It has become more and more common for newly pregnant patients to request a cesarean section delivery on their first visit to me for prenatal care. Because it is happening more often, I thought it would be good to review the available data on the topic.
Cesarean section on maternal request is defined as a primary (meaning first) cesarean delivery on request in the absence of any medical or obstetric indication. The reasons for requesting cesarean delivery vary from patient to patient but can include fear of pain in childbirth, fear of poor outcomes with vaginal birth, or other critical life experiences which have an emotional impact on the anticipation of labor and delivery. It is estimated that 2.5% of all births in the United States are cesarean delivery on maternal request and in my own experience this seems to be on the rise. Because there are no good ways to track this particular statistic, it is hard to arrive at solid conclusions about the pros and cons of cesarean on maternal request. Here are the variables for which there is enough data to provide some guidance regarding delivery route. The data is mostly based on indirect comparisons so it must be interpreted cautiously.
- maternal hemorrhage (profuse bleeding) which may be a higher risk in planned vaginal birth
- maternal length of hospital stay which is higher in planned cesarean birth
- neonatal respiratory morbidity (baby having some breathing difficulties) which is higher in planned cesarean birth
- subsequent placenta previa or accreta (abnormal attachment of the placenta to the uterine wall) which is higher in planned cesarean birth
- subsequent uterine rupture (the uterine scar opening in a subsequent pregnancy with potentially disastrous results) which is higher in planned cesarean birth
Current recommendations from the American College of Obstetrics and Gynecology:
- Cesarean delivery on maternal request should not be performed before gestational age of 39 weeks which has been accurately determined.
- Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management.
- Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and the need for hysterectomy at the time of delivery increase with each cesarean delivery.
It is my belief that in the hands of a skilled obstetrician who is paying close attention to each pregnancy, planned vaginal birth with access to timely and safe cesarean section, if necessary, is the best approach to delivery for both baby and mom. But each woman is an individual with her own particular history and fears around birth and motherhood. If we are unable to allay fears or concerns so that planned vaginal birth is acceptable, well-timed cesarean birth may be the best way to achieve a good outcome for some women.
