My mothers-to-be are astonishingly different from one another as they arrive ready to give birth in all possible shapes, sizes, and stages of delivery. Yet, in another way, they are mostly of one mind... determined to do anything medically necessary for the well-being of their baby.
Fortunately, the majority of births are pleasantly routine and everyone goes home a bit sore, but happy, healthy and determined to be a successful family. Once in a while, a delivery that may seem quite routine at first, can suddenly become complicated for any number of reasons. If the problems become overwhelming, the OB/GYN will strongly suggest that the parents give their consent for delivery via cesarean section, commonly known as a C-section.
This decision should not be suggested lightly because, after all, it's surgery! Only after the OB/GYN deems that the risks of a C-section are lower than the risks of a vaginal delivery should the C-Section option be chosen. Safety for the mother and baby always come first and only the physician is trained to know when this procedure is medically necessary. In rare cases, parents may be told ahead of labor that a C-section will be medically necessary, (i.e. if the child did not turn around in the womb). This is not considered elective because the need for surgery is decided in advance.
After delivering more than 3,000 babies, I thought I had heard it all
A case history
B.P. is a 40 year old professor of obstetrics from a major university hospital who is admitted to labor and delivery at term contracting every 5 minutes for the last hour. This is her first child-having been conceived through in-vitro fertilization. She is a healthy woman with no medical problems, has had a completely uneventful pregnancy with all routine prenatal testing showing normal results, appropriate fetal growth, adequate amniotic fluid, baby in a perfect head down position, and a recent ultrasound estimating the baby to weigh approximately 7 pounds. On admission to the delivery floor she requests an elective cesarean section.
It has been established that an individual has the right to refuse medical procedures, but does it also follow that a person has the right to demand a medically unnecessary treatment?
C-section Trends
Obstetrical care throughout the world is undergoing dramatic changes. Cesarean deliveries are increasing to the extent that in some countries, such as China and parts of Latin America it is well over 50%. There have always been certain traditional reasons for performing a cesarean section but recently "maternal request" has been added as a new indication. The rate of elective cesareans in the United States is now estimated to be between 4 % and 18%.
Reasons for elective C-sections
Fear of labor-(tocophobia)
Some women have a fear of pain, fear of an emergency and/or having to undergo a traumatic experience involving higher morbidity and mortality associated with complications.
Maternal convenience
Scheduling takes into account childcare, work concerns, support systems, choice of surgeon.
Prevention of maternal floor damage
Concerns about urinary or bowel injury or future sexual functioning resulting from traumatic vaginal delivery.
"Designer Baby"
Expensive reproductive technology needed for conception and the need to deliver in the least traumatic way to avoid any risk to the child.
Neonatal benefits
Elective cesarean is associated with lower newborn infection rates, lower risk of intracranial hemorrhage, neonatal asphyxia, and encephalopathy.
Prevention of any birth asphyxia or potential birth trauma
Avoidance of injury such as bone fracture, nerve injury.
Prevention of stillbirth
The need for preventing a stillbirth or overdue pregnancy with the inherent associated risks.
Sterilization
Doing a cesarean can allow for a subsequent sterilization procedure in some countries where reproductive rights are not available to women on request.
As obstetricians, we are faced with a difficult situation. Should a mentally competent patient have the right to choose, ethically, how they would like their baby delivered? While patients have the ability to make personal choices in many other areas of medicine, clearly this can not apply to obstetrics. Why? Because the lives of not one, but two humans, are at stake.
Are there viable disadvantages to an elective C-section?
Surgery always poses additional risk factors. Elective cesarean section has a 2.84 fold greater risk of a woman's death than a vaginal birth.
Added risks include:
- Maternal morbidity
This includes surgical injury such as damage to other organs, risk of hemorrhage, hysterectomy, infection, fever due to other causes, hematoma, anesthetic complications, and blood clots. - Respiratory issues in the newborn
Transient tachypnea (rapid breathing) of the newborn occurs more frequently after elective cesarean and respiratory distress more likely if the surgery is booked prior to 39 weeks. - Potential complications with future pregnancies
This includes increased risk of uterine rupture if laboring during a subsequent pregnancy if you have a uterine scar from a previous cesarean, increased risk of placenta previa (low lying placenta adhering to the scar), placenta accreta (placenta growing into a previous uterine scar), and placental abruption (separation of the placenta from the uterine wall). - Complications from adhesions
Surgery can lead to abdominal adhesions which might effect future fertility, causing chronic pelvic pain, increase risk to bowel and bladder in future abdominal surgeries,and higher risk of ectopic pregnancies and miscarriages. - Injury to the baby
There is a 1.9% chance that a surgeons knife can accidentally lacerate the fetus when doing a cesarean. However, emergency cesarean sections after labor has a greater incidence of lacerations compared to elective cesareans.
What is the answer?
In today's day and age, is it acceptable practice to allow the patient to determine the medical decision, assuming she is competent and well informed of any additional risks she is placing on herself? (i.e. informed consent) Could a physician be at risk for denying a patient's request for a cesarean if, postpartum, the procedure results in injury to herself, or her child, immediately or several years down the road?
It behooves the obstetrician, or midwife, to weigh all the risks and benefits of providing this option after exploring the reasons for the request. The ethics committee of Gynecology and Obstetrics (FIGO) states "Only the woman can decide if the benefits to her of a procedure are worth the risks and discomfort she may undergo." We must respect the rights and autonomy of a mother. However, "performing cesarean section for non-medical reasons is not ethically justified."
The American College of Obstetrics and Gynecology, however, feels that after exploring the request and proper counseling with informed consent, the physician can comply with the patients request if it is felt that cesarean will promote the overall health of the patient and the fetus more than a vaginal delivery.
This ethical controversy will continue to plague us, especially with health care costs spiraling. Having patients elect to have more expensive procedures, can threaten the solvency of the larger community. Why? Because a C-section requires not only a surgeon and an assistant, but an anesthesiologist, additional nursing, added supplies, equipment, an operating room, possibly blood for transfusion and longer hospitalization stays for both mom and baby.
We must ask ourselves if it makes sense to utilize the valuable time of medical professionals, as well as the financial resources of a community, in order to accommodate a woman's desire to have the more expensive, and luxurious, C-section delivery?
Does respect for the rights of an individual outweigh the allocation of resources within a community? Right now, I personally don't have the answer. I just want all my babies and mothers to leave happy and healthy.
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