Should doctors perform an elective caesarean section on request?Yes, as long as the woman is fully informedMaternal choice alone should not determine method of delivery
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7156.462 (Published 15 August 1998) Cite this as: BMJ 1998;317:462All rapid responses
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EDITOR - Doctor Sara Paterson-Brown reports that the discussion about
women' choice of elective caesarean section is based on the dogma that
vaginal delivery is almost always better (1). We agree that the assumption
is simply a "dogma", since there is no scientific prove of it, but if we
have to analyse the terms of the question, we should rather address the
issue of induction of labour and eventually vaginal instrumental delivery
versus caesarean section. In that case both modern obstetrics and public
would be oriented to support the latter as safer and more acceptable. We
should therefore change the adjective better with natural or
physiological, but again what is there of natural and physiological in the
modern management of labour in most of the western world countries?
I would therefore move the question to the concepts of labour and
delivery, as they are commonly understood by practising physicians and lay
public. If we accept, for women and children sake, that they necessitate
technological and medical surveillance, then they have very little of a
natural event. In that case the woman has to choose between two options,
both thoroughly influenced by technological and medical interference and
therefore "unnatural". If we accept this point of view, and I believe we
have to, I cannot see why we should question the feasibility of women
choice, even without medical reason, between two events that are both
relatively safe.
As long as the woman is fully informed, is the condition that the Author
requests before any doctor should accept, before performing a caesarean
section on request. We also agree that the issue is essential, but it
cannot be overstated in terms of legal defence. A complication of the
surgical procedure cannot, at least in Italy, be simply covered by the
informed consent and the understanding of the patient. We have to be
prepared, in our opinion, to respect women's views and choices, also those
not in agreement with our current practice, but we do not have to
underestimate for any medical act the potential burden of its legal
implications.
Paterson-Brown S. Should doctors perform an elective caesarean
section on request? BMJ ; 317: 462-3
Professor Luigi Selvaggi
President of the Italian Society of Perinatal Medicine
Address: 2^ Clinica Ostetrica-Ginecologica,
Piazza Giulio Cesare Policlinico,
70124 Bari, Italy
Competing interests: No competing interests
EDITOR - The debate about elective caesarean section on patient
request is still open in Italy. The report that 1/3 of female
obstetricians in London would choose an elective caesarean delivery for
themselves (1) is, to our opinion, interesting.
We have recently performed a postal survey, addressed to hospital based
obstetricians, about their opinion on some management options such as
forceps/vacuum extractor use, vaginal breech delivery, partogram and
active management of labour, trial of labour after a previous caesarean,
caesarean section on request (2). Eighty-seven per cent of doctors have
agreed to fill the questionnaire and their replies have been matched
against demographic data, position, years of experience, interest in
private practice, personal legal exposure and rate of malpractice claims
for each hospital.
Eighty per cent of consultants (head of department) and
65% of senior registrars have stated that they accept to perform an
elective caesarean section on patient request. On multivariate analysis,
the position of the obstetrician has been the single factor to be
significantly associated with this trend.
We have realised that, in our reality, obstetricians, especially senior
obstetricians are more inclined than we had thought to fulfil the patient
wish. "Environmental" aspects such as private practice, previous legal
involvement, malpractice claim rate of the site of work are not important
factors for this attitude. This apparently means that the opinion of most
practising obstetricians in Italy is similar to female doctors from
London.
In the same paper, Doctor Paterson-Brown states that in Italy; "where
women's choice of mode of delivery must ,by law, be respected, 4% of lay
women choose caesarean section". This assumption need to be carefully
interpreted: the respect of women's choice does not mean, according to
many a lawyer, that an unnecessary intervention could be justified in a
trial. A hysterotomy does interfere with the future reproductive
performance and therefore, in case of a complication, any previous
informed consent from the patient would be of no value, since the subject
has no legal right to cause any harm to his own body.
This issue cannot be simply discharged as a discussion about risks for the
patient and ethical duties for the doctors, but it deserves, we believe,
more attention and possibly a consensus opinion from the medical
societies.
