Cesarean Delivery on Maternal Request
Cesarean delivery on maternal request (CDMR) was first introduced in 1985 by George B. Feldman, MD, in response to medical-legal concerns. While initially CDMR was a hotly debated topic, its momentum seems to have peaked and is waning. The debate is multifactorial and continues to be clouded by lack of evidence-based data regarding the benefits and risks of elective cesarean versus vaginal delivery. More recently, CDMR appears to have fallen further out of favor with obstetrician-gynecologists, with fewer agreeing to perform this procedure due to a shift in their perception of CDMR risks and benefits since the 2006 NIH State-of-the-Science conference on this topic. The following points outline the relative benefits and risks:
- Proponents (patients and/or obstetricians) cite such factors as:
- Fear of labor (patient)
- Maintaining control over one’s life (patient and obstetrician)
- Malpractice climate (obstetrician)
- Damage to pelvic floor (patient and obstetrician)
- Fear of fetal death or injury (patient and obstetrician)
- Opponents (obstetricians) cite such factors as increases in:
- Maternal morbidity and mortality
- Morbidity in future pregnancies (uterine rupture, hysterectomies, abnormal placentation, etc.)
- Morbidity related to future nonobstetrical surgery (adhesions)
When we look at these factors critically, it becomes obvious that there is a lack of sufficient data. A prospective, randomized trial of CDMRs versus vaginal deliveries would be extremely helpful. It is, however, doubtful that such a trial will ever be achieved. To add further confusion, professional organizations have widely divergent opinions regarding CDMR.
The subject of CDMR was last specifically addressed in ACOG Committee Opinion, Number 395, January 2008.
At this time, because of the lack of sufficient data regarding the risks and benefits of CDMR, the burden of proof falls upon those who advocate replacing a natural process (vaginal delivery) with a major surgical procedure (cesarean section [C/S]). The ethical principles of justice (the allocation of medical resources), and beneficence and nonmaleficence (a physician should offer only treatments that promote the health and welfare of the patient), and patient autonomy should be considered. ACOG recommends that each physician assess the current data regarding the risks and benefits of CDMR versus vaginal delivery:
If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal delivery, he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery. In this case, a referral to another health care provider would be appropriate if the physician and patient cannot agree on a route of delivery.
Given the lack of data, it currently is not ethically necessary to initiate discussion regarding the relative risks and benefits of elective cesarean delivery versus vaginal delivery with every pregnant patient.
A 24-year-old married white female P 1001 presented to her new obstetrician for prenatal care. Her first pregnancy was uncomplicated and resulted in the spontaneous delivery of a healthy 8 pound boy at 39 weeks’ gestation. Her past history was essentially negative. There were no risk factors, and her blood work was normal. At the first visit, the obstetrician and staff provided her with a vaginal birth informed-consent document, which she signed. This document covered possible complications of vaginal birth for her and her baby. Continued information was provided throughout her pregnancy and all her questions were answered. Excellent chart documentation was noted.
After a normal prenatal course, the patient presented to L&D in early labor at 40 weeks. The baby was found to be vertex at -2 station and her cervix was 80 percent effaced and 3 to 4 centimeters dilated. The fetal monitoring strip was reassuring.
While voiding, the patient ruptured her membranes, and profuse clear fluid was noted. She was immediately examined by the L&D nurse, and a prolapsed cord was noted with the FHR in the 70 to 80 range. The nurse placed her in the knee-chest position and placed her fingers in the vagina to elevate the fetal head. These maneuvers caused gradual return of the fetal heart rate to normal range, and the patient was immediately transported to the C/S suite.
The obstetrician and anesthesiologist both arrived within five to 10 minutes. A “crash” C/S was performed under general anesthesia, and the “decision-to-incision” time was less than 20 minutes. The nurse continued to elevate the fetal head throughout the entire procedure and reported intermittent bradycardia by cord palpation. The baby had Apgar scores of 3 and 5 and was resuscitated by the on-call pediatrician. At six hours’ postpartum, the baby began having significant seizures and was discharged one week later with multiple neurological deficits. The prognosis was guarded.
The patient had a normal postoperative and postpartum course. The obstetrician reviewed the entire case with the patient and her husband in the hospital and again at her two-week visit. She kept in close contact with her patient.
At six months’ postpartum, the patient sued the obstetrician. Among the complaints was the allegation that the obstetrician failed to meet the standards of care in her community because she had not discussed CDMR during the patient’s prenatal course.
Was the Obstetrician Obligated to Discuss the Option of CDMR with Her Patient?
This is a very complex question with no simple answers. With the present lack of good data, one can offer arguments to support or refute this question. Certainly the obstetrician would have been obligated to discuss CDMR if: (1) the patient had inquired about or requested it or (2) if the physician felt that CDMR discussion best promoted the overall health and welfare of the woman and her fetus.
If a patient requests CDMR and the obstetrician is morally opposed to it, he or she should make a referral to another physician. Certainly, there is no harm in the obstetrician’s discussing CDMR with a patient; however, it probably should not be mandatory considering our present state of knowledge. This ongoing debate should be closely followed by all pregnancy care providers.
Risk Management Tips
- Include a written vaginal birth informed consent process and document as part of all prenatal care plans.
- Document in the patient’s chart all other conversations regarding informed consent.
- Remember that every discussion initiated by the patient is important to that patient. Respond to discussions about CDMR with respect and concern regardless of your own professional opinion.
- Consult with the Patient Safety Department at The Doctors Company at (800) 421-2368, extension 1243, if a concern arises regarding CDMR.
CDMR is a reality in our society. Its true incidence has been difficult to assess. Providers should be prepared to discuss the rates of this procedure as well as its advantages and disadvantages with their patients. All pregnancy care providers should keep abreast of further studies and recommendations regarding CDMR.