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| REVIEW ARTICLE |
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| Year : 2013 | Volume
: 2
| Issue : 3 | Page : 141-145 |
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Cesarean delivery on maternal request
Ananya Das
Department of Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
| Date of Web Publication | 14-Feb-2014 |
Correspondence Address:
Ananya Das
Department of Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong - 793 018, Meghalaya
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2278-0521.127034
Cesarean delivery on maternal request has been producing a mirror of conflicts, which every obstetrician has to face in day-to-day practice. A mother requesting for cesarean reflects the common belief in society that elective cesarean is safer than vaginal delivery in terms of both fetus and mother. When a woman comes with the request of cesarean delivery, it should no doubt be individualized and considered keeping in view the mother's perspective, society, and also the evidence-based guidelines. Keywords: Cesarean delivery, maternal request, vaginal delivery
How to cite this article:
Das A. Cesarean delivery on maternal request. Saudi J Health Sci 2013;2:141-5 |
| Introduction | |  |
Bearing and rearing of babies is a wonderful experience exclusively bestowed upon females. With the anticipated fear and anxiety of labor and its pains, pregnant mothers especially primigravidas approach the obstetrician for elective cesarean section.
The cesarean delivery, though a rescue and sometimes a shortcut to life, has a long history. The Roman Lex Regia (ruling law), later the Lex Caesarea (imperial law), of Numa Pompilius (715-673 BCE), required the child of a mother dead in childbirth to be cut from her womb. [1] Although Cesarean sections were performed in Roman times, no classical source records a mother surviving such a delivery, [1] - the earliest recorded survival dates to the 12 th century scholar and physician Maimonides. The mother of Bindusara (born c. 320 BCE, ruled 298-c. 272 BCE), the second Mauryan Samrat (emperor) of India, accidentally consumed poison and died when she was close to delivering him. Chanakya, Chandragupta Maurya›s teacher and adviser, made up his mind that the baby should survive. He cut open the queen's belly and took out the baby, thus saving its life. [2] One of the earliest stories of performing cesarean is from 1411 when a German midwife claimed to have performed seven cesareans, where both the mother and child survived. [3] One of the highest mortality in cesarean history is due to its performance on an exhausted woman in labor for a few days. They died mostly because of puerperal infection, postpartum hemorrhage, postoperative ileus, and eclampsia. [4] When the knowledge of aseptic technique came in around the mid-18 th century, the mortality due to sepsis reduced by 25%. [5] The safety of cesarean section is derived largely from the evidence-based studies that elective cesarean section in experienced hands in the absence of contraindications can be almost as safe as a vaginal delivery for both the mother and baby.
Cesarean sections performed without medical indication, better known as cesarean delivery on maternal request (CDMR) have generated intense debate in recent times. Cesarean delivery on maternal request is defined as a primary prelabor cesarean delivery on maternal request in the absence of any maternal or fetal indications. It is estimated that 4-18% of all cesarean sections are done on maternal request; however, estimates are difficult to come by. [6] While uncommon in the past, a recent national audit in the United Kingdom revealed that 7% of all elective cesarean sections were performed for precisely this reason. [7] Not surprisingly, 69% of the obstetricians, when come across a woman requesting for cesarean delivery, would comply with such a wish. [8] The emergence of the maternal request cesarean section, as an entity, results from both the willingness of women to accept this intervention as well as that of their obstetricians to accede to this request.
