Caesarean delivery on maternal request

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Caesarean delivery on maternal request
Specialty obstetrics

Caesarean delivery on maternal request (CDMR) is a caesarean section birth requested by the pregnant woman without a medical reason. [1]

Contents

Background

The concept of "Caesarean delivery on maternal request" (CDMR) is not well-recognized in health care, and consequently, when it occurs there are no mechanisms in place for reporting it for research or distinguishing it in medical billing. [2]

Over the last century, delivery by Caesarean section (CS) has become increasingly safer; the medical reasons, therefore, for selecting a CS delivery over a vaginal birth are less likely to be those of necessity, and more likely to be motivated by other factors, such as considerations of pain in vaginal delivery and the effects of childbirth on vaginal muscle tone. Until recently,[ when? ] an elective caesarean section was done on the basis of medical grounds; however, the existence of CDMR makes the mother's preference the determining factor for the delivery mode.

An elective Caesarean will be agreed in advance. An elective Caesarean can be suggested by either the mother or her obstetrician, often as a result of a change in the medical status of the mother or baby. The term is used by the press and on the web in a number of different ways, but any Caesarean section which is not an emergency is classified as elective. The mother in essence has agreed to it but may not have chosen it.[ citation needed ]

The popular media suggest that many women are opting for Caesareans in the belief that it is a practical solution. [3] The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth. [4]

Prevalence

The movement for CDMR may have started in Brazil. [3] It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by. [1] The global nature of the CDMR phenomenon was underlined by a study that showed that in southeast China about 20% of women chose this mode of delivery. [5]

Maternal request

Increasingly, caesarean sections are performed in the absence of obstetrical or medical necessity at the patient's request, and the term Caesarean delivery on maternal request has been used. [1] Another term that has been used is "planned elective cesarean section". [6] As of 2006, there is no ICD code, thus the extent of the use of this indication is difficult to determine. The mother is the only party who may request such an intervention without indication.[ citation needed ]

Caesarean sections are in some cases performed for reasons other than medical necessity. These can vary, with a key distinction being between hospital- or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick Caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined. [7] It is through these lenses that CDMR can sometimes be viewed as an example of unnecessary health care.

Routine hospital practices

Non-medically indicated scheduling of childbirth before 39 weeks gestation brings "significant risks for the baby with no known benefit to the mother." Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%. [8] The researchers found many benefits but "no adverse effects" in the health of the mothers and babies at those hospitals. [8] [9]

In this context, it is worth remembering many studies have shown operations performed out-of-hours tend to have more complications (both surgical and anaesthetic). [10] For this reason, if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery.

Doctor fear of lawsuits

Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits. Italian gynaecologist Enrico Zupi, whose clinic in Rome, Mater Dei, was under media attention for carrying a record of Caesarian sections (90% over total birth), explained: "We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to defensive medicine. We will keep acting this way as long as medical mistakes are not depenalized. We are not martyrs. So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section". [11]

Mother's fear of vaginal birth

Studies of United States women have indicated married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women, although they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone. [12] In contrast, a 2004 study in the British Medical Journal retrospectively analysed a large number of Caesarean sections in England and stratified them by social class. Their finding was Caesarean sections are not more likely in women of higher social class than in women in other classes. [13] Some have suggested, due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, women should be discouraged or forbidden from choosing it. [14]

Some 42% of obstetricians[ clarification needed ] believe the media and women are responsible for the rising Caesarean section rates. [15] A study conducted in Sweden, however, concludes that relatively few women wish to deliver by Caesarean section. [16]

Reducing unnecessary caesarean sections

Requirements for a second opinion from an additional doctor before giving a caesarean section has a small effect on reducing the rate of unnecessary caesarean sections. [17] Communities of health care providers who peer review each other and come to agreement about the necessity of caesarean sections tend to use them less frequently. [17] When medical guidelines are shared by local community leaders which mothers trust, then those mothers are more likely to have vaginal delivery after having had a previous caesarean delivery. [17] When mothers have access to childbirth classes and relaxation classes mothers are more likely to use vaginal delivery when the pregnancy is otherwise low risk. [17]

Controversy

A meeting of experts sponsored by the NIH in March, 2006 attempted to address the medical issues and found "insuffient evidence to evaluate fully the benefits and risks" of CDMR versus vaginal delivery, and thus was not able to come to a consensus about the general advisability of a cesarean delivery by demand. [1] The available evidence suggests certain differences as follows:

Proponents for CDMR point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby. [1] Furthermore, there is some evidence that urinary stress incontinence as a long-term result of damage to the pelvic floor is increased after vaginal birth. Opponents to CS feel that it is not natural, that the costs are higher, infection rates are higher, hospitalization longer, and rates for breastfeeding decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk. Further, babies born after a vaginal delivery tend to be at a lower risk for the infant respiratory distress syndrome. [1]

Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is 184% higher in babies born by cesarean section. [18] This study was harshly criticized for excluding cases where unforeseen complications arose during labor from its cohort of vaginal deliveries, thereby retrospectively removing poor outcomes and artificially lowering the neonatal mortality rate in the vaginal delivery population, and for using birth certificate data instead of more reliable documentation, such as hospital discharge forms, to define cesarean sections with "no indicated risk", and thereby inappropriately including emergent cesarean sections in their "elective cesarean" cohort. [19] [20] [21] In response to this criticism, the authors published a second paper analyzing the same cohort, in which they did not systematically exclude vaginal deliveries in which unexpected complications arose, and concluded that the increased risk of neonatal mortality associated with cesarean section was 69%, rather than 184%. However, they did not address the inadequacies of their data set, and did not attempt to determine the degree of error introduced when identifying elective cesarean sections by birth certificate. [22] A study published in the February 13, 2007 issue of the Canadian Medical Association Journal found that between 1991 and 2005, women who had scheduled cesarean sections for breech birth had a 2.7% rate of severe morbidity, compared with 0.9% for women who had planned vaginal deliveries. [23]

Related Research Articles

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure to deliver a baby through an incision in the mothers abdomen

Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or child at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

<span class="mw-page-title-main">Multiple birth</span> End of a multiple pregnancy where two or more offspring are born

A multiple birth is the culmination of one multiple pregnancy, wherein the mother gives birth to two or more babies. A term most applicable to vertebrate species, multiple births occur in most kinds of mammals, with varying frequencies. Such births are often named according to the number of offspring, as in twins and triplets. In non-humans, the whole group may also be referred to as a litter, and multiple births may be more common than single births. Multiple births in humans are the exception and can be exceptionally rare in the largest mammals.

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In developed countries, most deliveries occur in hospitals, while in developing countries most are home births.

<span class="mw-page-title-main">Breech birth</span> Birth of a baby bottom first

A breech birth is when a baby is born bottom first instead of head first, as is normal. Around 3–5% of pregnant women at term have a breech baby. Due to their higher than average rate of possible complications for the baby, breech births are generally considered higher risk. Breech births also occur in many other mammals such as dogs and horses, see veterinary obstetrics.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

Labor induction is the process or treatment that stimulates childbirth and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. Inductions are most often performed either with prostaglandin drug treatment alone, or with a combination of prostaglandin and intravenous oxytocin treatment.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

In case of a previous caesarean section a subsequent pregnancy can be planned beforehand to be delivered by either of the following two main methods:

Tokophobia is a significant fear of childbirth. It is a common reason why some women request an elective cesarean section. Factors often include a fear of pain, death, unexpected problems, injury to the baby, sexual problems and a lack of self-belief of the capacity to birth a child. Treatment may occur via counselling.

<span class="mw-page-title-main">Vasa praevia</span> Condition in which fetal blood vessels cross or run near the internal opening of the uterus

Vasa praevia is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections), though it is not clear whether this is causal.

In obstetrics, asynclitic birth, or asynclitism, refers to the malposition of the fetal head in the uterus relative to the birth canal. Many babies enter the pelvis in an asynclitic presentation, but in most cases, it corrects itself spontaneously during labor. Asynclitic presentation is not to be confused with a shoulder presentation, where the shoulder leads first.

<span class="mw-page-title-main">Shoulder presentation</span> Childbirth in which the arm, shoulder, or trunk emerges first

In obstetrics, a shoulder presentation is a malpresentation at childbirth where the baby is in a transverse lie, thus the leading part is an arm, a shoulder, or the trunk. While a baby can be delivered vaginally when either the head or the feet/buttocks are the leading part, it usually cannot be expected to be delivered successfully with a shoulder presentation unless a cesarean section (C/S) is performed.

<span class="mw-page-title-main">Monoamniotic twins</span> Identical twins sharing the same amniotic sac in the womb

Monoamniotic twins are identical or semi-identical twins that share the same amniotic sac within their mother's uterus. Monoamniotic twins are always monochorionic and are usually termed Monoamniotic-Monochorionic twins. They share the placenta, but have two separate umbilical cords. Monoamniotic twins develop when an embryo does not split until after formation of the amniotic sac, at about 9–13 days after fertilization. Monoamniotic triplets or other monoamniotic multiples are possible, but extremely rare. Other obscure possibilities include multiples sets where monoamniotic twins are part of a larger gestation such as triplets, quadruplets, or more.

