C-Section on Request (on Demand)

In the United States today, between 1% and 3% of women will request an elective C-section as her method of delivery. Although a great deal of controversy exists concerning the subject, the consensus opinion from both the medical community and patient advocacy groups is that once properly informed of the pros and cons, the patient is entitled to make the ultimate decision.

Our national advisory committee, The American College of Obstetrics and Gynecology, states “Patient autonomy and increased access to information has prompted more patient requests for surgical interventions not necessarily recommended by their physicians. Decision making in obstetrics and gynecology should be guided by ethical principles of respect for patient autonomy…Once the physician is satisfied that the patient fully comprehends the options, her decision ordinarily should be respected and supported” (ACOG Committee Opinion).

Fear of labor, a friend’s negative labor experience, a previous difficult delivery, media influence, being able to choose a date, family influence, and fear of injury to the vagina are some of the major reasons that patients choose elective C-section. In addition, a planned C-section gives certain patients piece of mind to know that the delivery is scheduled in a controlled, non-emergency, environment with the delivery team prepared and ready.

Each patient may be very different.  Although major life threatening problems are no greater with C-section than with vaginal delivery, there are certain potential complications that can arise as a result of C-section which are not encountered with vaginal delivery.  I believe it is the physician duty to properly inform the patient of these complications, and at the same time the physician has an ethical responsibility to ultimately respect the patient’s decision and not disregard it.

Benefits:

• A more controlled and non-emergency environment
• Able to schedule a specific time
• Avoidance of the uncertainty of labor
• Limit the potential risks of labor for the baby
• Although large studies are not available, more studies are emerging   indicating a higher incidence of compromise in vaginal support – urinary incontinence (loss)
• Although the risk is small with vaginal delivery, hemorrhage after C-section is even less
• Avoidance of the mental trauma of emergency C-section  
• Avoidance of potential trauma at birth of a large baby

Disadvantages and risks:

• Longer recovery
• Higher incidence of infection
• Higher incidence of wound bleeding
• Higher incidence of breathing problems secondary to pain
• More painful
• Potential scarring and long term pain
• Potential injury to adjacent organs
• Complications in subsequent pregnancies are infrequent yet include:
  • Separation  of the uterine scar in subsequent pregnancies potentially    causing injury or death to the baby
  • Placenta previa (afterbirth lying over the cervix) causing possible heavy bleeding, injury to the baby, and prematurity
• Increase in the above surgical risks in an overweight patient

There certainly are arguments for and against C-section upon request.  Once the considerations have been properly discussed, it is my belief – like most others, that it is the patient’s ultimate choice! ACOG couldn’t have said it any better: “Once the physician is satisfied that the patient fully comprehends the options, her autonomous decision should be respected and supported… However, even though the decision should be respected, respect might not include supporting the decision, particularly when doing so is in direct conflict with other guiding ethical principles.”  In this situation, the doctor should politely suggest the patient obtain a second opinion.