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Rates of caesarean section are rising, and mothers’ requests for elective caesarean section in an uncomplicated pregnancy are not uncommon. Performing a caesarean section when it is not clinically indicated has traditionally been considered inappropriate, but views may be changing. Sara Paterson-Brown and Olubusola Amu and colleagues debate the issue
Surgery is performed by doctors when they believe it is clinically justified and in accordance with accepted medical practice. In obstetrics an elective caesarean section in an uncomplicated pregnancy has traditionally been considered inappropriate, and any request for such a procedure has been refused.1-1 However, the view that this procedure is clinically unjustifiable has been challenged,1-2 and over the past decade or so prophylactic caesarean section has been gaining credence.1-3,1-4 The balance of benefit versus harm between caesarean section and vaginal delivery is crucial to this debate; although the evidence is incomplete, it challenges the dogma that vaginal delivery is almost always better.
The strongest argument against caesarean section relates to maternal complications. However, evidence supporting this for elective operations under regional blockade with antibiotic cover and thromboprophylaxis is poor. Data on mortality from caesarean section relate to procedures performed for medical or obstetric reasons, often emergencies and often under general anaesthesia.1-5,1-6 These are not comparable to the elective procedure, which most practising obstetricians consider safe. Recent evidence of maternal morbidity after caesarean section and normal and instrumental vaginal delivery challenges some deep rooted obstetric and midwifery teachings: normal vaginal deliveries can cause damage to the pelvic floor,1-7 and instrumental vaginal deliveries are associated with slower recovery1-8 and greater pelvic floor damage and incontinence1-9 than normal delivery and caesarean section. Previous caesarean section does compromise future obstetric performance,1-10,1-11 but evidence is limited and, with reduced family size, this has probably become less important in decision making.
Evidence on intrapartum fetal safety reveals that a baby weighing >1500g at birth has a risk of death of 1 in 1500 in the United Kingdom.1-12 The risk of permanent brain damage due to labour is difficult to quantify: 1 in 1750 labours results in hypoxic ischaemic encephalopathy,1-13 from which many babies recover, whereas intrapartum events account for about 10% of all babies with cerebral palsy,1-14 although recent work suggests this might be an underestimate.1-15 In addition to these risks, as gestation progresses beyond the due date and spontaneous labour is awaited, unexpected intrauterine death occurs in about 1 in 600 pregnancies.1-16 Elective caesarean section cannot guarantee normality, but it avoids the above problems by virtue of avoiding labour and prolonged pregnancy. Short term complications to the neonate of transient tachypnoea and respiratory distress syndrome are reduced by delaying elective caesarean section until 39 weeks of pregnancy have been completed.1-17
Armed with this information, and exposed to the risks of both vaginal delivery and caesarean section in everyday practice, 31% of London female obstetricians with an uncomplicated singleton pregnancy at term would choose an elective caesarean section for themselves.1-18 This group is clearly unrepresentative of women as a whole, and we do not know what proportion of British women would make the same choice. In Italy, however, where women’s choice of mode of delivery must, by law, be respected, 4% of lay women choose an elective caesarean section.1-19 Even though it is probably only a small minority of women who would opt for elective caesarean section, contributing little to the overall rise in caesarean section rates, there is no doubt that women’s choice has a big impact on decisions about caesarean section in obstetric situations that are not completely straightforward.1-20,1-21 Vaginal delivery of a fetus in breech presentation is becoming a rare obstetric art, and half of pregnant women who have already had a caesarean section choose to have another.1-22,1-23 What we do not know is what has changed the views of both the women and their obstetricians about the balance of benefit to harm in these situations to the extent that the risk of trial of vaginal delivery is considered too high.
We are at a turning point in obstetric thinking, brought about not only by the advances that have made caesarean section safe and the evidence that vaginal delivery can be associated with substantial morbidity but also by the attitudes of our society, which reflect intolerance to risk. We encourage “family planning” and prepregnancy counselling, we routinely perform antenatal screening, and we offer prenatal diagnosis—all of which are “unnatural” and promote a concept of the “designer baby.” Can we do all this and then refuse a woman a safe mode of delivery (caesarean section) that removes the gambles associated with labour and which she personally finds unacceptable?
The reports Health Committee Maternity Services and Changing Childbirth suggested that women should have a pivotal role in their obstetric care,1-24,1-25 yet some are now being criticised for the choices they are making. These choices should not be discredited simply because they are not the ones that were expected. We should respect a woman’s view and choice if it is fully informed, if she expresses a logical reason for wanting a caesarean section, and if she can demonstrate an understanding of the implications of the procedure. We should not be dictating to women what they should think, nor should we be judgmental of their values if they happen to differ from our own.
This does not mean that obstetricians should become technicians at the mercy of women’s choice, but that they should be partners in the process of decision making. There is no room for complacency with such incomplete evidence, and further research is needed; but on the basis of the available evidence the concept of a prophylactic caesarean section being outrageous has been shattered by the fact that almost a third of female obstetricians would choose it for themselves.1-18 Prophylactic caesarean section can no longer be considered clinically unjustifiable, and it now forms part of accepted medical practice.
The Cumberledge report, in response to the select committee report of 1992 (the Winterton report), advocated a shift of maternity services to a more woman centred approach to provide a service that is appropriate and acceptable to the individual and is effective and efficient.2-1 The report recommended that women should be provided with adequate information to enable them to participate in decisions about their care and to help them make informed choices.
