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Caesarean Section On Maternal Request

Caesarean Section On Maternal Request

The term ‘maternal request’ is used when delivery by caesarean section occurs for the mother’s preference when there is no medical or obstetric reason for avoiding vaginal birth.

The information provided in this handout is based on the most up to date and best research available at this time. It is important to understand that there have been no high level studies that directly compare outcomes in women who intend to have a vaginal birth with women who request caesarean section. The knowledge we have has been drawn from studies about elective caesarean sections performed for medical or obstetric reasons ( e.g. for breech babies). So conclusions about the risks and benefits of cesarean delivery on maternal request is only indirect and may not be completely applicable.

Understanding your reasons for requesting cesarean delivery can help you make an informed choice about delivery that you will feel comfortable with now and in the future. For example concerns about the process and pain of child birth, may be addressed by attending birthing classes, appropriate books and sometimes even counselling.

The risks and benefits of caesarean delivery for maternal request need to be balanced with the risks and benefits of a planned vaginal delivery. Many factors can affect the choice of delivery route , these include other medical conditions, body mass index, planned family size, prior childbirth experience ( or that of family/ friends), previous surgical procedures, and the woman’s personal philosophy about childbirth.

Most women will request caesarean section for one of the following reasons.

  • Convenience of a planned delivery
  • Fear of the pain, process, and complications of labor and vaginal birth
  • Prior poor labor experience
  • Concerns about harm from labor and vaginal birth to the baby
  • Concerns about developing anal and/or urinary incontinence from labor and vaginal birth
  • Concerns about emergency caesarean or instrument-assisted vaginal delivery
  • Need for control
The following table has been constructed to compare the risks and benefits of maternal request for planned caesarean birth with planned vaginal delivery.

Advantages Disadvantages No known difference

Planned date for delivery

However induction of labor may also be arranged for a planned date.

Longer recovery period

Following caesarean section.

 

Increased maternal morbidity

Some studies report women to be more likely to have problems including cardiac arrest , wound complications, hysterectomy, major infection, anaesthetic complications , venous thromboembolism, and haemorrhage requiring hysterectomy.

However, the overall risk of these events is low for both groups.

Maternal mortality

There is no difference in maternal death rate for planned caesarean versus planned vaginal delivery.

Avoidance of post term pregnancy

The chance of a term baby dying or suffering a severe disability until 40-41 weeks is about 1 in 500 to 1750 . In post term pregnancies the rates, while still low, start to increase. Induction of labor can also avoid post term birth.

Anaesthetic complications

Spinal anaesthetic used for caesareansection has a higher failure rate than epidural used during labour.

Spinal anaesthetic may need to be converted to a general anaesthetic so the woman cannot be awake for the birth of her baby.

Postpartum sexual function

Post partum sexual dysfunction is not related to method of delivery.

Reduction in risk of stress associated with unplanned surgery

Planned vaginal delivery may result in an uncomplicated spontaneous vaginal birth (50%), or an instrument-assisted vaginal birth (25%), or an emergency caesarean delivery (25%).

Emergency caesarean has been associated with postnatal depression and post traumatic stress.

Risks of haemorrhage in future pregnancies from

  1. Abnormal placental attachment to the uterus in a subsequent pregnancy. The risk increases with the number of caesarean sections and can lead to life-threatening haemorrhage and caesarean hysterectomy.
  2. Possible higher risk of placental separation and haemorrhage during future pregnancy.

Reduction in risk of pelvic floor injury

There is no evidence that caesarean section is protective against urinary or fecal incontinence after pregnancy.

Prevention of term stillbirth before or during labour

Fetal death in labour occurs 1 in 5000 births. Planned cesarean delivery at term will avoid most of these rare deaths, although fetal death can still occur (rarely) at a planned caesarean section.

Increased risk of uterine rupture

Most uterine ruptures occur in labourafter a previous cesarean delivery. Uterine rupture is associated with an increased risk of fetal death and maternal injury such as hysterectomy and haemorrhage.

Reduced infection transmission

eg, active herpes virus and some HIV positive women.

Stillbirth

Some studies have reported an association between cesarean delivery for a previous baby and stillbirth during a future pregnancy. The reasons for this are unclear and not all studies agree.

Increased risk of medical problems in babies and children

  1. There is a 3 times greater risk of breathing problems in the new bornperiod (12/100 vs 3/100) in babies delivered by cesarean before the onset of labor.
  2. Possible association of caesarean delivery and asthma and bronchiolitis in children.
  3. A lack of exposure to maternal bowel flora during labour may affect immunity in the future child.
The following will compare the risks and benefits of maternal request for planned caesarean birth with planned vaginal delivery.

