Elective Primary Elective Primary Cesarean SectionCesarean Section

Paul Wendel, MDPaul Wendel, MDAssociate ProfessorAssociate ProfessorResidency DirectorResidency Director

UAMS Department of Obstetrics & GynecologyUAMS Department of Obstetrics & Gynecology

• Patient choicePatient choice• Maternal requestMaternal request• On demandOn demand

All refer to primary cesarean section in the absence of medical/obstetrical indications.

Concept Origins:Concept Origins:Most recently traced to 1985Most recently traced to 1985

Stimulated by medicolegal case Stimulated by medicolegal case involving intrapartum fetal neurologic involving intrapartum fetal neurologic injuryinjury

Authors discussed “prophylactic Authors discussed “prophylactic cesarean section” ‘at term’cesarean section” ‘at term’

Notion of informed consent for route of Notion of informed consent for route of delivery was introduceddelivery was introduced

C-section offered as a means of avoiding C-section offered as a means of avoiding the risks associated with vaginal deliverythe risks associated with vaginal delivery

Feldman, GB Prophylactic cesarean at term? NEJM 1985; 312 pp. 1264-67

Patient PerspectivePatient Perspective

Elective Elective cesarean cesarean sections sections currently currently account for 4-account for 4-18% of all c-18% of all c-sections.sections.

Why do Women ask for C-Why do Women ask for C-Sections?Sections?

Extreme tocophobia (fear of childbirth)

Death (patient or baby)

Fetal injuryGenital tract

injury

When Psychotherapy was When Psychotherapy was employed by trained employed by trained professionals to address professionals to address tocophobia:tocophobia:

2/3 women ultimately chose 2/3 women ultimately chose vaginal birthvaginal birth

These same women…These same women…Ultimately viewed their birth Ultimately viewed their birth

experience as goodexperience as good

Physicians’ PerspectivePhysicians’ Perspective Several studies have been Several studies have been

done in UK, New Zealand, done in UK, New Zealand, Ireland, Canada, Israel Ireland, Canada, Israel regarding physicians’ and regarding physicians’ and midwives’ attitudes toward midwives’ attitudes toward “elective c-section”“elective c-section” 7-30% of OB/GYN’s and 4.4% of 7-30% of OB/GYN’s and 4.4% of

midwives preferred c-sections midwives preferred c-sections for themselves if female or for themselves if female or their partner if maletheir partner if male

62-81% reported a willingness 62-81% reported a willingness to perform c-sections on to perform c-sections on demanddemand

Physicians’ Perspective Physicians’ Perspective (con’t)(con’t)

Similar to their patients, obstetricians Similar to their patients, obstetricians cited the following as reasons leading cited the following as reasons leading to primary elective c-sections:to primary elective c-sections:Fear of childbirth 27%Fear of childbirth 27%Perineal injury 80-95%Perineal injury 80-95%Fetal injury 24-39%Fetal injury 24-39%Anal or urinary incontinence 81-83%Anal or urinary incontinence 81-83%Sexual dysfunction 58-59%Sexual dysfunction 58-59%Convenience 17-39%Convenience 17-39%Control 39%Control 39%Pain 7%Pain 7%

Attitudes of Urogynecologist’s Attitudes of Urogynecologist’s & MFM’s to Elective C-sections& MFM’s to Elective C-sections

Survey was distributed by Survey was distributed by UNC via web baseUNC via web base

53% of SMFM/AUGS members 53% of SMFM/AUGS members respondedresponded

Survey ResultsSurvey ResultsOverall, 65% of physicians Overall, 65% of physicians

would perform an elective would perform an elective primary cesarean sectionprimary cesarean section

Compared with other Compared with other countries:countries:

69% England69% England67% Australia/New Zealand67% Australia/New Zealand

AUGS / SMFM Survey AUGS / SMFM Survey ComparisonComparison

80% of AUGS members vs. 80% of AUGS members vs. 55% of SMFM members for 55% of SMFM members for primary elective c-sectionprimary elective c-section

45% of AUGS and 9.5% of 45% of AUGS and 9.5% of SMFM members would choose SMFM members would choose a primary c-section for a primary c-section for themselves or their partnersthemselves or their partners

Ethical PrinciplesEthical Principles Can an elective c-section Can an elective c-section

for an uncomplicated for an uncomplicated pregnancy be ethically pregnancy be ethically justified?justified?

Decision making based Decision making based on:on: BeneficenceBeneficence NonmaleficenceNonmaleficence AutonomyAutonomy JusticeJustice VoracityVoracity

Ethical PrinciplesEthical PrinciplesBeneficenceBeneficence: physicians responsibility to : physicians responsibility to

promote the patients’ health/welfarepromote the patients’ health/welfareNonmaleficenceNonmaleficence: complimentary principle : complimentary principle

refers to the physician’s obligation to do refers to the physician’s obligation to do no harm to the patientno harm to the patient

AutonomyAutonomy: obligates the physician to : obligates the physician to discuss reasonable alternatives and elicit discuss reasonable alternatives and elicit a decision within the framework of a decision within the framework of informed consentinformed consent

Ethical PrinciplesEthical Principles

Typically, patients retain a “negative right” (right to decline care) but do not hold a “positive right” (the right to demand care that may be unnecessarily risky or medically unproven).