The high rate of cesarean sections could be attributed to four main reasons; first is the lack of a dedicated obstetric anesthetic staff member to offer epidural analgesia within the labor wards; second, the more liberal view of cesarean section as an accepted mode of delivery by junior obstetricians, especially at the emergency unit; third, the observed low rate of successful vaginal birth after cesarean (VBAC) (22.23%); and fourth, the absence of any evidence of attempted instrumental (forceps and ventouse) deliveries in many instances where it may have been successful. [9]
| Why do women prefer cesarean section? | | |
While the reasons for this are varied, their elucidation is the key to understanding and tackling this issue. Protection of the pelvic floor is a frequently cited reason for requesting a cesarean section and also the basis on which obstetricians make the choice. [8] The belief that childbirth inevitably damages the pelvic floor, and that cesarean sections can effectively prevent subsequent incontinence, prolapsed, and sexual dysfunction, is often tempered by strong cultural and peer pressures. There is controversy surrounding the etiology of pelvic floor dysfunction arising after pregnancy, and the cause of this may relate to pregnancy rather than labor and delivery. [10] Despite the possible conveniences that elective cesarean sections offer, this does not appear to be the main reason for maternal request cesarean sections as most pregnant women are aware of the debilitating effects of major surgery. [11] The prospect of labor and subsequent delivery is understandably frightening, particularly to nulliparous women who have had no prior experience of it. In a small group of women, a morbid fear of labor and childbirth, sometimes termed tokophobia, make them request for elective cesarean section. [12] Tokophobia may occasionally be the result of child sexual abuse, rape, or a manifestation of depression. Secondary tokophobia may occur as a result of a previous traumatic delivery. Most women who had a previous unsuccessful vaginal delivery resulting in emergency cesarean section usually do not prefer vaginal delivery the next time. In the Indian scenario, again, most obstetricians do not prefer vaginal birth after a cesarean delivery. Also, some multiparous women request to have cesarean section because they want bilateral tubectomy at the same time.
| Maternal Consideration | | |
A triennial report on all maternal deaths in England, Scotland, and Wales suggest that the mortality from an elective cesarean section is three times higher than that in a vaginal birth. [13] Proponents of maternal request cesarean section point out that the mortality data for elective sections are drawn largely from a population of women who have valid medical indications for the operation. Safety data on elective cesarean sections on request in women with no intercurrent medical indications are not available and may well show it to be safer than elective cesarean sections in general. Morbidity is a less tangible aspect of safety that is difficult to quantify. It is important to acknowledge that elective cesarean section is not entirely risk-free. Febrile morbidity and sepsis, wound infection, blood loss, operative injury, predisposition to placenta praevia and uterine rupture, and anesthesia-related complications may be uncommon, but always remain a potential threat for mother and baby. The prevalence of hysterectomy after cesarean section is found to be 10 times higher than in vaginal births. [14] A number of surgical complications are reported related to cesarean delivery, such as injury to the bladder, ureters, laceration of the uterine artery, and other abdominal structures. [15] Pulmonary embolism remains a leading cause of maternal mortality, which is far more likely to occur following a cesarean section. There is also evidence of decreased fecundity, increased risk of ectopic pregnancies, placenta praevia, and adverse fetal outcome in a future pregnancy. In addition, blood loss for a healthy woman after a vaginal delivery is estimated to be 500 ml in comparison to 1,000 ml for a cesarean delivery, thus increasing the possible need for a blood transfusion during the postpartum period. [15] Undeniably, there is an association between pregnancy and pelvic floor disorders, such as urinary and fecal incontinence and prolapse. Ultrasound findings suggest that anal sphincter disruption occurs in 33% of women undergoing an uncomplicated spontaneous vaginal delivery. [16] This figure seems alarmingly high, particularly in a group of women in whom overt sphincter damage has not occurred. Much of the pelvic floor weakening may be due to pregnancy. Urinary incontinence commonly starts in pregnancy and rarely, if ever, after childbirth. [17],[18] In a population of women who have been delivered exclusively by cesarean section, protection against subsequent incontinence is only apparent in women who have had one child. [19] When repeat cesarean sections are performed, all protection is lost and more than a third of women who have had three cesarean sections report urinary stress incontinence. [20] The prevalence of fecal incontinence in one large study was 6% during pregnancy and only 5.5% after delivery, suggesting that all or most of the causation could be attributed to pregnancy itself. [21] It has also been suggested that instrumental