Maternal request cesarean delivery

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 5^th to 6^th 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 10^th to 12^th 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).