ACOG issues opinion on elective cesareans
The decision should depend on many factors
Over the past decade, obstetricians have noted an interesting phenomenon — more women rejecting the concept of a natural birth and requesting elective cesarean deliveries, sometimes called "patient-choice cesareans" or "cesareans on demand."
According to many OB/GYNs, there are a number of factors fueling this trend.
"I think we are seeing a lot of people influenced by pregnant celebrities and Hollywood," notes Adelaide Nardone, MD, FACOG, an OB/GYN practicing and medical advisor to the Vagisil Women’s Health Center in White Plains, NY. "Pregnancy is now in vogue, so to speak. When I was pregnant, I didn’t tell anyone until the month before the birth. Now, women are baring their bellies and showing them off. And I think women are also following another celebrity trend of having elective C-sections so they feel in control of when the baby arrives."
Many women also are requesting cesareans in the belief that a surgical delivery will help them avoid pelvic support problems or sexual dysfunction later in life, Nardone adds, although clinical evidence supporting this belief is slight.
Women also may ask for a cesarean because they are afraid they won’t be able to endure the pain of labor and want to avoid it altogether, she adds.
Over the past four or five years, some OB/GYNs have supported allowing women who otherwise would have no reason to have the surgery to choose a cesarean as their delivery method. Others, however, believe that selecting a surgical procedure over a natural process, without a compelling medical need, is unethical.
New committee opinion
Responding to the controversy, the ethics committee of the American College of Obstetricians and Gynecologists (ACOG) has issued an opinion to guide doctors in making decisions about surgical treatments when there is a lack of firm evidence for or against a procedure.1
Where medical evidence is limited, the opinion states, there is no one answer on the right ethical response by a physician considering a patient’s request for surgery. The decision on whether to perform an elective cesarean will come down to the physician’s evaluation of a number of ethical factors, including the patient’s concerns and the physician’s understanding of the procedure’s risks and benefits.
For example, in the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she ethically is justified in performing the surgery. Similarly, if the physician believes that performing a cesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she ethically is obliged to refrain from performing the surgery. In this case, a referral to another health care provider would be appropriate if the physician and patient cannot agree on a method of delivery.
The last point is a particularly important one for many OB/GYNs, Nardone says.
"Many of them are facing enormous pressure from their patients to do this, but they don’t believe it is right," she notes. "I think the ACOG opinion very strongly states that they are not required to do this at a patient’s request and that, if they believe the procedure not to be in the patient’s best interest, it is permissible to refer them to someone else."
The opinion also states that OB/GYNs are under no ethical obligation to initiate discussions about elective cesareans as an option for delivery, if they believe the procedure is not indicated, she adds.
"The statement clearly says, In the absence of significant data regarding the risks and benefits of cesarean delivery, the burden of proof should fall on those who are advocates for a change in policy in support of elective cesarean delivery [i.e., the replacement of a natural process with a major surgical procedure]’," she notes. "There is no obligation to initiate a discussion about a procedure the physician does not consider medically appropriate."
Questions about risks and benefits
With advances in technology and technique, the risks of a cesarean delivery to a woman without other health problems are very low, and comparable to an uncomplicated vaginal birth, proponents of elective cesareans claim.
Many studies indicate higher rates of complications from cesarean surgery, but these data are not completely reliable because they often compare women who had cesareans for a medical reason with women who had uncomplicated vaginal births, and other variables might have influenced the complications.
And limited data indicate women who have had cesareans may suffer fewer problems with pelvic floor support and sexual functioning later in life.
However, Nardone notes, newer studies indicate that this may not be the case at all.
"We don’t have enough data yet to reliably say why some women suffer vaginal prolapse, incontinence or sexual dysfunction later in life," she says. "Genetic factors may come into play. There may be environmental or behavioral factors. It may be that just carrying a pregnancy to term causes the same changes in the female body that lead to these complications later."
As more healthy women with uncomplicated pregnancies are allowed to choose cesareans on demand, large-scale retrospective studies should be initiated to determine true comparisons of the risks and benefits, both Nardone and ACOG say.
Decisions should be individualized
It’s important for obstetricians and their patients to realize that decisions about cesareans must be made with the woman’s long-term interest in mind and that what might be appropriate for one woman may not necessarily be OK for another, Nardone says.
"Personally, I believe that a vaginal birth is preferable unless there is some compelling reason to perform surgery," she says. "Nature has provided a way for birth to occur, the vagina is an organ that is particularly suited to this process. However, there are times when an elective cesarean is appropriate."
A patient may have coexisting health problems that would complicate a vaginal birth, such as a chronic infection, high blood pressure, or a previous pelvic injury, she says.
And in some cases, she might consider a cesarean purely for patient choice, she adds. The point being, she emphasizes, is that such decisions must be made after a substantive discussion with each individual patient.
"You can’t say that you support it in all cases or that you don’t," she says. "The decision must be made in each individual case."
If, for example, a patient pregnant with her first child at age 45, had used assisted reproductive technology, and felt this was her only chance to have a child, might be a more appropriate candidate than a younger woman who intended to have more than one baby, she explains.
"If the first woman said to me, This is going to be my only child. I don’t want to take any chances, please just take the baby,’ I might consider it," she says. "But if a woman is 30 and tells me she intends to have two or three kids, then there is no way I am going to perform a section on her first pregnancy without some compelling reason."
Although the complication rates for vaginal and cesarean births may be similar, women who have had cesareans are at higher risk for some complications with subsequent pregnancies.
The conditions placenta previa and placenta accreta are more common in women who have had prior cesareans, she says.
Women who have had at least one cesarean have a 4% chance of developing placenta previa or placenta accreta in a subsequent pregnancy. Placenta previa is the term for a "low-lying" placenta that covers all or part of the internal opening of the cervix. Placenta accreta is a placenta that attaches itself too deeply and too firmly into the wall of the uterus. The conditions most often occur in the second and third trimesters of pregnancy. They may cause serious morbidity and mortality to both fetus and mother. They also can lead to vaginal bleeding in the second and third trimesters.
After four cesareans, the chance jumps to 10%. It is difficult for many women to have a vaginal birth after an initial cesarean due to the risk of uterine rupture.
Additionally, approximately 7% of women who have placenta accreta die.
"You can’t just look at that pregnancy and what the woman’s wishes are; you have to be sure you look at the long term and what her goals are in terms of having a family," she says.
It’s also important for both patients and physicians to realize that, even if they agree on an elective section, nature may have other ideas.
"Most OB/GYNs would not perform an elective C-section before 39 weeks," she notes. "But, many women don’t make it that long. They go into labor at 37 weeks or 38 weeks. What do you do then? If they come to the hospital and they are already nine centimeters dilated, do you stop that labor and do a C-section? Labor is very unpredictable. You might have someone get to the hospital and the baby has already started to enter the birth canal. At that point, it is very risky to stop the labor and attempt a section. I would find that unthinkable."
1. American College of Obstetricians and Gynecologists. Surgery and patient choice: The ethics of decision making. ACOG Committee Opinion No. 289. Obstet Gynecol 2003; 102:1,101-1,106.
- Adelaide Nardone, MD, FACOG, Vagisil Women’s Center, Combe Inc., 1101 Westchester Ave., White Plains, NY 10604.