References
1. Paterson-Brown S: Should doctors perform an elective Caesarean Section
on request? Yes, as long as the woman is fully informed. BMJ 317 (1998)
462-3
2. Vimercati A, Greco P, Kardashi A, Rossi C, Loizzi V, Scioscia M,
Loverro G: Choice of Caesarean Section and perception of legal pressure. J
Perinat Med (accepted for publication)
Authors
Pantaleo Greco
Senior Lecturer/Consultant in Obstetrics and Gynaecology
Antonella Vimercati
Research Fellow in Obstetrics and Gynaecology
Luigi Selvaggi
Professor in Obstetrics and Gynaecology
Franco Vimercati
Professor of Legal and Forensic Medicine University
of Bari Italy
Corresponding Author:
Dottor Pantaleo Greco
II Clinica Ostetrica /Ginecoloogica
Policlinico Piazza G. Cesare
70124 Bari
Competing interests: No competing interests
I delivered my first child in an unscheduled cesaerean section due to
fetal heart distress and my own lack of dilation (I went up to nine
centimeters twice and then back to five again). I had an easy recovery,
and felt well enough to leave my bed and care for myself by the end of the
second day. Two years later when I became pregnant again, I decided I
would not like to try for a vaginal delivery because I believed my body
would not cooperate.
I informed my OB/GYN of my wishes and she cautioned me strongly
against my decision but she respected my decision and I signed the waiver.
The recovery from my second Cesarean was horrific. I did not feel well
until two months after the birth. I almost wished I had listened to her
and elected for a VBAC, but I'm not sure that decision would have helped.
I had titanic contractions that were one minute apart when I reached the
hospital, but I was only dilated 3 centimeters. I'm not sure I would have
still wanted a vaginal birth under those circumstances. I just wanted the
baby out so that the pain would stop. I certainly would not recommend
second Cesareans to any woman if they are not necessary.
Competing interests: No competing interests
Editor-As a practising obstetrician I receive only an occasional
request for elective caesarean section in the absence of a medical
indication (1). Although an increasing number of women may be asking for
information about
primary elective caesareans only a small number will actually want one
once they have been fully informed. In one UK prospective audit only 5 of
559 caesarean sections (0.9%) were done for this reason (2). Mothers may
have a natural tendency to avoid a major surgical procedure even when its
safety is well established.
Regarding the relative safety of caesarean and vaginal birth two
points are worth noting. First, unplanned caesarean section carries a
greater level of risk than planned surgery (3), as the operation may be
hurried, technically more difficult in advanced labour, and carried out
with less supervision. The greater the likelihood that emergency surgery
will be necessary the more tempting it becomes to avoid the labour
altogether. However, our lack of ability to predict the outcome of labour
except at the extremes means
that this knowledge will only occasionally be useful to couples and their
obstetrician making a prospective decision.
Second, obstetricians need to be more aware of the so-called
"miseries of childbirth" (perineal scarring and dyspareunia, sphincter
damage, uterovaginal prolapse and urinary incontinence) so as to reassure
prospective mothers that likely risk factors such as prolonged second-
stage labour or different types of forceps deliveries will be discussed
with them in more detail during their antenatal care. For example, few
obstetricians routinely discuss with their patients in the antenatal
clinic how hard they would wish them to try to achieve vaginal delivery.
In this way the patient and her obstetrician could agree a threshold for
caesarean section in labour. At one end of the spectrum this may take the
form of an elective caesarean operation.
In making these decisions I am concerned that the results from the
often quoted survey of female obstetricians in London (4) may have an
undue influence. Female obstetric registrars and senior registrars in the
UK, constituting the majority of respondents in the survey, train in the
management of obstetric complications and thereby develop expertise in
births by ventouse, forceps and caesarean section. They do not witness or
participate in the 60-70% of births that occur naturally and with minimal
iatrogenic trauma. Their views can hardly be considered representative of
the maternity services in the UK. Midwives on the other hand deliver most
pregnant women in the UK and their views about elective caesarean may be
very different. It may also be useful to find out what general
practitioners think, as their more holistic perspective may be important
when it comes to informing the general population about these complex
issues.
