Case Scenario

A 34-year-old pregnant patient (gravida 2, para 0, at 28 weeks gestation) has asked one of my partners if she can schedule a cesarean delivery rather than go into labor. Because I am the family physician in my group who is privileged for cesarean deliveries, my partner has asked for my advice. The patient’s pregnancy has been uncomplicated, and she is in excellent health. The patient has no history of prior surgery and has read a great deal about pregnancy and childbirth. She told my partner that she is concerned about her family history, which includes two sisters who ultimately had cesarean deliveries after long labors. In addition, the patient has minimal pain tolerance, and she is concerned also that vaginal birth could put her at risk for incontinence in the future.

Commentary

Patient-choice cesarean delivery, although uncommon in the United States, has become controversial in the medical literature and among pregnant women and their maternity care providers over the past three years.¹The American College of Obstetricians and Gynecologists (ACOG) has recently published an ethical opinion² recommending acceptance of patient-choice cesarean delivery based on the principles of patient autonomy and informed consent. The ACOG opinion states, “If the physician believes that (elective, primary) cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing a cesarean delivery.”

The ACOG ethical opinion supports physicians who agree to patient-choice elective cesarean delivery as long as they believe it is in the best interests of the patient. In contrast, the international Federation of Gynecologists and Obstetricians states, “At present, because hard evidence of net benefit does not exist, performing cesarean section for nonmedical reasons is ethically not justified.”³ The American College of Nurse-midwives has condemned the decision to offer patient-choice cesarean delivery, stating that women “are being enticed to consider ‘c-sections on demand,’ based upon questionable promises… A cesarean delivery should be the last resort, not an option based on convenience or defensive practice.”⁴

Past national and international efforts to reduce the cesarean delivery rate were based on the belief that it increased maternal morbidity and mortality. The World Health Organization and the U.S. Department of Health and Human Services’ Healthy People 2000 Report^5,6 recommend that the cesarean delivery rate should not exceed 15 percent, but scant evidence exists to support these statements. Although cesarean delivery has been associated with a fourfold increase in the rate of maternal mortality as well as increased risks of other morbidity,⁷ including infection, hemorrhage, transfusion, anesthesia reactions, and visceral injuries, these risks are most often associated with unscheduled cesarean delivery, particularly when it occurs in advanced labor.⁸

Advocates of patient-choice cesarean delivery have argued that the differences in risk are minimal when one compares scheduled elective cesarean delivery to planned vaginal delivery. Two small studies of fewer than 1,000 women undergoing elective cesarean delivery showed equivalent morbidity or only an increase in febrile morbidity when compared with vaginal delivery.^9,10 Maternal mortality registries, however, still demonstrate increased maternal mortality with relative risk of 1.4 to 2.8 when comparing elective cesarean delivery with vaginal delivery.^11,12

Although a scheduled primary cesarean delivery may have minimal increased risk compared with the first vaginal delivery, it is essential to consider all future pregnancies in a woman’s reproductive life to determine risks and benefits of elective cesarean delivery. Women who deliver vaginally in their first pregnancy are at much lower risk of requiring a cesarean delivery during a future pregnancy. Moreover, women who have had a prior cesarean delivery are at increased risk of complications in their next pregnancy, whether they choose a repeat cesarean delivery or a trial of labor. The risks include a higher incidence of placenta previa and placenta accreta, which may lead to hysterectomy and maternal mortality. The risk of placental abnormalities increases with the number of prior cesarean deliveries.¹³

Do any maternal or neonatal health benefits support an acceptance of elective cesarean delivery? Although the incidence of stress urinary incontinence is higher at three months postpartum in women who deliver vaginally versus those who deliver by cesarean, these differences do not appear to persist.^9,14 Even the short-term protective effect of cesarean delivery on urinary incontinence disappears when a woman has had three prior cesarean deliveries.^15,16 By age 50 years, nonobstetric risk factors predominate and the likelihood of a woman having stress urinary incontinence is not affected by obstetric history.¹⁵

Anal incontinence of stool or gas may occur after an overt or occult anal sphincter laceration. Anal incontinence is much less responsive to medical or surgical treatment than urinary incontinence, presenting the potential for significant long-term morbidity. Operative vaginal delivery and episiotomy are the primary risk factors for anal sphincter lacerations^17,18and avoiding these procedures is an alternative to elective cesarean delivery.

Maternal fear of childbirth is the most common reason for nulliparous women to request cesarean delivery.¹⁹ Some women may fear the pain of labor or potential injury to their own body or to their infant. Women with a history of sexual abuse or rape may be uncomfortable with the genital exposure and examinations common to vaginal birth. Women with fear of childbirth pain or with a history of abuse may benefit from referral for psychological counseling. Women with extreme fear of labor (tocophobia) may develop posttraumatic stress disorder if they feel “forced” to go through vaginal delivery, and these women need to have psychiatric consultation.²⁰ The majority of women entering into counseling due to fear of childbirth ultimately elect vaginal delivery and are satisfied with that decision after childbirth.²¹

Advocates of patient-choice cesarean delivery have suggested that neonatal benefits may include a decreased incidence of birth trauma (including brachial plexus palsy from shoulder dystocia), minimization of birth asphyxia from difficult labor and delivery, and a decrease in intrauterine fetal demise due to scheduled delivery at 39 weeks.¹ Potential negative effects on the fetus from elective cesarean delivery include iatrogenic prematurity because of inaccurate dating, an increased incidence of neonatal respiratory disease,²² and the potential for neonatal trauma during surgical delivery.²³

What are the economic costs of patient-choice cesarean delivery? At least for the index nulliparous pregnancy, the cost of elective cesarean delivery may differ little from that of vaginal delivery, given our current medicalized birthing model, which includes high rates of induction, epidural analgesia, and unscheduled cesarean delivery.²⁴ Because subsequent births after an initial vaginal delivery have a low incidence of emergent delivery and a shorter duration of labor, an analysis of the economic effects during a women’s reproduction lifetime may demonstrate additional costs to primary elective cesarean delivery.

The family physician whose patient requests elective cesarean delivery should review the patient’s history, discuss the reasons for the request, and determine the patient’s knowledge of risks and benefits of each delivery method. The short- and long-term effects of vaginal and cesarean delivery should be discussed in relation to the individual woman’s reproductive history and future childbearing plans. If, after these discussions, a woman still desires primary elective cesarean delivery, that option should be made available to her, even if it requires referral to another physician. Family physicians performing cesarean deliveries and obstetrician/gynecologists need to determine for themselves if they are willing to offer patient-choice cesarean. Although the appropriate response to a woman’s request for elective cesarean delivery remains controversial, all professional and national advisory organizations agree that physicians need not routinely offer elective nonmedically indicated cesarean delivery

In the specific scenario mentioned, the family physician should meet with the patient and discuss her concerns regarding pelvic floor injury. Together, they can discuss several ways to reduce the likelihood of requiring a cesarean delivery during labor, including the use of a doula for labor support, avoidance of elective labor induction, and delaying admission to the labor and delivery unit until she is in active labor. To minimize the risks of anal sphincter laceration, the physician should also avoid the use of episiotomy and operative vaginal delivery unless needed for fetal well-being.

Patient information titled, “What Every Pregnant Woman Needs to Know About Cesarean Section,” is available online athttp://www.maternitywise.org/cesareanbooklet.

LAWRENCE LEEMAN, M.D., M.P.H., is assistant professor of family and community medicine and obstetrics and gynecology at the University of New Mexico School of Medicine, Albuquerque. He is director of family practice maternity and infant care and co-medical director of the mother-baby unit at the University of New Mexico Hospital, Albuquerque.