deliveries, particularly forceps deliveries, prolonged second stage of labor with consequent nerve damage, [22] and unnecessary episiotomy [21] are the true culprits in pelvic floor damage. Strategies to avoid these predisposing factors may have a greater impact in the prevention of fecal incontinence than further increase in cesarean section rates. In the long term, it is possible that aging pelvic tissues may counteract any benefit of cesarean section. [23] In a country like Saudi Arabia, where having a large family is encouraged by social and cultural influences, it is not unusual to see women planning for their sixth or seventh cesarean section. One major complication of repeat cesarean sections is uterine scar rupture with subsequent adverse fetal and maternal consequences. The prevalence of dense intra-abdominal adhesions and bladder injury during cesarean section was higher in women with a history of three or more previous cesarean sections than in women with one previous cesarean section. [24]
| Neonatal Consideration | | |
There is one intrauterine death beyond 38 weeks in 600 pregnancies. [15] These largely unexplained stillbirths are distressing, especially since antecedent events are usually absent, and therefore, a strategy to prevent these cannot be devised. Proponents of maternal request cesarean section argue that an elective cesarean section at 38 weeks would prevent these intrauterine deaths. It is further postulated that one death in 1,500 neonates of birth weight > 1.5 kg in labor, [25] one case of hypoxic ischemic encephalopathy in 1,750 births, and 10% of cases of cerebral palsy [26] would be avoided by a policy of elective cesarean section. These estimates are based on the risks of adverse fetal outcomes associated with labor. This argument for elective cesarean section is flawed by virtue of the fact that it disregards the possibility of iatrogenic fetal damage and makes the assumption that abdominal delivery will circumvent all risks associated with labor. We are reminded by the findings of large series of elective cesarean sections that normal babies do die after elective cesarean sections. Respiratory distress syndrome and transient tachypnea in the newborn are more common after delivery by cesarean section. [27] This is particularly so if the woman is not in labor. In addition, elective cesarean sections are scheduled based on the expected date of delivery (EDD). When the EDD is uncertain, a proportion of cesarean sections may inadvertently be performed prematurely, resulting in a further increase in neonatal respiratory complications. In a study, fetal lacerations sustained at the time of cesarean section were documented to be 1.4% of all vertex presentations. [28] The analytical difficulty is that elective cesarean section numbers are small, amounting to less than 10% of deliveries occurring by this route. Planned vaginal delivery has again fewer incidences of Neonatal Intensive Care Unit admissions, oxygen resuscitation, and jaundice. [29]
| Medicolegal, Ethical, and Socioeconomic Issues | | |
Can cesarean section in an uncomplicated pregnancy on maternal request be justified from an ethical point of view? There are several aspects to be considered here. The physician should conduct proper counseling of the patient to give her an opportunity to have an informed consent. Patients have the right to decline care, but not to demand treatment that the physician considers unnecessarily risky. In case of cesarean section on maternal request, the surgery must be consistent with the desired outcome. Legal considerations aside, the obstetrician is duty-bound to ensure that his/her actions are ethically correct. The FIGO Committee for the Ethical Aspects of Human Reproduction has argued that it is unethical to perform a cesarean section without a medical indication because of inadequate evidence to support a net benefit. [30] In their deliberations, FIGO distinguishes between the individual's rights and the rights of society. When the rights of society are deemed to be of greater importance than the individual's rights, the latter becomes a privilege. The rights are the same for a woman in any country, but the privilege varies. In a resource-poor country with socialistic healthcare, performing elective cesarean sections for non-medical reasons may over-ride the rights of society if insufficient resources remain to provide for medically indicated cesarean sections and may be refused for that reason alone. In a developed country with ample resources, this privilege may be allowed. While this assertion may be acceptable, it still leaves us with the dilemma of whether to oblige and provide that privilege, especially if the woman is prepared to pay. As obstetricians, we have to contend with the difficulty of decision-making as the balance of benefit versus harm between cesarean section and vaginal delivery is crucial to this debate. Hence, performing an elective cesarean section would be ethically sound if it was genuinely safer or more beneficial than labor and vaginal delivery. Refusal to perform one would seem reasonable if the intervention was more likely to result in harm than good. When the set of risks for an intervention and that for refusing the intervention (and allowing the natural course of events to take place) are perceived to be similar in magnitude, the patient's choice can be reasonably included in the