Cesarean by choice
Patient choice Cesarean has become more common – careful consideration is still necessary.
ACOG NEWS RELEASE
| For Release: | May 9, 2006 |
| Contact: | ACOG Office of Communications |
| (202) 484-3321 | |
| communications@acog.org |
The total cesarean delivery rates increased rapidly in the 1970s and the 1980s, although the rates declined in the late 1980s through the mid-1990s. In 2004, 29.1% of all live births were delivered by cesarean, according to the National Center for Health Statistics (NCHS). One of the major drivers of the overall increase in cesarean delivery has been that, after a cesarean delivery, the likelihood of cesarean delivery increases in subsequent pregnancies. The increase in primary cesarean delivery parallels the total cesarean delivery rate, which cannot, therefore, be explained by the decreasing use of vaginal birth after cesarean (VBAC). “Some indications for cesarean delivery, whether planned or emergency, include breech presentation, poor fetal heart rate, uterine rupture, prolapsed umbilical cord, abruption placental, and placenta previa,” says Stanley Zinberg, MD, MS, ACOG deputy executive vice president, and vice president of ACOG’s Practice Activities division.
Mary E. D’Alton, MD, director of obstetrics and gynecology services at Columbia University Medical Center, College of Physicians and Surgeons in New York City, was the conference chair of the recent National Institutes of Health State-of-the-Science Conference on Cesarean Delivery on Maternal Request. “One of the key points that came out of the conference is that more research is needed. There just isn’t sufficient evidence at this time to fully evaluate the benefits and risks of cesarean delivery based on maternal request compared to normal vaginal delivery.” There was consensus, says Dr. D’Alton, that CDMR is not recommended for women who are planning on having several children since the risks of placenta previa and placenta accrete increase with each cesarean delivery. “While some data show an association between both vaginal and cesarean delivery with pelvic floor problems and incontinence later, the data are not definitive,” according to Dr. D’Alton.
“Patient-requested cesarean is but one of the many factors that have converged over the years to produce the current cesarean rate,” says Fredric D. Frigoletto Jr, MD, associate chief of staff and vice chair at Massachusetts General Hospital in Boston, and an ACOG past president. “At this time, the best delivery mode for any woman is best decided by her and her physician, considering her individual circumstances. A woman must be thoroughly and accurately informed about the risks and benefits of each option for her as she participates in the decision,” Dr. Frigoletto added.
“ACOG continues to review all of the issues surrounding maternal-request cesarean, but at this time our position is that cesareans should be performed for medical reasons,” says Dr. Zinberg. While the increase in cesarean deliveries over the years has been significant, it’s important to understand that there has been a noticeable shift in the demographic of women at high risk for cesarean, Dr. Zinberg noted. Some of these high-risk groups include women carrying multiple fetuses conceived through fertility treatments, older women becoming pregnant, and overweight and obese women.
Both Dr. Zinberg and Dr. D’Alton stress that women who request cesarean delivery in the absence of any medical indication should be counseled on the risks associated with cesarean, including a higher risk of infection, adhesions (painful scar tissue under the skin), pulmonary embolisms (blood clots), complications from the use of anesthesia, and the potential need for future cesareans, which entail additional risk. They also pointed out that the decision to perform a CDMR should be carefully individualized and consistent with ethical principles. “There is also a growing concern of the increased risk of babies born before 39 weeks of gestation; therefore, CDMR should not be performed prior to 39 weeks of gestation or without verification of lung maturity,” says Dr. Zinberg.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 49,000 members who provide health care for women.