Elective Primary Cesarean Section

1. Elective Primary Cesarean Section Paul Wendel, MD Associate Professor Residency Director UAMS Department of Obstetrics & Gynecology

2. Patient choice • Maternal request • On demand All refer to primary cesarean section in the absence of medical/obstetrical indications.

3. Concept Origins:Most recently traced to 1985 • Stimulated by medicolegal case involving intrapartum fetal neurologic injury • Authors discussed “prophylactic cesarean section” ‘at term’ • Notion of informed consent for route of delivery was introduced • C-section offered as a means of avoiding the risks associated with vaginal delivery Feldman, GB Prophylactic cesarean at term? NEJM 1985; 312 pp. 1264-67

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

6. Why do Women ask for C-Sections? • Extreme tocophobia (fear of childbirth) • Death (patient or baby) • Fetal injury • Genital tract injury

7. When Psychotherapy was employed by trained professionals to address tocophobia: • 2/3 women ultimately chose vaginal birth These same women… • Ultimately viewed their birth experience as good

8. Physicians’ Perspective • Several studies have been done in UK, New Zealand, Ireland, Canada, Israel regarding physicians’ and midwives’ attitudes toward “elective c-section” • 7-30% of OB/GYN’s and 4.4% of midwives preferred c-sections for themselves if female or their partner if male • 62-81% reported a willingness to perform c-sections on demand

9. Physicians’ Perspective (con’t) • Similar to their patients, obstetricians cited the following as reasons leading to primary elective c-sections: • Fear of childbirth 27% • Perineal injury 80-95% • Fetal injury 24-39% • Anal or urinary incontinence 81-83% • Sexual dysfunction 58-59% • Convenience 17-39% • Control 39% • Pain 7%

10. Attitudes of Urogynecologist’s & MFM’s to Elective C-sections • Survey was distributed by UNC via web base • 53% of SMFM/AUGS members responded

11. Survey Results • Overall, 65% of physicians would perform an elective primary cesarean section • Compared with other countries: • 69% England • 67% Australia/New Zealand

12. AUGS / SMFM Survey Comparison • 80% of AUGS members vs. 55% of SMFM members for primary elective c-section • 45% of AUGS and 9.5% of SMFM members would choose a primary c-section for themselves or their partners

13. Ethical Principles • Can an elective c-section for an uncomplicated pregnancy be ethically justified? • Decision making based on: • Beneficence • Nonmaleficence • Autonomy • Justice • Voracity

14. Ethical Principles • Beneficence: physicians responsibility to promote the patients’ health/welfare • Nonmaleficence: complimentary principle refers to the physician’s obligation to do no harm to the patient • Autonomy: obligates the physician to discuss reasonable alternatives and elicit a decision within the framework of informed consent

15. Ethical 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).

16. Ethical Principles • Justice: requires that a physician treat patients fairly and make decisions that consider societal good with respect to limited health resources • Voracity: refers to truthfulness in patient counseling

17. 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

18. American College of OB/GYN 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.

19. Medical 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

20. Cape Town, South Africa 1975-1986 • Compared maternal mortality from elective c-section vs. vaginal delivery: • Elective c-section – 23/100,000 RR = 3.8 • Vaginal – 6/100,000

21. Saches and Colleagues (1988) Study (1954-1985) assessed c-section related mortality rate in Massachusetts Death rate C-sections - 5.9/100,000 vs. Vaginal delivery - 10.8/100,000

22. Washington State 1987-1996 Large 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.

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

24. Washington State Retrospective 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

25. Philadelphia 1994-1997Retrospective 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.

26. Randomized Multicenter Trial of Management 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: • Hemorrhage • Genital tract injury • Wound breakdown • Infection

27. Fetal Morbidity • Original premise: C-section at term would avoid intrapartum fetal neurologic injury • Data suggests fetal neurologic injury affects 2-3/1000 intrapartum events 3,000 – 5,000 elective cesarean sections would be needed to avoid one such injury.

28. C-section Rate (mid 1970’s – present) • Pooled data from these countries have shown significant rise of c-section rates: • Sweden Canada England Ireland • Australia Denmark Norway U.S. • Cerebral palsy rates have remained stable internationally • C-section is not neuroprotective for the fetus

29. Birth 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.

30. Conclusion • The debate over elective c-sections is growing. • Obstetrician should be aware of the issues and their colleagues’ beliefs. • No adequate study has compared elective c-sections and planned SVD. • In the absence of data, professional organizations will have different opinions on ethical acceptability.

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