<span class="mw-page-title-main">Circumvallate placenta</span> Medical condition

Circumvallate placenta is a rare condition affecting about 1-2% of pregnancies, in which the amnion and chorion fetal membranes essentially "double back" on the fetal side around the edges of the placenta. After delivery, a circumvallate placenta has a thick ring of membranes on its fetal surface. Circumvallate placenta is a placental morphological abnormality associated with increased fetal morbidity and mortality due to the restricted availability of nutrients and oxygen to the developing fetus.

The Human Microbiome Project (HMP), completed in 2012, laid the foundation for further investigation into the role the microbiome plays in overall health and disease. One area of particular interest is the role which delivery mode plays in the development of the infant/neonate microbiome and what potential implications this may have long term. It has been found that infants born via vaginal delivery have microbiomes closely mirroring that of the mother's vaginal microbiome, whereas those born via cesarean section tend to resemble that of the mother's skin. One notable study from 2010 illustrated an abundance of Lactobacillus and other typical vaginal genera in stool samples of infants born via vaginal delivery and an abundance of Staphylococcus and Corynebacterium, commonly found on the skin surfaces, in stool samples of infants born via cesarean section. From these discoveries came the concept of vaginal seeding, also known as microbirthing, which is a procedure whereby vaginal fluids are applied to a new-born child delivered by caesarean section. The idea of vaginal seeding was explored in 2015 after Maria Gloria Dominguez-Bello discovered that birth by caesarean section significantly altered the newborn child's microbiome compared to that of natural birth. The purpose of the technique is to recreate the natural transfer of bacteria that the baby gets during a vaginal birth. It involves placing swabs in the mother's vagina, and then wiping them onto the baby's face, mouth, eyes and skin. Due to the long-drawn nature of studying the impact of vaginal seeding, there are a limited number of studies available that support or refute its use. The evidence suggests that applying microbes from the mother's vaginal canal to the baby after cesarean section may aid in the partial restoration of the infant's natural gut microbiome with an increased likelihood of pathogenic infection to the child via vertical transmission.

Nicholas Maxwell Fisk is an Australian maternal-fetal medicine specialist, academic and higher education lead. As a researcher, his group has pioneered advances in understanding fetoplacental disease and its treatment, including characterising early human fetal stem cell populations and their lifelong persistence in maternal tissues, documenting “fetal pain” and its blockade by opioid analgesia, and unravelling the vascular basis of twin-to-twin transfusion syndrome. As an obstetrician, Fisk is known for inventing the natural caesarean operation, also referred to as the family centred caesarean section.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

Maternal health outcomes differ significantly between racial groups within the United States. The American College of Obstetricians and Gynecologists describes these disparities in obstetric outcomes as "prevalent and persistent." Black, indigenous, and people of color are disproportionately affected by many of the maternal health outcomes listed as national objectives in the U.S. Department of Health and Human Services's national health objectives program, Healthy People 2030. The American Public Health Association considers maternal mortality to be a human rights issue, also noting the disparate rates of Black maternal death. Race affects maternal health throughout the pregnancy continuum, beginning prior to conception and continuing through pregnancy (antepartum), during labor and childbirth (intrapartum), and after birth (postpartum).

