Monday, February 01, 2010

Designer Obstetrics: Cesarean Section on Demand

Should women be able to request a cesarean section to deliver their baby just because they can?

Cesarean Section on demand is defined as a primary or first cesarean section at the request of the mother in the absence of any medical or obstetrical indication. A cesarean section is usually done for maternal or fetal reasons in accordance with accepted medical practice and guidelines set forth by the American College of OB/GYN (ACOG). An electively requested cesarean section in an uncomplicated pregnancy has traditionally been considered inappropriate and not done by most obstetricians. However, in recent years this belief has been challenged and more obstetricians are honoring their patients decisions. ACOG, in their committee opinion No. 394, December 2007, outlines the most recent guidelines when confronted with cesarean delivery on maternal request.

There are risks and benefits for both planned a vaginal birth and for cesarean section. Some mothers requesting cesarean section rather than proceeding with a planned vaginal birth do so because they believe that a vaginal birth will cause damage to the pelvic floor. Later in life this could contribute to urinary/fecal incontinence and pelvic organ prolapse. Others opt for cesarean section because they fear the pain of labor and delivery. While others prefer the convenience of a scheduled delivery. The strongest argument against a cesarean section are problems that can arise in future pregnancies. Subsequent pregnancies following a primary cesarean section have increased rates of placental abnormalities (placenta previa, accreta and increta), uterine rupture, hemorrhage and gravid hysterectomy. Nationwide because of the overall increasing rates of primary cesarean sections and the repeat cesarean sections the rates of these life threatening complications have been on the rise.

Ethically, the question we obstetricians face is "which ethical principle should triumph - patient autonomy or non-maleficence?" Should the patient's right to autonomy be respected, after being advised and explained all the risks, benefits and alternatives, that is after informed consent is obtained? On the other hand should the physician as healer respect the principle of non-maleficence, "first do no harm" and so, refuse to accede to a patient's demand?

[Aycan Turkmen, MD, is an obstetrician/gynecologist and a guest blogger for the Women's Bioethics Blog.]


Anonymous said...

The words planned and birth, whether vaginal or cesarean, should rarely be used together to ensure the safest outcome for mother and baby. And what of the additional costs for cesarean section? How many women, if they were forced to pay out of pocket for the additional cost of their care and the lengthened time away from work, would or could afford to consider that option even if it were deemed ethical? What of the increased utilization of resources, ie waste generated by the surgery?
Health care workers seem to believe it is their right to deny women birth control, access to information and or abortion based on their personal beliefs. I propose a movement to refuse to participate in unethical wasteful care simply because a patient demands it as their "right".

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SabrinaW said...

The words planned and birth, whether vaginal or cesarean, should rarely be used together to ensure the safest outcome for mother and baby.

I don't think that the word "unplanned" can in any way be considered safe either.

Unfortunately, evolution has conspired against women to make the birthing process more dangerous than for any other mammal. So previous generations were left with an unacceptable choice: intervene so fewer women would die (as was the norm until only recently) or let all women who couldn't survive a complicated vaginal birth die and let natural selection occur?