Karl W Murphy
Consultant Obstetrician & Gynaecologist
Subspecialist in Fetal Medicine
Clinical Director of Womens & Childrens Services
St Mary's Hospital
London W2 1NY
1. Paterson-Brown S, Amu O, Rajendran S, Bolaji II. Should doctors
perform an elective caesarean section on request? BMJ 1998;317:462-5. (15
August)
2. McAra L, and Murphy KW. The contribution of dystocia to the
caesarean section rate. Am J Obstet Gynaecol 1994;171:71-7.
3. Lilford RJ, Coeverden De Groot HA, Moore PJ, Bingham P. The
relative risks of caesarean section (intrapartum and elective) and vaginal
delivery; a detailed analysis to exclude the effects of medical disorders
and other
acute pre-existing physiological disturbances. Br J Obstet Gynaecol
1990;97:883-892.
4. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians personal
preference and discretionary practice. Eur J Obstet Gynaecol Reprod Biol
1997;73:1-4.
Competing interests: No competing interests
EDITOR
In her article on maternal choice and caesarian section, Sara Paterson-
Brown appears to make the assumption that there is an unconditional right
for an autonomous patient to have her wishes fulfilled. The (negative)
right to decline treatment needs to be distinguished from the supposed
(positive) right to demand it. In english law, the principle of autonomy
allows, for example, competent individuals the right to refuse life-saving
treatment, and physicians have a correlative duty to respect this right.
The dying patient, however, does not have the right to impose a duty on a
health care professional to end his/her life.
With respect to medical and surgical interventions, the law is also
clear. A patient, however competent, cannot invariably impose his/her
demands, and force a practitioner to act in a way which he/she believes to
be contrary to the patient's best interests. This prerogative would be
viewed by the courts as "an abuse of power as directly or indirectly
requiring the practitioner to act contrary to the fundamental duty which
he owes to his patient" (per Lord Donaldson).
Health care professionals could not preserve their professional
integrity, self-respect or credibility if they were to act as mere
instruments to the "foolish" or "irrational" demands of patients,
particularly if this ran contrary to good medical practice, or violated
their deeply held values. Decision making should be made as a
collaborative enterprise based on mutual respect with the shared goal of
the good of the patient.
Distributive justice also deserves consideration here. If patients
demand expensive treatments, such as caesarian sections, in circumstances
for which there is little or no evidence of benefit - and, indeed, there
may evidence of harm - the opportunity costs should be considered.
The profession and the public, in the interest of patient welfare,
should consider setting limits to personal autonomy and to professional
self-effacement.
Paquita de Zulueta
Clinical Lecturer
Department of General Practice and Primary Care
St Mary's Campus
Imperial College School of Medicine
Norfolk Place
London W2 1PG
Conflict of interest: none
1 Paterson-Brown S. Controversies in management: Should doctors
perform an elective caesarian section on request? BMJ 1998;317:462.
2 Re C (adult refusal of treatment) [1993] 15 BMLR 77.
3 Re J (A minor) (Child in Care: Medical Treatment) [1992] 4 All
E.R. 614, C.A.
4 General Medical Council. Good Medical Practice.
Competing interests: No competing interests
EDITOR - I read with interest the article by Amu et al.1, arguing
against open access for caesarean section in the absence of a medical
indication. However, I take issue with their assertion that maternal age
does not influence vaginal delivery rates. There is a wealth of data
showing increased incidence of instrumental and caesarean deliveries in
older women2, 3, and I recently examined this issue at Queen Charlotte’s
and Chelsea Hospital in London4. I found that this effect is incremental
i.e. the older the woman, the lower her chances of having a spontaneous
vaginal delivery. In the Queen Charlotte’s series of over 6,000 nuliparae,
35 year old women had only a 49% chance of a spontaneous vaginal delivery,
compared with 71% in 20 year old women. By the time a women was 40 years
or older, her risk of an instrumental delivery in labour was 42%. Whilst
it could be argued that maternal or obstetricians’ anxiety may be higher
in older women, prompting higher rates of intervention, the incremental
nature of the increase in operative delivery rates, and the fact that
there was also an incremental increase in failure to progress as a cause
of instrumental delivery, points to a genuine biological effect. Older
women have a right to know that their chances of a spontaneous vaginal
delivery decreases with each year they delay childbirth. If they then
request an elective caesarean section in order to avoid the high risk of
emergency operative delivery (and its proven longterm sequaelae), then
shouldn’t obstetricians grant them that wish?