equation. Perhaps, this third scenario best sums up the ethical ground on which the maternal request cesarean section stands. No general surgeon would agree to perform a total appendicectomy in a patient with no appendicular pathology in spite of it being a vestigial organ, just as no gynecologist would agree to perform a hysterectomy for a healthy 20-year-old woman. Yet, 69% of obstetricians would perform a cesarean section on maternal request. [8] This can only mean that the obstetricians believe that the risks of cesarean section are so close to the risks of labor and vaginal delivery that maternal choice can be allowed to influence this decision. The Arab countries exhibited great disparities in their population-based cesarean section rates. These differences were explained to a great extent by the countries' demographic transition and socioeconomic development. The strongest associations were found between the prevalence of population cesarean section rate and female literacy, percentage urban, Infant Mortality Rate, and the proportion of physicians per 100,000 people. Clearly, countries with better sociodemographic and health parameters, as well as those that are better off economically, have been moving more rapidly toward a medicalization of maternal healthcare through specialized, high-technology models. [31]
Obstetrician's decision
The first step for the obstetrician is to listen to the patient and why and what source of information made her to request for a cesarean section. Once the reasons for the request are established, the obstetrician should give clear and unbiased information about the validity of the reasons provided by the woman to support her request and the established benefits and disadvantages of an elective cesarean section. Clinicians are invariably influenced in their outlook by anecdotal experiences and personal opinions. Every effort should be made to provide only information that has been scientifically proven to be true and to make known the aspects for which the benefit or harm are unclear. Subsequently, a plan should be formulated after discussing all the pros and cons of both vaginal and abdominal routes of delivery. In women who still want a cesarean section, the obstetrician may feel that carrying out this request is justified. This may be particularly so in women who have suffered previous traumatic experiences, such as intrapartum death of a baby. In such circumstances, most obstetricians accept the mother's request. While it is true that such events are not prevented by cesarean section, the psychological stress faced by such women can be debilitating. Obstetricians, who feel that, in good conscience, they cannot agree to an elective cesarean section on the basis of the reasons provided by these women, should refer them to a colleague for a second opinion. Within countries, cesarean section rates varied with non-medical risk factors such as age, education, and rural-urban residence. Specifically, women with secondary level of education, living in urban places, and over 35 years of age were more likely to undergo cesarean section deliveries than other women. However, higher rates of cesarean section among older women cannot entirely be explained by their tendency toward more complicated pregnancies and births. In some situations, maternal preferences, perceived potential for complications by medical doctors, as well as convenience of delivery may also be important determinants of cesarean section delivery. [32] Defensive obstetrics is another common reason for high rates of cesarean section. It has been observed that 82% of physicians performed cesarean section to avoid negligence claims. [33]
| Conclusion | | |
The incidence of cesarean sections performed on request without medical indications is rising. The reasons for this are not only for perceived medical benefit, but also due to social, cultural, and psychological factors. Despite dramatic improvements in the safety of anesthesia and surgery, mortality and morbidity are greater in elective cesarean sections compared to vaginal deliveries. An association exists between pelvic floor damage and childbirth, but this cannot be attributed entirely to vaginal deliveries and does occur even after a cesarean birth. The incidence of late intrauterine deaths is unlikely to be reduced by a policy of universal elective cesarean section, as these procedures carry a risk of iatrogenic fetal morbidity and mortality. The legal and ethical issues of request cesarean sections are complex. The validity of informed consent for non-indicated surgery is unclear. An individual has his/her rights and so does the society. When society's rights are judged to have priority, the individual's right becomes a privilege. Based on this principle, maternal request cesarean sections must not compromise the provision of care to women requiring medically indicated cesarean sections or should not dent the resources of public healthcare. In dealing with requests for cesarean sections, obstetricians should establish the reasons for the request and provide clear, unbiased information based on the best available evidence. Individualized modifications to the management of labor may allow some women to have vaginal deliveries. A second opinion from a colleague may help the patient to reconsider the request and make a more informed choice.
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