Trip Answers

Question answered:01/12/07 Warning! this question is over two years old.

According to the RCOG's Clinical Queries service:

A Cochrane review of caesarean section for non-medical reasons at term found no evidence from randomised controlled trials upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term.

The NICE guideline on caesarean section (CS) published by the RCOG in 2004 includes a section on maternal request. This makes the following recommendations:

“Maternal request is not on its own an indication for CS and specific reasons for the request should be explored, discussed and recorded. (Evidence level IV)

When a woman requests a CS in the absence of an identifiable reason, the overall benefits and risks of CS compared with vaginal birth should be discussed and recorded. (Evidence level IV)

When a woman requests a CS because she has a fear of childbirth, she should be offered counseling (such as cognitive behavioural therapy) to help her to address her fears in a supportive manner, because this results in reduced fear of pain in labour and shorter labour. (Evidence level 1b)

An individual clinician has the right to decline a request for CS in the absence of an identifiable reason. However the woman's decision should be respected and she should be offered referral for a second opinion. (Evidence level IV)”

A Danish health technology assessment report on caesarean section on maternal request found:

“ the international literature concerning risks for mother and child is characterised by heterogeneity, low standards of evidence and fundamental methodological problems. Concerning the mother, there are no studies comparing the complications among healthy pregnant women who had caesarean sections purely on maternal request, with pregnant women who choose to give birth vaginally. Danish register data show an increased risk of infection and reoperation after an elective caesarean section. These complications should be compared with the risk of sphincter rupture and invasive intra-uterine palpation (examination of the uterus) in planned vaginal births. Serious complications such as hysterectomy and thromboembolism are very rare. However, there is a need for a more detailed analysis of the rare, serious complications of caesarean section in validated extracts from the Danish registers. Likewise, there is a need for further research into the risks of serious complications in any subsequent pregnancy. Concerning the risks to the child, no advantage has been shown with certainty for the child arising from elective caesarean section, either in terms of perinatal mortality, morbidity or long-term complications There appears to be a raised incidence rate of respiratory problems following elective caesarean section, connected to the gestation age. Danish register data show, with the exception of a slightly lower risk of low Apgar score after elective caesarean section, no significant difference in the frequency of selected complications for the child in the two delivery methods.”

Similarly, the US Agency for Healthcare Quality reported that

“ Virtually no studies exist on [caesarean delivery on maternal request (CDMR)], so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent.

Given the limited data available, we cannot draw definitive conclusions about factors that might influence outcomes of planned CDMR versus [planned vaginal delivery].”

The U.S. National Institutes of Health published a consensus conference statement which says:

“ Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.

Given that the risks of placenta previa and accreta rise with each cesarean delivery, cesarean delivery on maternal request is not recommended for women desiring several children.
Cesarean delivery on maternal request should not be performed prior to 39 weeks of gestation or without verification of lung maturity, because of the significant danger of neonatal respiratory complications.
Maternal request for cesarean delivery should not be motivated by unavailability of effective pain management. Efforts must be made to assure availability of pain management services for all women.”
 

Source: http://www.rcog.org.uk/index.asp?PageID=2262

---

DISCLAIMER: TRIPanswers is a collection of clinical questions and answers.  Each provider will have their own methodology in answering questions and these are likely not to be as rigorous as systematic review.  If you have any doubt as to the implications of this contact the Q&A Service Provider for further information. This document is presented for information purposes only. This document cannot and should not be used as a basis of diagnosis or choice of treatment, and is in no way intended to replace professional medical care or attention by a qualified practitioner. TRIPanswers and TRIP Database Ltd are not responsible or liable for, directly or indirectly, ANY form of damage whatsoever resulting from the use/misuse of information contained in or implied by this document.  Also, ensure you have read the terms and conditions for using the site.