Adam Rosenthal (Clinical Research Fellow)
Gynaecology Cancer research Unit,
St. Bartholomew’s Hospital,
West Smithfield,
London EC1A 7BE
REFERENCES
1 Amu O, Rajendran S, Bolaji II. Should doctors perform an elective
caesarean section on request? BMJ 1998; 317: 462-5
2 Ezra Y, McParland P, Farine D. High delivery intervention rates in
women over age 35. Eur. J Obstet and Gynaecol and Reprod. Biol. 1995; 62:
203-207
3 Kirz DS, Dorchester W, Freeman RK. Advanced maternal age: the
mature gravida. Am J Obstet Gynecol 1985; 152: 7-12
4 Rosenthal AN, Paterson-Brown S. Is there an incremental rise in the
risk of obstetric intervention with increasing maternal age? Br J Obstet
Gynaecol 1998; 105: 1064-1069
Competing interests: No competing interests
Time has gone that the world is governed by London. This also holds
true for the obstetric world. The fact that '31% of London female
obstetricians with an uncomplicated singleton pregnancy at term would
choose an elective caesarean section for themselves' (BMJ 1998; 317: 462-
65) is brought as a 'changing view' and misleadingly translated into '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'. What are the facts then? Out of 206 London-
based obstetricians 33 (17%) would opt for a prophylactic caesarean
section for no obvious reason. Gender was an important determinant of
making this choice: 23 female obstetricians (31% of approx. 85 women!)
versus 10 male ones (8%) choose caesarean section for uncomplicated
pregnancy. One cannot seriously state, however, that 'almost one third
of female obstetricians' make this choice based on the opinions of 23
female London-based obstetricians only, because those 23 will be far less
than one percent of all female obstetricians in this global village. We
conducted a similar anonymous postal survey among all obstetricians in The
Netherlands with a response rate of 67%. Only 8 out of 567 (1.4%) opted
for caesarean section in an uncomplicated singleton pregnancy.
Prophylactic caesarean section must still be considered clinically
unjustifiable, because there is excess maternal mortality and morbidity
(including infertility), and excess neonatal and particularly respiratory
morbidity after caesarean section as compared to vaginal birth[1].
Financial costs are unnecessarily much higher. Women are denied the
experience of giving birth themselves and instead become victims of
medicalization without good reasons.
The paper also wrongly states that 'vaginal delivery of a fetus in breech
presentation is becoming a rare obstetric art'. In our survey, 60-79% of
obstetricians opt for vaginal delivery in primigravid breech delivery and
86-94% in multigravid breech delivery as compared to 43 and 60% of our
London colleagues.
Although caesarean section is relatively safe in some parts of the
world, instant and remote maternal mortality and morbidity is a serious
problem in others parts[2]. The suggestion as done by Sara Paterson-Brown,
if taken up lightly by obstetricians in other places of this global
village, will definitely lead to more maternal deaths and misery for women
who already share a disproportionate part of ill-health in this world. As
part of a Confidential Enquiry into Maternal Deaths in the Netherlands, we
made the following statement: 'If the caesarean birth rate in the United
States of America was similar to the rate in the Netherlands (9%),
approximately half a million more births would occur annually by the
vaginal route. At present, these births occur by caesarean section and
would be associated with approximately 130 extra maternal deaths, if the
reported Dutch mortality rates after caesarean section were applied in the
United States' 1.
Demanding unnecessary intervention in some cases, implies denying that
service in other cases. On the global level this is seen in the growing
gap between 'developed' and 'developing' countries: in the first there is
the problem of unnecessarily high rates of caesarean section, while in the
second there is a high unmet need for caesarean section[3].
The suggestion that one does not need a valid reason to perform caesarean
section, will enlarge this unacceptable gap.
Leiden University Medical Centre, The Netherlands
Jos van Roosmalen, consultant Obstetrician
[1] Schuitemaker N, van Roosmalen J, Dekker G, van Dongen P, van
Geijn H, Bennebroek Gravenhorst J. Maternal mortality after cesarean
section in The Netherlands. Acta Obstet Gynecol Scand 1997; 76: 332-34.
[2] Van Roosmalen J, van der Does CD. Caesarean birth rates
worldwide. A search for determinants. Trop Geogr Med 1995; 47: 19-22.
