future pregnancies, and a greater risk of uterine rupture if a trial of
labor is attempted. Planned cesarean delivery minimizes the risk of
surgical complications associated with unplanned cesarean delivery, which
may be necessitated during attempted vaginal delivery.
- The patient and provider also need to take
into account patient-specific issues when estimating the risks and
benefits of planned cesarean delivery. Comorbid medical conditions, body
mass index (BMI), future reproductive plans, prior childbirth experiences,
outcome of previous surgical procedures, and the patient's personal
philosophy about childbirth must be considered when choosing the method of
delivery.
In addition, it is important to inquire about the motivation for the request, including work and family pressures, personal fears and anxieties, and concerns about pain. Providing women with the best available information about pertinent childbirth issues and appropriate support may alleviate some of their concerns about vaginal birth.
- For women planning several pregnancies, it is suggested avoiding cesarean delivery on
maternal request. Placenta previa and accreta are significantly more
common in pregnancies following one or more cesarean deliveries. Moreover,
these complications may necessitate cesarean hysterectomy. If the patient
undergoes a trial of labor in the future, she will be at increased risk of
uterine rupture.
- For scheduled cesarean deliveries, it is
suggested to scheduling the procedure at 39 to 40 weeks of gestation
rather than at 37 to 38 weeks (Grade 2B).
