Cesarean delivery on maternal request

REASONS WOMEN OPT FOR CESAREAN DELIVERY ON REQUEST — Reasons for choosing cesarean delivery on request include: ●Convenience of scheduled delivery ●Fear of the pain, process, and complic

Cesarean delivery on maternal request

Author

Errol R Norwitz, MD, PhD

Section Editor

Charles J Lockwood, MD, MHCM

Deputy Editor

Vanessa A Barss, MD, FACOG

Disclosures: Errol R Norwitz, MD, PhD Consultant/Advisory Boards: Hologic [Preterm birth

testing (Fetal fibronectin test to predict preterm birth)]; Natera [Fetal aneuploidy screening (NIPT as a screening test for fetal aneuploidy)] Patent Holder: Bayer [Use of urinary angiogenic

factors to predict preeclampsia (Prediction test for preeclampsia)] Charles J Lockwood, MD, MHCM Nothing to disclose Vanessa A Barss, MD, FACOG Employee of UpToDate, Inc

Contributor disclosures are reviewed for conflicts of interest by the editorial group When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content Appropriately referenced content is required

of all authors and must conform to UpToDate standards of evidence

Conflict of interest policy

All topics are updated as new evidence becomes available and our peer review process is

complete

Literature review current through: Dec 2014 | This topic last updated: Oct 17, 2014

INTRODUCTION — Cesarean delivery on maternal request (or “on demand”) refers to a

primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications for avoiding vaginal birth A woman’s right

to be actively involved in choosing the route of her delivery is now widely accepted by clinicians and patients [1-3] 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 [1,2,4-9] However, obstetricians are not obliged ethically or

professionally to perform these procedures Early referral to another healthcare practitioner is appropriate in such cases [1]

PREVALENCE — Estimates of the prevalence of cesarean delivery on maternal request range from 1 to 18 percent of all cesarean deliveries worldwide, and <1 to 3 percent of all cesarean deliveries in the United States [9-12] These are crude estimates since birth certificates and discharge codes usually do not indicate whether a cesarean was performed at maternal request The prevalence of the procedure appears to be increasing and correlated with increasing

affluence [13,14]

Surveys of obstetricians, urogynecologists, and colorectal surgeons have reported a preference for cesarean by request for themselves and their family members [15,16]

OVERVIEW — The Agency for Healthcare Research and Quality (AHRQ) has published a detailed report on Cesarean Delivery on Maternal Request [17] A synopsis of their findings, as well as subsequently published data, is provided below These data are limited because no

randomized trials on cesarean delivery for nonmedical reasons have been performed [18] Thus, conclusions about the risks and benefits of cesarean delivery on maternal request are not based upon high-quality evidence Available studies have serious methodological issues or provide indirect evidence because the cesareans were performed for breech presentation [19]

As with any medical procedure, the risks and benefits of cesarean delivery on maternal request need to be balanced with the risks and benefits of a planned vaginal delivery Patient-specific issues that can affect the choice of delivery route include comorbid medical conditions, body mass index, future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the woman's personal philosophy about childbirth

Providing women with the best available information about pertinent childbirth issues and

appropriate support may alleviate some of their concerns about attempted vaginal birth The motivation for cesarean delivery should be determined and addressed Family pressure should not influence the patient’s decision 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 personal trauma, previous childbirth

experiences, or the childbirth experiences of friends and family should also be addressed

REASONS WOMEN OPT FOR CESAREAN DELIVERY ON REQUEST — Reasons for choosing cesarean delivery on request include:

●Convenience of scheduled delivery

●Fear of the pain, process, and complications of labor and vaginal birth

●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

●Concerns about the need for and risks of emergent cesarean or instrument-assisted vaginal delivery

●Need for control

A patient’s statement during a case conference published in a journal aptly summarizes the opinion of many women who choose cesarean delivery: “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” [20]

POTENTIAL BENEFITS OF PLANNED CESAREAN DELIVERY

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

As discussed above, 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 in risks associated with unplanned surgery — Although a planned cesarean usually results in a cesarean delivery, a planned vaginal delivery may result in an uncomplicated

spontaneous vaginal birth, instrument-assisted vaginal birth, or intrapartum cesarean delivery

An emergency cesarean delivery is often a traumatic experience for women, and has been

associated with postnatal depression and posttraumatic stress [21] Emergency surgery is also associated with slightly higher maternal and fetal risks than elective surgery [17,22-24] These risks include, but are not limited to, infection, accidental injury to abdominal organs, fetal

laceration during hysterotomy, hemorrhage, and anesthesia-related complications

Instrument-assisted vaginal birth may cause maternal and/or fetal injury Although 20 to 50 percent of women who undergo an instrument-assisted vaginal birth will develop a vaginal, cervical, perineal, or rectal laceration, 100 percent of women who undergo cesarean delivery are incised

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?" [25] 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 [3,25-28] The frequency of intrapartum fetal death is lower and estimated to

be 1 in 5000 births [3] The wide 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 [29]

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 [30,31] 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) [17,30,32]

The risk of perinatal transmission of some infections (eg, herpes simplex virus, human

immunodeficiency virus [HIV]) is also reduced by avoiding vaginal birth The best means of protecting the neonate from maternal infection varies according to the specific infection and the absolute risk and consequences of perinatal transmission As an example, cesarean delivery is recommended to reduce perinatal transmission of active herpes infection or HIV infection in women without a low viral load, but passive and active neonatal immunization is adequate protection against perinatal hepatitis B transmission The value of cesarean delivery in the setting

of maternal hepatitis C infection or human papillomavirus (HPV) infection is unproven These issues are discussed in detail separately in UpToDate topic reviews on each infection