[3] Belghiti A, de Brouwere V, Kegels G, van Lerberghe W. Monitoring
unmet obstetric need at district level in Morocco. Trop Med Int Health
1998; 3: 584-91.
Competing interests: No competing interests
EDITOR -
We can hardly believe that anyone could write "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."(1)
Is it proposed that the law should make a distinction between the
freedom of choice of "foolish" pregnant women and "other adults"? And if
so, into which category would the 31% of London female obstetricians who
would choose an elective caesarean section for themselves, fall?
Isabel Dakyns Barrister, 9 Bedford Row, London, WC1R 4AZ,
Judith James G.P. Registrar, Balmore Park Surgery, Caversham, Reading, RG4
7SS.
(1) Amu O., Rajendran S., Bolaji I. Maternal choice alone should not
determine method of delivery. BMJ 1998; 317:463-4. (15 August.)
Competing interests: No competing interests
In the debate on caesarian section on "maternal request"1 2 rather than for obstetric indications, there is agreement that a woman's choice should be respected both for ethical reasons and because, in light of current evidence, such operations can be regarded as clinically justifiable.3 Paterson-Brown and Amu et al are in agreement on this provided that the patient is making an appropriately informed choice.
The resource implications have been alluded to briefly by Paterson-Brown by referring to the 4% of Italian women who make this choice and the speculation that only a small minority of British women would choose likewise. However, it has been suggested that the current increase in caesarian section rate may already be partly influenced by patients' requests4 and there may be a further escalation if the results of the survey of female obstetrician's personal preferences5 becomes widely appreciated by the public. If the demand does escalate we can expect a new pressure on obstetric and anaesthetic resources.
An unusual situation we have experienced was of a multiparous woman who had planned for an elective caesarian section but presented in spontaneous labour late at night at a time when the delivery suite staff were very busy. The situation was regarded as an "obstetric emergency" in that a caesarian section had to be performed quickly enough to avert a vaginal delivery, thus removing staff from other duties.
Although most cases of caesarian delivery on maternal request would take place during office hours, obstetric units may not have the staff or financial resources to cope with an increase in workload. At a time when the National Health Service is having to confront the difficult issue of rationing, if it becomes popular, caesarian section on request may need to be added to the growing list of medical interventions which are important to patients but are not of the highest clinical priority.
Philip Segar Specialist registrar in anaesthesia
Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter EX2 5DW.
Colin B Berry Consultant in anaesthesia
Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter EX2 5DW.
1. Paterson-Brown S. Yes, as long as the woman is fully informed. BMJ 1998;317:462-3. (15 August.)
2. Amu O, Rajendran S, Bolaji I. Maternal choice alone should not determine method of delivery. BMJ 1998;317:463-5. (15 August.)
3. Tranquilli A, Garzetti G. A new ethical and clinical dilemma in obstetric practice: Cesarean section "on maternal request". Am J Obstet Gynecol 1997;177:245-6.
4. Mould T, Chong S, Spencer J, Gallivan S. Women's involvement with the decision preceding their caesarian section and their degree of satisfaction. Br J Obstet Gynaecol 1996;103:1074-7.
5. Al-Mufti R, McCarthy A, Fisk N. Survey of obstetricians' personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol 1997;73:1-4.
Competing interests: No competing interests
If they request for it,better you do it!
A pateint who request for Elective C section requests mainly because
she has a fear of labour and pain.Such a pateint who request for C section
is apprehensive and in my experience,they never really progress in
labour.Probably the old obstetric dictim the "a tense mind , a tense
cervix"is true.If you have a pateint who requests for C section please do
it,if you dont do it you will have to do it eventually either way.
So now with modern anesthesia and better surgical care why dont we do
it if the pateint request for it.Its better to do it other wise you will
have to do it eventuslly.
I personally feel the most important factor which helps in good
progress of labour is the pateints attitude A strong pateint has always a
better progress.
I wish some one could do a study on the pateints attitiude labour and
the outcome in labour!
DR JAYARAMAN NAMBIAR M
DR TMA PAI ROTARY HOSPITAL,KARKALA-574104 INDIA
Competing interests:
None declared
Competing interests: No competing interests