The knowledge of the right to choose, however, has led to increasing exercise of positive and negative rights. Many units, including ours, are now experiencing the phenomena of maternal requests for elective caesarean section (positive right) and cases of women refusing a medically indicated intervention (negative right). The latter are powerful rights and can be abrogated only under the most extreme circumstances. The result is the ethical conflict between patients’ rights to autonomous decision and carers’ right to autonomy in operating in accord with accepted medical practice.2-2
Caesarean section remains an important area of controversy as the rate of this operation has risen dramatically worldwide.2-3 Breech presentation, prematurity, increased use of electronic fetal monitoring, and the fear of litigation have been implicated,2-4,2-5 and obstetricians have been largely blamed for the rising trend without consideration that women’s preference may play a part (caesarean section on maternal request).
Some women who have had a difficult instrumental vaginal delivery or an emergency caesarean section after a long and painful labour would not contemplate further attempts at vaginal delivery. Vaginal delivery after a previous caesarean section is not considered at all by some women because of concerns about fetal brain damage during labour and the ability to schedule delivery in advance with elective delivery. Requests are now being made for elective caesarean section to protect the pelvic floor from obstetric trauma and its sequelae.2-6,2-7 A survey of female obstetricians by Al Mufti et al showed that 31% would prefer to give birth by elective caesarean section rather than vaginal delivery, and 80% of these doctors indicated fear of perineal damage as their main reason.2-8 Anecdotal evidence also suggests that delayed onset of childbearing by professional women may be associated with increased demands for caesarean section.
Conversely, some women choose vaginal delivery despite doctors’ recommending caesarean section, and, occasionally, court orders have had to be sought to effect delivery of the fetus by caesarean section.2-9 Some women believe that vaginal birth results in healthier children, some associate caesarean section with reproductive abnormality, and others make their choice largely because of fear of major surgery.
Women’s requests for a particular mode of delivery for fear of the consequences of the other method are not necessarily rational.
Forceps delivery has been shown to be the single independent factor associated with trauma to the anal sphincter, and most women who sustain anal sphincteric damage do so in their first pregnancy.2-10 Maternal age has not been shown to have any bearing on the vaginal delivery rate, even after a caesarean section.2-11 Most developmental delays are unrelated to the method of delivery, so a policy of elective caesarean sections would not necessarily prevent long term disability. An elective caesarean section does, however, avert the need for episiotomies, prolonged and painful labours, and difficult instrumental deliveries. Trauma to the pelvic floor and to the urethral and anal sphincters, associated with long term predisposition to genital prolapse and urinary and anal incontinence, would also be avoided.2-12
Caesarean sections are not without complications and consequences. Maternal risks in the short term include haemorrhage, infection, ileus, pulmonary embolism, and Mendelson’s syndrome. The prevalence of hysterectomy due to haemorrhage after caesarean section is 10 times that after vaginal delivery, and the risk of maternal death is increased up to 16-fold.2-12 Long term morbidity—including formation of adhesions, intestinal obstruction, bladder injury, and uterine rupture—is often underestimated during subsequent pregnancy. There is evidence suggesting decreased fecundity, increased risk of ectopic pregnancy, placenta praevia, and worse infant outcome in subsequent pregnancies, although the effect on non-reproductive health is unclear and contradictory.2-13 Feelings of inadequacy, guilt, and failure in not completing a natural process may affect bonding between mother and infant, particularly if the operation was conducted under general anaesthetic.
No proper data exist about the risks and benefits of elective caesarean section versus labour in uncomplicated pregnancies, looking at multiple medical outcomes as well as psychological, social, and economic implications. Obstetricians do not always know best; no doctor can say whether a mother or fetus will be damaged in labour; and current surveillance tests are not always reliable indicators of poor outcome. Despite these uncertainties, it is the responsibility of the healthcare professional to impart information to women and their partners that is accurate and readily understandable.
We strongly support patients’ right to autonomy, and we believe that choice is a fundamental human right, and there are few justifiable constraints on women’s choice. Choice, however, needs to be informed. Ultimately, competent women are free to decline medical advice and treatment for rational or irrational reasons, or for no reason, even if, as a consequence, they or their fetus suffer death or injury. The law is clear that the unborn child has no independent status and that a mentally competent expectant mother’s wishes must take precedence.2-14 Unfortunately, the law does not distinguish between the rights of a mentally competent but foolish (unwise) pregnant woman and other adults. Therefore, if caesarean section is the preferred mode of delivery by the mother, her choice, however foolish or irrational, must be respected.
Healthcare providers must be aware of the importance and consequences of decisions about mode of delivery, as neither method is devoid of risks. Accepting maternal choice as the sole determinant of the method of delivery is probably doing pregnant women a disservice and may constitute a lack of responsibility. The trend for increasing use of caesarean section, coupled with a greater emphasis on patients’ autonomy in medical decision making, has clearly progressed too far for a return to paternalistic directions to women on how they should give birth.2-15 Women with particular needs or views about treatment should be offered adequate information about alternative options.
Conflicts between maternal and fetal interests are potentially complex, ethically and emotionally, and difficult to resolve. Our view is that doctors, midwives, and childbirth educators must give full and honest advice based on the available information; they may persuade but never coerce. Active participation by patients should be encouraged to arrive at a safe and logical informed decision about method of delivery, with carers recommending what they perceive to be the best course of action in keeping with the available evidence.