Ethical PrinciplesEthical PrinciplesJusticeJustice: requires that a physician : requires that a physician

treat patients fairly and make treat patients fairly and make decisions that consider societal decisions that consider societal good with respect to limited good with respect to limited health resourceshealth resources

VoracityVoracity: refers to truthfulness : refers to truthfulness in patient counselingin patient counseling

Committee of the Ethical Aspects of Human Reproduction of the International Federation of Obstetrics and Gynecology (FIGO) in 1999 issued a report regarding c-section for non-medical reasons:

C-section was a surgical procedure

Greater allocation of resources for c-section

Vaginal delivery was safer in long/short term for mother/fetus

Elective c-section was not ethically justified

American College of OB/GYN American College of OB/GYN Committee on Ethics (2003)Committee on Ethics (2003)

If a patient requests cesarean section after informed counseling and the physician believes it will promote the overall health of patient and fetus, “…the elective c-section is ethically justified.”

If the physician disagrees, the patient should be referred to another provider.

Medical IssuesMedical Issues

Historically, c-sections have a higher risk of maternal mortality than vaginal delivery. However, most studies do not adjust for:

Elective vs. emergency c-section

Contributing medical/obstetric conditions

Cape Town, South Africa 1975-Cape Town, South Africa 1975-19861986

Compared maternal mortality from Compared maternal mortality from elective c-section vs. vaginal delivery:elective c-section vs. vaginal delivery:Elective c-section – 23/100,000Elective c-section – 23/100,000

RR = 3.8RR = 3.8Vaginal – 6/100,000Vaginal – 6/100,000

Study (1954-1985) assessed c-section Study (1954-1985) assessed c-section related mortality rate in Massachusettsrelated mortality rate in Massachusetts

Death rateDeath rate C-sections - 5.9/100,000 C-sections - 5.9/100,000

vs. vs. Vaginal delivery - 10.8/100,000 Vaginal delivery - 10.8/100,000

Saches and Colleagues Saches and Colleagues (1988)(1988)

Washington State 1987-1996Washington State 1987-1996Large retrospective study addressed postpartum mortality among primiparas (adjusting for age, marital status, preeclampsia):

C-section 6.8/100,000

vs.

Vaginal delivery 8.2/100,000

*Limited datasets suggest that elective cesarean sections and vaginal deliveries do not increase direct maternal death.

Maternal MorbiditiesMaternal Morbidities

Discussions of puerperal complications must make distinctions between c-sections performed before and after labor and between spontaneous and operative vaginal deliveries.

Washington State Washington State Retrospective Study 2000Retrospective Study 2000

Association between delivery method and maternal re-hospitalization within 60 days of delivery:

Spontaneous vaginal delivery – 10/1000

Operative vaginal delivery – 12/1000

Cesarean section – 17/1000

Philadelphia 1994-1997Philadelphia 1994-1997Retrospective StudyRetrospective Study

Hospital readmissions by delivery route within 60 days of delivery:

C-sections – 35.6/1000

Operative vaginal delivery – 29.5/1000

Spontaneous vaginal delivery – 17.7/1000

*Study did not distinguish between c-sections with and without labor.

Randomized Multicenter Trial of Randomized Multicenter Trial of Management of Breech at TermManagement of Breech at Term

Peripartum Maternal Morbidity

Planned Cesarean section – 41/1041 (3.9%)

Planned Vaginal delivery – 33/1042 (3.2%)

*No differences between groups:HemorrhageGenital tract injuryWound breakdownInfection

Fetal MorbidityFetal MorbidityOriginal premise: C-section at term Original premise: C-section at term

would avoid intrapartum fetal would avoid intrapartum fetal neurologic injuryneurologic injury

Data suggests fetal neurologic injury Data suggests fetal neurologic injury affects 2-3/1000 intrapartum eventsaffects 2-3/1000 intrapartum events

3,000 – 5,000 elective cesarean sections would be

needed to avoid one such injury.

C-section Rate (mid 1970’s – C-section Rate (mid 1970’s – present)present)

Pooled data from these countries have shown significant rise of c-section rates:

Sweden Canada England IrelandAustralia Denmark Norway U.S.

Cerebral palsy rates have remained stable internationally

C-section is not neuroprotective for the fetus

Birth InjuryBirth Injury

Available data suggests that “pre-labor” cesarean section does not offer a clear fetal benefit with respect to intracranial, brachial plexus, or fracture injury.

May increase the risk of laceration injury in the infant.

ConclusionConclusionThe debate over elective c-sections The debate over elective c-sections

is growing.is growing.Obstetrician should be aware of the Obstetrician should be aware of the

issues and their colleagues’ beliefs.issues and their colleagues’ beliefs.No adequate study has compared No adequate study has compared

elective c-sections and planned SVD.elective c-sections and planned SVD. In the absence of data, professional In the absence of data, professional

organizations will have different organizations will have different opinions on ethical acceptability.opinions on ethical acceptability.

ConclusionConclusion

Available data, though not robust, suggests that overall maternal and perinatal mortality, short- and long-term maternal and neonatal morbidity favor a vaginal delivery.