References

  1. 1 2 3 4 5 6 NIH (2006). "State-of-the-Science Conference Statement. Cesarean Delivery on Maternal Request". Obstet Gynecol. 107 (6): 1386–97. doi:10.1097/00006250-200606000-00027. PMID   16738168.
  2. ↑ "Committee Opinion No. 559: Cesarean Delivery on Maternal Request". Obstetrics & Gynecology. 121 (4): 904–907. 2013. doi:10.1097/01.AOG.0000428647.67925.d3. ISSN   0029-7844.
  3. 1 2 Finger, C. (2003). "Caesarean section rates skyrocket in Brazil". Lancet. 362 (9384): 628. doi:10.1016/S0140-6736(03)14204-3. PMID   12947949. S2CID   54353381.
  4. ↑ Minkoff, H.; Powderly KP; Chervenak F; McCollough LB (2004). "Ethical dimensions of elective primary cesarean delivery". Obstet Gynecol. 103 (2): 387–92. doi:10.1097/01.AOG.0000107288.44622.2a. PMID   14754712. S2CID   21783487.
  5. ↑ Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z (2008). "Cesarean delivery on maternal request in southeast China". Obstet Gynecol. 111 (5): 1077–82. doi:10.1097/AOG.0b013e31816e349e. PMID   18448738. S2CID   5914048.
  6. ↑ Hannah, Mary E. (2 March 2004). "Planned elective cesarean section: A reasonable choice for some women?". Canadian Medical Association Journal. 170 (5): 813–814. doi:10.1503/cmaj.1032002. PMC   343856 . PMID   14993177 . Retrieved 11 December 2018.
  7. ↑ MacKenzie IZ, Cooke I, Annan B (2003). "Indications for Caesarean section in a consultant obstetric unit over three decades". J Obstet Gynaecol. 23 (3): 233–8. doi:10.1080/0144361031000098316. PMID   12850849. S2CID   25452611.
  8. 1 2 "Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age" (PDF). Archived from the original (PDF) on 2012-11-20. Retrieved 2012-07-13.
  9. ↑ Reddy, Uma M.; Bettegowda, Vani R.; Dias, Todd; Yamada-Kushnir, Tomoko; Ko, Chia-Wen; Willinger, Marian (June 2011). "Term Pregnancy: A Period of Heterogeneous Risk for Infant Mo... : Obstetrics & Gynecology". Obstetrics & Gynecology. 117 (6): 1279–1287. doi:10.1097/AOG.0b013e3182179e28. PMC   5485902 . PMID   21606738 . Retrieved 2012-07-12.
  10. ↑ Cullinane M, Gray A, Hargraves C, Lansdown M, Martin I, Schubert M. Who operates when? – The 2003 Report of the Confidential Enquiry into Perioperative Deaths (PDF) (Report). Archived from the original (PDF) on 2012-02-20. Retrieved 2009-07-30.
  11. ↑ "La clinica dei record: 9 neonati su 10 nati con il parto cesareo". Corriere della Sera . 14 January 2009. Archived from the original on July 24, 2009. Retrieved 2009-02-05.
  12. ↑ Wagner, Marsden (November 2006). Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First . University of California Press. p. 42. ISBN   978-0-520-24596-9.
  13. ↑ Barley K, Aylin P, Bottle A, Jarman B (2004). "Social class and elective Caesareans in the English NHS". BMJ. 328 (7453): 1399. doi:10.1136/bmj.328.7453.1399. PMC   421774 . PMID   15191977.
  14. ↑ Bewley S, Cockburn J (2002). "The unfacts of 'request' Caesarean section". BJOG. 109 (6): 597–605. doi:10.1111/j.1471-0528.2002.07106.x. PMID   12118634. S2CID   9702229.
  15. ↑ Usha Kiran TS, Jayawickrama NS (2002). "Who is responsible for the rising Caesarean section rate?". J Obstet Gynaecol. 22 (4): 363–5. doi:10.1080/01443610220141263. PMID   12521454. S2CID   218854960.
  16. ↑ Hildingsson I, Rådestad I, Rubertsson C, Waldenström U (2002). "Few women wish to be delivered by Caesarean section". BJOG. 109 (6): 618–23. doi:10.1111/j.1471-0528.2002.01393.x. PMID   12118637. S2CID   24902574.
  17. 1 2 3 4 Chen, Innie; Opiyo, Newton; Tavender, Emma; Mortazhejri, Sameh; Rader, Tamara; Petkovic, Jennifer; Yogasingam, Sharlini; Taljaard, Monica; Agarwal, Sugandha; Laopaiboon, Malinee; Wasiak, Jason; Khunpradit, Suthit; Lumbiganon, Pisake; Gruen, Russell L.; Betran, Ana Pilar (2018-09-28). "Non-clinical interventions for reducing unnecessary caesarean section". The Cochrane Database of Systematic Reviews. 2018 (9): CD005528. doi:10.1002/14651858.CD005528.pub3. ISSN   1469-493X. PMC   6513634 . PMID   30264405.
  18. ↑ MacDorman, MF; Declercq, E; Menacker, F; Malloy, MH (2006). "Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts". Birth. 33 (3): 175–82. CiteSeerX   10.1.1.513.7283 . doi:10.1111/j.1523-536X.2006.00102.x. PMID   16948717.
  19. ↑ Källén, K.; Olausson, PO (2007). "Letter: Neonatal Mortality for Low-Risk Women by Method of Delivery". Birth. 34 (1): 99–100. doi:10.1111/j.1523-536X.2006.00155_1.x. PMID   17324187.
  20. ↑ Pettker, C.; Funai, E (2007). "Letter: Neonatal Mortality for Low-Risk Women by Method of Delivery". Birth. 34 (1): 100–101. doi:10.1111/j.1523-536X.2006.00155_2.x. PMID   17324188.
  21. ↑ Roberts, C; Lain, S; Hadfield, R (2007). "Quality of Population Health Data Reporting by Mode of Delivery". Birth. 34 (3): 274–275. doi:10.1111/j.1523-536X.2007.00184_2.x. PMID   17718880.
  22. ↑ MacDorman, MF; Declercq, E; Menacker, F; Malloy, MH (2008). "Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an "Intention-to-Treat" Model". Birth. 35 (1): 3–8. doi:10.1111/j.1523-536X.2007.00205.x. PMID   18307481.
  23. ↑ Liu, Shiliange, Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term Canadian Medical Association Journal, February 13, 2007; 176 (4).
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