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Elective C-Sections: Doctors Debate Risks Versus Planning

Eleven years ago this July, two doctors in Italy described a new "phenomenon" in a letter to American Journal of Obstetrics & Gynecology. A recent law allowed pregnant women "the choice of the route of delivery"—and a small number were actually opting for C-section. The journal called it "a new ethical and clinical dilemma."

Today, that dilemma has swept developed nations the world over. Medical journals have published viewpoints from obstetricians, midwives, even anesthesiologists ... but few actual studies on whether elective C-sections are, in fact, a good idea.

"There is no direct evidence comparing cesarean delivery on maternal request to planned vaginal delivery," says the National Institutes of Health's 2006 consensus statement. After all these years, doctors are left with "more research is needed." The NIH statement does recommend that certain women not get elective C-sections, including those "desiring several children" (because of an increased risk for placental complications with future C-sections) and those less than 39 weeks pregnant "or without verification of lung maturity." But it also says, "After thorough discussion and review, cesarean delivery on maternal request may be a reasonable alternative ...."

And this is where the debate begins. Doctors themselves are split over whether the practice truly is reasonable.

Cesarean delivery is equally as safe for the mother and baby, if not safer, than a vaginal delivery."


the-great-debate-elective-c-sections-2.jpgAnnette Perez-Delboy, M.D., F.A.C.O.G., board-certifed ob-gyn and maternal-fetal medicine specialist; assistant clinical professor, Department of Obstetrics and Gynecology, Columbia University Medical Center Eastside.

We live in a democratic country where freedom of speech, religion and choice are important. With that said, why doesn't the mother have the autonomy to decide her own medical treatment? With the use of modern technology we have reached the point where the cesarean delivery is equally as safe for the mother and baby, if not safer, than a vaginal delivery.

Cesarean delivery by maternal request (CDMR) occurs for multiple reasons. They include the fear of experiencing a vaginal birth, uncertainty of the timing of delivery, being successful with the endeavor, safety to the baby, fear of the unknown or loss of control of one's body in labor. Another strong argument is prevention of pelvic floor damage, which may cause stress urinary-incontinence, pelvic-organ prolapse and anal incontinence.

Finally, a potentially more persuasive argument is based on the fear of injury to the baby. There's a higher risk with complicated vaginal delivery and unplanned cesarean section than with cesarean delivery by maternal request for things including intrapartum death, cerebral palsy, birth injuries, neonatal infection and stillbirth at term before the onset of labor. In light of these uncommon but devastating outcomes, CDMR are not necessarily riskier than vaginal deliveries.

There are many issues that should influence the decision, including the patient's age, future childbearing plans and obesity. Furthermore, an attempt should be made to identify subgroups of women at higher risk for complications that would benefit most from CDMR.

The question of CDMR is not an easy one to answer. But it is our responsibility as obstetricians to counsel our patients about the risks and benefits of what has been traditionally viewed as a nonindicated cesarean delivery. In this day and age, the discussion should include the patient's right to decide on the risks she wants to take.


The potential risks preclude us from offering it to all women."

Elective cesarean delivery is becoming increasingly popular. Use of CDMR by celebrities has certainly increased its notoriety. CDMR allows women to choose the birth date as well as avoid the uncertainty of labor and delivery, so why not just give women the choice? I believe the potential risks of this particular elective surgery preclude us from offering it to all women.

Despite one goal of Healthy People 2010 being a 15 percent primary cesarean rate, cesarean delivery in the U.S. reached its highest level yet in 2006, of 31.1 percent. Cesarean deliveries have been associated with higher risks of maternal hemorrhage, infection, and even death. Additionally, neonates delivered via cesarean appear to experience higher rates of respiratory complications and possibly death. Further, there are risks from a cesarean delivery for both maternal and neonatal outcomes in future pregnancies, including intrauterine fetal demise, uterine rupture, and placenta previa and accreta.

Interestingly, CDMR is a common practice in several other countries, including Brazil, Chile, and Taiwan. However, there is evidence that in these countries the cesarean rate is being driven by physicians more than the women undergoing these procedures. CDMR was examined in a recent NIH State-of-the-Science conference. The statement from this meeting concluded that future research is necessary to examine both the "current extent of CDMR and attitudes about it."


So, why not just offer CDMR and let women decide? The problem is women may be making the decision based on other issues unrelated to what is best for their health. Thus, to offer an elective procedure that may lead to increased maternal and neonatal mortality in current and future pregnancies with unclear benefits is medically and ethically questionable.


hands pulling rope

Dr. Caughey's

First, let's be clear: Cesarean delivery is a major abdominal surgery associated with higher maternal morbidity and mortality compared to vaginal birth. Additionally, women with one prior cesarean have higher maternal and fetal/neonatal risks in subsequent pregnancies.

Moreover, many women are choosing CDMR because of concerns for fear, pain, or scheduling convenience. It is our job as clinicians to provide counseling and guidance regarding a woman's fears, reassurance with respect to the ability to control pain during labor, and if scheduling is so important, schedule the induction, not CDMR.

Dr. Perez-Delboy's

Women in our society have become more knowledgeable in identifying the complications associated with vaginal and emergent cesarean deliveries and have the right to request a cesarean delivery. There is no question that there are also risks but CDMR does appear to be a relatively safe option for certain women.

On January 2008 the American College of Obstetricians and Gynecologists stated, "If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal delivery, he or she is ethically justified in performing a cesarean delivery."



Last updated and/or approved: June 2010. Original article appeared in May/June 2008 former print magazine. Bio current as of May 2008. This article is not meant as individual advice. Please see our disclaimer.
Comments (1)add comment
Women's Rights
written by Sherah , October 03, 2011

In the US a women is given the right to choose whether or not she would like to have a child, or have an abortion. But when a women choose the Right to Life option, she loses her right to choose her medical options as to surgery. If a C-section can be performed in an emergency, one should medically be safe to be performed electively. All these statements regarding infection and deaths to the mother were all based on C sections performed, not just electively but also Emergency C Sections, correct? So if a women is scared she may have to have a C Section after being subjected through hours and hours of vaginal labor, why not allow her the right to choose the C Section in the first place. She has the right to refuse medical care, so she should also have the right to CHOOSE what care she receives.
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