Education And Debate Controversies in management

Should doctors perform an elective caesarean section on request?Yes, as long as the woman is fully informedMaternal choice alone should not determine method of delivery

BMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7156.462 (Published 15 August 1998) Cite this as: BMJ 1998;317:462

Should doctors perform an elective caesarean section on request?

Rates of caesarean section are rising, and mothers' requests for elective caesarean section in an uncomplicated pregnancy are not uncommon. Performing a caesarean section when it is not clinically indicated has traditionally been considered inappropriate, but views may be changing. Sara Paterson-Brown and Olubusola Amu and colleagues debate the issue

Yes, as long as the woman is fully informed

  1. Sara Paterson-Brown, consultant in obstetrics and gynaecology (s.paterson-brown@rpms.ac.uk)
  1. Queen Charlotte's and Chelsea Hospital, London W6 0XG
  2. Department of Obstetrics and Gynaecology, Leicester General Hospital, Leicester LE5 4PW
  3. Department of Obstetrics and Gynaecology, Grimsby Hospital, Grimsby DN33 2BA

    Surgery is performed by doctors when they believe it is clinically justified and in accordance with accepted medical practice. In obstetrics an elective caesarean section in an uncomplicated pregnancy has traditionally been considered inappropriate, and any request for such a procedure has been refused.1 However, the view that this procedure is clinically unjustifiable has been challenged,2 and over the past decade or so prophylactic caesarean section has been gaining credence. 3 4 The balance of benefit versus harm between caesarean section and vaginal delivery is crucial to this debate; although the evidence is incomplete, it challenges the dogma that vaginal delivery is almost always better.

    Evidence of risks

    The strongest argument against caesarean section relates to maternal complications. However, evidence supporting this for elective operations under regional blockade with antibiotic cover and thromboprophylaxis is poor. Data on mortality from caesarean section relate to procedures performed for medical or obstetric reasons, often emergencies and often under general anaesthesia. 5 6 These are not comparable to the elective procedure, which most practising obstetricians consider safe. Recent evidence of maternal morbidity after caesarean section and normal and instrumental vaginal delivery challenges some deep rooted obstetric and midwifery teachings: normal vaginal deliveries can cause damage to the pelvic floor,7 and instrumental vaginal deliveries are associated with slower recovery8 and greater pelvic floor damage and incontinence9 than normal delivery and caesarean section. Previous caesarean section does compromise future obstetric performance, 10 11 but evidence is limited and, with reduced family size, this has …

    Correspondence to: Dr Bolaji

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