WASHINGTON — Any decision to choose between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section have been discussed, concluded an independent panel of experts on cesarean section.
“Her decision should be honored,” Dr. Mary E. D'Alton, panel chairperson, said at a conference on cesarean delivery sponsored by the National Institutes of Health.
The panel, convened to assess the science regarding cesarean delivery on maternal request, concluded that available information on the risks and benefits of C-section on maternal request versus planned vaginal birth does not provide the basis for a recommendation in either direction.
The panel defined C-section on maternal request as a mother's request for a cesarean delivery for a singleton pregnancy when she has no established medical indication for the procedure. This is distinct from emergency C-section or C-section performed after attempted vaginal delivery.
“We don't believe [C-section on maternal request] should be discouraged or encouraged. We believe there should be a full discussion of the risks and benefits as we know them right now,” said Dr. D'Alton, chair of obstetrics and gynecology at Columbia University in New York.
Many believe that the rate of cesarean delivery by maternal request is increasing, with domestic and international estimates ranging from 4% to 18% of all cesarean deliveries. In 2004, almost one-third (29%) of all U.S. live births were by C-section, the highest rate ever reported.
Cesarean delivery on maternal request “may be a reasonable alternative” to planned vaginal delivery, after thorough discussion with the patient, the panel of 18 experts said in a draft state-of-the-science report. “When a provider cannot support this request, it is appropriate to refer the woman to another provider.”
The panel advised against C-section for women desiring to have several children, but did not specify a number to use as a cutoff. Evidence seems to indicate that the risks of placenta previa and accreta rise with each C-section. Planned vaginal delivery “provides an improved benefit/risk ratio for women who desire several children,” the panel concluded.
The panel also recommended that C-section on maternal request should not be performed prior to 39 weeks or without verification of lung maturity. Evidence suggests an increased risk of neonate respiratory morbidity with C-section, compared with vaginal delivery.
The panel encouraged physicians to discuss with a woman her reasons for requesting a C-section, and to discuss pain management options if she is motivated by a fear of pain. “Efforts must be made to assure availability of pain management services for all women,” the panel said.
Good quality data on the benefits and risks of C-section on maternal request are limited. It is often difficult to retrospectively assess whether a C-section was genuinely requested by the mother. Frequently, emergency C-sections and/or C-sections following a trial of labor are lumped in with the ones by maternal request.
The interpretation of many outcome variables was confounded by a lack of appropriate comparison groups, inconsistency in outcome definitions, and the frequent use of composite outcomes. The panel identified two maternal outcome variables—both short term—with moderate-quality evidence.
One suggests a lower risk of blood loss associated with planned C-section than with the combination of planned vaginal delivery and unplanned C-section. The second indicates that C-section was associated with longer hospital stays than was vaginal delivery. The panel also identified one neonatal outcome with moderate-quality evidence—increased respiratory morbidity associated with planned C-section.
The final statement is available at http://consensus.nih.gov