Cesarean on Demand

Prevention of maternal floor damage: Concerns about urinary or bowel injury or future sexual functioning resulting from traumatic vaginal delivery.

"Designer Baby": Expensive reproductive technology needed for conception and the need to deliver in the least traumatic way to avoid any risk to the child.

Neonatal benefits: Elective cesarean is associated with lower newborn infection rates, lower risk of intracranial hemorrhage, neonatal asphyxia, and encephalopathy.

Prevention of any birth asphyxia or potential birth trauma: Avoidance of injury such as bone fracture, nerve injury.

Prevention of stillbirth: The need for preventing a stillbirth or overdue pregnancy with the inherent associated risks.

Sterilization: Doing a cesarean can allow for a subsequent sterilization procedure in some countries where reproductive rights are not available to women on request.

As obstetricians, we are faced with a difficult situation. Should a mentally competent patient have the right to choose, ethically, how they would like their baby delivered? While patients have the ability to make personal choices in many other areas of medicine, clearly this can not apply to obstetrics. Why? Because the lives of not one, but two humans, are at stake.

Are There Viable Disadvantages to an Elective C-section?

Surgery always poses additional risk factors. Elective cesarean section has a 2.84 fold greater risk of a woman's death than a vaginal birth.

Added risks include:

Maternal morbidity: This includes surgical injury such as damage to other organs, risk of hemorrhage, hysterectomy, infection, fever due to other causes, hematoma, anesthetic complications, and blood clots.

Respiratory issues in the newborn: Transient tachypnea (rapid breathing) of the newborn occurs more frequently after elective cesarean and respiratory distress more likely if the surgery is booked prior to 39 weeks.

Potential complications with future pregnancies:
This includes increased risk of uterine rupture if laboring during a subsequent pregnancy if you have a uterine scar from a previous cesarean, increased risk of placenta previa (low lying placenta adhering to the scar), placenta accreta (placenta growing into a previous uterine scar), and placental abruption (separation of the placenta from the uterine wall).

Complications from adhesions: Surgery can lead to abdominal adhesions which might effect future fertility, causing chronic pelvic pain, increase risk to bowel and bladder in future abdominal surgeries,and higher risk of ectopic pregnancies and miscarriages.

Injury to the baby: There is a 1.9% chance that a surgeons knife can accidentally lacerate the fetus when doing a cesarean. However, emergency cesarean sections after labor has a greater incidence of lacerations compared to elective cesareans.

What is the Answer?

In today's day and age, is it acceptable practice to allow the patient to determine the medical decision, assuming she is competent and well informed of any additional risks she is placing on herself? (i.e. informed consent) Could a physician be at risk for denying a patient's request for a cesarean if, postpartum, the procedure results in injury to herself, or her child, immediately or several years down the road?

It behooves the obstetrician, or midwife, to weigh all the risks and benefits of providing this option after exploring the reasons for the request. The ethics committee of Gynecology and Obstetrics (FIGO) states, "Only the woman can decide if the benefits to her of a procedure are worth the risks and discomfort she may undergo." We must respect the rights and autonomy of a mother. However, "performing cesarean section for non-medical reasons is not ethically justified."

The American College of Obstetrics and Gynecology, however, feels that after exploring the request and proper counseling with informed consent, the physician can comply with the patients request if it is felt that cesarean will promote the overall health of the patient and the fetus more than a vaginal delivery.