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 for

cesarean delivery [33,34]; however, these concerns are not based on high-quality evidence

In the Term Breech Trial, fewer women had urinary incontinence in the months after a planned cesarean delivery [35], but 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 [36] In addition, planned cesarean delivery did not appear to confer protection against fecal incontinence compared with planned vaginal delivery [36,37] However, data are discordant 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) [38] Compared with women with cesarean deliveries only before labor, the risk of pelvic organ prolapse was increased in women who had a spontaneous vaginal birth or an operative vaginal birth (adjusted OR 5.64, 95% CI 2.16-14.70 and aOR 7.50, 95% CI 2.70-20.87,

respectively)

Although there is some evidence that cesarean delivery on maternal request may reduce the long-term risk of pelvic organ prolapse, the relationships between pelvic organ prolapse/urinary incontinence/anal incontinence and pregnancy/labor/vaginal delivery/cesarean delivery are not well-defined This topic is discussed in detail separately

Reduction in early postpartum hemorrhage — A report on cesarean delivery commissioned by the National Institute for Health and Clinical Excellence noted that the risk of early postpartum hemorrhage was lower with planned cesarean versus planned vaginal delivery in women with uncomplicated pregnancies and no previous cesarean (4 to 56 fewer hemorrhages per 1000) [39] However, this was based on low- to very low-quality data and was not associated with a

significant reduction in transfusion or hysterectomy for control of bleeding

POTENTIAL DISADVANTAGES AND RISKS OF PLANNED CESAREAN

DELIVERY — In addition to the concern that planned cesarean delivery is “not natural,”

objections to planned cesarean include:

●Increased risk of abnormal placentation in future pregnancies

●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 uterine rupture in future pregnancies

●Cost

Theoretic concerns of planned cesarean delivery include risks to offspring from not experiencing labor-related stress and immune activation, lack of exposure to maternal vaginal flora, and

potential epigenetic changes related to mode of delivery

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 [40] The increased risk of abnormal placental

attachment is a major concern because of the frequency of this complication and the potential for life-threatening hemorrhage

Increased risk of placental attachment 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 (table 1) 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 [1]

First delivery by cesarean also may be associated with a higher risk of abruptio placentae in future pregnancies [41,42]

Increased risk of uterine rupture — Most uterine ruptures are related to a trial of labor after a previous cesarean delivery (TOLAC) 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

Adhesions can also cause bowel obstruction 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) and for primiparous women (OR 1.3) (but not multiparous women) [43] However, the analysis excluded the largest published study, which included almost 1.8 million singleton second births in women with no underlying medical conditions and fetuses with no structural or chromosomal abnormalities and found no association between previous cesarean and future-term fetal demise [44]

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 regional anesthesia for 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 [35]

Increased maternal morbidity — Maternal morbidity appears to be higher with planned cesarean delivery than with planned vaginal delivery [45-49] 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) [48] Compared with 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), but the absolute rate of these events was low for both groups

On the other hand, in the Term Breech Trial, the difference in serious maternal morbidity

between women who planned cesarean delivery and those who planned vaginal birth was not statistically significant (3.9 versus 3.1 percent; RR 1.28, 95% CI 0.81-2.02) [50]

Increased risk of respiratory problems in offspring — Neonatal respiratory problems (eg,

respiratory distress syndrome, transient tachypnea of the newborn) are more common after scheduled cesarean than after vaginal delivery, and may lengthen the neonate's hospital stay [51-54] In one study, 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 delivered by cesarean during labor (12.2/1000) or vaginal birth (5.3/1000) [52] An association between scheduled cesarean delivery and asthma and bronchiolitis has also been reported

[55,56]

Respiratory problems are more frequent after cesarean delivery without labor because

mechanisms for reabsorbing lung fluid are not fully activated and, sometimes, as a result of iatrogenic prematurity [57-60] However, respiratory distress related to prematurity is virtually eliminated if delivery occurs after 39.0 weeks of gestation [51,52,54]

The American College of Obstetricians and Gynecologists (ACOG) recommends that cesarean delivery on maternal request be performed at ≥39 weeks of gestation [1]

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 [61] 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 [62] 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

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 [17] There are no data specifically addressing the maternal death rate for cesarean delivery on maternal request 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 resource-rich 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 fewer than 1 in 70,000 cesarean deliveries [63-66]

If cesarean is more dangerous than vaginal delivery, then one would expect a higher maternal mortality rate among populations with high cesarean delivery rates, but this association has not been demonstrated [63,67] In fact, using national estimates of cesarean delivery rates after 1990

in 19 Latin American countries [68], one study found that the highest maternal mortality was 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 for the mother than vaginal delivery

Some authors have interpreted available data as showing that planned cesarean delivery is safer than planned vaginal delivery [69] The safety of cesarean has been attributed to safer surgical and anesthetic techniques and widespread use of prophylactic antibiotics and

thromboprophylaxis

Postpartum sexual function — Postpartum sexual function does not appear to be related to

method of delivery [17,70]

CLINICIAN RESPONSIBILITIES — Professional standards do not mandate discussing the option of cesarean delivery on maternal request with every patient, given the high degree of uncertainty about its clinical benefits and risks compared with vaginal birth [4,71,72]

When asked about cesarean delivery on maternal request, the clinician should find out the

reasons for the patient’s request; explore her values, emotional, and social needs; address her concerns about labor and vaginal birth and any misinformation leading to those concerns (eg, unavailability of effective pain management); and engage her and possibly her support persons in

a balanced discussion about the risks and benefits (relative and absolute) of the procedure over a series of visits [20] Obstetricians are not obliged ethically or professionally to perform cesarean delivery on maternal request; early referral to another healthcare practitioner willing to act in accordance with the patient’s request is appropriate in such cases [1]