Should women be able to request a caesarean section? No
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7565 (Published 23 November 2011) Cite this as: BMJ 2011;343:d7565
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Caesarean section on demand raises many controversies especially when rates of caesarean section have gone very high throughout the world. Tocophobia which is an intense fear of childbirth seems to be the most common reason for request for caesarean on demand in most but not all communities (1). Most obstetricians try to counsel the women about the risks of caesarean section like increased morbidity and increased chances of morbidly adherent placenta in future pregnancies. However, a better approach would be to explore the reasons for the request for caesarean on demand (1). The woman should be interrogated in details about the reasons of her request including any bad experiences of childbirth in her or her friends or relatives. Her fears should be allayed in consultation and she should be provided with all the support whatever her decision is including adequate pain relief in labour like epidural analgesia. Most women will thus accept vaginal delivery if there is no judicious indication for caesarean section. Most international organizations discourage caesarean section on demand. Infact International Federation of Gynecology and Obstetrics (FIGO) considers performing caesarean section in the absence of judicious medical indication as unethical (2).
The Society of Obstetricians and Gynaecologists of Canada also advises caesarean section only if there is real threat to the health of the mother and or the baby (3). The American College of Obstetricians and Gynecologists advises that caesarean on demand should not be performed before 39 weeks and is not recommended for women wanting to have many children (4).
In conclusion, the women requesting caesarean section on demand should be properly counseled about the pros and cons of caesarean section including reasons for request. By addressing her fears and other related issues and offering painless labor can motivate most women to try vaginal birth in absence of indication for caesarean section.
References
1, Nama V, Wilcock F. Caesarean section on maternal request: is justification necessary? The Obstetrician & Gynaecologist 2011;13:263-269.
2. Schenkar JG, Cain JM. FIGO Committee Report. FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. International Federation of Gynecology and Obstetrics. Int J Gynecol Obstet 1999;64:317-22.
3.Halpen S.SOGC Joint Policy Statement on Normal Childbirth. J Obstet Gynaecoll Can 2009;31:602.> 4. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No 394. December 2007. Caesarean delivery on maternal request. Obstet Gynecol 2007;110:1501.
Competing interests: No competing interests
Operative delivery, caesarean section, is attended with risks.
To women, a scar in their uterus could lead to problems with their next pregnancy (dehiscence, risk of placenta previa during subsequent pregnancies)
Subjecting themselves to anaesthesia and its attended risks needs to be considered.
Finally, why should NHS provide facilities for caesarean section when normal birth is cost effective and better.
Are we not permitting the choice agenda to extend too far?
Competing interests: No competing interests
Dear Sir,
It is important to consider the context in which NICE have allowed for maternal request of C-section. NICE recommend that if a woman is requesting a C-section because of anxiety she should first be consulted by a health professional who can give her the appropriate mental health support.
This recommendation puts the onus on doctors to properly explain the advantages and disadvantages of the procedure. If there is no clinical indication for C-section, I would agree that performing one is putting the patient at unnecessary risk. However, if a vaginal delivery is going to adversely affect the patient’s mental health, an important consideration during the perinatal period, then I belief this risk is justified.
Competing interests: No competing interests
Dear sir,
I am happy that some one is saying no the guidelines on "cesarean section on demand" by NICE(1,2). The complications of trial of of labor following one cesarean section, the difficulties of a laparotomy especially in an emergency for a subsequent cesarean section when there may be extensive adhesion/fibrosed tissue are very often underestimated. what is also relevant is that there are no studies looking at the difficulties of gynecological surgeries in these women later eg hysterectomy when dissection can be very difficult.
No laparotomy should be taken light. Virginity of the abdominal tissues are lost once opened and it predisposes to many complications later
The NICE should be careful before recommending such a thing.
Ref:News: Any pregnant woman who wants a caesarean section should not be denied it, says NICE. BMJ 2011;343:bmj.d7632
2.Rouhe H. Should women be able to request a caesarean section? No BMJ 2011;343:bmj.d7565
Competing interests: No competing interests
Re: Should women be able to request a caesarean section? No
The child's perspective
A significant proportion of expectant mothers around the world now consider the mode of delivery an issue of autonomy. Some may feel anxious about giving birth, while others may have insufficient knowledge about the long-term effects of this major surgical procedure. As Doctor Rouhe stated, fear of childbirth can be treated with excellent results, and thus unnecessary caesarean sections can be avoided. Counseling also includes giving the future parents information on possible complications. Another point worth taking into consideration is the health of the newborn, which involves much more than the possibility of cerebral palsy associated with "substandard intrapartum care" brought up by professor Turner. As several serious complications are also associated with substandard intrapartum care during and after caesarean section, this remark can be left without further comment.
Caesarean section affects the developing composition of intestinal bacteria of the infant (1,2), and increases the risk of developing asthma (3), allergies (4-7), and infections (8). Ceasarean sections to women with "no indicated risk" even seem to increase neonatal mortality rates (9, 10) and medically induced preterm births (11). As mothers tend to want the best for their children, these risks are also worth mentioning.
"Primum non nocere" (do no harm) should still be the guiding principle of all doctors, especially when dealing with children. Thus caesarean section without a true medical indication is irresponsible and unethical.
1. Penders J, Thijs C, Vink C, et al. Factors influencing the composition of the intestinal microbiota in early infancy. Pediatrics 2006;118:511-521.
2. Biasucci G, Benenati B, Morelli L, et al. Cesarean delivery may affect the early biodiversity of intestinal bacteria. J Nutr 2008;138:1796S-1800S.
3. Metsälä J, Kilkkinen A, Kaila M, et al. Perinatal factors and the risk of asthma in childhood - a population-based register study in Finland. Am J Epidemiol 2008;168:170-178.
4. Metsälä J, Lundqvist A, Kaila M, et al. Maternal and perinatal characteristics and the risk of cow's milk allergy in infants up to 2 years of age: a case-control study nested in the Finnish population. Am J Epidemiol 2010;171:1310-1316.
5. Pistiner M, Gold DR, Abdulkerim H, et al. Birth by cesarean section, allergic rhinitis, and allergic sensitization among children with a parental history of atopy. J Allergy Clin Immunol 2008;122:274-279.
6. Renz-Polster H, David MR, Buist AS, et al. Caesarean section delivery and the risk of allergic disorders in childhood. Clin Exp Allergy 2005;35:1466-1472.
7. Sjögren YM, Jenmalm MC, Böttcher MF, et al. Altered early infant gut microbiota in children developing allergy up to 5 years of age. Clin Exp Allergy 2009;39:518-526.
8. Merenstein DJ, Gatti ME, Mays DM. The association of mode of delivery and common childhood illnesses. Clin Pediatr 2011;50:1024-1030.
9. MacDorman MF, Declercq E, Menacker F, et al. Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk", United States, 1998-2001 birth cohorts. Birth 2006;33:175-182.
10. MacDorman MF, Declergc E, Menacker F, et al. Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an "intention-to-treat" model. Birth 2008;35:3-8.
11. Malloy MH. Impact of cesarean section on intermediate and late preterm births: United States, 2000-2003. Birth 2009;36:26-33.
Competing interests: No competing interests