 Advantages

Planned date for delivery

However induction of labor may also be arranged for a planned date.

Avoidance of post term pregnancy

The chance of a term baby dying or suffering a severe disability until 40-41 weeks is about 1 in 500 to 1750 . In post term pregnancies the rates, while still low, start to increase. Induction of labor can also avoid post term birth.

Reduction in risk of stress associated with unplanned surgery

Planned vaginal delivery may result in an uncomplicated spontaneous vaginal birth (50%), or an instrument-assisted vaginal birth (25%), or an emergency caesarean delivery (25%).

Emergency caesarean has been associated with postnatal depression and post traumatic stress.

Prevention of term stillbirth before or during labour

Fetal death in labour occurs 1 in 5000 births. Planned cesarean delivery at term will avoid most of these rare deaths, although fetal death can still occur (rarely) at a planned caesarean section.

Reduced infection transmission

eg, active herpes virus and some HIV positive women.

Disadvantages

Longer recovery period

Following caesarean section.

Increased maternal morbidity

Some studies report women to be more likely to have problems including cardiac arrest , wound complications, hysterectomy, major infection, anaesthetic complications , venous thromboembolism, and haemorrhage requiring hysterectomy.

However, the overall risk of these events is low for both groups.

Anaesthetic complications

Spinal anaesthetic used for caesareansection has a higher failure rate than epidural used during labour.

Spinal anaesthetic may need to be converted to a general anaesthetic so the woman cannot be awake for the birth of her baby.

Risks of haemorrhage in future pregnancies from

  1. Abnormal placental attachment to the uterus in a subsequent pregnancy. The risk increases with the number of caesarean sections and can lead to life-threatening haemorrhage and caesarean hysterectomy.
  2. Possible higher risk of placental separation and haemorrhage during future pregnancy.

Increased risk of uterine rupture

Most uterine ruptures occur in labour after a previous cesarean delivery. Uterine rupture is associated with an increased risk of fetal death and maternal injury such as hysterectomy and haemorrhage.

Stillbirth

Some studies have reported an association between cesarean delivery for a previous baby and stillbirth during a future pregnancy. The reasons for this are unclear and not all studies agree.

Increased risk of medical problems in babies and children

  1. There is a 3 times greater risk of breathing problems in the new bornperiod (12/100 vs 3/100) in babies delivered by cesarean before the onset of labor.
  2. Possible association of caesarean delivery and asthma and bronchiolitis in children.
  3. A lack of exposure to maternal bowel flora during labour may affect immunity in the future child.

No known difference

Maternal mortality

There is no difference in maternal death rate for planned caesarean versus planned vaginal delivery.

Postpartum sexual function

Post partum sexual dysfunction is not related to method of delivery.

Reduction in risk of pelvic floor injury

There is no evidence that caesarean section is protective against urinary or fecal incontinence after pregnancy.

 

 

SUMMARY AND RECOMMENDATIONS

  • Caesarean delivery on maternal request is when caesarean delivery is performed because the mother requests this method of delivery when there is no recognised medical or obstetric reason for avoiding vaginal birth.
  • The risks and benefits of cesarean delivery on maternal request need to be balanced with the risks and benefits of a planned vaginal delivery. Issues that can influence the choice of delivery route for a woman can include medical conditions she has, her body mass index, her future reproductive plans, her prior childbirth experiences ( and sometimes those of her friends), outcome of previous surgical procedures, and the woman’s personal philosophy about childbirth.
  • The best available evidence suggests that
    • Advantages of planned caesarean birth are
      • a lower associated risk of fetal injury than planned vaginal delivery ( although the risk overall is very small).
      • reduces the risk of surgical complications associated with unplanned caesarean delivery, which may become necessary during attempted vaginal delivery.
    • Disadvantages of planned caesarean delivery are
      • longer hospital stay/recovery for the mother.
      • increased risks of respiratory problems for the baby after birth.
      • potential complications in future pregnancies including placental abnormalities ( which can lead to haemorrhage during pregnancy and after delivery) and uterine rupture if a trial of labor is attempted.

Current recommendations are that

  • Women who would choose several pregnancies should be discouraged to have caesarean delivery on maternal request as placenta retention problems (praevia and accreta) are significantly more common in pregnancies following one or more caesarean deliveries. Moreover, these complications may necessitate caesarean hysterectomy. If the patient undergoes a trial of labor in the future, she will be at increased risk of uterine rupture.
  • For caesarean delivery on maternal request of an uncomplicated pregnancy scheduling the procedure at 39 to 40 weeks of gestation will reduce the risk of neonatal respiratory problems.

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